Every finding on record at Newton Village Health Care Center

Based on resident record, family and staff interviews, change of condition and dietary policy, the facility failed to serve a resident the correct textured meal. Resident #4 required a pureed diet due to a diagnosis of dysphagia. On 6/27/26, during the dinner meal time, a facility CNA assisted Resident #4 to eat a pureed meal provided by the facility culinary staff. The facility CNA prepared a second meal plate from the steam table for Resident #4 which consisted of scrambled eggs, sausage and hash browns and did not alter the consistency of the food. The resident told the staff member no and the staff continued to feed the resident. At 5:21pm, Resident #4 began to cough up phlegm and scrambled eggs after eating the meal. Resident #4 was taken to her room by a different staff CNA, the nurse was called and she visually monitored resident #4 until she went to bed at 6:30 PM. Prior to going to bed Resident #4's oxygen saturation rate dropped to 88% and her supplemental oxygen was increased from 1.5 liters (L) nasal to 3L with a facial mask. During an assessment completed at 8:38 PM, Resident #4 was found to have coarse lung sounds. At 10 PM during shift report, the night nurse was informed of the choking incident and assessed the resident at approximately 11:00 PM. Resident #4 was found to be anxious, short of breath, hands on her throat, coughing, blue color around her lips and an oxygen saturation level of 75% with supplemental oxygen at 3 L. Resident #4 was sent out to the hospital at 11:34 PM. On 6/28/26, Resident #4 was admitted to the hospital and died on 6/29/26 with a cause of death being aspiration pneumonia. The facility currently has 3 other residents on a mechanically altered diet and was at risk for choking if served the wrong consistency.The above failure rose to a level of immediate jeopardy and the facility was notified of IJ on 7/9/26 at 3:23 pm. The failure began 6/27/26 for Resident #4. The facility removed the immediacy on 7/13/26 after the State Survey Agency (SSA) verified removal actions taken by the facility that included the following steps; Complete immediate facility audit of all residents with physician-ordered therapeutic diets including all mechanically altered diets. Physician orders, electronic medical record diet orders, tray tickets, and resident diet lists were compared to ensure complete accuracy. Upon audit, there were 3 current residents residing at the facility with mechanically altered diet orders. Every resident receiving a mechanically altered diet was assessed by licensed nursing staff for signs or symptoms of aspiration, choking, respiratory distress, or other adverse outcomes. Any concerns identified were immediately communicated to the attending physician. For the next scheduled meal, every tray that required mechanical alteration was individually verified by both dietary staff and licensed nursing staff before being served to residents. The CNA involved in the incident resigned from the facility on 6/27/26, and has not worked since. A current master diet roster was generated from physician orders and verified for accuracy. Audit completed of tray cards and care plans to ensure diet listed matches current physician ordered diet. Only dietary staff will be assigned to plate food prior to being served to residents. All other staff will request assistance from dietary staff if more or different food is requested. Licensed nurses remain immediately available during meal service to address any concerns.Staff Education:All staff prior to next working shift will receive education on the following: Physician-ordered mechanically altered diets Identification of mechanically altered diets and orders for thickened liquids Snack options available on-site meeting mechanically altered diet requirements Aspiration precautions Proper tray card identification Dietary staff ONLY to plate food prior to being served to residents. All other staff (non-dietary) will request assistance from dietary staff if more or different food is requested Verification with licensed nurse will be completed by all staff prior to serving snacks to residents Immediate actions required if an incorrect tray is identified Facility policy regarding mechanically altered dietsEducation will be provided by Administrator, Director of Nursing or designee.Each employee will successfully complete competency validation through correctly answering questions on post education quiz.System Changes Implemented:To prevent recurrence, the facility immediately implemented the following process improvements: Dietary staff ONLY to plate food prior to being served to residents during meal times All other staff (non-dietary) will request assistance from dietary staff if more or different food is requested during meal times Verification with licensed nurse will be completed by all staff prior to serving snacks to residents to ensure diet orders are followed Snack storage will be relocated to a secure locationThe scope and severity of the failure lowered from a J level to an D level on 7/13/26 after the facility removed the immediacy of the health threat. The facility reported a census of 22 residents. Findings include:The Minimum Data Set (MDS) dated [DATE] for Resident #4 revealed diagnoses of dysphagia (difficulty swallowing), chronic lung disease with a dependency on supplemental oxygen and diabetes mellitus. Resident #4 was provided supervision and touch assistance for eating and moderate assistance for oral hygiene. The MDS identified the mechanically altered diet required change in texture of food or liquids. The MDS identified that Resident #4 did not experience shortness of breath with exertion, when sitting at rest or when lying flat. The MDS identified Resident #4 as not experiencing fever, vomiting or dehydration. The MDS identified 2 days of participating in Physical and Occupational Therapy and no days with the Speech Language Pathology for the dysphagia. Hospital Notes revealed Resident #4 was admitted to the hospital from home on 6/16/26 for Severe Sepsis (infection) due to a urinary tract infection (UTI), malnutrition (poor intake of food) due to a dysfunctional gastrointestinal (GI) system as evidenced by nausea, vomiting, diarrhea and poor appetite. Resident #4 had dysphagia (difficulty swallowing) and was on a dysphagia diet (mechanically altered diet) and was managed by the Speech, Language Pathologist (SLP). Resident #4 had history of respiratory failure, followed by a pulmonary provider, and had been stable for years. Resident #4 was on oxygen at 2 liters. Resident #4 was discharged from the hospital on 6/25/26 and admitted to Skilled Nursing Care (SNF) facility with a treatment plan of Activities of Daily Living (ADL) retraining with Physical Therapy (PT) and Occupational Therapy (OT). Basic Care Plan for Resident #4 dated 6/25/26 failed to identify diet orders. Identified a risk for weight loss, a goal to maintain weight, and eats in the dining room. Resident #4 was identified to be alert, cognitively intact and wears glasses. Therapy was identified as PT and OT. The Care Plan did not identify speech language pathologist (SLP). A document titled Observation Detail List Report dated 6/25/26 at 10:30 am for Resident #4 revealed the admission documentation by Staff Q, Registered Nurse (RN). Resident #4 was identified as having dysphagia without oral or dental issues. Resident #4 lung sounds were clear both upper lobes and diminished both lower lobes and denied shortness of breath. Resident #4 abdomen was soft with bowel sounds present. Incontinence of bowel and bladder was identified. Resident #4 denied having pain and was oriented to the facility. A document identified by Staff K, Assistant Director of Nursing (ADON) as the nursing communication sheet. The document identified Resident #4 on date 6/24/26, diagnoses of Atrial Fibrillation (irregular heart beat) and Diabetes without medication, pressure area on buttocks, pureed food, thin liquids and no straw. Resident #4 required assistance of two staff, identified aspiration risk, required oxygen (O2), moon boots, and was found unresponsive at home on the toilet. On 6/26/26 documented OK O2 1.5 liters. On 6/27/26 documented OK, oxygen saturation 98% on day shift. The evening shift documented Read Nurses Notes (NN), watch for aspiration, got wrong diet. Resident Information Sheet admission Information for Resident #4 dated 6/25/26. Identified Resident #4 was Diabetic, can eat in the bedroom or dining room and require assistance. Incontinent of bowel and bladder, use medium disposable briefs. Resident #4 had glasses, a front wheeled walker, a wheelchair, a two person assist for transfers, skin reposition every 2 hours, float heels, use a wheelchair cushion, moon boots, and pressure areas to both buttocks. Resident #4 had a pureed diet with thin liquids and no straws. The document was initialed by Staff A, CNA; Staff G, CNA; Staff N, CNA; Staff O, CNA; Staff P, CNA; and 2 unidentified initials. Change of Diet Form (Send changes to dietary promptly) dated 6/25/26 revealed Resident #4's diet as pureed food, thin liquids and no straws. The document was signed by Staff Q, Registered Nurse (RN) and Staff M, Culinary Assistant (CA).Progress notes for Resident #4 revealed: On 6/25/26 at 10:47 pm, Staff B, Licensed Practical Nurse (LPN) documented Resident on oxygen (O2) at 2 liters with saturation of 96%. Blood Pressure 132/70, pulse 67, respiration 18, Temperature 98.0. On 6/26/26 at 1:24 am, O2 saturation of 99% on 1.5 liters. Resident #4's respirations regular, non-labored and denied having pain. On 6/27/26 at 9:53 am, Staff I, RN documented Resident #4 was on O2 at 1.5 liters with no shortness of breath at rest. Resident #4 was weak on standing and transfer to the chair. Progress notes dated 6/27/26 for Resident #4 revealed: At 5:21 pm Staff A, CNA asked what diet that Resident #4 required. Staff B LPN informed Staff A the diet was pureed with thin liquids with no straws three times. Dietary staff were not at the steam table and Staff A prepared a plate of regular textured food for Resident #4 and fed it to her. Staff C dietary aide returned to the dining room, questioned the food texture and clarified with Staff B. Staff A responded no she's not and exited the dining room. Resident #4 appeared to be anxious, choking, coughed up phlegm and eggs, mouth breathing and had an oxygen level of 88%. Staff B placed an oxygen mask on Resident #4 and set the oxygen delivery to 3 liters. Resident #4's oxygen level rebounded to 92 % and was taken to her room by staff. Resident #4 stated she did not want to see Staff A again. At 6:31 pm Staff B, LPN removed the oxygen mask and placed a nasal cannula on Resident #4. Staff B documented an assessment of pink skin, oxygen level of 92% to 94% and unlabored breathing. Resident #4 had stopped coughing up food. At 20:38 pm, Staff B, LPN documented Resident #4 seemed anxious and oxygen level dropped to 86% and replaced the oxygen mask. Staff B offered to go to the emergency room with Resident #4 responding no. Staff B's assessment revealed lung sounds that were course in the lower lungs, BP 126/78, P 78, R 22, Sat 90% and Resident #4 continued to grab at her throat. The Director of Nursing) DON was notified earlier of Resident #4's condition. At 11:50 pm, Staff D, RN assessed Resident #4 O2 3 l with sat 75%, T97.7, Pulse 100, resp 22. Called the DON and the on call dr. Order to send to the hospital. Resident left the facility at 11:34 pm via ambulance. On 6/28/26 at 4:12 am Staff D, RN called the hospital and Resident #4 was admitted for aspiration pneumonia. On 6/28/26 at 11:36 am, Resident #4's sister took personal belongings and stated Resident #4 will not be returning to the facility and refused the bed hold. Hospital Emergency (ER) notes dated 6/27/26 at 11:42 pm revealed Resident #4 presented with aspiration. The Emergency Medical Service (EMS) reported on scene Resident #4 stated it felt like there was liquid in her lungs that occurred at dinner. Resident #4 stated she had 2 episodes of vomiting since dinner. Oxygen was set to 3 liters with her oxygen saturation at 72%. The EMS placed Resident #4 on 15 liters nonrebreather mask and her oxygen saturation was 95% on arrival to the ER. Resident #4 had symptoms that included cough, shortness of breath and wheezing. Resident #4's vital signs: blood pressure 124/59, heart rate 131, respirations 26 and temperature 99.1. At 3:09 am, the ER provider documented having an extensive discussion with Resident #4's family regarding a very poor prognosis due to aspiration pneumonia likely from aspirating at the nursing home. Resident #4's family wished for her to be admitted to the hospital.Hospital Course (included Reason for Hospitalization): Resident #4 was admitted on [DATE] for aspiration pneumonia and acute hypoxic respiratory failure (a sudden, life-threatening condition where the lungs cannot transfer enough oxygen into the bloodstream). Resident #4 was on 15 Liters of oxygen via a nonrebreather mask in the ER and transition to Airvo (high flow nasal cannula) at 50 L. Resident #4 had a [NAME] Blood Count of 28.7 (normal 4.5-11.0). Resident #4 was started on two intravenous (IV) antibiotics. The hospital provider documented as having a long discussion with Resident #4 and her family as they were unclear if Resident #4 was to be transitioning to comfort care or continuing full treatment. Resident #4 was severely deconditioned and on presentation could have passed away without immediate intervention. Resident #4 decided to be a Do Not Resuscitate (DNR) but still wanted full treatment up to that point. On 6/29/26, a review of nursing notes indicated Resident #4 had a general decline around 3:40 am and time of death was declared at 5:40 am from respiratory failure secondary to pneumonia. At discharge the final diagnosis was aspiration pneumonia.During an interview on 7/9/2026 at 3:23 pm, Resident #4's family member stated in the hospital her mother told her the dinner meal on 6/27/26 was not right, it was the sausage and it got her. The family member stated the girl CNA's were nice to her, but felt the incident, it was negligent care and was glad the incident was being investigated. During an interview on 7/13/26 at 1:01 pm, Staff Q, RN stated she had worked at this facility for 5.5 years. Staff Q stated she admitted Resident #4 and she had an order for pureed food and thin liquids with no straw. Staff Q stated she may have failed to document the diet on the basic care plan. Staff Q stated the CNA does not have the ability to see the basic care plan filled out when the resident was admitted . Staff Q stated a second set of papers were put into the huddle book to include if the resident would go to the in the dining room to eat and basic care. Staff Q stated a book for diets was located behind the nurse's station and the CNA review it. Staff Q stated the assignment sheets for the CNA's were in the same location. Staff Q stated if the CNA needed to know the diet a resident was on, ask the nurse or dietary. During an interview on 7/8/26 at 12:55 pm, Staff G, Certified Nursing Assistant (CNA) stated during the morning shift on 6/27/26, she assisted Resident #4 to eat and was doing really well on the puree diet.During an interview on 7/8/26 at 1:31 pm, Staff H, CNA stated she worked when Resident #4 was admitted to the facility. Staff H stated she assisted with the puree diet and Resident #4 consumed 100%. Staff H stated she did not work the weekend of 6/27/26. During an interview on 7/8/26 at 12:28 pm, Staff F, CNA stated she worked on 6/27/26 evening shift. Staff F stated she observed Staff A, CNA go behind the steam table and make a plate of food as the dietary staff not present in the area at that time. Staff F stated Resident #4 required assistance with the pureed diet and Staff A gave her a plate of regular food and fed it to her. Staff F stated when Staff P, Culinary Assistant (CA) returned to the dining room and seen Staff A giving Resident #4 regular food, she questioned Staff A then approached Staff B, Licensed Practical Nurse (LPN). Staff F stated she overheard Staff B say she is not to have that diet. Staff F stated Staff A was