Every finding on record at Princeton Transitional Care & Assisted Living

Based on facility policy review, observations and interviews, the facility failed to ensure the electronic medical records were protected for 2 residents (Resident #76 and #41) by using safeguards to ensure the electronic medical records were not available for public to view. The findings include: Review of the facility's policy titled, Medication Administration General Guidelines, dated 9/18, revealed .Resident's health information needs to remain private .The .MAR [Medication Administration Record] .containing resident health information must remain closed or covered when not in direct use . Review of the medical revealed Resident #76 was admitted to the facility on [DATE] with diagnoses including Hypertension, Diabetes, and Malnutrition. Review of a 5-day Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #76 scored an 8 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was moderately impaired. During an observation on 5/11/2026 at 2:37 PM, the wound care cart was unattended. The computer on top of the wound care cart was open and the electronic medical record for Resident #76 was available for the public view. During an interview on 5/11/2026 at 2:40 PM, the Wound Care Nurse returned to the wound care cart and confirmed the computer screen had been left open to Resident #76's electronic medical record and was available for public view. Review of the medical record revealed Resident #41 was admitted to the facility on [DATE] with diagnoses including Acute Respiratory Failure with Hypoxia, Essential Hypertension, Type 2 Diabetes Mellitus, and Paroxysmal Atrial Fibrillation. Review of a 5-day MDS assessment dated [DATE], revealed Resident #41 scored a 13 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. During a medication administration observation on Cart 700 on 5/12/2026 at 7:40 AM, revealed Registered Nurse (RN) A walked away from the medication cart leaving the computer open and the electronic medical record for Resident #41 was available for public view. During an observation on 5/12/2026 at 8:01 AM, RN A entered room [ROOM NUMBER], leaving the computer open and the electronic medical record for Resident #41 was available for public view. During an interview on 5/12/2026 at 8:06 AM, RN A confirmed the computer screen was open with Resident #41's electronic medical information available for public view. During an interview on 5/12/2026 at 11:58 AM with the [NAME] President of Clinical Operations confirmed the electronic medical record should not be unattended and left open for public view.

Based on facility policy review, observations, and interviews, the facility failed to ensure medications were securely stored in 1 medication cart (Cart 700) of 3 medication carts reviewed.The findings include:Review of the facility's policy titled, Medication Administration General Guidelines, dated 9/18, revealed .During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse .During a medication administration observation on Cart 700 on 5/12/2026 at 7:40 AM, revealed Registered Nurse (RN) A walked away from the medication cart, leaving the medication cart unlocked and unattended. During an observation on 5/12/2026 at 8:01 AM, revealed RN A entered room [ROOM NUMBER], leaving the medication cart unlocked and unattended. During an interview on 5/12/2026 at 8:06 AM, RN A confirmed she should have locked the medication cart when left unattended. During an interview on 5/12/2026 at 11:59 AM, the [NAME] President of Clinical Operations confirmed the medication carts should be locked when left unattended.

Based on facility policy review, observations, and interviews the facility failed to dispose of expired blood collection tubes in one medication room (400-500 hall medication room) of one medication room observed for medication storage. The findings include: Review of the facility's policy titled, Medication Storage dated 1/2025, revealed .biologicals are stored properly, following manufacturers or provider .recommendation .storage conditions .monitored on a regular basis as a random quality assurance .check .problems are identified, recommendations are made for corrective action to be taken . During an observation of the 400-500 hall medication room on [DATE] at 1:04 PM, revealed 9- 3 milliliter (ml) blue top blood collection tubes with an expiration date of [DATE] and 28- 4 mL green top blood collection tubes with an expiration date of [DATE] were stored in medication room and was available for resident use. During an observation and interview on [DATE] at 1:09 PM, the Corporate Care Consultant Nurse observed the 9- 3 mL blue top blood collection tubes, confirmed the expiration date was [DATE]. Continued observation and interview with the Corporate Care Consultant Nurse stated the expiration date on the 28- 4 mL green top blood collection tubes was [DATE]. The Corporate Care Consultant Nurse further stated he would reach out to a representative with their contracted laboratory to discuss the date on the blood collection tubes. During an interview on [DATE] at 4:20 PM, the Corporate Care Consultant Nurse confirmed the 9- 3 mL blue top blood collection tubes and the 28- 4 mL green top blood collection tubes were expired and were available for resident use.

