Every finding on record at Trinity Terrace

Based on observation, interview, and record review the facility failed to provide pharmaceutical services to ensure accurate acquiring, receiving, dispensing, and administering of all medications for 1 of 3 residents (Resident #2) reviewed for medication administration. The facility failed to administrator Resident#2's Brimonidine Tartrate Ophthalmic Solution 0.2 % (Brimonidine Tartrate) as ordered from 05/15/26 to 05/27/26. The facility documented Resident #2's Brimonidine Tartrate Ophthalmic Solution 0.2 % (Brimonidine Tartrate) was administered when the medication had not been delivered to the facility from 05/15/26 at 7:00 P.M, 05/16/25 at 10:00 A.M. and 7:00 P.M till 5/19/26 was documented as administered. On 5/23/26 at 7:00 P.M till 06/25/26 was documented as administered. This failure placed residents at risk of complications related to routine medications not available in the facility. Findings included:Record review of Resident #2's face sheet dated 05/29/26, reflected Resident #2 was a [AGE] year-old male, was initially admitted on [DATE] and readmitted on [DATE]. Resident #2 was diagnosed with Hypertension (High Blood Pressure Condition), Renal Insufficiency, Renal Failure, or End-Stage Renal Disease (ESRD) (bilateral. Refers to a condition where both eyes show early or suspicious signs of glaucoma but with minimal risk of progression, requiring careful monitoring rather than immediate treatment.) Record review of Resident #2's MDS dated [DATE] reflected, Resident #2 had a BIMS of 13 which indicated intact cognition. Record review of Resident #2's order summary, dated 05/29/26, reflected Brimonidine Tartrate Ophthalmic Solution 0.2 % (Brimonidine Tartrate) Instill 1 drop in both eyes two times a day related to open angle with borderline findings, low risk, bilateral, initiated on 01/20/26. Record review of Resident #2's progress notes, dated 05/29/26, reflected from 5/15/26 to 5/2726. Resident #2 was out of Brimonidine Tartrate Ophthalmic Solution 0.2%. Record review of Resident #2's May MAR dated 05/29/26 reflected on 5/15/26 at 10 am the eye drops were not available. MAR reflected on 5/15/26 LVN F administered eye drops until 10 am on 5/19/26. On 5/19/26 at 7 P.M, MA D documented until 05/22/26 at 10:00 A.M., that medication was not available. From 5/22/26 to 5/25/26 at 7:00 P.M., LVN C documented he administered eye drops. From 5/22/26 to 5/25/26 until 10:00 A.M., MA E documented eye drops were not available from 5/25/26 to 5/27/26 MA D documented at 10 am and 7:00 P.M., the eye drops were not available. During an interview on 5/27/26 at 10:00 A.M., Resident #2 stated that he had not had one of his eye drops for several days. Resident #2 stated the facility was working on getting eye drops for him. Resident #2 stated that he did not believe his vision had changed, but he was waiting. During an interview on 05/27/26 at 10:30 A.M, MA D stated she ordered the eye drops on 5/11/26 and they should have come in two days later. MA D stated she reordered again and turned in a daily list of medications that needed to be reordered and gave it to ADON J. MA D stated on Tuesday 5/26/26 she spoke directly to the DON about Resident #2's eye drops.During an interview on 05/28/26 at 8:25 A.M., the DON stated the pharmacy would not refill the drops because it was too soon. The DON stated on Tuesday, on 05/26/26 she started to reach out to the pharmacy called and emailed, the medication was too soon to fill on 05/24/26. The DON stated the medication was supposed to be delivered this evening, The DON stated since Resident #2 received eye drops twice a day in both eyes, the bottle was only good for a 15-day supply, not a 30-day supply. The DON stated she also needed to speak with LVN C about signing off on medication that was not there. The DON stated nurse management was responsible for following up on orders.During an interview on 05/28/26 at 2:50 P.M, LVN C stated on 05/23/26 to 05/25/26 he was without a medication aide and had to pass medication aide medications. LVN C stated he needed to make sure the medication was present before he documented that the medication was given. LVN C stated the resident was prescribed medication for a reason to prevent the medication from loss of effectiveness. Attempted telephone interview with the pharmacy on 05/28/26 at 3:30 P.M. and the line was busy.Attempted telephone interview with MA E on 05/28/26 at 3:35 P.M and the number was disconnected. Attempted telephone interview with MA F 05/28/26 at 3:48 P.M, and number was not available. Attempted telephone interview with an ophthalmologist on 05/28/26 at 3:45 P.M and left a voice message. During an observation on 5/29/26 at 10:15 A.M., Brimonidine Tartrate Ophthalmic Solution 0.2% was not on the medication cart.During an interview on 05/29/26 at 11:19 A.M., ADON H and ADON I stated, the DON in-serviced staff about checking the carts at night and making sure they order within the week before the eye drops run out. ADON H stated she notified the doctor on 05/28/26 and did an eye assessment, and no concerns were found. ADON H stated staff cannot document that medication was given if the medication was not on the medication cart. ADON H stated resident could be assed incorrectly because of the medication not being administered correctly.Record review of facility in-service, Topic: Correctly documenting, medication administration, 05/28/26, reflected, .documentation that a medication was administered when it was not physically received by the resident is unacceptable, and is not permitted.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infections for 1 of 4 residents (Resident #17) reviewed for infection control.The facility failed to ensure CNA A performed hand hygiene in between glove changes while providing toileting care for Resident #17.These failures could place residents at risk of infections.Findings included:Review of Resident #17's quarterly MDS, dated [DATE], revealed the resident was an [AGE] year-old male admitted on [DATE] with diagnoses of cancer, renal failure and diabetes. The MDS also listed that Resident #17 was dependent on toileting. The MDS listed the resident's BIMS as 08, which indicated moderate cognitive impairment. Review of Resident #17's care plan, revised on 3/30/2026, revealed the resident had a history of UTI and was at risk of UTI due to incontinence. In an observation on 5/27/2026 at 9:15am, CNA A and CNA B were providing toileting care for Resident #17 before they transferred him from bed to wheelchair for his shower. Both CNAs washed hands before providing care to the resident. CNA A wiped Resident#17's bottom which was noted to have stools. CNA A removed her soiled gloves and proceeded to change gloves without performing hand hygiene. CNA B was observed to hand sanitize after she removed her soiled gloves before she put on a new pair of gloves. Both CNAs washed hands after they provided toileting care to the resident. In an interview on 5/27/2026 at 9:35am, CNA B stated she noticed CNA A did not perform hand hygiene after she removed her soiled gloves. She stated she whispered to CNA A to wash her hands. She stated she was not sure if CNA A heard her but CNA A did not wash her hands. She stated that put the resident at risk for infection. She stated the last in-service on hand hygiene was provided last month. In an interview on 5/27/2026 at 10:41am, CNA A stated she realized she did not sanitize her hands after she removed the soiled gloves. She stated she got nervous and she just kept going. She stated the risk of not performing hand hygiene in between glove change included infection. She stated she was provided in-service on hand hygiene last month. In an interview on 5/29/2026 at 9:35am, the Infection Preventionist stated he provided in-services regarding hand hygiene and infection control. He stated his expectation from his staff regarding hand washing was they need to wash hands before patient care, in between glove change, and after providing resident care. He stated he was made aware of the incident on 5/27/2026. He stated the risk of not performing hand hygiene in between glove change included infection. He stated he provided in-services on infection control and hand hygiene monthly or as needed. He also performed spot checks randomly to make sure staff followed infection prevention protocols. Record review of facility's Handwashing/Hand hygiene policy, revised 02/2023, revealed the policy stated if hands are not visibly soiled, use an alcohol-based hand rub. for the following situations:. after contact with resident's intact skin, after removing gloves. The policy also stated the use of gloves does not replace handwashing/hand hygiene.

Based on observation and interview, the facility failed to ensure that drugs and biologicals were stored in locked compartments and permit only authorized personnel to have access to the keys, for 1 (medication cart #1) of 2 medication carts observed for medication storage. On 05/27/2026 at 3:24 P.M., MA D failed to ensure medications were secured or attended to by authorized staff when MA D did not lock medication cart #1. These failures place residents at risk of access to medications or drug diversion.Findings Included:During an observation on 05/27/2026 at 3:24 P.M., medication cart #1 red panel was outwards to indicate the cart was unlocked. The medication cart was observed midway down the hallway with drawers facing outward and unlocked. Observation revealed three visitors and a housekeeper walked by the open medication cart. Observation revealed MA D was not in view of the medication cart. During an interview on 05/27/2026 at 3:32 P.M., MA D stated she ran around the corner real quickly and didn't know she left the cart open. MA D stated the medication court was supposed to be locked so residents cannot get into it. During an interview on 05/28/26 at 10:00 A.M., RN G stated the medication cart had to be locked before staff could walk away. During an interview on 05/29/26 at 11:19 A.M., the ADON stated that when staff step away from the medication cart, they should lock the cart. The ADON stated the medication cart needed to be secured for the residents and visitors' safety. Record review of facility's Medication storage in the facility, revised 01/2018, reflected .B. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) permitted to access medications. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access.

