Every finding on record at Fairburn Heights of Journey LLC

Based on observations, staff interviews, and review of the facility policy titled, Food Storage: Cold Foods, the facility failed to properly store opened, unopened and sealed food items in the walk-in freezer. The deficient practice had the potential to affect 87 residents receiving an oral diet from the kitchen. Findings include:Review of the facility policy titled Food Storage: Cold Foods, states under Policy Statement: All Time/Temperature Control for Safety in accordance with guidelines of the FDA food Code. All food items will be stored, wrapped or in covered containers, labeled and dated and arranged items should be covered, sealed, labeled, and dated appropriately.Observation on 02/10/2026 at 9:35 AM of the cold storage area in the walk-in freezer revealed an opened freezer burned bag of eggs that was not securely closed, without a labeled open date or an expiration date, observation also revealed an opened expired pimento cheese spread container with best by date 02/05/2026.During an interview on 02/10/2026 at 9:37 AM, the Certified Dietary Manager (CDM) confirmed the walk-in freezer contained an opened freezer burned bag of eggs and the bag was not securely closed, it also was without a labeled open date or an expiration date, as well as an opened expired canister of pimento cheese spread best by date, dated 02/05/2026. The CDM revealed he expected dietary staff to routinely perform routine inventory in the walk-in freezer also to document the food products received dates upon delivery, and to perform routine inventory of the walk-in freezer documenting product open and expiration dates to ensure proper handling and safe food storage.Observation on 02/10/2026 at 9:45 AM of the walk-in freezer revealed two unopened five-pound bags of dry noodles without a labeled open date or an expiration date, the dates of 12/22/2026, and 01/06/2026 were written on the two bags of noodles, observation also revealed a bag of unopened rotten potatoes with an expiration date of 01/12/2026.During an interview on 02/10/2026 at 9:47 AM, the CDM confirmed the two unopened five-pound bag of dry noodles were without a labeled open date or an expiration date, he also confirmed the dates of 12/22/2026, and 1/6/2026 that were written on the two unopened bags of the noodles, he confirmed he was not able to confirm whether the dates listed on the two unopened bags of noodles were the received or expiration dates. While in the walk-in freezer the CDM confirmed a bag of unopened rotten bag of potatoes was expired with an expiration date of 01/12/2026. The CDM revealed he expected dietary staff to date opened food items before storage and expected dietary staff to routinely perform routine inventory in the walk-in freezer to ensure all received, opened and expiration dates are in accordance with the regulation and policy procedures.Observation on 02/10/2026 at 9:55 AM of the walk-in freezer revealed an opened expired bag of improperly stored bag of green onion with an expiration date of 01/30/2026 and a bag of unopened rotted green onion with an expiration date of 01/19/2026, observation of the walk-in freezer also revealed a bag of unopened rotted green celery with an expiration date of 01/16/2026.During an interview on 02/10/2026 at 10:02 AM, with the CDM the CDM confirmed there was an opened expired bag of improperly stored green onion with an expiration date of 01/30/2026 and a bag of unopened rotted green onion with an expiration date of 01/19/2026, as well as a bag of unopened rotted green celery with an expiration date of 01/16/2026 was in fact in the walk-in freezer. The CDM revealed he expected dietary staff to date opened food items before storage and expected dietary staff to routinely perform routine inventory in the walk-in freezer to ensure all received, opened and expiration dates are in accordance with the regulation and policy procedures.

Based on observations, staff interviews, and review of the facility policy titled, Routine Cleaning and Disinfection, the facility failed to ensure that Packaged Terminal Air Conditioning (PTAC) Units were free of dust and debris preventing proper filtration for heat and air in five of 15 resident (R ) (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) rooms, and failed to ensure nails protruding from the wall were removed to prevent accident hazards.Findings include: The facility policy for Cleaning Packaged Terminal Air Conditioning Units was requested but not provided.Review of the facility policy titled Routine Cleaning and Disinfection revised date of February 2025 revealed under Policy: To ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible.During the initial facility tour on 02/10/2026 at 11:32 AM, a heavy accumulation of dust was observed on the filter for the PTAC unit in room [ROOM NUMBER]. Also, the toilet tissue dispenser in the bathroom was rusted and the toilet tissue was propped on top of holder and could not be secured on the holder. Observation on 02/10/2026 at 11:54 AM in room [ROOM NUMBER] revealed a heavy accumulation of dust on the filter for the PTAC unit.Observation on 02/10/2026 at 12:05 PM in room [ROOM NUMBER] revealed a heavy accumulation of dust on the filter for the PTAC unit.Observation on 02/10/2026 at 12:03 PM in room [ROOM NUMBER] revealed a heavy accumulation of dust on the filter for the PTAC unit.Observation on 02/10/2026 at 12:19 PM in room [ROOM NUMBER] revealed a heavy accumulation of dust on the filter for the PTAC unit. The PTAC unit had debris resembling food crumbs on top of the PTAC unit and on the unit control panel. Multiple nails were observed protruding from the wall. Observation on 02/10/2026 at 12:33 PM revealed a heavy accumulation of dust on the filter for the PTAC unit in room [ROOM NUMBER]. Observation on 02/12/2026 at 9:14 AM in room [ROOM NUMBER] revealed a heavy accumulation of dust on the filter for the PTAC unit. Observation on 02/12/2026 at 9:14 AM in room [ROOM NUMBER] revealed a heavy accumulation of dust on the filter for the PTAC.Interview and observation on 02/12/2026 at 11:03 AM with two Surveyors, the facility Administrator and Maintenance Director revealed a heavy accumulation of dust on the PTAC unit filters in resident rooms 210, 211, 212, 213, and 214. The Administrator and Maintenance Director confirmed observations of dirty filters for the PTAC units, bathroom baseboard and other general plant matters. The Maintenance Director reported he would clean all PTAC units on the unit that same afternoon, including those not identified during the environmental tour. The Administrator acknowledging all the PTAC units on the Unit were in the same condition and that she had seen enough. She expressed her expectations for all PTAC units to be cleaned in accordance with the Preventative Maintenance Schedule in the TELS system and going forward, every three months; to include Maintenance retaining logs validating that the PTAC units were cleaned. Filter cleaning, coil cleaning and inside the PTAC will be the responsibility of the Maintenance Team.

Based on record review, staff interviews, and review of the facility policy titled, Resident Assessment- Coordination with PASRR (Preadmission Screening and Resident Review) program, the facility failed to ensure that one of 46 sampled residents (R) (R7) was assessed for level two PASRR to the appropriate state-designated authority for evaluation and determination of specialized services (PASRR), if warranted. The deficient practice had the potential for R7's needs and services to go unmet.Findings include:Review of the facility's policy titled, Resident Assessment- Coordination with PASARR program date 02/10/2024 revealed under Policy: This facility coordinates assessments with the preadmission screening and resident review (PASRR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Under Policy Explanation and Compliance Guidelines revealed: The Social Services Director shall be responsible for keeping track of each resident's PASARR screening status and referring to the appropriate authority. Recommendations, such as any specialized services, from a PASARR level II determination and/or PASARR evaluation report will be incorporated into the resident's assessment, care planning, and transitions of care.Review of R7's electronic medical record (EMR) revealed that she was admitted to the facility with diagnoses including but not limited to paraplegia, cognitive communication deficit, other schizophrenia, bipolar disorder, major depressive disorder.Review of the quarterly Minimum Data Set (MDS) dated [DATE] documented R7 with a Brief Interview of Mental Status (BIMS) score of 15, indicating R7 cognitively intact.Review of the Care Plans for R7 revealed care plan dated 06/18/2025 revealed resident has a mood problem r/t (related to) diagnosis of bipolar disorder, major depressive disorder, schizophrenia. She should be observed for s/s (signs/symptoms) of worsening mood such as alterations in sleeping pattern, appetite changes, sudden mood swings. Goal revealed the resident will have improved or stabilized mood state through the review date. Interventions revealed monitor/document/report PRN (as needed) any risk for harm to self: suicidal plan, past attempt at suicide, risky actions (stockpiling pills, saying goodbye to family, giving away possessions or writing a note), intentionally harmed or tried to harm self, refusing to eat or drink, refusing med or therapies, sense of hopelessness or helplessness, impaired judgment or safety awareness. Monitor/record mood to determine if problems seem to be related to external causes, i.e. medications, treatments, concern over diagnosis. Monitor/record/report to MD prn acute episode feelings or sadness; loss of pleasure and interest in activities; feelings of worthlessness or guilt; change in appetite/ eating habits; change in sleep patterns; diminished ability to concentrate; change in psychomotor skills. Monitor/record/report to MD prn mood patterns s/sx of depression, anxiety, sad mood as per facility behaviour monitoring protocols. Monitor/record/report to MD prn risk for harming others: increased anger, labile mood or agitation, feels threatened by others or thoughts of harming someone, possession of weapons or objects that could be used as weapons. Observe for signs and symptoms of mania or hypomania racing thoughts or euphoria; increased irritability; frequent mood changes; pressured speech; flight of ideas; marked change in need for sleep; agitation or hyperactivity.Review of the Preadmission Screening/Resident Review (PASRR) Level two list dated 02/07/2026 revealed R7 was not listed.Review of the PASRR Level one dated 06/05/2026 revealed approved with physician signature. PASRR Level two dated 02/12/2026 revealed pending.Interview conducted on 02/12/2026, at 12:50 PM with the Assistant Director of Nursing (ADON) disclosed that she was neither responsible for nor involved in the PASRR process for the residents. It was noted that the resident's PASRR had been finalized by the Administrator and the Social Worker.Interview on 02/12/2026 at 01:34 PM with the Administrator confirmed that the Social Worker Director recently finalized an audit in which R7 was possibly overlooked. Administrator confirmed that R7 should have been included due to her diagnoses. The Administrator further confirmed that the PASSR will be submitted immediately.Interview on 02/12/2026 at 2:45 PM with the Social Service Director (SSD) disclosed that her responsibilities included processing the PASRR. The SSD indicated that the facility conducted PASRR level one upon admission and subsequently, the admission Coordinator provides her with names for further assessment to submit for a PASRR level two. The SSD mentioned that she conducted an audit two to three weeks ago for residents with issues related to schizophrenia, depression, and bipolar disorder, but she was unable to locate the submission for R7.

