**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure the Comprehensive Care plan was reviewed and revised after each assessment, including both the comprehensive and quarterly review assessments for one (Resident #1) of 12 residents reviewed for Care plans. The facility failed to ensure their IDT or MDS [BH1] Coordinator added Resident #1's ICD Code L89.300 Pressure injury of buttock, unstageable diagnosis to his care plan when on 01/31/24, he was diagnosed with an unstageable pressure injury of buttock and prior to his discharge on [DATE]. This failure could affect all residents by placing them at risk of not having a complete profile which could result in inadequate care and result in a decrease in health and psycho-social well-being.Findings included: Record review of Resident #1's Quarterly MDS assessment dated [DATE] by RN W revealed, a [AGE] year-old male who admitted [DATE]. He had a BIMS score 15 (no cognitive impairment) and had upper and lower extremity impairment on both sides and dependent - helper did all effort for all ADL's. He was always incontinent with bladder and frequently incontinent with bowel and he had medically complex conditions. His diagnoses was Malnutrition, depression, Amyotrophic lateral sclerosis, adjustment disorder, GERD, other lack of coordination, chronic pain, dysphagia. Skin Conditions: At risk of developing pressure ulcers/injuries, no skin conditions. Record review of Resident #1's Order Recap Report printed 08/14/25 revealed, Resident may be seen by Wound care Dr. V, for evaluation and treatment. every 7 day(s) for open areas noted on baseline skin assessment Verbal 09/27/2024 start 09/28/2024 and DC 12/20/2024 by Doctor J. Apply zinc oxide to buttock as needed for Wound (started 05/26/24 - 12/20/24) by Doctor J. Ammonium Lactate External Cream 12 % (Lactic Acid (Ammonium Lactate)) Apply to both lower extremities topically two times a day for dry skin (start 12/12/24 - 12/20/24). Hydrocortisone External Lotion 2.5 % (Hydrocortisone (Topical)) Apply to Skin topically two times a day for itchy areas Resident able to state where itch is occurring (started 03/05/24 - 12/20/24). Mupirocin External Ointment 2 % (Mupirocin) Apply to affected areas to RLE topically two times a day for skin infection until 12/22/2024 Apply to RLE x 10 days (start 12/13/24 - 12/20/24). Record review of Resident #1's Care plans printed 08/21/25 and date initiated 03/18/23 revealed, Resident #1 have bowel incontinence related to immobility & Amyotrophic Lateral Sclerosis: Interventions: check resident every two hours and assist with toileting as needed, provide loose fitting, easy to remove clothing, provide pericare after each incontinent episode and see care plans on mobility, ADL's, Cognitive deficit, communication. And date initiated 04/24/23 - Resident #1 have potential impairment to skin integrity related to impaired mobility and incontinence; he prefers to have incontinent pad in recliner chair: Interventions: avoid scratching, and keep hands and body parts from excessive moisture. Educate resident/family/caregivers of causative factor and measures to prevent skin injury. Encourage good nutrition and hydration in order to promote healthier skin. Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. (Resident #1 did not have a pressure injury care plan). Record review of Resident #1's Progress Note by NP B dated 01/31/24 revealed, Diagnosis, Assessment and Plan - Assessment ICD Codes L89.300 Pressure injury of buttock, unstageable. Plan Discussed with Nursing & patient Apply zinc oxide in area and cover with dressing. Try to offload pressure to area. Record review of Resident #1's Nurses Note dated 01/31/2024 at 9:41 am by LVN A revealed, Reopened area about resident Left buttock area about 0.2x0.2cm. NP B here notified. New order noted -apply zinc oxide QD until healed. RP notified. Record review of Resident #1's Nurses Notes dated 09/16/2024 at 8:07 pm by LVN E revealed, Resident requested for wound consult for pressure wound to buttock. MD notified, waiting for response. Resident stable, alert and oriented x 4 with no s/s of pain or discomfort noted at this time. Vitals within normal range, call light within reach, will continue with care plan. Record review of Resident #1's Nursing Notes dated 09/26/2024 at 10:47 pm by Former DON F revealed, Baseline skin assessment completed. Noted open areas to sacral area. Refer to wound care doctor to evaluate and treat. Continue to monitor. Record review of Resident #1's Nurses Notes dated 11/03/2024 at 1:30 pm by LVN C revealed, Apply