Every finding on record at Sandgate Gardens Rehab and Nursing Center

Based on observation, interview, and record review, the facility failed to follow the portion sizes listed on the menu for regular and puree diets that were signed by the Registered Dietitian. This had the ability to affect 8 residents who were on the pureed diet and 66 on a regular diet. The census at the time of survey was 102. The findings included: Observations were made on 08/04/26 at 11:50 AM in the kitchen of the lunch tray line. A review of the menu for week 5 Tuesday lunch menu revealed the puree menu included 6-ounce (oz) puree chicken parmesan, 4 oz puree pasta, 4 oz puree Italian Vegetables, 2-oz puree roll with garlic butter and 4-oz puree apple cobbler. During the dishing of the food, it was observed that they were using a 4-oz scoop instead of a 6-oz scoop for the puree chicken. The surveyor intervened and asked what size scoop they were using for the puree chicken and the server in tray line stated it is a 4 oz scoop. The surveyor then asked what the menu documented for scoop size. The Regional Dietitian stated it should be 6-oz but was unable to find a 6-oz scoop. They then took the 4-oz spoodle, which is a hybrid kitchen tool that combines a spoon and a ladle into one. It has holes on the bottom to serve liquids, sauces or grains. The server took this utensil from the pasta which was 4-oz and used it for the puree chicken but began only scooping half the portion size for the puree chicken. They then used a tong to serve the regular pasta which was a 4-oz portion.During an interview on 08/04/26 at 2:00 PM with Staff O, cook, when asked if they follow the menu portion sizes, he stated yes but they had a food delivery truck that morning and with me being there they were nervous.Observations were made on 08/05/26 at 8:15 AM, in the kitchen of the breakfast food tray line, of pancakes being dished unto plates. The Dietary Aide that was doing the serving size was giving 1 pancake to each resident who had a regular diet. A review of the menu for week 5 Wednesday breakfast documented for the regular menu the residents are supposed to get 2 pancakes each, a 2-oz sausage patty, choice of cereal, 4-oz of juice, and 8- oz milk of choice.During an interview on 08/05/26 at 8:22 AM with Staff P, Dietary Aide, she was asked how many pancakes the residents are who are on a regular diet menu should be getting. She stated they get 1 pancake. The surveyor asked are they were not supposed to get two? She stated, we always give one pancake. The Dietary Manager looked at the menu and told her to start giving two.

Based on policy review, observation, record review and interviews, the facility failed to provide care and services for 5 of 11 sampled residents as evidenced by the failure to prevent significant weight loss and follow Physician and Registered Dietitian orders for weights for Resident #37 and #72 and failed to follow Physician and Registered Dietitian orders for weights for Residents #41, #59, and #5. The resident census at the time of survey was 102.The findings included: Review of the policy titled, Weight Assessment issued on 09/2022 and revised on 12/2024 revealed, in part, 1. With the resident's permission, the nursing staff will measure the resident weight within 72 hours of admission and monthly thereafter or as determined by the physician or per the resident's preference. #4. Weight variance changes that are unplanned since the last weight assessment will be retaken as soon as practical for confirmation. If the weight is verified, nursing will communicate with the Dietician or the Physician. #5. Weight variances will be addressed by the Registered Dietitian, as soon as practicable, following the weight being obtained. 1. During an observation on 08/03/26 at 10:08 AM, Resident #37 was in her wheelchair being pushed by a staff member to activities and appeared to be very thin and leaning her right shoulder against the right armrest of the wheelchair. Review of the record revealed Resident #37 was admitted to the facility on [DATE] and had only one documented weight of 70.8 pounds on 07/21/26. Review of the physicians' orders for Resident #37 documented an order for the weight to be taken within 72 hours of admission and then weekly x 3 and then monthly. Further review of physicians' orders documented an order dated 07/21/26 for a house supplement two times a day for 90 days. An interview was conducted on 08/05/26 at 1:42 PM with Staff F, Restorative Aide, and the Director of Nursing (DON). Staff F was asked how soon after a resident is admitted are weights taken and she stated within 72 hours. Staff F and the DON were then asked about Resident #37's weight since there was only one weight documented for 07/21/26 and she was admitted on [DATE]. The DON stated she was sure that Staff F had weighed Resident #37 within the 72-hour time frame. Staff F was able to find Resident #37's weight on a piece of paper that had handwritten weights dated 07/13/26 and Resident #37's weight was 78.8 pounds. When Staff F was asked if there were any other weights for Resident #37, she stated that she had the residents' name and weight on a piece of paper, but it was not dated. The [NAME] agreed with the findings that based on Resident #37's weight of 78.8 pounds on 07/13/26 and her weight on 07/21/26, Resident #37 had a 10.5% weight loss in 11 days. An interview was conducted on 08/05/26 at 3:01 PM with the Registered Dietitian (RD) who was asked if she wrote an order for Resident #37 on 07/21/26 for house supplement 2x a day for 90 days and she stated she had. The RD was then asked why she waited until 07/21/26 to write the order when the Resident was admitted on [DATE]. The RD appeared to be very surprised and stated that she had not been advised that Resident #37 was admitted on [DATE] and was unsure why there was only one weight documented in Resident #37's Electronic Health Record (EHR). The RD was then asked why the supplement order was changed on 07/28/26 to three times a day and she stated because Resident #37 does not eat very well and that she was going by the By mouth monitoring tool that the facility uses to track how much a resident eats and did not need a weight to tell her that Resident #37 was not getting enough calories and that is why she increased the supplements to three times a day. The RD was then asked if Resident #37 was weighed recently and she stated Resident #37 was weighed on 08/04/26 and she weighed 67 pounds and agreed that it was not entered into the residents EHR. The RD was then asked what her understanding of when weights are to be taken on newly admitted residents and she stated they are taken within 72 hours and then monthly as per the facility policy on weights. The RD agreed with the findings that Resident #37 now had a 14.97% weight loss since her admission date of 07/10/26. 2. Clinical record review revealed Resident #72 was admitted to the facility on [DATE] with a diagnosis of a medically complex condition. The admission comprehensive assessment, with an Assessment Reference Date (ARD) of 06/08/26, recorded a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. The comprehensive assessment identified a weight loss of 5% or greater not associated with a prescribed weight loss regimen. The resident was also noted to be receiving a therapeutic diet. Review of physician orders dated 07/09/26 revealed an order for House Supplement 60 mL, administered once daily. Review of the care plan, revised 05/31/26, identified the resident was at risk for altered nutrition, need for therapeutic diet, BMI (body mass index), diabetes mellitus, and impaired skin integrity. Interventions included obtaining weights as ordered or indicated. Review of a nutrition progress note dated 06/13/26 at 7:07 PM revealed the resident remained at nutritional risk due to significant weight loss despite fair meal intake and protein supplementation. The resident's weight was documented as 169.2 pounds on 06/06/26, decreased from 189.2 pounds on 05/14/26, reflecting a 20-pound (10.6%) weight loss within approximately one month, which was identified as clinically significant. The note indicated meal intake remained approximately 75% of meals, and the resident continued to receive House Protein NSA daily for additional protein support. The Registered Dietitian (RD) recommended continued monitoring, weekly weights/reweights to verify weight changes, encouragement of meal and supplement acceptance, and monitoring of weights, meal intake, hydration status, and nutrition-related labs. Review of a nutrition progress note dated 07/12/26 at 2:32 PM revealed the resident continued to have significant weight loss of 23.6 pounds (12.5%) over two months. The RD documented that weight loss was acceptable with a goal of weight stability. The resident reportedly had good oral intake, consuming 75% or more of meals, and continued to receive oral supplements providing an additional 220 calories and 22 grams of protein daily. The RD recommended continuation of the current plan of care. Review of weekly weight records revealed that, following the RD recommendation on 06/13/26, there were no weights documented for the following periods: 06/14/26–06/20/26, 06/21/26–06/27/26, 06/28/26–07/04/26, 07/12/26–07/18/26, and 07/19/26–07/25/26. On 08/05/26 at 3:21 PM, an interview was conducted with Staff F, Restorative Aide, responsible for obtaining weights. When asked to explain the facility's weekly weight monitoring process, Staff F stated that the RD provides information regarding residents who require weekly weights. Staff F reviewed the weight monitoring clipboard and stated that Resident #72 was on weekly weight monitoring. However, she stated the resident had only recently been placed on weekly weights and that the first weekly weight obtained was on 07/26/26. On 08/06/26 at 8:48 AM, an interview was conducted with the dietitian. The dietitian stated she began employment at the facility on 06/15/26. When asked about the facility process for obtaining weights, she stated that new admissions are weighed within 72 hours of admission and monthly thereafter. She explained that when weekly weights are needed, the dietitian communicates with the DON, ADON (Assistant DON), or restorative aide regarding residents requiring increased monitoring. The dietitian reviewed Resident #72's record and acknowledged the 06/13/26 nutrition note, written by the previous dietitian, which included a recommendation for weekly weight monitoring due to significant weight loss. The dietitian reviewed the resident's weights in the electronic record and stated she did not see evidence that weekly weights were completed as recommended. She stated that Resident #72 should have been placed on weekly weight monitoring due to the significant weight loss identified in June 2026. When asked why weekly weight monitoring did not begin in June as recommended, she stated she was unsure but acknowledged there should have been better communication among the staff involved. 3. Review of the record revealed Resident #59 was admitted to the facility on [DATE] with diagnoses to include Traumatic Brain Injury (TBI), stroke, and Dysphagia (difficulty swallowing). Review of the current MDS dated [DATE] documented the resident had a BIMS score of 0, on a 0 to 15 scale, indicating the resident was severely cognitively impaired. This MDS documented that the resident had lost weight while not on a prescribed weight loss program and required partial to moderate assistance with eating. Review of the weight history revealed on 04/01/26, the resident weighed 174.4 pounds and on 07/28/26, the resident weighed 146.8 pounds, which was a 15.83% loss in three months. On 01/06/26, the resident weighed 179.6 pounds and on 07/28/26, the resident weighed 146.8 pounds which was an 18.26% loss in months. A Dietary Profile assessment dated [DATE] documented Resident #59 had had a significant weight loss and staff were to monitor weights weekly. A progress note dated 05/10/26 by the previous Registered Dietician also documented the significant weight loss with the intervention that staff were to obtain weekly weights. Neither documented for how long to monitor the weekly weights nor was there a physician order for weekly weights in the record at that time. Review of the weight history following the RD recommendation documented weights were obtained on 06/05/26, 07/02/26, 07/28/26 and 08/04/26. On 08/05/26 at 8:43 AM, Resident #59 was being fed by Staff T, CNA, who stated the resident was not wanting to eat sausage, pancake, or eggs. When the CNA asked if she wanted oatmeal, the resident nodded yes. The CNA went to the kitchen to see if they had oatmeal, further stating they sometimes are waiting on the truck. On 08/05/26 at 9:56 AM, when asked what she was told by the kitchen regarding the pureed oatmeal, Staff T, CNA, stated they told her they didn't have any that morning. During an interview on 08/05/26 at 1:56 PM, Staff F, Restorative Aide, confirmed she was responsible for obtaining all weights. When asked how she knew who is on weekly weights, the Restorative Aide stated she gets a list of residents on Mondays with highlighted names of those that are on weekly weights. The Director of Nursing (DON) was present during the interview and was told there were no weekly weights for Resident #59 as of the RD recommendation on 05/10/26. The DON stated there should be an order for weekly weights as well. During an interview on 08/05/26 at 3:21 PM, the current Registered Dietician (RD) stated she would typically do weekly weights for 3 or 4 weeks, but that there was not an order as far as she was aware. When told Resident #59 did not eat any breakfast that morning, had agreed to oatmeal but it wasn't available that morning, the RD stated it should have been. 4. Review of Resident #5 medical record revealed the resident was admitted to the facility on [DATE] with a diagnosis to include Hemiplegia and Hemiparesis following Cerebral Infarction, Metabolic Encephalopathy, Type II Diabetes, Essential Hypertension, Major Depressive Disorder, Dysphagia, and Gastrostomy, A review of the physician's orders revealed the resident had a NPO (nothing by mouth) diet, NPO texture, NPO consistency, had a Peg tube and received all medications and food through the peg tube. Another physicians' order documented 'Weight within 72 hours of admission then weekly x 3 and then monthly everyday shift for Monitoring for 3 Days AND every day shift every 7 day(s) for Monitoring for 3 Weeks AND every day shift every 30 day(s) for Monitoring. Start Date 05/07/26.' A review of Resident #5 weights documents only one weight for each month starting on 05/07/26. On 05/07/26, the resident weighed 145.4 pounds, on 06/05/26 he weighed 143.4 pounds, on 07/03/26 he weighed 141.2 pounds, and on 08/04/26 he weighed 142.6 pounds. 5. Review of Resident #41 medical records revealed the resident was admitted on [DATE] with a diagnosis of Hepatic Encephalopathy, Acute Respiratory Failure with Hypoxia, Gastrointestinal Hemorrhage, Alcoholic Cirrhosis of Liver without Ascites, and Muscle Weakness. A review of the physician's orders documented the resident was on a regular diet, regular texture, thin consistency. He had an order from the Medical Director dated 07/10/26 to be weighed within 72 hours of admission then weekly x 3 and then monthly everyday shift for Monitoring for 3 Days and every day shift every 7 day(s) for Monitoring for 3 Weeks and every day shift every 30 day(s) for Monitoring. A review of Resident #41 weights documented he had only two weights documented in the computer. One weight was document on 07/21/26 at 118.2 pounds and one on 08/04/26 at 122.2 pounds. During an interview on 08/05/26 at 11:15 AM with Staff E, CNA (Certified Nursing Assistant), she was asked if she does residents' weights. She stated no restorative does it. During an interview on 08/05/26 at 11:46 AM with Staff F, Restorative Aide, she was asked if she does resident weights. She stated yes! when asked she knew when to weigh the resident and how often, she stated the nurse or dietician would let her know. She stated she puts it in her book. She does not input the weights into the computer. On 08/05/26 at 1:40 PM Staff F, Restorative Aide and the DON came into the conference room. The restorative aide reviewed this resident's weights and stated the last weight was done on 08/04/26. The surveyor read her the order, and the DON then stated, we follow our policy and weights are done monthly. The surveyor said, do you not follow what the physician order writes. The DON stated we should, but we only go by our policy. Staff F, Restorative Aide stated that she had another weight from 07/13/26 for Resident #41. She said he weighed 128.8 lbs. She didn't know why it was not put into the computer. During an interview on 08/06/26 at 12:55 PM with the Dietician, she was asked if they are not following the orders for weights, how would they know about weight loss for this resident who is being fed by gastrostmy tube (GT). She said they get weighed once a month.