Based on observations, staff interviews, record review, and review of the facility's policies titled, Hand Hygiene and Enhanced Barrier Precautions, the facility failed to use proper hand hygiene during wound care for one of 46 sampled residents (R) ( ) and failed to provide signage and PPE protocols for two of 46 sampled R's (R127 and R88). The deficient practice had the potential to cause the spread of infection to other residents and staff.Findings include:Review of the facility's policy titled Hand Hygiene revised 02/01/2024, under section 6. a. revealed that the use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves and immediately after removing gloves.Review of the facility's policy titled Enhanced Barrier Precautions revised 03/20/2025, under section 2b states, An order for enhanced barrier precautions (EBP) will be obtained for residents with any of the following: i. Wounds (e.g. Chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wound, and chronic venous stasis ulcers) and or indwelling medical devices (e.g. central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, peripheral inserted central catheter (PICC) lines, midline catheters) even if the resident is not known to be infected or colonized with a multi drug resistant organism (MDRO). (Peripheral IVs, continuous glucose monitors, insulin pumps, or ostomies without an associated indwelling medical device are not an indication for EBP. Section 3. a, b, c, d read: Implementation of Enhanced Barrier Precautions includes a. Make gowns and gloves available immediately near or outside of the resident's room. Personal Protective equipment (PPE) for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned before entering the resident's room. C. Ensure access to alcohol-based hand rub in every resident room (ideally both inside and outside of the room). D. Position a trash can inside the resident room and near the exit for discarding PPE after removal, before exit of room, or before providing care for another resident in the same room.Review of the electronic medical record (EMR) revealed resident R127 was admitted to the facility with pertinent diagnoses, including but not limited to metabolic encephalopathy, staphylococcal arthritis of the left knee, atherosclerosis of native arteries of the extremities with intermittent claudication in the right leg, kidney disease stage 2, chronic embolism and thrombosis of deep veins of the left lower extremity.Review of R127's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11, indicating R127 had moderate cognitive impairment. Section GG (Functional Abilities and Goals) revealed, admission performance- requires supervision for eating, oral hygiene, is dependent for toileting hygiene, dependent for shower/bath, dependent for dressing upper and lower body, and dependent for putting on and taking off footwear. She is dependent on bed mobility and positioning to the sitting position. Review of R127 Care Plan dated 02/03/2026 revealed IV antibiotic therapy for staphylococcal arthritis to the left knee, stop date 3/7/2026, R127 is on IV Medications r/t (related to) left septic knee. Enhanced barrier precautions r/t wounds and midline IV access. Review of the hospital records in the electronic medical record (EMR) revealed that R127 had an order for a PICC line for intravenous antibiotic therapy.An observation on 02/10/2026 at 11:32 AM with R127 revealed R127 has a vascular access PICC line with no date on the dressing. The resident states she thought it was changed yesterday. The resident in A bed, R88, was on a low air mattress with no sheet. R88 explained that she has a wound on her bottom and that the mattress should ot have a sheet on it to work the best at pressure relief. Bags of linen were seen in the sink area, and R88 explained that it was clean linen that they use throughout the day to change their beds. There was no signage noted outside indicating that residents R127 or R88 were on EBP. There was no PPE available, and no trash can to remove PPE in the room.Observation on 02/11/2026 at 8:10 AM revealed R127 and R88 were both in room [ROOM NUMBER], and both were care planned for EBP, but there were no PPE supplies available or signage outside the room. Licensed Practical Nurse (LPN) DD and Certified Nursing Assistant (CNA) AA donned (put on) gloves to reposition R127 in C bed, but no gown was donned.An observation on 02/11/2026 at 8:17 AM revealed LPN DD and LPN KK Unit Manager enter room [ROOM NUMBER] and reposition C bed (R127), who has orders for EBP. There is no PPE or signage available on the door. They donned gloves. An observation on 02/11/2026 at 8:20 AM, a CAN was observed delivering a breakfast tray to room [ROOM NUMBER] B without hand hygiene upon entrance or exiting room.An observation on 02/11/2026 at 9:20 AM, LPN DD and CNA RR entered R127's room to turn and perform personal care without PPE other than gloves.An observation and interview on 02/11/2026 at 9:24 AM with LPN DD revealed that 311-bed A also had a wound according to her orders, it was a stage IV, and she was also care planned for enhanced barrier precautions; there was no signage or PPE available. An observation on 02/11/2026 at 9:30 AM, LPN DD went into room [ROOM NUMBER] and assisted the residents with hygiene and positioning. She did not wear PPE or gloves at this time. An interview with LPN DD on 02/11/2026 at 9:33 AM revealed LPN DD confirmed that residents R127 and R88, both in room [ROOM NUMBER] A and C, were supposed to be on EBP, and there was no sign on the door or PPE available. She said there should have been a sign because of R88, even before R127 was admitted . She also confirmed that the staff had not been wearing PPE during the care of these residents. An observation of wound care on 02/11/2026 at 9:58 AM revealed Wound Care, LPN EE donned PPE gown and gloves, and performed hand hygiene. Instructed R127 on the procedure and left the room to collect supplies. 02/11/2026 at 10:02 AM, LPN EE collected supplies including normal saline, calcium alginate with silver, and foam protective dressing. She performed hand hygiene and donned her gown and gloves. She has already dated and put her initials on the foam dressing. R127 was assisted to roll on her left side, and LPN EE removed the old dressing and disposed of it in a red bag. She then removed her dirty gloves and donned clean gloves without hand hygiene. She cleaned with normal saline and 4x4 gauze, removed her dirty gloves, donned clean gloves without performing hand hygiene, and applied calcium alginate with silver and applied a foam dressing. An interview on 02/11/2026 at 11:30 AM with LPN EE confirmed that she did not use hand sanitizer between glove changing but she was told not to bring hand sanitizer into the room. An interview on 02/11/2026 at 01:46 with the Director of Nursing (DON) confirmed that she expected wound care to be done in an aseptic manner. She denied telling the wound care nurse not to bring the alcohol in the room and would sort out a way to have the nurse perform hand hygiene in between glove changes when doing wound care.

Based on record review, staff interviews and review of facility's policy titled, Emergency Staffing, the facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week for six days, 04/05/2025, 04/06/2025, 05/03/2025, 05/24/2025, 05/25/2025, and 05/26/2025. This failure had the potential to affect all residents residing in the facility. The facility census was 110.Findings Include:Review of facility's policy titled Emergency Staffing Policy reviewed on 02/16/2024 revealed under section titled, Policy Explanation and Compliance Guidelines: The number of staff required for meeting resident needs on a daily basis are determined through the facility assessment. Schedules shall reflect sufficient staff with minimum use of scheduled overtime. In an emergency, the Administrator and key staff (as designated by the facility's Incident Command System) shall meet for briefing on staffing needs and develop an action plan. Staffing needs will be fulfilled in a step-wise fashion:a. On-duty staff and scheduled staff.b. Off-duty staff and on-call staff, including department managers.c. Staff from sister facilities (i.e., owned by same company), and non-medical volunteers who are already on file with the facility.d. Staff from other facilities with which the facility has a Memorandum of Understanding on file to provide staff in the event of an emergency or disaster.e. Staff from receiving facilities who intend to stay and assist with providing care.f. Volunteers from Medical Reserve Corps (or similar agency available to facility) in which credentialing has been pre-verified.g. Healthcare professional volunteers who present to the facility to provide assistance.The staffing schedule and timecard punches were requested of the DON on 2/10/2025 for the following dates 04/06/2025, 05/03/2025, 05/24/2025, 05/25/2025, and 05/26/2025. Due to salaried status of the Registered Nurses, no extra evidence was available to verify physical presence in the facility on the identified dates.Review of timecard punches/payroll revealed:04/06/2025 (Sunday): Payroll reflected RN TT as salaried; however, no supporting documentation was provided to verify RN TT's presence.05/03/2025 (Saturday): Payroll reflected RN SS as salaried; however, no supporting documentation was provided to verify RN SS's presence.05/24/2025 (Saturday), 05/25/2025 (Sunday), and 05/26/2025 (Monday): Payroll reflected RN SS as salaried; however, no documentation was provided to verify RN SS's presence for at least eight consecutive hours.Record review of staffing schedule revealed:04/06/2025 (Sunday): Staffing sheet reflected zero RN hours, and no documentation was provided to verify RN presence.05/03/2025 (Saturday): Staffing sheet reflected zero RN hours, and no documentation was provided to verify RN presence.05/24/2025 (Saturday), 05/25/2025 (Sunday), and 05/26/2025 (Monday): Staffing sheet reflected zero RN hours, and no documentation was provided to verify RN presence.Interview on 02/12/2026 at 2:43 PM with the Director of Nursing (DON) revealed all RNs were salaried so they did not clock in or out. She stated the facility's process regarding having RN coverage was that an RN was here Monday through Friday. She stated if she was off, then the ADON was here. She stated on weekends, if there was no scheduled RN coverage, then she would take a day or the ADON would take a day. She stated they always have to have eight hours of coverage and would get an RN to work to ensure coverage. She further stated they could not find supporting documentation that an RN was in the building for the additional identified dates 04/06/2025, 05/03/2025, 05/24/2025, 05/25/2025, and 05/26/2025. She stated her expectation as DON was that the DON or ADON would be present Monday through Friday, and on weekends the supervisor would be present, and if not, between the ADON or DON, one of them would be in the facility. When asked about potential negative outcomes of not having RN coverage, she stated the assessment component could be affected, stating that LPNs can assess, but sometimes an RN could be more clinical than an LPN. She stated if a patient codes (stops breathing and heart stops), an RN would be required to pronounce death, as LPNs cannot pronounce. She stated that much of the RN role was management and clinical oversight.Interview on 02/12/2026 at 3:59 PM with the Administrator revealed the facility's process was that you always have RN coverage. She stated the expectation is that they ensure they always have nurse coverage and that they have been doing a whole lot better. She confirmed they could not provide evidence that there was an RN present on 04/06/2025, 05/03/2025, 05/24/2025, 05/25/2025, and 05/26/2025, and she acknowledged documentation was not available to verify RN presence. She stated the expectation was to ensure nurse coverage daily. She stated a potential negative outcome from not having RN coverage was clinical is not covered and there would be a lack of clinical leadership in the building.

Based on observations, resident and staff interviews, record review, and review of the facility policy titled, Oxygen Administration, the facility failed to ensure proper maintenance of an oxygen (O2) concentrator (machine that produces O2) and failed to secure an O2 tank for one of 23 residents (R) (R58) receiving oxygen. This practice had the potential to cause respiratory distress, increased risk of respiratory complications, and injury Findings include:Review of the facility policy titled Oxygen Administration revised [DATE], under the section titled Policy Explanation and Compliance Guidelines, number 2 documented, Personnel authorized to initiate oxygen therapy include physicians, RNs (Registered Nurses), LPNs (Licensed Practical Nurses), and respiratory therapists (RTs).A review of the electronic medical records (EMR) revealed R58 was admitted to the facility with diagnoses including, but were not limited to, acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD) with acute exacerbation, and shortness of breath.Review of R58's physician orders revealed an order dated [DATE] for oxygen at night during sleep, 2L (liters)/min (minute) via nasal cannula every night shift.Review of R58's physician orders revealed an order dated [DATE] . oxygen at night during sleep, 4L/min via nasal cannula every night shift.Observation on [DATE] at 1:45 PM revealed R58 was receiving oxygen via O2 concentrator. The O2 concentrator emitted a continuous beeping throughout the observation.Observation on [DATE] at 5:10 PM revealed R58's O2 concentrator filter to be heavily soiled with visible dust and debris accumulation. Further observation revealed the O2 concentrator covered in dirt and the service tag was expired by five years. Also observed was an O2 tank standing upright, unsecured and unsupervised while in the R58's room. The O2 concentrator was constantly beeping during the observation.Observation on [DATE] at 12:15 PM revealed R58's O2 concentrator was covered in dirt and the O2 concentrator filter to be heavily soiled with visible dust and debris accumulation and the service tag was expired by five years. An unsecured oxygen tank was standing upright and unsupervised while in the residents' room, with the O2 concentrator alarm consistently beeping. Interview on [DATE] at 12:40 PM with R58, she revealed there was a loud and distracting beeping noise coming from the O2 concentrator. She mentioned she had been complaining for months to the Director of Nursing (DON); however, no one responded to her concerns. Interview on [DATE] at 1:15 PM with the DON revealed she was not aware of any issues related to R58's O2 concentrator nor was she aware there was an O2 tank standing upright and unsecured, without use, in a residents' room. She also mentioned that the Assistant Director of Nursing (ADON) was responsible for the monitoring of the O2 concentrators and or any respiratory equipment.Interview on [DATE] at 1:35 PM with the ADON revealed the 02 concentrators were cleaned on a routine basis. She also mentioned that O2 concentrators were the Unit Managers responsibility, however due to the Unit Managers overwhelming case load, she wanted to assist by assuming the responsibility but was not aware of an issue with R58's O2 concentrator.

Based on observations, staff interviews, and record review, the facility failed to ensure physician orders were followed and documented for routine suprapubic catheter changes for one of four sampled residents (R) (R5). This deficient practice had the potential risk of infection and complications associated with prolonged indwelling catheter use when routine catheter changes were not completed and documented as ordered.Findings include:Review of the electronic medical record (EMR) for R5 revealed admission to the facility with diagnoses of but not limited to obstructive and reflux uropathy, benign prostate hyperplasia with lower urinary tract symptoms, personal history of malignant neoplasm of prostate.Review of physician orders dated 11/10/2025 directed that R5's suprapubic catheter (20 French, 10 mL (milliliter) balloon) be changed monthly and as needed.Review of the care plan for R5 identified catheter-related interventions on 10/14/2025 (catheter dislodgement and replacement) and on 01/08/2026 (catheter change and irrigation); however, no documentation was identified verifying that the resident's suprapubic catheter was changed between 10/24/2025 and 01/08/2026.Observation on 02/11/2026 at approximately 11:00 AM revealed R5 with a suprapubic catheter in place draining to a bedside collection bag. The resident was alert and responsive urine was flowing well at the time of observation.Interview on 02/12/2026, Licensed Practical Nurses GG and HH acknowledged they were unable to locate documentation in the EMR verifying a suprapubic catheter change during the period of 10/24/2025 through 01/08/2026 and stated the physician order required routine catheter changes every 30-39 days.Interview on 01/12/2026 with the Assistant Director of Nursing confirmed there was no documented evidence of a catheter change during this timeframe and stated facility expectations were for staff to follow physician orders and document care provided.

