Every finding on record at Willows Health Center

Based on interview and record review the facility failed to ensure nursing staff were working with an active nursing license which applies to all 91 residents in the facility. The findings include:The Facility Data Sheet dated 1/26/26 showed the facility had a current census of 91 residents.The facility's undated copy of V3's (Licensed Practical Nurse/LPN) from the state licensing agency summary showed V3's license was suspended from 12/15/25 through 12/24/25.V3's Timesheet Summaries printed on 1/26/26 showed V3 worked on 12/16/25, 12/19/25, and 12/23/25 during their license suspension.The Facility's Daily Census Sheets printed on 1/26/26 showed the on 12/16/25 was 67, 0n 12/19/25 the census was 64, and on 12/23/25 the census was 66.On 1/26/26 at 10:20 AM, V2 (Human Resources) stated V3 did not let us know their LPN license was temporarily suspended. Nurses should not work while their licenses are suspended.The state licensing agency's frequent asked questions showed suspended licensees are prohibited form practice during the suspension term and may be subject to certain terms and conditions.

Based on interview and record review the facility failed to prevent a resident from acquiring a new pressure ulcer. This applies to one of three residents (R1) reviewed for pressure ulcers in the sample of six.The findings include:The facility face sheet for R1 shows she was admitted to the facility on [DATE] with diagnoses to include pathological fracture to left femur, congestive heart failure, atrial fibrillation and osteoporosis. The facility assessment dated [DATE] shows R1 to be cognitively intact and requires maximum assistance with transfers and rolling in bed. The admission nursing note dated 11/13/2025 shows R1 was admitted with a surgical wound to her left hip and no other areas of concern were observed or documented. On 12/16/2025 at 12:55 PM, V2 (Licensed Practical Nurse) and Nurse Manager said when R1 was admitted to the facility, she completed her admission skin check and R1 did not have any open areas or redness to her heels. V2 said on 11/20/2025 she was alerted by staff that R1 had a pressure ulcer to her left heel. V2 said she went and assessed the wound and found it to be unstageable with areas of black tissue present. V2 said she notified the Physician for orders for wound care and ordered an air mattress for R1 as well as heel boots.On 12/16/2025 at 1:00 PM, V2 (Director of Nursing) said skin checks are done weekly for the residents. V2 said R1's new pressure ulcer may have shown up after her skin check was done as a pressure wound can develop in a few days. V1 said it may be possible if a full inspection of the feet were done daily when R1's legs were wrapped with an ace wrap, that the staff should have noted a change in R1's heels.The Physician orders for R1 dated November 2025 shows an order for ace wraps to both lower extremities from toes to thigh every day.A skin note dated 11/20/25 shows a new facility acquired pressure ulcer was identified as unstageable to R1's left heel.The facility care plan for R1 dated 11/13/2025 for risk for impaired skin shows an intervention to apply ace wraps to both lower extremities, keep skin clean and well lubricated, monitor bony prominences for redness, utilize pillows to avoid direct contact with bony prominences and utilize pressure relieving devices.The facility policy with a revision date of 8/2025 shows the purpose is to provide a systematic assessment that includes visual, identification of risk factors and early interventions.

Based on observation, interview and record review the facility failed to follow speech therapy recommendations for a resident (R46) at risk for aspiration. The facility also failed to ensure a resident (R1) at high risk for falls and exhibiting restless behaviors was supervised. This failure resulted in (R1) falling from her wheelchair and sustaining a right hip fracture. This applies to 2 of 16 residents (R1, R46) reviewed for safety and supervision in the sample of 16.The findings include:1.) R1's face sheet shows she has diagnoses including Alzheimer's Disease, dementia, anxiety disorder, weakness, and a fracture of the neck of the right femur. R1's active care plan initiated 1/8/25 shows she has a cognitive impairment, requires extensive assistance with her Activities of Daily Living/ADL's, requires a mechanical lift for transfers, and is at high risk for falls. Interventions listed on the care plan include prompt response to all requests for assistance, a bed and chair alarm and to encourage resident to engage in activities.An incident note completed by V16 (Registered Nurse/RN) on 8/10/25 shows at approximately 12:00 PM, R1 was found on the floor in the hallway. R1 was complaining of pain to her right extremity and had bleeding from the back of her head. R1 said she was unable to move so 911 was called and she was transported to a local emergency room (ER) for assessment and treatment. An incident note completed by V18 on 8/10/25 shows that R1 was noted to be restless throughout the morning (prior to her fall) and was making comments about needing to go to school. The note also shows that R1 had tried to stand up many times and that her chair alarm was not very loud. An incident note completed on 8/11/25 shows the facility called the hospital for an update and were notified that R1 has a right hip fracture and will be having surgery that day.R1's history and physical from a local community hospital completed on 8/10/25 shows R1 was complaining of pain a 10/10 to her right hip and knee and stated, this side is killing me. Hospital X-ray results completed on 8/10/25 shows that R1 has an acute moderately displaced right femoral fracture. A hospital physician consultation note shows that R1 will need surgical intervention to repair her right femoral head fracture. On 11/24/25 12:11 PM, V16 (RN) said I was called by a CNA (Certified Nursing Assistant) to come to the unit because a resident was on the floor. When I got to the unit, I found her (R1) on the floor bleeding from her head and not able to move her right leg. I assessed her and called 911. The nurse on that unit was on her lunch break at the time and I am not sure where the other staff on the unit were. She did have a chair motion alarm in place that day. On 11/24/25 12:23 PM, V2 (Director of Nursing) said she was aware of R1's fall and she did investigate it with V1 (Administrator). V2 said R1 was anxious that day and trying to stand up from her chair. On 11/24/2025 12:40 PM, V18 (RN) said she was working on the unit the day R1 fell. V18 said they were keeping R1 in their site and had her at the nurses' station that day due to her increased anxiety and trying to stand up from her wheelchair all day. V18 said she went on break and was not on the floor when R1 fell but another staff person came to tell her she had fallen. On 11/24/25 1:00 PM, V19 (CNA) said R1 was extremely restless the day she fell and continuously standing up from her wheelchair. The staff were keeping R1 at the nurses' station or taking her with them room by room if they left her line of site. V19 said I was trying to keep her by me at all times, but I had to take another resident to the bathroom, so I left R1 by another CNA (V17) who I asked to watch her. I had just put the other resident on the toilet when I heard someone yelling for help. I went out and found a resident leaning over consoling R1 who was on the floor. V19 said V17 no longer works at the facility, and I don't know where V17 had gone but she came up from behind me, so she had left the nurses station and R1 was not by her. V17 said R1 did have a chair alarm on her wheelchair but it is very quiet so when she was in the bathroom with the other resident, she could not hear it. V19 said someone should have remained with R1 and not have left her alone by the nurses' station unsupervised. Two attempts were made to contact V17 by phone on 11/25/25 with no success. 2.) R46's face sheet shows he was admitted to the facility on [DATE] from a local hospital and has diagnoses including Parkinson's Disease and dementia.R46's hospital transition report that was sent with the patient on transfer to the facility and a hospital speech pathology and dysphagia treatment plan recommendations completed on 11/17/25 both show that R46 requires 1:1 feeding assistance due to aspiration risk and should not use straws. The speech pathology treatment plan recommendation also states, At discharge, recommend continued SLP services for dysphagia/continued monitoring of swallowing function in the setting of Parkinson's disease. On 11/23/25 at 10:16 AM, R46 was in bed, on the bedside table next to him were 2 Styrofoam cups with liquid inside and straws in both. On 11/23/25 at 1:14 PM, R46 was served his meal tray which also had Styrofoam cups with liquid inside both and straws on the tray. Again on 11/24/25 at 10:31 AM, and 11/25/25 at 9:18 AM, R46 was in his room with cups containing liquid and straws inside all of them. On 11/24/25 at 11:05 AM, V2 (Director of Nursing) said nurses should be following the recommendations from hospital transfer papers that come with a resident on admit.On 11/24/25 at 1:23 AM, V22 (Director of Therapy) said R46 has not yet been assessed by the speech therapist and until he is the facility should be continuing to follow the precautions that were indicated from the hospital. V22 said based on the report from the speech therapy from the hospital no straws should be used due to R46 being at risk of aspiration due to having Parkinson's disease.On 11/25/25 at 11:23 AM, V23 (Speech Therapist) said he finished his evaluation of R46, and his recommendations are that R46 should not have straws due to a potential risk for aspiration. V23 also said staff should follow the speech therapy recommendations for residents who are admitted to the facility and not using straws for R46's liquids is not a hard request to follow. R46's Speech Therapy Evaluation and Plan of Treatment completed by V23 shows for R46's safety it is recommended no straws are used.The facility's Aspiration Risk Policy dated 8/2025 shows the facility staff including nurses, CNA's, dining service and therapy staff should identify and implement interventions for residents at risk for aspiration.