Based on policy review, medical record review, and interview, the facility failed to follow policy and track 1 resident's (#1) alteration in skin integrity of 3 residents reviewed. The findings include: Review of the facility's policy Skin Observation/Evaluation and Prevention showed, . All resident alterations in skin integrity will be tracked weekly in the EMR (electronic medical record) and reviewed and documented weekly at the At-Risk-Meeting . Medical record review showed Resident #1 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of nursing, physical therapy, and occupational therapy evaluations showed the resident required the assistance of 2 throughout the 29 day length of stay for transfers. Review of a Wound Management Report, dated 9/22/2020, showed a left ankle pressure ulcer was identified as a Deep Tissue Injury (DTI) to lateral maleolus measuring 4 cm (centimeters) in length and 2 cm in width. The ulcer was determined to be unstageable as a DTI with necrotic tissue covering the ulcer. Review of the medical record revealed no other Wound Management Report was done by the facility after 9/22/2020. Interview with the Wound Care Nurse, on 12/3/2020, at 3:40 PM, confirmed the weekly tracking of the wound, due 9/29/2020, had not been completed. Interview confirmed no further measurement of the left ankle pressure ulcer was done after 9/22/2020. Interview by telephone, with the Administrator on 12/8/2020 at 3:30 PM, confirmed the weekly full body report of skin integrity did not include any documentation of the presence of the ulcer of the left ankle wound. Interview confirmed the required weekly Wound Management Report had not been performed, and the facility's policy had not been followed.

Based on facility policy review, observation, and interview, the facility failed to ensure staff wore appropriate beard coverings during food preparation and failed to ensure staff followed appropriate hand hygiene practices during meal preparation in 1 of 1 kitchen observed; potentially affecting 42 of 43 residents. The findings include: Review of facility policy HANDWASHING AND GLOVE USE, last revised 2/1/14, revealed .Hands must be washed .when working with different food substances .and following contact with unsanitary surface .opening doors .Gloves must be changed as often as hands need to be washed .Gloves may be used for one task only .It is important to remember that gloves can often give a false sense of security and can carry germs the same as our hands . Review of facility policy Personal Hygiene, last revised 7/5/18 revealed .Beards or any body hair that may be exposed .must be covered . Observation of the kitchen during meal preparation on 7/29/19 from 11:55-12:25 PM, revealed the Chef and Kitchen Staff #1 with beards. Further observation revealed the Chef and Kitchen Staff #1 did not wear a beard covering during food preparation. Continued observation revealed a cooking utensil fell into a bin containing pork chops with liquid. Further observation revealed the Chef removed the wet utensil from the pork chop bin with a gloved hand, then proceeded to retrieve a piece of bread from a plastic bag, placed the bread on a plate, opened the door to the hot box, retrieved broccoli from the hot box, and placed it in the steamer wearing the same glove. Interview with the Certified Dietary Manager on 7/31/19 at 1:30 PM, in the conference room, confirmed the facility failed to follow appropriate hand hygiene practice during food service and failed to ensure facial hair was covered during meal preparation. Further interview confirmed the facility failed to follow facility policy.

