Every finding on record at Grace Skilled and Nursing Therapy Norman

Based on record review and interview, the facility failed to ensure a resident was notified before there room was changed for 1 (#29) of 6 sampled residents reviewed for notification of room change. The administrator identified 104 residents resided in the facility. Findings: A facility document titled Oklahoma Resident Rights and Responsibilities, dated 11/29/22, read in part, 9. Every resident shall have the right to receive notice before the room or roommate of the resident is changed and if the resident has a telephone in his or her room, the resident must be informed of any charges to be incurred when moving. A facility document titled Census List [Resident #29], dated 11/25/25 through 01/25/26, showed Resident #29 was in room [ROOM NUMBER] on 12/15/25 at the time of discharge to a hospital. The document showed on 12/22/25 Resident #29 was in room [ROOM NUMBER]. An admission assessment for Resident #29, dated 12/02/25, showed the Resident #29 was admitted on [DATE] with diagnoses which included osteomyelitis and methicillin susceptible staphylococcus infection. The assessment showed Resident #29's cognition was fully intact with a BIMS score of 14. A discharge assessment for Resident #29, dated 12/15/25, showed Resident #29 discharged to a hospital for a short-term stay. On 01/28/26 at 10:02 a.m., Resident #29 stated they were hospitalized from [DATE] through 12/20/25. They stated their personal items were moved prior to them returning from the hospital. Resident #29 stated they did not receive any notification their room had been changed while they were in the hospital. On 02/02/26 at 9:59 a.m., LPN #2 stated when a resident's room was changed the resident should be notified. They stated a resident's room could be changed while they were in the hospital if the room was needed. LPN #2 stated Resident #29 was hospitalized from [DATE] through 12/20/25. They stated Resident #29's room was changed while they were in the hospital because they needed the bed for a resident of the opposite sex. On 02/02/26 at 10:32 a.m., the ADON stated they followed resident rights regarding room changes, and all cognitive residents should have been notified before a room was changed. The ADON stated on 12/15/25 there was no documentation in Resident #29's progress notes showing they were notified of the room change.

Based on observation, record review, and interview, the facility failed to ensure clean dishes were stored in a sanitary manner during 1 of 1 observation of the storage of dishes in the kitchen.The DM identified 100 residents received nutrition from the kitchen. Findings: On 01/27/26 at 12:51 p.m., a crockpot was observed to be stained with an off-white coloring and food and dust. The crockpot was on the second shelf of a wire rack. A bowl was observed being used as storage for weighted silverware. The bottom of the bowl had dust and debris inside it. The bowl was located on the third shelf of the same wire rack. A Dry storage of Dishes and Utensils policy, revised 06/25/12, read in part, Clean and sanitized dishes and utensils will be stored in a clean and safe manner. On 01/27/26 at 12:55 p.m., the DM stated the crockpot was someone's personal crockpot and it should not have been stored there. The DM stated the bowl was dusty because they were not using the weighted silverware currently. The DM stated they would run the silverware and bowl through the dishwasher before using them. On 01/30/26 at 2:50 p.m., the DM stated the cleaning was supposed to be done daily but had not been completed for the past three days.

Based on record review and interview, the facility failed to ensure a bed hold policy was given to resident at the time of being discharged to the hospital for 1 (#29) of 6 sampled residents reviewed for bed hold policies given upon discharge.The administrator identified 104 residents resided in the facility. Findings: A facility policy titled Bed Hold Policy, dated 01/23/08, read in part, In the event the Resident is absent from the Facility temporarily for hospitalization or other leave, the Resident may request that the facility hold open the Residents bed during this time. This in known as a 'bed hold.' Resident shall be given notice of the bed hold option at the time of hospitalization or other leave. An admission assessment for Resident #29, dated 12/02/25, showed Resident #29 admitted on [DATE] with diagnoses which included osteomyelitis and methicillin susceptible staphylococcus infection. The assessment showed Resident #29's cognition was fully intact with a BIMS score of 14. A discharge assessment for Resident #29, dated 12/15/25, showed Resident #29 discharged to a hospital for a short-term stay. On 01/28/26 at 10:02 a.m., Resident #29 stated they were not made aware of the bed hold policy and did not receive a bed hold policy at the time of discharge on [DATE]. On 02/02/2026 at 9:42 a.m., LPN #1 stated when a resident was sent out to the hospital it was the case manager's responsibility to ensure a resident bed hold policy was provided to the resident. On 02/02/26 at 9:59 a.m., LPN #2 stated bed holds were handled by the nurses who sent the resident to the hospital. On 02/02/26 at 10:32 a.m., the ADON stated when a bed hold policy was provided to a resident it should be documented in the nurses' notes. The ADON stated Resident #29 went to the hospital on [DATE]. They stated there was no documentation showing a bed hold policy was given to Resident #29 in the nurse's notes on 12/15/25.

Based on observation, interview, and record review, the facility failed to ensure nail care was performed for two (#26 and #94) of two residents reviewed for nail care. The DON reported 111 residents resided in the facility. Findings: 1. Res #26 was admitted to the facility with diagnoses of anxiety, depression, psychotic disorder, and dementia. On 05/13/24 at 10:37 a.m., resident #26 was observed up in his wheelchair. The resident's fingernails were observed to be long and discolored. On 05/14/24 at 1:01 p.m., the resident was asked when the last time staff cut his fingernails. He reported he couldn't remember. The resident was asked if he usually has them that long, he reported no. On 05/14/24 at 11:35 a.m., the resident reported the nurse cut his nails last night. On 05/16/24 at 11:11 a.m., the DON reported if resident is diabetic podiatry comes monthly and performs nail care. Reports if they are not diabetic then CNA or any staff are responsible for nail care. 2. Res # 94 admitted to the facility with diagnoses of hypertension, stroke, and diabetes. An admission assessment, dated 02/29/24, documented impairment on one side of the upper and lower extremities. On 05/13/24 at 8:38 a.m., resident #94 was observed eating breakfast and the resident's fingernails were observed to be long. On 05/14/24 at 12:56 p.m., the resident was asked when the last time his nail care was done. He reported the last time his nails were trimmed was by his daughter in law. On 05/15/24 at 11:25 a.m., the resident was observed in the dining room. The resident reported a nurse cut his nails yesterday. On 05/16/24 at 11:11 a.m., the DON reported if resident is diabetic podiatry comes monthly and performs nail care. Reports if they are not diabetic then CNA or any staff are responsible for nail care.

Based on record review and interview, the facility failed to complete a new PASARR Level I assessment when a new serious mental illness diagnosis was received for one (#6) of three sampled residents reviewed for PASARR assessments. The DON identified 111 residents who resided in the facility. Findings: A Level I PASARR, dated 05/26/17, documented Res #6 did not have a serious mental illness. On 05/05/20, Res #6 had a new documented diagnosis of psychosis not due to a substance or known physiological condition. There was no documentation the OHCA had been contacted to see if a Level II PASARR was required. On 05/14/24 at 11:25 a.m., the DON was asked to provide documentation the OHCA was notified when Res #6 had new diagnosis of psychosis to see if a Level II PASARR was required. On 05/14/24 at 1:05 p.m., the DON stated there was no documentation indicating the OHCA had been notified.

