Based on observation, record review and interview, the facility failed to ensure 1 (Resident #2) of 4 ( Resident #1, Resident #2, Resident #3, and Resident #4) sampled residents received the necessary treatment and services to prevent and promote the healing of pressure ulcers by failing to perform hand hygiene during treatment of a pressure ulcer.Findings:Review of the facility's undated policy titled Clean Dressing Change read in part.Policy: 3. Each wound will be treated individually. 7. Perform hand hygiene and put on clean gloves. 9. Loosen the tape and remove the existing dressing. 10. Remove gloves, pulling inside out over the dressing if able. Discard. 11. Perform hand hygiene and put on clean gloves. 12. Cleanse wound as ordered. 14. Perform hand hygiene and put on clean gloves. 16. Secure dressing. Review of Resident #4 's medical record revealed an admit date of 05/15/2025 with diagnoses that included: Adult Failure to Thrive, Long Term use of Antibiotics, Anxiety Disorder, Functional Quadriplegic, Encephalopathy, Methicillin Resistant Staphylococcus Aureus Infection, Contracture of the right and left shoulder, Contracture of the right and left upper arm, Contracture of right and left hand, and Cognitive Communications Deficit. Review of Resident #2's admission Minimum Data Set (MDS) with an ARD of 05/26/2025 revealed a Brief Interview for Mental Status (BIMS) score of 00 , indicating severely impaired cognition. Resident #2 was totally dependent on staff and required physical assistance for all activities of daily living.Review of Resident #2's 06/2025 Physicians Orders read in part.06/25/2025 -Clean Right Hip wound with wound cleanser of choice, pat dry, apply vashe or Dakin's solution on dampened gauze, apply barrier of choice to periwound and apply dry dressing daily.Observation of Resident #2's wound care on 08/06/2025 at 11:00 a.m. with S2 Treatment Nurse revealed during wound care to the right hip wound, S2 Treatment Nurse did not remove gloves and perform hand hygiene after removing old dressing, before or after cleaning the wound, or before applying a new dressing. Interview on 08/06/2025 at 11:10 a.m. with S2 Treatment Nurse confirmed she did not remove gloves and perform hand hygiene after removing dressing, after cleaning wound or prior to applying a new dressing, but should have. Interview on 08/06/2025 at 1:34 p.m. with S1 DON confirmed S2 Treatment Nurse had a skills checkoff on hand hygiene in 03/2025 with no issues and should have changed gloves and provided hand hygiene during wound care.

Based on observation, interview, and record review, the facility failed to ensure a resident received services in the facility with reasonable accommodation of needs for 1 (#15) of 2 (#15 and #41) sampled residents reviewed for call bell placement. The facility failed to ensure Resident #15 had a call bell in reach in order to call for assistance. Findings: A review of Facility's undated policy dated 11/27/2023 titled Call Lights: Accessibility and Timely Response, read in part . 6. The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room. Review of Resident #15's medical record revealed an admit date of 06/27/2024, with diagnoses that included Microcephaly, Cognitive Communication Deficit, and Muscle Wasting and Atrophy. Review of Resident #15's Minimum Data Set (MDS) with an ARD of 07/26/2024, revealed Resident #15 had moderately impaired decision. The MDS revealed Resident #15 required staff assistance for oral hygiene, toileting, bathing, dressing and transferring. Interview on 08/05/2024 at 7:52 a.m. with S4 LPN revealed Resident #15 was able to use the call light if she needs. Observation on 08/05/2024 at 7:52 a.m., 9:17 a.m., 12:09 p.m., and 1:31 p.m. revealed Resident #15 lying in bed with the call light on the floor next to the left hand side of the bed. Interview on 08/06/2024 at 8:45 a.m. with S5 LPN/MDS, revealed Resident #15 was able to use a call bell if she needs assistance.

Based on observation, record review and interview, the facility failed to ensure ADLs (activities of daily living) were performed for 1 (#40) of 2 (#34 & #40) residents reviewed for ADLs. The facility failed to ensure Resident #40 received nail care. Findings: Review of the medical record for Resident #40 revealed an admit date of 09/22/2023 with diagnoses that included in part .Type 2 Diabetes Mellitus, Chronic Kidney Disease, Heart Failure, and Major Depressive Disorder. Review of Resident #40's Quarterly MDS with an ARD of 05/29/2024 revealed a BIMS score of 12, which indicated moderate cognitive impairment. Review of the MDS revealed Resident #40 required supervision or touching assistance with personal hygiene. Review of Resident #40's current care plan revealed Resident #40 requires assistance for all ADLs related to general weakness and impaired cognition. Interventions included give verbal cues to help prompt, break up tasks into smaller steps. Resident requires supervision/cues for personal hygiene. An observation on 08/05/2024 at 7:15 a.m. revealed Resident #40 was noted to have multiple long fingernails to both hands. Interview with Resident #40 at that time revealed he would like his nails cut. Resident #40 stated he did not refuse to have them cut. An observation and interview on 08/06/2024 at 3:23 p.m. with S2 LPN revealed Resident #40 had long nails on both hands. S2 LPN stated Resident #40 had some nails that definitely need cutting. S2 LPN reported the treatment nurse cut the nails of the diabetic residents and nurses can, if needed. Resident #40 was asked if he wanted his nails cut and he said, Yes.

Based on observation, interview, and record review the facility failed to meet the nutritional needs of residents in accordance with established national guidelines. The facility failed to follow the menu to ensure nutritional adequacy for 3 (#15, #19, and #22) of 3 (#15, #19 and #22) residents on a pureed diet. Findings: Record review of the menu for the 08/05/2024 lunch meal for residents on a pureed diet revealed in part: Sliced Ham - #10 scoop Red Beans and [NAME] - #8 scoop Seasoned Greens - #10 scoop Cornbread - #10 scoop Fruit Crisp - #8 scoop Observations on 08/05/2024 at 10:30 a.m. of the food serving line in the kitchen, revealed S7 Dietary Assistant preparing trays on the serving line for residents #15, #19 and #22 that were on pureed diets. As the trays were prepared, they were then given to the CNAs to serve the residents. Observations revealed that seasoned greens, cornbread and fruit crisp were not being served and were not on the serving line. Interview on 08/05/2024 at 10:40 a.m. with S6 Dietary Manager, confirmed that the menu called for seasoned greens, cornbread and fruit crisp which were not served on the serving line.