zinc oxide to buttock as needed for Wound Full shower provided. Excoriation and peeling skin to buttocks. No bleeding. BP=115/80, P=76, T=97.6, O2SAT=98, ROOM AIR, R=18. Will monitor. Record review of Resident #1's Weekly Skin Observation Tool dated 12/03/24 revealed, Does the resident have any observed skin issues? Yes- 3.Excoriation to buttocks: Dry skin to lower extremities, shoulders, thighs, abdomen, shoulders, calves; Eczema on abdomen. Healing blister to right inner thigh. Interview on 08/14/25 at 1:59 pm, LVN A stated Resident #1 did not have any wounds but he had redness on his buttock and zinc oxide cream was used to treat it last year 2024. Interview on 08/14/25 at 2:21 pm, CNA K stated Resident #1 the nurses applied cream on his left buttock because he had a small wound on it last year 2024. Interview on 08/14/25 at 2:38 pm, CNA L stated Resident #1 had scratches on his right buttock, it was a shear that started last year (2024) sometime. Interview on 08/14/25 at 2:55 pm, CNA M stated Resident #1 had a wound on his bottom, he developed a wound after his shower one day she noticed it. She stated his nurses would put some cream and covered with dressing. She stated Resident #1's wound on his bottom was the size of a quarter last year 2024. Interview on 08/18/25 at 10:21 am, NP I stated he was the NP for Doctor J and saw Resident #1 before he discharged the facility December 2024. He stated oh yes he remembered Resident #1 very well, he used a tablet to communicate with and had ALS because he could not talk (speak). He stated he discharged to another place. He stated he saw Resident #1 once or twice before he discharged this facility in December 2024. He stated he did a head to toe assessment and his legs were swollen and he ordered a water pill for him to start taking. He stated Resident #1 had a couple of skin issues, a wound on butt and rash on his lower leg. He stated the only issues Resident #1 had was his legs were swollen and he had the wound on his buttock. Interview on 08/19/25 at 9:44 am, NP I stated when he assessed Resident #1 in December 2024, he could not remember the size of his butt wound but there was no odor or draining. He stated Resident #1 had a wound in the crack of his butt area. He stated Resident #1 had wound care orders but said ‘Let's make changes to his orders' and added the mupirocin ointment for his butt crack wound. Interview on 08/19/25 at 1:16 pm, Doctor J stated Resident #1 had some skin issues on his legs and a wound on his bottom January 2024 and sometime in May 2024. He stated Resident #1 was diagnosed with a pressure wound of his sacral area. Interview on 08/20/25 at 11:28 am, CNA T stated she started working at this facility the spring of 2024 and saw Resident #1's butt sore but did not talk to anyone about it. Interview on 08/20/25 at 11:49 am, CNA M stated she first noticed Resident #1 had a butt wound last year, last summer August or September 2024. Interview on 08/20/25 at 12:01 pm, LVN N stated Resident #1 had a sore with a dressing on his coccyx and was kind of not sure of the size. She stated she forgot because it had been so long ago last year 2024. She stated she was not aware he had a wound care consult. Interview on 08/20/25 at 3:21 pm, CNA R stated she remembered Resident #1, he had a sore on his butt more like circular and sometime would see just a little blood coming from it last year 2024. Interview on 08/22/25 at 4:16 pm, former CNA U stated Resident #1 had a wound and noticed it when she started working at that facility last September 2024 up until he discharged this facility. Interview on 08/20/25 at 12:46 pm, MDS P stated the timeframe for completing care plan she was not sure. She stated for new diagnosis she would create a care plan and discuss in the IDT meeting. She stated she was not sure why Resident #1's pressure injury diagnosis was not care planned because she was not the MDS Coordinator at that time. She stated she went over the resident's documentation weekly by using a calendar to check five residents per day their nurses notes, doctor's notes and hospital records and psychiatric records for any new additions to the resident's EMR profile. She stated if the diagnosis were not added the resident could have a change of condition and need to go to the hospital or get infections. She stated the resident might receive improper care, not get the right treatment for skin issue. She stated they had 14 days to revise care plan as soon as she was aware of the new diagnosis. Interview on 08/21/25 at 4:57 pm, the Administrator