aware what he did was wrong. Staff F stated Staff A left the facility, in the middle of the shift, and did not return. Staff F stated Resident #4 coughed up egg throughout the evening, appeared fearful and did not want to be left alone. Staff F stated she stayed with Resident #4 until 8:15 pm.During a follow-up interview on 7/14/26 at 10:51 am, Staff F, CNA stated on 6/27/26 it was approximately 5:15 pm when Staff B, LPN became aware that Staff A, CNA fed the regular diet to Resident #4. Staff F stated when Resident #4 was returned to her room immediately after the incident, she did not want to be left alone and made the comment Please tell me I will not have to see him again. Staff F stated she had asked Resident #4 if she was aware that the food she just ate was not pureed foods and she said yes but thought he knew what he was doing because he works here. Staff F stated Resident #4 was very fearful to be left alone and was coughing up food. Staff F stated she asked Resident #4 multiple times if she wanted her family to be contacted and she said no I'll be ok. Staff F stated she did not think Resident #4 knew how bad she was. Staff F stated Resident #4 was taken to the nurse's station to be monitored until 6:45 pm, then returned to her room. During an interview on 7/8/26 at 2:35 pm, Staff I, RN Nurse Manager she had worked the day shift on 6/27/26 and conducted a skilled assessment on Resident #4. Staff I stated Resident #4 was alert, her lungs were little diminished without crackles and her O2 saturation was reading high 90's. Staff I stated she had a family member (Staff C) working in dietary department on the evening shift, who came home at 7 pm, and reported that she served Resident #4 pureed as ordered. Staff I stated Staff C stated she had left the dining room after shutting off the steam table and went to the main kitchen. Staff I stated Staff C reported she observed Staff A, CNA feeding Resident #4 a regular diet and informed Staff B, LPN immediately. Staff I stated Staff C told her the DON was notified and Staff A walked out and did not return. Staff I stated she returned to work on 6/28/26 when Resident #4's family member came to the facility and stated it's not good, we are not saving her bed. Staff I stated she called the hospital to get a notification the Resident #4 was admitted for aspiration pneumonia. Staff I stated she discharged Resident #4 to the hospital since the family was not going to do a bed hold. Staff I stated she directed Staff C and Staff E, Culinary Aides to write a statement of the incident and notified the Dietary Supervisor that she was getting statements from his employees so he was made aware. Staff I stated the DON was aware of the statements and directed to place the statements on her desk and she would address it on Monday 6/29/26. Staff I stated she did not report this incident to the State Survey Agency (SSA) stating she assumed the DON filed a report. Staff I stated the DON told staff Resident #4 was already aspirating on the thin liquids, that was what killed her. Staff I stated she completed Resident #4's skilled assessment on 6/27/26 and did not identify the signs or symptoms of aspiration. During an interview 7/9/26 at 3:55 pm, Staff A, CNA stated he had worked at the facility for nine months and given the facility his two-week resignation, last day would be 7/6/26. Staff A stated he was on vacation for three weeks and was sick for a few days. Staff A stated on 6/27/26 he was on the 2-10 shift assisting residents in the dining room for dinner. Staff A stated he heard during the shift report that Resident #4 did not eat the noon meal. Staff A stated he assisted Resident #4 with the first plate of food. Staff A stated Resident #4 was eating by herself under his supervision. Staff A stated Resident #4 asked for more food but the dietary aide was not present at that time. Staff A stated he asked Staff B, LPN what diet Resident #4 had ordered and Staff B stated a regular diet with thin liquids, no straw. Staff B stated he went to the steam table and plated the regular meal, eggs, bacon and tater tots. Staff A stated it was a full plate and Resident #4 consumed all of the food. Staff A stated he asked Resident #4 if she wanted the desert. Staff A stated Staff C, Culinary Assistant had returned to the dining room and heard the offering of dessert. Staff A stated Staff C said there was only certain foods Resident #4 can have due to the pureed diet order. Staff A stated he told Staff C that Staff B said regular diet. Staff A stated he inquired again and Staff B stated regular diet. Staff A stated Staff C took the dietary information ticket that was attached to the steam table to Staff B. Staff A stated he did not see the dietary card when he plated the food at the steam table. Staff A stated Staff C showed the dietary card to Staff B who responded, that is what I said pureed. Staff A stated he did not go behind the steam table before that evening but was not aware he could not do that. Staff A stated Resident #4 coughed a little after she was done eating but it did not alert him. Staff A stated when he took a break, Resident #4 was receiving a nebulizer treatment. Staff A stated Staff F, CNA, Staff T, CNA and Staff U, CNA were working with other residents and took Resident #4 to her room. Staff A stated there was another resident eating so he could not leave the area but when finished, he helped to get the resident back to room. Staff A stated he asked to go to break and did not know what happened after that. Staff A stated when he returned from break, Resident #4 was still at the nurse station on a nebulizer. Staff A stated Staff B was sitting at the nursing desk. Staff A stated he left because he felt there was drama and did not feel comfortable being at the facility. Staff A stated he had text messaged the DON about the situation and he was leaving. Staff A stated the DON texted back stating Staff B had told her what happened. Staff A stated he was not sure to be 100% accurate about the content of the text. Staff A stated he had anxiety and left the facility and did not return. Staff A stated he had a different job not in the health care setting. During an interview on 7/8/26 at 5:03 pm, Staff B, LPN stated she had been employed at this facility for over 2 yrs and verified she was the charge nurse on the evening shift on 6/27/26. Staff B stated Staff A, CNA asked if Resident #4 could have a tray. Staff B stated she verified Resident #4's diet as puree, thin liquids and no straw and Staff A said I don't think so and she checked again. Staff B stated she was the only nurse on duty and the pharmacist was bring in medications and she was charting. Staff B stated she remembered Staff C, Culinary assistant had inquired about Resident #4's diet since she seen Staff A feeding Resident #4 a regular diet of eggs, sausage and tater tots. Staff B stated she looked it up again, verified a pureed diet and Staff A covered his face with his hand. Staff B stated Staff C returned to her work and Staff A got up from the table and walked down the hall. Staff B stated Resident #4 requested to go to her room. Staff B stated she did not look at Resident #4's plate to see what was left. Staff B stated the other two CNA's propelled Resident #4 in her wheelchair to her room at approximately 6 pm and reported Resident #4 was coughing up food. Staff B stated Resident #4 was coughing up egg and phlegm and her oxygen saturation was 89% to 92%. Staff B stated Resident #4 was very anxious and the CNA's were able to relax her. Staff B stated Resident #4 made the statement she did not want to see that man again so she notified the DON. Staff B stated the DON inquired why did Staff A plate Resident #4's food, he should have not gone in the back of the steam table and he should have looked at the dietary card. Staff B stated she informed Staff A what the DON and Staff A responded, ok, I'm going on break. Staff B stated Staff A did not return at 6:30 pm from his break. Staff B stated the CNA's attempted to call Staff A but he did not answer the calls. Staff B stated she was observing Resident #4 at the nurse station until approximately 7:30 pm. Staff B stated she had to do the medication pass so she directed the CNA's to assist Resident #4 to bed. Staff B stated she checked on Resident #4 approximately every half hour and her oxygen saturation reading low 90%. Staff B stated she stopped in the middle of the medication pass, after 7 pm, to phone an update to the DON regarding Resident #4's condition and reported Staff A did not return from break. Staff B stated she informed the DON Staff A does what he wants when he wants. Staff B stated she told the DON she was angry because Staff A does not listen. Staff B stated she completed an assessment of Resident #4's lungs and it was course in her lower lobes. Staff B stated Resident #4 was very anxious using a Kleenex as she coughed up the phlegm and her skin color was pale but she was always pale. Staff B stated she did not call the physician. Staff B stated she reported to Staff D, RN at 10 pm. Staff B stated she could not remember when Staff D provided her assessment of Resident #4 but it was not immediately after report. Staff B stated Staff D informed her that Resident #4's oxygen saturation was low so she called DON who told Staff D to send Resident #4 to the hospital. Staff B stated Staff D called the on-call physician and received the order. Staff B repeated she did not call the physician. Staff B stated Resident #4 did not return from the hospital and the family did not hold the bed. Staff B stated she was unaware of Resident #4's condition after discharge but the DON had informed the staff that it looked like there was fluid in her lungs. During an interview on 7/13/26 at 2:22 pm, Staff U, CNA stated she worked on 6/27/26 evening shift. Staff U stated she had provided are for Resident #4 and was aware she was on a pureed diet. Staff U stated Staff A, CNA was one that offered quite a bit to sit in the dining room to assist residents to eat when there were residents waiting to get up from bed to eat dinner. Staff U stated if the diet was not listed on a new care plan, each resident will have a meal ticket that arrives with the plate of food and has the diet order on it. Staff U stated she saw Staff A feeding Resident #4 and she was coughing. Staff U stated Staff A called on the walkie stating Resident #4 was ready to return to her room. Staff U stated Staff A did not report anything about Resident #4 eating the wrong diet. Staff U stated she was propelling Resident #4 back to her room and could see her coughing up food. Staff U remembered asking Resident #4 if she wanted to lay down and she said no. Staff U stated Staff F, CNA was assisting, called the nurse in and a basin to spit the food out. Staff U stated Resident #4 was gagging, throwing up and she was struggling to breath. Staff U stated Resident #4 was on oxygen with a tube in her nose and Staff B, LPN placed a mask on her. Staff U stated Staff B was checking Resident #4's oxygen saturations but did not place a stethoscope to her chest to listen to her breath. Staff U stated staff took Resident #4 to the nurse station and Staff F would take turns sitting with her while Staff B was passing pills. Staff V, CNA arrived to work, she was new and did not know much about what was going on. Staff U stated Resident #4 was not choking and her oxygen saturation was better so Staff B directed Staff V to help transfer Resident #4 to bed with the head up high. Staff U stated when Resident #4 was breathing, she was wheezing, and usually she did not have that much difficulty. Staff U stated Resident #4 had a soiled brief and Staff T, CNA changed her quickly but she was struggling to breath. Staff U stated she asked Resident #4 if she needed to cough but she was unable to spit anything up. Staff U stated Staff T assisted to sit Resident #4 up high in the bed. Staff U stated Resident #4 was anxious, her breathing was bad and felt it was likely that Resident #4 would have been sent out. Staff U stated she was worried about Resident #4 stating, I was sick to my stomach that whole night. Staff U stated Resident #4 looked scared and said not leave her alone. Staff U stated Resident #4 told Staff F, don't let me see that man again and that she thought he would know what he was doing. Staff U stated told the night nurse about the incident. During an interview on 7/14/26 at 12:11pm, Staff C, Culinary Assistant (CA) stated she provided meal service from the steam table on 6/27/26. Staff C stated at 5:15 pm she made sure everyone had the right food, turned the steam table off, and went to the kitchen to get something for a resident. Staff C stated Staff E, CA was passing trays and Staff A, CNA was assisting Resident #4 with her pureed food. Staff C stated when she returned, Staff A was giving Resident #4 regular eggs. Staff C stated she asked Staff A why he had that as Resident #4 received pureed food and the response was that he asked Staff B, LPN. Staff C stated at that time there was still food, eggs, on the plate. Staff C stated Staff B was sitting at the nurse station and when inquired about the diet order, Staff B stated she told Staff A what it was. Staff C stated she returned to the steam table, the dietary card attached with tape and showed it to Staff B who said oh yeah pureed. Staff C stated Staff A was giving Resident #4 a regular diet. Staff C stated when she returned to the dining room, there was nothing left on Resident #4's plate and Staff A said nothing when he was shown the diet card. Staff C stated Staff B did not come into the dining room to assess Resident #4. Staff C stated the CNA's took Resident #4 back to her room and Staff A left the facility appearing to be upset. Staff C stated she was [AGE] years old and did not feel Staff B was listening to her so she returned to her work.During an interview on 7/8/26 2:11pm, Staff D, RN stated she worked on 6/27/26 at 6 am-2 pm shift and she observed Resident #4 was in dining room for her meals. Staff D stated Staff I, RN was at the facility and completed Resident #4's skilled assessment. Staff D stated she went home to sleep and returned at 10pm. Staff D stated during report, Staff B, LPN told her that Resident #4 was served a regular diet at dinner and the oxygen saturation level dropped. Staff D stated finding Resident #4 in bed wearing an oxygen mask, looked very anxious, blue/grey lips, and low O2 saturation level of 78%. Staff D stated Resident #4 was by herself, no one in the room with her and she appeared so scared. Staff D stated she listened to Resident #4's lungs, hearing very low crackles and wheezes in both. Staff D stated did not discuss it with Staff B. Staff D stated she called the on-call physician and the ambulance took about 10-15 minutes. Staff D stated she directed the CNAs to stay with Resident #4 while she called the family. Staff D stated the family asked what was wrong and responded she was having respiratory distress. Staff D stated she did not tell Resident #4's family she was served regular food. Staff D stated she returned to Resident #4's room to find the Emergency Medical Service (EMS) had Resident #4 on the gurney. Staff D stated she gave a report to EMS. Staff D stated Resident #4 was very anxious, looked scared I felt so bad for her. Staff D stated she gave reassurance to Resident #4; to go to hospital and she hardly had the air to say ok. Staff D stated she had notified the DON that Resident #4 was sent to the hospital.During an interview on 7/14/26 at 11:26 pm, Staff K, Assistant Director of Nursing (ADON) stated she was not the on-call nurse on 6/27/26 and became aware of the incident on Monday 6/29/26. Staff K stated she absolutely would call the doctor when the aspiration happened. Staff K stated she did not know why [NAME] RN didn't call the doctor. During an interview on 7/13/26 at 1:38 pm, Staff S, Culinary Assistant and CNA stated the CNA was not allowed in the kitchen or near the steam table. Staff S stated she worked as need as a CNA and when she was scheduled as a CNA, she didn't don't go near the kitchen. Staff S stated CNA's can go to the cupboards to get a cup but not near the steam table. Staff S stated, There are bo