Based on observation, interview and record review, the facility failed to ensure that food was properly stored, prepared, distributed and served in accordance with professional standards for food service safety. The facility failed to ensure: 1. Food was properly labeled and stored; and 2. Cooked food was maintained at or above 135 degrees Fahrenheit on the serving line. Findings: 1. Observation of the kitchen on 08/05/2024 at 6:05 a.m. with S6 Dietary Manager revealed the following: A block of cheese was partially wrapped and open to air in the walk-in cooler. The cheese closest to the opening was darker in color. A tube of ground meat was defrosting on the bottom shelf of the walk-in cooler. The tube of ground meat was partially in a shallow pan on the wire rack of the cooler shelf. The tube of ground meat was dripping blood tinged liquid onto the wire shelf and floor. A bag of frozen fish with approximately 10-12 pieces was in a Ziploc bag that did not have an expiration or use by date. An interview with S6 Dietary Manager at the time, reported that the block of cheese should have been sealed and not left open to air, the ground meat should have been defrosting over the pan, and the frozen fish should have had a use by date. Observations of the dry storage area on 08/05/2024 at approximately 6:20 a.m. with S6 Dietary Manager revealed the following: A 46 ounce canned Steen's syrup and a 20 ounce canned Pineapple sauce on the shelf that had approximately a ½ inch dent along the top seal. A large bag of open Fettuccini noodles stored on a shelf. An interview with S6 Dietary Manager at the time, reported that the canned Steen's syrup and Pineapple sauce should have been pulled from the shelf and the Fettuccini noodles should have been placed in a sealed bag. 2. Observation on 08/05/2024 at 6:40 a.m. revealed breakfast trays were being prepared and served. The pureed sausage was on the steam table in a non-heated area. S6 Dietary Manager took the temperature of the pureed sausage upon request, and revealed a temperature of 125 degrees. An interview with S6 Dietary Manager at that time reported that the sausage was not at the required holding temperature.

Based on observation and interview the facility failed to post nurse staffing information on a daily basis that included the resident census, and total number and actual hours worked by RNs, LPNs and CNA staff directly responsible for resident care per shift. The facility census was 47. Findings: Observation on 08/05/2024 at 6:03 a.m. revealed a form for daily nursing hours dated 08/01/2024- 08/12/2024 was posted on a bulletin board near the nurse's station. Daily staffing hours were not posted for 08/02/2024, 08/03/2024, 08/04/2024, and 08/05/2024. Interview with S3 RN revealed she was unsure who was responsible for completing and posting the daily nursing hours over the weekend, but that they should be posted daily. Observation on 08/05/2024 at 7:45 a.m. revealed the form for daily nursing hours dated 08/01/2024- 08/12/2024 was not updated and posted to include the required information. Interview on 08/05/2024 at 12:35 p.m. with S1 DON revealed she was responsible for updating and posting the facility's daily nursing hours. S1 DON confirmed no one had updated or posted the daily nursing hours for 08/02/2024- 08/05/2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that a resident's person-centered plan of care for the use of bright tape to her bathroom door frame was followed for 1 (#2) of 3 (#1, #2, and #3) sampled residents. The facility had a total census of 50. Findings: Review of Resident #2's clinical record revealed an admit date [DATE] with diagnoses which included in part . Unspecified Dementia, Aphasia, Dizziness and Giddiness, Drusen (degenerative) of Macula Left Eye and Other Specified Anxiety Disorders. Review of Resident #2's admission MDS with an ARD of 04/24/2024 revealed a BIMS score of 7 (indicating severely impaired cognition), and required supervision or touching assistance with transfers and toilet use. Resident #2 had no impairment of ROM to her upper or lower extremities. Review of Resident #2's care plan with a review date of 08/02/2024 revealed she had a fall in her room while attempting to ambulate to the bathroom on 06/03/2024, with interventions that included-will add bright tape to door frame. Observation on 06/06/2024 at 1:35 p.m. revealed Resident #2 sitting in the day room on the memory care unit. Observation of Resident #2's room at this time revealed no bright tape to her bathroom door frame. Interview with S1 DON on 06/06/2024 at 1:55 p.m. revealed she was aware of Resident #2 not having bright tape to her bathroom door frame as indicated in her person- centered plan of care. S1 DON stated she had ordered the bright red tape, but it had not arrived. S1 DON confirmed no other fall prevention measures had been implemented for Resident #2.

Based on observation, interview, and record review, the facility failed to ensure that residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene. The facility failed to provide oral care and nail care to dependent residents for 2 (Resident #1 and Resident #2) of 3 (Resident #1, Resident #2, and Resident #3) residents sampled for ADL's. Findings: Review of the Facility's policy/procedure titled Activities of Daily Living (ADLs) read in part: The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. 1. Bathing, dressing, grooming and oral care. Policy Explanation and Compliance Guidelines: 3. A residence who is unable to carry out ADL will receive necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review of the Facility's policy/procedure titled Oral Care read in part: It is the practice of this facility to provide oral care to residents in order to prevent and control plaque-associated oral diseases. 3. Use tongue depressor and penlight to assess the integrity of the resident's mouth (lips, teeth, mucosa, gums, palate and tongue). Review of the Facility's policy/procedure titled Nail Care read in part: The purpose of this procedure is to provide guidelines for the provision of care to resident's nails for good grooming and health. 3. Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. 4. Routine nail care, to include trimming and filing, will be provided on a regular schedule. Nail care will be provided between schedule occasions as the need arises. 6. a. Nails should be kept smooth to avoid skin injury. #1 Review of Resident #1's EHR (Electronic Health Record) revealed an admission date of 10/17/2019, diagnosis included Alzheimer's disease, Major Depressive Disorder, and Benign Prostatic Hyperplasia. Review of Resident #1's 02/2024 physician orders revealed he was admitted to Hospice care on 02/15/2024 for Alzheimer's and was NPO. Review of Resident #1's Care Plan with a target date of 03/06/2024 revealed Resident #1 required extensive to total assistance of 1-2 staff members for all areas of ADLs. Review of Resident #1's Quarterly MDS with an ARD of 11/22/2023 revealed no BIMS score (resident is rarely or never understood). Resident #1's functional status revealed he required extensive assistance one-two person physical assistance with all ADLS. Review of the physician progress notes on 02/24/2024 by S3 NP revealed an on-site visit of Resident #1. The notes read in part: CC: thrush. Resident noted with a thick white coat to his tongue. Dx. - Candidiasis (Thrush) with Nystatin oral 100,000 IU -swab 5 ml. to oral cavity qid x 10 days. Review of Resident #1's detailed care by CNAs revealed: 02/15/2024- oral care at 8:50 p.m. 02/16/2024- no documentation of oral care or bath. 02/17/2024- oral care at 5:05 p.m. 02/17/2024- no documentation of a bath. 02/18/2024- oral care at 3:11 p.m. and 9:04 p.m. 02/18/2024- no documentation of a bath 02/19/2024- no documentation of oral care. 02/19/2024- bed bath at 6:08 p.m. 02/20/2024- oral care at 2:00 p.m. and 8:14 p.m. 02/20/2024- bed bath at 8:14 p.m. Observation on 02/19/2024 at 11:00 a.m. revealed Resident #1 was positioned in bed on