Based on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 5 of 19 residents (Residents #11, #18, #19, #33 and #94) reviewed for infection control. MA A failed to sanitize a reusable blood pressure cuff between uses on Residents #11, #18, #19, #33 and #94. This failure could place residents at risk of cross contamination of infections from other residents. Findings included: Observation of medication administration in the East Tower by MA A on 03/26/25 from 7:01 AM to 8:10 AM revealed she did not sanitize her re-useable blood pressure cuff between blood pressure checks for Residents #11, #18, #19, #33 and #94. Record review of Resident #94's EHR revealed she was on Enhanced Barrier Precautions due to having an open wound. Interview on 03/26/25 at 8:10 AM with MA A revealed she did not usually check resident blood pressures. She stated the nurses normally did it because she was the only medication aide for the entire facility. She stated she was checking blood pressures due to her nurse being behind schedule. She stated she knew the cuff should be sanitized between each resident. MA A stated the risk to residents if the blood pressure cuff was not sanitized was that it could expose the residents to germs from other residents. Interviews on 03/27/25 from 11:00 AM to 11:41 AM with RN B, CNA C, CNA D, CNA E, CNA F, CNA G and RN H revealed they had been in-serviced on 03/26/25 by the ADON about sanitizing cuffs between resident use. They all stated the cuff had to be sanitized between residents to avoid cross contamination from one resident to another. Interview on 03/27/25 at 11:48 AM with the ADON revealed MA A notified him that she had not sanitized the blood pressure cuff between resident uses, so he provided an in-service training to all nurses and CNAs. He stated the cuff had to be sanitized with disinfecting wipes and left to dry for one minute to avoid cross contamination between residents. Interview on 03/27/25 at 11:55 AM with the DON revealed any equipment that was shared between multiple residents had to be sanitized between uses to avoid cross contamination between residents. Record review of the facility's Infection Control Standard Precautions policy, dated March 2022, reflected: .3. Resident-Care Equipment .b. Ensure that reusable equipment is not used for the care of another resident until it has been appropriately cleaned, disinfected, and reprocessed .

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for food and nutrition services. Cook I failed to wear a hair restraint while in the facility's kitchen on 03/25/25. These failures could place residents at risk for food contamination and foodborne illness. Findings included: Observation on 03/25/25 at 7:00 AM revealed [NAME] I not wearing a hairnet while in the kitchen. [NAME] I was observed to be walking around the kitchen where food was being cooked. [NAME] I's hair was down with the length of her hair reaching her neck area. Interview on 03/25/25 at 7:15 AM with [NAME] I revealed the first thing the staff were required to do upon entering the kitchen was to put on a hairnet restraint. She stated she had arrived at her shift a quarter before six and noticed salads were not prepped, and she got overwhelmed and began to prep the salads. She stated she got busy and forgot to put on a hairnet. She stated the potential risk of not wearing a hairnet could be hair falling inside the food. Interview on 03/25/235 at 10:58 AM with the Nutrition Services Manager revealed all staff must wear a hairnet upon entry of the kitchen. She stated hairnets and beard nets were located at each entrance of the kitchen. She stated the risk of not wearing a hairnet would be contamination and hair falling on the food. Record review of the facility's Uniform Dining Services policy, revised November 2024, reflected: Hair . must be pulled up and contained in a hair net. Record review of the Federal Food Code 2022 reflected: 2-402.11 Effectiveness. (Hair Restraints) 1. Code of Federal Regulations, Title 21, Sections 110.10 Personnel. (b) (1) Wearing outer garments suitable to the operation . (4) Removing all unsecured jewelry . (6) Wearing, where appropriate, in an effective manner, hair nets, head bands, caps, beard covers, or other effective hair restraints . (8) Confining .eating food, chewing gum, drinking beverages or using tobacco and (9) Taking other necessary precautions

Based on observation, interview and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls for 1 (Medication Aide Cart) of 6 carts reviewed for pharmacy services. The facility failed to ensure MA-B secured her medication cart before walking away from it. This failure could allow residents to access medications not prescribed to them. Findings included: Observation on 02/08/24 at 10:30 AM revealed the medication aide's cart for the [NAME] Hall was unsecured. All of the drawers were able to be opened without the use of a key. Drawers contained both over the counter medications as well as prescribed medications. Interview on 02/08/24 at 10:35 AM, MA B stated she secured her cart before walking away, but she might not have pushed the button all the way in. MA B stated they had a problem a couple of weeks ago of carts not locking but she thought they had been repaired. She stated the risk of the cart being left unsecured was a resident getting a medication not prescribed for them. Interview on 02/08/24 at 11:10 AM, the DON stated the pharmacy company sent a tech out the previous week to work on two carts that were not securing properly. The DON stated she thought MA B's cart was one of the carts that was looked at. The DON stated the risk of a cart being left unsecured was a resident getting medications not prescribed for them and possibly having side effects that could be life threatening. Review of the facility's Medication Administration policy, dated February 2024, reflected: .5. Controlled drugs must be placed under lock and key immediately after they have been inventoried .

Based on observation and interview, the facility failed to provide pharmaceutical services, including procedures that assure the accurate administering of all biologicals, to meet the needs of each resident for 2 of 4 glucose test strips reviewed for pharmacy services. Staff failed to remove expired glucose test strips, used to check residents' blood glucose levels, from the nurse medication cart. This failure could place the rresidents at risk of inaccurate blood testing results. Findings included: Observation on [DATE] at 10:00 AM of Nurse Medication cart revealed two vials of glucose monitoring strips had expired on [DATE]. The strips had been marked with an opening date of [DATE], which was two days after they had expired. Interview on [DATE] at 10:05 AM, LVN A stated she had not checked the glucometer strips recently because none of the residents on her hall required finger stick glucose monitoring. LVN A stated the nurse that opened the new vials should have checked for their expiration date. A new vial is marked with the opening date because they are only good for 30 days after they have been opened. LVN A stated using expired test strips could lead to an erroneous reading from the glucose monitor. Interview on [DATE] at 11:00 AM, the DON stated her expectation was for the nurses not to place expired test strips, or anything expired, on their carts. The test strips were checked weekly for acuracy when the glucose meter was checked for accuracy.

Based on observation, interview, and record review, the facility failed to provide a private meeting space for residents' monthly council meetings for 4 of 4 reviewed for resident council. The facility failed to provide a private space for resident council meetings. This failure could place residents, who attended resident council meetings, at risk of not being able to voice concerns due to a lack of privacy. Findings included: Interview on 02/07/24 at 1:56 PM with the Activity Director revealed the resident council meeting would be held in the bird room which is the living/lounge room. She stated it was the best place with the most privacy. She stated she would keep a watch on the hall to make sure staff were aware of the meeting. Observation and interview on 02/07/24 beginning at 2:00 PM, during a confidential resident group meeting with four residents, revealed the meeting was held in the living/lounge room. There were no doors to close off the room. A sign was posted to indicate that a confidential meeting was being held. However, multiple staff and visitors walked through the hall to get to another hall and entering/exiting the elevators located across the living/lounge room. Also, the nurses' station was located next to the lounge room. During the confidential group meeting, three residents revealed the meeting was held each month in the dining area. While the meeting was being held, a confidential resident proceeded to state No privacy here while staff were exiting the elevator. The residents stated they were used to having staff around during their resident council meetings. Interview on 02/08/24 at 12:07 PM with the Activity Director revealed resident council meetings were held in the dining room area or at times in the living/lounge room. She stated after they completed an activity she would conduct a resident council meeting. She stated she would get more participation when residents were in the dining room. She stated normally four to five residents attended the resident council meetings monthly. She stated the facility did not have a private room area. However, since the census lowered in the last three weeks, they had rooms available. The Activity Director stated all the residents who participated in the resident council meetings monthly felt comfortable talking and there were no potential risks. Interview on 02/08/24 at 1:45 PM with the Administrator revealed the resident council meetings were always held in the dining room or in the bird room living/lounge room. She stated her expectations were for residents to be comfortable during meetings and if they wanted the meeting to be held in the dining room it should be respected. She stated she was not aware that the resident council meetings needed to be in a private area. She stated it had never been brought up to her attention. Record review of the resident council minutes for October 2023 through January 2024 revealed no requests for a private area. Record review of the facility's Resident Council Meetings policy, revised August 2013, revealed in part the following: It is the policy of the Company, when a resident(s) wish to organize a group meet, the facility will allow them to do so without interference. 1. The facility will provide the group with a private place to meeting