Based on record review and interview, the facility failed to communicate services between Hospice and the nursing home, related to the Do Not Resuscitate (DNR) order for 1 of 1 sampled resident, Resident #40, reviewed for Hospice.The findings included:Review of Resident #40's medical records revealed the resident was admitted to the facility on [DATE] with a diagnosis to include Pulmonary Fibrosis; Malignant Neoplasm of Bone; Malignant Neoplasm of the Prostate; Major Depressive Disorder; Generalized Anxiety, and a cancer with Metastasis to the bone. Review of the electronic medical records and the physician's orders documented this resident was a full code. A review of the Hospice binder that is at the nurse's station revealed the resident has a DNR (Do Not Resuscitate) which means no CPR (Cardiopulmonary Resuscitation) would be initiated when there is no pulse or breathing. The DNR was signed [DATE]. During an interview on [DATE] at 10:25 AM with Staff A, RN (Registered Nurse), she was asked to review this resident's electronic record. She acknowledged that the resident was a full code. When the surveyor asked, how would you know his code status, she stated we look at the face sheet, look at the yellow binder that shows who is a DNR and also look at the physician orders. The surveyor went to yellow binder that is sitting on the crash cart, looked for this resident's DNR, and did not see any DNR. Staff A was asked who could change it to the DNR. She stated the Unit Manager or Social Service Director. During an interview on [DATE] at 10:30 AM with Social Service Director, she was asked about the DNR orders. She stated she cannot change any orders. She has no access. During an interview on [DATE] at 10:40 AM with Staff B, Unit Manager, she stated she was just told he is a DNR and is in the process of changing it right now but wants to talk to DON (Director of Nursing) and left to review with her. On [DATE] at 10:54 AM, the DON and Staff B came into the conference room. The DON stated we were waiting on the son/nephew to sign the DNR. Hospice did not tell us that he had signed the DNR. She stated that they did not tell us that they dropped off the binder. Hospice said the chaplain dropped it off possibly on [DATE]. During an interview on [DATE] at 1:45 PM with the Hospice Nurse and her Supervisor from Hospice, the Hospice Supervisor stated that the nurse brought the binder to the facility but does not remember when but thinks it was brought over on [DATE]. The nurse acknowledged that she did not communicate with the facility to let anyone know about the DNR. It was signed [DATE] by the resident's biological son and he had signed the DNR on behalf of the resident after communication with all the siblings.

Based on observations, menu review and interviews the facility failed to have food prepared in a form designed to meet individual needs as evidence by the puree food not pureed or served appropriately. This had the ability to affect 8 residents who were on the pureed diet that includes Resident #38. The findings included:Observations were made on 08/04/26 at 11:50 AM in the kitchen of the lunch tray line. The puree menu included 6-ounce (oz) puree chicken parmesan, 4-oz puree pasta, 4-oz puree Italian Vegetables, 2-oz puree roll with garlic butter and 4-oz puree apple cobbler. On 08/04/26 at 12:30 PM, two surveyors taste-tested the puree food and found that the puree pasta was very gummy and thick like 'Paper Mache'.During an interview on 08/04/26 at 2:00 PM with Staff O, Cook, he was asked how he made the puree pasta. He stated he takes the pasta and puts it in the machine (Called Robot Coupe R2 Ultra) and adds a little water and blends it for 5-10 min. A review of the pureed pasta instructions that were provided to this surveyor for review on 08/04/26 documented the following instructions: For ease of blending cook pasta 2-3 times longer. Usin Blixer/commercial food processor place desired amount of cooked pasta into processor. Provide liquid, broth, water, etc. Blend bread and gradually add liquid until pasta mixture is smooth and consistent. (Puree mixture should be consistency of pudding or custard.) If mixture is to thin; add additional cooked pasta or a commercial thickening agent until desired consistency is achieved. If mixture is to thick add additional liquid until desired consistency is achieved. If serving warm heat mixture to 140 degrees F and hold at 135 degrees F for service.Observations were made on 08/05/26 at 8:15 AM, in the kitchen of the breakfast food tray line being dished out. The Dietary Aide that was doing the serving size was giving the puree residents regular oatmeal.During an interview on 08/05/26 at 8:22 AM with Staff P, Dietary Aide, she was asked if the Oatmeal that they give a resident who is on puree, the regular oatmeal. She stated yes, the puree residents get the regular oatmeal. The surveyor asked for a small sample to take back to the survey team to try.On 08/05/26 at 8:30 AM, 2 surveyors tested the Oatmeal and found that it was not smooth and creamy but lumpy.During an observation on 08/05/26 at 8:45 AM, it was observed that Resident #38 was in her room being assisted with her breakfast meal by Staff R, Certified Nursing Assistant (CNA). The staff had taken a spoonful of Jell-O and was getting ready to give the resident the Jell-O when she began to cough/choke and was foaming at the mouth. He began to take a tissue to clear the secretions from her mouth. He stated he did not know why she had a package of Frosted Flakes Cereal on her tray but would never give her that. A review of the Diet type report given to this surveyor by the Dietary Manager documented Resident #38 is on CCHO (Constant or Consistent Carbohydrate) puree food with Nectar/Mildly thick fluid consistency.During an interview on 08/05/26 at 12:07 PM with Staff Q, Speech Therapist, she was asked if someone who is on a Nectar thickened liquid could have Jell-O. She stated, I was told someone on a nectar thick should not have a Jell-O. When asked if someone on Puree could have regular Oatmeal, she stated, the Oatmeal has to be pureed. We don't follow the IDDSI (International Dysphagia Diet Standardization Initiative) guidelines. When asked the definition of puree, she stated smooth puree, no chunks and on the moist side usually not too moist. During an interview on 08/06/26 at 8:32 AM with the Dietician she was asked what her definition of puree was. She stated completely smooth, no chunks or very few or in between if chunky puree fruit. When asked if they go by the IDDSI, she stated, no they go by the old school dysphagia which means regular, mechanical soft and puree meals only. When asked if a resident who is on a puree diet could have Jell-O, she stated yes. When asked if they are on a thickened liquid could the resident have Jell-o, she said no, it melts in the mouth like ice cream. She was asked about oatmeal and stated, no puree should be getting regular oatmeal or cereal.During an interview on 08/06/26 at 11:18 AM with Staff R, CNA, he was asked about assisting Resident #38. He acknowledged he was assisted her eating yesterday. He was asked about Jell-O and stated, I was about to give it to her, but she began to choke, she was foaming at her mouth, she never got it. It was a spoonful of Jell-O.During an interview on 08/06/26 at 2:45 PM with the Dietary Manager, he was asked what his definition of puree would be, and stated smooth, no lumps, creamy and not too liquidly.