his back with his mouth open, tongue shifted to right side near his bottom lip, tongue with thick white coating, lips dry and cracking with strings of skin peeling from his bottom lip. Observation on 02/19/2024 at 2:45 p.m. revealed Resident #1 positioned on his right side with his bottom lip folded inside of his mouth. The top lip and corner of mouth was noted to be dry with white substance noted. Observation on 02/20/2024 at 8:25 a.m. revealed Resident #1 positioned in bed on his left side, tongue still with a thick white coating slightly protruding out of the right side of mouth, and lips dry and cracking with strings of skin peeling from his bottom lip. Observation on 02/20/2024 at 10:20 a.m. of Resident #1 accompanied by S2 ADON was positioned in bed on his back, still with dry cracked lips and a thick white coating on his tongue. S2 ADON stated Resident #1's mouth looks better than it did whenever he returned from the hospital (02/15/2024). S2 ADON stated his lips were not dry because his face was not dry and the white crust on his tongue would not come off and maybe the resident did have thrush. S2 ADON stated she was not certain about the resident's tongue so she would have S3 NP exam Resident #1. Observation on 02/20/2024 at 10:30 a.m. of Resident #1 accompanied by S3 NP revealed Resident #1 still with dry cracked lips and a thick white coating on his tongue. S3 NP performed oral care on Resident after examination of his lips and mouth. S3 NP performed oral care on Resident #1 using a moist oral swab to scrub and clean the tongue and gums, lemon glycerin swab and applied lip ointment (pomegranate). There was a foul odor coming from Resident #1's mouth as S3 NP performed oral care. S3 NP confirmed that Resident #1 Candidiasis (thrush), and lips were dry, and cracking. S3 NP confirmed that Resident # 1was in need of oral care. S3 NP stated she would order Nystatin qid for 10 days. #2 Review of Resident #2's EHR revealed an admission date of 12/16/2018, diagnosis included Anorexia, Essential (primary) HTN, Osteoarthritis bilateral knee, and Hemiplegia Subarachnoid hemorrhage. Review of Resident #2's Care Plan with a target date of 04/24/2024 revealed the resident required extensive to total assist with dressing, toileting, and personal hygiene. Review of Resident #2's Quarterly MDS with an ARD of 01/10/2024 revealed a BIMS of 3 (severely impaired cognition). Resident #2 required substantial/maximal assistance with oral care, upper/lower body dressing, and personal hygiene Observation on 02/19/2024 at 9:30 a.m. revealed Resident #2 in wheelchair in the dining area, fingernails on right hand untrimmed with dark substance underneath the nailbeds. Resident #2's left hand was contracted, fingernails cleaned but untrimmed. Interview with Resident #2 at the time of the observation, revealed she raised her right hand up, looking at her fingernails. When ask the resident if her fingernails were dirty and needed to be clean and cut, she looked at her nails and stated yes they are dirty and are long. Observation on 02/19/2024 at 11:00 a.m. revealed Resident #2 sitting in the dining room eating lunch. Resident #2's fingernails on right hand were still untrimmed with dark substance underneath the nailbeds and fingernails on left hand untrimmed. Observation on 02/19/2024 at 12:15 p.m. revealed Resident #2 in her wheelchair near the dining room entrance. Resident #2's fingernails on right hand still untrimmed with dark substance underneath the nailbeds and fingernails on left hand untrimmed. Observation of Resident #2 on 02/19/2024 at 2:10 p.m. in her wheelchair propelling self near the dining room. Resident #2's fingernails on right hand still untrimmed with dark substance underneath the nailbeds and fingernails on left hand untrimmed. Observation of Resident #2 on 02/20/2024 at 8:15 a.m. in her wheelchair near dining room entrance. Resident #2's fingernails on right hand still untrimmed with dark substance underneath the nailbeds and fingernails on left hand untrimmed. Interview on 02/20/2024 with S1 DON after inspection of Resident #2's fingernails, confirmed Resident #2's fingernails needed to be cleaned, filed and trimmed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety by failing to: 1) ensure cooking equipment was cleaned after each use, 2) ensure food preparation equipment was cleaned after each use, 3) ensure spices and seasonings containers were placed on the shelf in a sanitary condition, and 4) ensure spices and seasonings stored on the shelf were not expired and were labeled and dated properly. This deficient practice had the potential to affect the 48 residents that received meals prepared in the facility's kitchen. Findings: Review of the facility's Policy and Procedure title Cleaning Instructions Cleaning Ranges read in part: Policy: The cook on each shift is responsible for keeping the range as clean as possible during the preparation of the meal. The range will be cleaned after each use. Spills and food particles will be wiped up as they occur. Review of the facility's Policy and Procedure title Cleaning Instructions Cleaning Toaster read in part: Policy: Toaster will be cleaned after each use. Review of the facility's Policy and Procedure title Cleaning Instructions Cleaning Food Preparation Appliances read in part: Policy: Small appliances and food appliances (such as mixers, and food processors) will be cleaned and sanitized after each use. Review of the facility's Policy and Procedure title Cleaning Dishes Manual dishwashing read in part: Policy: Dishes and cookware will be washed and sanitized after each meal to assure that all dishes are cleaned and sanitary. Review of the facility's Policy and Procedure title Care of the storeroom read in part: Procedure 6. Foods with expiration dates are used prior to the date on the package. Canned and dry foods without expiration dates are used within six months of delivery. Observation of the kitchen on 08/07/2023 at 10:00 a.m. revealed: 2-large side by side ovens with large amount of black substance covering the entire bottom panel, removable wired rack with large amount of caked-on gel-like dark brown drippings. Convection oven- blower located on the back panel with a buildup of thick layers of grayish substance with flexible extended coils covered with dust particles. Rice cooker stored on the counter top with a filmy white substance around the rim, dried white substance inside. Food processor with long strand of black hair, covered with greasy film- S2 Dietary Manager not certain when it was last cleaned and was last used this morning. Toaster- large amount of black crumbs on the crumb plate. Microwave inside top surface with covered with large amount of brown, yellowish and orange color substance, and bottom panel with spattered yellow and brown substance. Mixer/bread kneading was covered with a plastic bag was noted to have a large amount dried white substance inside of the blade. 3-12 cup cupcakes baking pan stacked on top of one another with large brown clumpy cake-like substance, greasy film (dark brown on the bottom surface). 6-24 cupcakes baking pan stacked on top of one another with large amount of dark brown greasy pasty gel-like substance around the bottom and inside of the pans. 6 large pot lids located on the floor between the wall and stationary storage/sink area- dusty, greasy film. 2 large deep serving pans with dried brown/black thick greasy film around the bottom rim and inner surface. 2 small deep serving pans with dried white substance in the bottom of the pan and one with greasy film in the inner surface and outer. 