Based on interview and record review, the facility failed to secure all controlled medications. LVN A failed to secure controlled medication behind a double lock by placing it in an unsecured cabinet in the medication room. This failure placed residents at risk of their controlled medications being misappropriated and thereby worsening their medical condition. Findings included: Record review of Resident #2's care plan, dated 11/21/23, revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] with a primary diagnosis of hip replacement. Record review of Resident #2's annual MDS, dated [DATE], revealed the resident was cognitively intact with a BIMS score of 15. Her Functional Status indicated she required assistance with all her ADLs. Interview on 12/07/23 at 8:55 AM with DON revealed the resident was admitted on [DATE] by LVN B. The DON stated Resident #2 came from home with bag of medications all inside their bottles. The DON said that LVN B told Resident #2 that she couldn't keep the medications in her room. So LVN B counted the medications in each bottle, wrote the number of each one on the bottle, and then placed them bag in the sack. The DON stated LVN B did not create a count sheet for the Oxycodone (controlled medication). LVN B then locked the bag of medications in the controlled medications box on the medication cart. The DON revealed Resident #2 told LVN B that her family was coming that evening, and she would pick up the sack of medications at that time. However, Resident #2's never arrived that evening. The DON revealed on 10/30/23 LVN A removed the bag of medications from the locked box on the cart and placed them in an unlocked cabinet in the medication room. On 11/1/2023, Resident #2's asked for Resident #2's meds. LVN A went to retrieve the sack of medications, and it was not in the cabinet. The bag of missing medications was never located by the facility. The DON stated their consultant Pharmacist is involved. The Pharmacist said to reconcile and do a controlled meds dispense report which the DON completed. The DON stated the facility policy states that if a resident brings medications from home, the family should take the medications back home. Policy, per DON, also stated that if family doesn't take medications back home immediately, the medications are to be destroyed. The DON revealed home medications that were controlled medications were supposed to be counted and documented on the controlled medications sheets. The oncoming nurse/MA counts the controlled medications with off-going nurse/MA and they each sign the narc sheet. The DON revealed that LVN A did not follow this policy, which could possibly have led to the missing controlled medications. The DON stated there wasn't a negative impact to the resident. However, she stated that the facility did owe Resident #2 re-imbursement for the missing medication. The DON stated that Resident #2 was updated on the process. Observation on 12/07/2023 at 9:55 AM revealed medications for destruction are kept in the DON's office. They were observed to be under two locks in DON's office. The discontinued drugs log showed they were destroyed monthly when the pharmacist comes with the DON and pharmacist. They were last destroyed on 11/13/2023. Interview on 12/7/2023 at 10:43 AM revealed LVN A said she saw a bag of medications in her medication cart (not in the locked compartment). LVN stated that on 10/30/2023 she took the bag of medications (without looking inside the bag) and put the bag in the medication room in an unlocked cabinet. LVN A stated that the following day the family arrived to pick up the medications. LVN A went to retrieve the medications, and they were not in the cabinet. She stated she saw the bag of medications only once. She also revealed she should have looked in the bag. LVN A stated that if she would have opened the bag, she would have seen the controlled medication. Then she would ask another nurse to count and put them on the controlled medications sheet and reported it to the DON per policy. After this occurrence she was in-serviced. Since she has been here has been in-serviced on controlled medications twice. LVN A stated controlled medications should be stored in the medication cart in the lock box. LVN A said controlled medications should be always under two locks. She confirmed the bag of medications was placed in the locked medication room in an unlocked cabinet. She revealed only the MA's and nurses have access to the med room. Interview on 12/07/23 at 3:48 PM with LVN B revealed she admitted Resident #2 and completed the assessments on 10/27/23. LVN B stated that Resident #2 had brought a sack of her medications from home. LVN B stated that the sack of medications included: Over the counter medications, vitamins, and a 30-day supply of Oxycodone. Resident #2 said she would have her family come and pick up her sack of medications and take them back to her home. LVN B then called Resident #2's family and requested that she pick up Resident #2's medications The family member said that she would come that night to see the resident and pick up the medications. LVN B stated she then counted the Oxycodone and put the number of the pills in the bottle on the bottle along with each of the other bottles of medications accordingly. LVN B stated she then put the bag of medications in the lock box on the cart. LVN B revealed she should have made a count sheet for the Oxycodone because it was a narcotic. She stated she did not make a count sheet because she thought was going to pick up the medications that evening. She also stated she knew the resident would not be using the Oxycodone brought from home because the facility would provide any medications that were needed. LVN B then stated that was the last time she saw the sack of medications. LVN B stated there was a risk of misappropriation to the resident because it was not counted. And it was taken from the resident ultimately. LVN B stated it was her responsibility to place the controlled medication on the count sheet. LVN B stated the facility policy says to keep track of the meds. LVN B stated she did not think that anybody would steal it. She thought that a family member would come and take it home that evening and that the medications would not be kept in house. Review of facility's current Narcotic Count, Conducting policy, dated April 2022, reflected: .2.c .narcotics are to remain in the narcotics/bin drawer and counted during each count until they are appropriately destroyed

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate documentation and disposition of controlled substances for one of two medication carts (Med Cart #2) reviewed for pharmacy services. The facility failed to remove Resident #1 discontinued meds from the Med Cart #2. These failures placed the residents at risk for diversion of controlled substances. Findings included: Record review of Resident #1's Admission Record dated 12/07/23 revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included stroke and dementia with difficulty swallowing related to stroke. Record review of Resident #1's annual MDS, dated [DATE], revealed a BIMS score of 09 indicating he had moderate cognitive impairment. His Functional Status indicated he required assistance with all his ADLs. Interview with MA C on 12/07/23 at 11:24 AM revealed that the medication carts controlled medication boxes on the medication carts should be audited and signed off between the oncoming and off-going nurse/medication aide at every shift change. Observation on 12/07/23 at 11:57 AM of Controlled Drugs Count Record for the month of December 2023 for medication cart #1 revealed shift change count was documented correctly by off-going nurse/MA and on-coming MA/Nurse for 3 residents for all shift changes. Observation on 12/7/2023 at 12:05 PM and record review for medication cart #2 revealed (3) .5 mg of Lorazepam were in the locked narc otics box and counted for Resident #1. Resident #1's Lorazepam was discontinued 3 days prior. All the Lorazepam were accounted for. However, per policy, the resident's Lorazepam should have been taken to the DON when it was discontinued. Interview with DON on 12/7/2023 at 1:30 PM revealed that the Lorazepam should have been removed from the medication cart when it was discontinued. The DON acknowledged that a system failure occurred, and numerous shift changes failed to remove the discontinued controlled medication from the locked box and take it to her to place in the medication destruction box. Interview on 12/7/2023 at 1:46 PM with LVN B revealed that the controlled meds boxes on the medication carts are supposed to be audited and signed by the oncoming and off-going nurse/medication aide at every shift change. She also stated that this is facility policy. When asked if there were (3) .5mg Lorazepam that were in the drawer and on the controlled meds count for Resident #1, she confirmed there were. She stated they counted them in the shift change controlled meds count. When asked if they were supposed to be in the drawer, she stated, No. She went on to explain that the Lorazepam had been discontinued, but not taken to the DON. Review of facility's current Medication Administration: Controlled Drugs Record Keeping-SNF policy, dated February 2021, reflected: .3. The nurse receiving them will inventory and document receipt .4. Controlled drugs must be placed under lock and key immediately after they have been inventoried and the form for each medication has been signed and received. Review of facility's current Narcotic Count policy, dated February 2021, reflected: .1 At end of every shift .between oncoming and off-going staff .

Based on observations, interviews, and record reviews, the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (Resident #36) of one resident reviewed for wound care, in that: LVN A failed to complete the treatment for one wound at a time, to change gloves and perform hand hygiene appropriately, and to clean her scissors while providing wound care for Resident #36. These failures could place residents with wounds at an increased and unnecessary risk of cross contamination causing possible complications such as pain, worsening of existing wounds, and infections. Findings included: A review of Resident #36's Admission Record dated 12/22/22 revealed a [AGE] year-old male readmitted to the facility on [DATE]. Resident #36 had diagnoses of atherosclerotic heart disease of native coronary artery (plaque build-up in the coronary artery), chronic kidney disease stage 3, acute osteomyelitis (inflammation in bone caused by infection) right ankle and foot, stage 4 pressure ulcer of right heel, and unstageable pressure ulcer of left heel. A review of Resident #36's Admission MDS dated [DATE] revealed his BIMS score was 15, which meant he had no cognitive impairment. The Admission MDS reflected he required extensive assist of 2 plus staff for bed mobility, transfers between surfaces, dressing and toilet use. This document further revealed he had a stage 4 pressure ulcer of his right heel and an unstageable pressure ulcer of his left heel A review of Resident #36's care plan revised on 10/11/22 indicated problem, goals, and interventions: -Problem: The resident has unstageable pressure ulcer to right heel and a left heel stage II of the left heel r/t disease process coronary artery disease, acute kidney disease, anemia, and immobility. -Goal: The resident's pressure ulcer will show signs of healing and remain free of infection through review date of 02/15/22. -Interventions: Administer treatments as ordered and monitor effectiveness. Follow facility policies and procedures for the prevention/treatment of skin breakdown. A review of Resident #36's Wound Evaluation dated 12/19/22 reflected, unstageable pressure ulcer of the left heel that measured 1.41 CM length X0.94 CM width. It also revealed the ulcer had a stable progress. The wound eval further revealed a Stage 4 pressure ulcer of his right heel that measured 3.75 length CM X 2.75 CM width and it had a wound bed of slough (necrotic tissue that needs to be removed) with a light amount of exudate (drainage). A review of Resident #36's Medication Review Report reflected an order dated 12/13/22 for: Wound #1: Cleanse left heal wound with N/S, pat dry. Apply Silver Alginate dressing, and cover wound with bordered gauze dressing every day shift related to PRESSURE ULCER OF LEFT HEEL, UNSTAGEABLE (L89.620) AND as needed related to PRESSURE ULCER OF LEFT HEEL, UNSTAGEABLE (L89.620) If dressing becomes soiled or dislodged. A review of Resident #36's Medication Review Report reflected an order dated 12/13/22 for: Wound #2: Cleanse Right Heel wound with N/S, pat dry, Cover with Silver Alginate, ABD pad, wrap with Kerlix and secure with tape every day shift related to PRESSURE ULCER OF RIGHT HEEL, STAGE 4 (L89.614) AND as needed If dressing becomes soiled or dislodged. An observation on 12/22/22 at 11:25 AM revealed LVN A, after removing Resident #36's bilateral soft boots and placing them under his lower legs, she opened and placed a chuck (A disposable incontinent pad) under his feet. LVN A removed the island dressing from Resident #36's left heel which left the silver alginate dressing stuck to the wound bed. LVN A picked up her scissors and cut through the kerlix wrap on Resident #36's right foot, took it off with the ABD pad and placed them on the chuck under his feet. The silver alginate dressing remained stuck to the wound bed on his right heel as well. LVN A washed her hands, gloved, took a 4X4 gauze and NS bullet, wet the gauze and cleaned Resident #3's left heel wound, removing the silver alginate dressing. Without changing her gloves or performing hand hygiene, LVN A got another 4X4 gauze , wet it using a NS bullet, placed it over the right wound with silver alginate stuck to wound. LVN A Held it there for a few moments then held it against the silver alginate on his right heel wound bed, then worked the silver alginate off. LVN A used another 4X4 gauze , wet it with the NS and cleaned the right heel wound again. LVN A then changed her gloves and sanitized her hands, picked up the scissors, and without sanitizing them, opened the silver alginate dressing and cut it to the size of the left heel wound and stuck it into the wound bed then placed an island dressing over it. LVN A, without changing gloves and performing hand hygiene, picked up the silver alginate dressing and placed it into the right wound bed, put an ABD pad over it, then used a gauze roll to wrap Resident #36's foot, and taped it at the end. An interview on 12/22/22 at 12:05 PM with LVN A, after asking about doing the wounds together, said this was only her second time working with Resident #36, she was an agency nurse, did not do wounds very often and had never done them with state observing. When asked about the scissors she stated I realized as soon as I cut the silver alginate that I should have cleaned them first to prevent contaminating the wound, but it was already done so she had continued. An interview on 12/22/22 at 12:40 PM revealed the DON expected her staff to wash their hands, after cleaning the table, set up their supplies, wipe their scissors before starting and after cutting a bandage off, before cutting another clean dressing so there was no contamination. The DON stated if there were multiple wounds, they should do one wound at a time, to prevent cross contaminating the wounds. The DON stated she also expected her staff to wash their hands before they started, between dirty to clean tasks/areas, and if they were visibly soiled. After explaining what LVN A had done, the DON said she was going to send in one of the facility's nurses, but figured they needed to see what the agency nurse knew. She said they were nurses so they should know the correct way to do things. An interview on 12/22/22 at 1:40 PM the DON said they were starting check offs with all the nurses including the agency nurses on wound care and multiple wounds. She also said she had talked with LVN A who told her she knew she had done wrong, but she was nervous and did not know what to do. The DON said she told LVN A she could have started over on the wound care if nothing else. The DON said they do have checkoffs with the agency nurses when they come to work the first time, but they were going to redo them with all nurses now. Review of the facility's Licensed Nurse Competency Checklist for LVN A dated 11/16/22 revealed: 8. Performed hand hygiene, put on gloves. 9. Removed dirty dressing and place in plastic bag. 10. Removed gloves and placed in plastic bag. 11. Performed hand hygiene. 12. Put on gloves. 13. Performed treatment . 15.Removed gloves and place in plastic bag. 16. Performed hand hygiene/Clean scissors or other equipment. Review of the facility policy and procedures for Skin-Wound Issues last revised 11/2015 revealed: .wash and dry your hands thoroughly .Put on gloves .Apply dressings as indicated .Clean and disinfect reusable supplies ( .scissor blades .) with alcohol or other disinfectant as indicated.