Based on review of facility policy, observation and interview, the facility failed to provide necessary treatment and services, consistent with professional standards of practice, for 1 resident (#119)of 4 residents reviewed that had pressure ulcers, of 12 residents reviewed. The findings include: Review of the facility Pressure Ulcer (Injury) Treatment .Procedure: . undated, revealed .wash and dry hands thoroughly before treatment. Apply gloves .remove soiled dressing .remove soiled gloves .wash and dry hands thoroughly. Apply gloves .Apply dressing/treatment .Remove and discard gloves. Wash hands thoroughly . Medical record review revealed Resident #119 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation of wound care on 9/6/18 at 9:10 AM, in Resident #119's room, revealed Registered Nurse (RN) #1 entered Patient #119's room with wound care supplies to perform a dressing change on a pressure ulcer on Resident #119's coccyx. Continued observation revealed RN #1 donned gloves, removed soiled dressing, removed soiled gloves, donned gloves, applied dressing/treatment, removed soiled gloves, gathered supplies and exited the room. Handwashing was not observed at any time during the procedure. Interview with RN #1 on 9/6/18 at 9:25 AM, outside of Resident #119's room, confirmed she did not wash her hands at any time during the procedure. Interview with the Director of Nursing (DON) on 9/6/18 at 9:47 AM, in the conference room, revealed she would have expected RN #1 to wash her hands: 1) before donning gloves prior to wound care. 2) Every time she changed her gloves during wound care. 3) After wound care. Continued interview confirmed the facility failed to provide necessary treatment and services, consistent with professional standards of practice.

Based on review of the Minimum Data Set (MDS) 3.0, review of the Resident Assessment Instrument (RAI) Manual, medical record review, and interview, the facility failed to conduct an accurate MDS assessment for Activities of Daily Living (ADLs) for 2 residents (#4, #83) of 25 residents reviewed. The findings included: Medical record review of the RAI Manual dated 5/13, with instructions for completing assessments, revealed .review the medical record, speak with the treatment nurse and direct care staff .examine the resident . Medical record review revealed Resident #83 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission (5 day) MDS dated [DATE] revealed, the resident's functional status for walking in the room was coded as 1 requiring supervision, and locomotion status on unit was coded as 1 requiring supervision. Medical record review of the 14 day MDS dated [DATE] revealed the resident's functional status for walking in the room was coded as 2, requiring limited assistance with 1 person physical assist. Further review revealed locomotion on the unit was coded as 3, extensive assistance with 1 person physical assistance. Medical record review of the Physical Therapy Discharge Summary dated 7/26/17 revealed Progress & (and) Responsive to Tx (treatment): Pt (patient) has progressed in functional mobility to allow pt to return to home. Medical record review of the Occupational Therapy Discharge Summary dated 7/27/17 revealed Progress & (and)Response to Tx: Pt made good progress with all functional goals, especially functional ADL (activities of daily living) transfers and ADL skills. Interview with the MDS coordinators (#1, #2) on 8/15/17 at 2:45 PM, in the MDS office confirmed we were told by Corporate to use only what the CNA's (Certified Nursing Assistants) documented . Continued interview confirmed the facility had failed to perform an accurate assessment of Resident #83's functional status for the 14 day MDS assessment. Interview with the Rehab Director on 8/15/17 at 5:15 PM, in the Conference Room confirmed Resident #83 was an active participant, who showed improvement in functional abilities in Physical and Occupational Therapies. Further interview confirmed Resident #83 had no decline in ADL's during her stay at the facility. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Discharge MDS dated [DATE] revealed Functional Status, Bed Mobility, coded as 2 (Llimited Assistance); Transfer, coded as 2 (Limited assistance), and Locomotion on unit coded as 2 (Limited Assistance) . Medical record review of the Physical Therapy Discharge Summary dated 3/26/17 revealed bed mobility and transfer required minimal assistance, ambulation on level surfaces for unlimited distances required minimal assistance. Pt has displayed significant advancement with all mobility . Interview with MDS Coordinator #1 on 8/15/17 at 3:15 PM, confirmed she retrieved information from the Certified Nurse Aide documentation to complete the MDS. Continued interview confirmed information from the physical and/or occupational therapy assessments were not included. Further interview confirmed the MDS for the Resident was not accurate.