Based on record review and interview, the facility failed to obtain physician ordered labs for 1 of 5 sampled residents, Resident #115.The findings included:Review of the record revealed Resident #115 was admitted to the facility on [DATE]. Review of the current physician orders documented the need for a CBC (complete blood count), CMP (comprehensive metabolic panel), and a Depakote level (a medication for seizures) on 08/01/26.Review of the record lacked any lab results for 08/01/26.During an interview and side-by-side review of the record on 08/06/26 at about 1:00 PM, the Unit Manager agreed with the order and was unable to locate the results. The Unit Manager stated she would look into it and find out what happened.During a subsequent interview on 08/06/26 at 1:30 PM, the Unit Manager explained that the Interdisciplinary Team (IDT) ordered the labs related to a possible gradual dose reduction (GDR) and put the order into the electronic medical record (EMR). The EMR would then trigger the night nurse to either put the order directly into the software program for the laboratory or the nurse could do a hand written requisition. The night nurse wrote out the requisition but failed to put the name on the daily log of labs needed. The Unit Manager explained that the lab technician goes by the daily log, and if the entry were not on the log, the technician would not draw it, which was what happened.

Based on observation, interview, and record review, the facility failed to ensure proper urinary and catheter care for 3 of 3 sampled residents, as evidenced by failure to ensure appropriate positioning of urinary catheter drainage bags, and use of catheter securement devices for Resident #40; failure to ensure proper perineal care for a resident with a urinary tract infection (UTI) for Resident #44; and failure to ensure appropriate use of a urinary catheter anchor for Resident #10. The findings included: 1. Clinical record review revealed Resident #44 was initially admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of end-stage renal disease (ESRD). Review of the admission comprehensive assessment with a reference date of 07/10/26 revealed the resident rarely/never understood related to cognitive impairment. The comprehensive assessment documented the resident was frequently incontinent of bowel and bladder. The assessment further indicated the resident was dependent on staff for toileting hygiene and shower/bathing and required substantial to maximal assistance with personal hygiene. Review of a physician order dated 07/29/26 revealed an order for Ciprofloxacin HCl Oral Tablet 500 mg, one tablet by mouth daily for 5 days for treatment of Urinary Tract Infection (UTI). Review of July 2026 Medication Administration Records (MARs) and Treatment Administration Records (TARs) revealed the resident received Ciprofloxacin 500 mg on 07/29/26, 07/30/26, and 07/31/26 at 1:00 PM. Review of August 2026 MARs and TARs revealed the resident received Ciprofloxacin 500 mg on 08/01/26 and 08/02/26, completing the ordered 5-day course. Review of the care plan with a revision date of 07/16/26 indicated the resident was at risk for complications related to bowel and/or bladder incontinence. A care plan initiated on 07/05/26 indicated the resident was at risk for UTI related to incontinence. Review of an interdisciplinary team (IDT) progress note dated 07/28/26 revealed laboratory results were reviewed by the provider, and a new order was received for Ciprofloxacin 500 mg by mouth daily for 5 days for treatment of UTI. The order was carried out and acknowledged, and the plan of care remained ongoing. On 08/05/26 at 9:06 AM, Staff N, Certified Nursing Assistant (CNA), was observed providing morning care to Resident #44. A package of wet wipes was observed on the resident's bed. The surveyor requested to observe the provision of perineal care. Staff N obtained towels from a plastic bag, performed hand hygiene, and donned gloves. She gathered paper towels and placed them on the bedside table, then placed a clean towel on top of the paper towels. Staff N opened the drawer, obtained a basin, turned on the water, and filled the basin. She gathered additional care supplies, including soap and perineal cleansing spray. Staff N removed the resident's pants and raised the bed using the bed controls. At 9:18 AM, without changing gloves after contact with the environment, Staff N began providing perineal care using a small wet washcloth, rotating to clean sections of the washcloth during cleansing. She then turned the resident onto her side and cleansed the buttocks and perianal area. At 9:22 AM, Staff N opened the closet with the same gloves, obtained a clean adult brief, and applied it to the resident. On 08/05/26 at 3:04 PM, an interview was conducted with the Director of Nursing (DON). The care process was explained, and the DON was allowed to review the documented observation. The DON acknowledged Staff N should have changed gloves prior to continuing care. 2. Clinical record review revealed Resident #40 was initially admitted to the facility on [DATE] with a diagnosis of obstructive uropathy. Review of the admission comprehensive assessment with a reference date of 07/19/26 revealed the resident rarely/never understood related to cognitive impairment. Review of April 2026 MARs/TARs indicated the resident received Doxycycline 100 mg by mouth from 04/08/26 through 04/16/26 for treatment of UTI. Additional record review revealed the following physician orders: 07/16/26: Indwelling urinary catheter change, 16 French, 10 mL catheter, tubing, and collection bag as needed when medically necessary. 07/16/26: Methenamine Hippurate 1 gram tablet, one tablet by mouth twice daily for prevention of recurrent UTI (prophylaxis). 07/17/26: Indwelling urinary catheter, size 16 French, 10 mL balloon, for diagnosis of obstructive uropathy. Review of progress notes dated 04/04/26 at 4:50 PM revealed the resident complained of severe pain when urine passed through the Foley catheter. The Foley was draining pink-colored urine. The Foley was flushed, and a pink-like clot was noted with clear yellow urine. A progress note dated 04/04/26 at 5:16 PM documented the resident continued to report severe pain and requested transfer to the hospital. The Foley catheter was draining pinkish-yellow urine. The resident's vital signs were documented as blood pressure 85/50, pulse 112, temperature 97.4 degrees F, and oxygen saturation 98%. The physician and supervisor were notified, and an order was received to transfer the resident to the emergency room. Another progress note dated 04/09/26 at 1:11 PM documented the resident was readmitted to the facility on [DATE] with a diagnosis of UTI. The Foley catheter was in place and draining clear yellow urine. Antibiotic treatment was ongoing with no adverse reactions noted. On 08/05/26 at 1:00 PM, catheter care was observed being provided by Staff N, CNA. Staff N performed hand hygiene, obtained clean linens, and placed them in a plastic bag, which was then placed on the nightstand. Staff N performed hand hygiene again, obtained water in a clean basin, placed paper towels on the bedside table, gathered a gown, donned the gown and gloves, and placed the basin on top of the paper towels. Several washcloths were placed into the basin. Staff N closed the privacy curtains, closed the door, and raised the bed using the bed remote. She adjusted the under-pad beneath the resident and removed the resident's pants and brief. The urinary catheter was observed without a catheter anchor securing it in place. At 1:15 PM, without changing gloves after touching items in the room and removing the soiled brief, Staff N proceeded with catheter care. On 08/05/26 at 3:10 PM, an interview was conducted with the DON. The care process was explained, and the DON reviewed the documented observation. The DON acknowledged Staff N should have changed gloves before performing catheter care. The DON was also informed that the catheter did not have an anchor to secure it. At 3:12 PM, an observation was conducted with the DON, who acknowledged the catheter drainage bag was touching the floor and that there was no catheter anchor in place. 3. Review of the manufacturer's instructions for the Catheter Securement Devices, not dated, documented in part, 4. Apply Catheter Securement Device to securement site. 5. Wrap the press-and-seal tab below the 'Y' lumen of the catheter and above the connection with the drainage bag. Review of the record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses to include BPH (benign prostatic hypertrophy / enlarged prostate) and obstructive uropathy (a blockage in the urinary tract that stops urine from flowing normally). Review of the Quarterly MDS assessment dated [DATE] documented the resident had a BIMS of 15, on a scale of 0 to 15, indicating cognitively intact and that he had an indwelling urinary catheter. Review of the current orders documented as of 10/18/24 that staff were to encourage and assist the resident to use the catheter tube securing device. The current care plan initiated on 01/12/24 documented the resident was at risk for injury or infection related to the presence of a suprapubic urinary catheter but lacked any intervention related to the securing device. During an observation on 08/03/26 at 12:02 PM, when asked if he had any type of device on his leg to secure the urinary catheter tubing, a catheter securement device was noted to the resident's thigh and dated 07/14/26, with the tubing in the tab above the 'Y' lumen and not keeping the tubing from pulling. Resident #10 stated sometimes the catheter pulls. On 08/04/26 at 2:37 PM, Resident #10 was in bed, and the catheter tubing was again noted in the catheter securement device above the 'Y' lumen and the tubing appeared taut. An interview and observation on 08/05/26 at 11:20 AM with Staff S, Licensed Practical Nurse (LPN), revealed the tubing loosely in the securement device tab, as per the previous two days. The nurse did not attempt to correct it. When asked if the catheter securement device was keeping the tubing secured, the nurse moved the tubing up and down through the tab. The nurse fiddled with the device and tubing, and then placed the tab below the 'Y' junction of the tubing to keep it from moving. The nurse was made aware the tubing had been loose in the securement device for the past two days.