Based on observations, staff and interviews, record review, and review of the facility's policies titled, Comprehensive Care Plans, the facility failed to follow the interventions of the comprehensive care plan for one of 46 residents sampled residents (R) (R12). This deficient practice could increase the risk of injury during a fall.Findings include:Review of the facility's policy titled Comprehensive Care Plans revised 01/01/2025, revealed under Policy Explanation and Compliance Guidelines: .3. a. The comprehensive care plan should describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.Review of R12's care plan dated 02/07/2026 indicated a problem of Risk for falls. Interventions included, but were not limited to, Fall [NAME] on the floor on the right side of the bed when the resident is in bed. The resident is with Hospice and is a Full Code. R12 has a condition or chronic disease that may result in a life expectancy of less than six months.Review of the Physician's Orders for R12 included, but was not limited to: wound care to sacral wound, EBP (enhanced barrier precautions), tramadol HCL (hydrochloride) 50mg (milligrams) four times a day routine, lorazepam 1 mg every four hours prn (as needed), morphine 20mg/ml (milligram per milliliter) give 0.25ml every 2 hours for severe pain, Scopolamine transdermal patch 1mg, change every 3 days, place behind the ear for secretions. Carbidopa-Levodopa 10-100mg four times a day.Observation on 02/10/2026 at 12:34 PM with R12 revealed the resident lying on her back, half side rails in place, the bed was in the lowest position, R12's eyes were closed, and there was no fall mat on either right or left side of her bed as per her care plan.Observation made on 02/11/2026 at 3:50 PM of R12 revealed R12 lying in bed on her back, half side rails in place, there was no fall mat present on the right or left side of her bed on the floor.Observation made on 02/12/2026 at 9:43 AM of R12 revealed R12 lying in bed, head of bed elevated 45 degrees, and the resident was leaning to the right side. Her eyes were closed, and half rails were in place. No fall mats were on the floor as care planned.An interview on 02/12/2026 at 9:46 AM with Licensed Practical Nurse (LPN) HH revealed she did not recall having a fall mat on the floor beside R12's bed.An interview on 02/12/2026 at 10:58 AM with Registered Nurse (RN) FF revealed that she was the RN supervisor on the evening that R12 fell out of bed. She stated she went into R12's room after the CNA told her about the fall. She stated that she found the resident sitting on the floor beside the right side of the bed; no fall mat was present at the time. An interview on 02/12/2026 at 2:43 PM with the Director of Nursing (DON) confirmed that there were no fall mats in place on R12's floor. She states that her expectation for following the care plan was that it be followed. An interview on 02/12/2026 at 3:02 PM with the Administrator revealed that he expected whatever the policy stated to be done.

Based on observations, resident and staff interviews, record review, and review of the facility's policies titled, MDS 3.0 Completion, the facility failed to correctly assess and identify intravenous (IV) access ordered and inserted the day after admission for one of 46 sampled residents (R) (R127). This deficient practice had the potential to confound care and monitoring of IV access, as well as the timely change of IV access.Findings include:Review of the facility's policy titled MDS 3.0 Completion, revised 12/23/2023, section d. ii. Revealed: Based on the CAA (Care Area Assessment) review, key findings regarding a resident's status are documented, including the nature of the condition, complications and risk factors that affect the care planning decision, factors that must be considered in developing care plan interventions, and the need for referrals or evaluation by appropriate health professionals. The assessment must be accurate and correct. Section 3. A. iii. Revealed: The PPS (prospective payment system) assessment authorizes payment for the entire PPS stay, so the initial assessment needs to be correct and accurate.Review of the electronic medical record (EMR) revealed R127 was admitted to the facility with pertinent diagnoses including but was not limited to; metabolic encephalopathy, staphylococcal arthritis of the left knee, atherosclerosis of native arteries of the extremities with intermittent claudication in the right leg, kidney disease stage 2, chronic embolism, thrombosis of deep veins of the left lower extremity, and sacral pressure ulcer.Review of R127's admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11, which indicated R127 had moderate cognitive impairment. Section GG, Functional Status, revealed R127's admission performance- requires supervision for eating, oral hygiene, is dependent for toileting hygiene, dependent for shower/bath, dependent for dressing upper and lower body, and dependent for putting on and taking off footwear. She is dependent for bed mobility and positioning to the sitting position. Section H, Bowel and Bladder, R127 is always incontinent of bowel and bladder. Section M, Skin Conditions, Resident has a stage 3 pressure ulcer and 3 venous/arterial ulcers, all present on admission. Section O, Special Treatments, Procedures and Treatments, documented IV access as a midline catheter for antibiotic therapy. Review of R127's care plan dated 02/3/2026 indicated a problem of IV medications related to left septic knee. Enhanced barrier precautions (EBP) related to wounds and midline IV access in the left upper arm. IV antibiotic therapy for staphylococcal arthritis to the left knee, stop date 3/7/2026Review of the hospital records in the EMR revealed an order from the infectious disease physician for a peripheral percutaneous inserted central line catheter (PICC) line IV access to be placed for antibiotic therapy with weekly dressing changes and care of vascular access.Review of the Physician's Orders for R127 included but were not limited to: Wound care to sacral the vascular wound every Monday, Wednesday, and Friday. Vancomycin 1000mg (milligrams)/250ml (milliliters) daily IV. Ceftriaxone sodium solution 2 g (gram) two times daily IV. PICC (peripherally inserted central catheter) line placement order. PICC line care.Review of the Progress note from admission revealed: Effective Date: 2/3/2026 at 21:24 (09:24 PM), by Unit Manager Registered Nurse (RN) FF. Resident arrived to facility via ambulance on stretcher. Alert and orientated x (times) 3, periods of confusion noted. Pain 10/10 in the L (left) knee with any touch or movement. Vs stable and wnl. Skin on les tight and scaly, extremely dry. wounds noted to R (right) ankle and l buttock. Buttock wound unable to stage due to large loose brown slough being present. Incontinent of urine and bm (bowel movement). Loose brown bm, upon arrival, urine clear yellow with no odor. Abd (abdomen) soft nontender bs (bowel sounds) x 4. Lungs diminished, denies any dyspnea or cough. L knee swollen and tender. Currently to receive IV antibiotics but no IV access noted. Notified MD (medical doctor) on call Dr and orders received for PICC line placement. Called name of IV company and spoke with RN and nurse will be out to place line in the morning. New orders for Tramadol received for pain. Resident educated on bed controls and call light. Denies any questions. No emergency contact listed.Observation and interview on 02/10/2026 at 11:32 AM with R127 revealed the resident had an IV access with a gauze under a clear dressing with no date on the dressing. The access dressing was clean, dry, and intact. She stated she thought they changed it yesterday or something. She was confused as to the situation; she stated she was in the hospital.Interview on 02/11/2026 at 03:45 PM with the MDS (Minimum Data Set) coordinator revealed that R127 came in with no IV access, and the nurse on the floor called the pharmacy to have the IV access team come and insert an IV access for R127. The last company we used would only place midline IV access. She stated that she just assumed that that was what the resident had. She confirmed the PICC line order by the physician.Interview on 02/11/2026 at 04:15 PM with the MDS Coordinator revealed that the documentation had not been uploaded into the system yet, and she brought a copy of the PICC line insertion done on 02/4/2026 at 06:35 PM from name of IV company. Interview on 02/12/2026 at 11:23 AM with the Director of Nursing (DON) revealed that her expectations for the admission assessment were that the assessment be correct and accurate and that PICC and midline dressings be dated at time of change. Interview on 02/12/2026 at 03:25 PM with the Administrator confirmed that her expectations were that the nursing assessments be correct and accurate before they were sent to Medicare.

Based on document review, staff interviews, and review of the facility's policy, the facility failed to ensure their infection control and prevention program included infection control surveillance documentation for the year 2024. This failure placed all residents at risk of the spread of infections. Findings include: Review of the facility's policy titled Infection Surveillance dated 2/1/2024 revealed, .The purpose was to identify infections and to monitor adherence to recommended infection prevention and control practices in order to reduce infections and prevent the spread of infections . Review of R3's undated admission Record, located in the resident's electronic medical record (EMR) under the Profile tab revealed R3 was admitted on [DATE], readmitted on [DATE], and discharged on 3/2/2025. Review of R3's physician Orders located in the resident's EMR under the Orders tab revealed an order dated 12/24/2024 for Cipro [an antibiotic medication] 500 milligram (MG) tablet by mouth twice a day for a urinary tract infection (UTI) for two days to start on 12/25/2024. Review of R3's Medication Administration Record (MAR) dated December 2024 and located in the resident's EMR under the Orders tab revealed the resident was administered the Cipro antibiotic medication as ordered on 12/25/2024 and 12/26/2024. Review of R3's laboratory results dated [DATE] and provided by the facility revealed the culture and sensitivity confirmed the resident had a UTI. Review of the facility's Infection Control Surveillance manual provident by the facility revealed the only surveillance documentation was for the months of January 2025 through June 2025. The manual did not contain any surveillance information for the year 2024. During an interview on 6/18/2025 at 9:41 am, the Director of Nursing (DON) confirmed that the facility was unable to locate any Infection Control surveillance for 2024.

Based on observations, document review, and resident and staff interviews, the facility failed to ensure menus were prepared in advance for residents' diet orders. The facility failed to ensure menus indicated the serving size for each diet and whether each food item could be served for the diet. The failure placed all residents in the facility who receive oral meals from the kitchen at risk of nutritional problems and dissatisfaction with their meals. Findings include: During the entrance conference with the Administrator, Director of Nursing (DON), and Assistant DON (ADON), they were all asked for copies of all the weeks of the facility's menu cycle and for this week's menu the spread sheet with includes the extensions, portion size and whether the food item could be served, for each diet. During an interview on 6/17/2025 at 12:09 pm, the Administrator was again asked for the menus and meal extensions for this week's menu. She stated that she would get the menus. During an observation on 6/17/2025 at 12:06 pm of the lunch meal, all residents received beef stew, minced vegetables, a cup of ice cream, and a drink. During an interview on 6/17/2025 at 1:34 pm, the Administrator stated that on 6/17/2025 the dietary department oven caught fire, and dietary staff were unable to use the stove. She stated food was prepared using three induction burners and one hot plate that had two electric burners. During an interview on 6/17/2025 at 2:45 pm, the District Dietary Manager stated that the facility had been using the emergency menus since the fire. She provided the five weeks of menus and only provided the menu extensions for the week of the survey and only the lunch menu. Review of an undated Modified Diet document provided by the facility revealed the document did not identify what foods the residents would receive who were ordered diets of soft and bite sized diets, the Potassium (K+) restriction diets, the finger food diets or the reduced Sodium diets. Additionally, the document did not include what foods the residents would receive who were ordered no added salt (NAS) diets or the residents who were ordered renal (kidney) diets. The Regional Dietary Manager stated that the NAS and renal diets would receive the same meal as the regular diet. During an interview on 6/17/2025 at 2:45 pm, the District Dietary Manager stated that the facility had been using the emergency menus since the fire. She provided the five weeks of menus and only provided the menu extensions for the week of the survey (6/17/2025) and only the lunch menu. The District Dietary Manager also stated residents who were ordered the NAS and the renal diets would receive the same meal as the regular diet. Review of a document titled Three-day emergency menu from [Name of food service vendor] and provided by the facility revealed for lunch on 6/16/2025, the residents were to receive chicken and dumplings for lunch and sloppy joe sandwiches for supper. During an interview on 6/17/2025 at 9:58 am, Resident (R) 22 stated for the 6/16/2025 lunch meal, he received ravioli, a salad, and a sandwich. The resident stated he received soup for supper. During an interview on 6/17/2025 at 12:23 pm, R23 and R24 stated they received ravioli, a salad, and a sandwich for lunch on 6/16/2025. Observation and interview on 6/17/2025 at 3:11 pm in the dietary department revealed Dietary Aide (DA) 1 was preparing turkey or ham sandwiches using two slices of wheat bread. DA1 placed two pieces of meat of either turkey or ham on the bread until DA2 stated to use three pieces of meat. The Dietary Manager (DM) stated at this time, all residents would receive a ham or turkey sandwich, chips, and pasta salad for the dinner meal on this date. The DM stated the potato chips would be either plain chips or barbeque chips. Observation at this time revealed taped to the tray line was a handwritten document that indicated for the dinner meal tonight to serve turkey or ham sandwich, chips, and pasta salad. This handwritten document did not indicate how much turkey or ham to add to the sandwiches, how much pasta salad to serve, or how much chips to serve. This document did not indicate which diets would receive these food items and did not indicate the portion size for each diet. During an interview with the Registered Dietician (RD) on 6/18/2025 at 1:24 pm, that the RD stated the facility received all of their menus from (Name of food service vendor) and that (name of food service vendor) provided each meal for all the diets whether that food item was to be served and the portion size. The RD stated that she was aware of the stove's fire and that the facility purchased the three induction burners and one hot plate with two electric burners. The RD stated that (name of food service vendor) had a three day, a five day, and a seven-day emergency menu that indicated for each meal for all diets, whether the food item could be served and the portion size. The RD stated that (name of food service vendor) also provided the recipes and a shopping list of what to order. The RD stated that the DM only had to communicate with GFS and had the DM done that, their representative would have helped them during this emergency period. The Administrator was asked for the dietary policy regarding menus that will be prepared in advance and that the menus will indicate for each diet whether the food item would be served and the portion size. The policy was not provided before exit on 6/19/2025 at 5:15 pm.