Based on review of facility policy, medical record review, observation, and interview, the facility failed to identify, re-weigh, and report weight loss/gains for 2 residents (#158, #189) of 4 residents reviewed for weight loss of 25 sampled residents. The findings included: Review of the facility policy, Weight Monitoring Program, reviewed 6/1/15, revealed .residents with +/- (plus/minus ) 3 lbs (pounds) in one week will be reweighed .ADON (Assistant Director of Nursing)/Designee will review all weights and compare . Resident #158 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the weights revealed the admission weight dated 4/28/17 as 75.23 kilograms (kg) or 166 lbs.; on 4/29/17 a weight of 61.85 kg or 136 lbs.; on 4/30/17 a weight of 61.3 kg or 135 lbs.; and on 5/10/17 the weight of 61.23 kg or 135 lbs. Further review revealed no additional weights were obtained on 4/28/17 or 4/29/17. Continued review revealed a weight loss of 30 lbs. from 4/28/17 to 4/29/17. Medical record review revealed Resident #189 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the weights revealed the admission weight dated 8/2/17 as 78.3 kg or 172 lbs. Further review revealed on 8/12/17 weight as 74.4 kg (164 lb.); on 8/13/17 a weight of 87.57 kg (193 lb.), and on 8/14/17 a weight of 72.6 (160 lb.). Further review revealed no additional weights were obtained on 8/12/17 or 8/13/17. Continued review revealed a weight gain of 29 lbs. from 8/12/17 to 8/13/17. Interview with the Registered Dietician (RD) on 8/16/17 on 9:05 AM, in the Conference Room confirmed the weights for Residents #158 and #189 were '' .inconsistent .and they were expected if they have a 3 pound difference to reweigh the patient . Telephone interview with the Licensed Practical Nurse #1 on 8/16/17 at 10:15 AM, confirmed she cared for Resident #189 on 8/13/17; reviewed the resident weight, entered the weight into the computer, but did not look at the previous weight, and failed to monitor and identify the resident's weight change. Interview with the Administrator on 8/16/17 at 11:25 AM, in the Conference Room confirmed the facility failed to identify, monitor, and reweigh Residents #158 and #189 for discrepancies in weights.

Based on review of the facility policy, medical record review, and interview the facility failed to monitor behaviors for 1 resident (#5) of 5 residents reviewed for unnecessary medications. The findings included: Review of the facility policy, Behavior Management, undated revealed .Implement a Behavior/Intervention Monthly Flow record .It is the responsibility of Clinical Manager to ensure the Licensed Nurses are completing the Behavior/Intervention Monthly Flow record .Nursing will document each episode of the residents behavior, interventions and outcomes of the interventions with noted side effects . Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Medication Administration Record, [REDACTED]. Interview with Registered Nurse #1 on 8/15/17 at 3:10 PM, on the 200 hallway confirmed the resident's behavior associated with the use of the antianxiety medication had not been monitored. Continued interview confirmed a flow sheet is to be filled out to monitor behavior and side effects of the [MEDICAL CONDITION] medications for any resident who is on [MEDICAL CONDITION] drugs.