Based on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three (CNA A, and CNA B) of five staff observed for infection control practices. CNA A, CNA B and Housekeeper C failed to wear the appropriate PPE prior to entering the rooms of two residents who were on quarantine for COVID-19. These failures could place the residents at risk of exposure to communicable diseases and infections. Findings included: Review of Resident #1's face sheet printed on 06/22/22 revealed the resident was an [AGE] year-old female admitted to the facility from the hospital on 06/16/22. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's care plan dated 06/22/22 reflected she had potential for COVID-19 related to national pandemic related to not being vaccinated. Interventions included to initiate droplet and contact precautions for signs/symptoms of respiratory illness. Review of Resident #2's face sheet printed on 06/22/22 revealed she was a [AGE] year-old female admitted to the facility from home on 06/15/22. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's care plan dated 06/19/22 reflected she was on isolation for COVID-19 precautions for ten days. Interventions included to immediately initiate droplet and contact precautions for signs/symptoms of respiratory illness. Observation on 06/22/22 at 9:40 AM revealed there was PPE hanging on the outside of Resident #1's door that included gown, gloves, and surgical masks. There were two signs on the door, the first one stated Please see nurse before entering and the other stated All Visitors Must Wear Personal Protective Equipment including mask, gown, and gloves for entire duration of visit. CNA A was observed coming out of Resident #1's room, sanitized her hands, and the only PPE observed was a surgical mask. Interview on 06/22/22 at 10:03 AM with CNA A revealed she worked for an agency and she had been working at the facility since last August (2021). She stated the staff will wear the PPE that is was hanging on the door of each quarantine room and they could wear either goggles and face shields with residents that were showing sign and symptoms of COVID-19. CNA A further reflected the residents in the quarantine rooms were not contagious because they were just residents that had not been vaccinated prior to being admitted to the facility. Observation on 06/22/22 at 10:13 AM revealed CNA B entered Resident #2's room, and the only PPE she was wearing was a surgical mask. The CNA shut the door and she then came out of the room carrying a clear bag of trash. Further observation on 10:27 AM revealed CNA B again entered Resident #2's room but prior to, she donned a gown and gloves and wore a surgical mask. CNA B later exited the room carrying another clear bag of trash. Interview on 06/22/22 at 1:54 PM with CNA B revealed she worked for an agency and had been working at the facility for about three or four months. She stated she used the PPE that was available on each quarantine room prior to entering the room. She stated she knew she needed to have donned PPE prior to entering Resident #2's room the first time but did not because she had gone in real quick to gather trash and make a quick walk through. CNA B said it was important to don full PPE prior to entering a quarantine room because it helped prevent the spread of infection. Interview on 06/22/22 at 1:47 PM with LVN C revealed she worked for an agency and she had been at the facility for about two months. She stated the residents in quarantine were non-vaccinated against COVID-19 and they were to don PPE available on the resident's door and they had never used any N95 masks. LVN C further stated it was important to wear full PPE prior to entering quarantine rooms because it helped protect everyone against COVID-19. Interview on 06/22/22 at 2:50 PM with the ICP (Infection Control Preventionist) revealed they had two residents that were on isolation for 10 days because they had been admitted non-vaccinated against COVID-19. She stated all PPE hanging on each resident's door should be worn to include gown, gloves, and a surgical mask to prevent the spread of infection. The ICP further stated they facility staff had always used a surgical masks and no protective eye wear for residents that were on isolation for COVID-19 as long as she could remember. She said the facility did have N95 masks and eye wear protection and they would begin implementing that right away. Interview on 06/22/22 at 3:24 PM with the Interim DON revealed she had been here for a little over a month and the facility staff have worn surgical masks in quarantine rooms since she started. The Interim DON said she thought there had been a change allowing surgical masks to be worn in quarantine rooms but she was not able to find anything that stated that when she looked. She further stated it was important for the staff to wear appropriate PPE to help prevent the spread of infection. Review of the facility's policy and procedure titled Infection Control Precautions - Categories of Transmission Based Precautions last revised on 02/2022 reflected the following: .c. Masks 1. In addition to Standard Precautions, wear a mask before entering resident's room. d. Eye Protection 1. In addition to Standard Precautions, wear eye protection (goggles) or face shield before entering the resident's room. Further review of the policy and procedure revealed there was no information regarding the type of mask to be worn. Review on 06/06/22 of CDC guidelines Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes accessed at https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html reflected the following: .Personal Protective Equipment HCP who enter the room of a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face)

Based on interview and record review, the facility failed to use the services of a registered nurse for at least eight consecutive hours a day, seven days a week for six (07/11/21, 07/25/21, 08/07/21, 08/08/21, 08/15/21, and 09/12/21) of 88 days reviewed for nursing services. The facility failed to have RN coverage for eight consecutive hours for six weekends (Saturdays and Sundays) beginning 07/03/21 until 09/26/21. This failure could place residents at risk for missed resident nursing assessments, interventions, care, and treatment. Findings included: Record review of timecards for RN A, RN B, RN C, and the DON's for the time period of 07/02/21 to 09/27/21 revealed there was not eight consecutive hours of RN coverage for six out of 88 days reviewed for weekend RN coverage on Saturdays and Sundays. Record review of the Employee Timesheets for the time period of 07/02/21 to 09/27/21 revealed the following for RN A, RN B, RN C, and the DON: - Sunday 07/11/21, RN A timesheet: Time in 10:15 p.m.- Out 4:17 a.m.; Time in 4:47 a.m.- Out 7:36 a.m. (07/12/21, Monday). 1 hour and 45 minutes worked on 07/11/21 (Sunday). - Sunday 07/25/21, RN B timesheet: Time in 4:37 p.m.- Out 1:54 a.m. (07/26/21, Monday). 7 hours and 23 minutes worked on 07/25/21. - Saturday 08/07/21, DON timesheet: Time in 10:30 p.m.- Out 2:00 a.m.; Time in- 2:30 a.m. - Out 7:15 AM (08/08/21, Sunday). 1 hour and 30 minutes worked on 08/07/21. - Sunday 08/08/21, RN B timesheet: Time in 5:05 p.m.- Out 12:09 a.m. (Monday, 08/09/21). 6 hours and 55 minutes worked on 08/08/21. - Sunday 08/15/21, RN B timesheet: Time In 4:58 p.m.- Out 3:10 a.m. (08/16/21, Monday). 7 hours worked on 08/15/21. - Sunday 09/12/21, RN C timesheet: Time in 4:27 p.m.- Out 11:00 p.m. 7 hours worked on 09/12/21. During an interview on 10/14/21 at 3:59 p.m. with the DON, she revealed she was not aware RN coverage needed to be eight consecutive hours a day. The DON stated she did not have any other scheduled RNs working on the days reviewed. The DON stated she was not aware some of the RNs were not working their full eight hours during the weekend. The DON stated it was her responsibility to complete the RN schedules. She stated the potential harm of not having an RN was if an emergency happened during that time the resident would not benefit from not having an RN available. A policy for RN coverage was requested; however, the DON stated they only had a nursing services policy. During an interview on 10/14/21 at 4:28 p.m. with the Administrator, he revealed he was not aware RN coverage needed to be eight consecutive hours a day. The Administrator stated it was the nurse management/DON responsibility to complete the RNs' schedules. The Administrator stated his expectations were for his RNs to finish their scheduled shifts. When asked for potential harm for residents if an RN was not available, the Administrator stated there was no actual harm not having an RN because they had LVNs, and the LVNs were aware to contact the DON if there was an emergency. Record review of facility presented policy titled, Nursing Services, revised January 2020, revealed the following: The facility will use the services of a registered nurse for at least 8 hours a day, 7 days a week (except when waived by state regulations). Duties of the RN are set forth to allow incorporation of the position of Assistance Director of Nursing, Resident Care Manager, MDS Coordinator, Infection Preventionist, or Staff Development.

Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #1) of four residents observed for infection control. The facility failed to quarantine Resident #1 for 14 days following re-admission to the facility. This failure placed residents at risk for infection. Findings included: Review of Resident #31's Face Sheet, printed 12/15/20, revealed Resident #1 was a [AGE] year-old female originally admitted to the facility on [DATE]. The Face Sheet reflected Resident #1 had been at the hospital from 12/02/20 through 12/04/20. The Face Sheet reflected Resident #1 had been readmitted to the facility from the hospital on [DATE]. Review of Resident #1's quarterly MDS assessment, dated 10/29/2020, revealed Resident #1 had moderate cognitive impairment. Resident #1 required supervision and set-up assistance with bed mobility, dressing, bathing, and toilet use. Resident #1 was independent with eating and personal hygiene. Resident #1's [DIAGNOSES REDACTED]. Review of Resident #1's Physician Telephone Orders, dated 12/04/20, revealed the following: .Re-admit to (Facility Name) .Covid precaution isolation X 14 days Interview on 12/15/20 at 12:05 PM with the DON revealed the facility had four residents on quarantine due to new admission or hospital return status. The DON stated surveyors and facility staff would be able to identify which residents were on quarantine by the presence of storage bins containing PPE hanging on the outside of residents room doors. The DON stated staff were to wear a face mask, gown, and gloves when inside a quarantine room. Observation on 12/15/20 at 12:28 PM revealed Resident #1 inside her room. There was not a storage bin of PPE hanging on Resident #1's door. There was not a sign on Resident #1's door indicating she was on quarantine precautions. Observation on 12/15/20 at 12:52 PM revealed Lead Nutritional Aide A passed Resident #1's lunch meal to her inside her room. Lead Nutritional Aide A was observed wearing a face mask. Lead Nutritional Aide A was not observed to don additional PPE prior to entering Resident #1's room. Observation on 12/15/20 at 1:45 PM revealed LVN B outside of Resident #1's room with a medication cart. LVN B was observed wearing a face mask. LVN B took a blood pressure cuff from the medication cart and entered Resident #1's room. LVN B did not don additional PPE prior to entering Resident #1's room. LVN B closed the door once inside Resident #1's room. Interview on 12/15/20 at 5:11 PM with LVN B revealed she had performed a blood pressure check on Resident #1 earlier in the day. LVN B stated Resident #1 had been on quarantine but was removed from quarantine on 12/14/20. LVN B stated she knew Resident #1 was not on quarantine because she had been notified that morning during report that Resident #1 had been removed from quarantine the previous day. LVN B stated she was also able to determine Resident #1 was not on quarantine because there was not an isolation kit containing PPE outside of the resident's door. When asked about potential negative outcomes of a resident being taken off quarantine too early, LVN B stated that not wearing appropriate PPE for the entire duration of the quarantine period could leave staff at risk of being exposed to the infection the resident was being quarantined for. Interview on 12/15/20 at 3:48 PM with the DON revealed Resident #1 had gone to the hospital for approximately three days prior to re-admitting to the facility. The DON stated Resident #1 was placed on quarantine for 14 days upon return to the facility on [DATE]. The DON stated Resident #1's 14-day quarantine period ended on 12/14/20. When asked if 12/14/20 (end of quarantine) was 14 days after 12/04/20 (re-admitted ), DON stated the math did not add up and she would follow-up regarding the correct dates. In a follow-up interview on 12/15/20 at 3:56 PM the DON stated Resident #1 had been taken off quarantine too early. The DON stated Resident #1 should have been on quarantine through 12/18/20. The DON stated when a resident admitted or readmitted to the facility, the ADON calculated the anticipated end date for the resident's quarantine period and put the date on the calendar. The DON stated Resident #1's quarantine end date had been incorrectly calculated and listed on the calendar as 12/14/20. When asked about potential consequences of a resident not being quarantined for 14 days upon admission or re-admission, the DON stated it could be an infection control concern if the resident ended up developing signs/symptoms of COVID-19 and staff had not been wearing the appropriate PPE while assisting the resident. The DON stated Resident #1 would be placed back on quarantine at that time. Review of facility policy (Facility Name) Pandemic Response Plan, dated 03/14/20, revealed the following: .Health Care Admissions .Resident is screened for virus symptoms .Resident does not present any virus symptoms and has no known exposure: resident is allowed to admit to the community, placed on droplet precautions for 14 days and monitored for symptoms .

Based on observations, interviews and record review, the facility failed to ensure resident rooms were adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for one of 27 residents (Resident #19) reviewed for resident call system. The facility failed to ensure Resident #19 had working call light. This failure could place residents at risk of being unable to obtain assistance for activities of daily living or in the event of an emergency. Findings included: Review of Resident #19's MDS assessment dated [DATE] reflected he was a [AGE] year-old-male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He required supervision of one person with transfers and limited assistance of one person for dressing and toilet use. An observation with CNA C on 08/28/19 at 11:30 AM of Resident #20's room revealed the red bathroom light did not illuminate above his door when pressed and did not alert up at the nurse's station call light computer system. The regular call light illuminated green above his door but did not alert up on the computer system at the nurse's station. Resident #20 was not able to be interviewed as he was in another part of the facility in an activity. Interview on 08/28/19 at 4:00 PM with CNA C revealed they have had problems on and off for several months with call lights not alerting the nurse's station computer system but the problem would be resolved when administration was notified. Interview on 08/28/19 at 4:25 PM with CNA D revealed they had been having problems with the call lights not showing up at the nurse's station computer system or some would not illuminate above the room doors. Facility Services were always notified to try and fix the problem. In an interview on 08/29/19 at 3:03 PM the Administrator stated he was not aware the call lights to Resident #20's room were not working. He stated maintenance would check them monthly and he would check them periodically. In an interview on 08/29/19 at 4:09 PM the Director of Facility Services stated he was not aware the call lights for Resident #20's room were not working. He said call lights were checked weekly by a maintenance tech. He said the call light checks were completed on 08/09/19 and 08/15/19. He further stated he was not able to find a call light check for last week and it should have been completed either on Thursday or Friday (08/22/19 or 08/23/19) and did not know why it was not done. Review of the Healthcare Maintenance Inspection checklist for (MONTH) 2019, reflected the call lights were working for Resident #20's on 08/09/19 and 08/15/19 and there was not a checklist completed for the previous week (08/22/19 or 08/23/19.

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #20) of 12 residents reviewed for accidents and hazards. The facility failed to have Resident #20's bed in the lowest position while she was in bed on 8/27/19 and the resident's fall mat was not in place while she was in bed on 08/28/19. This failure could place residents at risk for accidents and injuries. Findings included: Review of Resident #20's MDS assessment dated [DATE] reflected she was a [AGE] year-old-female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She required limited assistance of one person with bed mobility, transfers, and walking. Review of Resident #20's Care Plan dated 07/18/19 reflected she was at risk for falls related to recent [MEDICAL CONDITION]. Approaches included a fall mat at bedside to prevent serious injury in case of a fall. An observation on 08/27/19 at 10:29 AM revealed Resident #20 was in bed with her eyes closed. There was a fall mat in place, but her bed was not at the lowest position. The bed was about waist high. An observation on 08/28/19 at 8:22 AM revealed Resident #20 was in bed with her eyes closed. Her bed was in the lowest position but her fall mat was observed leaning against the foot of her bed. Review of Resident #20's progress notes dated 08/21/19 reflected she was noted to be in the floor in the doorway lying on her left side. The resident was assessed, and she was able to move all four extremities without signs or symptoms of pain or discomfort but a hematoma was noted to her left hand. Interview on 08/29/19 at 10:40 AM with CNA A revealed Resident #20 was slowly declining and required limited assistance with ADL's and at times would try to get up unassisted from bed in the afternoon. She stated while the resident was in bed, the bed had to be in the lowest position and a fall mat should be in place. She was not aware the bed had not been in the lowest position or the mat was not in place because she did not work with the resident the last two days. An interview on 08/29/19 at 11:11 AM with CNA B revealed Resident #20's bed had to be in the lowest position with a fall mat in place while she was in bed. She stated the day before, 08/28/19, she was going to try and get the resident out of bed and had removed the mat and leaned it up against the foot of her bed. She went to get the charge nurse for assistance and stated she should have put the fall mat back in place while she was out and forgot. Interview on 08/29/19 at 1:11 PM with the DON revealed Resident #20's bed should be in the lowest position while she is in bed with a fall mat in place. Review of the facility's policy titled Fall Reduction and Management Program reviewed on (MONTH) 2019 reflected the following: It is the policy of the Facility that every effort be made to reduce and/or prevent falls from occurring and/or minimize serious injury if a fall should happen. .4. Evaluate each resident's need for supervision, the resident environment, and assistive devices to avoid a fall.