Based on observation, clinical record review, staff interview, manufacturer's inserts, and policy review the facility failed to ensure the full dose of insulin was given by failing to hold the insulin pen needle in the skin for the recommended period of time for 1 of 5 residents (Resident #9) observed for medication administration. The facility reported a census of 23 residents.Findings include:1. The Minimum Data Set (MDS) dated [DATE] revealed Resident #9's diagnosis of diabetes and documented Resident #9's use of insulin. Review of April 2026, Medication Administration Record (MAR) revealed Resident #9's orders to receive Novolog FlexPen (rapid acting insulin) 28 units subcutaneous (under the skin) twice daily and Tresiba FlexTouch pen (long acting insulin) 80 units subcutaneous once daily for diabetes. During an observation on 4/2/26 at 8:01 AM, Staff A, Registered Nurse (RN) prepared Resident #9's Novolog pens, one pen had 6 units remaining and a new pen was used, set for 22 units to total 28 units as ordered and the Tresiba was prepared to administer 80 units. Staff A, RN, administered both Novolog pens to Resident #9's right lower abdomen and the Tresiba to her left lower abdomen removing the pen needles from the skin within 2-3 seconds of injecting the insulin. Review of Novolog FlexPen Manufacturer insert directed after preparing the insulin pen, to insert the needle into the skin, inject the dose by pressing the button all the way in until the dose selector reads 0, then keep the needle in the skin at least 6 seconds while keeping the button pressed all the way in until the needle has been pulled out from the skin. This will make sure that the full dose has been given. Review of Tresiba FlexTouch Manufacturer insert directed after preparing the insulin pen, insert the needle into the skin, press and hold down the dose button until the dose counter shows 0. Keep the needle in the skin after the dose counter has returned to 0 and slowly count to 6. When the dose counter returns to 0, you will not get your full dose until 6 seconds later. In an interview on 4/2/26 at 11:20 AM, the Director of Nursing (DON) reported, when administering insulin pens, nurses need to hold the insulin pen in place for 10 seconds after injection, to ensure the full dose is administered. Review of facility provided Insulin Pen Policy, reviewed 9/30/25, directed staff to inject the insulin by pushing the button on the insulin pen all the way in. Keep the button pressed and count to 10 before removing the needle from the skin.