12 quart size pot with dried white substance in the inside. Medium stainless steel colander with dried green substance on the side and in holes in the center. Large stainless steel colander with white flaky substance in the holes. Stationary floor mounted stainless steel table with sink insertion was noted to have an 8 pack hamburger buns opened and not secured with a wrapper, fastener or tied closed with 6 buns remaining with a used by date of 08/05/2023. The following seasonings and spices were located on a shelf above a floor mounted stationary stainless steel table were noted to have yellow labels with the following dates and use by date: 2 - 16 ounces ground all spice- 12/06/2017 use by 12/06/2020 25 ounces cream of tartar- 12/04/2013- use by 12/04/2016 14 ounces ground cumin - 10/30/2019- use by 10/30/2022 14 ounces bay leaves- 10/02/2013- use by 10/02/2016 The following seasonings and spices were located on a shelf above a floor mounted stationary stainless steel table were noted with illegible yellow label (unable to read the date) faded with no use by readable date, was on the shelf opened and available for use: 14 ounces ground cumin 2 ounces ground black pepper 24 ounces rotisserie chicken seasoning 24 ounces ground thyme 12 ounces ground oregano 12 ounces ground thyme 2- 12 ounces ground sage 28 ounces lemon pepper seasoning. There was a total of 33 plastic containers of spices and seasonings on the shelf which were all opened with greasy film, caked substance, drippings on the outside of the bottles and or tops. Refrigerator in dry storage area was noted to have 4 bags of expired hot dogs - 1- 07/15/2023, 2 - 07/22/2023, and 1-07/26/2023. During the observation some of the following items were on the counter top below the above seasonings and spices, were opened/dated in black with yellow labels: 28 ounces jiff peanut butter, 16 ounces iodized salt, 16 ounces seafood/crab boil, 8 pound plastic container of [NAME] Chachere's creole seasoning, 6.5 pound plastic container of granulated garlic, 128 ounces browning season sauce, and 128 ounces of parsley flakes were opened and dated. Interview on 08/07/2023 at 12:10 p.m. with S2 Dietary Manager confirmed all of the above findings at the time of the observation. S2 Dietary Manager stated the food purchasing company provides the facility with yellow labels which includes the date of delivery. S2 Dietary Manager stated a label is placed on each item and no date is placed on the item(s) once it is opened. S2 Dietary Manager stated the yellow stickers that the yellow label provided by the purchaser with the date of delivery is the date that is used as the date of opening the item(s). S2 Dietary Manager stated the items are used until the expired date according to the stamped date on the item. S2 Dietary Manager stated she had no explanation as of why there were outdated, faded unreadable, and/or no legible use by date containers of spices and seasonings opened and available on the shelf for use. S2 Dietary Manager confirmed that she also had no explanation as of why some of the items had yellow labels but were still marked in black with a date. S2 Dietary Manager confirmed the date marked in black was the date the item(s) was opened. S2 Dietary Manager confirmed that all of the food preparation equipment, cookware, and seasonings/spices were all in unsanitary condition. S2 Dietary Manager confirmed that all seasoning and spices should be checked by dietary staff for use by date before being used for food preparation. Interview on 08/09/2023 at 1:30 p.m. with S1Administrator revealed the dietary department uses yellow labels provided by the food purchasing company. S1 Administrator stated the yellow sticker implies the receiving date not necessarily the opening date. S1 Administrator stated the facility had no system in place as it relates to opening (dated) of food items such as seasoning, spices and other food favoring items. S1 Administrator stated the facility uses the manufacturer use by date as a guide for usage. When surveyor asked about items which were dated in black, S1 Administrator stated she was not certain about that and was unable to answer that question. S1 Administrator stated she would have to refer back to S2 Dietary Manager. S1 Administrator invited to surveyor to accompany her to the Dietary Department. S2 Dietary Manager confirmed that some of the food items were improperly labeled as evidenced by presenting the ones identified by the surveyor (during kitchen tour) for inspection by S1 Administrator. S1 Administrator confirmed that the using of the yellow labels by the food purchasing company was not effective and something else would have to be devised through the Facility's Quality Assurance Program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the Facility failed to ensure the orders for Advance Directives accurately reflected the preference; choice of the resident; or responsible party for 1 (Resident #46) of 2 (#42 and #46) sampled residents for advance directives. Findings: Review of the Facility's Advance Directives policy revealed in part . Information about whether or not the resident has executed an Advance Directive will be displayed in resident's medical record. Review of Resident #46's Face sheet revealed an admission date of [DATE] and a re-admission date of [DATE] with diagnoses that included Hypoglycemia, unspecified, Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, Hypertensive Heart Disease with Heart Failure and Cerebrovascular Disease. Further review of Resident #46's Face Sheet revealed additional information of Advance Directives status Full Code. Review of Resident #46's LAPOST dated [DATE] revealed to attempt CPR with Full Treatment of medical interventions, long term artificial nutrition if needed and the basis for these orders is patient's declaration. Review of Resident #46's Living Will dated [DATE] revealed to perform Cardiopulmonary Resuscitation. Review of Resident #46's Physician's Orders for [DATE] revealed an order dated [DATE] with information of Advance Directive Status: Living Will/ LAPOST (effective [DATE]) Do Not Resuscitate. Further review of Resident #46's Physician's Orders dated [DATE] signed by S2 ADON. Review of Resident #46's Annual MDS with an ARD of [DATE] revealed a BIMS score of 13 indicative of intact cognition. Review of Resident #46's Care Plan with target date of [DATE] revealed a goal to make her decisions for my end of life care known. Interventions with a start date of [DATE] revealed in part . to receive CPR, clinical chart updated and SSD to review/ initiate LAPOST/ Living Will with me and my family/ representative to determine my wishes regarding my end of life care in the event I have a terminal condition and the attending physician determines it to be irreversible or incurable, and death is imminent. Interview on [DATE] at 09:14 a.m. with S17 [NAME] Clerk revealed she was responsible for placing the Physician's Orders on the resident's charts every month. She stated the resident's Physician's Orders are reviewed and signed either by S12 DON or S2 ADON and then given to her to be placed on the resident's medical charts. Interview on [DATE] at 11:34 a.m. with S3 LPN revealed the green dot located on the outside of Resident #46's medical chart meant the resident is a Full Code and to do CPR. S3 LPN further revealed Resident #46's LAPOST and Living Will both stated resident had a Full Code status. S3 LPN verified the code status on Resident #46's Physician's Orders for [DATE] stated to Do Not Resuscitate. S3 LPN further confirmed the DNR status noted on the Physician's orders for [DATE] was incorrect and should have stated to do CPR instead. Interview on [DATE] at 11:39 a.m. with S2 ADON confirmed Resident #46's LAPOST and Living Will stated to perform CPR. S2 ADON stated either she or the DON reviewed and manually signed all Physicians Orders monthly before putting on the charts. S2 ADON further confirmed her signature on Resident #46's Physician's Orders dated [DATE]. S2 ADON confirmed the Advance Directives noted on the Physician's Orders was incorrect and should have stated Full Code instead of DNR. Interview on [DATE] at 11:45 a.m. with S7 SSD confirmed Resident #46's Advance Directives status noted on the Physician's Orders for [DATE] was incorrect and should have stated Full Code instead of DNR. S7 SSD stated it was an oversight with the printing of the Physician's Orders.