stated the MDS Coordinator was responsible for ensuring medical records were accurate and care plans are updated. She stated the timeframe for inputting new diagnosis into care plans was 14 days. Record review of the Facility's Care Plan Policy Revised March 2022 revealed, Policy Statement: The Interdisciplinary team is responsible for the development of the care plan. Policy Interpretation and Implementation: 1. Resident care plans are developed according to the timeframes and criteria established by 483.21 and 2. Comprehensive person centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure the residents received care, consistent with professional standards of practice, to prevent pressure ulcers and did not develop pressure ulcers unless the resident's clinical condition demonstrated that they were unavoidable for one (Resident #1) of 12 residents reviewed for Wound care services. The facility failed to ensure Resident #1 was free from pressure injuries and on 01/31/24 he developed a pressure injury of buttock, unstageable and wound care treatments were started. Subsequently, on 09/27/24 Resident #1's Dr./NP ordered for him to get a wound care consult because he had an open sacral wound, however it was not completed because ADON G said he did not have a wound. Additionally, Resident #1 was never assessed by the Wound care doctor prior to his discharge on [DATE] and from 09/02/24 to 12/17/24 there was 34 times the CNA's coded Resident #1's skin observations as red, discoloration and open. This failure could place all residents at risk of getting wounds or skin issues if the Dr./NP orders were not followed, which could cause continued skin issues and result in health decline and decreased psycho-social well-being. The findings included: Interview on 08/19/25 at 2:33 pm, Wound care Dr. V stated he had not been to this facility in a while and was not familiar with seeing Resident #1. He stated he was the wound care doctor at this facility from 08/14/24 to 12/18/24 and he had no discussions with the staff about Resident #1. He stated he was very diligent on documenting each resident and he had no consults with this resident. He said he did not take a look at Resident #1 and not document it. Interview on 08/14/25 at 5:46 pm, Resident #1 sitting up in bed at a 30 degree level and via the use of an eye gazing tablet to generate speech. He stated while he was at [The previous Nursing Facility] they did not refer him to the wound care doctor after he developed a wound on his butt. He stated they were not doing any treatments to attempt to heal it and he still had the wound on his butt when he left that facility. Record review of Resident #1's Quarterly MDS assessment dated [DATE] by RN W revealed, a [AGE] year-old male who admitted [DATE]. He had a BIMS score 15 (no cognitive impairment) and had upper and lower extremity impairment on both sides and dependent - helper did all effort for all ADL's. He was always incontinent with bladder and frequently incontinent with bowel and he had medically complex conditions. His diagnoses was Malnutrition, depression, Amyotrophic lateral sclerosis, adjustment disorder, GERD, other lack of coordination, chronic pain, dysphagia. Skin Conditions: At risk of developing pressure ulcers/injuries, no skin conditions. Record review of Resident #1's Discharge instruction by LVN H dated 12/19/24 , revealed he discharged this facility with no in home care or services, to another Healthcare Center.current treatments, G-tube, medications and skin treatments, catheter care. Record review of Resident #1's Order Recap Report printed 08/14/25 revealed from 03/25/24 to 12/20/2024: Resident may be seen by Wound care Dr. V, for evaluation and treatment. every 7 day(s) for open areas noted on baseline skin assessment Verbal 09/27/2024 start 09/28/2024 and DC 12/20/2024 by Doctor J. Apply zinc oxide to buttock as needed for Wound (started 05/26/24 - 12/20/24) by Doctor J. Ammonium Lactate External Cream 12 % (Lactic Acid-Ammonium Lactate) Apply to both lower extremities topically two times a day for dry skin (start 12/12/24 - 12/20/24). Hydrocortisone External Lotion 2.5 % (Hydrocortisone (Topical)) Apply to Skin topically two times a day for itchy areas Resident able to state where itch is occurring (started 03/05/24 - 12/20/24). Mupirocin External Ointment 2 % (Mupirocin) Apply to affected areas to RLE topically two times a day for skin infection until 12/22/2024 Apply to RLE x 10 days (start 12/13/24 - 12/20/24). Record review of Resident #1's Care plans Printed 08/21/25 