Based on clinical record review, observation, family interview, staff interview and policy review the facility failed to provide appropriate services to maintain or improve resident abilities with ambulation for 1 of 1 residents reviewed for rehab/restorative. (Resident #29). Findings include: The Minimum Data Set (MDS) for Resident #29 admission to the nursing facility from assisted living dated 02/27/25 listed diagnoses included non-Alzheimer's dementia, peripheral vascular disease, osteoarthritis, muscle weakness, unsteadiness on feet and fibromyalgia. Functional abilities section of the MDS coded partial, moderate assistance for transferring and supervision or touching assist to walk 10-150 feet once standing. The Brief Interview for Mental Status (BIMS) exam scored 6 out of 15 indicated severe cognitive impairment. The Care Plan last revised 3/10/25 documented goal, functional maintenance plan established per occupational, physical therapy recommendations and directed encourage exercise group five times weekly. Resident has limited mobility in her right ankle and requires the use of an Ankle Foot Orthosis (AFO) for extra support with walking. Goal will safely transfer and walk with assistance of one and her walker using the AFO. A Physician Order 2/19/25 for Resident #29 move from assisted living memory care to the nursing facility included standby physical assist, to and from meals and activities, required direction with walker. The Base Line Care Plan dated 2/20/25 directed to maintain current functional status, activities of daily living included transfer assist of one person, walking assist of one person, used four wheeled walker. An Observation Detail List Report, Admission Functional Abilities assessment dated [DATE] for Resident #29 documented supervision or touching assistance for ambulation 10-150 feet. A Functional Maintenance Plan (FMP) dated 2/21/25 directed group exercise (seated) five times weekly. A Progress Note dated 3/6/25 at 1:17 PM documented during care conference discussion included Resident #29 family reported resident was walking with supervision from her room to dining and activities nearly daily at the assisted living. A response documented Certified Nursing Assistants (CNA's) will attempt and if Resident #29 is too weak will request and order for therapy consult. The Point of Care History documented activity for Resident #29, look back 3/2/25 to 3/13/25. a. Section Titled: How did resident walk in room was unanswered or activity did not occur for the following dates: 3/2/25; 3/4/25; 3/6/25; 3/8/25; 3/10/25; 3/12/25; 3/13/25. b. Section Titled: How did resident walk in the corridor was unanswered or activity did not occur for the following dates: 3/2/25; 3/3/324; 3/4/25; 3/6/25; 3/8/25; 3/9/25; 3/10/25; 3/11/23; 3/12/25; 3/13/25 During an observation on 3/13/25 at 10:15 AM Resident # 29 sitting in the common area, Director of Nursing (DON) confirmed after inquiry that resident was not wearing the AFO had socks, no shoes. In an interview on 3/10/25 at 2:42 PM family relayed Resident #29 wears an AFO for right ankle support when up, reported therapy was mentioned at a care plan meeting and was not certain of any decisions regarding therapy. In an interview on 3/13/25 at 10:18 AM the Director of Nursing (DON) relayed Resident #29 is not wearing shoes so did not need the AFO on. The DON relayed the resident can stand and pivot to transfer, does not walk. Queried about Resident #29 restorative or exercise program, the DON referred to the FMP order in the therapy book that directed seated group exercises only, five days a week. The DON stated Resident #29 is new to the facility and would be evaluated for therapy if not transferring well. DON relayed understanding that Resident #29 admitted not walking. The DON said was aware family did say resident was walking but, is not sure of that. In an interview on 03/13/25 at 10:36 AM with the Director of Assisted Living Facility (ALF) Registered Nurse (RN) Staff A relayed Resident # 29 had increased urinary, fecal incontinence with advancing dementia, cognitive changes led to more care needs. Staff A relayed Resident #29 did walk while at the ALF, usually 50-75 feet daily to all meals and activities and wore an AFO daily for ankle support. In an interview on 03/13/25 at 11:49 AM Therapy Staff B relayed did evaluate Resident #29 at admit to the facility, recommended group exercises five days a week, further explained the group exercises are done while residents are seated, may use hand weights and balls, relayed walk to dine may be appropriate for residents that walk. Staff B relayed the nursing staff will come to therapy for a plan and consideration is taken for such things as resident willingness and abilities to do things in the past. Relayed the facility does not have restorative aides. Staff B did not believe Resident #29 was walking and did not see any doctor's orders stating otherwise. In an interview on 03/13/25 at 1:10 PM with the DON and the Administrator, both acknowledged understanding of benefits of residents maintaining abilities. The DON voiced the family was aware Resident #29 was not wanting to walk. The Administrator and DON relayed had impression that Resident #29 was not walking prior to admit. The DON stated there was obviously lack of communication, had thought family was aware resident was not walking at the nursing facility. The DON confirmed therapy was not recommended other than the seated exercises. Facility Policy Subject: Restorative Nursing/Functional Maintenance Program Review, date reviewed 3/8/24 documented, It is the policy to provide residents with appropriate programs to achieve skills enabling their highest level of function.

Based on clinical record review, staff interview, and policy review the facility failed to notify the Long Term Care Ombudsman of discharge/transfer of residents as required for 2 of 3 residents reviewed who were discharged or transferred from the facility (Residents #2, and #23). The facility reported a census of 23 residents. Findings include: 1. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had an unplanned discharge to the hospital and reentered the facility on [DATE]. The Census List on the resident's electronic medical record revealed Resident #2 hospitalized [DATE]-[DATE]. Review of the Notice of Transfer Form to the Long Term Care (LTC) Ombudsman, dated [DATE], lacked documentation of Resident #2's discharge to the hospital on [DATE] as required by federal regulation. 2. Review of the MDS assessment dated [DATE] revealed Resident #23 had expired on [DATE]. The Census List on the resident's electronic medical record revealed Resident #23 was transferred to the hospital and later expired on [DATE]. Review of the Notice of Transfer Form to the Long Term Care (LTC) Ombudsman, dated February 2025, lacked documentation of Resident #23's transfer to the hospital and expiration on [DATE] as required by federal regulation. In an interview on [DATE] at 4:02 PM the Administrator acknowledged the Notice of Transfer Form to the Long Term Care (LTC) Ombudsman for [DATE] and February 2025 lacked documentation of Resident #2 and Resident #23's transfers and discharges and stated these residents should have been included. Review of Facility provided Discharge planning and Ombudsman Notification policy, reviewed [DATE], stated notification to Ombudsman related to discharge or transfer for emergency transfers to emergency room or hospital from the facility or from an appointment or other outside provider, facility will complete notice of transfer even in the Electronic Health Record (EHR), once per month Health Information Management will submit a list of emergency transfers to the Office of the Ombudsman.