Based on observations, interviews and record reviews, the facility failed to provide the necessary care and services to ensure and maintain good hygiene and grooming for 2 Residents (#5, and #37) of 31 sampled Residents. Findings: Review of the Facility's P/P titled Nail Care read in part: The purpose of this procedure is to provide guidelines for the provision of care to a Resident's nails for good grooming and health. 1. Assessment of Resident nails will be conducted on admission and readmission to determine the Resident's nail condition, needs, and preferences for nail care, if possible. 3. Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. 5. Residents without complicating disease processes may have their nails clipped and cleaned by appropriate nursing staff. Resident #5 Review of Resident #5's EHR revealed an admission date of 04/03/2017 with admitting Diagnoses of Essential (Primary) Hypertension, Hyperlipidemia, Peripheral Vascular Disease, Anxiety Disorder, Unspecified Dementia with Behavioral Disturbance, and Alzheimer's disease. Review of Resident #5's Care Plan revealed Resident #5 had self-care deficits related to ADLs and required total assistance with all ADLs. The Care Plan further revealed that Resident #5 had difficulty expressing herself so staff must anticipate her needs and provide care accordingly. Review of Resident #5's MDS Quarterly Assessment with ARD of 05/18/2022 revealed a BIMS of 99 (severely impaired). Resident #5's functional status revealed she required maximum assistance for transferring, shower/bathing, toileting and dressing. Observation on 08/15/2022 at 10:12 a.m. and 2:50 p.m. revealed Resident #5 lying in bed, her nails were noted to be untrimmed with dark black substance underneath her nails. Interview on 08/15/2022 at 3:00 p.m., S8 RN/IP confirmed after observation of Resident #5's nails, they were dirty and needed to be cleaned and trimmed. She further stated the CNAs are responsible for non-diabetic Resident(s) nail care and Resident #5's nails should have been cleaned and trimmed at the time of her bath by the CNAs. Resident #37 Review of Resident #37's EHR revealed an admission date of 07/02/2010 with admitting Diagnoses of CVA , Anemia, Alcohol Dependence, Polyosteoarthiritis, Cerebral Ischemia, and Hereditary and Idiopathic Neuropathy, GERD, Essential (Primary) Hypertension, and, Epilepsy. Review of the Care Plan revealed Resident #37 had a Diagnosis of CVA with Hemiplegia and required maximum assistance with all ADLs. Review of Resident #37's MDS Annual Assessment with ARD of 07/27/2022 revealed a BIMS of 15 (cognition intact). Resident #37's functional status revealed he required maximum assistance with transferring, and all of his ADLs. Observation on 08/15/2022 at 10:35 a.m. and 3:10 p.m. of Resident #37 lying in bed revealed a salt and pepper beard with thick long unkempt hair, and a salt and pepper thick unkempt mustache. Interview with Resident #37 at the time of the observation revealed that he was unable to shave himself and he required total assistance from the staff to shave him. He stated he was unable to recall the last time that he was shaved and he needed and wanted to be shaved. Interview on 08/15/2022 at 3:15 p.m., S8 RN/IP confirmed after observation of Resident #37's beard and mustache confirmed that he needed to be shaved. She further stated that the CNAs should have shaved Resident #37 during bath time and didn't.

Based on observation, record review and interview, the facility failed to ensure 1 (Resident #7) of 1 (#7) residents, who were incontinent and required indwelling catheterization, received appropriate treatment to prevent urinary tract infections. Findings: Observation on 08/15/22 at 09:17 a.m. revealed Resident #7 awake in bed. Resident #7's indwelling Foley catheter drainage bag was observed on the floor next to the resident's bed. Observation on 08/16/2022 at 8:20 a.m. revealed Resident #7 asleep in bed. Resident #7's Foley catheter drainage bag was observed on the floor next to the resident's bed. Review of Resident #7's Electronic Health Record revealed an admit date of 11/18/2021 with diagnoses including: Hemiplegia following Cerebral Infarct, Gastrostomy, Retention of Urine, Aphasia following Cerebral Infarct, Dysphagia following Cerebral Infarct, and Muscle Wasting. Review of Resident #7's Quarterly MDS with an ARD of 05/25/2022 revealed the resident required the extensive assistance of 1 person for transfers and had an indwelling catheter. Review of the CPOC for Resident #7 revealed in part . Urinary Catheter: Indwelling Foley catheter r/t Urinary Retention. I will have no injuries r/t catheter; I will have no s/s of infection through next quarter. Review of the clinical record revealed Resident #7 had been treated for a diagnosis of UTI on 02/28/2022 through 03/07/2022 with Cefdinir 300mg capsule per peg tube BID x 7 days. Review of the clinical record revealed Resident #7 had been treated for a diagnosis of UTI on 05/23/2022 through 05/30/2022 with Cipro 500mg tablet per peg BID x 7 days. Observation on 08/16/2022 at 8:53 a.m. accompanied by S5 LPN revealed Resident #7's Foley catheter drainage bag on the floor next to the resident's bed. Findings confirmed with S5 LPN at time of observation. S5 LPN stated that Resident #7's Foley catheter drainage bag should have been hooked to the bedframe when he was assisted to bed after breakfast and had not been.

Based on observation, record review and interview, the facility failed to ensure that expired medications/ biologicals were not available for use/ administration to Residents. Findings: Review of the facility's Medication Storage policy revealed in part: 4. Medication rooms are routinely inspected by the consultant pharmacist and nursing staff for discontinued, outdated, defective, or deteriorated medications . These medications are destroyed in appropriate manner. Observation on 08/17/2022 at 10:30 a.m. of the facility's medication storage refrigerator accompanied by S4 LPN revealed it contained the following on a shelf for use: 1 Ziploc bag containing (6) Acetaminophen 650mg suppositories with an expiration date of 05/2022 and 1 Ziploc bag containing (8) Acetaminophen suppositories with an expiration date of 07/2022. Interview with S4 LPN at the time of the observation confirmed the Acetaminophen suppositories were expired and were available for administration to Residents. She further stated that the suppositories should have been disposed of and had not been. Interview on 08/17/2022 at 11:00 a.m. with S2 ADON revealed that it was the responsibility of the nurses and the Pharmacist to check for expired an outdated medications. She further confirmed that the expired medications were available for Resident use and should have been disposed of.

Based on observation and interview, the Facility failed to ensure garbage was disposed of properly. The total facility census was 47 Residents. Findings: Observation on 08/15/2022 at 8:33 a.m. of the Facility's trash receptacles accompanied by S6 DM revealed two large dumpsters. The dumpster located on the right side was noted with the lid open. Observation at this time revealed two deflated mattresses folded in half on the ground close to the back kitchen door. Further observation revealed multiple dirty blue gloves on the ground surrounding the dumpsters. Interview at this time with S6 DM stated the housekeepers brought the mattresses out this past Friday, 08/12/2022 to the dumpsters. S6 DM confirmed the two mattresses and the gloves should not have been on the ground surrounding the dumpsters. She further confirmed that the lid to the dumpster on the right should have been closed and had not been closed. Interview on 08/16/2022 at 08:20 a.m. with S11 HSK SUP stated the mattresses were thrown out Friday, 08/12/2022. She stated the two mattresses were placed on the ground because the dumpsters were full. She stated the garbage truck came Friday to empty the dumpsters but did not pick up any trash outside of the dumpsters.