Based on review of facility policy, observation, and interview, the facility failed to maintain a sanitary kitchen for use of approved hair restraints, undated, repackaged prepared foods, personal food in utensil drawers, and dust debris on cooling fans for 3 of 7 walk-in refrigerator/freezers for 1 of 1 kitchen reviewed. The findings included: Review of facility policy, Dress Guidelines for Food Service Management and Clinical Nutrition Staff, revised 1/14 revealed .hair restraints are worn by all when in the kitchen. Review of facility policy, Food and Storage Procedures, revised 7/14 revealed .date unused portion. Review of facility policy, Food Service Cleaning Duties, undated revealed .empty out the utensil totes.workstation shelves. Review of facility policy, Area and Equipment Cleaning, revised 1/14 revealed .clean equipment.refrigeration coils. Review of facility policy, Food and Supply Storage Procedures, revised 7/14 revealed .foods stored on ''ladder/speed'' racks must be fully covered to prevent contamination from airborne contaminants. Observation with the Dietary Manager (DM) and the Patient Service Manager, of the kitchen on 8/10/15 at 4:00 PM, in the cold prep area revealed 1 Cold Prep Dietary Aide with a black cotton cap on the head with visible hair on the sides of the face and a pony tail extending past the cap. Continued observation revealed the Cold Prep Dietary Aide cutting up strawberries. Observation with the DM and the Patient Service Manager on 8/10/15 at 4:20 PM, of reach-in cooler #6 revealed a metal pan with 6 undated, repackaged unbaked pizza crusts. Observation with the DM and the Patient Service Manager on 8/10/15 at 4:25 PM revealed a utensil drawer with the following: 2 can openers, scissors, 2 measuring cups, and 1 pastry brush. Further observation revealed 1 large candy bar and 5 small chocolate candies in the drawer. Observation with the DM and the Patient Service Manager on 8/10/15 at 4:30 PM, of the walk-in produce cooler #3 revealed dust debris on the triple cooling fan and on the sides of the adjacent walls. Further observation revealed a ladder cart with a plastic cover ripped open and 4 peach cobblers exposed to the fans. Observation with the DM and the Patient Service Manager on 8/10/15 at 4:35 PM, of the walk-in catering refrigerator revealed dust debris on the duel cooling fans. Continued observation revealed open boxes of uncut assorted fruit and vegetables. Observation with the DM and the Patient Service Manager on 8/11/15 at 10:30 AM, of the walk-in dairy cooler #8 revealed dust on the duel cooling fans. Interview with the DM on 8/13/15 at 8:10 AM, in the Activity/Dining room confirmed the facility failed to monitor the approved hair restraints, to date opened, repackaged foods, to store personal foods with dietary utensils, and to clean cooling fans to maintain sanitary conditions in the kitchen.

Based on observation and interview, the facility failed to maintain dignity for 4 residents (#133, #120, #122, #126) of 7 residents sampled with urinary drainage bags for indwelling catheter use. The findings included: Observation during the initial tour on 8/10/15 at 10:30 AM revealed the Resident (#133) had a urinary drainage bag containing urine, hanging from the bedframe, and visible to the public from the hallway. Observation of Resident #120 on 8/11/2015 at 9:15 AM, in the resident's room revealed the resident had a urinary drainage bag (1/4 full) hanging from the bedframe. Continued observation revealed the urinary drainage bag was visible from the hallway. Observation of Resident #122 on 8/11/15 at 1:15 PM, in the resident's room revealed the resident had a urinary drainage bag (1/2 full) hanging from the bedframe, and visible to the public from the hallway. Interview with the Administrator on 8/11/15 at 10:18 AM, in the hallway outside her office, confirmed the urinary drainage bags should be covered. Observation of Resident #126 on 8/11/15 at 8:00 AM, on the 3300 hallway, outside the resident's room, revealed a urinary catheter bag with yellow colored urine, attached to the bedframe visable from the hallway. Interview on 8/11/15, at 8:15 AM, with the Director of Nursing, outside the resident's room, confirmed .we don't use catheter covers here, it's a hospital setting.we don't have a policy. Continued interview confirmed the facility failed to cover the urinary catheter bag.

Based on observation and interview, the facility failed to maintain a clean environment in 7 rooms (6 resident rooms and the shower room) on 2 of 2 wings of 22 rooms observed and failed to maintain a ceiling flange (chrome ring around sprinkler head) for 1 room of 22 rooms observed. The findings included: Interview and observation with the Maintenance Director on 8/12/15 at 2:45 PM, confirmed room #3212, #3218, #3316, #3317, #3318, #3319, and the shower room all had a large accumulation of dust in the ceiling heating and air vents. Interview confirmed room #3212 had a missing flange around the sprinkler head. Continued interview confirmed the vents are now cleaned by a contractor service and the vents had not been cleaned in some time.