Based on observation, interview and record review that facility failed to store food in a sanitary manner and failed to ensure the cooking areas were clean and sanitary. This applies to all 35 residents residing at the facility. The findings include:The CMS 671 Long-term Care Facility Application for Medicare and Medicaid Form dated 11/24/25 shows that there are 35 residents residing in the facility. On 11/23/25 at 9:56 AM, during tour of the kitchen, there was an opened box of French baguettes stored directly below the condenser/evaporator in the walk-in freezer. There was an unwrapped French baguette sticking out of the top of the box. The box had ice build-up on the outside of the box. The exhaust hood had a build-up of dust debris on the fire suppression lines that were directly above the cooking area. On 11/23/25 at 9:56 AM, V26 (Corporate Executive Chef) took the box of French baguettes out of the freezer and disposed of the top baguettes and said that that they should not be stored the way they were stored. On 11/24/2025 at 2:37 PM, V27 (Dietary Liaison) said that food in the freezer should be stored securely by placing the food in a sealed bag or a container with a lid and the food should not be left exposed. V27 said that the exhaust hood is cleaned by an outside company and maintenance schedules their visits. The facility's Production, Purchasing, Storage Policy revised 1/25 shows, Cover, label and date unused portion and open packages .Store bulk materials in NSF approved containers that have tight fitting lids Use food grade plastic bags for food storage . The Facility's Sanitation and Infection Prevention/Control Policy revised on 1/25 shows, Written procedures are available, detailing daily and weekly (as needed) cleaning for all areas and equipment in the department The facility's Maintenance Department is scheduled to clean equipment that requires special training and equipment, such as the ice maker, refrigeration coils and exhaust hood .

Based on observation, interview, and record review, the facility failed to provide meaningful activities to dementia residents for 4 of 16 residents (R23, R11, R26, R35,) reviewed for activities in the sample of 16.The findings include:1. R23's electronic face sheet show R23 has with diagnosis of Alzheimer's dementia.On 11/23/25 at 9 AM, R23 was sitting in his wheelchair in front of the TV. At 9:30 AM, R23 was asleep. At 10:20 AM, during a family interview R23's son (V5) said he had been making a point to visit R23 on the weekends because there were no ongoing activities on either Saturday or Sunday. V5 said R23 was an Engineer in the past. V5 said he wanted R23 to engaged in activities.R23's Activity Care plan dated 6/12/25 documents The resident has impaired cognitive function/dementia or impaired thought processes r/t Dementia but has no activity intervention included in R23's care plan.2. R11's electronic face sheet show, R11's diagnoses include dementia, anxiety and mood disorders.On 11/23/25, at 9AM R11 was wheeling herself around the activity room to the dining room being repeatedly redirected by V8 (License Practical Nurse). R11 continued to wheel herself around in wheelchair wandering. At 2:16 pm, R11 was sitting in the wheelchair facing the TV. R11 said there was nothing to do. V8 said R11 has some moments of being alert and knows what's going on.R11's activity care plan dated 4/22/25 documents, The resident has impaired cognitive function/dementia or impaired thought processes r/t Neurological symptoms, Dx Dementia but R11 had no activity interventions noted.3. R26's electronic face sheet show R26 has diagnoses of Dx Alzheimer's dementia. On 11/23/2025 at 9AM AM R26 was also sitting in her wheelchair in front of the TV asleep. At 11:30 AM, R26 was now awake looking around, still with no ongoing activities. R26's care plan dated 4/26/24 documents, The resident (R26) is dependent on staff for leisure or pursuits. Life Enrichment will continue to keep R26 on individual visits and monitor activity participation and adjust when needed. 4. R35's electronic face sheet show R35 has diagnosis of dementia.On 11/23/25 at 9 AM, R35 sat at a recliner at the end of the activity room. After lunch at 12:30 PM, R35 sat in the activity table just looking around but no ongoing activities R35's care plan had no activity care plan.The Memory Care Activity Calendar dated 11/23/25 (Saturday) were as follows, 9AM: Positive Affirmation, 10 AM, 1:1 reminisce, 12 PM Short stories, 1 PM [NAME] Games, 2pm Music and movement 3pm Sensory Exploration. None of the above activities were provided.On 11/23/25 at 1PM, V8 (License Practical Nurse) said she works in the dementia unit every other weekends. There were no activities being offered in the dementia unit on the weekends both Saturdays and Sundays. V8 said in between her passing meds and other nursing job, she tries to talk to residents redirect them or sit them by the TV. On 11/23/25 at 1:45 pm, V6, V7, and V9 (all Certified Nursing Assistants/CNAs) said they have their own duties to do, and in between, they try to find time to sit down with the residents to help with puzzles or read a book in between doing their nursing work (toileting, transferring residents to or from bed, feeding). V6, V7, and V9 all said there's no activity on the weekends.On 11/24/25 at 10AM, V10 (Life Enrichment Director) said residents in the Dementia Unit need activities for engagement, keep them stimulated and to enhance their quality of life. On 11/24/25 at 10:12 AM, V12 (Director of Memory Wellness) said there was no Activity staff on the weekends in the Dementia Unit, these activities are for engagement, connection, socialization and to slow cognitive decline. V12 said there will be an activity staff starting by next month (December 2025)The facility policy on Activities dated 11/1/19 show: Establishments activities available to person cognitive or memory diseases. (Dementia): residents' activities upon residents remaining abilities and interests. These activities are at the core of services designed to promote resident wellbeing. Will use ability-centered care as the basis for a structured dementia program. Meaningful activities that focus on the president's ability rather than their disabilities are continually available to residents. An activity-based program has the goal of maintaining and rebuilding the resident's self-esteem while helping residents maintain his or her optimal functional level.

Based on interview and record review the facility failed to have a system in place to ensure as needed (PRN) psychotropic medications had a stop date for 1 of 5 residents (R14) reviewed for psychotropic meds in the sample of 16.The findings include:R14's Physician Order sheet with an order date of 11/5/25 show an order of: Ativan 0.25 ml sublingual every 2 hours as needed for anxiety. The order had no stop date.On 11/24/25 at 3PM V12 (Nurse Manager) said he was in charge of psychotropic meds making sure psychotropic meds have diagnosis and stop dates. V12 said he was not aware of R14's antianxiety order with no stop date. V12 said this order was carried out by a Hospice staff. They should have clarified the order and got a stop date. V12 said he does not know why the order was placed in the electronic charting with no stop date. On 11/25/25 at 9AM V12 Nurse Manager presented a document for R14's antianxiety order but was not reflected in R14's medical record. V12 said all R14's ordered medications including psych meds with stop dates should be reflected in R14's medical record. V12 said all as needed psychotropic medications including anti-anxiety should have a stop date. The facility policy on Psychotropic Medication Policy, dated 8/25 documents, Appropriate use evaluation and monitoring of Psychotropic medications to comply with state and federal guidelines while providing medication of a therapeutic level to enable residents to experience an optimum quality of life.

Based on observation, interview and record review the facility failed to provide toileting assistance to a resident dependent on staff for cares in a timely manner for 1 of 16 residents (R46) reviewed for activities of daily living (ADLs) in the sample of 16.The findings include:R46's face sheet shows he was admitted to the facility on [DATE] and has diagnoses including Parkinson's disease and dementia. R46's admitting care plan shows he has an ADL self-care deficit due to weakness and requires assistance from staff. On 11/23/25 at 10:15 AM, R46's door was closed. Upon entering his room this surveyor observed R46 to be confused and very restless with his legs half on and half off the bed. R46 kept saying he had to stand up and use the bathroom. The surveyor put R46's call light on immediately to get staff assistance. R46 continued to appear very restless and hanging his legs over the side of the bed, the surveyor stayed by R46 continuously and encouraged him to remain in bed and wait for assistance. At 10:27 AM, V20 (Certified Nursing Assistant/CNA) came into the room and turned R46's call light off. V20 said she did not work on this unit but would go try and find the CNA assigned to R46 and left the room. At 10:31 AM, V15 (Registered Nurse/RN) came to R46's doorway and said the CNAs are coming and will be here soon the surveyor informed V15 that R46 is trying to get up on his own to use the bathroom. V15 left the doorway of R46's room. At 10:35 AM V13 and at 10:37 AM, V14 both CNAs came into R46's room to take him to the bathroom. V14 said R46 requires 2 staff to transfer him from bed. At 11:02 AM after toileting R46, V14 said the goal is to answer call lights in 15 minutes but it depends on the acuity of the unit and what is going on. On 11/24/25 at 11:05 AM, V2 (Director of Nursing) said all 3 of the nursing staff who were working on the unit with R46 on 11/23/25 were in the room with another resident however they should have made sure someone was on the unit and not all in the same resident room. The facility Call Light System policy dated 8/2025 shows that staff should respond and assist a resident to the bathroom in a timely manner and if staff are unable to respond in a timely manner due to workload or an emergency, they should notify a supervisor.