Based on record review and interview, the facility failed to ensure proper assessment and safety for 1 of 2 sampled residents, as evidenced by failing to ensure a complete physician's order as per their policy, failure to ensure assessment prior to Leave of Absence (LOA), and ensure safe transfer of Resident #115 prior to leaving the facility. The findings included:Review of the policy Leave of Absence [LOA], revised 02/2024, documented in part, 1. A physician order should be obtained regarding the resident's LOA status. 2. Each resident should be given one of the following LOA orders based off the LOA assessment: May go LOA independently; May only go LOA with Escort. 3. Each resident leaving the premises (excluding transfers/discharges) should be signed out. Registers should indicate the resident's expected time of return, a valid contact number and destination.Review of the Leave Of Absence Sign Out Sheet, not dated but utilized by the facility in 2025, documented in part, The undersigned accept complete responsibility for the health and welfare of resident. This form lacked any area to document the resident's destination.Review of the record revealed Resident #115 was admitted to the facility on [DATE] with a new diagnosis of orthopedic aftercare from fracture dated 11/22/25. Review of the current Annual Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 14, on a 0 to 15 scale, indicating the resident was cognitively intact. Review of the Quarterly MDS assessment dated [DATE], just prior to the resident's fracture, also documented the same BIMS score of 14. This MDS documented that the resident had impairment to both the upper and lower extremity of one side and did not rate his transfer ability at that time. Review of the care plan initiated on 07/02/24 documented the resident had an activities of daily living (ADL) self-care deficit related to impaired mobility and included the intervention that the resident was dependent upon two staff for transfers as he was unable to assist. This same care plan also documented staff were to use a mechanical lift for transfers.Review of physician orders at the time of the fracture documented as of 04/06/25, LOA: Resident may have therapeutic LOA privileges. A duplicate current order was dated 08/04/26. Neither order documented if the LOA privileges were independently or with an escort.Review of a change in condition assessment dated [DATE] documented Resident #115 was observed outside next to a family transporter that arrived at the facility to transport to church. The resident explained that the visitor lost grip of his jacket and he slid to the floor. The resident was subsequently sent to the ER with a hip fracture.Review of a progress note documented by 11/16/25 at 11:04 AM by Staff G, Licensed Practical Nurse (LPN), documented in part, Resident found outside next to a family transporter that arrived to the facility for (name of Resident #99) to attend church. The visitor (van driver) was provided education on transfer of other residents without notification to the nurse, as well as all parties involved. All were interviewed as well and provided education by this writer regarding the importance of alerting the nurse when a resident has plans to leave the facility.The record lacked any progress note prior to the fracture documenting the resident's desire to go LOA, an assessment as to his ability to go LOA, or an account of him leaving the building.Review of the facility investigation included contradictory statements from Staff H, Certified Nursing Assistant (CNA who was assigned to Resident #115 on the morning of the fracture). Staff H's written statement dated 11/16/25 documented the CNA provided care and got him dressed for church, leaving the resident at the reception desk for his family member to pick him up. A statement written by Staff I, a Regional Nurse Consultant, documented the consultant phoned Staff H on 11/18/25 and the CNA reported he thought there were church services in the dining room and left the resident in the front area by the desk.During an interview on 08/04/26 at 9:23 AM, when asked if he had a fall with a fracture while at the facility, Resident #115 stated about two months ago he was going to his home church, being transported by his church staff and church van. The resident explained that the facility staff transferred him by Hoyer lift into his wheelchair, but the church van driver, who did not have a wheelchair lift, attempted to lift the resident into the van and dropped him. The resident stated he suffered a right hip fracture with subsequent surgery. During a subsequent interview on 08/05/26 at 3:46 PM, Resident #115 clarified and stated he was up front when the church bus arrived and the driver told him he could go to church if he wanted. The driver took him out to the van and the resident told the driver he could stand up. The driver tried to assist him up, but lost grip of the resident's jacket and dropped him.During an interview on 08/06/26 at 9:24 AM, when asked the process for a resident to go on an LOA, Staff J, receptionist, explained they get a yellow or green pass from the nurses station, then sign out in book at receptionist desk. The yellow pass indicated the resident needed an escort, and the green pass indicated the resident could go on LOA independently.During an interview on 08/06/26 at 9:40 AM, when asked about the process for a resident to leave on a therapeutic LOA, Staff L, Licensed Practical Nurse (LPN) and Unit Manager stated, first staff should review and see if the resident was independent or dependent to leave. If depended, staff should speak with whoever is taking them out, to find out who is taking them, to where, and for how long. The nurse would do a skin assessment and enter all of this in a progress note. The nurse should also verify in the electronic record that the person who is taking them out is okay to do so and make sure whoever is taking them can transfer them and the type of transportation that would be needed. When asked specifically about Resident #115 and his subsequent fracture, the Unit Manager stated she was not in the building at the time, but she believed the nurses were not aware he was leaving but was coaxed to go by Resident #99. The Unit Manager stated she believed Resident #115 told the driver he could walk. When asked how the independent verses escort needed for LOA was determined, the Unit Manager explained it goes by their BIMS score and need for assistance. The Unit Manager stated Resident #115 was cognitively intact but needed staff or assistance if leaving the premises. The Unit Manager confirmed the LOA status, and pre-event assessment was not documented in the medical record.During an interview on 08/06/26 at 9:51, when asked about the day Resident #115 sustained a fracture, Staff K, Activity Assistant and Receptionist, stated Resident #115 was ready for church, and someone came and signed him out. Staff K volunteered the resident had gone to church before. When asked who signed him out Staff K stated the driver had signed him out. Staff K stated the resident told the driver he could move so the driver took him. Staff K stated she did not see anything more as she was at the desk and they went out to the parking lot. Note, the parking lot is not visible from the receptionist's desk.On 08/06/26 at 10:21 AM, the Administrator provided the sign out sheet for Resident #115 for November 2025. The form documented the resident signed himself out, lacking the phone number of the driver or the destination. When asked if the staff should be getting the phone number of the person transporting/driving the vehicle, the NHA stated they should have.During a phone interview on 08/06/26 at 10:32 AM, when asked what happened the day Resident #115 sustained a hip fracture, Staff H, CNA, stated the resident needed to get out of bed because a family member was picking him up. The CNA stated he could only take him to the front desk because they need to sign him out. When read the conflicting statements as per the facility investigation, the CNA did not explain and simply said it was a poor choice of words.During a phone interview on 08/06/26 at 11:05 AM, when asked what happened in November 2025, when Resident #115 wanted to go to church, the van driver explained he was just a volunteer who wanted to take residents to church, further stating he was very strong and could assist people into his van as long as they can stand and bear weight. The van driver explained he had been taking Resident #99 to church for quite a while and Resident #115 voiced on and off for about a month that he would like to go. On the day Resident #115 was ready to go to church, the van driver asked the resident if he could stand on at least one leg. The van driver described that the resident signed himself out and upon getting the resident up from the wheelchair, the resident's arms went straight up in the air, and the resident slipped down. The van driver stated he did not go down hard and then he gently assisted the resident to a lying position. The van driver stated that Resident #99 was spotting him through out the process to ensure the wheelchair did not move. When asked if he spoke to anyone at the facility about taking Resident #115 out of the facility, the van driver stated yes and that they said if he wants to go, let him go, but they did not think it was a good idea. The van driver stated he signed himself out and that he himself did not sign anything. When asked who told him it wasn't a good idea, the van driver stated, I would say it was the nurses as the receptionist wouldn't know.During a subsequent interview on 08/06/26 at 11:59 AM, when asked if she knew that Resident #99 and Resident #115 had been talking about going to church together for about a month or so prior to his fracture, the Unit Manager stated some staff had mentioned that, as if Resident #99 was cohering Resident #115 to go with her. When asked if anything was done to assess the situation and to maintain the resident's safety, the Unit Manager stated they just don't send a resident with another resident, and again explained the process of assessing the situation, but agreed this hadn't been done. When told there was a comment that staff did not think it was a good idea, the Unit Manager stated then staff should have reached out to management and or the physician.

Based on observation, record reviews and interviews, the facility failed to provide care and services related to proper positioning in a wheelchair for 1 of 1 sampled resident, Resident #37. The findings included:Review of the record revealed that Resident #37 was admitted to the facility on [DATE] with diagnoses, in part, of Displaced Intertrochanteric Fracture of Left Femur, Age-Related Osteoporosis, Scoliosis, Muscle Weakness, and Unspecified Dementia. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #37 had a Brief Interview for Mental Status (BIMS) score of 00 on a scale of 0-15 indicating severe cognitive impairment. An observation was conducted on 08/03/26 at 10:08 AM of Resident #37 being transported in her wheelchair to the activities department. Resident #37 had her right shoulder leaning against the right armrest and a wide gap of space on the left side of her upper body. At 12:49 AM, Resident #37 was observed sitting at the nurse's station with her upper body and right arm resting against the right armrest.An interview was conducted on 08/05/26 at 10:00 AM with Staff C, Certified Nursing Assistant (CNA), who was asked why Resident #37 had a pillow on the right side of the wheelchair next to the armrest and Staff C stated that Resident #37 was leaning too much on her right side.An observation was conducted on 08/05/26 at 11:40 AM of Resident #37 seated at a dining room table while leaning her upper body against a pillow that was positioned on her right side. At 11:56 AM when staff started to assist Resident #37 with eating, she sat upright briefly but then leaned back against the pillow on the right side of her wheelchair.An interview was conducted on 08/05/26 at 12:15 PM with the Director of Rehabilitation (DOR) who had been assisting another resident with eating at the same table as Resident #37 in the dining room. The DOR was asked about Resident #37's positioning in her wheelchair, and the DOR stated she was not sure if the Physical Therapist had addressed it and that she did not know that Resident #37 was leaning to the right in her wheelchair.On 08/05/26 at 1:16 PM, the DOR stated that she reviewed the Physical Therapy (PT) evaluation that was conducted on 08/04/26 and stated that the wheelchair positioning had not been assessed as part of the evaluation.On 08/05/26 at 1:22 PM, the DOR advised the surveyor that Resident #37 looked much better in her wheelchair, so we observed her position together and Resident #37 was positioned in her wheelchair without the pillow to her right side and had her right arm leaning against the right armrest. The DOR attempted to reposition Resident #37 by shifting Resident #37's trunk to the left but when the DOR let go of Resident #37's trunk, she went right back to leaning on the right armrest. The DOR was then asked if the wheelchair was the appropriate size for Resident #37 since the armrest where the resident elbow is supposed to rest on is up closer to her shoulder than her elbow. The DOR stated she would see if they had a smaller, 16-inch wheelchair that would fit Resident #37 better. The DOR agreed with the findings that Resident #37 was not supported properly in her wheelchair to be able to maintain an upright posture.On 08/05/26 at 1:39 PM, the DOR returned to tell the surveyor that they added some padding to the right side of Resident #37's wheelchair and that Occupational Therapy (OT) would do an evaluation on Resident #37 for wheelchair assessment.An observation was conducted on 08/06/26 at 11:35 AM in dining room where Resident #37 was sitting at a table with a blue cushion around the right armrest and a pillow that was on Resident #37's lap in front of her right side. When staff in the dining room were asked why the pillow was on Resident #37's lap they were unsure and went to get the floor nurse. On 08/06/26 at 11:39 AM, an interview was conducted with Staff D, Licensed Practical Nurse (LPN), who stated that the CNA put the pillow on the wheelchair since Resident #37 leans so far to right. Staff D was then asked if she had communicated to any other facility staff, like therapy, to let them know that Resident #37 was not able to sit upright in her wheelchair. She stated that she had not communicated with other staff and agreed with the findings.

Based on interview and record review the facility failed to report 1 of 3 credible allegations of abuse, neglect, or misappropriation of resident property, as evidenced by the failure to report to the Agency the alleged misappropriation of money for Resident #6.The findings included: Review of the record revealed Resident #6 was admitted to the facility on [DATE], with a transfer to the hospital on [DATE], and a return to the facility on [DATE]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 14, on a 0 to 15 scale, indicating the resident was cognitively intact. This MDS also documented the resident's preferred his native language [language documented].During an interview on 08/03/26 at 2:41 PM, Resident #6 was visiting with her adult son, and they were speaking in the native language. When asked if the resident could speak English, the son stated very little, so an interview was conducted with the son, with input from the resident speaking to her son in their native language. The son stated Resident #6 had gone into the hospital last year and had left her purse in the room with $2500 in it, which was missing upon her return. The son stated he spoke with the Social Services Director (SSD) upon the resident's return from the hospital and followed up with an email of a formal complaint. When asked if he recalled the date of the hospitalization, the son asked the resident, who told him October of 2025. The resident's son stated he never heard anything back from the facility.Review of the facility grievance log and reportable log for the month of October 2025 lacked any entry for Resident #6 related to misappropriation of personal property.During an interview on 08/06/26 at 2:07 PM, when asked if she was aware of the allegation of $2500 missing from Resident #6 in October of 2025, the SSD stated she would have to look through the grievance logs. When told the son of Resident #6 had sent her an email regarding the missing money, the SSD stated she would look back through her emails and let the surveyor know what she found.During a subsequent interview on 08/06/26 at 2:23 PM, the son's wife was able to locate the email sent to the SSD regarding the missing money and it was dated 10/13/25 at 12:51 PM. This email explained that the son had been giving his mother $1000 per month for expenses for her to use for food and other personal items. Her mother had saved a small amount each month and had accumulated $2500 that she had kept in her purse. Upon return from the hospital Resident #6 noted her purse had been moved and identified the missing money.A side-by-side review of the investigation and Agency portal partially completed report on 08/06/26 at 4:18 PM was made with the current Administrator. Although the facility reported the incident to law enforcement and to the abuse registry, and completed an investigation, the facility failed to report the incident to the state Agency, as evidenced by the report status of Cancelled documented on the Agency report dated 10/13/25 by the previous Administrator. This report had only the basic information as noted above but had not been completed or submitted to the Agency. When asked if there was a reason for the lack of submission to the state Agency, the Administrator stated she did not know as she was not here at the time.