Based on medical record review, observation, and interview, the facility failed to prevent cross-contamination during direct patient care for 1 resident (#110) of 2 residents reviewed for direct patient care of 30 sampled residents. The findings included: Medical record review revealed Resident #110 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record reveiw of the care plan dated 8/6/15 revealed resident with methicillin resistant staphylococcus aureus (MRSA) .Goal.caregivers will verbalize measures to reduce the risk of infection. Observation on 8/12/15 at 9:20 AM revealed Treatment Nurse #1 and Certified Nursing Assistant (CNA) #1 providing care to Resident #110 in contact isolation. Observation revealed the resident had soiled self with liquid stool expanding to the lower back and into patient wound. Continued observation revealed the Treatment Nurse began cleaning the resident with wipes and did not thoroughly clean the resident, did not remove the soiled disposable sheet under the resident, and proceeded to complete wound care on the resident. Further observation revealed the Treatment Nurse completed a dressing change and rolled the resident with the newly applied dressing change over the soiled sheet. Interview with the Treatment Nurse on 8/12/15 at 10:15 AM, in the Administrator's office confirmed the facility failed to prevent cross contamination by not thoroughly cleaning the wound and not removing the soiled disposable sheet prior to completing a dressing change to resident.

Based on observation and interview, the facility failed to store drugs and biologicals correctly in 1 of 2 electronic medication delivery systems. The findings included: Observation of Registered Nurse (RN) #1 on 8/13/15 at 8:15 AM revealed the RN conducting a medication pass. Continued observation revealed a Lasix (medication for increased fluid) was not in the medication cart. Observation revealed the RN obtained a medication from the electronic medication delivery system identified to be in the Lasix bin. Further observation revealed the RN obtained a medication from the Lasix bin which was Amodopine (medication for hypertension or coronary artery disease). Observation and review of the Lasix bin revealed multiple Lasix and a total of 4 Amodopine pills in the same bin. Interview with RN #1 on 8/13/15 at 8:24 AM confirmed the medication was stored incorrectly in the electronic medication system.

Based on review of facility policy, medical record review, and interview, the facility failed to monitor the effectiveness of the pain medication and to provide reassessment of the pain medication for 2 (#126, #117) of 2 residents of 30 residents sampled. The findings included: Review of facility policy, Pain Assessment and Management, reviewed on 1/15, revealed .pain is reassessed.after pain management intervention. Resident #126 was admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Discharge Medication Administration Record [REDACTED]. Further review revealed 20 doses of [MEDICATION NAME] were not reassessed for effectiveness within an hour of administration. Medical record review of the Resident Care Plan, Alteration in Comfort: Pain, dated 7/29/15, revealed an intervention administer medications and evaluate responses to medications. Medical record review of the Admission Minimum Data Set, dated dated [DATE] revealed a Brief Interview Mental Status of 0 (0 to 7 indicating severe impairment), physical and verbal behaviors directed toward others 1 to 3 days and pain medication for chronic pain. Interview with the Director of Nursing (DON) on 8/13/15 at 12:00 PM, in the DON's office confirmed the facility failed to reassess Resident #126 for the effectiveness of the pain medication. Medical record review revealed Resident #117 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Medication Administration Record [REDACTED]= 2 tab PO (by mouth) (Q (every) 6 HRS (hours) prn (as needed)). Reason: Pain or Fever. Medical record review of the Medication Administration Check from 8/5/15 through 8/13/15 revealed Resident #117 had requested Tylenol 7 times. Further review revealed after the administration of the Tylenol, 4 of the 7 doses (8/7/15 at 12:12 PM, 8/10/15 at 9:38 AM, 8/11/15 at 8:09 AM, and 8/12/15 at 9:17AM) had not been assessed for effectiveness. Interview with Resident #117 on 8/13/15 at 8:07 AM, in the resident's room confirmed the resident preferred to take Tylenol for her pain, her pain relief was at an acceptable level, and she could participate in therapy. Interview with the Director of Nursing (DON) on 8/13/15 at 8:40 AM, in the hallway outside of the DON's office confirmed the effectiveness of pain medication to be evaluated 1 hour after administration of pain medication.