Based on interview and record review the facility failed to inform the dietitian of a resident's continued weight loss. The facility failed to obtain weights on a newly admitted resident as per facility policy. These failures apply to 1 of 4 residents (R47) reviewed for weight loss in the sample of 16.The findings include:R47's hospital progress note dated 10/24/25 showed R47 was hospitalized on [DATE] after being diagnosed with a subdural hematoma (brain bleed) where R47 subsequently underwent a craniotomy (brain surgery) on 10/22/25 to repair/drain the bleed. R47's facility admission record showed R47 was admitted to the facility on [DATE]. R47's admission care plan (dated 10/28/25) showed R47 was at risk for weight loss with a goal of Resident will maintain current weight. On 11/23/25 at 9:17 AM, R47 was seated in a recliner in his room. R47 was alert and cognitively intact. R47 stated he recently had brain surgery because they found bleeding in my brain. R47 stated he was transferred to the facility for rehab after his recent hospitalization. R47 stated he had lost a lot of weight since his surgery. R47 stated, After my surgery, food just turned me off. I wasn't hungry. My appetite has started to get better. R47 stated he had been weighed a couple of times in the facility. R47 denied ever refusing to be weighed in the facility. R47's November 2025 Medication Administration Record (MAR) showed a physician order, dated 10/28/25, for R47 to be weighed once a week (every Tuesday). The MAR showed no documented weight for R47 on 11/11/25.R47's Weights and Vitals record showed R47 weighed 179 lbs (pounds) on 10/28/25, 170.4 lbs on 11/4/25, and 167.4 lbs on 11/18/25. The record showed no documented weight was completed on 11/11/25. The record showed R47 sustained a weight loss of 6.5% from 10/28/25-11/18/25. The record showed R47 lost 4 pounds from 11/4-11/18/25. Facility nutrition assessments dated 10/30/25 and 11/4/25 showed R47 was seen and assessed by V4 (Dietician). R47's 11/4/25 assessment showed V4 assessed R47 after his significant weight loss from 10/28/25-11/4/25. The note showed R47's weight loss was likely secondary to fluid shifts related to edema and swelling caused by intravenous fluids R47 received while hospitalized . The note showed facility staff were to continue to monitor R47's weights and notify V4 with any continued weight loss. On 11/24/25 at 9:10 AM, R47's weight record, November 2025 MAR, and progress notes dated 11/11/25-11/18/25 were reviewed with V4 (Dietician). The progress notes showed no documentation of R47 refusing to be weighed. V4 stated, Yes, I see he wasn't weighed on 11/11/25. He should have been weighed weekly. V4 stated when she initially saw R47 on 10/30/25, R47 did not report a decrease in appetite to her. V4 stated, He told me his weight is usually around 170 lb. I expected some weight loss due to fluid shifts after his surgery. He also had some swelling to his legs upon his admission here that has resolved. When V4 was asked if the facility notified her that R47 continued to lose weight from 11/4/25-11/18/25, V4 stated, No. I should have been notified. I would have seen and assessed (R47) again to discuss his diet, intake, and if needed supplements.The facility's Resident Weight Measurements policy dated March 2025 showed, Weigh residents weekly for the first 4 weeks after admission.

Based on observation, interview and record review the facility failed to ensure residents medications were available for administration for 2 of 16 residents (R46,R56) reviewed for pharmacy services in the sample of 16.The findings include: 1.R56's admission Record showed R56 was admitted to the facility on [DATE]. Physician orders dated 11/21/25 showed R56 was to receive D-Mannose Oral Capsules (supplement to prevent urinary tract infections) 500 mg; give 4 capsules by mouth three times a day and Simvastatin 40 mg; give one tablet once a day. On 11/24/25 at 8:20 AM, V8 (Registered Nurse/RN) prepared and administered R56's morning medications to R56. V8 stated, I can't give (R56's) D-Mannose medication. We don't have it. It looks like we haven't gotten it from our pharmacy. We don't have that medication in our (stock medication cart). We also don't have her Simvastatin, but I can pull that medication from our (stock medication cart). V8 walked over to the facility's (stock medication cart). V8 removed a dose of Simvastatin, to administer to R56. At 8:25 AM, V8 administered all R56's morning medications to her except her D-Mannose medication. R56's November 2025 Medication Administration Record (MAR) showed R56 received no doses of her D-Mannose medication from 11/21/25-11/24/25. The MAR showed R56 received no doses of her Simvastatin on 11/22/25 or 11/23/25. R56's progress notes dated 11/21/25-11/24/25 showed R56 had not received her doses of D-Mannose or Simvastatin on those dates because the medication is not available or awaiting delivery of the medication from pharmacy. On 11/24/25 at 11:10 AM, V2 (Director of Nursing/DON) stated upon a resident admission, medication orders are verified and faxed as soon as possible to the facility's pharmacy. V2 stated the pharmacy delivers medications to the facility every day at 5 AM. V2 stated, If nurse sees that we don't have a resident's medication, they should pull the medication from our (stock medication cart) if we have it. If we don't have the med in the (stock medication cart), the nurse should call the pharmacy and order the med STAT. The facility's Medication: Delivery by Nursing Personnel policy dated August 2025 showed. If a medication is unavailable for dispensing the nurse will first attempt to utilize the pharmacy (stock medication cart) machine located on the Medicare unit. If not available in the (stock medication cart), the nurse may check availability of the facility's floor stock. The pharmacy will be notified of any unavailable medication and arrangements for delivery will be made. A STAT delivery from the pharmacy will be requested for medication not available in the (stock medication cart) or floor stock.) 2. R46's face sheet shows he was admitted on [DATE]. R46's Care Transition Document sent with him to the facility on admission shows that he should receive the following medications on discharge from the hospital: carbidopa-levodopa 25-100 mgs. (milligrams) (medication to treat symptoms of Parkinson's disease) 2 tablets 5 times a day at 7:00 AM, 10:00 AM, 1:00 PM, 4:00 PM, and 7:00 PM and 1 1/2 tablets at night 10:00 PM. And Pravastatin (medication for cholesterol control) 80 mg at 4:00 PM. R46's Medication Administration Record shows R46 did not receive his carbidopa-levodopa on the evening of 11/21/25 and he did not receive the Pravastatin on 11/21 or 11/22/25. R46's Physician Order Summary (POS) shows active orders for the carbidopa-levodopa with a start date of 11/21/25. The POS shows R46's Pravastatin order was changed to Atorvastatin on 11/23/25. On 11/24/25 at 2:07 PM, V24 (R46's family member) said when R46 was admitted the facility they did not have the Parkinson's medication to give to him as it was supposed to be given. On 11/24/2025 at 12:31 PM, V2 (Director of Nursing) said she contacted the nurse who worked on 11/21 and 11/22/25 and the nurse verified that R46's wife brought in and gave R46 his carbidopa at 7:00 PM on 11/21/25 but the nurse did not give his bedtime dose. V2 also confirmed this medication is available in the facility (stock medication cart) and should have been obtained and given. V2 said R46's Pravastatin should be obtained from the pharmacy and given but was not. V2 also said R46's Pravastatin was changed on 11/23/25 to another brand of the medication. On 11/25/25 at 9:07 AM, V8 (Registered Nurse) said when residents are admitted from the hospital, they use the hospital discharge summary and transfer orders and confirm medications with the residents and the physician. V8 said if there is a medication not in the stat safe or (stock medication cart) they should call the Nurse Practitioner and get a stat order for the medication and then obtain it from a local pharmacy or ask family to bring it in. V8 called the pharmacy while the surveyor was present and verified that carbidopa is available in the (stock medication cart) but Pravastatin is not. V8 said if R46's family did not have these medications to provide they should notify the supervisor who can pick them up from a local pharmacy.

Based on observation, interview and record review the facility failed to ensure the required personnel protective equipment was worn in a covid isolation room and failed to implement enhanced barrier precautions for a resident with a peripherally inserted central catheter line (PICC) for 2 of 16 residents (R46, R48) reviewed for infection control in the sample of 16.The findings include: 1.) R46's face sheet shows he was admitted on [DATE] and has Covid-19 infection. R46's Physician order summary shows he is on contact and droplet precautions for Covid-19. On 11/23/25 at 10:16 AM, there were 2 signs outside R46's doorway indicating that he is on contact and droplet precautions and gowns, gloves, face shields or goggles, and masks should be worn inside the room. There was a plastic bin outside the room containing all the required PPE to enter his room. At 10:27 AM, V20 (Certified Nursing Assistant/CNA) entered R46's room with no PPE on at all and turned off R46's call light. On 11/23/25 at 11:44 AM, V21 (Occupational Therapist) entered R46's room and did not apply a face shield. On 11/24/25 at 1:39 PM, V3 (Infection Control Nurse) said no staff should enter R46's room without all the required PPE on, and eyeglasses alone are not acceptable a face shield is still required over the eyeglasses. The facility provided Infection Control Covid-19 policy shows that PPE that should be worn inside a Covid-19 isolation room include a N95 or higher-level respirator, a gown, gloves and eye protection. 2.) R48's admission Record dated 11/14/25 showed he was admitted , from a local hospital, with diagnoses including sepsis and bacteremia. R48 was admitted to the facility with a PICC line (peripherally inserted intravenous central catheter) his left arm to facilitate the administration of intravenous antibiotics in the facility. R48's November 2025 Medication Administration Records showed R48 completed his intravenous antibiotic therapy on 11/21/25 however the PICC line remained in place to R48's left arm. The records showed no physician order for R48 to be on Enhanced Barrier Precautions related to his PICC line. A facility Isolation List dated 11/23/25 showed no documentation R48 was on Enhanced Barrier Precautions or any isolation precautions. On 11/23/25 at 9:37 AM, R48 was in bed with a PICC line noted to his left arm. No Enhanced Barrier Precautions signage was noted on or around the door to R48's room. No isolation cart containing PPE (personal protective equipment) was noted outside of or around the doorway to R48's room. On 11/24/25 at 7:42 AM, R48 was in bed with a PICC line noted to his left arm. No Enhanced Barrier Precautions (EBP) signage was noted on or around the door to R48's room. No isolation cart containing PPE was noted outside of or around the doorway to R48's room. On 11/24/25 at 1:50 PM, V3 (Infection Preventionist) stated R48 was not on any isolation precautions or EBP. V3 stated residents with a PICC line or any type of intravenous access should be on Enhanced Barrier Precautions. On 11/24/25 at 2:07 PM, R48 was in bed with a PICC line noted to his left arm. No Enhanced Barrier Precautions (EBP) signage was noted on or around the door to R48's room. No isolation cart containing PPE was noted outside of or around the doorway to R48's room. The facility's Enhanced Barrier Precautions in Skilled Nursing Facilities policy dated August 2025 showed, To prevent the spread of MDROs (multidrug-resistant organisms) by the use of gloves and gowns during high contact resident activities for residents with chronic wounds and/or indwelling medical devices regardless of MDRO colonization, as well as, for residents with MDRO infection or colonization. Post clear signage on the door or wall outside of the resident room, indicating the type of precautions and required PPE. For Enhanced Barrier Precautions, signage should clearly indicate the high-contact resident care activities that require the use of gown and gloves. Make PPE available outside of, or near the resident's room, including gown and gloves.