and date initiated 03/18/23 revealed, Resident #1 have bowel incontinence related to immobility & Amyotrophic Lateral Sclerosis: Interventions: check resident every two hours and assist with toileting as needed, provide loose fitting, easy to remove clothing, provide pericare after each incontinent episode and see care plans on mobility, ADL's, Cognitive deficit, communication. And date initiated 04/24/23 - Resident #1 have potential impairment to skin integrity related to impaired mobility and incontinence; he prefers to have incontinent pad in recliner chair: Interventions: avoid scratching, and keep hands and body parts from excessive moisture. Educate resident/family/caregivers of causative factor and measures to prevent skin injury. Encourage good nutrition and hydration in order to promote healthier skin. Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. (Resident #1's Care Plans was not updated and there were no revised care plans for Pressure injury and ointment treatments). Record review of Resident #1's EMR revealed from 01/31/24 to 12/19/24, there were no wound care consults progress notes anywhere in the resident's records. Record review of Resident #1's Progress Note by NP B dated 01/31/24 revealed, Diagnosis, Assessment and Plan - Assessment ICD Codes L89.300 Pressure injury of buttock, unstageable. Plan Discussed with Nursing & patient Apply zinc oxide in area and cover with dressing. Try to offload pressure to area. Record review of Resident #1's Nurses Note dated 01/31/2024 at 9:41 am by LVN A revealed, Reopened area about resident Left buttock area about 0.2x0.2cm. NP B here notified. New order noted -apply zinc oxide QD until healed. RP notified. Record review of Resident #1's Nurses note dated 03/18/2023 at 5:55 pm by LVN A revealed, Resident is 36 Yrs (years) old admitted to [This Facility] under the care of Dr./NP. Arrived in facility via wheelchair accompanied by parent and transported by family. Alert and oriented x 3. Respiration even and unlabored. Skin warm and dry to touch. Noted rashes all over resident body. contractures noted to resident fingers. Resident noted with G/Tube and condom catheter. resident on continue feeding (formula) 1.4 at 100ml/hr. cont. Able to make needs known. Denies pain or discomfort at this time. Shower given. Ate 50% of his dinner. Message left for Dr. to call. Record review of Resident #1's Nurses note dated 05/26/2024 at 10:17 pm by LVN C revealed, Resident said the buttocks wound are healed. MD notified and changed zinc oxide cream qd to PRN. Call light in reach. Record review of Resident #1's Nurses note dated 07/08/2024 at 09:22 am by Nurse D revealed, Nurse asked about buttocks abrasion and resident stated it is healing. Will continue to monitor. Record review of Resident #1's Nurses note dated 07/10/2024 1:17 pm by Nurse D revealed, Nurse asked resident about buttocks wound after his shower and resident verbalized it is healing. Record review of Resident #1's Nurses Notes dated 07/10/2024 at 10:09 pm by RN E revealed, Nurse cont. to monitor wound to buttocks, no s/s of infection noted. Resident stable, alert and oriented x 4 with no s/s of pain or distress noted at this time. Vitals within normal range. Call light within reach. Will continue with care plan. Record review of Resident #1's Nurses Notes dated 07/23/2024 at 2:36 pm by Nurse D revealed, Nurse did wound care treatment per residents request because both residents buttocks cheeks skin was irritating him. Record review of Resident #1's MARs/TARs dated 09/01/24 - 09/30/24 revealed, Hydrocortisone External lotion 2.5% topical apply to skin topically two times a day for itchy areas resident able to state where itch is occurring (start date 03/05/24 and DC date 12/20/24). Apply zinc oxide to buttock as needed for wound (start date 05/26/24 and DC date 12/20/24). Record review on Resident #1's CNA Point of Care skin observations from 09/02/24 to 12/17/24 revealed coding for Item value 1 Red area - Item value 2. Discoloration and item value 4. open area was coded 34 times by various CNA's. Record review of Resident #1's Nurses Notes dated 09/16/2024 at 8:07 pm by LVN E revealed, Resident requested for wound consult for pressure wound to buttock. MD notified, waiting for response. Resident stable, alert and oriented x 4 with no s/s of pain or discomfort noted at this time. Vitals within normal range, call light within reach, will continue with care plan. Record review of Resident #1's Weekly Skin Observation Tool dated 09/22/24 revealed, 1. Does the resident have any observed skin