Based on record review and interview, the facility failed to ensure the physician was notified timely of a final culture and sensitivity from a urinalysis for one (101) of two sampled residents reviewed for antibiotic use. The DON reported 111 residents resided in the facility. Findings: Resident #101 was admitted to the facility on [DATE] with diagnosis to include respiratory failure with hypoxia. A skilled nursing assessment, dated 04/30/24, read in part, .urine was light urine and very cloudy, c/o burning with urination. Order received for UA . A nurse's progress note, dated 05/01/24 at 5:36 p.m., read in part, .abnormal UA, awaiting cultures . A physicians's order, dated 05/02/24, documented the Resdient was to receive one tablet of Augmentin 875-125 MG (Amoxicillin & Pot Clavulanate) twice a day for five days for a urinary tract infection. A final laboratory services report with culture and sensitivity. dated 05/03/24, documented the resident was resistant to amoxicllian. There was no documentation in the nurses progress notes or in the electronic clinical record the physician was notified of the final report until 05/06/24. A handwritten note on the final laboratory report, documented the physician was notified of the results on 05/06/24 and an order was given to Linezolid 600 mg. A physician's order, dated 05/06/24, documented the order for the antibiotic switched to one tablet of Linezolid 600 MG (Linezolid) by mouth two times a day for a urinary tract infection. The hand written note was written by LPN #1. The May 2024 Medication Administration record documented Resident #101 continued to receive Augmentin after the final laboratory report was received on 05/03/24 for six doses. On 05/15/24 at 9:05 a.m., LPN #1 stated Resident #101 was diagnosed with a UTI and the facility was waiting on the culture and sensitivity to come back and notify the physician of the final results. LPN #1 stated when the initial report came back Resident #101 was started on Augmentin when the nurse practitioner was notified of the preliminary results came back positive for a UTI. LPN #1 stated the final results were dated 05/03/24 and when they came to work on 05/06/24 they noticed the physician had not been notified yet. The LPN then stated they notified the nurse practitioner and noted in on the final lab results. LPN #1 then stated the resident was resistant to Augmentin so the antibiotic was changed by the nurse practitioner. On 05/16/24 at 11:38 a.m., the DON stated the physician was notified in the afternoon on 05/06/24 and he did not make any changes to the medications ordered. The DON then stated staff had notified the nurse practitioner on 05/06/24 prior to the doctor coming in for rounds. On 05/16/24 at 12:23 p.m., the regional nurse stated the facility did not notify the physician until three days after culture and sensitivity came back. The regional nurse then stated it was not a timely notification of the results.

Based on observation and interview, the facility failed to ensure the kitchen was kept clean and maintained in good repair. The Resident Census and Conditions of Residents report, dated 04/03/23, documented 115 residents. Two residents received nutrition and hydration solely through a feeding tube. Findings: On 04/03/23 08:50 a.m., a tour of the kitchen was conducted. The following observations were made: a. there was an accumulation of black and brown residue on the floor and the walls in the dish wash area, b. there was a large hole in the wall in the dish wash area, c. there was an accumulation of white, brown, and black residue inside of the ice machine, d. there was an accumulation of grease and food on the floor in the cook area, e. there was an accumulation of pink and black residue, and ice buildup on the wall in the walk in cooler, f. paint was peeling off of the floor, and there was an accumulation of food and black residue on the floor in the walk in cooler, g. there was an accumulation of lint and black residue on the racks in the walk in cooler, and h. the material on the floor was separating, there were gaps and the floor was not easy to clean. On 04/03/23 at 1:11 p.m., the CDM was asked how staff ensure the kitchen was kept clean and maintained in good repair. She stated they had a cleaning schedule. She stated they cleaned daily and as needed. She stated they reported maintenance concerns to the maintenance supervisor for repairs. She was made aware of the above observations.

Based on record review, observation, and interview, the facility failed to ensure medications were administered in accordance with physician orders for one (#83) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents report, dated 04/03/23, documented 115 residents resided in the facility. Findings: Res #83 had diagnoses which included secondary hypertension. A physician order, dated 07/22/22, documented to administer losartan potassium 25 mg one time per day for secondary hypertension. The order documented to hold the medication if blood pressure was below 120/80. A MAR for July 22 2022 through July 31 2022, documented the resident received the losartan when blood pressure was below parameters four out of 10 opportunities. A MAR for August 2022 documented the resident received the losartan when blood pressure was below parameters four out of 31 opportunities. A MAR for September 2022 documented the resident received the losartan when blood pressure was below parameters 10 out of 30 opportunities. A MAR for October 2022 documented the resident received the losartan when blood pressure was below parameters four out of 31 opportunities. A MAR for November 2022 documented the resident received the losartan when blood pressure was below parameters nine out of 30 opportunities. A MAR for December 2022 documented the resident received the losartan when blood pressure was below parameters ten out of 31 opportunities. A MAR for January 2023 documented the resident received the losartan when blood pressure was below parameters four out of 31 opportunities. A MAR for February 2023 documented the resident received the losartan when blood pressure was below parameters two out of 28 opportunities. A MAR for March 2023 documented the resident received the losartan when blood pressure was below parameters 15 out of 31 opportunities. A MAR for April 1 2023 through April 5 2023 documented the resident received the losartan when blood pressure was below parameters two out of five opportunities. On 04/05/23 at 3:36 p.m., the DON stated someone should have clarified the order before administering the medication outside of blood pressure parameters. She stated the medication should not have been administered if the blood pressure was below the physician ordered parameters.

Based on record review, observation, and interview, the facility failed to ensure a resident's O2 concentrator was set according to physician's orders for one (#43) of one sampled resident reviewed for oxygen. The Resident Census and Conditions of Residents report, dated 04/03/23, documented 28 residents received respiratory treatments. Findings: Res #43 had diagnosis which included dependence on supplemental O2. A physician order, dated 03/01/22, documented 02 at 3 lpm via NC to keep saturation greater than 90 percent. A quarterly resident assessment, dated 03/09/23, documented the resident's cognition was intact. On 04/03/23 at 10:18 a.m., Res #43 was observed with O2 in place via NC at 2 lpm. They stated their O2 was supposed to be set at 3 lpm. On 04/03/23 at 10:46 a.m., RN #3 was asked about Res #43's O2. She stated their O2 could be 2 to 4 lpm. She was asked to review the physician's order for the resident's O2. She stated the order was 3 lpm. She was made aware the resident's O2 was observed at 2 lpm.