Based on interview and record review, the facility failed to ensure residents who were eligible for a pneumococcal vaccine according to the Centers for Disease Control and Prevention (CDC) were offered the vaccine for 2 of 5 residents (R23 and R36) reviewed for immunizations in the sample of 16. The findings include:1.R23's Face Sheet shows that he admitted to the facility on [DATE] and is [AGE] years old. R23's Immunizations Report shows that he has not received a pneumococcal vaccine. R23's Progress Note dated 3/11/22 shows, [R23] shares that he received the Pneumococcal 23 vaccination after age [AGE].No other documentation of a pneumococcal vaccine was provided for R23. 2. R36's Face Sheet shows that she was admitted to the facility on [DATE] and is [AGE] years old. R36's Immunizations Report shows that she received the Pneumococcal 23 vaccine on 12/8/21 and no other pneumococcal vaccines were documented as administered. No other documentation of a pneumococcal vaccine was provided for R36. On 11/25/25 at 11:16 AM, V1 (Administrator in training) said that the unit clerk keeps track of the resident's immunization status and if they are due for a specific immunization. V1 said that the facility follows the CDC's recommendations for the pneumococcal vaccine and all immunizations. The CDC Adult Immunization Schedule Notes dated 10/7/25 shows, Pneumococcal Vaccine: age [AGE] years or older who have: Previously received only PPSV23 should receive: 1 dose PCV15 or 1 dose PCV20 or 1 dose PCV21 at least 1 year after the last PPSV23 dose.The facility's Immunization Policy and Procedure: Influenza, Pneumococcal and COVID 19 Policy revised 9/2025 shows, The facility shall: Offer and administer recommended vaccines to all eligible residents and staff. Document all immunizations, refusals, and contraindications .Comply with IDPH, CDC, and CMS immunization requirements .Pneumococcal Vaccine .Type: PCV 20 or sequential PCV 15 + PPSV23 per CDC guidelines Timing: Upon admission and as needed based on immunization history .

Based on interview and record review the facility failed to ensure a resident was free from misappropriation for 1 of 3 residents (R2) reviewed for misappropriation in the sample of 3.The findings include:R1's face sheet showed R1 was admitted to the facility on [DATE] with diagnoses to include atherosclerotic heart disease, insomnia, spinal stenosis, dementia with psychotic disturbance, panic disorder, restlessness and agitation, and mood disorder.R2's face sheet showed R2 was admitted to the facility on [DATE] with diagnoses to include anemia, chronic congestive heart failure, hypertension, gout, restlessness and agitation, dementia with behavioral disturbance, and anxiety disorders. R1's physician order sheet showed no order for liquid Ativan obtained until 9/25/25. R2's September 2025 eMAR (electronic Medication Administration Record) showed an order for Lorazepam Oral Concentrate 2ML/ML, give 0.5 ml by mouth every 1 hour as needed for agitation and anxiety.R1's September 2025 eMAR showed no order for liquid Ativan until 9/25/25. This same eMAR showed an order for Ativan Oral Tablet 0.5 mg to be given by mouth every 4 hours as needed. This eMAR documented on 9/24/25, R1 received his ordered 0.5mg tablet of Ativan at 3:00 PM and another 0.5 mg tablet dose at 7:00 PM.On 11/15/25 at 2:10 PM, V2 (Director of Nursing/DON) said, It was reported to me by V7 (Certified Nursing Assistant/CNA) on 9/25/25 that the night of 9/24/25 the nurse V6 (Licensed Practical Nurse/LPN) administered [R1] a liquid medication. [V6] told [V7] she was giving [R1] an 'extra dose'. [The nurse didn't document that the medication was given. She documented that she had given [R2] a dose of his Ativan earlier in the day, but we don't know if she really did. we took off the 0.5 ml so that it would be exactly correct. We knew it was [R2's] Ativan because when we watched the video [V6] had a medication in her hand with a white stopper, [R2's] Ativan was the only one with a white stopper. When I spoke with V6 about the allegation she said, If the video says I did it, I guess I did it and she hung up on me. I think when V7 reported to her day nurse (V8) that [V6] had given R1 a liquid medication it stood out to her because [R1] didn't have a liquid medication and that prompted [V8] to tell [V7 CNA] to report it to me. On 11/15/25 at 2:34 PM, V8 (LPN) said, I think [R1] had his own Ativan order, but he received a liquid. He didn't have a liquid Ativan order at that time. V7 (CNA) told me that the agency nurse (V6) said to her, if you don't see this, I can give him something and then gave [R1] a liquid medication out of a dropper. [V7] was concerned about that, and I told her she needed to report it. I know she had written a statement. I also told our Administrator when she came up. I asked her (V7) if she reported it and she said no, I didn't put that in my statement, then she added it. I think they investigated it after that. I don't know whose Ativan [V6] used but if there is not an order for it, we can't give it. The facility's Abuse/Neglect Investigation report dated 9/25/25 showed, . Resident Name: [R1]. Date/Time of Incident: 9/24/25 at approximately 7:00 PM. Type of Allegation: Unauthorized administration of medication (Medication Error), Description of Incident: Resident was observed wandering near the nursing station, appearing anxious and agitated. The nurse on duty contacted the Director of Nursing (DON). During follow-up, CNAs reported the nurse verbalized giving an extra dose of medication to manage behavior. Investigation Findings. Video Review. Confirmed nurse administered liquid medication to resident. Resident's MAR (medication administration record) did not include any oral liquid medications. Conclusion: Nurse administered Ativan without a valid liquid PO (by mouth) order. Final Determination, this incident constitutes, Medication Error, Unauthorized Administration of a Controlled Substance, Violation of Resident Rights and Safety Standards. On 11/15/25 at 11:32 AM, V3 (Registered Nurse) said, We absolutely cannot give a resident a medication that is not ordered by the physician, that is not our scope and practice. We can't give them another resident's medications. Giving a resident someone else's medication can affect the other resident by them then being short on supplies.The facility's policy and procedure with review date of 8/2025 showed, Abuse and Neglect Prevention Protocol Policy, Policy: It is the policy of this facility to not tolerate abuse or neglect of its residents by any individual. Misappropriation of resident property means using a resident's cash, clothing, or other possessions without authorization by the resident or the resident's authorized representative.

Based on observation and interview the facility failed to ensure a resident was free of a medication error for 1 of 3 residents (R1) reviewed for medication administration in the sample of 3.The findings include:R1's face sheet showed R1 was admitted to the facility on [DATE] with diagnoses to include atherosclerotic heart disease, insomnia, spinal stenosis, dementia with psychotic disturbance, panic disorder, restlessness and agitation, and mood disorder.R1's undated care plan showed, The resident uses anti-anxiety medications related to anxiety disorder. Administer anti-anxiety medications as ordered by physician. Monitor for side effects and effectiveness every shift.R2's face sheet showed R2 was admitted to the facility on [DATE] with diagnoses to include anemia, chronic congestive heart failure, hypertension, gout, restlessness and agitation, dementia with behavioral disturbance, and anxiety disorders. R1's physician order sheet showed no order for liquid Ativan obtained until 9/25/25. R2's September 2025 eMAR showed an order for Lorazepam Oral Concentrate 2ML/ML, give 0.5 ml by mouth every 1 hour as needed for agitation and anxiety.The facility's Abuse/Neglect Investigation report dated 9/25/25 showed, . Resident Name: [R1]. Date/Time of Incident: 9/24/25 at approximately 7:00 PM. Type of Allegation: Unauthorized administration of medication (Medication Error), Description of Incident: Resident was observed wandering near the nursing station, appearing anxious and agitated. The nurse on duty contacted the Director of Nursing (DON). During follow-up, CNAs (Certified Nursing Assistants) reported the nurse verbalized giving an extra dose of medication to manage behavior. Investigation Findings. Video Review. Confirmed nurse administered liquid medication to resident. Resident's MAR (medication administration record) did not include any oral liquid medications. Conclusion: Nurse administered Ativan without a valid liquid PO (by mouth) order. Final Determination, this incident constitutes, Medication Error, Unauthorized Administration of a Controlled Substance, Violation of Resident Rights and Safety Standards. On 11/15/25 at 2:34 PM, V8 (Licensed Practical Nurse/LPN) said, I think [R1] had his own Ativan order, but he received a liquid. He didn't have a liquid Ativan order at that time. V7 (CNA) told me that the agency nurse (V6) said to her, if you don't see this, I can give him something and then gave [R1] a liquid medication out of a dropper.On 1/15/25 at 11:20AM, V4 (Registered Nurse/RN) said, We contact the nurse practitioner or the physician if we need an electronic prescription for a new prescription. We can't borrow someone else's, that is dangerous. You never borrow any medications, and you can't give medications they don't have an order for. we are not doctors, we can't prescribe medications. On 11/15/25 at 11:32 AM, V3 (RN) said, We absolutely cannot give a resident a medication that is not ordered by the physician, that is not our scope and practice. We can't give them another resident's medications. Giving a resident someone else's medication can affect the other resident by them then being short on supplies.On 11/15/25 at 2:10 PM, V2 (Director of Nursing) said, It was reported to me by V7 (CNA) on 9/25/25 that the night of 9/24/25 the nurse V6 (LPN) administered [R1] a liquid medication. [V6] told [V7] she was giving [R1] an 'extra dose'. [The nurse didn't document that the medication was given. She documented that she had given [R2] a dose of his Ativan earlier in the day, but we don't know if she really did. we took off the 0.5 ml so that it would be exactly correct. We knew it was [R2's] Ativan because when we watched the video [V6] had a medication in her hand with a white stopper, [R2's] Ativan was the only one with a white stopper. When I spoke with V6 about the allegation she said, If the video says I did it, I guess I did it and she hung up on me. I think when V7 reported to her day nurse (V8) that [V6] had given R1 a liquid medication it stood out to her because [R1] didn't have a liquid medication and that prompted [V8] to tell [V7 CNA] to report it to me. The facility's policy and procedure with review date of 08/2025 showed, Medication: Delivery by Nursing Personnel; Purpose: To establish a process to ensure that medication is safely and accurately administered. Policy Statement: Medications are administered utilizing the 5 rights of administering medications: 1. Right Resident, 2. Right Medication, 3. Right Dose, 4. Right Route, 5. Right Time. Practice: . 3. A two-step identification process may consist of asking a resident their name, using their photo in our electronic medical record, birth date, or the resident's name on their door. 5. Medications will be administered from the packaging bearing the individual resident's name, prescribing physician, and directions for administration.