Based on observations, clinical record review, and resident interviews, the facility failed to answer call lights within a reasonable amount of time. (Residents #5, #6) The facility census was 22. Findings include: 1. According to a Minimum Data Set (MDS) with a reference date of 12/14/23, Resident #6 had a Brief Mental Status (BIMS) score of 15 indicating an intact cognitive status. Resident #6 required maximal assistance with transfers, mobility, dressing, toilet use and personal hygiene needs. Resident #6's diagnosis included congestive heart failure, diabetes mellitus, and chronic obstructive pulmonary disease. During an interview on 3/6/24 at 1:00 p.m. Resident #6 stated call lights are usually answered within 10-15 minutes, but have been known to take up to 30 minutes plus, although no specific dates or times were provided. During an observation on 3/6/24 at 1:46 p.m. the call light monitor at the nurse's station indicated call lights had been activated for room [ROOM NUMBER], 21 minutes earlier and room [ROOM NUMBER] (Resident #6), 19 minutes earlier. Staff responded to room [ROOM NUMBER] to transfer the resident. The Administrator responded to room [ROOM NUMBER], who was wanting to be transferred into his recliner. Staff arrived to room [ROOM NUMBER] to transfer the resident into his recliner at 2:04 p.m., 39 minutes after his call light was first activated. 2. According to a MDS with a reference date of 12/14/23, Resident #5 had a BIMS score of 15 indicating an intact cognitive status. Resident #5 required extensive assistance with transfers, mobility, dressing, toilet use. Resident #5's diagnosis included congestive heart failure, renal insufficiency, and chronic obstructive pulmonary disease. During an observation on 3/7/24 at 8:30 a.m. the call light monitor at the nurse's station indicated Resident #5's call light had been activated 21 minutes earlier. Resident #5 was anxious, stating she needed a breathing treatment. The call light was answered 23 minutes from time of activation.

Based on clinical record review, policy review, and staff interview, the facility failed to ensure 3 of 5 residents were offered up to date pneumococcal vaccinations (Residents #4, #5, #6). The facility reported a census of 24 residents. Findings Include: 1. Resident #4's Face Sheet listed her age as [AGE] years old. The Immunization Record for Resident #4 stated she received PCV13 (a type of pneumonia vaccination) on 3/15/16 and 11/16/17. The resident's clinical record lacked further documentation of additional pneumococcal vaccines offered or administered. 2. Resident #5's Face Sheet listed her age as [AGE] years old. A Preventive health Care document stated the resident received PPSV23 (a type of pneumonia vaccination) on 9/14/10. The resident's clinical record lacked further documentation of additional pneumococcal vaccines offered or administered. 3. Resident #6's Face Sheet listed her age as [AGE] years old. A Preventive Health Care Document, created 2/13/23, stated the resident received a pneumococcal vaccine on 9/11/2017. The form lacked documentation of which pneumococcal vaccine the resident received. The resident's clinical record lacked further documentation of additional pneumococcal vaccines offered or administered. The Centers for Disease Control and Prevention(CDC) guidance Pneumococcal Vaccination: Who and When to Vaccinate, reviewed 2/13/23, listed the following guidance: For adults who only received PCV13 give 1 dose of PCV20(a type of pneumonia vaccination) or PPSV23 at least 1 year after PCV13. For adults who only received PPSV23, give 1 dose of PCV15(a type of pneumonia vaccination) or PCV20 at least 1 year after the most recent PPSV23 vaccination.(Retrieved from https://www.cdc.gov/vaccines/vpd/pneumonia/hcp/who-when-to-vaccinate. html on 9/21/23). The facility policy Pneumococcal Vaccine, revised 6/22/23, stated the facility would offer resident immunization against pneumococcal disease in accordance with the current CDC or state guidelines and recommendations. On 9/21/23 at 11:34 a.m., the Infection Preventionist stated residents should be up to date on their vaccinations if they wished to receive them.

Based on personnel file review and staff interview, the facility failed to ensure the Infection Preventionist completed specialized training in infection prevention and control. The facility reported a census of 24 residents. Findings Include: In email correspondence on 9/21/23 at 8:38 a.m., the Administrator stated the Infection Preventionist started this role in April of 2023. She stated she did not have the certificate because the facility thought she had 6 months to complete this. In email correspondence on 9/21/23 at 2:33 p.m., the Administrator stated the facility utilized the regulatory requirements regarding Infection Preventionist training but stated she would check with the home office if other policies would be applicable.

Based on clinical record review, policy reviews, and staff interviews, the facility failed to carry out assessments in accordance with professional standards for 1 of 3 residents reviewed for pressure ulcers (Resident #1). The facility reported a census of 24 residents. Findings: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue). may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound bed. Other staging considerations include: Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The MDS assessment tool, dated 3/30/23, listed diagnoses for Resident #1 which included diabetes, hip fracture, and malnutrition. The MDS stated the resident had 1 unhealed Stage 2 pressure ulcer and listed the resident's Brief Interview for Mental Status (BIMS) score as 14 out of 15, indicating intact cognition. The facility policy Skin Integrity, revised 8/5/22, stated the facility utilized an interdisciplinary approach to promote best practice in areas of skin injury prevention and promotion of healing. The policy stated staff would complete skin assessments for new admissions weekly x 4 and stated wound assessments should include: location, length, width, depth, drainage, odor, and wound edges. The undated Baseline Care Plan stated the resident admitted to the facility on [DATE] and had a dressing to the sacrum (area above the tailbone). The Care Plan directed staff to turn and reposition every 2 hours and provide an air mattress. A 3/24/23 Progress Note stated the resident admitted from the hospital and had an open area on the sacrum measuring 1 inch x 1/4 (unit not specified). The note stated the area surrounding the open area was red to deep purple. The resident's Face Sheet stated she discharged from the facility on 4/6/23. The facility lacked further assessments of the wound from 3/24/23-4/6/23. On 9/21/23 at 11:30 a.m. the Director of Nursing (DON) stated she completed the resident's initial wound assessment. She stated she should have had more assessments but it was not triggered and stated she did not know how this happened.

Based on observation and staff interview, the facility failed to hold hot food at a temperature high enough to ensure prevention of bacterial pathogen growth. The facility reported a census of 18 residents. Findings include: On 11/24/19 at 11:38 a.m., Staff A, Homemaker, observed turning on the steam table in the dining room prior to transferring food from the kitchen warmer to the steam table. Staff A reported she didn't realize the steam table had not been turned on by the employee that had been working in the dining room earlier in the day. Lunch service began at 12:05 p.m. and ended at 12:37 p.m. on 11/24/19. During an observation on 11/24/19 , Staff A took temperatures on all of the food items directly after serving all the residents in the dining room. The temperature of the chicken was 120.2 degrees Fahrenheit. In an interview with the Certified Dietary Manager (CDM) on 11/24/19 at 1:10 p.m. she revealed the expectation would be for holding temperatures to be 135 degrees or above on the steam table. On 11/26/19 at 10:47 a.m., Staff B, Cook revealed 15 residents were served chicken for lunch that day. Food Preparation and Service policy dated 1/1/2019 revealed the danger zone for food temperatures is between 41 degrees and 135 degrees Fahrenheit. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. The longer food remains in the danger zone the greater the risk for growth of harmful pathogens. The FDA 2013 Food Code, deemed that a standard practice in the foodservice industry is all potentially hazardous hot food must be held for service at a minimum of 135 degrees Fahrenheit. The facility failed to ensure food was held at a high enough temperature.

Based on observation, interview and record review, the facility failed to develop a comprehensive person-centered assessment of resident's needs in 2 out of 10 residents (Resident's #17 and #122). The facility reported a census of 18 residents. Findings include: 1. A Minimum Data Set ((MDS) dated [DATE], documented Resident #17 with a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. [DIAGNOSES REDACTED]. The MDS further documented that insulin injections were given in 7 of the last 7 days. A Care Plan for Resident #17 with an edited date of 11/21/19, documented Resident #17 required a diabetic restriction on her diet related to a [DIAGNOSES REDACTED]. In an interview on 11/25/19 at 4:15 p.m., the MDS Coordinator stated she did not care plan the use of insulin or the signs or symptoms of the medication for Resident #17. The MDS Coordinator stated she understood why it should be care planned for this resident and that she failed to have it care planned. In an interview on 11/26/19 at 8:30 a.m., the Director of Nursing (DON) stated she was made aware of insulin and diabetes not being included in individualized Care Plans for residents who use insulin and carry a [DIAGNOSES REDACTED]. 2. A MDS 11/19/19, documented Resident #122, documented Resident #122 with a BIMS score of 13, indicating intact cognition. [DIAGNOSES REDACTED]. This resident required limited assistance of 1 staff for bed mobility, dressing and personal hygiene. An observation on 11/24/19 at 11:30 a.m., revealed the resident sitting in his room with an eye mask over his eyes. The lights were off in his room. A message was written on his white board next to his bed stating the resident sleeps with his eyes open. At 12:10 p.m. on the same day, observed Resident #122 seated in the dining room wearing glasses. Resident's head was bent forward and resident was holding his hand to his forehead. On 11/25/19 at 10:29 a.m., Resident #122 observed sitting in his recliner in his room wearing an eye mask over his eyes. The lights were off in his room and the door was open. On 11/25/19 at 1:40 p.m., this resident's wife stated that resident has been using the eye mask for years. The wife said he has bad [MEDICAL CONDITION]. She said the resident puts on and tasks off the mask by himself as he desires. The resident's wife stated she supplies the masks. On 11/25/19 at 2:20 p.m., an observation revealed the resident resting in his bed wearing the eye mask. Wife stated she wrote the message on his white board regarding the resident sleeps with his eyes open. She stated it was written on a white board in the hospital and she felt it was a good idea. She said it can be deceiving if you walk in to his room and see his eyes are open as it may give the impression he is awake when he may not be. Review of the Care Plan for Resident #122 with a problem start date of 11/14/19, directed staff to assure the resident's glasses are clean and kept within reach of resident. It also directed that resident had 3 different eye drops ordered. The goal on this Care Plan stated resident will see well enough to participate in activities of daily living. This Care Plan includes a [DIAGNOSES REDACTED]. The Care Plan did not include that the resident slept with his eyes open or that he uses an eye mask. On 11/25/19 at 2:35 p.m., the DON acknowledged that both the eye mask and the fact that the resident sleeps with his eyes opened should be care planned. The DON acknowledged neither of these facts were included on this resident's Care Plan. The facility failed to develop a person centered care plan for Resident #17 and Resident #122.