Based on observation and interview, the facility failed to follow proper food service sanitation. The DON identified 91 residents who received services from the kitchen. Findings: On 11/03/21 at 5:40 a.m., a tour of the main dining room was conducted. The following observations were made: a. Brown residue and/or trash in the cabinets and/or the floor below the drink station, b. An uncovered bowl of brown sugar on a shelf in the serving area, and c. two boxes of foam to go containers stored on the floor in the serving area. At 5:50 a.m., a tour of the kitchen was conducted. The following observations were made: a. An accumulation of lint on the ceiling vents and/or ceiling area around the vents, b. Bowls, plates, and silverware were stored with the food contact surface facing upward on dish storage racks in the dish wash area, c. Ceiling lights were burned out, d. An accumulation of black residue was inside the ice machine, e. An accumulation of brown residue was in the bottom of the ice scoop container used for the ice machine. f. An accumulation of white residue was on the floor under the ice machine, g. Tips of four knives were missing and/or bent located on the knife magnet holder on the wall, h. A plastic bag of unpackaged bologna was dated 10/21/21 in the four door reach in cooler, i. Plastic bags of ham, bologna, sliced cheese, and a container of red onions were not sealed/covered during storage in the four door reach in cooler, j. A buildup of black residue was on four metal grates used to drain grease off of foods, k. Black duct tape was used to cover up cracks on a food processor container stored on a rack next to the four door reach in cooler, l. An accumulation of black residue was on on the base of the table mounted can opener, m. An oven hood light was burned out, n. Fiberglass reinforced panels/wall areas in bad repair on the electrical panel wall. The wall was not secure and was pushed in, o. The cook area had food buildup and grease on the floor, wall, fryer, stove, oven and tilt skillet. p. The three compartment sink area had food splatters on the wall and black residue on the floor, q. The three compartment sink area had a wall in bad repair, holes in the sheet rock, and metal was not secured to the wall, r. An accumulation of brown residue was on the plastic dish storage containers in the walk in cold hold unit hallway, s. Three boxes of foam to go containers were stored on the floor in the dry storage room, t. A white bulk bin lined with a black plastic bag had a white dry substance which was not tabled. u. A metal scoop stored on top of the container had a dried white substance, v. The ceiling was not finished in the walk in cold hold unit hallway. Material was peeling and the sheet rock was not sealed, w. The chemical rack in the mop sink room was rusted, x. Lights were not shielded or shatterproof in the dry food storage room, y. A 25 pound bag of table salt on a shelf in the dry storage room was open and not sealed, z. The walk-in cooler had an accumulation of ice buildup and black residue on a wall, gaps between the ceiling and walls, holes in the walls, material peeling off of the floor, and accumulation of black residue on the racks. At 7:10 a.m., a tour of the bistro was conducted. The following observations were made: a. No paper towels stored at the hand sink, and b. The barista was preparing food without proper hair restraints. At 7:15 a.m., a tour of the serving area on hall 200 was conducted. There was glass cleaner, oven cleaner, carpet spotter, and ant/roach spray stored next to clean plastic food storage containers in a cabinet below the counter. On 11/04/21 at 2:50 p.m., the DM was asked what was the protocol for maintaining food service equipment and food service areas in good repair and kept clean. He stated he had cleaning schedules. He stated they cleaned upon opening and closing and as needed. He stated any maintenance issues were to be reported to the maintenance department for repairs. He was asked how dishes, utensils, single service items, and food was to be stored. He stated up off of the floor, food contact surface down, containers closed and date marked. He stated food should be discarded within 24 hours after it was opened. The DM was asked what staff were required to wear to protect food and equipment from contamination. He stated hair restraints. He was asked what was required to be stored at the hand sink. He stated paper towels. He was asked where chemicals were to be stored. He stated separate from dishes and food. The DM was made aware of the above observations.

Based on record review and interview, the facility failed to guarantee the person designated to serve as the DM was certified no later than one year after hire. The DON identified 91 residents received services from the kitchen. Findings: An employee handbook signature page documented the DM started employment at the facility on 08/05/19. There was no documentation the DM was certified as a dietary manager. On 11/03/21 at 5:50 a.m., the DM was asked how long he had been in his current position. He stated about two years. He was asked if he was certified as a DM. He stated he was not. He stated he had taken all of the courses for the class, but needed to test again.

Based on interviews the facility had routinely been working the DON as charge nurse. The ''Census and Conditions of Residents'' report documented 95 residents resided in the facility. Findings: On 11/03/21 at 6:47 a.m., during entrance conference with the administrator and DON, they were asked about the full time DON coverage. The DON stated she worked at least 40 hours a week. She stated one day a week or every other week she worked the floor as a charge nurse. On 11/10/21 at 9:03 a.m., the staffing coordinator was asked how often the DON worked as charge nurse. She stated the DON worked one to three times a week as charge nurse. She stated the facility was trying to hire nurses to fill the needed positions. On 11/10/21 at 9:27 a.m., the administrator stated the DON had been working as charge nurse. The administrator stated the DON was the first one to come off the schedule if they had someone to work as charge nurse. She stated the facility was trying to hire more nurses and CNAs.

Based on interviews and record review the facility failed to provide a sufficient number of staff on a 24 hour bases to meet the needs of the residents. The ''Census and Conditions of Residents'' report documented 95 residents resided in the facility. Findings: A ''Resident Listing Report,'' dated 11/03/21, documented the following: a. Sixteen residents resided on Hall 100, b. Seventeen residents resided on Hall 200, c. Thirty residents resided on Hall 300, and d. Thirty-two residents resided on Hall 400. A ''Daily Schedule, dated 11/02/21 and 11/03/21, for the 11 p.m. to 7 a.m. shift documented the following: a. One CNA for Hall 100, b. One CNA for Hall 200, c. One CNA for Hall 300, and d. One CNA for Hall 400. On 11/03/21 at 5:47 a.m., LPN #1 stated on night shift there were four CNAs, each assigned to one of four halls. The LPN stated there also were two nurses. She stated we used to have more CNAs for night shift. The LPN stated it was difficult to get it all done. On 11/03/21 at 5:58 a.m., LPN #2 stated he was working as a CNA that night. On 11/03/21 at 10:00 a.m., Resident (Res) #3 was asked if he received the help and care he needed without having to wait a long time. He stated it took over 30 minutes for his call light to be answered. He stated the facility was short staffed. On 11/04/21 at 9:36 a.m., Res #57 stated last night when she woke up and needed to be repositioned from back to side, it took an hour and ten minutes for her light to be answered. She stated her light went on around 3:00 a.m. She stated she had back problems. On 11/04/21 at 3:00 p.m., during the resident group meeting, the residents were asked if they received the help and care needed without waiting a long time. The residents stated on 400 Hall it took from 20 minutes to an hour for their call lights to get answered. They stated it depended on the time of day. They said it was hard to get help during meal times and while showers were being given. The residents stated on 300 Hall on evening shift the wait was 20 to 30 minutes and weekends were not good. The residents stated night shift was short staffed on 300 and 400 Halls. They said you had to wait 45 minutes to an hour to get help. The residents stated they did not get the help they needed for toileting which resulted in incontinence. Eight of ten residents in the meeting voiced problems with call lights being answered timely. The residents stated they had to wait at least an hour three to four times a week. On 11/10/21 at 9:03 a.m., the staffing coordinator stated it was the facility's goal to have five to six aides on night shift, but had not been able to do that recently. She said the facility was in the process of hiring more nurses and CNAs.

Based on observation and interview, the facility failed to store distilled water for use in [CONDITION(S)] machine and/or oxygen concentrator in a sanitary manner up off of the floor for two (#57 and #75) of three residents reviewed for oxygen. The DON identified eight residents who used oxygen concentrators and three residents who used [CONDITION(S)] machines. Findings: 1. Resident (Res) #57 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A physician order, dated 03/27/19, documented for the resident to use a [CONDITION(S)] machine when sleeping at bedtime related to obstructive sleep apnea. An opened partial plastic gallon jug of distilled water was observed stored on the floor between the resident's bed and bedside table on 11/03/21, 11/04/21, and 11/09/21. 2. Res #75 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated 10/08/21, documented to change the oxygen water canister every 72 hours. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/03/21 at 9:12 a.m., a plastic container of distilled water was observed on the floor next to her oxygen concentrator with humidifier. A physician order, dated 11/05/21, documented the resident was to receive oxygen at 3L via nasal cannula at bedtime. On 11/09/21 at 1:53 p.m., the DON stated she was not aware distilled water was being stored on the residents' floor. The DON stated the water should be stored on a table top.