Based on observation and interview, the facility failed to ensure a clean and sanitary environment affecting 9 of 31 sampled residents (Residents #7, #10, #23, #28, #38, #46, #59, #74 and #113).The findings included:During the initial pool process on 08/03/26 and 08/06/26, the survey team identified the following concerns:a) On 08/04/26 at 9:15 AM, the wall behind Resident #7's bed had multiple caulking spots, and the sink was missing caulking.b) On 08/03/26 at 12:06 PM, the sink in Resident #10's room was coming away from the wall, there were white stains on the sink counter, and a hole in the wall at the baseboard and bathroom door frame. The resident's bed control cord was wrapped in crinkled plastic that was filled with tan and brown debris.c) On 08/03/26 at 10:09 AM, the privacy curtain and floor in Resident # 23's room were dirty.d) On 08/03/26 at 3:53 PM, the tube feeding pump had fluid spilled on the front of the machine in Resident #28's room.e) On 08/03/2026 at 10:59 AM, the floors were dirty in Resident #38's room.f) On 08/03/2026 at 11:11 AM, Resident #46's room had a strong foul urine-like smell. The odor persisted throughout the week.g) On 08/03/2026 at 9:22 AM, the floor mat in Resident #59's room was dirty.h) On 8/03/26 at 3:59 PM, the tube feeding pump had spilled liquid on the face of the machine.i) On 08/03/26 at 10:28 AM, Resident# 113 stated that the cleaning staff do not seem to clean the bathroom and the floors, and do not replace the toilet paper. There was a commode overtop of the toilet, and the commode had rusted parts, the toilet seat and toilet bowl had brownish stains, and the two toilet paper dispensers were empty with one small roll of toilet paper resting on top of one of the dispensers.During an observation tour on 08/05/26 at 10:31 AM, the Regional Plant Operations Manager agreed with the above findings.An interview was conducted on 08/06/2026 at 7:41 AM with Staff S, Licensed Practical Nurse (LPN) who was asked who is responsible for cleaning the tube feeding pump and she stated the nurses are and agreed with the findings.

Based on record review, observations and interviews, the facility failed to provide adequate supervision and assistive equipment to prevent 1 of 3 sampled residents, Resident #1, from having a fall with injury.The findings included:Record review revealed Resident #1 was admitted to the facility on [DATE]. Review of a quarterly assessment dated [DATE] documented a Brief Interview Mental Status (BIMS) score of 00 on a 0-15 scale, indicating unable to assess. Review of the medical diagnosis for Resident #1 documented a history of hemiplegia (paralyzed on one side) affecting the dominant side on the right, traumatic brain injury, aphasia (difficulty expressing words), and history of falls. Review of a report dated 10/22/25 documented Resident#1 was found on the floor lying on her left side after reportedly rolling off the bed while being assisted by one staff for incontinent care. The resident was assessed, and a small amount of bleeding was noted from the resident's mouth. There was no documentation related to staff involved in the incident. There was a documented intervention for the fall, that stated the resident will now be required to have the assistance of 2 people for bedside incontinent care.Review of the care plan dated 09/15/25 documented a focus that Resident #1 was at risk for falls related to cognitive deficit and poor balance with a goal of the resident's potential for sustaining a fall-related injury will be minimized by utilizing fall precautions and interventions. A second focus documented Resident #1 had a ADL (activities of daily living) self-care deficit related to chronic medical conditions with a goal that the resident will not have a decline in ADL functioning with the following interventions: for bed mobility the Resident #1 needs extensive help to move and reposition in bed, will need one or two person assistance to change position or scoot up in the bed, this may involve some lifting of legs or boosts; for toileting the resident is dependent and is not able to participate in the task at all and will need staff to move, cleanse, and dress him. This may require the dependent assistance of 2 people to be done thoroughly and safely and bilateral bedrails for bed mobility.Review of a physician order dated 06/24/24 instructed staff to check bilateral bedrails for functionality and safety every night shift.Review of the October 2025 Treatment Administration Record for Resident #1 revealed staff signed indicating that bilateral bedrails for bed mobility was checked for functionality and safety.During an interview on 11/03/25 at 12:18 PM, the Administrator asked if there were any other documents needed. She was made aware that documentation of a thorough investigation including the witness statements for the fall incident for Resident #1 on 10/22/25 was needed for review.During an interview on 11/03/25 at 12:40 PM, the Administrator provided a printed out copy of a progress note documented by the nurse regarding the fall incident on 10/22/25. She was made aware that there was no documentation that indicated the staff involved or witness statement from the staff involved. On 11/03/25 at 1:41 PM, the Administrator provided a copy of a witness statement and stated, Do you want to talk to the CNA involved in the incident? We called her in. During an interview on 11/03/25 at 1:42 PM, when Staff A, the Certified Nursing Assistant (CNA) providing care to Resident #1 on 10/22/25, was asked when the resident fell out of the bed, Staff A stated, Yes, I was changing her brief, I turned her on her right side and she rolled off of the right side of the bed. I was on the left side. When asked were the side rails up, she stated, She doesn't have side rails. When asked if she was the only one assisting the resident at the time of the fall, she stated, Yes, after the resident fell I went to the door and called the nurse. Me and two nurses assisted her back in bed. The nurse said that the resident was on hospice she needed to call them and then do a follow up and send her out to the hospital. When asked when the incident happen, she stated, Early in the morning. I was getting ready to go off shift. I work the 11AM to 7AM shift. When asked if she noticed if the resident had any injuries, she stated, No, nothing new. She had injuries from the previous fall, the forehead on the right side was swollen and her right eye was purple. When asked how Resident #1 is normally when providing care, Staff A stated, She is normally calm. During an observation on 11/03/25 at 1:50 PM, Resident #1's bed was not observed with bilateral side rails. During an interview on 11/03/25 at 2:00 PM, the DON and Administrator were made aware of the interventions that were not followed relating to the resident's fall on 10/22/25, to provide 2-people to assist with incontinent which was already care planned as an intervention since 2024; and that the resident had a physician's order for bilateral side rails which the resident didn't have at the time of the fall. The DON responded, She does? I do realize that there is an issue with doing a thorough investigation.

Based on observation, menu review, and interview, the facility failed to follow the menu for 1 of 2 observed meals (lunch on 04/16/25) affecting 96 of 99 resident who consume food orally. The findings included: Review of the menu for the lunch meal on 04/16/25 documented the following menu items. The following observations were made on the tray line in the kitchen on 04/16/25 beginning at 11:30 AM: a) The menu for the regular Philly Beef sandwich was documented to include a cheese sauce made with a cheese sauce mix and hot water. The observed sandwiches, prepared by the cook for the regular and mechanical soft diets, was topped with shredded cheese. b) The menu for the regular lunch meal was to contain a parsley sprig for garnish. The cook added finely chopped parsley to the top of the sandwich. c) The menu for the mechanically altered Philly Beef sandwich was to contain the same cheese sauce as the regular texture, along with a parsley sprig. The cook prepared the sandwiches for this diet with shredded cheese and finely chopped parsley. d) The menu for the pureed Philly Beef sandwich was to include pureed bread, cheese sauce, and powdered parsley. The cook failed to make the cheese sauce and pureed bread. There was no powdered parsley. During an interview on 04/16/25 at 12:42 PM, Staff H, Dietary [NAME] stated he forgot to make the pureed bread. When asked about the cheese sauce, the Certified Dietary Manager (CDM) stated the residents did not like the canned cheese sauce. When asked about the cheese sauce mix to make a cheese sauce, the CDM stated he did not try to obtain that item.

Based on observation and interview, the facility failed to ensure the form of food met the needs of residents who consume pureed and mechanical soft foods for 1 of 2 meals observed (lunch on 04/16/25), affecting sampled Residents #69, #31, #82, and #30 who consume pureed foods, and affecting sampled Residents #59, #2, #73, #12, and #58 who consume mechanical soft foods. This practice had the potential to affect 12 of 99 residents who consume pureed foods, and 20 of 99 residents who consume mechanical soft foods (20). The findings included: An observation of the lunch meal on 04/16/25 revealed the main entree was a Phili Beef Sandwich. Review of the recipe for the ground meat sandwich revealed the cook was to place the cooked meat into a food processor and process lightly to a coarse consistency. During the observation of the food service line beginning on 04/16/25 at 11:30 AM, the cook had a tray of cooked beef that contained large pieces of meat. The only other meat on the food service line was a pureed meat. Review of the recipe for the pureed meat documented the cook was to place the cooked beef in a food processor and process to a fine consistency. Observation of the pureed meat revealed the pureed meat was not smooth in texture. Upon tasting the pureed meat after the lunch meal service, the meat had a gritty texture. Observation was made of the lunch meal tray line on 04/16/25 at 11:30 AM and the cook prepared all Philly Beef sandwiches for the regular and mechanical soft diets, topped with shredded cheese and finely chopped parsley (not as per menu). The meat for the pureed diets was not processed to a puree form. During an interview on 04/16/25 at 12:42 PM, when asked about the mechanical soft/ground meat for the Phili sandwich, the cook stated he had prepared the regular meat in such a way as it was chopped up for the mechanically altered meal as well. Upon observation of the meat served for both the regular and mechanically altered meal, large chunks of meat, larger than a teaspoon, was noted. Photographic Evidence Obtained. When asked if that meat was coarsely ground, the CDM agreed it was not. When asked about the texture of the pureed meat, the CDM did not agree or disagree.