Based on interview and record review, the facility failed to follow infection control practices to prevent the development and transmission of COVID-19. The facility failed to: 1. Develop a policy for ensuring all staff, except for staff who have pending or granted qualifying exemptions to the vaccination requirements, or staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC (Centers for Disease Control and Prevention), due to clinical precautions and considerations, have received, at a minimum, one dose of the COVID-19 vaccine prior to providing care/treatment/services for the facility and/or its residents. 2. Ensure 2 (S9 CNA and S10 HSK) of 69 staff received, at a minimum, one dose of the COVID-19 vaccine or obtained a qualifying exemption prior to providing care or services to residents resulting in a staff vaccination rate of less than 100 percent. Findings: Review of the facility's policy titled Employee COVID-19 Vaccinations revealed in part . 5. New hires who are unvaccinated will receive their first shot within 1 month in which time TB will be completed. During this time, they will wear a KN95 or higher facemask with all patient care, comply with PCR COVID-19 tests (twice weekly). Review of a CDC document titled TB Tests and mRNA COVID-19 vaccines dated 01/07/2021 revealed in part . There are no data to inform the impact of the COVID-19 mRNA vaccines on either the tuberculin skin test (TST) or the interferon release assay (IGRA). There is no immunologic reason to believe that a TST or blood draw for IGRA will impact the effectiveness of COVID-19 mRNA vaccines. Review of a CDC document titled COVID mRNA, TST, and IGRA - Follow-up dated 08/31/2021 revealed in part . COVID-19 vaccination should not be delayed because of testing for TB infection. Testing for TB infection with one of the immune-based methods, either tuberculin skin test (TST) or an interferon release assay (IGRA), can be done before, after, or during the same encounter as COVID-19 vaccination. Review of the facility's Staff Vaccination Matrix revealed the facility had a total of 69 staff members. Further review revealed 42 of the 69 staff members had been fully vaccinated, and 24 staff members had qualifying exemptions. Two (S10 HSK and S14 CNA) staff members were listed as temporarily delayed. One (S9 CNA) staff member was listed as having a pending exemption. Interview on 08/15/2022 at 10:02 a.m. with S8 RN/IP revealed S14 CNA had a medical condition and was in the process of getting clearance from her doctor for the second dose of the COVID-19 vaccine. Further interview with S8 RN/IP revealed S10 HSK was newly hired and was scheduled to get her first dose of the vaccine 08/16/2022. S8 RN/IP also stated S9 CNA had filled out an exemption request. Interview on 08/15/2022 at 10:10 a.m. with S10 HSK revealed she started working at the facility last month. S10 HSK reported she did housekeeping and laundry. S10 HSK further stated when she worked housekeeping she went into the residents' rooms to clean. S10 HSK stated she never requested an exemption for the COVID-19 vaccine nor had she received any doses of the vaccine. Interview on 08/15/2022 at 11:00 a.m. with S8 RN/IP revealed S10 HSK was hired on 07/26/2022. Review of S10 HSK's time sheet revealed she had worked 14 days since hire. Interview on 08/15/2022 at 1:40 p.m. with S8 RN/IP revealed S9 CNA's date of hire was 06/28/2022. Review of S9 CNA's time sheet revealed she had worked 39 days since hire. Interview on 08/15/2022 at 1:31 p.m. with S8 RN/IP revealed newly hired staff had four weeks to turn in an exemption request. S8 RN/IP further stated new employees had a month to receive the COVID-19 vaccine due to the facility's two step TB test. S8 RN/IP stated they were not sure of the effect of doing them at the same time. Interview on 08/15/2022 at 1:55 p.m. with S1 Administrator and S8 RN/IP revealed they did not have an exemption request on file from S9 CNA. S8 RN/IP reported S9 CNA had turned an exemption request in a while ago but S9 CNA had filled the request out incorrectly. S8 RN/IP reported she reeducated S9 CNA on filling out the exemption form and she was to return it. S1 Administrator stated S9 CNA's exemption request was due on 07/26/2022. S1 Administrator confirmed S9 CNA did not have a qualifying exemption nor had she received any doses of the COVID-19 vaccine. Interview on 08/16/2022 at 11:58 a.m. with S8 RN/IP revealed she and S12 DON wrote the staff vaccination policy together. S8 RN/IP reported new hires were a temporary delay from the CDC because they were receiving the two step TB test. S8 RN/IP reported she saw documentation from the CDC regarding giving the COVID-19 vaccine at the same as the TB test which is why the policy was written for new hires to be vaccinated in one month. Interview on 08/16/2022 at 2:25 p.m. with S8 RN/IP revealed she based the facility staff vaccination policy on the CDC guidance dated 01/07/2021. S8 RN/IP stated she was not aware the CDC had updated the guidance on 08/31/2021 until today. When asked who was responsible for checking for updates, S8 RN/IP stated there was no way for her to be notified of updated CDC information. Further interview revealed the facility's policy had been reviewed/revised on 02/01/2022. S8 RN/IP confirmed that updated information from the CDC had not been used for the policy revisions made on 02/01/2022. S8 RN/IP confirmed the facility's Employee Vaccination policy did not meet the requirements for staff vaccinations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure 1 of 1 sampled residents (Resident #39), reviewed for pressure ulcers, and at risk for pressure sore development, received the necessary treatment and services to prevent and promote the healing of pressure ulcers. The total sample was 31 residents. The Facility failed to: 1. Timely identify/assess a new pressure ulcer to Resident #39's right heel and an open excoriation to right buttocks; 2. Implement treatment timely for newly identified unstageable PU to Resident #39's left heel, stage 2 to left great toe, and stage 2 to the top of left foot; 3. Follow Physician's orders for treatment to an unstageable PU to Resident #39's left heel, stage 2 to left great toe, and stage 2 to the top of left foot; 4. Follow policy and procedures for wound treatment/assessment; 5. Implement infection control practices during treatment of a pressure ulcer; and 6. Follow care plan interventions for pressure ulcers. Findings: Review of the facility's policy and procedure titled Documentation of Wound Treatments revealed in part . wound assessments are documented upon admission, weekly, and as needed if the resident or wound deteriorates. The following elements are documented as part of a complete wound assessment: type of wound, stage of wound, measurements and description of the wound characteristics. Review of Resident #39's Face Sheet revealed she was admitted to the facility on [DATE]. Resident #39's diagnoses included: Osteoporosis, Post Polio Syndrome, Paraplegia and Fracture of Femur, Tibia and Fibula prior to admission. Review of Resident #39's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 9 (indicating moderate cognitive impairment). The MDS revealed Resident #39 required extensive 2+person physical assistance for bed mobility and dressing, totally dependent upon staff for transfers, toilet use and hygiene, and had ROM impairment to lower extremities both sides. The MDS revealed Resident #39 had one Unstageable Pressure Ulcer and two Stage 2 Pressure Ulcers. Review of Resident #39's care plan with a start date of 06/02/2022 revealed the resident was at high risk for the development of Pressure Ulcers related to