Based on observations, staff interviews, and facility policy review, the facility failed to ensure resident rooms and dining rooms were in good repair creating a homelike environment for 13 of 49 resident rooms (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) and the main Dining Room. Findings include: Review of the facility's policy titled Resident Environmental Quality, dated 2/16/2024 indicated that the facility is to keep a safe, functional, sanitary, and comfortable environment for residents. Observation of the four units, 100, 200, 300 and 400, of the facility on 6/17/2025 at 9:50 am through 11:06 am revealed the following: 1. In the main dining room, the lower portion of the wall adjacent to the door to enter the dietary department had gauged and marred drywall. There were missing tiles from underneath the soda machine, snack machine and ice machine in this room. Behind these machines, there was dark discoloration around the baseboard. Two of the 20 tables in the dining room had the laminate worn off in places. The wall by the door to the hallway was marred with areas of gouged drywall. The dining room door to the hallway had areas of gauged wood that had splintered. 2. room [ROOM NUMBER] revealed the base of the wall next to the bathroom door and the drywall was crumbing. The window blind had broken slats. The wall next to bed A had streaks of black marks. 3. room [ROOM NUMBER]'s bathroom door had a half inch hole in the door. 4. room [ROOM NUMBER]'s wall behind the bed had been patched with white plaster; however, the wall had not been sanded and repainted to match the blue/gray paint. 5. room [ROOM NUMBER]'s window blind had missing slats and broken ends. Additionally, the wall behind Bed A had drywall that had separated at the seam exposing the area behind. 6. room [ROOM NUMBER]'s wall along the sink had marred and gauged dry wall. The window blind had broken and missing slats. 7. room [ROOM NUMBER]'s drywall next to the bathroom door had deteriorated at the base of the wall. 8. room [ROOM NUMBER]'s window blind had slats that were broken off. 9. room [ROOM NUMBER]'s window blind appeared to be loose from the top frame of the window causing the window blind to hang down and had slats that were either broken or bent. 10. room [ROOM NUMBER] had three tiles underneath the sink that had missing pieces of tile. 11. room [ROOM NUMBER]'s window blind had missing slats and slats that were broken off. 12. room [ROOM NUMBER]'s wall behind the bed closest to the door was marred and gauged behind the bed. 13. room [ROOM NUMBER]'s free-standing closet was missing a bottom drawer. The wall behind the bed was marred and gauged. Three tiles under the sink were missing pieces of tile. 14. room [ROOM NUMBER]'s base molding was missing from sections under the sink and around the corner next to the bathroom door. Observations and interviews on 6/19/2025 at 1:44 pm were completed with the facility's Maintenance Director and Regional Maintenance Director. The Regional Maintenance Director stated that he was new to the corporation and was not aware of the repair issues that was needed. The facility's Maintenance Director stated that he was aware of the issues. He confirmed that he had repaired the drywall with the white patching; however, he had not sanded the patching or repainted the wall.

Based on observations, staff interviews, and a review of the facility policy titled Date marking for food safety, the facility failed to ensure that food was properly labeled, stored, and prepared in a sanitary condition to prevent foodborne illness, failed to monitor and log daily temperature of refrigerator and freezer temperatures to ensure food was preserved per recommended guidelines, failed to monitor and log daily steam table temperatures, failed to monitor and log daily dishwasher temperatures, failed to test and log daily test sanitation solution in three-compartment sink. In addition, the facility failed to ensure the cleaning of appliances (stoves, ovens, fryers), countertops, food preparation areas, floor tiles, and ceilings. The deficient practice had the potential to affect 97 of 112 residents receiving an oral diet. Findings included: Review of the facility policy titled, Date marking for food safety, not dated, stated under Policy: The facility adheres to date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food. Under, Policy Explanation and Compliance Guidelines for Staffing: 2. The food shall be marked to indicate the date or by which the food shall be consumed or discarded. 3. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. 4. The marking system shall consist of a color-coded label, the day/date of opening, and the day/date the item must be consumed or discarded. 6. The head cook, or designee, shall be responsible for checking the refrigerator daily for food items that are expiring, and shall discard accordingly. 7. The Dietary Manager or designee shall spot-check refrigerators weekly for compliance and document accordingly. Corrective action shall be taken as needed. The tour of the kitchen on [DATE] started at 9:30 am with the Dietary Manager (DM). The following concerns were noted during the tour: 1. Observation of the walk-in cooler revealed a container of a brown liquid substance later identified as tea was not labeled or dated, a bag of shredded lettuce that was not dated, a jar of relish with the best used-by date of [DATE], a tub of dark brown items later identified by DM as cooked sausage patties not labeled or dated, and two opened bags of hot dog buns not dated. 2. Observation of one stand-up freezer revealed four containers of Yoplait yogurt with an expiration date of [DATE]. 3. No record of daily temperature logs for two stand-up freezers and a walk-in cooler 4. No record of daily temperature logs for the dishwasher since [DATE]. 5. No record of daily steam table temperatures 6. No records or logs of the testing of the sanitizing solution for the three-compartment sink since [DATE]. 7. The oven had a buildup of dark, thick, greasy substances that coated the outside walls and oven doors. 8. The fryer contained dark brownish almost black colored oil 9. The fryer was coated with the buildup of a dark brown greasy substance 10. The convection oven was covered with a white and light brown substance 11. Food preparation areas were soiled in food crumbs, dirt, and grime. 12. A wired rack was pushed against a wall that stored pots and pans. The wall was covered in a dark brownish-black substance, and the floor underneath the shelf was covered in food crumbs, dirt, and debris 13. A black substance was found in the ice machine once the surveyor wiped the inside frame 14. Sanitizing sink soiled with a white substance, debris containing food particles surrounding it. The shelving unit above is rusty, missing paint, and covered in a greasy soiled substance 15. Glassware crates stored on the floor covered in a brown substance 16. Kitchen floor covered with food particles, grime, and grout-stained 17. Handwashing sink lacked paper towels and a garbage can; a five-gallon bucket was observed under the sink covered in a brown substance with an insect glue trap on top. 18. The meat and vegetable sink is not labeled. A broken broom and handle under the meat and vegetable sink; under the sink, floor soiled, white pipes with a dark brown substance; the meat and vegetable sink counter on the left side contained a soiled rag, two different cleaning substances, and a container with a brown liquid substance. The surface was soiled with debris and particles. On the right side, the counter contained a hose, a steel sponge, a butcher knife a serrated knife, and a bottle of a cleaning agent. The surface was covered with debris containing food particles and dust. 19. A container of clean utensils was observed to be sitting on top of a counter in a food preparation area with paper receipts on top of them. 20. Three holes in different ceiling tiles along with a sticky fly trap hanging from the ceiling. 21. The hood vent located above the stove was coated in a dark brown substance 22. Dish washing machine covered in debris, and food particles both on top of the machine and underneath. Interview and rounding on [DATE] at 10:30 am with the Dietary Manager and Administrator confirmed there are no temperature logs for the low-temperature dishwasher machine for [DATE], [DATE], [DATE], or [DATE]. The DM confirmed there are no temperature logs for the walk-in cooler or two stand-up freezers for the last year. The DM confirmed there are no logs of the testing of the sanitizing solution for the 3-compartment sink for [DATE], [DATE], [DATE], or [DATE]. The DM also confirmed that steam table temperatures were not being done. The DM and administrator confirmed environmental concerns of the kitchen including the condition of the appliances (fryer, oven, and convection oven; soiled, covered in grime), dark colored grease in the fryer, floors (covered in debris, grime, food particles), ceiling (tiles with holes), food preparation counters covered in debris, grime, and grease, glassware storage crates resting on the floor and covered in a brown substance. The Administrator confirmed the hood needed cleaning. DM revealed that clean utensils should not be stored in the food preparation area and that paper receipts should not be covering clean utensils. DM revealed there is no cleaning list. The staff just communicate what needs to be cleaned. The DM revealed his staff do not use the two-compartment sink for meat or vegetables and that is why it is not labeled. He revealed his staff cannot read and if they needed to wash vegetables they would use a large bowl. The Administrator advised that the facility needs to deep clean the kitchen by pressure washing but it would need to be closed. She stated that she intends to close the kitchen and have the cook's grill outside so deep cleaning can be done and ceiling tiles can be replaced. The Administrator revealed everything in the kitchen needed to be scrubbed. DM and the Administrator confirmed there were four expired yogurts in the stand-up freezer a container of tea not labeled or dated, a bag of lettuce not dated, 2 opened bags of hot dog buns not dated, and a jar of relish expired in the walk-in cooler. The Administrator revealed that she expects the DM to manage the kitchen appropriately and that all food items were labeled and dated according to policy. An interview on [DATE] at 10:10 am with the day shift cook revealed he has been a cook for four months. He revealed he has never logged steam table temperatures because he never knew he was supposed to do it. He reported he wipes down appliances every day. An interview on [DATE] at 11:55 am with Dietary Aid EE revealed she has worked at the facility for two years. She revealed that she has received in-services on various topics such as food handling and handwashing but does not remember when the last time she had an in-service. She stated that if a resident complained of their food being cold, she would replace the food with another tray. She revealed that there used to be a cleaning list posted but there has not been one for a while. An interview on [DATE] at 4:25 pm with the only maintenance worker for the facility who has been employed for [AGE] years revealed he cleans the ice machine every 3 months, which is the manufacturer's recommendation. He stated the administrator keeps the logs and he last did them in May. Otherwise, no other cleaning/maintenance is completed. The surveyor was given a document titled ice machine cleaning and sanitation log dated [DATE]. The document had a time of 8:30 pm and a checkmark under the header cleaned and a checkmark under the header sanitized. Neither the maintenance worker nor the Administrator have the manufacturer's cleaning recommendations. An interview on [DATE] at 4:30 pm with the Administrator revealed if the ice machine is dirty, she expects that it be emptied, drained, and cleaned. She revealed having a dirty ice machine is a risk to residents and could make them ill. The surveyor asked for the manufacturer's cleaning recommendations and all policies on the sanitation of the ice machine.

Based on observations, record reviews, staff interviews, and a review of the facility policy titled, Menus the facility failed to ensure residents were served meals that were palatable, appetizing, and attractive. The deficient practice had the potential to affect 97 of 112 residents who consume an oral diet. Findings included: A review of the facility policy titled, Menus issued April 2024 revealed, Menus shall meet the nutritional needs of residents, be prepared in advance, and be followed Guidelines 6. Deviations from menus that have already been posted will be noted (including the reason for the substitution and/or deviation) in the kitchen and/or recorded in the record book used solely for recording such changes. The Dietitian should be made aware of these changes and have signed off on them on the Substitute log. 7. Menus will provide a variety of foods from the basic daily food groups and will indicate standard portions at each meal. An observation on 8/1/2024 at 6:30 pm revealed a meal that included meatless hotdog bun with a slice of cheese and 8 ounces of chicken noodle soup along with a side portion of lettuce. Interview on 8/1/2024 at 6:37 pm with Administrator and Regional Nurse Consultant verified the dinner meal was unacceptable and proceeded to the kitchen for the Dietary Manager CC to address and prepare a meal. Interview on 8/1/2024 at 6:41 pm with Dietary Manager (DM) CC revealed he was providing the menu of submarine bread with grilled cheese; however, he used a hot dog bun due to the kitchen running out of bread. He stated that the small portions of chicken noodle soup were the correct ounces according to his Registered Dietician. He stated the salads did not have meat because he did not have any deli meats in the cooler. An interview on 8/3/2024 at 1:45 pm with DM CC revealed the items purchased are limited since they have to use the upright freezer as well as the deep freezer. He stated there is a menu that has been developed by the registered dietitian but due to the menu constantly changing, he must constantly substitute the meals that are on the menu. He further stated the meal that is served is not on the menu that he handed me but what is served is always on the menu that is posted outside for the residents. Interview with the Registered Dietitian (RD) LL on 8/1/2024 at 12:55 pm revealed when asked about the menus, such as the alternate food or always available menu, she stated she has not checked to see if they were posted but they should be posted. Furthermore, RD LL revealed the alternate menu consists of comparable choices to the posted menu. She revealed the residents should know what the alternate meal choice is when they choose their meal for the day because the coordinator should tell them at the time when they are picking what they would like to eat for their meal. She further stated choices should be available for the residents even if they decide at the last minute, that they no longer want what they chose to eat earlier in the day. The RD LL revealed the menus were on a 30-day cycle, therefore they repeat monthly.