Based on observation, interview and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #134) of 12 residents reviewed for falls. The facility failed to ensure a fall mat was placed in Resident #134's room after it was identified as a care plan intervention and per family request to prevent injuries after the resident had three falls. The failure placed the six residents, who were at high risk for falls, at risk for falls and injuries. Findings included: Review of Resident #134's MDS assessment dated [DATE] revealed the resident was an [AGE] year-old female admitted on [DATE]. The resident's [DIAGNOSES REDACTED]. She had severely impaired cognition and required extensive assistance of one to two staff for walking. It revealed she was unsteady and only able to stabilize with staff when moving from a seated to standing position, walking, tuning around, moving on and off toilet and transferring. Review of an incident report for Resident #134 dated 05/08/18 revealed the resident was found with her back against the wall next to the bedroom door, across from the bathroom. It revealed she had [DIAGNOSES REDACTED]. The incident investigation revealed the resident had a [DIAGNOSES REDACTED]. There was documentation the care plan was updated. Review of an incident report for Resident #134 dated 07/03/18 revealed the resident was found on the floor sitting down between the bed and the bathroom. She complained of tenderness to left hand and fingers when touched. The investigation reflected the cause of the fall was the resident will attempt to ambulate without assistance and without use of walker or wheelchair. She is non-compliant with use of call light. The plan of care on the 07/03/18 incident report reflected the following interventions: frequent rounds, toileting schedule, putting the bed in a low position, floor mats, neurological checks, and pain assessment. Review of an incident report for Resident #134 dated 07/17/18 revealed the resident was found sitting on the floor by the bathroom. The assessment reflected the resident had a sling on her fractured left arm. The report reflected the resident said she got up to use the restroom, and she missed the bathroom door handle and fell backward landing on her bottom with her back against the wall. The incident documentation reflected the care plan was updated. The investigation follow-up revealed the resident had a previous fall earlier that month and fractured her left hand. Her arm had a cast, and she wore a sling for support. The report reflected the resident had a history of [REDACTED]. Review of Resident #134's current Care Plan dated 07/10/18 revealed the resident had a fractured fifth metacarpal of the left hand. Review of the care plan revealed no updates or revisions following the resident's fall on 07/17/18. Review of Resident #134's current undated Care Plan revealed the resident was at high risk for falls related to a history of falls, weakness, unsteady gait, and poor safety awareness. One of care plan goals was for the resident to have no avoidable injuries from falls in the next 90 days. The care plan interventions dated 05/22/18 included: use of a wheelchair as an assistive device, occupational and physical therapy evaluations and treatment to increase functional mobility and safety as ordered, providing activities that minimize the potential for falls while providing diversion and distraction, keeping the floors free from spills or clutter, placing commonly used/personal items within reach, assisting the resident to wear non-skid/proper fitting footwear, transferring the resident with the moderate assistance of one person, and reminding the resident to use the call light for assistance/keeping the call light within reach. Review of Resident #134's Care Plan for falls revealed it was updated on 07/10/18 with one intervention, which was to toilet the resident every day at 4:00 a.m. and 6:00 a.m. Review of Resident #134's Care Plan included a category dated 07/10/18, which reflected the resident had a fractured fifth metacarpal of the left hand. No care plan update or revision was noted after Resident #134's fall on 07/17/18. Observation on 08/07/18 at 12:02 p.m. revealed Resident #134 was alert, awake and sitting up in her wheelchair in her room. Observation of the resident's room revealed there was not a fall mat by her bed. Observation of Resident #134's room on 08/08/18 10:25 a.m. revealed there was no fall mat in the resident' room. There was no fall mat in closet or under bed. Observation of Resident #134's room on 08/09/18 11:15 a.m. revealed Resident #134 sitting in her wheelchair responding to questions by staff. There was no fall mat in her room, under her bed or in her closet. Observation on 08/10/18 at 6:45 a.m. with the DON revealed there was no fall mat in Resident #134's room, while the resident was asleep in her bed which was in a low position. Interview with Resident #134's family member on 08/07/18 12:02 p.m. revealed Resident #134 had a fall which resulted in a fracture, and the resident had recently had her cast removed. Interview with another family member of Resident #134 on 08/08/18 11:40 a.m. revealed the family had requested a fall mat, but the facility had not put one in the resident's room. The family member stated the resident did not know to press the call bell for help and got herself up. The family member stated the resident had a recent fall with a major injury. Interview with CNA D on 08/10/18 at 6:15 a.m. revealed she did frequent checks and toileted Resident #134 during the night shift. She had not seen a fall mat in Resident #134's room last night or any other nights when she was caring for her. Interview with the DON on 08/10/18 at 6:45 a.m. revealed she was surprised there was no fall mat in Resident #134's room because she had put one in the room herself. She stated the resident was a fall risk and care planned to have a fall mat in her room. She said she would make sure there was a fall mat put back in the resident's room. Interview with the DON on 08/10/18 at 11:45 a.m. revealed she had included floor mats in Resident #134's incident plan of care after two different falls. She said the intervention for floor mats was not put into the regular care plan. She said she still thought the Resident #134 should have fall mats in her room. Review of Resident #134's Fall Risk assessment dated [DATE] revealed the resident was risk for falls because of three or more falls in past six months. Interview with the Administrator 08/10/18 at 12:20 p.m. revealed that the IDT committee discussed issues in their stand-up meetings. He said he could not remember conversations in IDT meetings regarding Resident #134 and floor mats. He had no specific IDT committee documentation that revealed a decision about floor mats. Review of the facility's current Fall Reduction and Management Program Policy, revised (MONTH) (YEAR), revealed the following: .Key elements to the success of this program are ongoing communication, education, monitoring, care planning, interdisciplinary approach and consistent follow up. .Evaluate each resident's need for supervision, the resident environment, and assistive devices to avoid a fall. Evaluation should consider supervision that may be needed based on the individual resident's needs and risks. Considerations of special needs may include, but not limited to: a. Residents with cognitive impairment. b. Residents with recurrent falls. c. Toileting supervision . d. Unsafe behaviors. e. Physical or mental condition changes. .Based on resident fall evaluation, an individualized care plan with the goal to prevent falls and/or minimize serious injury if fall occurs will be developed, implemented, monitored, and modified as needed. .Communicate care plan goals and interventions with the unit staff, resident/family and interdisciplinary team. .Implement the care plan in collaboration with the unit staff, resident/family and interdisciplinary team. .Review, evaluate, revised or modify the care plan on a quarterly basis and as needed. .There will be an ongoing supervision and monitoring of residents at risk for falls and effectiveness of current interventions which may or may not result in modifications or adjustments of current interventions as needed. .All direct care staff will perform routine room checks and shift rounds, and will pay close attention to residents identified at risk for falls. Rounds will be completed per any specific care plan intervention and at anytime as needed during their assigned shift. Review of a list provided by the DON on 08/10/18 revealed of six residents were considered at high risk for falls.

Based on observation, interview, and record review, the facility failed to provide food prepared in a form designed to meet individual needs for one of two meals observed for one (Resident #129) of three residents on pureed diets. The facility failed to provide pureed collard greens in a smooth, pudding-like consistency on 08/07/18 that met the needs of residents with a swallowing deficit. This failure placed three residents on a pureed diet at risk of choking, aspiration, and respiratory illness. Findings included: Observation of the lunch meal service on 08/07/18 from 12:00 p.m. to 1:00 p.m. revealed the kitchen had prepared and was serving beef stew, collard greens, and potatoes. Observation of Resident #129's plate on 08/07/18 at 12:18 p.m. revealed the pureed collard greens had one-half-inch strings/small chunks. Observation of the serving pan of collard greens on the steam table in the kitchenette on 08/07/18 at 12:47 p.m. revealed the collard greens had one-half- inch strings in the food. Interview with the Nutritional Supervisor on 08/07/18 at 12:47 p.m. revealed the collard greens looked stringy, but she was not sure if the machine did not blend the food enough or if the collard greens could not physically get to a pudding consistency. She stated if she added thickener or liquid she ran the risk of decreasing the nutritional value. The Nutritional Supervisor revealed the facility took the pureed collard greens very seriously and they took the food off of the menu. Review of an in-service provided by the Nutritional Supervisor on 08/08/18 at 10:56 a.m. revealed on 08/07/18 an in-service was conducted by the chef regarding how to properly puree the vegetables for the second floor and procedures to be followed when it comes to the proper pureeing of food items. Review of the facility's Braised Greens pureed policy, dated 08/07/18, revealed: .well cook greens, process to smooth consistency . potato consistency Review of the facility's Dysphagia Puree (Level 1) Diet, dated 2008, revealed: .Vegetables should be soft, well cooked and pureed using an appropriate recipe, and free from chunks, lumps and/or seeds All foods are the consistency of moist mashed potatoes or puddings Review of the facility's Diet Roster, dated 08/06/18, revealed three residents were on a pureed diet.