issues? Yes- 3.Excoriation to buttocks: old scars to both hands, dry skin to lower extremity, shoulders (rear), thighs, and right calf; Eczema on abdomen, thigh and rear lower legs. Treatment in progress. Record review of Resident #1's Nursing Notes dated 09/26/2024 at 10:47 pm by Former DON F revealed, Baseline skin assessment completed. Noted open areas to sacral area. Refer to wound care doctor to evaluate and treat. Continue to monitor. Record review of Resident #1's Nurses Note dated 09/27/2024 at 2:36 pm by Former DON F revealed, Follow up to baseline skin assessment findings. Resident was referred to [Wound care] Dr. for eval and treatment. Face sheet and medication list faxed, order is in the system. Record review of Resident #1's Weekly Skin Observation Tool dated 09/29/24 revealed, Does the resident have any observed skin issues? Yes- 3.Excoriation to buttocks: old scars to both hands, dry skin to lower extremity, shoulders (rear), thighs, and right calf; Eczema on abdomen, thigh and rear lower legs. Resident may be seen by Wound care Dr. V. Record review of Resident #1's MARs/TARs dated 10/01/24 - 10/31/24 revealed, Hydrocortisone External lotion 2.5% topical apply to skin topically two times a day for itchy areas resident able to state where itch is occurring (start date 03/05/24 and DC [BH7] [S(8] date 12/20/24). Apply zinc oxide to buttock as needed for wound (start date 05/26/24 and DC date 12/20/24). Record review of Resident #1's Weekly Skin Observation Tool dated 10/06/24 revealed, Does the resident have any observed skin issues? Yes- 3.Excoriation to buttocks: old scars to both hands, dry skin to lower extremity, shoulders (rear), thighs, and right calf; Eczema on abdomen, thigh and rear lower legs. Record review of Resident #1's Weekly Skin Observation Tool dated 10/20/24 revealed, Does the resident have any observed skin issues? Yes- 3.Excoriation to buttocks: old scars to both hands, dry skin to lower extremities, shoulders (rear), thighs, and right calf; Eczema on abdomen, chafing rash between thighs. ABD Pad in place. Record review of Resident #1's Weekly Skin Observation Tool dated 10/27/24 revealed, Does the resident have any observed skin issues? Yes- 3.Excoriation to buttocks: old scars to both hands, dry skin to lower extremities, shoulders (rear), thighs, and right calf; Eczema on abdomen. Old blister to right inner thigh. Record review of Resident #1's MARs/TARs dated 11/01/24 - 11/30/24 revealed, Hydrocortisone External lotion 2.5% topical apply to skin topically two times a day for itchy areas resident able to state where itch is occurring (start date 03/05/24 and DC date 12/20/24). Apply zinc oxide to buttock as needed for wound (start date 05/26/24 and DC date 12/20/24). Record review of Resident #1's Nurses Notes dated 11/03/2024 at 1:30 pm by LVN C revealed, Apply zinc oxide to buttock as needed for Wound Full shower provided. Excoriation and peeling skin to buttocks. No bleeding. BP=115/80, P=76, T=97.6, O2SAT=98, ROOM AIR, R=18. Will monitor. Record review of Resident #1's Weekly Skin Observation Tool dated 11/03/24 revealed, Does the resident have any observed skin issues? Yes- 3.Excoriation to buttocks: old scars to both hands, dry skin to lower extremities, shoulders (rear), thighs, and right calf; Eczema on abdomen, Old blister to right inner thigh. Record review of Resident #1's Weekly Skin Observation Tool dated 11/10/24 revealed, Does the resident have any observed skin issues? Yes- 3.Excoriation to buttocks: Flaky dry skin to lower extremities, shoulders (rear), thighs, and right calf, abdomen. Record review of Resident #1's MARs/TARs dated 12/01/24 - 12/19/24 revealed, Ammonium Lactate external cream 12% apply to both lower extremities topically two times a day for dry skin (start date 12/12/24 - DC date 12/20/24). Hydrocortisone External lotion 2.5% topical apply to skin topically two times a day for itchy areas resident able to state where itch is occurring (start date 03/05/24 and DC date 12/20/24). Apply zinc oxide to buttock as needed for wound (start date 05/26/24 and DC date 12/20/24). Mupirocin external ointment 2% apply to affected areas to RLE topically two times a day for skin infection until 12/22/24, apply to RLE x 10 days (start date 12/13/24 - DC date 12/20/24 Record review of Resident #1's Weekly Skin Observation Tool dated 12/03/24 revealed, Does the resident have any observed skin issues? Yes- 3.Excoriation to buttocks: Dry skin to lower extremities, shoulders, thighs, abdomen, shoulders, calves; Eczema on abdomen. Healing blister to right inner thigh. Record review of Resident #1's Weekly Skin Observation Tool dated 12/10/24 revealed, Does the resident have any observed skin issues? Yes- 2. 