Based on observations, staff interviews, and a review of the facility policy titled, Disinfection of Bedpans and Urinals the facility failed to ensure a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by not labeling and properly storing bath basins, bed pans, and urinals in eight of 49 rooms (309, 313, 315,402, 404, 405, 407, and 408). Findings included: A review of the policy titled Disinfection of Bedpans and Urinals dated 2/12/2022, revealed policy: bedpans and urinals are handled in a manner to prevent the spread of infection through personal equipment. Under Policy Explanation and Compliance Guidelines: 1. Bedpans and urinals are for single resident use only. [NAME] with resident's name and discard upon discharge. 2. Store bedpans and urinals in the resident's bedside cabinet or drawer after placing them in a plastic bag or as per facility policy. Observations on 7/30/2024 at 11:19 am and 8/1/2024 at 11:15 am revealed eight basins and two bedpans in the bathroom located in room [ROOM NUMBER] on the 300 hall were not labeled or bagged. Observations on 7/30/2024 at 11:19 am and 8/1/2024 at 11:15 am revealed five basins and one bedpan in the bathroom located in room [ROOM NUMBER] on the 300 hall were not labeled or bagged. Observations on 7/30/2024 at 12:26 pm and 8/1/2024 at 11:15 am revealed one basin located in room [ROOM NUMBER] B on the 300 hall not labeled or bagged. Observations on 7/30/2024 at 2:00 pm, 7/31/2024 at 8:30 am, and 8/1/2024 at 11:50 am revealed bed pans, bath basins, and urinals not bagged or labeled in the following bathrooms: An observation in the bathroom shared between room [ROOM NUMBER] and room [ROOM NUMBER] revealed three bath basins not bagged or labeled. An observation in the bathroom shared between room [ROOM NUMBER] and room [ROOM NUMBER] revealed two bath basins, and three urinals, were not bagged or labeled. An observation in the bathroom of room [ROOM NUMBER] revealed four urinals on the floor, four urinals on the shelf above the toilet, and three bath basins on the shelf above the toilet all not bagged or labeled. During an interview and rounding on 8/1/2024 at 12:18 pm, CNA BB revealed after observing all rooms, CNA BB revealed all bath basins and urinals should be bagged and labeled. She stated all basins and urinals should be cleaned after each use and changed out every night. During an interview and rounding on 8/1/2024 at 12:23 pm, LPN AA confirmed all urinals and bath basins should be bagged and labeled. During an interview on 8/1/2024 at 3:30 pm, the Director of Nursing (DON) confirmed all urinals and bed pans should be bagged and labeled to eliminate the risk of cross-contamination. 49675

Based on observation, record review, staff interview, and review of the policy titled, Medication Administration the facility failed to ensure a medication error rate of less than five percent (5%) during medication administration for three of six Residents (R) (R44, R46, and R61). There were 35 opportunities observed resulting in three medication errors. The medication error rate was 8.57%. The facility census was 112. Findings included: Review of the policy titled, Medication Administration date implemented 2/12/2022, under the section, Policy Explanation, and Compliance Guidelines: Review MAR to identify medication to be administered and Compare medication source with MAR to verify resident name, medication name, form, dose, route and time. Record review for R44 revealed diagnoses of but not limited to Alzheimer's Disease, Retention of urine, and Essential Hypertension. Orders - cranberry 450 mg 1tab po daily for urinary tract health, order started 8/2/2024, Ferrous Sulfate Tablet 325 (65 Fe) mg. Care Plan - The resident is at risk of bladder incontinence related to abnormalities in gait, diagnosis of urinary retention, dementia, and Alzheimer's disease. During Medication Administration Observation on 7/31/2024 at 9:03 am R44 was given Cranberry 450mg - 1; the order is Cranberry 425mg. Record review for R46 revealed diagnoses of but not limited to Type 2 Diabetes Mellitus, Urinary incontinence, and a History of Cerebral Infarction. Orders - cranberry 450 mg 1 tab po daily for urinary tract health, the order started 8/2/2024. Care Plan - Resident has a risk for infection related to incontinence of bowel and bladder and a history of UTI. During Medication Administration Observation on 7/31/2024 at 11:36 am R46 was given Cranberry 450mg 1; Order was Cranberry 425mg. Record review for R61 revealed diagnoses of but not limited to Cerebral Infarction and Prediabetes. Orders - VIT Ds 125mcg 1 tab po daily for a supplement, order changed on 8/2/2024. Care Plan - The resident has DM II dx and should be monitored for hyperglycemia: increased thirst, appetite, pallor, and slurred speech. During Medication Administration Observation on 7/31/2024 at 12:02 pm R61 Vitamin D3 5000 IU 125mcg - 1 was given but the Order is Vitamin D3 25mcg. During an interview on 8/1/24 at 9:10 am, with Licensed Practical Nurse (LPN) QQ, the following medications were reviewed and confirmed as given with the nurse; R44 - given Cranberry 450mg but the order was for Cranberry 425mg, R46 - given Cranberry 450mg but the order was for Cranberry 425mg, R61 - given Vitamin D3 125mg but the order was for Vitamin D3 25mcg. During an interview on 8/1/2024 at 3:15 pm DON revealed she expects the staff to follow the orders of the physician. DON's role and responsibility is to make sure everything flows well between the departments and nursing. The DON monitors staff to make sure they are doing what needs to be done for the Residents through audits, being on the floor, and observation.

Based on interview, record review, and review of the facility policy titled Bed Hold Policy, the facility failed to provide bed hold information, in writing, at the time of transfer to the hospital, or within 24 hours, for one resident (R), R154 of three sampled residents. Findings included: A review of the facility policy titled Bed Hold Policy (2/12/22) stated at the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or the resident representative written notice which specifies the duration of the bed-hold policy and addresses information explaining the return of the resident to the next available bed. Bed Holds Notice Upon Transfer 1. Before a resident is transferred to the hospital or goes on therapeutic leave, the facility will provide the resident and/or the resident representative written information that specifies. (a). The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility. A review revealed that R157 has the following diagnoses but not limited to chronic diastolic (congestive) heart failure, renal disease, and Type 1Diabetes Mellitus. The Admission Minimum Data Set (MDS) dated [DATE] listed a Brief Interview Mental Status Score of 14 which indicates little to none cognitive impairment. A review of R157 's hospital record, census, and MDS record (discharge and entry tracking record) revealed that R157 was hospitalized on [DATE], 3/5/2024, 4/12/2024, 5/6/2024, and 6/20/2024. Although the facility provided written information about the bed hold policy on admission, a review of the clinical and financial records revealed no evidence that the resident and responsible party were provided with written information on bed hold at the time of transfer or within 24 hours for the hospitalization s. During an interview on 8/3/2024 at 2:42 pm, the Business Office Manager (BOM) confirmed not having any electronic medical record (EMR) or hard copy bed hold forms documents to show that bed hold information was provided for the hospitalization s. She stated that the business office manager and licensed nursing staff are responsible for ensuring the resident/family are provided with the form at the time of transfer to the hospital. The next step is to upload the hard copy into the resident's EMR record. During an interview on 8/3/2024 at 2:43 pm LPN reported licensed nurses' staff are responsible for giving the resident bed hold form at the time of transfer hospital. During an interview on 8/3/2024 at 3:40 pm, the Administrator reported that she expects the bed hold form to be given to the resident by the staff. She was unaware that the forms were not being given. The Administrator stated that she would provide a copy of the bed hold policy to the surveyor.

Based on observations, record reviews, staff interviews, and a review of the facility policy titled Menus, the facility failed to honor residents' rights to make choices related to meals and snacks. This had the potential to affect 108 of 112 residents who can consume meals. Findings included: A review of the facility policy titled Menus revealed that the residents' council would be included periodically in menu planning . and if a food group is missing from a resident's daily diet (e.g. dairy products) the resident will be provided with an alternate means of meeting the resident's nutritional needs (e.g. calcium supplementation or fortified non-dairy alternative). A review of the last six months of resident council meeting minutes revealed that residents voiced that they had not been receiving snacks and that residents were not notified if snacks were being put out or distributed; food was cold and not delivered promptly; and residents could not eat in the dining room because staff did not assist them into the dining area. During an observation on 7/31/2024 at 5:30 pm, no residents were in the dining room awaiting dinner. During an interview on 8/1/2024 at 1:03 pm, R66 stated all residents eat dinner in their room because they do not have the staff to assist them to the dining room. Trays come down the hall around 4:30-5:30 pm with no snacks afterward. The resident stated that the staff will go around and ask the residents about dinner preferences, but it is pointless because it is not what they will have for dinner. She further stated that the staff was not passing out snacks or letting the residents know snacks were available. The resident stated there used to be a store in the facility available for the residents to buy their own snacks but they closed it down. During an interview on 8/3/2024 at 1:45 pm, the Dietary manager (DM) stated there is a menu that has been developed but due to the menu constantly changing, he has to substitute the meal that is on the menu. He further stated to not pay attention to the menu he handed out because it is not correct. During an interview on 8/5/2024 at 12:20 pm, the Registered Dietitian (RD) HH revealed she understood that if a resident voiced a request, nursing would communicate that to the dietary department. She revealed the menu is on the wall and the alternatives she can't remember seeing on the wall. Furthermore, RD HH revealed she noticed that with the alternatives, there may be some gaps. She revealed she does not recall seeing menu cards on the resident's tray. Tray cards are the keyway to communicating alternatives. The tray card is the direct dietary communication and at the time of the tray card it will show preferences and allergies for the resident.

Based on observations, interviews, and record reviews the facility failed to identify and submit a Preadmission Screening/Resident Review (PASARR) Level 2 review for one of three residents (R) (R60). Findings included: A review of the PASRR Level I Assessment revealed that the Resident has a Primary Diagnosis of serious mental illness, developmental disability, or related condition. There is presenting evidence to indicate a suspected diagnosis for an undiagnosed condition as indicated by substantial functional limitations in three or more of the following areas of major life activities; self-care, understanding and use of language, learning, mobility, self-direction and capacity for independent living. Review of the Nurse Practitioner Psychiatric Consultant on 7/16/2024 included: Assessment and Plan: 1) Schizophrenia ICD-10 code F20.9- Stable on current regime. Continue with the plan of care as GDR is contraindicated due to the risk of worsening depression, psychosis, and/or anxiety. 2) Staff to continue to monitor mood and behavior and document accordingly. 3) Will continue to care with a follow-up in 12 weeks or sooner if needed. Time Spent: 16 minutes A review of the medical record revealed the physician's orders (e.g., psychoactive medications) - Ativan Tablet 0.5 mg give 1 tablet by mouth one time a day for Anxiety Lyrica Capsule 150 MG (Pregabalin) give 150 mg by mouth three times a day for tremors, Target Behavior: Anxiety, Agitation, Delusions, Hallucinations). Document # of behaviors each shift. Frequency= number of times behavior occurred and Intensity= how easily behavior is redirected. 0= did not occur, 1= easily redirected, 2= difficult to redirect, Care now to evaluate and treat. Diagnosis: schizophrenia, Cyanocobalamin Tablet 1000 MCG Give 1000 mcg by mouth one time a day related to Adult Failure to Thrive, Benztropine Mesylate Tablet 2 mg give 2 mg by mouth at bedtime related to Schizophrenia, Remeron Tablet 15 MG (Mirtazapine) give 15 mg by mouth at bedtime related to Adult Failure to Thrive, Zyprexa Tablet 15 mg give 15 mg by mouth at bedtime related to Schizophrenia. Medical Diagnosis - Hemiplegia and hemiparesis, Other Hereditary and Idiopathic Neuropathies, Lack of Coordination, Schizophrenia, Generalized Anxiety Disorder, Adult Failure to Thrive, Cerebral Infarction The care plan includes Self-care deficits related to the diagnosis of failure to thrive, neurological deficits, pain, and Mood; The resident has a mood problem diagnosis of Schizophrenia, Resident uses daily anti psychotropic medication for his diagnosis of Schizophrenia During an interview on 8/2/2024 at 12:55 pm NP RR; this Resident has not exhibited any adverse behaviors. During an interview on 8/3/2024 at 10:00 am with the Wound Care Nurse; he does not have any behaviors. During an interview on 8/3/2024 at 12:15 p.m. with LPN JJ, no behaviors were noted. He is independent and makes his needs known. During an interview on 8/3/2024 at 1:15 pm, the Social Service Director; PASARR Level 1 and 2 came with the Resident from the hospital. There is only a Level 1 for this Resident. He does see psych services. During an interview with the administrator on 8/3/2024 at 3:42 p.m., it was revealed that the Resident did not have a Level 2 completed by the hospital in 2021. The Social Service Director will complete Level 2 now. During an interview on 8/5/2024 at 2:50 pm with the Social Service Director; the process for PASARR is the hospital will initiate Levels 1 and 2. If the hospital does not initiate Level 2 the Social Service Director at the facility should initiate Level 2. She is not sure why Level 2 was not initiated for this Resident; she states he was admitted before her time.