Based on observation, interview and record review, the facility failed to provide a therapeutic diet prescribed by the physician for one (Resident #17) of two residents reviewed for therapeutic diets. The facility failed to provide Resident #17 with a fortified diet as ordered by his physician. This failure could affect the two residents with orders for a fortified diet resulting in weight loss or other medical problems. Findings included: Review of Resident #17's MDS assessment revealed an [AGE] year-old male, admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. It also revealed the resident had severely impaired cognition, a catheter and required only setup assistance for eating. Review of Resident #17's care plan dated 06/18/18 revealed the resident was at high risk for weight loss related to [MEDICAL CONDITION] and dementia. Review of Resident #17's Nutrition and Skin Weekly documentation, dated 07/19/18, revealed the resident's current diet was mechanical soft with a fortified diet. The note revealed the resident had significant weight changes recently related to a decrease in intake. The resident's weight was 121 pounds on 06/16/18 and 114.6 pounds on 07/14/18. Review of Resident #17's physician orders [REDACTED]. This order had a start date of 09/26/17. Review of Resident #17's lunch meal tickets, for 08/07/18 and 08/08/18 revealed fortified mashed potatoes with gravy. Observation of Resident #17 in the dining room for lunch on 08/07/18 from 12:21 p.m. to 12:41 p.m. revealed the resident received beef stew, collard green, and potatoes with tomatoes and onions. The resident consumed 25% of his beef stew, 0% of the collard greens, and 50% of the potatoes. No fortified meal item was observed. Interview with Nutritional Aide B on 08/08/18 at 12:36 p.m. revealed the fortified meal item was the mashed potatoes. Observation of Resident #17 in the dining room for lunch on 08/08/18 from 12:45 p.m. to 1:00 p.m. revealed the resident received pot roast, carrots, and pasta. The resident consumed 25% of the pot roast, 75% of the carrots, and 75% of the pasta. No mashed potatoes were on the resident's plate. Interview with the Nutritional Supervisor on 08/08/18 at 1:48 p.m. revealed mashed potatoes were the usual fortified food, but sometimes it was soup. She stated the server took the resident's order and asked the resident if he wanted mashed potatoes. She stated if the resident did not request mashed potatoes, they were not brought to them. She stated the cook should put the fortified meal item on the resident's plate anyway. Interview with the ADON on 08/09/18 at 8:04 a.m. revealed Resident #17 was losing weight. She stated the resident's weight fluctuates and he was currently in a decline. Interview with the Registered Dietitian on 08/09/18 at 1:35 p.m. revealed the facility's policy was resident choice first. She stated the resident did not always want mashed potatoes, so they did not provide them. She stated Resident #17 probably told her he did not like soup or hot cereal so she wrote the recommendation for fortified mashed potatoes. She stated they saw a drop in Resident #17's weight last month. Review of the facility's Food and Nutrition Services policy, dated (YEAR), revealed: .9. Therapeutic diets ordered by physician are provided . Review of the facility's Diet Roster, dated 08/06/18, revealed two residents received fortified diets.

Based on observation, interview and record review, the facility failed to provide the appropriate treatment and services to prevent complications of eternal feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormality and nasal-pharyngeal ulcers for one (Resident#3) of one residents reviewed for feeding tubes. RN A failed to ensure Resident #3's enteral feeding was infusing according to physician orders. The failure placed the one resident, who had a feeding tube, at risk weight loss. Findings included: Review of Resident #3's MDS assessment, dated 05/05/18, revealed the resident was an [AGE] year-old male, admitted to the facility on [DATE]. The resident [DIAGNOSES REDACTED]. Review of Resident #3's current, undated care plan revealed the resident had a feeding tube and was a risk for possible injury and/or infection. The goal was that Resident's feeding tube and tube site will be continually setup properly. One action included Administer the tube feeding formula as ordered. Review of Resident #3's physician order, dated 08/07/18, revealed the resident received [MEDICATION NAME] 1.5 calories 20 hours every day. This order had a start date of 05/13/18. The resident had an ordered stop time of 10:00 a.m. daily and a restart time of 2:00 p.m This order had a start date of 07/20/17. Observation of Resident #3 on 08/07/18 at 9:42 a.m. revealed the resident was lying in bed, and the resident's tube feeding was not infusing. Observation of Resident #3 on 08/07/18 at 2:25 p.m. revealed the resident was lying in bed, and the resident's tube feeding was not infusing. Observation of Resident #3 on 08/07/18 at 2:46 p.m. revealed the resident was lying, and the resident's tube feeding was not infusing. Observation of Resident #3 on 08/08/18 at 7:43 a.m. revealed the resident was lying in bed with the [DEVICE] not running. Observation of Resident #3 on 08/08/18 at 8:30 a.m. revealed the resident was lying, and the resident's tube feeding was not infusing. Observation of Resident #3 on 08/08/18 at 8:54 a.m. revealed the resident was lying, and the resident's tube feeding was not infusing. Observation of Resident #3 on 08/08/18 at 9:07 a.m. revealed the resident was lying, and the resident's tube feeding was not infusing. Observation of Resident #3 on 08/08/18 at 9:40 a.m. revealed the resident was lying, and the resident's tube feeding was not infusing. Interview with RN A on 08/08/18 at 9:05 a.m. revealed he did not notice Resident #3's [DEVICE] feeding was turned off this morning. He stated he left the tube feeding off to give medications. RN A was observed finished with medication administration through the gastric tube at 9:40 a.m. RN A stated he would not start the feeding again because staff would be providing care to Resident #3. Interview with the DON on 08/08/18 at 10:56 a.m. revealed she called the night nurse who stated she thought she turned the feeding for Resident #3 back on, but she got busy and forgot to start the feeding. The facility calculated a loss of 75 calories and they normally have the resident off the feeding for four to five hours. She stated she spoke to the doctor who ordered the feeding to resume for the resident of the day and to follow the normal schedule the next day. Interview with RN A on 08/08/18 at 11:10 a.m. revealed he started his shift at 6:30 a.m. and he normally did not check the [DEVICE] immediately when he came in the building. He stated the night shift changed the tubing and started the feeding. He stated he normally checked the feeding around 8:00 a.m. or 8:30 a.m He stated he should check the [DEVICE] immediately when he came in the door. He stated he turned the feeding of for the downtown between 9:30 a.m. and 10:00 a.m He stated if he turned the feeding back on at 2:30 p.m., it was late going back on. Interview with the DON on 08/08/18 at 12:50 p.m. revealed she would expect RN A, or the nurse coming on shift, to check Resident #3's [DEVICE] pump to make sure it was running according to the physician's orders [REDACTED].#3's room together. She stated there would be an in-service covering this issue. Review of the in-service provided by the DON on 08/10/18 revealed an in-service conducted on 08/08/18 regarding the nurse should round at shift change and every hour. Review of the facility's current Enteral Tube Feeding and Medication Administration policy, approved (MONTH) (YEAR), revealed the following: It is the policy of the Company to provide appropriate treatment and services per standards and physician orders [REDACTED]. Review of the Resident Census and Conditions of Residents Form CMS-672, signed and dated by Resident Care Manager C on 08/08/18, revealed the was one resident with a [DEVICE] in the facility.