Based on observation and interviews, it was determined the facility failed to ensure spas and shower rooms were cleaned and sanitized after use for two (100 and 400) of four shower/spa rooms observed. The facility identified 98 residents resided in the facility. Findings: On Sunday, 09/08/19 at 12:04 p.m., the spa/shower room located on hall 100 was observed. The whirlpool tub had soiled washcloths and two opened packets of Vit A and D ointment located on the bottom of the tub. There was a pile of soiled towels on the floor, next to the whirlpool tub. At 12:10 p.m., the spa/shower room was observed on hall 400. The shower stall located to the right of the door was observed to have a dark black/brown fecal substance on the floor and around the shower chair. On 09/09/19 at 10:45 a.m., and again at 2:10 p.m., the shower rooms were observed again. They were found in the same condition. On 09/11/19 at 2:24 p.m., the DON stated the shower rooms, tubs and showers were to be cleaned and sanitized after each use. The DON was informed of the observations. He stated the spa/shower rooms should have been cleaned and not left like that. He then stated the facility did not have a policy regarding cleaning and sanitizing the shower rooms.

Based on observation, record review and interview, it was determined the facility failed to ensure residents were treated with dignity during one of one dining room observations. The facility identified 98 residents who resided in the facility. Findings: A review of the facilities dietary policies and procedures documented the noon meal was to be served at 11:30 a.m. On Sunday, 09/08/19 at 11:20 a.m., the noon meal was observed. Residents were seated in the dining room awaiting their meal. Residents stated the facility liked them to be in the dining room ready for their meal at 11:00 a.m. They stated the meal was to be served at 11:30 a.m. At 11:48 a.m., the first meal was observed to be provided to a resident. At 12:35 p.m. resident #24 observed to still be sitting at the back of the dining room and had not received her meal yet. At 12:36 p.m., registered nurse #1 was observed to approach the resident and then leave. The resident was asked about her meal. She stated they took her tablemate's order but not hers. On 09/09/19 at 10:52 a.m., resident #4 stated on the weekends you had to wait in excess of 30 to 40 minutes to receive your meal. On 09/10/19 at 2:00 p.m., a resident group meeting was held with nine alert and oriented residents. All nine resident's stated they had to wait an hour for meals to be served after orders were taken. All residents agreed that it was too long to wait. On 09/11/19 at 2:15 p.m., the dietary manager confirmed the residents waited too long for their noon meal on 09/08/19.

Based on observation and interviews, it was determined the facility failed to ensure food was prepared and stored in a sanitary manner: ~ Staff did not wear hair nets/beard guards; ~ Staff did not change gloves when required; and ~ Staff did not ensure a measuring cup was not stored in the flour bin with the handle in contact with the flour. The facility identified 97 residents who received meals from the kitchen. Findings: On 09/08/19 at 11:29 a.m., the dietary manager was observed preparing the noon meal. He had facial hair that was not covered and he was not wearing a hair net on his head. He continued to remain free of a hairnet and beard guard until 11:45 a.m. At 11:45 a.m., the dietary manager was observed on the serving line wearing gloves. He was observed handling plates, touching counters/serving surfaces, trays, utensils, menu cards and going in and out of the kitchen without changing his gloves. While at the serving line he was observed picking up hamburger buns and placing them on the resident's plates without changing his gloves. At 12:20 p.m., dietary aide #4 was observed to be wearing gloves, while on the serving line. Without changing her gloves, she was observed to touch other surfaces, utensils, getting plates, menu cards, trays and picking up hamburger buns and placed them on the residents plates. The dietary aide stated it was alright to wear gloves while serving and did not know if she should have changed them. At 12:45 p.m., the dietary manager stated you can use gloves or tongs to handle bread. He was asked if gloves should be changed after handling other surfaces and before handling hamburger buns with the same gloved hand. He stated it was okay to wear the same gloves. On 09/09/19 at 3:55 p.m., a measuring cup was observed in the bulk flour bin. The handle of the measuring cup was touching the flour. The dietary manager was asked if the measuring cup was maintained in the bulk flour bin. He stated it shouldn't be. Dietary cook #1 was observed as she prepared the pureed food. Her hair was not completely covered with a hairnet. Dietary aide #1 was observed as he prepared dessert dishes for the evening meal. His hair was not completely covered with a hairnet. At 4:30 p.m., dietary cook #1 was observed as she served the evening meal. Her hair was not completely covered with a hairnet. Two dietary aides were observed as they wrapped silverware in napkins. Facial hair was not contained within beard guards. On 09/10/19 at 8:30 a.m., dietary aides #1 and #3 were observed in the food preparation area. Their hair was not completely contained in hairnets. Dietary cook #1 was observed in the food preparation area. Her hair was not completely contained in a hairnet. At 9:30 a.m., the dietary manager was asked about the hairnets/beard guards. He stated the hair/facial hair should be completely covered and he would talk to the staff. On 09/11/19 at 10:39 a.m., the dietary manager stated he was aware hairnets and beard guards were to be worn. He acknowledged he was not wearing a hairnet and a beard guard while preparing the meal on Sunday. At 11:53 a.m., the registered dietician and DON were asked for the policy regarding food service and wearing gloves. The registered dietician stated they did not have a policy but the employees were taught not to handle food with bare hands. She then stated gloves should have been changed before handling the hamburger buns.

Based on observation, record review and interview, it was determined the facility failed to ensure a box, which contained a vial of [MEDICATION NAME] (insulin), had a change of direction label applied; after the physician had changed the order. The facility documented 26 residents received injections. Findings: On 09/10/19 at 8:40 a.m., LPN #5 was observed preparing to administer a routine injection of [MEDICATION NAME]. The label for the insulin documented the resident was to be administered 12 units after each meal. The LPN drew up 8 Units. She started to walk away from the cart. She was asked to review the physician's orders [REDACTED]. She was asked what the label documented. She stated it documented 12 units, she added a change of direction label should have been applied She was asked which order was correct. She stated 8 units was correct. She was asked how she knew what the correct dosage was. She stated the screen on the TARs was correct. She was asked what the process was if there was a discrepancy in an order. She stated she knew the TAR was correct. She was asked if she should review the original physician's orders [REDACTED]. [REDACTED]. The DON was asked to come to the medication cart. She was asked to review the insulin container and the order on the TAR screen. She stated the LPN should have reviewed the physician's orders [REDACTED]. The pharmacists stated the LPN should have looked for the original order when the discrepancy was brought to her attention and a change of direction label should have been applied to the box.