Based on interview and record review the facility failed to complete a thorough investigation into an allegation of misappropriation of narcotic medications. This applies to four of four residents (R4-R7) in certified beds of the facility reviewed for abuse investigation in the sample of 13. The findings include: The facility census provided by the facility dated 1/28/2025 for December 24 to December 25, 2024 shows there were four residents residing in certified beds in the E-wing that also had orders for controlled medications. The facility provided a schedule for 12/24/24 which shows V21 (Agency Licensed Practical Nurse/LPN) was assigned the E-wing unit of the health care center from 2:00 PM to 10:30 PM. On 1/21/25 at 12:30 PM, V3 (Director of Nursing/DON) said, . It was [V21 Agency LPN] that was accused. She worked for us for that one day and only worked on the sheltered care side of the facility. She would not have had access to any other medication carts, medication rooms, or comfort packs on any other unit. On 1/22/25 at 3:30 PM, V3 (DON) said no concerns were reported to her regarding the certified wing. V3 said there was no audits completed of any other units other than the sheltered units. On 1/21/25 at 11:30 AM, V1 (Administrator) said the allegation of a drug diversion was not reported to the state agency or the police because nothing could be proved, and the facility could be sued for slander if they began making accusations without proof. On 1/21/25 at 2:20 PM, V22 (Registered Nurse/RN) said, I had worked night shift on Christmas Eve. I was late and did not get there until 11:00 PM. I did not count the narcotics, I assumed it was done by someone else. The next morning when I went to count with the day shift nurse, the count was off. I went down to sheltered care and told [V21 Agency LPN] she needed to come back upstairs to count and see where the problem was. She didn't come up with me. I don't know if she ever did come up . On 1/22/25 at 10:20 AM, V6 (RN) said, I was working [the certified wing]. My shift started at 6:00 AM. At first when I started to do the count, I noticed the first 3 cards were off. I wasn't tripping at first because you might get in a groove and forget. After the third one was off, I called down and spoke with [V4 LPN]. When I got here and got the keys I was waiting for [V21 Agency Nurse] to come up and count. I was looking over them myself as I waited for [V21]. I then reached out to [V4], and she said her count was off too. [V21 Agency Nurse] came up to verify the count. She was very rushed. I said, 'hey things are off.' She was rushing through and signing medications off. I finally told her she needed to slow down . [V21] was exhibiting different behaviors . she was trying to get into the medication refrigerator to 'get her lunch' . I wouldn't let her back there. Then she went to [another upstairs unit] and then back downstairs . the DON (Director of Nursing) was called, and she said to walk [V21] out . the maintenance guy got her . We count every shift unless we are working a double on the same unit. The whole point of doing a count is to make sure it's right . On 1/22/25 at 12:19 PM, V7 (Maintenance) said he was called over to the radio on Christmas Day to remove a nurse who was acting erratic. V7 said, I was told her shift was done and she needs to leave the building right away. She was trying to outrun me, but I cut her off since I know the building well and told her she needed to leave. She was acting strange . Her pupils were extremely dilated. She was acting like she took some 'gummies' or something. She didn't smell like anything, but she was acting erratic . I took her to the exit, but I didn't think she was going to leave. She sat in her car for at least 10 minutes, just sitting there. So, I picked up the phone to act like I was calling someone and then she headed out. I followed her for a bit just to make sure she actually left . No one at the facility has asked me anything about this . The facility provided an email dated 12/25/24 at 8:26 AM, which showed it was from V3 (DON) to V1 (Administrator). The email showed, . this morning, [V4 LPN] called me with concerns regarding a nurse on [sheltered care unit] for night shift. The nurse was [V21 Agency LPN]. She stated that a CNA (Certified Nursing Assistant) stopped her prior to clocking in and told her the nurse she was working with on nights was all over the place and was caught sleeping 3 times. I was not notified of any of this throughout the night and neither was the nurse on call. She said the office was in complete disarray and she noticed discrepancies in the narcotic count. She forgot to sign out an Ambien, but I did verify with another nurse that this was given, and the count was corrected. [V4] stated a bottle of Norco was unaccounted for but they did locate it in the other narcotic drawer prior to the nurse leaving. [V4] also stated an oxycodone count was off but the pill was located in the bottom of the drawer and count was correct. [V4] stated when they counted the liquids in the fridge, she noticed the consistency seemed off and stated the liquids smelled of mouthwash and Robitussin. I did let her know that the narcotics sent from hospice in comfort packs did have a sweet smell. [V4] stated the nurse kept looking around the unit like she lost something and I advised her that if she did not leave, to please have maintenance escort her out if need be. She did end up leaving on her own accord. I have removed her from her double shift today and will notify her agency about the above. I will also check our policy for suspected medication diversion and consult with pharmacy as the need arises. Please let me know if there is anything you need from me at this time . The facility provided an email thread dated 12/31/24 at 7:43 AM which showed V8 (Pharmacy Nurse Consultant) contacted V3 (DON). This email showed, . Can you please call me this morning . we received a call from a nurse, [V4]. She is concerned that 2 residents morphine/lorazepam liquids from the hospice kit were switched with water and is asking if there is a way to test it . On 12/31/24 at 8:46 AM, V4 (LPN) was added to the email and additionally V5 (LPN Nurse Manager) and V1 (Administrator) were copied. This email showed, [V4], I spoke with [V8 Pharmacy Nurse Consultant] this morning. She confirmed there is no test to check the morphine/lorazepam. She consulted with the pharmacist and best practice would be to document (which we have) and ask hospice or pharmacy to supply a new bottle. I am attaching the policy we follow from [the pharmacy] . All proper documentation has already been filed and her agency has already disabled her account. We likely won't know what comes of this for quite some time but we do have all the information we need to move forward . [V5 LPN Nurse Manager] can we please dispose of the narcotics we believe have been tampered with and ensure hospice is able to send a new bottle? . The facility did not provide interviews with all the staff involved in the incident such as the maintenance man who had to escort V21 from the facility. No records of medication cart and drug audits were provided. The facility's policy and procedure received from the facility's pharmacy dated March 2021 showed, Discrepancies, Loss and or Diversion of Medications; Policy: All discrepancies, suspected loss, and/or diversion, the Administrator, Director of Nursing, and Consultant Pharmacist are notified, and an investigation is conducted. The Director of Nursing leads this investigation . The facility's policy and procedure with revision date of 3/5/24 showed, Abuse and Neglect Prevention Protocol Policy . It is the policy of this facility to not tolerate abuse or neglect of its residents by any individual . Definitions: . 11. Misappropriation of resident property means using a resident's cash, clothing, or other possessions without authorization by the resident or the resident's authorized representative . Investigation will be performed by Abuse Prevention Coordinators including but not limited to and interviews of residents and staff members .

Based on interview and record review the facility failed to ensure a narcotic count was completed upon nursing shift change. This applies to one of one resident (R6) in certified beds of the facility reviewed for narcotic counts in the sample of 13. The findings include: The facility face sheet for R6 shows he was admitted to the facility with diagnoses to include encounter for palliative care, hypertensive heart disease with heart failure, atrial fibrillation, dementia, and congestive heart failure. The medication administration record for R6 shows medication orders for lorazepam (anti-anxiety medication) 2 mg/ml (milligrams/milliliters) give 0.5 ml every four hours as needed and morphine (opioid pain medication) 20 mg/ml give 0.25 ml every four hours as needed. (Lorazepam and morphine are controlled substances.) On 1/21/25 at 2:20 PM, V22 (Registered Nurse/RN) said, I had worked night shift on Christmas Eve. I was late and did not get there until 11:00 PM. I did not count the narcotics, I assumed it was done by someone else. The next morning when I went to count with the day shift nurse, the count was off. I went down to sheltered care and told [V21 Agency Licensed Practical Nurse/LPN] she needed to come back upstairs to count and see where the problem was. She didn't come up with me. I don't know if she ever did come up . On 1/22/25 at 10:20 AM, V6 (RN) said, I was working [the certified wing]. My shift started at 6:00 AM. At first when I started to do the count, I noticed the first 3 cards were off. I wasn't tripping at first because you might get in a groove and forget. After the third one off, I called down and spoke with [V4 LPN]. When I got here and got the keys I was waiting for [V21 Agency LPN] to come up and count. I was looking over them myself as I waited for [V21]. I then reached out to [V4], and she said her count was off too. [V21 Agency LPN] came up to verify the count. She was very rushed. I said, 'hey things are off'. She was rushing through and signing medications off. I finally told her she needed to slow down . [V21] was exhibiting different behaviors . she was trying to get into the medication refrigerator to 'get her lunch' . I wouldn't let her back there. Then she went to [another upstairs unit] and then back downstairs . the DON (Director of Nursing) was called, and she said to walk [V21] out . the maintenance guy got her . We count every shift unless we are working a double on the same unit. The whole point of doing a count is to make sure it's right . On 1/22/25 at 3:30 PM, V3 (DON) said, . They should do a [narcotic] count every shift change. When a nurse is handing her keys off to anyone, they should be counting . On 1/28/2025 at 12:03 PM, V3 said the nurses count all scheduled II-V medications. The facility's Controlled Substance Shift to Shift Count Record for December 2024 showed, no signature on 12/25/24 AM (Morning) Off-going nurse or ON-coming nurse and no signatures showing a count was done for the 12/25/24 Off-Going PM nurse. The facility's policy and procedure with revision date of 7/2014 showed, . Medications: Storage of and narcotic counts; Purpose: To establish uniform guidelines concerning the storing of drugs and biologicals All Schedule II-V controlled medications will be counted with 2 nurses at each shift change and any discrepancies/corrected counts will be initialed and dated by both nurses.