Based on observations, interviews, record review, and review of the facility policy titled Medication Storage, the facility failed to assess four of 65 sampled residents (R) (R56, R44, R41, and R21) for the ability to self-administer medications before leaving medications at the bedside. Findings included: A review of the policy titled, Medication Storage dated 2/12/2022 revealed that the facility will ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. 1. A review of the electronic medical record (EMR) for R56 revealed that the resident presented with diagnoses of lupus erythematosus, asthma, Muscle weakness (generalized), cognitive-communication deficit, adult failure to thrive, and major depressive disorder. A review of the current physicians orders included Trelegy Ellipta Inhalation Aerosol Powder Breath Activated 100-62.5-25 mcg (microgram) (Fluticasone Umeclidinium-Vilanterol), Albuterol Sulfate Inhalation Aerosol Solution 108 (90 Base) mcg (Albuterol Sulfate), Incentive Spirometry, Claritin Tablet 10 MG (milligram) (Loratadine), Prednisone Tablet 5 MG. There was no assessment for self-administration of medications documented in the EMR. During an observation on 7/30/2024 at 10:00 am, the following medications were observed at R56's bedside: Zinc Oxide Ointment and Trelegy Ellipta Inhaler Aerosol. During an observation of R56's room on 7/30/2024 at 1:15 pm, a tube of Bacitracin Zinc was seen on the counter in the middle of the room. During an interview on 7/30/2024 at 1:30 pm, the DON and the Infection Control Nurse confirmed Zinc Oxide Ointment and Trelegy Ellipta Inhaler Aerosol were at R56's bedside. The DON stated there should not be medications at the bedside. During this observation, additional medications were found at the bedside: Dulcolax, Fluticasone Nasal Spray, and rubbing alcohol. DON stated she did not know who the medications belonged to. During an interview on 7/30/2024 at 2:15 pm, Licensed Practical Nurse (LPN) QQ confirmed that R56 was ordered the medications as needed (PRN) but stated that she was not sure who left the medication at the bedside. 2. A review of the EMR for R44 revealed that the resident had orders for Hydrocortisone External Lotion 2.5 % Hydrocortisone (Topical), Remeron Tablet 15 MG (Mirtazapine), Ferrous Sulfate Tablet 325 mg, Ergocalciferol Capsule 50000 Unit; that the resident presented with diagnoses of Alzheimer's Disease, adjustment disorder with mixed anxiety and depressed mood, pruritus, and atopic dermatitis. During an observation on 7/30/2024 at 2:00 pm, R44 was sitting on the side. The following medication was observed on the bedside table: Triamcinolone 0.1% cream. The resident stated that she uses this cream mostly at night for itching. During an interview on 7/30/2024 at 2:15 pm, LPN QQ confirmed that the medication was at the bedside in the resident's room and stated that the triamcinolone acetonide was ordered for R44 earlier in the year and discontinued on 6/17/2024. She pointed out the discontinued date located on the medication. She does not know who left the medication in R44's room. 3. A review of R41's EMR revealed diagnoses that included major depressive disorder, single episode, unspecified upper limb, unspecified glaucoma, insomnia, unspecified, muscle weakness, type 2 diabetes mellitus without complications, and hoarding disorder. A review of R41's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident presented with a Brief Interview for Mental Status (BIMS) score of 15, indicating that the resident was cognitively intact. A review of R41 orders revealed she has orders for Flonase suspension 50 mcg (fluticasone propionate) two sprays in both nostrils one time a day for postnasal drip/sinus/allergy and refresh ophthalmic solution 1.4-0.6 % (polyvinyl alcohol-povidone) instill one drop in both eyes twice (BID) a day for dry eyes, however, there is no order for self-administration in the chart Observation on 7/30/2024 at 11:19 am revealed fluticasone propionate nasal spray, a 24-hour nasal spray; tear eye drops; and medication in a small plastic cup on R41's bedside table. During an interview on 7/30/2024 at 11:35 am, LPN II revealed she gave R41 her morning medication but did not wait until she swallowed the medication. LPN II confirmed the medication in the plastic cup on R41's bedside table was her morning medication given to her at 8:40 am. LPN II also confirmed that R41 should not have nasal spray or tear eye drops at her bedside. During an interview on 8/1/2024 at 9:15 am, LPN II revealed she has been working at the facility since 2006 and that her hours are from 7:00 am to 3:00 pm. LPN II stated staff complete rounds daily to ensure there is no medication at the bedside. LPN II stated that R41 does not have an order for self-administration. During an interview on 8/2/2024 at 10:16 am, R41 revealed that the reason the nasal and eye medication was in the room was because she could get it when she needed it. 4. A review of R21 EMR revealed diagnoses that included hypertension, gastritis, chronic right heart failure, and obstructive sleep apnea. A review of R21 MDS dated [DATE] revealed, Section C-Cognitive Patterns: Brief Interview for Mental Status (BIMS) of 15; Section GG-indicated resident having no impairment. A review of R21's orders revealed she had an order for diclofenac sodium external Gel 1 %, however, there is no order in the chart for self-administration. During an observation on 7/31/2024 at 12:16 pm, medication (diclofenac sodium) was observed on R21's bedside table. During an interview on 8/1/2024 at 9:15 am, LPN II stated that R21 does not have an order for self-administration and confirmed that the medication (confirmed diclofenac sodium) was on R21's bedside table. During an interview on 8/1/2024 at 3:26 pm, the DON revealed she has been working at the facility since June 2023. She confirmed that prescribed medications should not be left with any resident and that no residents in the facility had self-administration orders. The DON stated all nurses are expected to visually see all residents take their medication before leaving the room.