Based on record review and interview, it was determined the facility failed to ensure coordination of care with hospice was conducted for one (#72) of one sampled resident who was reviewed for hospice services. The facility identified eight residents who received hospice services. Findings: Resident #72 was admitted with [DIAGNOSES REDACTED]. A care plan, dated 08/07/19, documented the resident was admitted to hospice services on 02/22/19 and the facility was to work in cooperation with the hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs were met. A significant change assessment, dated 08/20/19, documented the resident's cognition was severely impaired, required extensive assistance with most ADLs, had bilateral impairment of both upper and lower extremities, had an indwelling foley catheter, was frequently incontinent of bowel, and received hospice services. A hospice nurse's note, dated 08/26/19, documented, .Open area noted to center coccyx, no drainage noted. Area approx 0.5cm x 0.5cm. Area cleansed with normal saline. Duoderm dressing applied to open area per standing order. Facility nurse assisted with treatment . The hospice visit note was electronically signed by LPN #4. A hospice nurse's note, dated 08/28/19, documented, .Duoderm patch remains clean, dry and intact to patients (sic) coccyx . The hospice visit note was signed by LPN #2. A hospice nurse's note, dated 09/04/19, documented, .Coccyx area cleansed with normal saline, duoderm dressing applied to open area . The hospice visit note was signed by LPN #1. A hospice nurse's note, dated 09/06/19, documented, .New order received for treatment to patients (sic) coccyx. Baza antifungal cream and [MEDICATION NAME] ointment to be applied per order. Facility nurse notified and discussed new treatment orders, orders written for facility .Hospice provides wound care . The hospice visit was signed by LPN #2. A telephone order, written by LPN #2, dated 09/06/19, documented Baza cream was to be applied to the coccyx twice daily then discontinued 09/09/19, and Xanaderm was to be applied to the coccyx after each incontinent episode. A facility nurse progress note, documented by the wound nurse, LPN #3, dated 09/09/19, documented, .Focussed (sic) Skin Assessment related to onset of new wound .unstageable ulcer to Sacrum which measures approximately 0.9 x 0.5 x UTD cm, wound bed is purplish/red in color and has very small opening with pink tissue, periwound is intact with no [DIAGNOSES REDACTED] or maceration, there is no exudate and no odor present .Notified Dr. (Name withheld) and discussed onset of new wound, received the following orders for treatment .Multivitamin with minerals daily, vitamin c 500mg bid, [MEDICATION NAME] 1 packet daily, equagel contour cushion to recliner, low airloss mattress, for the wound cleanse with saline, pat dry, apply [MEDICATION NAME] cream to site every shift .Resident will be seen by the wound care provider, (Name withheld) on her next visit, to evaluate and treat the wound as indicated . On 9/10/19 at 8:45 a.m., LPN #3 was asked what the procedure was for wound care. He stated he received referrals from staff regarding identified wounds which he would evaluate and treat based on his assessment and physician orders [REDACTED]. He was asked if he had received any information from staff regarding the wound for resident #72. He stated yes, the wound was identified on Friday (9/6/19) by the hospice nurse, treatment was initiated, and he assessed the wound on Monday (09/09/19). The clinical record did not contain documentation of the wound identified on 09/06/19. On 09/11/19 at 8:45 a.m., the DON was asked why there was no documentation of the resident's wound in the clinical record. He stated the wound was identified and a telephone order was obtained. He was asked why there was no documentation of the description of the wound. He stated their procedure when a wound was identified was to notify the physician, initiate treatment, and notify the wound nurse for assessment of the wound. He was asked what the procedure was for a resident receiving hospice services. He stated when hospice staff visited, they checked in with a facility nurse, visited the resident, documented electronically in their computer, and reviewed the visit with a nurse who would then sign off on the visit. He was asked where the hospice visits were documented. He stated they had access to the hospice electronic records and could obtain any records needed. On 09/11/19 at 9:00 a.m., LPN #2 was asked if he had assessed the resident's wound on 09/06/19. He stated he was in the resident's room with the hospice nurse. He was asked where the assessment of the wound was documented. He stated he would normally document in the progress notes, but he did not think it had been documented. On 09/11/19 at 11:20 a.m., LPN #3 was asked if he was aware of the wound documented by hospice on 08/26/19. He stated No. He was asked what the procedure was regarding wound care if the resident was receiving hospice services. He stated the procedure was no different, he was to be notified of any wound which he would assess and treat. On 09/11/19 at 12:00 p.m., the DON was asked if he was aware of the wound documented by hospice on 08/26/19. He stated no, we were not aware of the resident's wound until 09/06/19 when the physician was notified and treatment was initiated. He was asked who provided wound care to a resident receiving hospice services. He stated LPN #3 was to be notified of any identified wound which he would assess and treat. He was asked if LPN #3 had been notified of the resident's wound after LPN #4 signed the hospice nurse's note dated 08/26/19 which described the wound. He stated no.

Based on observation, record review, and interviews, it was determined the facility failed to honor a meal choice for one (#13) of two sampled residents who were reviewed for food choices. The facility identified 97 residents who received meals from the kitchen. Findings: Resident #13 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 06/25/19, documented the resident's cognition was intact, could make himself understood and was able to understood others. On 09/08/19 at 12:05 p.m., the resident was observed ordering a salad for his noon meal. He was informed the facility was out of shredded lettuce and he would have to select another item. At 12:25 p.m., the resident's tablemate was served a salad. The lettuce was observed to be shredded. At 12:45 p.m., the dietary manager stated he did not have shredded lettuce and the resident was on a mechanical soft diet. He added he had heads of lettuce just not any that were shredded. He stated he could have cut lettuce up and made a salad if the resident had asked. At 4:01 p.m., the resident stated he asked for a salad at the noon meal and was told they were out of lettuce. He stated he had to settle for an egg and that happened a lot.