Based on interview and record review the facility failed to ensure a resident was positioned safely in bed to prevent a fall for 1 of 3 residents (R2) reviewed for safety and supervision in the sample of 5. The findings include: The Nurse's Note dated 9/20/24 at 8:30 PM showed, Resident (R2) was found at 7:30 PM by CNA (Certified Nursing Assistant) staff at the time this writer arrived resident vitals were assessed and stable. Client told staff she wanted to get her cranberry juice and slid out of her bed. No signs of distress or discomfort shown by client. Client expressed her bottom was hurting but she did not have any other pain. This writer reached out to clients POA with direct phone call and advised client would have to be sent out for further evaluation per standard protocol due to client being on blood thinner medication. On 9/21/24 at 1:00 AM staff was contacted by the hospital nurse and was notified that the resident was being admitted for a subarachnoid bleed. On 9/21/24 at 7:07 PM, Nurse to nurse report given by hospital nurse to this writer/nurse - the hospital performed a head computerized tomography scan that showed trace bilateral subarachnoid bleed. R2 given vitamin K in the emergency room . Resident returned to unit (at facility) by ambulance transport. The Hospital Record for R2 dated 9/21/24 showed the CT of the head for R2 was redone and, the previously mentioned subarachnoid hemorrhage is likely artifactual. On 9/24/24 at 1:19 PM, R2 was sitting in a wheelchair in the activity room. R2 was leaning forward in her wheelchair and was sleepy. On 9/24/24 at 1:47 PM, V11 CNA stated, V13 (CNA from the agency) had R2. V11 stated V13 sat R2 up on the side of her bed and had the tray table in front of her so she could eat. V11 stated when R2 was done eating she had pushed the tray table away from her. V11 stated R2 was sitting up on the side of her bed for over an hour. V11 stated R2 did not have good sitting balance because she sits forward. V11 stated when R2 is in her wheelchair she leans forward, and you can tell her to sit back, and she will. V11 stated R2 will fall asleep sitting up. R2 is usually put to bed right after lunch and dinner. V11 stated V13 wasn't doing anything; he told V13 to get up and go to the dining room. V11 stated they don't like to leave residents in their rooms for meals because they can't be monitored, and anything can happen. V11 stated R2 slid off the bed onto the floor. V11 stated the nurse came and had to assess to make sure the resident was okay. R2 said she didn't hit her head. It just looked like she slid out onto her butt onto the floor. R2 has poor balance when sitting and gets tired easily. V13 had her sitting up on the side of the bed too long. V11 stated they used a mechanical lift to get her up off the floor and into bed. On 9/24/24 at 2:25 PM, V12 (Licensed Practical Nurse/LPN) stated, the agency CNA had her that night on the 2:00 PM - 10:00 PM shift and R2's cares were explained. After dinner I heard V13 (CNA) yelling that R2 was on the floor. R2 was sitting on her bottom on the floor. I checked her vital signs, assessed her and then a mechanical lift was used to put R2 to bed. V12 stated she talked to the family, and they did not want R2 sent out but V12 told them she needed to because R2 was on a blood thinner. V12 stated she was doing the medication pass at the end of the hall and V11 got to R2's room before she did. V12 stated R2 was sitting on the side of the bed before she slid out and the pad that was under her was partially out of the bed. V12 stated she did not know why R2 was sitting on the side of the bed. R2 can't do that on her own; she is complete dead weight and leans forward all the time. V12 stated R2 said she was trying to get her cranberry juice and if R2 had been in bed with it (bed) in a lower position with the tray table next to her where she could get it then it would not have happened. V12 stated this fall could have been prevented. V12 stated R2 should not have been sitting on the side of the bed. On 9/24/24 at 2:55 PM, V3 (Director of Nursing) stated, R2 slid out of bed reaching for her juice and was sitting on the floor next to her bed. There was no evidence of her hitting her head, but she was on a blood thinner, so she was sent to the hospital. Initially R2 was admitted to the hospital for a bleed but they called us later and told us it was an old bleed. V3 stated she was told R2 rolled out of bed. V3 stated R2 shouldn't have been sitting on the side of the bed. R2 wouldn't be able to do that. The Face Sheet dated 9/24/24 for R2 showed diagnoses including pain in left knee, localized edema, atrial fibrillation, type 2 diabetes mellitus, anemia, anxiety disorder, gastroesophageal reflux disease, hyperlipidemia, history of falling, age related physical debility, and muscle weakness. R2's Care Plan with the next goal date of 11/29/24 showed she has a potential for falls related to decreased independence with mobility; 9/20/24 slid from bed to floor trying to reach cranberry juice. Sent to emergency room - no new injury. Staff will provide assistance with activities of daily living, transfers, and locomotion per therapy recommendations. Keep call light and personal belongings within resident's reach (5/20/22). Keep bed in low position while resident is resting/sleeping. Provide extensive 2 person assist for transfers with mechanical lift. Ensure resident has her items within reach i.e. glass when she is wanting something to drink (9/20/24). Decreased independence with mobility. Non-ambulatory - spends some of her day in her wheelchair. She is able to propel her wheelchair herself. Dependent on staff for mobility activities. Assist of 2 with repositioning. Propels self in wheelchair in the hallways. R2's care plan does not state that what her sitting balance is or that she leans forward in her chair. The Facility's Fall Prevention Policy (8/2024) showed, all staff will have training on fall prevention and their responsibility on hire and annually.