Based on observation, clinical record review, resident and staff interview, the facility failed to provide complete oral care for one of five residents reviewed. (Resident # 17) The facility census was 22 resident. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #17 had short and long term memory problems and required extensive assistance with personal hygiene needs. The Care Plan dated 7/14/18, directed staff to apply denture adhesive if the resident desires. During observation on 10/1/18 at 11:59 a.m., the resident was at the dining table. Observation revealed the residents dentures was falling out of their mouth. During observation on 10/2/18 at 11:53 a.m., the resident sat by the front door of the facility. Observation revealed the residents dentures was falling out. During observation on 10/2/18 at 12:15 p.m., the resident had 3/4 tube of denture paste sitting on the counter of their bathroom. During observation on 10/3/18 at 7:38 a.m., Staff B, Certified Nurses Aide, CNA removed the residents dentures from the cup, rinsed the dentures and patted the dentures dry with a paper towel. Staff B applied new gloves and placed the dentures in the residents mouth without applying or offering denture paste. During observation on 10/3/18 at 11:00 a.m., the resident sat near the front door asleep with their dentures falling out. During interview on 10/3/18 at 2:02 p.m., the resident stated it bothered them when their dentures was not snug in their mouth. During interview on 10/3/18 at 2:57 p.m., the Director of Nursing (DON) expected staff to ask and offer the denture paste daily.

Based on clinical record review and staff interview, the facility failed to complete a Minimum Data Set (MDS) for discharge on one resident. (Resident #1) The facility census was 22 residents. Findings include: 1. Clinical record review revealed Resident #1 was admitted for skilled care on 4/17/18. The resident was discharged to home on 5/4/18 and no discharge MDS was submitted. During interview on 10/3/18 at 2:03 p.m., the Director of Nursing (DON) acknowledged the missing MDS was not done timely. The DON stated it was an oversight and should have been completed upon discharge.

Based on clinical record review and staff interview, the facility failed to complete the required quarterly Minimum Data Set (MDS) when due. The facility census was 22 residents. Findings include : The minimum data set (MDS) assessment dated [DATE], documented Resident #2' most recent MDS. The Assessment due screen in the computer program listed the Quarterly MDS assessment was due on 8/16/18. The MDS activity report listed a quarterly MDS with an Assessment Reference Date (ARD) of 10/2/18 in progress, 139 days after the last ARD of 5/16/18. During interview on 10/3/18 at 2: 48 p.m., the Director of Nursing (DON) reported making the MDS schedule based on software reports. The DON stated the Social Worker identified not having a Care Conference for the resident in a while.

Based on observation and staff interviews, the facility failed to maintain a clean and sanitary kitchen. The facility census was 22 residents. Findings include: 1. Observation on 8/7/17 at 11:20 a.m., with the Dietary Manager revealed the following concerns: a. The two compartment sink was soiled around the inside walls of the sink. The sink was used for draining pasta and hamburger and washing vegetables, fruits and other food items. At the time the Dietary Manager stated the sink could use a good scrubbing. b. The Silver Star convection ovens in the kitchen revealed grease build up on the inside of the top and bottom doors, covering the glass and the area around the glass. Burnt debris was noted on both of the oven's bottom shelf on the inside. At the time the Dietary Manager stated staff cleaned the convection oven on Sunday. c. The dishwasher motor and shelf the motor sat on had calcium build up on the top of the motor and shelf. At the time the Dietary Manager stated staff clean the area as time allowed. d. The upright True Refrigerator had milk rings and food debris on the bottom shelf. The Beverage Air Freezer next to the refrigerator had frozen food debris on the bottom shelf. At the time the Dietary Manager stated the refrigerator and freezer was to be cleaned weekly. On 8/8/17 at 11:45 a.m., staff brought resident meals to the dinning area in the Carter Hoffman hot box. Observation revealed burnt on food debris covering the inside bottom shelf. Observation of the second hot box noted burnt on food debris covering the inside bottom shelf. At the time the Dietary Manager stated staff was not cleaning the inside of the hot box and both need to be cleaned.