Based on observations, interview and record review, the facility failed to ensure communication with a resident who was unable to speak English for 1 of 2 sampled residents, Resident #60. The findings included: Review of the policy titled Standards and Guidelines: ADL [Activities of Daily Living] Care and Services issued 04/2020 and revised 01/2024, documented, 4. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: e. Communication (speech, language, and any functional communication system.) Review of the facility's current admission packet documented in the section titled Nondiscrimination & Accessibility Requirements . The facility provides the following: Free language services to people whose primary language is not English, such as: qualified interpreters; information written in other languages. Review of the record revealed Resident #60 was last admitted to the facility on [DATE] with a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD) (a lung disease that makes it difficult to breathe.) Resident #60 was actively receiving hemodialysis (a treatment to filter wastes and fluids from the blood as the kidneys did when they were healthy.) Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #60 had a Brief Interview for Mental Status (BIMS) score of 9, on a 0 to 15 scale, indicating the resident was moderately cognitively impaired. This same MDS section A Identification Information documented the resident was of Hispanic, Latino or Spanish origin. The MDS documented the resident's preferred language as Spanish and her need/want of an interpreter to communicate with a doctor or health care staff. Review of the active orders revealed an order Monitor resident for pain every shift: Start Date 07/17/24. Review of the Treatment Administration Record (TAR) for all of March 2025 and April 2025 revealed documentation of a 0 pain level on a 0-10 scale; 0 being no pain and 10 being the worst pain. Review of the last wound evaluation dated 10/21/24 documented a right diabetic wound that was being treated at that time. Review of the current weekly skin check dated 04/12/25 documented no new skin issues. Review of the most current care plan dated 03/05/25 documented The resident has a communication problem related to language barrier: Spanish. Resident is noted to have a cognitive deficit and is usually understood / understands. Interventions included, Discuss with resident / family concerns or feelings regarding communication difficulty; Ask yes/no questions if appropriate, Use simple, brief, consistent words/cues, Use alternative communication tools as needed; The resident is able to communicate by a translator; Provide translator If resident needs and or wants one to communicate with the resident. During an interview conducted in Spanish on 04/14/25 at 11:26 AM, Resident #60 complained of right heel pain rated at a 10 level. Resident #60 stated that for approximately 2 months she had told staff many times about her pain but nothing had been done about it. During a follow up interview on 04/16/25 at 8:57 AM, Resident #60 stated she was in dialysis yesterday. When asked If she was in pain yesterday, she stated yes and today as well, I'm in pain everyday. When asked how she communicated with staff, Resident #60 stated I just speak but they don't speak Spanish. When asked if the resident is given any kind of translator or communication tools, she stated No, they haven't asked me but I would like a translator; that would help me communicate my needs better. Resident #60 stated it was very hard not to be able to communicate with staff. When I tell them I'm in pain, they don't understand me. When asked if any kind of pain assessment was done by the nurses taking care of her, Resident #60 stated No, I tell them my heel hurts when they get me up to the wheelchair; since they don't understand me they still get me up and I just have to deal with the pain. Resident #60 consented to have a skin check observation on 04/16/25 at 9:09 AM with Staff J, Certified Nursing Assistant (CNA). When Staff J removed the resident's sock she expressed pain; a healed wound was observed at the bottom of the right heel. Resident #60 also expressed pain when Staff J re-applied the sock back on the foot. An interview was conducted on 04/16/25 at 9:15AM with the Director of Nursing (DON) addressing the concerns regarding Resident #60's language barrier affecting her pain levels. When asked how many staff was available to speak Spanish, the DON stated she spoke Spanish herself but would get a list of Spanish speaking staff from Human Resources. This information was never provided to the surveyor. The DON stated she thought the resident spoke English. When asked what staff should normally do when a resident has a language barrier, the DON stated that the facility had a language line available they could use. Photographic Evidence Obtained. The DON agreed with the findings. During an interview on 04/16/25 at 9:24 AM, when asked how she communicated with Resident #60, Staff J stated the resident spoke English. When asked how she knew that, she stated Because she replies yes and no when I talk to her. When asked if any communication tools or communication lines were used with the Resident, Staff J replied no. During a phone interview on 04/16/25 at 10:01 AM, when asked about Resident #60's pain, the representative believed it was an arthritic pain and acknowledged being aware that the resident still complained of right heel pain and not wanting to get up due to the pain. When asked if there were any Spanish speaking staff available at the facility, Resident #60's representative stated she wasn't aware of any staff that spoke Spanish. The representative stated, It would be nice to have someone available to translate to her.

Based on record review and interview, the facility failed to complete comprehensive assessments within 14 days of admission, or annually in a timely manner, for 4 of 21 sampled residents, Residents #14, #61, #84, and #151. The findings included: Review of the Resident Assessment Instrument (RAI) Required Assessment Summary dated October 2024, revealed the resident's admission comprehensive assessment must have an Assessment Reference Date (ARD) no later than the 14th calendar day of the resident's admission, and must be completed no later than the 14th calendar day of the resident's admission. This document also revealed the Annual comprehensive assessment must have an ARD 366 calendar days after the last comprehensive assessment and be completed no later than 14 calendar days after that ARD. Review of the records revealed the comprehensive assessments were not completed timely for the following residents: a) Resident #14 was admitted to the facility on [DATE] and the comprehensive assessment was completed on 01/02/24, 15 days late. b) Resident #61 was admitted to the facility on [DATE], and the most recent annual assessment had an ARD of 12/06/24, and was completed on 12/23/24, four days late. c) Resident #84 was admitted to the facility on [DATE] and the comprehensive assessment was completed on 04/04/25, nine days late. d) Resident #151 was admitted to the facility on [DATE] and as of 04/17/25 the comprehensive assessment had not been completed. During an interview on 04/17/25 at 11:44 AM, when asked the timeframe for completion of the comprehensive assessments, the Minimum Data Set (MDS) Director stated they should be done within 14 days of admission to the facility, and annually thereafter. When asked why these assessments were late, the Regional MDS Director, who was also present, had no answer.

Based on observation, record review, and interview, the facility failed to ensure appropriate care and services for 2 of 6 sampled residents, as evidenced by the lack of offloading (relieve pressure) of a surgical wound for Resident #75, and failure to follow physician ordered parameters for antihypertensive (blood pressure) medications for Resident #82. The findings included: 1. Review of the record revealed Resident #75 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Further review of this assessment documented the resident had a surgical wound. Review of the wound care progress note dated 04/07/24 and written by Staff G, the wound care nurse practitioner, revealed the resident was to offload her heels as per the facility protocol. A second noted dated 04/14/25 documented, in part, to continue to reduce pressure to wound area. Offloading: Implement appropriate offloading interventions based on patient needs, utilizing standard facility practices and available support surfaces to minimize pressure on affected areas. Continue to encourage compliance and assistance with offloading and turning/repositioning. During an interview on 04/14/25 at 9:50 AM, Resident #75 was sitting up in bed. When asked what brought her to the facility, Resident #75 explained she had a wound on the outer side of her left foot. An observation of the dressing revealed shadowing was present, indicating the wound was draining. When asked if she was able to offload or relieve pressure to the wound while in bed, the resident explained that she tried to, but she purposely falls asleep on her right side, but during the night she automatically rolls over onto her left side. The resident stated, when she is on her left side the wound is directly on the mattress. When asked if they had provided any device to assist offloading, like a boot to wear in the bed, the resident stated they had not. During a wound care observation with Staff G, the Nurse Practitioner (NP), and the Wound Care Nurse on 04/14/25 at 12:28 PM, Resident #75 mentioned to the NP that when she falls asleep she automatically rolls over onto her left side. The NP stated, We have a fix for that. A foam boot for when you are in bed. During an interview on 04/17/25 at approximately 10:30 AM, Resident #75 was wheeling herself from therapy. When asked if she had received the foam boot to wear in the bed, the resident stated she hadn't seen one. Staff I, Certified Nursing Assistant (CNA), for Resident #75 was nearby and was asked if she had seen any foam boot for Resident #75 to use while in bed. The CNA stated she had not, but that the resident was usually up by the time she arrived. An observation in the resident's room with the CNA lacked any foam boot. During an interview on 04/17/25 at 10:39 AM, the Unit Manager stated she was unaware of any foam boot for Resident #75. During an interview on 04/17/25 at 2:50 PM, when asked about the provision of a foam boot for Resident #75, the Wound Care Nurse stated the NP had not entered an order for the boot. The Wound Care Nurse stated he did not hear the conversation between the NP and Resident #75 during the observed wound care. 39167 2. Review of the clinical records revealed Resident #82 was admitted to the facility on [DATE], with diagnoses that included orthostatic hypotension and fractures. The care plan, revised on 01/16/25, noted that Resident #82 had experienced falls and was at risk for further falls due to hypotension, an unsteady gait, and poor balance. Additional clinical records documented that Resident #82 had falls on the following dates: January 10, 2025; January 15, 2025; January 26, 2025; January 31, 2025; February 5, 2025; and February 13, 2025. Review of the physician's order dated 01/28/25 prescribed the administration of Midodrine 10 mg by mouth every 8 hours for low blood pressure, with a directive to hold the medication if the blood pressure exceeded 130. In the April 2025 medication and treatment administration records, it was indicated that Midodrine 10 mg was administered outside of the recommended parameters, on 04/04/25, at 6 AM, the blood pressure was recorded at 137/78, and on 04/05/25, the blood pressure was 137/72, yet the medication was still documented as administered to the resident. On 04/18/25, at 9:01 AM, an interview and a side-by-side review of Resident #82's record was conducted with the Director of Nursing (DON). The DON acknowledged the findings and agreed that Midodrine should have been withheld on those days.