Based on observation, interview and record review, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for one (Resident #1) of three residents reviewed for skin assessments. 1. The facility failed to ensure staff followed Resident #1's comprehensive care plan by properly off-loading or floating Resident #1's left foot and applying a Podus boot to prevent pressure ulcer development and/or deterioration; 2. LVN E failed to notify the physician when an unstageable pressure ulcer was identified on Resident #1's left buttock and two Stage 1 pressure ulcers were identified on the resident's lateral right foot; 3. LVN E failed to document the presence of an unstageable pressure ulcer on Resident #1's left buttock and two Stage 1 pressure ulcers on the resident's lateral right foot; 4. The facility failed to ensure the Duoderm patch, which was to be applied to Resident #1's left buttock indefinitely starting on 05/07/17, was applied as ordered by the physician or applied correctly; and 5. The facility failed to ensure Resident #1's toenails were trimmed to prevent the toenails from causing pressure to his toes. These failures placed the 23 residents, who resided on the B Hall, where LVN E was assigned, at risk for the development and/or worsening wounds, infection, and delayed healing. Findings included: 1. Review of Resident #1's MDS assessment, dated 05/06/17, revealed the resident was an [AGE] year-old male, who was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. He was incontinent of both bowel and bladder and required the assistance of two staff for turning, transfers and toileting. He was at risk for the development of pressure ulcers but had no pressure ulcers at the time of assessment. Review of Resident #1's comprehensive care plan updated 05/15/17 revealed the resident was at risk for mobility related to [MEDICAL CONDITION] (stroke) with left-sided [MEDICAL CONDITION] and positioning devices were to include pillows, left foot float, and Podus boot. The care plan did not address Resident #1's risk for pressure ulcer development or skin related concerns. Review of Resident #1's consolidated physician's orders [REDACTED]. 05/07/17 - Continue Duoderm to left buttocks for preventive measures indefinitely 02/07/17 - Skin assessment weekly on Thursday Indicate (-) if NO skin issues present Indicate (+) if skin issues present, then record information about skin issue in the skin condition section. An observation of Resident #1 on 06/07/17 at 1:19 p.m. revealed the resident lying in bed with a pillow beneath his legs and his heels resting on the mattress without being off-loaded or floated to prevent pressure. He had long pants on and a brace on his right leg. CNA G and CNA K turned the resident and performed peri-care. An observation of the resident's buttocks revealed a Stage 1 pressure ulcer on the resident's left buttocks, which measured approximately 1 inch x 1.5 inches. At the time of this observation, there was no Duoderm on the resident's buttocks as per the order dated 05/07/17. An interview with LVN E on 06/08/17 at 8:00 a.m. revealed she worked the 6:30 a.m. to 3:00 p.m. shift. She stated she performed weekly skin evaluations on Resident #1, and he had no skin issues. She stated if a resident did not have skin issues, she would indicate this by documenting negative on the resident's Treatment Administration Record (TAR). If the resident did have skin issues, she would then complete a Skin Evaluation Form. An observation of Resident #1 on 06/08/17 at 9:14 a.m. revealed the resident lying in bed with a pillow beneath his knees, and his heels rested on the mattress without being off-loaded or floated. LVN E assisted CNA G turn the resident to check his brief. An observation of the resident's buttocks revealed the resident had an unstageable pressure ulcer on his left buttock, which measured approximately 1 inch x 1 inch with a moist yellow surface. LVN E stated it was an old pressure ulcer, and the scab must have come off. She then used her gloved finger to scratch the yellow surface of the pressure ulcer, and she removed approximately 3 cm of the yellow surface to reveal redness with evidence of a small amount of blood beneath. LVN E stated, We'll have to start putting the Duoderm patch on again. Also during this observation of Resident #1, two Stage 1 pressure ulcers (non-blanchable areas) were observed on the bony prominences of the resident's lateral right foot. LVN E stated these areas were new. The resident's right ankle was noted to have blanchable redness, and the skin on the resident's bilateral heels were dry but without pressure ulcers. The resident's toenails were long, deformed, and pressing against the skin on the resident's toes. LVN E stated she would cut the resident's toenails. CNA G then placed a pillow beneath the resident's knees with the resident's heels resting directly on the mattress without being off-loaded or floated to prevent pressure. An observation of Resident #1 on 06/09/17 at 3:09 p.m. revealed the resident lying in bed with his heels resting on the mattress. CNA M and CNA N turned the resident and removed his brief. There was a Duoderm patch covering the unstageable pressure ulcer on the resident's left buttock. Above the Duoderm patch was a new Stage 2 ulcer, which measured approximately 1 inch x one inch. The area was red, with a deep red center that measured approximately 2 cm x 3 cm and was moist. CNA M placed a pillow beneath the resident's legs while the resident's heels rested on the mattress without being off-loaded or floated. An interview with LVN L on 06/09/17 at 2:36 p.m. revealed she worked the 2:30 p.m. to 11:00 p.m. shift on the B Hall. She stated she relied on the Skin Evaluation Form to determine if a resident had skin issues. She stated the day shift nurse assessed Resident #1 weekly for skin issues, and he currently had no skin issues. Review of Resident #1's May 2017 TAR revealed the resident had weekly skin evaluations. On 05/04/17, the resident had a positive evaluation which indicated skin issues were present. Further skin evaluations that month indicated no skin issues were present. An interview with Resident #1's Primary Physician on 06/09/17 at 2:11 p.m. revealed, as far as she was aware, Resident #1 had no skin issues at this time. She stated she relied on the nurses to notify her if a new issue developed. She further stated Resident #1 had weekly skin evaluations, and she would check the evaluations when she came to assess the resident. An interview with the Interim DON on 06/09/17 at 2:35 p.m. revealed LVN E should have completed a Skin Evaluation Form after she had discovered Resident #1 had skin issues on 06/08/17. Review of Resident #1's June 2017 TAR revealed LVN E had documented negative in the skin assessment area for 06/01/17 and 06/09/17 to indicate the resident had no skin issues. An observation of Resident #1 on 06/26/17 at 12:35 p.m. in his room. The resident was in a high-backed wheelchair a cushion was beneath his lower legs. He had protective cushioned boots on both feet. He was clean and appropriately dressed and had confused speech. An interview with Resident #1's family member on 06/26/17 at 12:40 p.m. revealed the facility staff had placed pillows between the resident's knees, but the resident's feet and heels often touched the mattress. An observation of Resident #1 on 06/26/17 at 1:32 p.m. with LVN F revealed the resident had been placed in bed, and his brief was removed to reveal a Duoderm dressing which had rolled upward and now only partially covered the pressure ulcers on the resident's left buttock. The resident's toenails were long, deformed and with ripped/jagged tips. A skin assessment along with measurements was performed by LVN F, and the assessment revealed the following: Right lateral foot - healing Stage 2 pressure ulcer, red area 0.2 cm x 0.1 cm surrounded by pink area 1 cm x 1 cm; Left buttocks - 8 cm x 3 cm x 0 cm total area of three healing Stage 2 pressure ulcers, which included the previously identified unstageable pressure ulcer; Medial aspect of left leg below knee and behind left knee - Stage 1 pressure ulcer 2 cm x 12 cm; Left lateral foot - healing Stage 1 pressure ulcer 1.0 cm x 2.0 cm; and An interview with the Interim DON on 06/26/17 at 12:05 p.m. revealed she had LVN L perform a full body skin assessment on Resident #1 on 06/10/17. Also, the DON stated she had personally performed a skin assessment on Resident #1 on 06/16/17 and 06/21/17. She stated skin assessment training had been provided to the LVNs on 06/20/17. Review of Resident #1's skin assessment sheet completed by LVN L on 06/10/17 revealed Resident #1 had an area described as friction/shear on the left buttock that was caused by pressure. The area was described as 1 cm x 1 cm shearing site without [DIAGNOSES REDACTED] noted, and in the section denoted as Stage was written inapplicable. The treatment document for the area was Duoderm to site every three days. A Nurses Note on the bottom of the sheet reflected: Full skin assessment completed, small 1 x 1 cm area to left upper buttock noted with Duoderm and a 1, ½ inch healed area to midline coccyx with surrounding skin intact, no other skin issues noted to this res. An interview with LVN L on 06/26/17 at 4:20 p.m. revealed she performed a head-to-toe skin evaluation on Resident #1 on 06/10/17. She stated she had removed the Duoderm from the resident's buttocks and found what looked like the skin under a broken blister, but there had been no redness or drainage. She stated the abrasion to the left knee and pressure ulcers to the lateral aspect of both feet were no longer there. An interview with the Unit Manager on 06/26/17 at 4:40 p.m. revealed Resident #1 had sheared areas on his buttocks which healed but remained pink but blanchable. On 06/09/17 the skin in that same area broke down into three Stage 2 pressure ulcers. A telephone interview with the Medical Director, who was Resident #1's Primary Physician, on 06/26/17 at 2:00 p.m. revealed she intended to meet with the facility to ensure skin evaluations were being performed and that physicians were being notified of any new skin issues. She stated she intended to review the facility's policy on routine skin assessments. She stated after speaking with the surveyor on 06/09/17 she assessed Resident #1's skin on 06/12/17 and found one superficial pink area on the resident's buttock. When asked if she had noted a second pressure ulcer with a yellow surface, the Medical Director stated there was possibly a smaller pressure ulcer with yellow slough. She stated she had documented her findings on a Progress Note in which she had indicated a pressure ulcer, now healed which was in reference to the superficial red area. She stated she did not know why she had not documented the smaller ulcer with yellow slough. She stated she did not change the order for the Duoderm dressing to be applied every three days and as needed. Review of the Physician's Progress Note, dated 06/12/17, for Resident #1 revealed the resident had contractures to both lower extremities and had left [MEDICAL CONDITION]. The note reflected the resident had an abrasion to the left knee, a 1 cm in diameter pink area to the buttock, and a 2 cm elongated healed pressure ulcer to the coccyx. Review of Resident #1's updated physician's orders [REDACTED]. 06/14/17 - Apply Duoderm right outer foot every three days. 06/16/17 - Continue Duoderm to multiple stage II pressure ulcers on left buttocks . Review of the Facility's Skin at Risk-Wound Management Procedure Guideline and Competency Checklist revised March 2015 revealed the following: .all residents in the Facility will be assessed for potential for the development of skin trauma/pressure ulcers upon admission, upon change in condition and no less often than quarterly. This is to assure that nursing approaches regarding skin care are focused on preventative measures. .Residents that have Skin At Risk problems will have a notation at least weekly in the medical record indicating that an assessment of the resident has been done and reflecting the condition of the resident's skin. It is recommended that the LVN document a weekly Skin Check on the TAR indicating a (+) for any skin impairment, and then documenting on the Weekly Skin Impairment Assessment or Wound Assessment form whichever is appropriate the assessment findings. A (-) on the TAR section for the weekly Skin Check would indicate that the skin assessment has no findings. .Any resident who has skin breakdown will immediately be placed on Alert Charting. If it is a pressure ulcer, the Weekly Wound Assessment form will be completed. For all other skin impairment, a Weekly Skin Impairment Assessment form will be initiated and placed in the Treatment Administration Record (TAR). It will be completed weekly until healed and documented as being resolved on the correct form. Review of the Wound Assessment Check sheet revealed the following: .Review the previous wound assessment and use as a comparison for this wound assessment .Assess the wound type (i.e. Surgical, pressure, trauma) Assess the extent of tissue involvement 10. Observe color of the wound Yellow tissue indicates the presence of exudates or slough; pus, [MEDICATION NAME], debris requires cleaning Record wound assessment findings and notify the physician Review of the facility's current policy entitled Pressure Ulcer Prevention and Care revealed the following: .Definition: A pressure ulcer is ulceration and sloughing of a localized area of tissue due to death of its cells as a result of pressure or stasis. .The aim is PREVENTION, assessment for risks, interventions to prevent breakdown if determined at risk .early detection and prompt attention to reddened areas. To promote healing and prevent reoccurrence of existing pressure ulcers . Review of the Resident Census list dated 06/06/17 revealed 23 residents resided on the B Hall.