Based on clinical record review, resident interview, group interview, and staff interview, the facility failed to ensure 2 of 9 sampled residents (Residents #6 and #2) received individualized, meaningful activity programs and failed to document routine quarterly activity assessments for 8 of 9 current residents reviewed (Residents #6, #2, #3, #7, #1, #4, #5, #9). The facility reported a census of 23 residents. Findings include: 1. Only comprehensive Minimum Data Set (MDS) assessments assess activity preferences. The most recent comprehensive MDS dated [DATE] for Resident #6 documented, under Preferences for Activities, the resident felt it was very important to: have books, newspapers, and magazines to read; keep up with the news; go outside to get fresh air when the weather was good; and participate in religious services or practices. The quarterly MDS assessment dated [DATE] for Resident #6 recorded a Brief Interview for Mental Status (BIMS) score of 7; indicative of severe cognitive impairment. The MDS identified [DIAGNOSES REDACTED]. The care plan activities problem area edited 7/12/16 identified the resident at a risk for lack of participation in activities due to little interest or pleasure in doing things. The approach directed staff to: inform the resident of daily activities and provide assistance as needed to attend; encourage to go to common areas to visit with other residents to promote socialization; remind of newspapers available to read; and on nice days, make an effort to take the resident outside to enjoy the weather. In an interview on 8/8/16 at 2:05 p.m., Resident #6 stated s/he gets tired of bingo and balloon volleyball so therefore does not participate in activities. Resident #6 commented s/he grew up on a farm and would love to be outdoors more. Resident #6 said s/he never gets to go outside for more than a very few minutes. Review of the resident's clinical record revealed no quarterly activity progress notes completed for the year. The record lacked documentation of the resident's progression toward individual activity goals and preferences. In an interview on 8/10/16 at 1:37 p.m., the Activity Director stated she just started in February 2016 and still learning what to include in progress notes and how to individualize programs. The Activity Director acknowledged there had not been a lot of variety in activities in the morning other than balloon ball exercises. 2. The most recent comprehensive MDS dated [DATE] for Resident #2 documented, under Preferences for Activities, the resident felt it was very important to: listen to music; do things with groups of people; do favorite activities; and go outside to get fresh air when the weather was good. The quarterly MDS assessment dated [DATE] recorded a BIMS score of 9, indicative of moderate cognitive impairment. The MDS documented [DIAGNOSES REDACTED]. The care plan activities problem area edited 7/8/16 identified the resident at a risk for decline in quality of life due to declining ability to self-initiate favorite activities. The approach directed staff to: remind the resident of daily exercise program; remind of favorite TV programs including Wheel of Fortune, and music shows; encourage to attend and actively participate in a variety of activities throughout the day; and at the monthly council meeting, encourage the resident to give feedback regarding preferred activities. Review of the resident's clinical record revealed only 1 quarterly activity progress note for the year that recorded only the following: attends a variety of group activities with (spouse) including live entertainment and balloon ball. The record lacked documentation of the resident's progression toward individual activity goals and preferences. During group interview on 8/8/16 at 2:00 p.m. the resident stated he/she wanted more exercises and other activities so she/he does not have to sit all the time. During observation on 8/9/16 at 11:30 a.m. the resident walked to the dining room and stated he/she was tired of sitting. The resident stated he/she wanted some exercise. 3. The most recent comprehensive MDS dated [DATE] for Resident #3 documented, under Preferences for Activities, the resident felt it was very important to: have books, newspapers, and magazines to read; listen to music; and participate in religious services or practices. The quarterly MDS assessment dated [DATE] recorded a short term memory problem with cognitive daily decision making skills moderately impaired. The MDS documented [DIAGNOSES REDACTED]. The care plan activities problem area created 3/10/16 identified the resident at a risk for lack of participation in activities due to decline in function and cognition. The approach edited 7/11/16 directed staff to: inform the resident of daily activities; offer assist to attend; encourage resident to go to common area to visit with other residents; turn on the radio when the resident in his/her room; offer the TV game shows and Sunday a.m. worship services; and to contact activity staff to arrange for 1:1 (one-to-one) visits. Review of the resident's clinical record revealed only 2 activity progress notes for the year dated 3/10/16 at 1:47 p.m. and 6/29/16 at 1:51 p.m. Neither progress note addressed the resident's progression toward individual activity goals and preferences. The clinical record also lacked documentation of 1:1 visits. 4. The most recent comprehensive MDS dated [DATE] for Resident #7 documented, under Preferences for Activities, the resident felt it was very important to: have books, newspapers, and magazines to read; listen to music; keep up with the news; do things with groups of people; go outside to get fresh air when the weather was good; and participate in religious services or practices. The MDS recorded a BIMS score of 5, indicative of severe cognitive impairment. The care plan activities problem area edited 5/17/16 identified the resident at a risk for lack of participation in activities due to decline in function, weakness, and impaired cognition. The approach edited 7/8/16 directed staff to: inform of daily activities and offer assist to attend; invite to church and bible study; encourage to go to the common area to visit with other residents; and offer to turn on the TV in the resident's room. Review of the resident's clinical record revealed only 1 activity progress note for the year recorded on 5/17/16 at 12:02 p.m. The record lacked any other documentation of the resident's progression toward individual activity goals and preferences. 5. The MDS dated [DATE] documented Resident #1 had [DIAGNOSES REDACTED]. The MDS documented the resident had a BIMS of 10 indicating moderately impaired cognition. The comprehensive MDS dated [DATE] included the Preferences for Customary Routine and Activities section. The MDS documented the resident expressed having books, newspapers, and magazines as very important. The MDS documented the resident expressed having music, keeping up with the news, and going outside as very important. The care plan dated 5/25/16 failed to include a measurable goal for the resident's participation in activities. Review of the resident's clinical record revealed 2 activity progress notes for the year recorded on 5/25/16 at 11:11 p.m. and 6/29/16 at 1:31 p.m. The record lacked any other documentation of the resident's progression toward individual activity goals and preferences. Review of the resident participation documentation revealed the resident participated in 10 activities in May 2016. Review of the resident participation documentation revealed the resident participated in 19 activities in June 2016. Review of the resident participation documentation revealed the resident participated in 18 activities in July 2016. 6. The MDS dated [DATE] documented Resident #4 had [DIAGNOSES REDACTED]. The MDS documented the resident had long and short term memory loss as well as severely impaired cognition. The care plan dated 4/26/16 failed to include a measurable goal for the resident's participation in activities. Review of the resident's clinical record revealed 3 activity progress notes for the year recorded on 10/23/15 at 9:29 a.m., 4/26/16 at 12:05 p.m. and 8/3/16 at 11:50 a.m. The record lacked any other documentation of the resident's progression toward individual activity goals and preferences. Review of the resident participation documentation revealed the resident participated in 24 activities in May 2016. Review of the resident participation documentation revealed the resident participated in 23 activities in June 2016. Review of the resident participation documentation revealed the resident participated in 9 activity in July 2016. The clinical record failed to contain an assessment of the resident's decline in activity participation. 7. The MDS dated [DATE] documented Resident #5 had [DIAGNOSES REDACTED]. The MDS dated [DATE] included the Preferences for Customary Routine and Activities section. The MDS documented the resident expressed having books, newspapers, and magazines as very important. The MDS documented the resident expressed doing favorite activities, going outside, and participation in religious activities as very important. The care plan dated 3/3/16 failed to include a measurable goal for the resident's participation in activities. Review of the resident's clinical record revealed 2 activity progress notes for the year recorded on 4/26/16 at 12:00 p.m. and 6/16/16 at 3:01 p.m. The record lacked any other documentation of the resident's progression toward individual activity goals and preferences. Review of the resident participation documentation revealed the resident participated in 16 activities in May 2016. Review of the resident participation documentation revealed the resident participated in 12 activities in June 2016. Review of the resident participation documentation revealed the resident participated in 8 activities in July 2016. The clinical record failed to contain an assessment of the resident's decline in activity participation. 8. The MDS dated [DATE] documented Resident #9 had [DIAGNOSES REDACTED]. The MDS included the Preferences for Customary Routine and Activities section. The MDS documented the resident expressed listening to music, do things with groups of people, do favorite activities, going outside, and religious activities as very important. The care plan dated 8/4/15 failed to include a measurable goal for the resident's participation in activities. Review of the resident's clinical record revealed 2 activity progress notes for the year recorded on 10/23/15 at 9:38 a.m. and 7/15/16 at 9:30 a.m. The record lacked any other documentation of the resident's progression toward individual activity goals and preferences. Review of the resident participation documentation revealed the resident participated in 13 activities in May 2016. Review of the resident participation documentation revealed the resident participated in 11 activities in June 2016. Review of the resident participation documentation revealed the resident participated in 4 activities in July 2016. The clinical record failed to contain an assessment of the resident's decline in activity participation.

Based on observation, menu review, and staff interview, the facility failed to follow the menu for one meal observed. The facility reported a census of residents. Findings include: The menu for the noon meal on 8/9/16 listed the following for the general diet and mechanical soft diet: 2 ham balls 1 sweet potato (no skin for the mechanical soft diets) 4 ounce mixed vegetables 4 ounce peaches 1 slice bread and butter The menu for the noon meal on 8/9/16 listed the following for the puree diet: Pureed ham balls Pureed sweet potato Puree mixed vegetables Pureed peaches Pureed bread and butter During observation on 8/9/16 at 10:40 a.m. Staff A, dietary cook, measured a ham ball as 2 ounces. Staff A put 3 two ounce servings of the ham balls into the robocoupe, added pork stock, and blended. Staff A measured 1 cup of the mixture that equaled a #12 scoop or 1/3 cup of the blended ham ball. The robocoupe still had a portion of the mixture. Staff A measured the entire contents of the robocoupe mixture which equaled 1 and 3/4 cup that equaled a # 8 and #20 scoop or 1/2 cup plus 1/8 cup. During service at 12:04 p.m. Staff B, homemaker, served the pureed diets a 1/2 cup of the pureed ham balls, 1/2 cup of the mashed sweet potatoes, and 1/4 cup of the pureed mixed vegetables. Staff A failed to pureed the bread and butter. The pureed diets received less of the pureed meat as measured. Staff failed to provide bread and butter for the general and mechanical soft diets. The mechanical diets received 1/3 cup of the mechanical soft meat instead of the 1/2 cup or 4 ounce of the meat. During an interview on 8/9/16 at 4:10 p.m. the dietary manager agreed the menu did not indicate how many ounces of the hall ball staff were to provide. The dietary manager stated she did not have a recipe for the ham balls but did have a recipe for ham loaf which called for 3 ounces of meat. The dietary manager stated Staff A had not been trained on the pureed process.

Based on record review and staff interview, the facility failed to complete approved notices for 2 of 3 residents (Resident #1, #11) reviewed who had been discharged from Medicare services after skilled services were deemed no longer covered to determine if the resident's representative wished to submit a demand bill to Medicare. The facility reported a census of 23 residents. Findings include: On survey entrance 8/8/16 at 9:00 a.m. the Administrator identified there had been no resident requests made for a demand bill. The form titled Census History provided by the Administrator documented the following residents received skilled services (Medicare Part A) and discharged to In House (also known as ICF (intermediate care facility) care: a. Resident #1 - skilled service from 5/16/16 until 6/13/16 b. Resident #11 - skilled service from 3/30/16 until 5/4/16 Review of the liability notices and beneficiary appeals forms revealed the facility failed to provide documentation that residents or family members signed the Center of Medicare/Medicaid Services (CMS) form or 1 of 5 uniform denial letters greater than 48 hours before discharge for Resident #1 and #11. In an interview on 8/11/16 at 7:20 a.m., the Licensed Baccalaureate Social Worker (LBSW), stated she found no documentation available to indicate the CMS form or 1 of 5 uniform denial letters completed for either Resident #1 or Resident #11.

Based on observation, facility policy review and staff interview, the facility failed to maintain the dishmachine rinse cycle at or above 180 degrees Fahrenheit as manufacturers recommendations required and failed to ensure staff contained their hair in a hair net and handled resident food items in a sanitary manner. The facility census was 20 residents. Findings include: 1. During initial kitchen tour on 9/28/15 at 8:25 a.m., Staff E, Cook, did not contain all of their hair in a hair net. Staff F, Dietary Aide had hair/bangs not contained in the hair net. At 11:27 a.m., Staff G, Dietary aide had hair not contained completely in the hair net. 2. Observation on 9/28/15 at 10:52 a.m., revealed Staff E, Cook, donned gloves and touched multiple surfaces including the outside of the oven door, pans, and utensils, then grabbed chicken breasts from the oven with the same gloved hands and placed them into the robot coup (high efficiency food processor). At 11:01 a.m., Staff E, who wore gloves, touched multiple surfaces, then grabbed two pieces of chicken from the oven and placed them into a blender. 3. During observation on 9/28/15 at 8:46 a.m., the high temperature dishmachine model CMA-180 had a rinse cycle of 158 degrees Fahrenheit (F). Listed on the outside of the dishmachine were final rinse temperatures of 180-195 degrees F. Other temperatures include: At 8:49 a.m. the final rinse cycle reached 172 degrees F. At 8:51 a.m. the final rinse cycle reached 156 degrees F. At 11:11 a.m. the final rinse cycle reached 130 degrees F. At 11:29 a.m. the final rinse cycle reached 168 degrees F. Observation at 11:10 a.m., revealed Staff E washed the container and lid for the blender and the final rinse cycle stated above read 130 degrees F. Staff E used those containers and lid to prepare pureed noodles. In a facility policy titled Employee Hygiene and Sanitary Conditions, dated 11/10/14 stated gloves are considered single-use items and must be discarded after completing the task for which they are used. The policy also stated hair nets or caps must be worn to keep hair from contacting exposed clean equipment, utensils and linens. During interview on 9/28/15 at 9:00 a.m., Staff F stated the final rinse cycle should be 180 degrees F - 190 degrees F. During interview on 9/28/15 at 11:30 a.m., the Dietary Manager stated the expectations for the dishmachine's final rinse was at least 180 degrees F. During interview on 9/30/15 at 9:45 a.m., the Dietician stated the expectation for staff is to contain all hair in a hair restraint and remove gloves between touching ready to eat foods and non food items.