Based on observation, interview, and record review, the facility failed to provide nail care for 3 of 3 sampled residents reviewed for Activities of Daily Livings (ADLs), Residents #59, #13, and #4. The findings included: 1. Review of the policy titled Standards and Guidelines: ADL Care and Services, issued 04/2020 and Revised 01/2024, documented, 4. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, mail care and oral care . Review of the record revealed Resident #59 was initially admitted to the facility on [DATE] with diagnoses that included Dysphagia (difficulty swallowing) and Aphasia (loss of ability to understand or express speech) following cerebral infarction (a serious condition where blood flow to the brain is blocked, leading to tissue damage and death.) Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #59 had a Brief Interview for Mental Status (BIMS) score of 3, on a 0 to 15 scale, indicating the resident was severely cognitively impaired. This same MDS also documented the resident had upper extremity impairment on one side of the body. Review of Resident #59's current care plan dated 1/30/25 documented, Resident has an ADL self-care deficit related to ADL needs and participation vary, chronic medical conditions, Impaired balance, Limited Mobility. Observations conducted on 04/14/25 at 9:42 AM, 04/14/25 at 2:27 PM, 04/15/25 at 9:02 AM, 04/16/25 at 8:48 AM and 04/17/25 at 9:26 AM revealed Resident #59 was found to have long, dirt-encrusted, unkempt nails on all days. During a phone interview on 04/14/25 at 2:27 PM, when asked how care was, Resident #59's representative stated she needed to tell staff to cut his fingernails as she had noticed they were long. When asked if she needed to ask staff for it to get done, she replied, yes, normally I have to ask. 2. Review of the record revealed Resident #13 was initially admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #13 had a BIMS score of 6, on a 0 to 15 scale, indicating the resident was severely cognitively impaired. Review of Resident #13's current care plan dated 02/06/25 documented, Resident has an ADL self-care deficit related to chronic medical conditions, ADL participation and needs may vary., disease process - Dementia. Observations conducted on 04/14/25 at 9:58 AM, 04/15/25 at 9:09 AM, 04/16/25 at 8:37 AM and 04/17/25 9:28 AM revealed Resident #13 was found with untrimmed and dirty nails on all days. 3. Review of the record revealed Resident #4 was initially admitted to the facility on [DATE] with a primary diagnosis of senile degeneration of brain (a term that refers to the cognitive decline). Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #4 had a Brief Interview for Mental Status (BIMS) score of 4, on a 0 to 15 scale, indicating the resident was severely cognitively impaired. An observation and interview were conducted on 04/14/25 at 10:09 AM, and Resident #4 nails were observed to be long, unkempt and with chipped nail polish. When asked if she receives nail care, Resident #4 stated, Sometimes they do my nails, and sometimes they don't. My daughter usually does my nails, but she is out of town. I would like them to help me do them. Follow up observations conducted on 04/15/25 at 9:12 AM, 04/16/25 at 8:51 AM, and 04/17/25 9:30 AM revealed Resident #4's nails were still long, unkempt and with chipped nail polish on all days. During an interview on 04/17/25 at 10:01 AM, when asked who is responsible for providing nail care to residents, Staff D, Certified Nursing Assistant (CNA), stated they were not allowed to cut fingernails and could only clean nails. When asked why they were not allowed to cut fingernails, Staff D stated it was for safety reasons. When asked how nails were cleaned, Staff D stated she used a washcloth. During an interview on 04/17/25 at 10:06 AM, when asked who is in charge of providing nail care to the residents, Staff E, CNA, stated the podiatrist was in charge of cutting nails and the CNAs were in charge of cleaning nails. An interview was conducted on 04/17/25 at 10:22 AM with Staff C, Licensed Practical Nurse (LPN), and Staff A, Unit Manager. When asked who was in charge of assigning CNAs to provide nailcare, Staff C stated she was. When asked who was in charge of providing nail care to residents, Staff C stated the CNAs should be providing nail care to residents on their shower days. When asked if CNAs were allowed to cut fingernails, Staff C stated, they were allowed to cut fingernails and the only exception was to toenails. Staff C stated she didn't know where the confusion was since they had been trained to cut nails. They were made aware of the above findings regarding Residents #59, #13, and #4's fingernails. Staff C agreed with the findings.

Based on record review and interview, the facility failed to ensure accurate Minimum Data Set (MDS) assessments for 4 of 21 sampled residents, as evidenced by inaccurate dialysis coding for Resident #86, inaccurate medication coding for Residents #70 and #31, and inaccurate hospice coding for Resident #69. The findings included: 1. Review of the record revealed Resident #86 was admitted to the facility on [DATE]. Review of physician orders and progress notes lacked any indication the resident had received any dialysis services. During an interview on 04/14/25 at 11:15 AM, Resident #86 stated he was not receiving dialysis services, and had never received them. Review of the admission MDS assessment dated [DATE] documented the resident was receiving dialysis services. During a side-by-side record review and interview on 04/17/25 at 11:38 AM, the MDS Coordinator agreed with the inaccurate MDS for Resident #86. 39167 2 Review of the clinical records revealed Resident #31 was admitted to the facility on [DATE] and again on 02/26/24, with diagnoses that included anxiety disorder and depression. The annual comprehensive assessment, reference date 03/27/25, indicated in section N regarding medication that the resident had received an antipsychotic during the look-back period, as evidenced by a yes recorded in subsection A. Review of the medication and treatment administration records for March 2025 did not provide any documented evidence of the resident receiving an antipsychotic during that time. On 04/18/25 at 7:43 AM, both MDS coordinators were interviewed. The record for Resident #31 was reviewed side-by-side with them, and the coordinators acknowledged the findings. 3. Review of the clinical records revealed Resident #69 was admitted to the facility on [DATE] and again on 12/13/23, with a diagnosis that included a stroke. In the quarterly comprehensive assessment conducted on 02/10/25, under section O for special treatments, procedures, and programs, no was recorded for hospice services. Review of physician orders dated 11/20/24 indicated that hospice care had been initiated on 08/05/24 for the diagnosis of late effects of a cerebrovascular accident (CVA) [stroke]. Review of the progress notes dated 08/05/24 confirmed that Resident #69 was admitted to hospice services, and family members were present with the hospice team during this time. On 04/18/25 at 7:43 AM, both MDS coordinators were interviewed. The record for Resident #69 was reviewed side-by-side with them, and the coordinators acknowledged the findings. 52127 4. Review of records revealed Resident #70 was admitted on [DATE] with diagnosis that included Encephalopathy, unspecified, cognitive communication deficit and unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. Review of the MDS dated [DATE] documented that Resident #70 was receiving Antipsychotic medication. The Admission nursing evaluation progress note dated 01/22/25, included, in part, that the resident is receiving antipsychotic medications that require an abnormal involuntary movement scale be completed. Review of record lacked any order for Antipsychotic medication from 01/22/25-01/29/25. During an interview on 04/16/25 at 11:48 AM, when asked why the antipsychotic medication was not provided to Resident #70 when it was listed on the MDS dated [DATE], the MDS Director responded that the medication was ordered on 01/30/25. Although the MDS Director did not state that the MDS was inaccurate, further review of records revealed that the MDS was modified immediately after the interview on 04/16/25 at 11:53 AM. and changed the Yes answer to No for Antipsychotic medication for Resident #70.

Based on record review and interview, the facility failed to complete quarterly assessments no less than every 3 months for 3 of 21 sampled residents, Residents #14, #21, and #61. The findings included: Review of the Resident Assessment Instrument (RAI) Required Assessment Summary dated October 2024, revealed the resident's quarterly assessment must have an Assessment Reference Date (ARD) 92 calendar days after the previous quarterly assessment, and must be completed no later than the 14th calendar day after the ARD date. Record reviews revealed the following quarterly assessments were not completed timely: a) The quarterly assessment with an ARD of 06/10/24 for Resident #14 was completed on 07/17/24. b) The quarterly assessment with an ARD of 09/10/24 for Resident #14 was completed on 10/03/24. c) The quarterly assessment with an ARD of 03/11/25 for Resident #14 was completed on 04/14/25. e) The quarterly assessment with an ARD of 05/25/24 for Resident #21 was completed on 06/21/24. f) The quarterly assessment with an ARD of 03/06/25 for Resident #21 was completed on 04/10/24. g) The quarterly assessment with an ARD of 03/09/24 for Resident #61 was completed on 03/25/24. h) The quarterly assessment with an ARD of 06/09/24 for Resident #61 was completed on 07/16/24. d) The quarterly assessment with an ARD of 09/09/24 for Resident #61 was completed on 10/03/24. During an interview on 04/17/25 at 11:38 AM, the MDS (Minimum Data Set) Coordinator and Regional MDS Director agreed with the findings.

Based on observation, interview, and record review, the facility failed to ensure that resident choices of television channels were respected for 1 of 5 sampled residents reviewed, Resident #34. The findings included: Clinical record review showed that Resident #34 was admitted to the facility on [DATE] and again on 06/02/24, with diagnoses that included anxiety disorder and depression. The quarterly comprehensive assessment dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 15, indicating he was cognitively intact. No mood or behavior concerns were noted. According to the quarterly activity assessment dated [DATE], Resident #34 spends time reading and watching TV (television) in his room. He enjoys sports but prefers not to participate in group programs, stating that he does not want to get out of bed. On 04/14/25 at 9:31 AM, Resident #34 expressed frustration with the facility's cable system, stating, We don't have a lot of channels. He indicated that although there were supposed to be 48-49 channels, only about 35 were available. He mentioned wanting to watch the show called The Masters on CBS the previous day but could not because the TV did not include CBS. The TV lacked WTCN, NBC, and ABC channels. On 04/15/25 at 8:41 AM, the resident was observed lying in bed watching TV. He reiterated that the facility had not addressed his concerns regarding the TV channels. On 04/18/25 at 8:37 AM, the Maintenance Director was interviewed. The surveyor informed her of Resident #34's concerns about the lack of WTCN, CBS, NBC, and ABC channels. She stated that she was unaware of these issues. Later that day, at 1:24 PM, an interview was conducted with the Maintenance Director and Resident #34. The Director presented documentation indicating that residents were supposed to have 49 channels. Upon checking, she found that ABC, WTCN, and CBS channels were not working, and NBC was stuck. These were channels preferred by Resident #34. He informed the Maintenance Director that he had previously complained about these channels to the staff, including the floor technician. When the surveyor inquired about the process for addressing environmental concerns, the Maintenance Director explained that when a resident reports an issue with the TV, staff should document it in the TELLS system, which would allow her to follow up and resolve issues. She admitted that she did not know the channels were not functioning.