41) Right lower leg (front). 3. Several dry yellow crusted over areas to BLE. Record review of Resident #1's Change in Condition dated 12/10/24 by ADON G and LVN H revealed, The Change In Condition/s reported on this CIC Evaluation are/were: Other change in condition At the time of evaluation resident/patient vital signs, weight and blood sugar were: - Blood Pressure: BP 122/75 - 12/10/2024 10:22 Position: Sitting r/arm - Pulse: P 78 - 12/10/2024 10:22 Pulse Type: Regular - RR: R 18 - 12/10/2024 10:22, - Temp: T 97.6 - 12/10/2024 10:22 Route: Forehead (non-contact), - Weight: W 134.2 lb - 12/6/2024 15:03 Scale: Bath - Pulse Oximetry: O2 97 % - 12/10/2024 10:23 Method: Room Air - Blood Glucose: Resident/Patient is in the facility for: Long Term Care Primary Diagnosis is: (blank) Relevant medical history is: (blank) Code Status: **Code Status:***FULL CODE*** Advance directives are: (blank), Resident/Patient had the following medications changes in the past week: Resident/Patient is on Coumadin/warfarin: No, The result of last INR: Date: (blank), Resident/Patient is on anticoagulant other than warfarin: (blank), Resident/Patient is on: (blank) Outcomes of Physical Assessment : Positive findings reported on the resident/patient evaluation for this change in condition were: - Mental Status Evaluation: No changes observed, - Functional Status Evaluation: No changes observed, - Behavioral Status Evaluation: - Respiratory Status Evaluation: (blank), - Cardiovascular Status Evaluation:(blank), - Abdominal/GI Status Evaluation: (blank), - GU/Urine Status Evaluation: (blank), - Skin Status Evaluation: Rash, - Pain Status Evaluation: Does the resident/patient have pain? (blank), - Neurological Status Evaluation: (blank), Nursing observations, evaluation, and recommendations are: (blank), Primary Care Provider Feedback : Primary Care Provider responded with the following feedback: A. Recommendations: no new orders, B. New Testing Orders:(blank), C. New Intervention Orders:(blank). Comments: (blank). Record review of Resident #1's Weekly Skin Observation Tool dated 12/17/24 revealed, Does the resident have any observed skin issues? Yes- 2. 34) Left thigh (front). 3. Multiple scabbed area to BLE; treatment in place. Record review of Resident #1's Weekly Skin Observation Tool dated 12/19/24 revealed, Does the resident have any observed skin issues? Yes- 2. Other (specify) BLE. 3. Multiple scabs on BLE. Interview on 08/14/25 at 1:59 pm, LVN A stated Resident #1 did not have any wounds but he had redness on his buttock and zinc oxide cream was used to treat it last year 2024. Interview on 08/14/25 at 2:21 pm, CNA K stated she could not remember when but while Resident #1 was at the facility, the nurses applied cream on his left buttock because he had a small wound on it last year 2024. Interview on 08/14/25 at 2:38 pm, CNA L stated Resident #1 had scratches on his right buttock, it was a shear that started last year (2024) sometime. Interview on 08/14/25 at 2:55 pm, CNA M stated Resident #1 had a wound on his bottom, he developed a wound after his shower one day she noticed it when he was at the facility. She stated his nurses would put some cream on it and covered it with dressing. She stated Resident #1's wound on his bottom was the size of a quarter last year 2024. Interview on 08/15/25 at 12:32 pm, Former DON F stated she used to be the DON at this facility about a year ago and did not remember anything about the residents including Resident #1. Interview on 08/15/25 at 1:19 pm, LVN N stated Resident #1 had skin breakdown on his butt that was the size of a quarter. She stated the nurses put dressing on it last year 2024. Interview on 08/15/25 at 2:17 pm, RN E stated he worked the overnight shift and yes Resident #1 had a wound on his bottom the nurses did treatment and dressings on last year 2024. Interview on 08/15/25 at 3:20 pm ADON G stated Resident #1 had really dry scaly skin and he had a topical cream that was used. She stated when Resident #1 considered (thought) he had a wound, but he was told he did not have one on his buttock that she could remember. She stated she talked to him all the time through a computer he used because he was not able to verbalize his needs. She stated he had a chronic skin condition and his skin cream was applied after his showers. She stated he had a shearing of his buttocks that healed in two weeks last year 