Based on observations, record review, interviews, and facility policy review, it was determined that the facility failed to provide care and treatment to promote healing of pressure ulcers and prevent new ulcers from developing for one of three sampled residents (R) (R#101) reviewed for pressure ulcers. Specifically, the facility failed to complete weekly skin assessments to allow for identification and treatment of new areas of skin breakdown; failed to complete weekly measurements and assessments of existing pressure ulcers to track healing progress or determine if deterioration had occurred; and failed to complete pressure ulcer treatments per the physician's orders to promote the healing and prevent potential infection for R#101. The failures resulted in R#101's pressure ulcer deteriorating from a stage 2 wound to an unstageable wound. The facility identified nine residents who had pressure ulcers. Findings included: A review of a facility policy titled, Skin Assessment, dated as implemented 2/1/22, revealed, A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury. A review of a facility policy titled, Pressure Injury Prevention and Management, dated as implemented 2/1/22, indicated, This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. The policy also indicated, Assessments of pressure injuries will be performed by a licensed nurse and documented on the (fill in blank for designated form). The staging of pressure injuries will be clearly identified to ensure correct coding on the MDS [Minimum Data Set]. Additionally, the policy specified, Evidence based treatments in accordance with current standards of practice will be provided for all residents who have a pressure injury present. A review of an Admission Record revealed R#101 had diagnoses that included hypertension, diabetes, chronic kidney disease-stage 3, and chronic deep vein thrombosis (a condition in which blood clots form in veins located deep inside the body, usually in the thigh or lower legs). A review of Weekly Skin Assessments, completed by a licensed nurse, revealed skin assessments were completed weekly from 3/25/21 through 7/21/21. The results of the 7/21/21 weekly skin assessment for R#101 indicated the resident had no pressure injuries but had a skin tear to the left lower leg. The next weekly skin assessment was dated as completed four months later, on 11/23/21. This skin assessment indicated R#101 had a stage 2 pressure injury to the left buttock measuring 1.5 centimeters (cm) long by (x) 1.7 cm wide x 0.1 cm deep. The nurse documented the date of onset for the pressure injury was 11/23/21. Review of a Progress Note, dated 11/23/21 by the treatment nurse, revealed staff had requested she assess R#101. The nurse documented the resident had a shear injury involving superficial skin. She noted there was no drainage or signs of infection. The note indicated the treatment nurse cleansed the wound and applied a protective dressing. A review of the November 2021 Treatment Administration Record (TAR) revealed that on 11/26/21, a treatment was added for R#101's left buttock wound to be washed with soap and water, patted dry, and covered with a foam dressing as needed every Monday and Friday. The treatments were signed as completed on Friday, 11/26/21 and Monday, 11/29/21. A review of a quarterly MDS, dated [DATE], revealed R#101 had a Brief Interview for Mental Status (BIMS) score of three, indicating the resident was severely cognitively impaired. The MDS indicated the resident had no behaviors, including rejection of care. According to the MDS, R#101 required extensive to total assistance for all activities of daily living and had one stage 2 pressure injury that was present on admission. A review of a weekly skin assessment list, completed by licensed nurses, revealed weekly skin assessments for R#101 were completed on 12/2/21, 12/7/21, 12/19/21, and 12/27/21. Review of the 12/2/21 Weekly Skin Assessment revealed the pressure wound to the resident's left buttock measured 1.5 x 1.5 x 0.1 cm and was a stage 2 wound. Review of the 12/7/21 Weekly Skin Assessment for R#101 revealed the location of the resident's pressure wound was now identified as the sacrum. The wound measured 1.5 x 1 x 0.1 cm and was a stage 2. A review of a Progress Note, dated 12/7/21, revealed the resident was assessed by a nurse following a staff request. The note indicated R#101 had a wound on the sacrum with a red skin base and peri-skin alteration with suspected deep tissue injury to the peri-skin. The nurse indicated the Nurse Practitioner (NP) was made aware and a new order was obtained for a foam dressing change weekly. A review of Progress Notes revealed on 12/7/21, the NP's assessment and plan for R#101 indicated there was a sacral wound and to continue to monitor. The note further indicated that treatments were in progress and to encourage the resident to turn and reposition. Review of a Progress Note, dated 12/19/22 by the treatment nurse, revealed a draw sheet was utilized for R#101. The note indicated other interventions included a wheelchair cushion; the head of the bed maintained at less than or equal to 30 degrees elevation, with the knees elevated; and turning and repositioning at least every two hours while in bed. The treatment nurse documented a semi-occlusive dressing was applied over the ulcer, affected by incontinence. A review of a skin assessment completed by the treatment nurse and signed on 12/22/21 indicated R#101 had a stage 2 pressure area to the sacrum measuring 1.5 cm x 1 cm x 0.1 cm. The date of onset was entered as 12/7/21, and the treatment was listed as a foam dressing. On the same day (12/22/21) the treatment nurse had completed another assessment of R#101's sacral pressure ulcer and documented the measurements as 1 cm x 0.8 cm x 0 cm and identified the wound as a stage 2. A review of the 12/27/21 weekly skin assessment completed by a licensed nurse for R#101 revealed the pressure injury was identified as a sacral pressure injury measuring 0.2 cm x 0.2 cm with the stage identified as not applicable (N/A). The treatment nurse completed a weekly skin assessment as well and entered the same information, with N/A for the stage. The treatment nurse identified the treatment for the sacral wound as skin barrier. A review of a Progress Note, dated 12/27/21 and written by the treatment nurse, indicated R#101 continued to receive skin care for a stage 2 wound to the sacrum. The pressure ulcer was described as pale pink epithelial tissue with no drainage or signs of infection. There were no more assessments of the sacral pressure ulcer found in R#101's medical record. A review of R#101's December 2021 TAR indicated multiple treatments. These treatments included: - A treatment dated as initiated 11/26/21 and discontinued 12/3/21 indicated to wash the left buttock with soap and water and pat dry, then apply a foam dressing. The dressing was to be changed as needed every Monday and Friday. The treatment was signed as completed on 12/3/21. - A treatment dated as initiated 12/3/21 and discontinued 12/7/21 indicated to wash the left buttock with soap and water and pat dry, then apply skin barrier every shift for a skin alteration. Seven scheduled treatments were signed as completed and four scheduled treatments were not signed as completed. - A treatment dated as initiated on 12/14/21 and discontinued 12/27/21 indicated to clean the sacral wound with saline, pat dry, and cover with a foam dressing, which was to be changed weekly and as needed every Tuesday on day shift. This treatment was signed as completed on Tuesday 12/14/21 and Tuesday 12/21/21. - A treatment dated as initiated 12/27/21 and discontinued 1/15/22 indicated to clean the sacrum with soap and water, pat dry, and apply skin barrier protection every shift. The area was to be left open to air. Four of the scheduled treatments were not signed as completed. The review of the January 2022 TAR for R#101 indicated the following treatments for the sacral wound: - A treatment dated as initiated 12/27/21 and discontinued 1/15/21 indicated to wash the sacrum with soap and water, pat dry, and apply skin barrier protection every shift. The area was then to be left open to air. Fourteen of the 43 opportunities to provide this treatment were not signed as completed for the resident. - A treatment dated as initiated 1/15/22 and discontinued 2/4/22 indicated to cleanse the sacrum with normal saline, pat dry, and apply skin prep and a dry dressing every shift until healed. Fourteen of the 47 opportunities to provide this treatment for R#101 were not signed as completed. Review of a nurse's Progress Note, dated 1/15/22, indicated the dressing to R#101's sacrum was changed. The nurse documented the area was a dime-sized opening. There were no sacral wound assessments found in R#101's chart that indicated if the sacral wound improved or declined during the month of January 2022. A review of a Registered Dietitian's (RD) Progress Note, dated 2/7/22, indicated the resident received a liquid supplement twice daily that was well accepted most of the time. The RD noted R#101's skin was intact, with no skin breakdown, and the resident was off the wound care caseload. Review of the February 2022 TAR for R#101 indicated the sacral wound was cleansed with normal saline and a skin prep was applied. This was to continue every shift until the wound was healed. The treatment started on 1/15/22 and ended on 2/4/22. Ten treatment opportunities were identified for R#101, with only five of the treatments signed as completed. No further treatments were documented for R #101's sacral pressure ulcer. There were no treatment notes that included measurements or descriptions of the resident's wound. A review of the weekly skin assessment listing indicated that after 12/27/21, the next weekly skin assessment for R#101 was completed three months later, on 3/29/22. Review of the results of the 3/29/22 skin assessment, completed by a licensed nurse, revealed R#101 had a stage 2 left buttock pressure ulcer measuring 1.5 cm x 1.5 cm x 0 cm. Additionally, the assessment indicated the resident had a stage 2 right buttock pressure ulcer measuring 2 cm x 2 cm x 0 cm. The assessment indicated R#101 had a wound on the right heel measuring 3 cm x 3 cm x 0 cm with the stage identified as N/A. This was not identified as a pressure wound. The onset date for the wounds was indicated to be 3/29/22. The description of the right heel wound was black tissue (indicating the tissue was dead) with no granulation (healthy) tissue. The treatment was to apply Betadine, a dry dressing, and kerlix (a gauze product that can be wrapped around an extremity to secure a dressing in place). Review of a Progress Note, dated 3/29/22 and written by a licensed nurse, indicated R#101 had two new wounds. The nurse noted R#101 had superficial wounds to the right and left buttock and a blister to the right heel. There were no further weekly skin assessments completed by the nurses for R#101 after 3/29/22. Review of the March 2022 TAR for R#101 indicated that on 3/30/22, treatments were initiated for R#101's right heel blister and right and left buttock wounds. The treatments were documented as completed on 3/30/22 and 3/31/22. Review of the RD's quarterly assessment, dated 4/5/22, indicated there were no wounds documented for R#101. Review of a Skin/Wound progress note, dated 4/11/22, revealed the resident's representative (RR) was notified the wound nurse would be assessing R#101. The RR requested a wedge for positioning and boots for the resident's feet. The nurse indicated the boots had already been ordered. A review of a consultant wound care note, dated 4/25/22, indicated R#101 had two pressure injuries. The first wound was a stage 2 on the buttock. The NP did not identify which buttock. Measurements were documented as 1.5 cm x 0.9 cm x 0.1 cm, with no drainage or odor. The wound was identified as improving. Wound #2 was identified as an unstageable pressure injury on the right heel, measuring 4 cm x 4 cm with no measurable depth. The NP indicated the wound bed was 76%-100% eschar. The NP indicated a recommendation to off-load the resident's heels per facility protocol. The NP also indicated under, Lower Extremity Assessment that there was no off-loading device in use for the resident's right heel and that there had been poor wound progression. A review of the April 2022 TAR for R#101 indicated the following treatments: - A treatment dated as initiated 3/30/22 and discontinued 4/6/22 indicated to cleanse the resident's right and left buttock wounds with normal saline and apply betadine and a dry dressing daily. Out of six opportunities to provide the treatment for R#101, only three were signed as completed. - A treatment dated as initiated 3/30/22 and discontinued 6/7/22 indicated to apply Betadine and kerlix daily to the resident's right heel blister. Of 30 opportunities to complete the heel treatment for R#101 in April 2022, five were not signed as completed. - A treatment dated as initiated 4/18/22 and discontinued 5/29/22 indicated to cleanse the resident's right and left buttock wounds with normal saline and apply hydrocolloid (an occlusive dressing) every three days. However, the TAR also indicated this treatment was to be completed on Mondays and Fridays. The treatments were signed as completed on Mondays and Fridays but not every three days. A review of a consultant wound care note, dated 5/3/22, indicated the right buttock wound had resolved. There was another right buttock pressure ulcer identified that was a stage 2, measuring 2.5 cm x 1 cm x 0.2 cm. A left buttock, stage 2 pressure ulcer measured 1.2 cm x 3 cm x 0.3 cm. The NP documented there was a moderate amount of drainage from the left buttock wound with no odor. The NP recommended a gel treatment that provided nutrients for new tissue growth and a calcium alginate (an absorbent fiber) treatment three times a week. The right heel wound for R#101 continued to be unstageable and measured 4.5 cm x 4.5 cm. There was no drainage or odor noted. The NP documented the recommendation of an off-loading device for the lower extremities and again noted there were no devices for off-loading in place. Further review of notes from the consultant wound care NP revealed the NP saw R#101 on 5/9/2022 and 5/16/22 and noted little change in the wound status. For both visits, the NP recommended offloading of the lower extremities and noted there were no off-loading devices in use for R#101's feet. A review of RD nutrition progress notes dated 5/9/22 indicated the resident had stage 2 pressure injuries to the right and left buttock and an unstageable wound to the right heel that had improved. The RD requested the current diet be continued and recommended encouraging intake and protein rich foods, continuing the frozen nutritional supplement, monitoring the resident's intake, diet status, and tolerance, and adding liquid protein 30 milliliters (ml) per day to help aid in wound healing. A review of the May 2022 Medication Administration Record (MAR) for R#101 revealed the RD's 5/9/22 recommendation for added protein for wound healing was not initiated. Review of a consultant wound care note, dated 6/6/22, revealed the right heel remained unstageable, with measurements of 3.5 cm x 6 cm. The wound was described as 76% to 100% eschar. A sacral wound was identified as stage 3, and no left or right buttock wounds were noted. The note indicated there was poor progression of the wounds. The NP again recommended off-loading of R#101's lower extremities and again noted there were no off-loading devices in place. Review of a RD nutrition progress note dated 6/13/22 indicated the RD again recommended adding 30 ml of liquid protein for R#101 to aid in wound healing. A review of a consultant wound care NP note, dated 6/13/22, indicated Resident #101's right heel remained unstageable and measured 4.2 cm x 5 cm with no drainage or odor. The NP noted there had been no change in the wound progression. The sacral wound was measured as 11 cm x 4 cm x 0.2 cm, with a moderate amount of drainage and a strong odor. The NP stated the peri-wound exhibited maceration (a term used to describe the softening and breaking down of skin because of prolonged exposure to moisture). The NP again noted there were no off-loading devices being used for R#101's feet. A review of Progress Notes, dated 6/14/22, indicated R#101's RR was notified to get consent for debridement (the surgical removal of non-viable tissue) of the sacral wound. Later that day, the progress notes indicated a midline intravenous catheter was placed in R#101's left upper arm. A review of Progress Notes, dated 6/14/22 and written by the facility NP, revealed R#101's sacral wound assessment was performed with the assistance of the treatment nurse. The NP indicated a strong odor was noted from the wound, along with necrotic tissue around the wound bed with a foul odor. The NP noted there was yellowish-green drainage oozing from the center of the wound bed and added that the wound NP had scheduled debridement for the following week. The NP indicated wound infection prophylaxis would be initiated, consisting of intravenous (IV) cefepime (an antibiotic) and Flagyl (an antibiotic) for 10 days. A review of the June 2022 MAR for R#101 revealed the liquid protein was added on 6/14/22. Review of Progress Notes, dated 6/20/22 by the facility NP, revealed R#101 had a wound infection/deterioration and was receiving IV hydration and continued antibiotic therapy. The NP noted the family was aware of R#101's health decline. A review of Progress Notes, dated 6/22/22, indicated R#101 was sent to the hospital per the RR's request. Licensed Practical Nurse (LPN) #1 was interviewed on 12/14/22 at 1:46 p.m. The LPN stated that when a pressure injury was found, the nurse was expected to start a treatment plan. She stated the facility had no wound care protocols in place, so the physician had to be called to order the needed treatments. The LPN stated skin checks for residents were completed weekly, either by the nurse on the hall or the treatment nurse. She stated that when a resident was due to have their skin checked, the information popped up on the electronic MAR. The LPN stated the danger of missing skin checks would be unrecognized skin breakdown. The LPN stated if an entry on the MAR or TAR lacked initials, that meant the treatment was not done or the medication was not given. The LPN stated she remembered R#101, adding the resident had been on hospice but the family dropped hospice due to wanting more aggressive treatment for the resident. During a telephone interview on 12/14/22 at 4:08 p.m., the Hospice Registered Nurse (HRN) stated R#101 was discharged from hospice sometime in late 2021. The HRN stated that right before R#101 was discharged from hospice, the resident had reddened skin on the buttocks but no skin breakdown. During an interview on 12/15/22 at 9:00 a.m., the Administrator stated that the treatment nurse who cared for R#101 had not worked in the building for over a year and indicated she had no contact number for the nurse. A telephone interview with the consultant wound nurse practitioner (WNP) was conducted on 12/15/22 at 9:21 a.m. The WNP stated she was only able to remember R#101's sacral wound. The WNP stated R#101 had limited mobility due to their size and had been difficult to position side to side. She stated she remembered the facility using a wedge to help position the resident, but the resident's feet were not off-loaded. She stated that even when staff used a pillow, R#101's heels were not off-loaded and just sat on the pillow. The WNP added that the initial sacral stage 2 wound could have been avoided, but the progressive decline of the sacral wound could not have been prevented due to the resident's poor intake and overall decline. The WNP stated missing treatments to the sacral wound did not help the wound healing. A telephone interview was conducted with the hospice case manager (HCM) on 12/15/22 at 9:45 a.m. The HCM had been R#101's first hospice nurse. She stated that during the time she had seen R#101, the resident had no injuries related to pressure. An interview was conducted with the facility NP on 12/15/22 at 10:08 a.m. The NP stated she consulted for all wounds, in addition to having the WNP see the residents. She stated staff made her aware of the wounds and she also reviewed wound care notes. The NP stated that when she was informed of R#101's sacral wound, the wound was already a stage 3. The NP stated she had a difficult conversation with R#101's family about the wound and the need for the wound care specialist to look at the resident's sacrum. The NP stated any missed treatments would increase the deterioration of the wound, especially in the condition R#101 had been in, adding the resident had co-morbidities that included diabetes, hypertension, recovering from COVID-19, blood clots in the resident's bilateral legs, seizures, hypothyroidism, and dementia. The NP reviewed the 4/25/22 WNP note for R#101 and stated the nursing assistants should have seen some type of impairment prior to R#101's heel wound becoming an unstageable wound. The NP stated she would have expected the staff to assess and measure the wounds weekly. The NP reviewed the list of skin assessments completed by the licensed staff and stated the nurses had done a poor job with skin assessments. The NP stated that during the months when no skin assessments were completed, R#101's wounds may have become worse with no one noticing. The RD was interviewed on 12/15/22 at 10:52 a.m. The RD stated she saw high-risk residents with weight loss or wounds monthly. The RD stated she usually was in the facility on Monday and expected recommendations to be implemented at the latest by Friday. She reviewed the recommendations for a frozen nutritional supplement and the liquid protein she had made and saw the delay in implementation. The RD added that between March 2022 and April 2022, and in May 2022 and June 2022, there had been several turnovers in the facility's Director of Nursing (DON). She stated one DON refused to initiate the recommendations, and it was left for other staff to complete. The RD stated the negative outcomes in delaying dietary recommendations for R#101 were delayed wound healing and weight loss. LPN#5 was interviewed on 12/15/22 at 11:41 a.m. LPN #5 had cared for R#101 during the resident's stay. The LPN stated R#101 had a pressure ulcer on the sacrum but she was unsure of any other skin breakdown. The LPN stated that when she first saw R#101's sacral pressure injury, it was considered a stage 2 and was not bad. She added the resident was followed by the wound consultant. LPN#5 stated interventions in place to help heal the sacral pressure injury and prevent more wounds included liquid supplements, vitamins, and frequent turning when in bed. The LPN stated R#101's feet were elevated on pillows. LPN#5 stated if a treatment was not signed as completed, it meant the nurse either forgot to sign the treatment or failed to do the treatment. She added if wound care treatments were not completed then the wound would get worse. The nurse stated weekly assessments and measuring wounds was the responsibility of the treatment nurse. Weekly skin checks for residents were the responsibility of the treatment nurse and the nurse on the halls. LPN#5 stated if skin checks were not done weekly, something could be missed. The nurse stated skin assessments for the residents were done on bath days and popped up on the MAR when they were due. The nurse reviewed the weekly skin checks and stated she was unaware there had been that many skin checks missed and could not explain why there had been a period of four months without skin checks and another period of three months without skin checks. She could not explain why treatments were missed. She indicated that at the time of discharge, R#101's wound was worse, and the family wanted the resident transferred to the hospital. CNA#13 was interviewed on 12/15/22 at 12:22 p.m. CNA#13 stated she was familiar with R#101. The CNA stated she remembered R#101 had a dressing on the buttock and had a bandage on the heels, but she had not seen the resident's wounds. The CNA stated R#101's position was changed every two hours, the heels were up on a pillow, and pillows were used for positioning. The DON was interviewed on 12/15/22 at 2:50 p.m. The DON stated the treatment nurse who had been responsible for R#101 left before she had arrived on 7/14/22. The DON stated if a treatment had no signature of completion, that treatment had to be counted as omitted since one could not be sure the treatment had been completed. The DON reviewed the December 2021 and January 2022 treatment sheets and stated with that many missed treatments, there had to be a negative effect on R#101's wounds. The DON stated her expectation was for all residents' skin to be inspected at least weekly and added if a resident failed to have a weekly skin check, then wounds could develop without anyone's knowledge. The DON reviewed the skin checks for R#101 and stated going three or four months without skin checks could result in wounds not being found until they were unstageable wounds. The DON stated she was unaware there were issues with skin checks being completed. The DON stated she expected wounds to be assessed weekly to include measurements and the condition of the wound. The DON stated she was unaware skin assessments, to include descriptions and measurements, were not being done weekly. The DON stated she thought no skin inspections between December 2021 and March 2022 had something to do with R#101's right heel wound not being found until it was an unstageable pressure injury. The DON stated it was the responsibility of the treatment nurse to teach staff how to offload and teach other preventative measures. The Administrator was interviewed on 12/14/22 at 4:20 p.m. The Administrator stated the treatment nurse was expected to provide treatments the way they were ordered, make rounds with the wound nurse, and communicate any wound changes to the DON. The Administrator stated treatments and weekly measurements of the wounds was the responsibility of the treatment nurse, and in her absence, the DON. The Administrator stated she expected skin checks to occur as scheduled. The Administrator stated any blank on the treatment sheet meant the treatment was not done. The Administrator stated if treatments were not completed as ordered, wounds could deteriorate, and omitted skin checks would delay identification of new areas of breakdown. The Administrator stated the negative outcome of not measuring wounds would be no knowledge of the progression of the wound. The Administrator stated she had changed DONs three times since November 2021, and there may have been problems with implementation of dietary recommendations. The Administrator stated she had expected the DON at the time R#101 was in the facility to make sure the assessments, skin checks, and treatments had been completed and added she was not aware of the problems with skin checks, wound assessments, and completion of treatments.