Based on review of facility policy, medical record review, observation, and interview, the facility failed to develop a patient specific comprehensive care plan with measurable outcomes and timetables for 2 (#126, #110) of 2 residents reviewed of 30 sampled residents. The findings included: Review of facility policy, Pain Assessment and Management, reviewed 1/15 revealed .pain is reassessed with [REDACTED]. Medical record review revealed Resident #126 was admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan, Alteration in Comfort, Pain, dated 7/29/15 revealed will obtain relief from discomfort/pain throughout SNF (Skilled Nursing Facility) stay and provide comfort measures (repositioning, distractions, adjustments to the environment, ect). Further review of the care plan revealed no measurable outcome or timetable. Medical record review of the Admission Minimum (MDS) data set [DATE] revealed a Brief Interview Mental Status of 0 (0 to 7 indicating severe impairment), physical and verbal behaviors directed toward others 1 to 3 days, and pain medication for chronic pain. Interview with the Director of Nursing on 8/13/15 at 12:00 PM, in her office confirmed .these aren't completed, yes, we should have completed a goal. Further interview confirmed no specific interventions for non-pharmacological interventions .not on this care plan. and the facility failed to develop a patient specific comprehensive care plan for Resident #126. Medical record review revealed Resident #110 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan, Skin Integrity Concerns related to Decubitus present Sacrum, feet, heels, dated 8/6/15 revealed .There will be no increase in number of ulcers throughout SNF (skilled nursing facility) stay. Further review of the care plan revealed no measurable outcome or timetable. Interview with the Director of Nursing on 8/13/15 at 12:00 PM, in her office confirmed .these aren't completed, yes, we should have completed a goal. Further interview confirmed the facility failed to develop a patient specific comprehensive care plan for Resident #110.

Based on medical record review and interview, the facility failed to offer a choice of individual needs and preferences for 2 of 2 residents (#111, #114) reviewed for choices of 30 residents sampled. The findings included: Medical record review revealed Resident #111 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Interview with Resident #111 on 8/11/15 at 10:16 AM, in the resident's room revealed the resident had not been given a choice about sleep times. Continued interview revealed .They wake me up around 4:30 AM to do labs (laboratory testing). I would rather sleep until 9:00 AM. Medical record review revealed Resident #114 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Interview with Resident #114 on 8/10/15 at 2:30 PM, in the resident's room revealed the resident had not been given a choice about sleep times. Continued interview revealed .I am woke up in early morning with vitals and door knocks.it's not like I am going to sleep until 10:00 AM. Interview with the Admission Shift Leader #1 on 8/12/15 at 10:38 AM, in the activity room confirmed the residents had not been given a choice on admission of wake up times.