2024. She stated Resident #1 discharged the facility and he did not have any wounds. She stated LVN H was the nurse who discharged him and December 2024 and he had no skin issues. Interview on 08/15/25 at 5:20 pm, DON O stated Resident #1 spoke to him on occasion and said he was going to get those staff but he did not go into any detail. He stated Resident #1 had no skin issues and said he saw his skin 11/24/25 because he worked that day on the floor. He stated Resident #1 had dry skin issues and had no shearing either before he discharged [DATE]. He stated he spoke to Resident #1 weekly to check on him with how things were going and he did not have any complaints about anything. Interview on 08/18/25 at 10:21 am, NP I stated he was the NP for Doctor J and saw Resident #1 before he discharged the facility December 2024. He stated oh yes he remembered Resident #1 very well, he used a tablet to communicate with and had ALS because he could not talk (speak). He stated he discharged to another place. He stated he saw Resident #1 once or twice before he discharged this facility in December 2024. He stated he did a head to toe assessment and his legs were swollen and he ordered a water pill for him to start taking. He stated Resident #1 had a couple of skin issues, a wound on butt and rash on his lower leg. He stated the only issues Resident #1 had was his legs were swollen and he had the wound on his buttock. Interview on 08/19/25 at 9:44 am, NP I stated when he assessed Resident #1 in December 2024, he could not remember the size of his butt wound but there was no odor or draining. He stated Resident #1 had a wound in the crack of his butt area. He stated Resident #1 had wound care orders but said ‘Let's make changes to his orders' and added the mupirocin ointment for his butt crack wound. Interview on 08/19/25 at 10:00 am, LVN H stated honestly she could not remember if Resident #1 had a wound care consult or treatment order because he was here a while ago in 2024. She stated Resident #1 did not have a wound on his bottom or infection on his leg and could not remember if she put any dressings on his lower leg but something was being put on them. She stated she never talked to the Wound care Doctor about Resident #1 and he was not seen by the Wound care Doctor. Interview on 08/19/25 at 10:29 am, LVN A stated Resident #1's buttock was excoriated and his skin peeled off that was treated with zinc oxide cream last year 2024. She stated his skin was peeling when they wiped him off. She stated they also used triamcinolone ointment on his skin. She stated she admitted Resident #1 and took him straight to the shower because of the rash on his legs and all over skin. She stated she could not recall Resident #1 being seen by the Wound Care Doctor. She stated Resident #1 never asked to see the wound care Doctor and he did not have a wound on his leg. She stated he had excoriation which was a whitish in color and no shearing on his butt. Interview on 08/19/25 at 12:17 pm, RN E stated Resident #1 had a butt wound and was not sure when but it was last year 2024. He stated it was always covered up with a dressing the size of 1.5 cm x 1 cm (about 1/2 size of dollar bill ). He stated he applied cream on his arms and could not remember which side the wound dressing was on. He stated he applied cream on both of his legs for dry skin but not his wound on him buttock because they did the treatment and dressing on the dayshift. He stated he could not remember if Resident #1 had a wound care consult. Interview on 08/19/25 at 12:24 pm, the Administrator stated she was not aware Resident #1 had a wound care referral when he was at this facility. She stated her expectation was for the nurses to identify if it appeared to be a wound they would notify the Doctor for a wound care referral. Interview on 08/19/25 at 12:31 pm, DON O stated he did not think Resident #1 had an order for a wound care consult and did not think he needed one because he did not have a wound. He stated ADON G or himself sent the wound care referrals to the wound care Doctor. He stated zinc oxide was not for an open wound and was a barrier cream. He stated he was not sure who called for the zinc oxide order for Resident #1. He stated if a resident had an order for a wound care consult they should follow the order to get the would care Doctor to evaluate the resident. He stated he was not sure why NP I said Resident #1 had a wound on his buttock. He stated why would Resident #1 have a wound care consult if he did not have a wound. He stated after reviewing