Based on observations, record review and interview, it was determined that the facility failed to turn and reposition as care planned for the prevention of pressure ulcers for one resident (R) (R#92) which resulted in actual harm to this resident who developed a facility acquired pressure ulcer. The sample size was 20 residents. Findings include: Review of the clinical record for R#92 revealed an admission date of [DATE] to the facility with the following [DIAGNOSES REDACTED]. Nursing Admission assessment dated [DATE] documented R#92 alert and oriented to person and place. The resident was admitted to the facility with one stage 3 pressure ulcer to coccyx. Review of the interim care plan dated 7/13/17 documented R#92 has impaired skin integrity or at risk for impaired skin: unstageable to the sacrum. Interventions included to perform body audit upon admission and as needed; and reposition/assist with turning every 2-3 hours and as needed. Observations, by the surveyor, on 7/19/17 at 8:30 a.m., 9:32 a.m., 10:15 a.m., and 12:10 p.m. revealed R#92 laying directly on his back with the head of bed elevated. Observation on 7/19/17 at 1:15 p.m. revealed R#92 laying directly on his back with the head of bed elevated. During an interview at this time, resident stated that no one has turned him today. Observation on 7/19/17 at 2:15 p.m., R#92 laying directly on his back with head of bed elevated. Resident's lunch tray was untouched on the bedside table. During an interview at this time with R#92 revealed that the resident was pretty hungry and that no one has turned him since the last interview with the resident. Continuous observation, by the surveyor, on 7/19/17 from 2:40 p.m. to 3:35 p.m., revealed that R#92 remained laying directly on his back with head of bed elevated in addition to observation from 2:40 p.m. to 2:53 p.m. of CNA FF feeding the resident and reports that he ate 100%. Observation of Licensed Practical Nurse (LPN) CC entered R#92's room on 7/19/17 at 3:15 p.m. stating to the resident that she is checking on him. R#92 responded that his butt hurts. LPN CC administered [MEDICATION NAME] 50 milligrams by mouth for pain without changing the resident's position or checking for the cause of the resident's pain. Observation on 7/19/17 at 3:20 p.m., Assistant Director of Nursing (ADON) observed going into resident's room although the resident remained in the same position. Observation on 7/19/17 from 3:25 p.m. to 3:35 p.m., revealed multiple other staff members going into R#92's room without repositioning the resident. Observation on 7/20/17 at 7:40 a.m. revealed R#92 laying directly on his back with head of bed elevated. Wedge pillow laying on the empty bed next to the resident's bed. When asked how he was doing, resident requested the foam pad be placed behind his back. LPN AA entered the resident's room at this time. Interview with the Director of Nursing (DON) on 7/20/17 at 3:50 p.m., revealed that her expectation is for staff to turn and reposition residents with pressure ulcers in order to keep them off the wound area. Specifically, she revealed that staff should know to turn R#92 alternating right and left side every two hours. Cross-refer to F314.

Based on observation, interview, and record review, the facility failed to prevent the development of one clinically avoidable pressure ulcers for one residents (R) R#92 of 20 sampled residents and failed to provide necessary treatment and services to promote the healing of the pressure ulcers. Specifically, the facility failed to assist the resident to turn and reposition and failed to use appropriate infection control technique during treatment to promote healing of the pressure ulcers. This resulted in actual harm for R#92. Findings include: Review of the Dressing Changes and Wound Care Policy revised in August 2013 revealed that the guideline of this facility is to provide dressing changes as needed using clean technique which includes guideline number 9: clean wound using circular motion from center of wound outward using only one gauze per wipe. The Skin Integrity Protocol dated January 2017 documented that it is the policy of this facility to accurately assess each resident's condition for prompt recognition of the risk of pressure injuries, to prevent occurrence and to appropriately treat any pressure injury which the resident may experience. Component E of the Skin Integrity Program indicated the treatment of [REDACTED]. Review of the clinical record revealed R#92 was admitted to the facility on [DATE] and had active [DIAGNOSES REDACTED]. Review of the Nursing Admission assessment dated [DATE] documented R#92 alert and oriented to person and place. The resident was admitted with one stage 3 pressure ulcer to coccyx and incontinent of bowel and bladder. Review of the admission Braden Scale-For Predicting Pressure Sore Risk dated 7/13/17 revealed that R#92 was At Risk for development of pressure sores with a score of 15 (Total score of 15-18 represents AT RISK). The risk assessment reflected that R#92 requires moderate to maximum assistance with moving. Review of the interim care plan dated 7/13/17 documented that R#92 has impaired skin integrity or at risk for impaired skin: unstageable to the sacrum. Interventions included to perform body audit upon admission and as needed; and reposition/assist with turning every 2-3 hours and as needed. Physical Therapy (PT) Treatment Encounter Notes dated 7/14/17 documented that PT educated Certified Nursing Assistant (CNA), unknown, on purpose and placement of wedge pillow. Observations on 7/19/17 at 8:30 a.m., 9:32 a.m., 10:15 a.m., and 12:10 p.m. revealed R#92 lying directly on his back with the head of bed elevated. Observation on 7/19/17 at 1:15 p.m. revealed R#92 laying directly on his back with the head of bed elevated. During an interview, at this time, R#92 revealed that no one has turned him today. Observation on 7/19/17 at 2:15 p.m., revealed R#92 lying directly on his back with head of bed elevated and the resident's lunch tray, which was untouched, on the bedside table. During an interview at this time, R#92 stated that he was pretty hungry and that no one has turned him since 1:15 p.m. interview. Continuous observation, by the surveyor, on 7/19/17 from 2:40 p.m. to 3:35 p.m., revealed that R#92 remained lying directly on his back with head of bed elevated and the following: 1. Observation on 7/19/17 from 2:40 p.m. to 2:53 p.m., revealed that CNA FF was observed feeding the resident and reports that he ate 100% although the resident's position was not changed. 2. Observation on 7/19/17 at 3:15 p.m., that Licensed Practical Nurse (LPN) CC entered R#92's room and stated to the resident that she is checking on him. R#92 responded that his butt hurts. LPN CC administered [MEDICATION NAME] 50 mg by mouth for pain without repositioning the resident or investigating the cause of the pain. 3. Observation at 3:20 p.m., revealed that the Assistant Director of Nursing (ADON) going into resident's room and the resident's position remains the same. 4. Observation from 3:25 p.m. to 3:35 p.m., revealed multiple other staff members going into R#92's room although the resident's position remains the same. Review of the Wound Management Note completed by the ADON on 7/18/17 at 8:22 a.m. revealed that R#92 had one stage 3 pressure ulcer identified on admission measuring 2.5 cm x 2.5 cm. No documentation of any other pressure ulcers were noted. Review of a Progress Note dated 7/19/17 at 9:25 p.m. documented that a new area to the left lower buttocks was noted. The Nurse Practitioner was notified and a new order was given to apply barrier cream each shift. No measurements or staging were documented. Observation on 7/20/17 at 7:40 a.m. revealed R#92 laying directly on his back with head of bed elevated. The Wedge pillow was observed laying on the empty bed next to the resident's bed. When asked how he was doing, resident requested the foam pad be placed behind his back. Review of a Progress Note dated 7/20/17 at 7:45 a.m. documented that bright red blood was noted to the open area to the coccyx. The Nurse Practitioner was notified and orders received to discontinue [MEDICATION NAME] Tuesday, Thursday, and Saturday. Clean open area to coccyx with normal saline, pat dry with clean gauze, apply Saf-gel, cover with 4 x 4 and secure in place with [MEDICATION NAME] tape daily and as needed. (Note edited at 9:45 a.m. to include the left ischium). Record review revealed a Physician order [REDACTED]. Cleanse open area to left ischium with normal saline, pat dry with clean gauze, apply Saf-gel, cover with 4 x 4 and secure in place with [MEDICATION NAME] tape. During observation of wound care on 7/20/17 at 11:45 a.m., LPN AA removed the dressing from the sacral area. Two wounds were noted: one to the sacrum and one to the left gluteal fold; both with a red, bloody wound bed. LPN AA dipped a 4 x 4 gauze in normal saline and cleaned both wounds with a back and forth wiping motion over each wound with the same 4 x 4 gauze. LPN AA repeated that action with a second 4 x 4 gauze. LPN AA then used a third 4 x 4 gauze with normal saline and wiped all over the resident's entire buttocks including both wounds with the same 4 x 4 gauze. LPN AA then applied the ordered Saf-gel with 4 x 4 gauze and covered with [MEDICATION NAME] tape. When asked about the measurements, LPN AA stated that measurements are done on Tuesday. During an interview on 7/20/17 at 2:15 p.m., LPN AA revealed she normally does the treatment for [REDACTED]. LPN stated that the resident is turned every 2-3 hours by the CNA's. LPN AA further revealed that she would normally clean the wounds separately and could not explain why she did them at the same time. During an interview on 7/20/17 at 2:40 p.m., CNA BB revealed that she did reposition R#92 on 7/19/17 every two hours. She stated that she placed the wedge pillow rotating under each side every two hours although she did not document that in the clinical record. Observation of repositioning technique by CNA BB, at 7/20/17 at 3:00 p.m., revealed that R#92 was in bed with the wedge pillow under his right side. CNA BB removed the wedge pillow, turned the resident more to the left side replaced the wedge to the right side with head of bed elevated. At this time the R#92 complained of pain and requested the head be let down. At this time LPN AA entered the resident's room and instructed CNA BB to turn the resident to the right side and place the wedge pillow under his left side. Further interview with CNA BB on 7/20/17 at 3:15 p.m. revealed that she has been employed at the facility for one year and yesterday was the first time that she had worked with R#92. CNA BB confirmed that she was not aware of any facility policy related to turning the residents. She stated that she usually raises the resident a little bit to the left, comes back in two hours and repositions even more to the left, then comes back two hours later and repositions to the right, and then comes back two hours later and reposition even more to the right. CNA BB denied receiving any in-service related to turning residents. Interview on 7/20/17 at 3:50 p.m., the DON revealed that the nursing staff should know the correct way to clean a pressure ulcer which would be to clean each wound separately and that each wound should be cleaned in a circular outward motion from the center of the wound. The DON confirmed that the resident was not admitted to the facility with the pressure ulcer to the left ischium and the wound was acquired in house. The DON also revealed that training had been provided to the CNA's on perineal care, Foley catheter care, and hand hygiene but they had not received training on turning and repositioning the residents.