Based on review of facility policy, medical record review, observation, and interview, the facility failed to provide care to 1 resident (#110) of 1 of 2 residents reviewed for pressure sores to prevent infection of 30 sampled residents. The findings included: Review of facility policy, Pressure Ulcers, revealed .procedure:.D. Perform hand hygiene and apply gloves.cleanse the wound of any debris. Resident #110 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review of the care plan dated 8/6/15 revealed resident with stage 3 pressure ulcer to the coccyx and DTI (deep tissue injury) to the left heel. Review of the Physician's current orders printed 8/13/15 revealed [MEDICATION NAME] 2% (antifungal cream) apply.thin layer to bilateral groin and inner thighs.venelex (ointment to promote healing) to entire buttocks. Observation on 8/12/15 at 9:17 AM revealed Registered Nurse (RN) #2 obtained the [MEDICATION NAME] cream and the venelex ointment, walked into the resident room and placed the cream and ointment on top of a biohazard waste trash can. Continued observation on 8/12/15 at 9:18 AM revealed Treatment Nurse #1 cleaned the residents overbed table and placed dressing supplies on the table. Observation revealed the resident had soiled self with liquid stool expanding to the lower back and into patient wound. Continued observation revealed the Treatment Nurse began cleaning the resident with wipes and did not thoroughly clean the resident, did not remove the soiled disposable sheet under the resident, and obtained the [MEDICATION NAME] cream and venelex ointment from the top of the biohazard trash and placed the cream and the ointment on the cleaned overbed table. Observation revealed the Treatment Nurse then applied the venelex ointment to the resident buttocks crossed the resident rectum and to the resident wound. Further observation revealed the Treatment Nurse completed the dressing change, rolled the resident with the newly applied dressing change over the soiled sheet, and applied the [MEDICATION NAME] ointment to the resident groin. Interview with the Treatment Nurse on 8/12/15 at 10:15 AM, in the Administrator's office confirmed the wound had not been cleaned thoroughly, the soiled sheet was not removed prior to the dressing change, and the ointment and creams were placed on the clean overbed surface after being obtained from the top of the biohazard trash can. Interview with the Director of Nursing (DON) on 8/13/15 at 10:40 AM, confirmed the facility policy was not followed for wound care to prevent infection to a resident with pressure sores.

Based on medical record review and interview, the facility failed to complete documentation of meal intake for 1 resident (#97) and failed to document an acurate skin assessment for 1 resident (#110) of 2 of 17 records reviewed. The findings included: Medical record review revealed Resident #97 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Daily Intake/Output Detail Reports dated 5/28/15 through 6/17/15 revealed 29 of 60 opportunities to record meal intake had not been documented. Interview with Registered Dietician (RD) #1 on 8/13/15 at 9:55 AM, in the nurse's station on the 3200 hallway confirmed the RD would expect the meal intake to be documented with the amount/percentage of the meal consumed for every mealtime. Interview with the Director of Nursing (DON) on 8/13/15 at 8:55 AM, in the DON's office confirmed the facility's expectation was for the meal intake to be documented for all meals and was aware the poor documentation had been an area of concern. Medical record review revealed resident #110 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review of a Skin assessment dated [DATE] on admission revealed .Red.heel on left.right heel DTI (deep tissue injury). Observation on 8/12/15 at 9:32 AM revealed Treatment Nurse #1 and Certified Nursing Assistant (CNA) #1 providing care to Resident #110. Continued observation revealed the resident to have a left heel DTI and the right heel to be red. Interview with the Director of Nursing (DON) on 8/12/15 at 2:32 PM, in the DON's office confirmed the admission skin assessment was inaccurate.

Based on review of facility policy, observation, and interview, the facility failed to maintain a clean area, free of debris, for 1 of 1 dumpster reviewed. The findings included: Review of facility policy, Dumpster Cleaning Process, not dated revealed .rinse dumpster and area.pick up any remaining trash. Observation with the Dietary Director and the Patient Service Manager on 8/11/15 at 10:55 AM, at the 1 of 1 dumpster revealed on the outside of the dumpster the following: 1 empty plastic water bottle, 2 blue rubber gloves, a large plastic bag of trash, and other trash debris. Continued observation revealed a mixture of food debris and wet fluid under the dumpster flowing approximately 16 feet to the common driveway. Interview with the Dietary Director on 8/11/15 at 11:00 AM, at the dumpster confirmed .it's kind of nasty. Further interview confirmed the facility failed to maintain the cleanliness of the dumpster area.