Based on observation, record review and interviews, it was determined the facility failed to prevent the development of an avoidable pressure ulcer for one (#40) of three sampled residents who were reviewed for pressure ulcers. The resident developed an unstageable pressure ulcer on her sacrum which developed an infection. The facility's 'Resident Census and Conditions of Residents' report, dated 07/31/17, documented seven residents had a pressure ulcer. Findings: Resident #40 was admitted to the facility with [DIAGNOSES REDACTED]. The quarterly assessment, dated 05/11/17, documented the resident's cognition was moderately impaired, she required extensive assistance with bed mobility, transfers, toilet use and ambulation. The assessment documented the resident had an impairment on both sides of her upper and lower extremities, utilized a wheelchair for mobility, was frequently incontinent of urine and always incontinent of bowel. The assessment further documented the resident was at risk for developing pressure ulcers. The resident had no unhealed pressure ulcers and had a pressure reducing device for her chair and bed. A quarterly Braden scale assessment, dated 05/17/17, documented the resident was at low risk for the development of a pressure ulcer. A skin/wound note, dated 05/18/17, documented the resident was seen by the wound care nurse (licensed practical nurse #9) for a quarterly assessment. She had a Braden score of 15 (low risk). The following interventions were in place: carefoam mattress, cushion to wheelchair, moisture barrier to buttocks every shift, weekly skin checks, frequent turning and to use draw sheets for lifts and repositioning. The physician was notified and risk factors for skin breakdown were discussed. The care plan regarding incontinence, dated on 05/18/17, documented the resident was frequently incontinent of her bladder and was at risk for urinary tract infections (UTIs) and skin breakdown. The interventions documented the resident wore disposable briefs, to anticipate and meet needs and provide incontinent care as needed. Weekly skin evaluations, dated 05/25/17, 06/01/17 and 06/08/17, documented there was no skin breakdown identified and no new areas identified which were not identified on the previous weekly assessment. Baza antifungal cream to groin area and buttocks every shift. A physician's orders [REDACTED]. A physician's orders [REDACTED]. The order was to cleanse with antimicrobial spray, pat dry, skin prep the periwound, apply [MEDICATION NAME] impregnated calcium alginate over the wound, cover with Allevyn life sacral dressing and change daily related to pressure ulcer of sacral region, stage II. A daily wound charting note, dated 06/14/17, 06/15/17 and 06/16/17, documented the resident had a stage II ulcer to the sacrum and there was a dressing/treatment in place and no sign of infection. A skin/wound note, dated 06/19/17, documented the resident was seen by the wound care nurse for initial onset of a new wound to the buttocks. The note documented a stage II pressure ulcer to the sacrum and measured approximately 2.5 centimeters (cm) x 2.7 cm x 0.1 cm. The note documented the wound bed had beefy red tissue, the periwound was intact with no [DIAGNOSES REDACTED] or maceration. There was a light tannish exudate and no odor present. The resident was on a carefoam mattress and had a cushion to her wheelchair. She received moisture barrier to buttocks every shift. Physician notified and discussed wound status. Orders were received to cleanse with antimicrobial spray, pat dry, skin prep periwound, [MEDICATION NAME] impregnated calcium alginate and cover with Allevyn life sacral dressing to be changed daily. A daily wound charting note, dated 06/19/17, documented the resident had a stage II ulcer to the sacrum and there was a dressing/treatment in place and no sign of infection. The care plan regarding activities of daily living (ADLs), dated 06/19/17, documented the resident had limited physical mobility related to [MEDICAL CONDITION] and required assistance with all ADLs. The interventions documented the resident was dependent with mobility in her wheelchair. Staff were to monitor/document/report to the physician as needed any skin breakdown. Daily wound charting notes, dated 06/20/17, 06/21/17 and 06/22/17, documented the resident had a stage II ulcer to the sacrum and there was a dressing/treatment in place and no sign of infection. A weekly skin evaluation, dated 06/22/17, documented there was no skin breakdown identified and no new areas identified which were not identified on the previous weekly assessment. Baza antifungal cream to groin area and buttocks every shift. A daily wound charting note, dated 06/23/17, documented the resident had a stage II ulcer to the sacrum and there was a dressing/treatment in place and no sign of infection. A physician's orders [REDACTED]. The orders also documented to provide a low air loss mattress with a bolster cover, Pro-stat advanced wound care (AWC) protein supplement, 1 ounce (oz) twice daily, Roho/Star cushion to wheelchair for pressure reduction. Nursing was to check placement every shift for pressure reduction. A skin/wound note, dated 06/23/17, documented, Resident seen by wound care nurse for assessment of wound today, residents wound has upgraded to an unstageable ulcer, site measures approximately 3.6 x 4.1 cm, the wound margins have developed necrotic tissue that is black/brownish in color and has a thin line of slough on the outer margins of wound, the center wound still has beefy red tissue, necrotic tissue is at about 50% and beefy red tissue is at about 50%, periwound is intact and has no [DIAGNOSES REDACTED] or maceration, there is light tannish exudate on old dressing and there is no odor present, Notified (name-deleted physician) and discussed wound status, received orders to d/c previous treatment and switch to cleanse with antimicrobial spray, pat dry, skin prep periwound, santyl to wound bed, calcium alginate and Allevyn life dressisng (sic) and change daily, also placed on low airloss mattress and a roho cushion for her wheelchair, also placed on multivitamins with minerals daily and pro-stat AWC protein supplement twice daily . The care plan regarding the pressure ulcer to the sacrum, dated 06/23/17, documented the resident had an unstageable ulcer to the sacrum. Interventions documented for staff to assess/record/monitor wound healing weekly, measure length, width, and depth of the wound, report any improvements and/or declines to the physician, and monitor dressing every shift and ensure it was clean, dry, and intact, if soiled replace with a new dressing. The care plan regarding impaired skin integrity related, last revised on 06/23/17, documented the resident had a Braden score of 16. Interventions documented for staff to apply Baza to excoriation to groin area and buttocks every shift (Initiated on 11/07/16, revised on 12/12/16), the Braden score was a 16. discontinue the carefoam mattress and wheelchair cushion, weekly skin checks, moisture barrier cream for prevention. Initiate a low airloss mattress for pressure reduction, initiate a Roho/Star cushion to her wheelchair for pressure reduction for an unstageable ulcer. Daily wound charting notes, dated 06/26/17 through 06/29/17, documented the resident had a stage II ulcer to the sacrum and there was a dressing/treatment in place and no sign of infection. A weekly skin evaluation, dated 06/29/17, documented there was no skin breakdown identified and no new areas identified which were not identified on the previous weekly assessment. Baza antifungal cream to groin area and buttocks every shift. A daily wound charting note, dated 06/30/17, documented the resident had a stage II ulcer to the sacrum and there was a dressing/treatment in place and no sign of infection. A wound report completed by the wound care nurse, dated 6/30/17, documented the wound was 3.8 cm in length, 4.4 cm in width and the depth was undetermined. The wound bed had necrotic tissue. Daily wound charting notes, dated 07/03/17 through 07/05/17, documented the resident had a stage II ulcer to the sacrum and there was a dressing/treatment in place and no sign of infection. A physician's orders [REDACTED]. A weekly skin evaluation, dated 07/06/17, documented there was no skin breakdown identified and no new areas identified which were not identified on the previous weekly assessment. Baza antifungal cream to groin area and buttocks every shift. (This was electronically signed by the wound care nurse on 07/10/17). A daily wound charting note, dated 07/06/17, documented the resident had a stage II ulcer to the sacrum and there was a dressing/treatment in place and no sign of infection. A wound culture report, dated 07/06/17, documented moderate escherichia coli (E coli), Proteus mirabilis, [MEDICAL CONDITION] (MRSA) and [MEDICATION NAME] faecalis. A daily wound charting note, dated 07/08/17, documented the resident had a stage II ulcer to the sacrum and there was a dressing/treatment in place and no sign of infection. An antibiotic/infection note, dated 07/08/17, documented the wound culture report had been received, the physician had been notified and a new order obtained. A physician's orders [REDACTED]. A daily wound charting note, dated 07/09/17, documented the resident had a stage II ulcer to the sacrum and there was a dressing/treatment in place and no sign of infection. A skin/wound note, dated 07/10/17, documented the resident was seen by the wound care nurse for a wound to the sacrum. The site measured approximately 3.9 x 4.5 x UTD. The wound bed was 90% necrotic tissue and 10% beefy red tissue, periwound was intact with no [DIAGNOSES REDACTED] or maceration. There was a light tannish exudate and no odor present. A daily wound charting note, dated 07/10/17, documented the resident had a stage II ulcer to the sacrum and there was a dressing/treatment in place and no sign of infection. A daily wound charting note, dated 07/11/17, documented the resident had an unstageable ulcer to the sacrum and there was a dressing/treatment in place and no sign of infection. (This was electronically signed by the wound care