Based on observation, interview, and record review the facility failed to ensure their infection control policies and procedures were reviewed annually and update the policies to include Enhanced Barrier Protection (EBP) and failed to have measures to prevent the growth of Legionella in the facility water systems for all 30 residents residing in the facility reviewed for infection control. The findings include: 1. The facility's CMS form 671, the Long-Term care facility application for Medicare and Medicaid documents 30 residents reside in the facility. On 8/21/24 at 1:50 PM, V3 (Infection Preventionist) said no residents were on EBP and does not know about the requirements for EBP. She said there is no need for postings or signs on residents' doors to indicate the enhanced barrier precautions, the staff know what they are supposed to wear into the rooms. She said if residents have open wounds or catheters, the staff know to wear a gown and gloves. On 8/22/24 at 8:56 AM, V6 (Licensed Practical Nurse/LPN) said residents with catheters and open wounds should be on EBP. I do not think they have that in place here. She said she is aware of EBP from working in other facilities. She said there were residents on the wing which should be under the EBP precautions, but no postings or signs have been placed. She did not recall if she received any information or training regarding EBP upon her hire 2 months ago. On 8/21/24, resident hallways were observed to have no residents on enhanced barrier precautions for oxygen or catheters, only contact or droplet isolation rooms have PPE and signs posted outside their doors. On 8/22/24 at 9:03 AM, V3 said she had since reviewed EBP procedures and said any resident with open wounds, urinary catheters or IVs should have signs on their door for EBP, with PPE (personal protective equipment) available such as gowns and gloves, and each resident should also have a care plan in place for the enhanced barrier requirements. V3 said she was not made aware of the changes, and therefore had not implemented EBP. V1 (Administrator) said there is no current policy for EBP. He said the previous administrator had been doing the infection control and did not share the updated information with V3 and did not update the policies in infection control. On 8/22/24 at 9:30 AM, V3 said the policy updates are issued to the medical director but could not say if all of the policies are reviewed annually. She said the policies and procedures are updated as needed and after quality assurance meetings every 3 months. The facility policy for Covid-19 was revised on 7/2024 but does not include EBP policies or procedures. Their policies for antimicrobial stewardship and flu and pneumovax were last reviewed 6/2023. The Infection control pathway was dated 5/2017. 2. On 8/22/24 at 9:30 AM, the facility water management program assessment was requested from maintenance. V4 (Maintenance Supervisor) said there has not been an assessment of the water systems and had no diagram of the water systems. He said there had been testing of the cooling tower, but no other measure put in place. He said no other monitoring/ protocols or policies were presented. On 8/22/24 at 10:00 AM, V1 said there is no policy for water management, and there has been no assessment for Legionella. He said if V4 and V5 (Director of Facility and Grounds) do not have the information, then there is none. 20042 3. On 8/21/24 at 1:14 PM, R10 was sitting in the recliner in his room. V8 (Certified Nursing Assistant/CNA) and V9 (CNA) had mask and gloves on when entering R10's room. V8 and V9 used a mechanical lift device to transfer R10 from his recliner to his bed. Once R10 was transferred to bed, V8 and V9 rolled him back and forth to remove the sling and adjust the linen under him. R10 had a wrinkled dressing to his left buttock, a dressing to his right knee, and dressings to his bilateral lower legs. V8 and V9 stated there was no reason to wear gowns for this activity. V8 stated there wasn't a sign on the door saying they needed to wear anything. V9 stated she just goes by whatever the sign that is posted states to do. V9 stated she didn't see any signs or isolation cart outside R10's room. On 8/21/24 at 1:26 PM, V7 (Licensed Practical Nurse/Nurse Manager) stated they did not have anyone on enhanced barrier precautions. V7 stated R10 has wounds but has not needed to be on any precautions. V7 stated she did not know about enhanced barrier precautions. V7 stated they have never worn gowns and gloves for him the entire time he has had wounds. The Physician Orders dated 8/21/24 for R10 showed, left buttock, medial and lateral wounds, cleanse daily, apply thin layer of Santyl to wound beds, and cover with bordered dressing every day. Right knee - once daily cleanse, apply thin layer of Santyl to wound beds. Cover with bordered dressing every day. The Nurses Note's for R10 showed, on 8/1/24 at 9:13 AM - wound to left buttock measures 1.6 cm x 1.0 cm. On 8/15/24 at 9:10 PM - wound on left buttock measures 1.9 cm x 2.0 cm. Wound bed is covered with slough. Report written to nurse practitioner. The Physician Orders dated 8/21/24 for R10 showed diagnoses including anemia, gout, non-pressure chronic ulcers to lower leg, adult failure to thrive, paroxysmal atrial fibrillation, osteoporosis, pressure ulcer left heel, osteoarthritis, pressure ulcer left buttock, and localized edema. On 8/21/24 the facility did not have a policy for Enhanced Barrier Precautions. 41639 4. R17's electronic face sheet printed on 8/22/24 showed R17 has diagnoses including but not limited to pressure ulcer of sacral region, dementia with behaviors, hematuria, and anxiety disorder. R17's physician's orders showed no orders for Enhanced Barrier Precautions. R17's care plan did not contain any care plan related to Enhanced Barrier Precautions. On 8/21/24 at 12:39PM, R17's doorway did not have any signs posted that indicated R17 was on Enhanced Barrier Precautions. R17's doorway and room did not have any PPE (Personal Protective Equipment) cart accessible to staff with gowns and gloves. V13 (CNA) and V14 (Nurse Manager) provided incontinence care for R17. V13 and V14 wore gloves and no gown for the entirety of R17's personal cares. V13 stated the only PPE staff wear in R17's room is gloves. V13 stated she does not know anything about residents on her unit being on enhanced barrier precautions and if no sign is on the door then she just uses standard precautions.

Based on observation, interview, and record review the facility failed to treat 8 residents with dignity. This applies to 4 of 4 residents (R6, R11, R12, R17) reviewed for dignity in the sample of 13 and 4 residents (R2, R9, R22, R23) outside of the sample. The findings include: On 8/21/24 at 11:35AM, R2, R6, R9, R11, R12, R17, R22, and R23 were being served their noon meal. All residents received their water, fruit cups, pasta salad, and cucumber tomato salads in disposable plastic cups. On 8/21/24 at 12:42PM, V12 (Dietary Manager) stated, The kitchen staff measured the food and placed them in plastic cups. They should have then placed the food into the small bowls we have but they forgot to. It's a dignity concern that they left everything in plastic cups because they should feel like they are eating with normal dishes. We only use disposable dishes if a resident is on isolation or if we have a malfunction with our dish machine. This was not the case today and my staff should know better. Any reasonable person would want to eat with regular dishes, not disposable. The facility's policy titled, Resident Dignity revised 9/2023 showed, (Facility) understands and believes each resident has a right to receive services and be addressed in a manner that maintains their dignity .

Based on interview and record review, the facility failed to complete weekly wound assessments for a resident (R17) with a stage 2 pressure ulcer, failed to ensure complete weekly wound assessments were done for a resident (R10) admitted with a stage 3 pressure ulcer. These failures apply to 2 of 2 residents reviewed for pressure ulcers in the sample of 13. The findings include: 1. R17's electronic face sheet printed on 8/22/24 showed R17 has diagnoses including but not limited to pressure ulcer of sacral region, dysphagia, dementia with behaviors, and anxiety disorder. R17's facility assessment dated [DATE] showed R17 has a Stage 2 pressure injury. R17's care plan dated 3/19/20 showed, At risk for Impaired Skin Integrity. Wound to buttocks .monitor wound progress and document and measure weekly. R17's weekly wound assessments from 6/2/24-8/2/24 showed R17 did not receive a weekly wound assessment from 6/25/24-8/2/24 (4 weeks). On 8/22/24 at 12:33PM, V15 (Director of Nursing/DON) stated, We do not have all of the weekly assessments for (R17). We thought hospice was doing them, but they were just doing a note saying, wound continues and documenting if they did a dressing change. I didn't realize we had to do our own wound assessments if they were a hospice patient. We definitely need to improve our process because wounds should be diligently monitored so they don't worsen. The facility's policy titled, Documentation and Treatment of Wounds revised on 6/2023 showed, It is the policy of (facility) to document wound status weekly. Wound status will be documented on the back of the treatment sheets. Pressure sore status will be documented on the pressure sore sheet .1. Documentation will include: i. description of size, color, drainage and odor at the time of discovery and a weekly progression thereafter. ii. Assess skin turgor, elasticity, and fragility of skin. iii. Last documentation will describe healed area. iv. Documentation will be done by the day shift unless treatment is only done by P.M. shift of night shift. Then shift doing treatment will do documentation . 20042 2. On 8/21/24 at 9:45 AM, R10 was lying in bed on his back. R10's left heel was offloaded with a pillow. R10's right heel was laying on the bed. R10 had dressings intact to his bilateral legs. R10 stated he had a wound to his buttock. R10 declined having his dressing change to his buttock observed. R10 stated he has very little privacy and would like a few minutes in private for the dressing change to be done. R10 stated the dressing is changed on night shift. On 8/21/24 at 1:12 PM, V8 (Certified Nursing Assistant/CNA) and V9 (CNA) transferred R10 from his recliner to his bed. R10 had gauze dressings wrapped around his bilateral lower legs. V8 and V9 turned R10 onto his side to remove the mechanical lift sling. A wrinkled, square dressing was on his upper, medial left buttock. A review of R10's record was conducted on 8/20/24 - 8/22/24. The wound documentation in the skin area on the electronic medical record was not up to date. R10 did not have complete weekly skin assessments for his pressure injury to his buttock and coccyx area. On 8/22/24 at 12:15 PM, V15 (DON) presented all the information she could find related to R10's wounds and was documented below in the record review. V15 stated they don't have a wound nurse in the building. V15 stated the NP (Nurse Practitioner) is overseeing treatment orders for wounds. V15 stated on resident's TARs (Treatment Administration Records) there are orders for weekly skin checks. V15 stated the nurse manager on each unit oversees the wound program for their unit. V15 stated hospice is overseeing wounds for their residents. V15 stated R10 had wounds upon admission to the facility. V15 stated weekly wound measurements and assessments should be done. V15 stated the assessments should be documented weekly in the skin care tab or wound notes. The NP only looks at a wound when they ask her to. On 8/22/24 at 12:55 PM V7 (Licensed Practical Nurse/Nurse Manager) stated there isn't a wound program at the facility. V7 stated right now the nurses are measuring wounds and documenting on them weekly. V7 stated they should be measuring the wound, describing the wounds appearance, if there is and pain and/or odor present. V7 stated R10 has an unavoidable stage 3 wound to his buttock; he is non-compliant with care. The Nurse's Notes for R10 showed, 4/8/24 at 10:48 PM showed R10 was admitted to the facility with multiple open areas noted At 11:22 PM the note showed multiple open areas including the left buttock 5.5 cm (centimeters) x 3 cm and 4 cm x 6 cm. No other description was given. The Wound Rounds notes for R10 showed, 4/15/24 - left buttock 9 cm x 9 cm x 0.1 clustered. No additional description or stage was documented. On 4/22/24 - left buttock measured 7 cm x 6.5 cm x 0.1 cm, clustered. No additional description or stage was documented of the wound. On 4/29/24 - left buttock 7 cm x 6 cm x 0.1 cm; coccyx 2 cm x 0.6 cm x 0.1 cm, stage 2 wound. There were no additional descriptions of the wounds given and no staging of the left buttock wound. The Wound Visit Report for R10 showed, 5/6/24 - wound #6 left medial buttock is stage 3 pressure injury ; 3 cm x 3 cm x 0.1 cm. There is a moderate amount of serosanguinous drainage noted. Wound bed has 51-75%, pink, granulation, 1-25% slough, no eschar, and no epithelialization present. Two open areas to buttock. Medial buttock wound erythema, 1 cm peri wound maceration present. Wound #7 left lateral buttock is stage 3 pressure injury ; Measurements are 1 cm x 2 cm x 0.1 cm There is a moderate amount of serosanguinous drainage noted. Wound bed has 76-100%, pink granulation, 1-25% slough, no eschar, and no epithelialization present. A Progress Notes for R10 showed, on 5/19/24 - left buttock 0.3 cm x 0.3 cm, 1 cm x 0.5 cm. There was no description of the wound or staging. On 5/23/24 showed, coccyx 0.5 cm x 1.5 cm. No other wounds were documented. There wasn't a description or stage of R10's coccyx wound. The Wound Rounds dated 6/25/24 for R10 showed, sacral wound 6 cm x 6 cm x 0.1 cm; slough 100%? The Nurses Note's for R10 showed, on 8/1/24 at 9:13 AM - wound to left buttock measures 1.6 cm x 1.0 cm. On 8/15/24 at 9:10 PM - wound on left buttock measures 1.9 cm x 2.0 cm. Wound bed is covered with slough. Report written to nurse practitioner. The Physician Orders dated 8/21/24 for R10 showed diagnoses including anemia, gout, non-pressure chronic ulcers to lower leg, adult failure to thrive, paroxysmal atrial fibrillation, osteoporosis, pressure ulcer left heel, osteoarthritis, pressure ulcer left buttock, and localized edema. R10's current Care Plan dated 4/8/24 showed, at risk for impaired skin integrity related to decreased movement. Observe for any changes in skin condition and notify nurse. Nurse to monitor skin and document on Weekly Skin Assessment.