Based on observation, clinical record review facility policy review and staff interview, the facility failed to provide complete incontinence care for four of five residents observed during personal cares. (Resident #1, #3, #6 & #7). The facility census was 20 residents. Findings include: An undated policy entitled Skill: 18 - Perineal Care and Skill: 55 - Perineal Care Incontinent Resident, revealed the following procedural steps when pericare and incontinence care provided: a. Wash perineal area using a washcloth, warm water and soap, moving front to back b. Use a clean area of the washcloth for each stroke c. Dry area thoroughly. Move towel from front to back. d. Position resident on side, wash, rinse, and dry area around the anus last. 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident # 1 required extensive assistance for toilet use and transfers and was incontinent of bladder and frequently incontinent of bowel. The care plan dated 6/3/15, revealed the resident experienced bowel and bladder incontinence and directed staff to provide incontinence care after the resident an incontinence episode and to check and change the resident every 2 hours. On 9/29/2015 at 2:25 p.m., staff removed the resident's pants and incontinence brief. The incontinence brief was soaked with urine. Staff A, certified medication aide, CMA used a disposable cloth and cleansed the residents right buttock in a downward motion, then in an upward motion. Staff A used the same surface of the disposable cloth when cleansing the buttocks. Staff rolled the resident to the right side and used a disposable cloth to cleanse between the residents buttocks in a back to front motion. On 9/30/2015 at 10:53 a.m., Staff B, certified nurse aide, CNA, reported the resident's incontinence brief was wet. Staff B used a disposable cloth and cleansed across the residents upper right and left buttocks in a back and forth motion, using the same surface of the cloth. Staff B cleansed between the residents buttocks front to back twice, using the same disposable cloth. Staff rolled the resident to the right side and cleansed the residents left buttock and hip in a circular fashion using the same surface of the cloth. During interview on 10/1/2015 at 9:55 a.m., the Director of Nursing reported staff were to follow the steps listed on the pericare/incontinence care audit tool. 2. A Physician order [REDACTED].#7 had [DIAGNOSES REDACTED]. The MDS assessment dated [DATE], documented the resident required extensive assistance for toilet use and transfers and limited assistance for personal hygiene. The MDS documented the resident experienced frequent bladder and occasional bowel incontinence. During observation on 9/13/15 at 11:36 a.m., Staff C, CNA used a disposable cloth and cleansed the resident's left buttock in a downward motion and cleansed upward on the left buttock, using the same surface of the cloth. Staff C used a disposable cloth and cleansed the residents right buttock in a downward motion back to front. 3. The MDS assessment dated [DATE], identified Resident #3 required total assistance for transfers and toilet use and was incontinent of urine and frequently incontinent of bowel. The care plan dated 2/19/15, directed staff to complete incontinence care after each incontinent episode. Observation on 9/29/15 at 8:53 a.m., revealed Staff D, CNA and Staff A, CNA removed the resident's incontinence brief and verified the brief as saturated with urine. Staff D placed one disposable wipe in the right groin and one disposable wipe in the left groin. Staff rolled the resident to the side and cleansed the buttock with a disposable wipe from front to back. The resident rolled to his/her back and the disposable wipes placed in the resident's groins were removed in a downward motion. During observation staff failed to cleanse the suprapubic area and bilateral hips. 4. The MDS assessment dated [DATE], identified Resident #6 as occasionally incontinent of urine and required limited assistance for transfer and toilet use. The care plan dated 6/24/15, directed staff to provide the resident with complete incontinence care after an incontinent episode. During observation on 9/30/15 at 11:44 a.m., Staff B, CNA and Staff C, CNA assisted the resident to the restroom. Staff B used one disposable wipe for each groin starting at the hip and wiping downward and upward using the same surface of the wipe. Staff used one disposable wipe to cleanse the front genital area downwards and upwards without changing the surface of the wipe. Staff B wiped the residents hips and buttocks in a circular motion and did not change the surface of the wipe. Staff used a disposable wipe with the same surface of the cloth to wipe the front genital area.

Based on observation, clinical record review and staff interview, the facility failed to promote healing of a pressure sore for one of two residents reviewed with pressure ulcers. The facility census was 20 residents (Resident #1) Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], identified the resident had [DIAGNOSES REDACTED]. The MDS reflected the resident had one Stage 1 pressure ulcer, two Stage 3 pressure ulcers and a skin tear. The resident experienced frequent episodes of incontinence and used a pressure reducing device for the bed and in the chair and had a turning/repositioning program with nutritional and hydration interventions. The resident had pressure ulcer care and applications of dressings to the feet. The Care Plan identified a problem with skin integrity on 1/9/15 due to being at high risk for skin breakdown. The approach directed the facility of the following interventions: On 1/12/15, the resident will have incontinent care completed at times of incontinence episodes. On 5/5/15, the resident will have moon boots on while in bed and when resident allows. Nursing will follow Dr. orders for treatment of [REDACTED]. On 7/10/15, the resident will have alternating air pump on bed. On 8/5/15 the resident ' s daughter requested the resident only be repositioned every 3 hours during sleep. On 8/5/15 the resident noted to have pressure relieve cushion in chair at all times, On 9/14/15, the resident noted with new skin issue on 9/10/15 (Stage I right gluteal area) and staff will follow doctor ' s orders until healed. The Braden Scale (a tool used to assess risk for pressure ulcer) performed on 9/10/2015 identified the resident scored 13 out of 23. A score of 13 represented a moderate risk for the development of pressure ulcers. The physician's orders [REDACTED]. The dressing change included hydrogel AG (a sterile dressing used to cover draining wound) and a foam dressing applied to the foot wound. The dressing change included [MEDICATION NAME], calcium AG, and foam dressing applied to the left malleolus. The following wounds and measurements were documented on the weekly pressure ulcer record: Right Lateral Foot On 4/14/15 - Length (L) 1.2 centimeter (cm) x (by) width (W) 1.6 cm x depth (D) 0. cm On 5/7/15 - L 1.3 cm x W 1.5 cm On 6/2/15 - L 1.0 cm x W 1.0 cm ; Resident on antibiotic for [MEDICAL CONDITION], On 6/16/15 - L 0.7 cm x W 1.0 cm x D 0.2 cm; wound bed macerated; Wound listed as a Stage 3 pressure ulcer. On 7/9/15 - L 0.5 cm x W 0.8 cm x D 0.1 cm , On 8/3/15 - L 1 cm x W 1 cm , On 9/4/15 - L 0.7 x W 0.3 cm calloused area, and L 0.2 cm x W 0.2 cm x D 0.2 cm open area On 9/22/15 - L 0.6 cm x W 0.5 cm x D 0.2 cm Left Malleolus 5/2/15 - L 2.3 cm x W 2.5 cm x D 0. cm, and L 0.5 cm x W 0.3 cm eschar. 5/7/15 - L 2.3 cm x W 3.0 cm with eschar area opened L 0.6 cm x W 0.4 cm x D 0.1 cm 6/2/15 - L 0.5 cm x W 0.2 cm 6/16/15 - L 0.5 cm x W 0.2 cm x D 0.1 cm - Staff documented wound at Stage III 7/9/15 - L 1.2 cm x 0.5 cm x D 0.1 cm 7/28/15 - L 0.5 cm x W 0.3 cm 8/18/15 - L 0.6 cm x W 0.5 cm x D 0.1 cm 9/22/15 - L 0.5 cm x W 0.3 cm x D 0.2 cm On 5/2/15 at 3:11 p.m., the nurse ordered moon boots to both heels while the resident in bed. Review of nursing notes revealed no documentation of moon boots applied until 5/7/15 at 3:16 a.m. On 7/9/15 at 10:53 a.m., the nurse's notes revealed a macerated callous wound on the ankle. Observation on 9/29/15 at 8:23 a.m., revealed the resident had gripper socks on, but no moon boots applied to feet while the resident laid in bed or pillow placed under the resident's heels (to float the heels off the bed). During observation on 9/30/15 at 10:53 a.m., Staff J, Registered Nurse (RN), measured wounds prior to wound care provided. Staff J reported the wound measurements as: a. (R) lateral foot - L 0.5 cm x W 0.6 cm b. (L) lateral malleolus - L 0.4 cm x W 0.2 cm x D 0 cm During interview on 10/1/2015 at 9:50 a.m., Staff J, RN, stated interventions to prevent pressure sores included a high protein diet and vitamins, resident checked and changed every 1 to 3 hours as needed, resident repositioned as needed, and if the resident had a pressure sore, an air mattress or pressure relieving device placed on the bed or in the chair.