nurse on 07/21/17). A progress note from the advanced practice registered nurse (APRN), dated 07/11/17, documented the resident had developed a non stageable sacral ulcer which was infected with e coli and Proteus mirabilis. Placed on [MEDICATION NAME] on 07/08/17. The note also documented a multiple drug resistant sacral wound infection and to continue the [MEDICATION NAME] and add [MEDICATION NAME] and [MEDICATION NAME]. A physician's orders [REDACTED]. A daily wound charting note, dated 07/12/17, documented the resident had an unstageable ulcer to the sacrum and there was a dressing/treatment in place and no sign of infection. (This was electronically signed by the wound care nurse on 07/21/17). A weekly skin evaluation, dated 07/13/17, documented there was no skin breakdown identified and no new areas identified which were not identified on the previous weekly assessment. Baza antifungal cream to groin area and buttocks every shift. (This was electronically signed by the wound care nurse on 07/17/17). Daily wound charting notes, dated 07/13/17 through 07/16/17, documented the resident had an unstageable ulcer to the sacrum and there was a dressing/treatment in place and no sign of infection. (These were electronically signed by the wound care nurse on 07/21/17). A skin/wound note, dated 07/16/17, documented the resident was seen by the wound care nurse for a wound to the sacrum. The site measured approximately 4.1 cm x 4.5 cm x UTD. The wound bed had 60% black necrotic tissue, 20% tannish slough and 20% pink tissue, periwound was intact with slight [DIAGNOSES REDACTED] from inflammation. There was a light tannish exudate on the old dressing and there was no odor present. A daily wound charting note, dated 07/17/17, documented the resident had an unstageable ulcer to the sacrum and there was a dressing/treatment in place and there was a sign of infection. (This was electronically signed by the wound care nurse on 07/21/17). A laboratory report, dated 07/17/17, documented the resident's total protein level was 5.7 (normal range is 6.4 - 8.3) and her [MEDICATION NAME] was 3.0 (normal is 3.5 - 5.0). A daily wound charting note, dated 07/18/17, documented the resident had an unstageable ulcer to the sacrum and there was a dressing/treatment in place and there was a sign of infection. (This was electronically signed by the wound care nurse on 07/21/17). Daily wound charting notes, dated 07/19/17 and 07/20/17, documented the resident had an unstageable ulcer to the sacrum and there was a dressing/treatment in place and there was a sign of infection. (These were electronically signed by the wound care nurse on 07/21/17). A weekly skin evaluation, dated 07/20/17, documented there was no skin breakdown identified and no new areas identified which were not identified on the previous weekly assessment. Baza antifungal cream to groin area and buttocks every shift. A skin/wound note, dated 07/21/17, documented the resident was seen by the wound care nurse for an unstageable ulcer to the sacrum. The site measured approximately 4.3 cm x 4.6 cm x UTD. The wound bed had 80% tannish slough, 10% black necrotic tissue and 10% beefy red tissue, periwound had slight [DIAGNOSES REDACTED] from inflammation. There was moderate tannish exudate and no odor present. Resident continued on low airloss mattress, and roho cushion to wheelchair. Resident refused to lay down during the day to relieve pressure to site. Multiple attempts made to try to get her to lay down and she refused. Daily wound charting notes, dated 07/21/17 through 07/26/17, documented the resident had an unstageable ulcer to the sacrum and there was a dressing/treatment in place and there was a sign of infection. A daily wound charting note, dated 07/27/17, documented the resident had an unstageable ulcer to the sacrum and there was a dressing/treatment in place and there was a sign of infection. Baza antifungal cream to groin area and buttocks every shift. A weekly skin evaluation, dated 07/27/17, documented there was no skin breakdown identified and no new areas identified which were not identified on the previous weekly assessment. (This was electronically signed by the wound care nurse on 07/28/17). A daily wound charting note, dated 07/28/17, documented the resident had an unstageable ulcer to the sacrum and there was a dressing/treatment in place and there was a sign of infection. A skin/wound note, dated 07/28/17, documented the resident was seen by the wound care nurse for a wound to sacrum. The site measured approximately 5.8 cm x 4.6 cm x UTD. Wound bed had 60% tannish slough, 10% black necrotic tissue and 30% beefy red tissue, periwound was intact with slight [DIAGNOSES REDACTED] from inflammation. There was moderate tannish exudate and no odor present. Daily wound charting notes, dated 07/29/17 through 08/02/17, documented the resident had an unstageable ulcer to the sacrum and there was a dressing/treatment in place and was no sign of infection. On 08/02/17 from 8:40 a.m. to 9:56 a.m., the resident was observed to be seated in the activity room. The wheelchair was observed to have had a built up cushion over the right chair arm and her right arm was on top of the cushion. The resident was leaned over on her right side and her eyes were closed. A seat cushion, which measured approximately 3 to 4 inches thick and an incontinent pad were observed in the seat of the wheelchair. At 9:56 a.m., the resident was wheeled out of the activity room by the activity staff and taken to another staff member on the hall. The resident made a moaning noise. The staff asked her if she wanted to go and lay down. The resident continued to lean to her right side in her wheelchair in the hallway. At 9:58 a.m. licensed practical nurse (LPN) #3 was observed to talk to the resident. The LPN pushed the resident into her room. On 08/02/17 at 10:15 a.m., wound care was observed to be performed on resident #40 by licensed practical nurse #9, the facility wound care nurse. He was observed to obtain a piece of barrier paper and placed it on a tray, which sat on top of a stool next to the treatment cart. He obtained an Allevyn life dressing from the treatment cart, dated it and placed it on the tray. He obtained a pair scissors out of the top drawer of the treatment cart and cut a piece of calcium alginate and placed it on top of the Allevyn package. He then opened a tube of Santyl and squirted some into a medication cup and placed it on the tray. He obtained a tongue depressor and placed it on the tray. He touched the treatment cart drawer handle as he obtained some non sterile 4 x 4 pieces of gauze out of the cart. He placed the gauze into a cup (poking them down with his fingers) and sprayed antimicrobial spray onto the gauze and repeated x 3. He also obtained gloves out of the treatment cart and placed them onto the tray. The wound care nurse asked what he had done prior to the surveyors observation of him preparing his supplies for the wound treatment. The wound care nurse stated he had cleansed the tray, prior to our arrival. He was asked if he had washed his hands prior to cleansing the tray and setting up his supplies. He stated, Not yet. He stated he was going to wash his hands when he went into the resident's room. At 10:25 a.m., the wound care nurse positioned the resident on her right side and pulled her pants down just enough to get to the dressing. He removed and disposed of the dressing. The wound was observed to be between the sacrum and the right ischium. The wound bed was observed to be pink with a brownish/gray area around the edge at 1:00. At 10:30 a.m., the wound care nurse was asked if there had been drainage on the bandage he removed. He stated there had been a light tannish drainage. From 11:27 a.m. to 11:56 a.m., the resident was observed seated at the dining room table where residents were assisted with feeding. She was observed to be leaning over onto her right side in her wheelchair. At 12:21 p.m., the resident was seated in her wheelchair in the lobby by the nurse's station. She was leaned to her right side and her eyes were closed. At 12:27 p.m., certified nurse aide (CNA) #6 was observed to take the resident to her room and assisted her to her recliner. The CNA was asked if the resident was able to tell staff when she needed to go to the bathroom. The CNA stated, Yes, she tells us, she can talk. She was asked how often the resident was incontinent. The CNA stated she was not sure. After the CNA assisted the resident from her wheelchair to her recliner, she placed a pillow under the resident's right arm. The CNA was asked about the built up cushion on the right arm of the resident's wheelchair. She stated the cushion was for the resident's right arm. She stated the resident favored leaning to her right side. The resident was observed to ask for a pillow under her head and for the remote to the television. The CNA placed the call light in the resident's lap. The CNA was asked if the resident was able to utilize her call light. She stated, Yes. The CNA instructed the resident to push her call light. The resident activated the call light. The CNA was asked how often the resident was repositioned. She stated, Every two hours. At 12:39 p.m., LPN #3 was asked about the resident's pressure ulcer. The LPN stated one day, she could not remember when, the CNAs were toileting the resident and they reported to her a reddened spot on her back side. She stated she got the wound care nurse and he got an order for [REDACTED]. The LPN stated around 06/11/17, she noticed the reddened area was a more pronounced excoriation. She reported to the wound care nurse and an order was obtained to cleanse and cover the area. She was asked who did the treatment which had been ordered. She stated she had been doing the treatment. She stated it seemed to be healing and doing great. She stated on 06/13/17, when she went to do the treatment, the area was scabbed over and she did not like the way the scab looked. She stated she reported it to the wound care nurse and he got a different order from the physician. She stated it was an order for [REDACTED]. She stated on 06/23/17, the scab started to pull away and she