immobility and incontinence. The care plan goal was for the resident to remain free of skin breakdown through the next quarter. One of the interventions included in the care plan was to float the resident's heels off the bed. Review of a revised care plan with a start date of 07/08/2022 revealed the resident returned from a hospitalization with an Unstageable Pressure Ulcer to her left heel, a Stage 2 Pressure Ulcer to the dorsal side of her left great toe and a Stage 2 Pressure Ulcer to the top of her left foot. New interventions included provide treatments to areas as ordered until resolved, adjust treatment per protocol, monitor for signs and symptoms of infection and notify the Physician as indicated. Review of Resident #39's medical record revealed a Transfer Form dated 07/01/2022, that revealed Resident #39 was sent to the hospital, and that Resident #39's skin was intact. Resident #39's medical record revealed she was hospitalized from [DATE] - 07/08/2022 with diagnoses that included UTI and AKI. Review of a Discharge Summary from the hospital dated 07/08/2022 revealed there was no documentation Resident #39 had any Pressure Ulcers. There was no documentation in the medical records from the hospital stay that Resident #39 received any treatments to any Pressure Ulcers during her hospital stay from 07/01/2022 - 07/08/2022. Review of a Nurses' Note for Resident #39 dated 07/08/2022 at 5:33 p.m., documented by S3 LPN read that Resident #39 returned from the hospital. The Nurses' Note revealed a skin assessment was documented as follows: Right foot bruise 4 X 5, R top foot 1st and 2nd toe abrasion, 4th toe and 2nd joint at 1 X 5.5 Dorsal Left foot 3.7 X 2 to great toe joint, 2.8 X 2.8, left heel necrotic 6.5 X 4, left foot bruising 3 joint dorsal 5th toe. Review of Resident #39's medical record revealed 3 Wound Assessment Reports were documented by S12 DON on 07/08/2022, and read as follows: 1. Left Heel - The assessment revealed the wound was an Unstageable pressure ulcer due to slough/eschar. There was no drainage; however, the surrounding skin was red and indurated. The area measured 6.5 cm in length, 4.0 cm in width and 0.1 cm in depth. S13 FNP was notified. Under the Treatments section of the form was documented Pending treatment orders. 2. Left Great Toe - Stage 2 to the Dorsal left great toe, proximal phalangeal/metatarsal, that measured 2.8 cm in length, 2.8 cm in width and 0 cm in depth. S13 FNP was notified, and under the Treatments section of the form was documented Pending treatment orders. 3. Top of Left Foot - Stage 2 to the top of left foot, mid-foot area which measured 3.7 cm in length, 2.0 cm in width and 0 cm in depth. S13 FNP was notified, and under the Treatments section of the form was documented Pending treatment orders. Review of the Wound Assessment Report and the Nurses' Notes revealed there were no other documented assessments or measurements per policy, of Resident #39's wounds until 07/22/2022. Review of Resident #39's Physician's Orders revealed a telephone orders were received on 07/10/2022 and documented by S3 LPN revealed the following: 1. Monitor bruising under right foot until healed, and then discontinue. Clean necrotic tissue to left heel with Normal Saline, pat dry, paint with Betadine, apply border dressing to protect area every 3 days until healed, and then discontinue. 2. Clean abrasions times 2 to top of left foot with Normal Saline, pat dry, paint with Betadine, apply border dressing to protect area every 3 days until healed, and then discontinue. Further review of Resident #39's 08/2022 Physician's Orders revealed an order with a start date of 06/12/2022 to apply moisture barrier to buttocks area every shift until healed. Review of Resident #39's EMAR dated 07/2022 revealed the treatment orders on 07/10/2022 to the left heel and top of left foot were not started until 07/11/2022. There was no documentation on the EMAR, or in the Nurses Notes that any treatment was provided to the necrotic area to Resident #39's left heel, or the two Stage 2 pressure ulcers to the top of the left foot until 07/11/2022. Further review of Resident #39's EMARs dated 07/2022 and 08/2022 revealed the Physician's Orders to clean the Unstageable area to Resident #39's left heel and the two Stage 2 areas to the left top of the foot were not documented as done on 07/23/2022 or 08/13/2022. Review of Resident #39's ETAR revealed moisture barrier was not documented as being applied every shift as ordered on 07/23/2022 or 07/24/2022. Review of Resident #39's Progress Notes from the Podiatrist dated 07/26/2022 at 10:45 a.m. revealed the resident had severe vascular disease with multiple Unstageable pressure ulcers of the left foot. The right foot is free of open lesions. There is an Unstageable dry gangrenous pressure ulcer on the posterior heel with well adhered dry eschar. There is no drainage, malodor or signs of acute infection. The Assessment/plan- PVD with Gangrene - continue offloading of heels while in bed and continue treatment orders with Betadine. Review of Resident #39's weekly Head to Toe Skin Assessments revealed the last documented assessment was dated 08/09/2022 by S2 ADON, and revealed no new skin issues at that time - existing issues only. Observation on 08/15/2022 10:05 a.m. revealed Resident #39 was lying in bed with a bandage noted to the left heel. The bandage was dated 08/10/2022. Resident #39's left and right heels were resting on pillows in her bed and not floated. There were two Stage 2 Pressure Ulcers to the top of the Resident #39's left foot that were not covered with a dressing. Observation on 08/15/2022 at 12:00 p.m. revealed Resident #39 was eating lunch in her room. Resident #39's heels were noted to be resting on pillows in her bed and not floated. There was no dressing on the top of the Resident's left foot, exposing the two Stage 2 Pressure Ulcers. During an interview with Resident #39 at that time, surveyor asked if she had any issues with her heels being floated, and she stated she did not mind if her heels were floated. Observation with S3 LPN on 08/15/2022 at 3:00 p.m. revealed the following: Resident #39 was lying in bed with both her heels resting on pillows in her bed and not floated. S3 LPN went in the room to perform treatments to Resident #39's pressure ulcers. At that time, S3 LPN confirmed there was a bandage to Resident #39's left heel dated 08/10/2022 with initials on the bandage as well. S3 LPN stated those were her initials from when she last changed the bandage on 08/10/2022. Interview with S3 LPN revealed she stated the Physician's Orders were to change the bandage every 3 days. S3 LPN picked up Resident #39's left heel off the pillow it had been resting on, removed the bandage dated 08/10/2022 and placed her heel, uncovered, back on the pillow without providing a protective barrier for the pillow. The area to the left heel covered the entire heel and was necrotic. S3 LPN cleaned Resident #39's left heel with Normal Saline and placed her heel back on the same pillow while she retrieved the Betadine. S3 LPN picked up Resident #39's heel, wiped it with Betadine and placed her heel back on the pillow while she retrieved a bandage. S3 LPN then picked up Resident #39's heel from the pillow, applied the bandage and placed her heel back on the pillow. Resident #39 grimaced as the treatment was being completed. Resident #39 stated she was ready for it to be over as it was painful to have staff move her foot and leg. Interview with S3 LPN on 08/15/2022 upon completion of Resident #39's treatment revealed Resident #39 did not have any open areas to her right heel or her buttocks. Resident #39's heels were both resting on