Based on clinical and administrative record review and staff interview, the facility failed to ensure that 1 of 3 sampled residents (Resident #2), reviewed for pressure ulcers, received care consistent with professionals standards of practice to accurately assess, provide services to promote healing, prevent infection and prevent the development of new ulcers. This failure is evidenced by the facility failing to provide wound care evaluation and treatment by a qualified professional in a timely manner; and failed to perform the prescribed medical treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings included: The facility's policy for Prevention and Management of Wounds, created July 1, 2017, was reviewed. The Policy did not have an identified last revision date. The procedure outlined in the policy documented the following: 1. The nurse will identify the impairment and stage if indicated. 2. Identify the appropriate treatment and interventions. 3. Notify Physician. 4. Refer the resident to the wound care specialist. 5. Notify Family or responsible party. 6. Document physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . 7. Complete treatment record in the EMR wound module or on paper. 8. Indicate interventions on the Resident's Plan of Care. 9. Refer to DON for inclusion in weekly clinical meeting. 10. Update CNA Plan of care on kiosk as needed. 11. Recognize factors contributing to pressure, resident needs and behaviors. Review of the clinical record revealed for Resident # 2 was admitted to the facility on [DATE] from a local hospital. The hospital's 3008 (Physician Referral) noted that the resident had a DTI ( Deep tissue Injury) to left hip, Stage I (superficial reddening of the skin that when pressed does not turn white (non-blanchable); skin is not broken) coccyx, Right heel Deep Tissue Injury and right great toe- black nail. The facility's Admission Nursing Packet on 04/08/21 at 3:10 PM documented that the resident had a small open area on the coccyx, left hip has an open area with some discoloration. There were no other open areas documented at this time on the nursing assessment. Review of the admission Braden risk assessment of 04/08/21 identified the resident was high risk for pressure ulcer development, with a score of 12.0 (10 and above is high risk). A 04/12/21' weekly skin check' documented the resident had a Stage 1 pressure wound on the coccyx and identified a skin issue on the left trochanter hip. There was no further description for the left trochanter hip wound. Documented in the comment section of this 04/12/21 skin check was Bilateral Upper extremities bruises, Stage 1 pressure wound, redness to the coccyx noted, treatment in progress. Review of the 04/14/21 Minimum Data Set Assessment (MDS) documented the resident requried extensive assist of one staff for bed mobility, dressing, toilet use and personal hygiene; and is totally dependent on one staff for transfers, eating, bathing and locomotion on the unit. There was no impairment noted in the resident's upper and lower extremities. The MDS identified that the resident had a pressure ulcer/injury; was at risk for developing pressure ulcers/injuries; and had one or more unhealed pressure ulcer/injuries. The current number of unhealed pressure ulcer/injuries at each stage was noted as 2 (two) - Stage 2 pressure ulcers and these two pressure ulcers were present on admission. There were no other pressure ulcers or other wounds identified on the MDS. Review of the 04/09/21 Plan of Care identified a focus of Impaired Skin Integrity. The documented intervention was to administer treatment as ordered. On 04/10/21, the facility identified a focus as The resident has potential for pressure ulcer development related to immobility. admitted with multiple ulcers. The interventions included: Administer medications as ordered. Monitor / document for side effects and effectiveness; Administer treatments as ordered and monitor for effectiveness; Follow facility policies/protocols for the prevention / treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . to ensure the resident's comfort; Turn and reposition resident every hour or as per protocol. Despite the resident being admitted to the facility on [DATE], there is no documented staging or measuring of the resident's wounds until 04/19/21 (11 days after the admission) when the wound care specialist evaluated the resident. On admission the resident was identified with two skin issues: a Stage 1 on the coccyx and a Deep Tissue injury on the left hip. When the Wound Care Physician evaluated the resident's wound 11 days later, the resident had 3 identified skin issues: a Stage 4 (Full thickness skin and tissue loss has occurred, with exposed fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer) pressure ulcer on her coccyx and two Unstageable (due to Necrotic tissue) pressure ulcers on both hips as identified below. The following wound care physician notes were documented: The 04/19/21 Wound Progress Note documented the resident (Site 1) had a Stage 4 pressure wound on the sacrum that measured 4 x 4 x 0.4 cm, moderate serous exudate; 30% thick adherent devitalized necrotic tissue; 60% slough and 10% granulation. The dressing treatment plan prescribed by the physician was Leptospermum honey, apply once daily and as needed for 30 days; alginate calcium apply once daily and as needed for 30 days; gauze island with border apply once daily; peri-wound [MEDICATION(S)] ointment apply once daily and as needed for 30 days. Further recommendations included reposition per facility; Group-2 mattress; low-air loss mattress; Vitamin C 500 mg twice daily by mouth; [MEDICATION(S)] [MEDICATION(S)] 220 mg once daily by mouth for 14 days; Multivitamin once daily by mouth. The progress note of 04/19/21 further documented that the physician performed a surgical excisional debridement procedure to remove thick adherent eschar and devitalized tissue (14.4 cm2 of devitalized tissue and necrotic muscle and surrounding fascia fibers along with slough and biofilm were removed at a depth of 0.4 cm and healthy bleeding tissue was observed. Hemostasis was achieved and a clean dressing was applied). The physician's addendum documented the resident's other wounds were included in the 04/19/21 Wound Evaluation as follows: Site 2 - Right Hip wound measuring 2 cm x 1 cm x 0.1 cm, surface area 2.00, Serosanguinous moderate, thin watery exudate, 10% slough, 90% necrotic black wound. Site 3- Left Hip Unstageable Pressure Ulcer measuring 5 cm x 5 cm x 0.2 cm, with moderate amount of serous exudate, 90 % necrotic black. The physician's treatment order included Leptospermum honey apply once daily, alginate calcium, cover gauze island with border dressing. The 04/26/21 Wound Progress Notes documented the follosing: a. Site 1 / sacrum/coccyx - Stage 4 wound now measuring 5 x 3 x 0.4 cm, moderate serous exudate; 95% thick adherent devitalized necrotic tissue; 5 % granulation. The dressing treatment plan continued to prescribe the same treatment orders and noted that she will change to Santyl if wound doesn't progress. The physician again documented a surgical excisional debridement procedure, removing necrotic tissue and establish the margins of viable tissue. The physician surgically excised 14.25 cm2 of devitalized tissue and necrotic muscle and surrounding fascial fibers were removed at a depth of 0.4 cm and healthy bleeding tissue was observed. b. Site 2 documented an unstageable (due to necrosis) of the Right Hip, pressure wound measuring 2 x 1 x 0.1 cm, surface area, 2.00 cm2, moderate serous-sanguineous exudate; 90% thick adherent black necrotic tissue (eschar). The physician documented that she removed necrotic tissue and establish the margins of viable tissue, remove thick adherent eschar and devitalized tissue. Treatment plan included Leptospermum honey apply daily, alginate calcium, gauze island with border. c. Site 3 - Unstageable (Due to Necrosis) of the Left Hip, measuring 7 x 5 x 0.2 cm, surface area 35.00 cm2; moderate serous exudate, 90% thick adherent black necrotic tissue (eschar); 10% thick adherent devitalized necrotic tissue. The physician documented that she removed necrotic tissue and establish the margins of viable tissue, remove thick adherent eschar and devitalized tissue. Treatment plan included Leptospermum honey apply daily, alginate calcium, gauze island with border. The 05/03/21 Wound Progress Note documented the following: a. Site 1 - Coccyx - Stage 4 wound now measuring 7 x 6 x 0.5 cm, surface area 42.00 cm2; moderate serous exudate; 95% thick adherent devitalized necrotic tissue; 5 % granulation tissue. Again, the physician had to surgically excise necrotic tissue 39.90 cm2 of devitalized tissue and necrotic periosteum and friable bone were removed at a depth of 0.5 cm. The procedure included a biopsy of a Stage 4 pressure wound of the sacrum to investigate the neoplastic process within the wound margins. The physician prescribed a change in the wound treatment plan, prescribing Dakin's solutions apply once daily. Additional recommendation included culture and sensitivity of wound, x-ray of sacrum. b. Site 3 - Left Hip - Unstageable ( Due to Necrosis) measuring 6 cm x 5 cm x 0.2 cm, surface area 30.00 cm2, moderate serous exudate; 90% thick adherent Black devitalized necrotic tissue (eschar); 10 % thick adherent devitalized necrotic tissue. Surgical excisional debridement procedure was done to remove Necrotic Tissue and establish viable tissue. The physician excise 30. cm2 of devitalized tissue and necrotic subcutaneous fat and surrounding connective tissues were removed at a depth of 0.2 cm. The treatment plan was changed to the Hydrogel gel with silver daily dressing. Review of the Treatment Administration Record (TAR) revealed that facility did not implement the prescribed wound treatment plan, prescribed by the Wound Care Consultant on 04/19/21 of the daily Leptospermum honey on the resident's wounds. The TAR documented a 04/09/21 wound care of Clean Open Area to Coccyx / Buttocks and Left Hip with Normal Saline and pat dry, cover with dry dressing every day shift every Monday, Wednesday and Friday. This wound care continued until 05/04/21 despite the physician prescribing other treatment orders. This failure to perform the prescribed treatment also attributed to the continued deterioration of the resident's pressure ulcers. The wound care physician evaluated the resident on 05/03/21 and again changed the wound care dressing for the coccyx and left hip wounds. The resident transferred to another skilled nursing facility on 05/06/21. The physician's treatment plan prescribed for the coccyx: Dakin's Solution and cover with gauze island dressing with border daily; and for the left hip treatment orders: Hydrogel with silver gauze island border dressing daily. Additionally, despite the physician prescribing the changes in the resident's treatment plan, the facility did not implement the new orders until 3 days later on 05/06/21. An interview was conducted on 05/13/21 beginning at 9:29 AM with the Wound Care Physician, who expressed that the 04/19/21 visit was the first visit she had with Resident #2. She stated she had just started with the wound care company and was assigned to this facility. She stated that the resident had the Stage 4 on the Sacrum and 2 unstageable on both hips and she was informed by the facility that the resident had these wounds upon admission. She didn't know what the wounds looked like previously and was unaware if someone else saw the resident previously. She was told to immediately go to the facility to provide wound care consultation. She believed that she and the wound care nurse were new to the facility. She further stated that she became aware that the initial wound progress note on 04/19/21 did not contain all three wounds but she called back an addendum to add the other two wounds to the 04/19/21 progress note. She said, wounds of this magnitude take a long time to heal especially the sacrum wound. She said she debrided the Stage 4 wound and prescribed the daily wound dressing for all three wounds. She stated she makes rounds with the Wound Care Nurse and they are to take the order from the progress note and input the order into the facility's electronic system. She was unaware that the facility staff were not performing the prescribed wound care. The sacrum wound did not improve and was noted to have white grayish color; was very deep and it looked infected. She said You could see the bone. She contacted the primary physician and the resident's son to inform them of the worsening sacrum wound. She did a biopsy and had requested the primary physician to order additional diagnostic testing and antibiotics. She received the biopsy results, which indicated the impression was acute [CONDITION(S)], infection of the bone. An interview was conducted on 05/13/21 at 11:00 AM with the Interim Part-Time Wound Care Nurse (WCN). She stated she has been helping out since February / March 2021. She works all day on Monday, rounding with the Wound Care Physician. They typically don't finish until late on Monday. The physician will then dictate the progress note and she will upload on Tuesday into the system. She works usually until 11:00 or 12:00 PM on Tuesday, putting in the assessments and orders from the previous days' wound rounds. She will also work until 11:00 AM - 12:00 PM on Wednesday and help with wound care for the residents. The physician measures the wounds. When the surveyor asked the WCN regarding the wounds for the resident, she stated when the wound care physician saw the resident, the resident had the three wounds. She doesn't recall the prescribed wound care. She initially stated it was a Monday, Wednesday and Friday dressing and then she said I think it was honey dressing. She believed she put in the treatment orders. Review of the wound care orders from 04/19/21 revealed they did not appear on the Treatment Administration Record and were not implemented. The WCN said, We tell the nurses about the wound care and if I don't finish the wound care, I will tell the nurses'. The 04/19/21 wound treatment plan was not implemented. The WCN indicated that on 05/03/21, the physician did a biopsy and culture on one of the visits and changed the wound care dressing to Dakin's solution. The surveyor asked regarding this wound care treatment because the physician saw the resident on 05/03/21 and the treatment order was not put in the electronic system until 05/05/21. This treatment was not documented as implemented until 05/06/21, the day the resident transferred to another facility. She stated that on 05/03/21, they did a lot of assessments and new orders so she was still inputting information on Wednesday, 05/05/21. An interview was conducted on 05/14/21 at 5:10 PM with the Office Manager for the Wound Consultant Company. He confirmed that the first Wound Care Consultant visit for Resident #2 was conducted 04/19/21. He denied any prior Wound Care Physician visits for the resident at the facility.