reported it to the wound care nurse. He got an order to change from metihoney to Santyl and he took over doing the wound care treatments at that time. She further stated the wound went from a stage II to unstageable. At 12:54 p.m., LPN #5, the director of nursing (DON) and the wound care nurse approached the surveyor and LPN #3. They were asked if anyone else had assessed the wound. LPN #5 stated the APRN looked at the resident's wound on 07/11/17, when she made rounds. LPN #5 was asked if the resident had been sent out to a wound doctor or if a wound consultant had seen the resident's wound. She stated the resident had not been sent out to a wound doctor and she was not sure if their wound consultant had seen the resident or not. No documentation was provided to indicate the wound consultant had assessed the resident's pressure ulcer. The DON was asked if he had assessed the resident's wound. He stated he had not seen it. The wound care nurse was asked if the physician had observed the pressure ulcer. He stated the physician had looked at the wound, but did not know if he documented it in a progress note. At 12:57 p.m., the resident was observed to be wheeled to the lobby in her wheelchair. She was leaning to her right side. At 2:39 p.m., the resident was observed in the hallway in her wheelchair. She was leaning to her right side. Staff was overheard to ask the resident if she wanted to go to bed. The resident was not observed to answer. Staff stood with her for a few minutes then walked away. The resident remained in the hallway in her wheelchair with her eyes closed as she leaned to her right side. At 2:48 p.m., a staff member was observed to take the resident into the activity room where other residents were playing bingo. The resident's eyes were closed. The resident continued to lean to the right side. From 2:48 p.m. and 3:37 p.m., the resident was observed in the activity room. She was seated in her wheelchair, leaning to her right side. The resident was not observed to move any part of her body except for her hands. At 3:16 p.m., the activity staff went over and asked the resident if she was okay. The resident opened her eyes briefly and was not observed to answer. At 3:37 p.m., the resident hollered out and the activity staff wheeled her out of the activity room and took her to CNA #2. At 3:42 p.m., CNA #2 was observed to reposition the resident's right arm. He was asked about repositioning the resident. He stated the resident wanted her arm moved. He stated it got stiff and he was observed to move her arm around and asked the resident if it was comfortable. He was asked about repositioning regarding the resident's pressure ulcer. He stated he turns her from side to side when she was in her bed to keep her off of her pressure ulcer. He was asked if he had specific repositioning instructions when she was in her wheelchair. He stated he did not have any specific instructions for repositioning except for when she was in her bed. The CNA was observed to wheel the resident into the lobby area. At 3:50 p.m., a nurse was observed to ask the resident if she wanted to go lay down. The resident told her no. The resident continued to lean to the right. At 3:59 p.m. CNA #2 was asked if he was the CNA assigned to the resident for this shift. He stated he was. He was asked if there were positioning instructions for the residents in which staff could refer to. He stated he thought there was a place in their electronic records where they could look to see what they were to do for the residents. He was asked again about positioning the resident when she was seated in her wheelchair. He stated the only thing he repositioned when she was in her wheelchair was her right arm. He stated he was supposed to watch her right arm to make sure it did not hang off of the arm of the chair. He further stated that was all he knew. He was asked if the resident was able to raise herself up and reposition herself. He stated he did not think so. The resident remained in the lobby area during this time. At 4:03 p.m., CNA #5 asked CNA #2 to assist him with the resident. CNA #5 pushed the resident into her room in her wheelchair. CNA #2 was asked if the resident was incontinent. He stated, Yes, she is. CNA #2 closed the door and both CNA #2 and CNA #5 were observed to wash their hands and don a pair of gloves. The CNAs were observed to change the resident's shirt. CNA #5 was asked why he changed the resident's shirt. He did not answer. CNA #2 told CNA #5 the surveyor wanted to know why they resident's shirt was changed. CNA #5 stated the resident drooled and had gotten her shirt wet. The CNAs were observed to position a pillow under the resident's right arm. They were not observed to check the resident for incontinence nor ask the resident if she needed to go to the restroom. The resident was wheeled to the lobby area. At 4:09 p.m., staff were observed to wheel the resident into the dining room area. At 4:20 p.m., the DON was observed to push the resident's wheelchair to the a dining room table where residents are assisted with feeding. CNA #2 was seated at the table where the resident was taken. He was observed to assist her with her meal. The resident remained in the dining room until 5:12 p.m. leaning on her right side. At 5:12 p.m. the resident was wheeled out of the dining room and taken to her room. Her eyes were open and she smiled. At 5:14 p.m., CNA #5 asked her what she wanted to do and she stated she wanted to get into her recliner. He left the room. At 5:19 p.m., CNA #5 returned with LPN #4. The CNA placed a gait belt around the resident's waist and assisted her from her wheelchair to her recliner. As the resident was being assisted, a large wet area was observed on the back of the resident's pants near the lower buttock area. Neither the CNA nor the LPN were observed to check the resident for incontinence. At 5:23 p.m., the LPN asked the resident if she was dry. The resident stated she did not know. The LPN asked the resident if she needed to be changed. The resident did not answer. He told the resident he would be back and check on her in a little bit. At 5:30 p.m., LPN #4 was asked by one of the surveyors to look at the resident's skin. At 5:38 p.m., LPN #4, CNA #1 and certified medication aide (CMA) #1 came into the resident's room. They were all observed to wash their hands. The LPN asked the resident if they could put her in bed so the surveyors could check her skin. The resident stated, Okay. At 5:46 p.m., they were observed to remove the resident's pants and disposable brief. The CNA was asked if the resident was incontinent of urine. The CNA, after checking the brief, stated no she is not wet. The pressure ulcer dressing was observed to be intact. A reddened area, located below the dressing, was observed. The LPN was asked about the reddened area. He stated the resident had a red bottom off and on. He further stated the red was blanchable. At 5:51 p.m., the CMA was asked to look at the resident's pants they had removed. She stated the pants they removed were wet. The CNA again was asked if the resident was incontinent of urine. She rechecked the brief and stated, oh yea, she missed that, she was wet. The brief was observed to be saturated with dark yellow urine. Incontinent care was performed on the resident. The CMA was asked where it was documented when the resident had been last checked for incontinence and her brief changed. The CMA stated she was not sure where it would be documented. At 5:56 p.m., CMA #1 was observed to ask LPN #5 where to look up to see when the resident had last been checked/changed. The corporate RN was also present. LPN #5 stated they chart in their electronic record every shift if a resident had a bowel movement or was incontinent of urine. She stated the resident could tell them if she needed to go to the bathroom. They were asked about repositioning the resident when she was seated in her wheelchair. LPN #5 stated they asked the resident all the time if she wanted to lay down and she would tell the staff she wanted to be up. A weekly skin evaluation, dated 08/03/17, documented there was no skin breakdown identified and no new areas identified which were not identified on the previous weekly assessment. Baza antifungal cream to groin area and buttocks every shift. On 08/03/17 at 9:00 a.m., the resident was observed in her room as she sat in her recliner and watched television. She leaned toward her right side. At 9:35 a.m., the resident was observed in her wheelchair as she leaned toward her right side. She was taken from her room to the activity room. At 10:46 a.m., the wound care nurse was asked who had obtained the measurements for the resident's pressure ulcer. He stated he had been the only one who had obtained measurements. He was asked who staged the wounds. He stated he called the physician and described the wound to the physician over the telephone and the physician instructed the wound care nurse how to stage the pressure ulcer. He was asked about when the pressure ulcer went to unstageable. He stated it had been the same way. He was asked if the physician looked at the resident's wound prior to staging it. He stated no. He stated the physician staged the wound from the description he had received from the wound care nurse over the telephone. At 11:03 a.m., the resident was observed to be wheeled outside by a visitor. She was seated in her wheelchair and leaned toward her right side. At 11:11 a.m., the DON was observed to take a cushion outside. He repositioned the resident slightly and placed the cushion along her right side. The cushion assisted the resident to sit up straighter in her wheelchair. She was observed outside in her wheelchair until 11:22 a.m. On 08/03/17 at 2:34 p.m., the wound care nurse and LPN #3 were observed to perform wound care on the resident. The wound care nurse was observed to wash his hands inside the room at the sink. He then went to the treatment cart and moved the cart away from the wall by the handles. He then grabbed his stool and sat it down and placed the tray on top of it. He did not sanitize the tray, the top of the treatment cart or the stool. He then obtained a barrier p