pillows at that time. Observation on 08/16/2022 at 8:30 a.m. revealed Resident #39 was awake in her bed. Resident #39's left heel remained covered with a bandage dated 08/15/2022; however, her heel was resting on the mattress of her bed and not floated. Resident #39's right heel was also resting on a pillow and not floated. Telephone interview with S4 LPN on 08/16/2022 at 8:50 a.m. revealed she worked the day shift on 08/13/2022 with Resident #39. S4 LPN stated she did not change the bandage to Resident #39's left heel on 08/13/2022, because she got sidetracked and forgot to change the bandage. S4 LPN stated she did treatment to the pressure ulcers on top of the Resident's left foot on 08/13/2022 but not her heel. S4 LPN stated she was not aware of any pressure ulcers to Resident #39's right heel, or any open areas to Resident #39's buttocks. Interview with S3 LPN on 08/16/2022 at 9:00 a.m. revealed she assessed Resident #39 upon return from the hospital on [DATE]. S3 LPN stated she did not remember why the treatments to Resident #39's pressure ulcers did not start until 07/11/2022. Observation with S15 CNA and S16 CNA on 08/16/2022 at 9:20 a.m. revealed they were entering Resident #39's room to provide incontinent care. Both of Resident #39's heels were noted to be resting on pillows in her bed, and not floated. S15 CNA and S16 CNA were observed removing Resident #39's brief and rolling her to her left side. Observation revealed no moisture barrier had been applied to Resident #39's buttocks. There was a round Duoderm dressing to her right buttocks approximately 3 inches in diameter. S15 CNA and S16 CNA stated they were not aware of any area to Resident #39's buttocks. While Resident #39 remained on her left side, her right heel was visualized. There were 2 dark areas to her right heel. The center of one of the areas was pink and the top layer of skin was missing from that pink area. They were approximately ½ inch each in diameter. S15 CNA and S16 CNA stated they had not provided care for Resident #39 in a few days, and were not aware of the areas to her right heel. S15 CNA informed S3 LPN of the right heel and buttock areas at that time. Observation on 08/16/2022 at 9:30 a.m. with S3 LPN revealed S3 LPN was shown the area to Resident #39's right buttocks with the Duoderm dressing. S3 LPN stated she was not aware Resident #39 had a dressing to her buttocks. S3 LPN instructed S15 CNA to remove the dressing. S15 CNA removed the dressing from Resident #39's buttocks and there was an open area of excoriation that was approximately ½ inch in length. The top layer of skin was gone. S3 LPN stated the area was a scratch. S3 LPN was shown the areas to Resident #39's right heel. S3 LPN stated those were old areas that healed. S15 CNA and S16 CNA placed a new brief on the resident and did not apply any moisture barrier to Resident #39's buttocks. Interview with S2 ADON on 08/16/2022 at 9:40 a.m. revealed she was not aware of any new areas of skin breakdown to Resident #39's buttocks, or right heel. The surveyor informed S2 ADON of those areas at that time, and S2 ADON stated she would assess these areas. S2 ADON confirmed the orders for treatment to Resident #39's pressure ulcers to the left heel and top of left foot were dated 07/10/2022. However, S2 ADON stated she thought this was a mistake and that the orders were obtained on 07/08/2022. Therefore, the next treatment would be dated 07/11/2022. S2 ADON was informed and confirmed there was no documentation that wound treatment was performed to Resident #39's left heel and top of left foot on 07/08/2022. S2 ADON was informed by the surveyor that S4 LPN reported she did not do the treatment to Resident #39's left heel on 08/13/2022, and there were no weekly measurements of Resident #39's wounds to the left heel and top of the left foot from 07/08/2022 - 07/22/2022. S2 ADON stated there were measurements in the Nurses' Notes; however, review of the Nurses' Notes revealed there were no weekly wound measurements in the Nurses' Notes after 07/08/2022 until 07/22/2022. Observation on 08/16/2022 at 10:57 a.m. revealed Resident #39 was lying in bed with her left heel resting on the bed, and her right heel resting on a pillow. Neither of her heels were floated. Review of a Nurses' Note for Resident #39 by S2 ADON dated 08/16/2022 at 2:02 p.m. revealed Resident #39's right heel noted to have reddened area. Area is blanching at this time and Resident #39 stated it was tender. Area of concern is approximately 2.5 cm of red circumference. Resident #39 stated she did not like to wear heel protectors due to the way they feel on her feet. Resident #39's right buttocks had an area of excoriation and some redness. All areas were blancheable. NP was contacted at that time with new orders noted. Review of Resident #39's orders by the NP on 08/16/2022 revealed monitor red area to right heel every day until healed and then discontinue (ok to float heels if resident allows); and apply moisture barrier to buttocks every shift until healed. Observation and interview with S2 ADON on 08/16/2022 at 4:20 p.m. confirmed Resident #39's right heel had 2 dark brown areas each approximately ½ inch. One of the areas had a pink center. When S2 ADON pressed the pink center, it did blanch. S2 ADON confirmed the area around the pink center was darkened. The surveyor pointed out to the S2 ADON that the top layer of skin was missing from the pink area to the right heel, and S2 ADON stated it was because Resident #39's skin was flaky and dry. S2 ADON then removed Resident #39's brief and the cotton padding beneath the brief's lining was stuck to the excoriated, open areas to Resident #39's right buttocks. S2 ADON peeled the padding from the brief away from the buttocks, and S2 ADON stated the area on the right buttocks was excoriated, and they received an order for moisture barrier. The surveyor informed S2 ADON that moisture barrier was an existing order that was originally dated 06/12/2022 to be applied each shift. S2 ADON stated she thought moisture barrier was only ordered prn. S2 ADON revealed her last assessment of Resident #39's skin was on 08/09/2022, and there was no excoriation to her buttocks, or skin breakdown to her right heel. S2 ADON confirmed if the moisture barrier was applied as ordered, someone should have noted the open area and informed a nurse and the physician. S2 ADON stated she had no idea who applied the Duoderm to Resident #39's buttocks. Observation of Resident #39 on 08/17/2022 at 9:05 a.m. revealed the right and left heels were not floated. Resident #39's right heel was resting on a pillow, and left heel was resting on the mattress. Telephone interview with S13 FNP on 08/17/2022 at 11:10 a.m. revealed she could not remember the exact date the staff notified her of Resident #39's pressure ulcers to the left heel and top of left foot. S13 FNP stated Resident #39's treatments to the pressure ulcers should have started prior to 07/11/2022, and that she was not informed of any delay in treatment by the facility staff. S13 FNP confirmed S2 ADON notified her of red areas to Resident #39's right heel and excoriation to her buttocks on yesterday (08/16/2022). The surveyor informed S13 FNP that observation on 08/16/2022 at 9:20 a.m. revealed Resident #39's right heel was not only red, but dark areas with the top layer of skin missing. S13 FNP stated she would assess it on her next visit. S13 FNP stated Resident #39's heels should be floated at all times to prevent the worsening of the current pressure ulcers and in an effort to prevent any new skin breakdown. S13 FNP stated she knew the resident did not like to wear heel protectors, but her heels should be floated.