Based on observation, interview, and record review the facility failed to ensure a catheter tubing remained free of kinks and the catheter tubing secure device was in place for 1 of 1 resident (R25) reviewed for catheters in the sample of 13. The findings include: On 8/20/24 at 1:35 PM, R25 was in his room in his recliner. R25 had an indwelling urinary catheter drainage bag attached to the lower part of his wheeled walker. R25 had thick white sediment and cloudy yellow urine in his catheter tubing. R25 did not have a catheter tubing secure device in place. R25 stated he has not had one (catheter secure device) on for two weeks. R25 stated they must have run out of them. R25 stated he wouldn't mind having one (catheter secure device) on now. R25 said it would help prevent his catheter from coming out. R25 stated his catheter is leaking right now. On 8/20/24 at 1:47 PM, V10 (Licensed Practical Nurse) stated, R25 had some pressure so to be on the safe side they collected a urine sample. V10 stated R25's tubing was kinked and that is why they took a urinalysis. V10 stated sometimes when R25 sits or moves the tubing gets kinked. V10 stated he thought this happened over the weekend. V10 stated staff should monitor R25 closer so his catheter tubing doesn't get kinked. V10 stated they use a catheter secure device for R25. V10 stated he did not recall if the facility ran out of the devices or had problems obtaining them. V10 stated he doesn't know if R25 has a catheter secure device in place or not. V10 stated the last time R25's catheter came out was on 8/15/24 and it came out during AM care. The Physician Orders dated 8/21/24 for R25 showed an order dated 4/1/24 for a catheter tubing secure lock device every shift. The Care Plan dated 8/18/24 for R25 showed, Indwelling catheter use with potential for infection. 18 French Coude, 10 cc (cubic centimeter) balloon. Secure catheter to leg to avoid tension on urinary meatus. The August 2024 TAR (Treatment Administration Record) for R25 showed secure lock for catheter every shift. The secure lock device was documented on 8/8/24, 8/17/24, 8/20/24 and 8/21/24 to show that it was in place. It is to be documented on the day shift that it is present. The Face Sheet dated 8/21/24 for R25 showed diagnoses including Parkinson's disease, mechanical complication of other urinary catheter, benign prostatic hyperplasia with lower urinary tract symptoms, restless leg syndrome, hypothyroidism, hyperlipidemia, gastro-esophageal reflux disease, history of falling, lack of coordination, muscle weakness, general anxiety disorder, weakness, and insomnia. The facility's Catheter Care policy (6/2023) showed, Purpose: To provide nursing measures to prevent infection and maintain the unobstructed flow of urine through catheter drainage system. Checks for patency of the tubing is to be checked with care each shift. The policy did not have anything in place for catheter secure devices.

Based on observation, interview, and record review the facility failed to assess and implement treatment orders for a resident with pressure injuries for one of one resident (R25) reviewed for pressure injuries in the sample of 13. These failures resulted in R25's pressure injuries worsening. The findings include: R25's Braden Scale for Predicting Pressure Sore Risk dated 6/23/2022 shows R25 is at risk for pressure injury development. R25's Care Plan started 11/30/21 shows, Impaired skin integrity related to pressure ulcer plantar aspect of left heel, unstageable. Wound care/dressing change as ordered. Monitor wound progress and document and measure weekly. Notify medical doctor if wound does not demonstrate signs of healing. Wound care nurse to follow. On 7/19/22 at 8:10 AM, V5 (Certified Nursing Assistant/CNA) removed R25's heel protective boot from R25's left heel. There was a large amount of dry drainage in R25's boot in the heel area. There was a washcloth noted inside of the boot in the heel area. R25 had a thick kerlix wrap wrapped around her left heel and foot. There was a large amount of orange/tan drainage noted to the outside of R25's dressing. There was no date on the dressing to verify when the dressing was last changed. V5 replaced R25's heel boot onto her left heel and wheeled her out to the dining room. At 9:30 AM, V5 and V6 (Licensed Practical Nurse/LPN) already had R25 in bed and the dressing to R25's left heel was freshly changed. V6 said she just changed the dressing to R25's left heel. V6 said the pressure injury to R25's left heel had a lot of purulent drainage. V6 said the dressing to R25's left heel is usually done on night shift. V6 said she did not see a date on the original dressing on R25's left heel. V6 said R25's left heel is necrotic. V6 said the pressure injury is covering R25's entire heel. V6 said she cleansed R25's left heel with peri cleanser, applied (name brand topical treatment) to the wound bed, applied two thick ABD pads, and wrapped the left heel in gauze wrap. V6 said this was the same treatment that V6 originally removed from R25's heel. V6 said the facility has not had a wound care nurse since June 2022. On 7/20/22 08:38 AM, the same dressing was noted to R25's left heel with no drainage noted to the outside of the dressing. R25 still had the same heel protective boots on that had dried drainage in the heel area. R25's Treatment Record for 7/2022 shows R25's wound to left heel was only measured on 7/8/2022 from 7/1/2022-7/18/2022. Orders dated 4/13/2022 for left heel wound-cleanse area and pat dry. Apply skin prep to periwound. Apply (name brand topical treatment) to wound bed cover with calcium alginate. Apply non bordered foam and wrap with (gauze). Change every other day and as needed. R25's progress notes from the nurse practitioner dated 5/10/2022 shows R25's chief complaint was a pressure injury to her left heel, stage 3. Patient initially with a blood-filled blister to her left heel that was intact and has developed a firm eschar. Wound with significant improvement with recent adjustments to her wound care. Pressure injury to plantar aspect of left heel, unstageable measuring 4.7 cm (centimeters) length X 3.7 cm width X 0.2 cm depth. There is some drainage noted. Will have staff cleanse area and pat dry, apply skin prep to periwound, apply (name brand topical treatment) to wound bed and place calcium alginate to wound bed, cover with a non-bordered foam and wrap with (gauze). R25's Skin Evaluation Form dated 6/20/2022 shows R25 has a full thickness pressure injury to her left heel that measures 6.0 cm X 5.0 CM with no depth. R25's Skin Evaluation Form dated 7/8/2022 shows R25's pressure injury to her left heel now measures 7.5 cm X 6.0 cm X 1.0 cm depth. There are no other measurements located in R25's medical record after 7/8/2022. On 7/20/22 at 8:05 AM, V4 (Registered Nurse/RN) said the wound nurse practitioner has not been in the facility since about 6/3/2022. V4 said the dressing is usually changed on night shift and the night shift nurses measure the wound. V4 said the pressure injury dressing should be changed any time it is soiled, saturated, or out of place. V4 said treatment to R25's left heel should be (name brand topical treatment) to the wound bed, calcium alginate, an un-bordered foam dressing, a thick ABD pad, and wrap it with (gauze). V4 said the purpose of the calcium alginate and foam dressing is to absorb more drainage. On 7/20/22 at 8:51 AM, V3 (Director of Nursing/DON) said nurse should follow the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . At 10:18 AM, V3 said the purpose of the weekly skin assessments are to monitor the wounds and make sure they are healing and improving. If the wound is not healing and/or improving, then the doctor should be notified. V3 said if weekly skin assessments aren't done or the incorrect treatment is in place, residents could have additional skin breakdown and it could be detrimental to the wound/resident and will possibly cause the wounds to get worse. V3 said skin assessment should be done weekly or more. V3 said the nurse are expected to notify the doctor and obtain different treatment orders if staff notice that there is a change in the wound. The facility's Skin Care Program reviewed 6/2018 shows, It is the philosophy of [facility] that all residents shall receive care which improves the circulation of movement, promotes maintenance of skin integrity, and enhances healing of any existing ulcer/wound. To provide appropriate preventative care to maintain skin integrity. Contaminated material to open areas increase potential for infection. Daily cleansing of the skin reduces the risk of pressure injury development and improves circulation. Licensed nurses assess ulcer/wound, indicating in the medical record the venue of where the ulcer was formed, provided treatment as prescribed by the physician, and provide documentation of the progression or regression of the wound/ulcer on a regular basis (at least weekly). Implement changes as directed by the facility skin care nurse, nurse practitioner and physician. All pressure injuries will be measured weekly. Documentation is to include size, color, drainage, treatment and response. These areas will be monitored until the area is healed. The physician or nurse practitioner will be notified of formation of pressure injury/wound, treatment orders received, kept updated with changes in status. The facility's Documentation and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply treatment to the wound as ordered by the physician. Apply the dressing as prescribed by the physician and tape the dressing in place.