Resident #1 records, he did not have a wound care order while he (Resident #1) was here. Interview on 08/19/25 at 1:01 pm, ADON G stated the staff needed to ensure the residents orders were followed through on. She stated it was the nurses responsibility to ensure the orders were done. She stated Resident #1 did not have a wound care consult because his wound healed before the Wound care Doctor came back to the facility for rounds. She stated the Wound care Doctor came once per week. She stated Resident #1 had an abrasion on his buttock that had healed because barrier cream was applied to his bottom. She stated they continued to put barrier cream on his bottom for his comfort and said Resident #1 had a skin disorder of dry and scaly skin. She stated she knew about Resident #1's wound care order but he did not have a wound so he did not need to be seen by the wound care doctor, She stated Resident #1 had a rash in December 2024 and could not say where it was. Interview on 08/19/25 at 1:16 pm, Doctor J stated Resident #1 had some skin issues on his legs and a wound on his bottom January 2024 and sometime in May 2024. He stated Resident #1 was diagnosed with a pressure wound of his sacral area and that the Wound Care Doctor had treated it. He stated he did not know that Resident #1 had not been assessed by the Wound Care Doctor. He stated the staff had changed so much at the facility and was not sure who he spoke to about it. He stated he never discontinued Resident #1's wound care order because he needed to see the Wound care Doctor for his skin issues. He stated no one had ever said Resident #1 did not need the Wound consult. He stated he expected the resident's wound care consults to be done in order to keep their skin issues from getting worse. Interview on 08/19/25 at 3:01 pm, ADON G stated Resident #1's Wound care consult order was not discontinued while he was at this facility in case another wound came up. She stated when the Wound care Doctor was at the facility and passing through doing rounds she told him Resident #1 did not have a wound and he said okay and did not see him. She stated she would have to look and see if she had spoken to Doctor J and NP I about Resident #1 having a wound on his buttock. She stated in December 2024, LVN H contacted Resident #1's Doctor about his rash and could not remember the location of it. Interview on 08/19/25 3:47 pm, DON O stated he checked again in the EMR and Resident #1 did not have a wound care consult order. He stated he was not really sure why Resident #1 did not see the Wound care Doctor and if he had a wound care consult, maybe Wound care Dr. V saw him and may not have documented seeing him. He stated he was not sure why his pressure injury was not added to his medical records because he was not working here at the time. He stated he had not spoken to NP I about Resident #1's butt wound yet. He stated the nurses called anything a wound, like skin tears and abrasions and wound was just a term they used. He stated nothing could happen to the resident if they did not get a wound care consult if they already had wound care orders. He stated the Doctors signed off and changed the medications as needed and if a resident had a stage 3 or higher wound they would refer the resident to the wound care doctor. He stated the nurses used the word wound loosely because eschar and skin tears were not the same and a lot of the staff were not able to tell what a real wound was. He stated the last time he saw Resident #1's buttock was right before Thanksgiving November 2024 or before he discharged [DATE] He stated the nursing staff have had wound care trainings earlier this year February 2025 or March 2025. He stated some of the nurses was still classifying everything as a wound and said they were currently educating the nurses on identifying wounds. Interview on 08/19/25 4:15 pm, ADON G stated Resident #1 discharged this facility she believed 12/20/24. She stated sometimes she rounded with the wound care Doctor and other times the DON or charge nurse did. She stated the Charge Nurses did their own skin assessments of their assigned residents. She stated she had not spoken to NP I and Doctor J about them saying Resident #1 had a wound on his buttock. Record review of an email dated 08/19/25 at 3:52 pm by ADON G revealed, Wound Consult is a standing order for possible wounds. If wounds are healed before or if not an actual wound, the wound doctor is contacted verbally, in person, or on the phone. In this case, the wound doctor was Wound care Dr. V, and he was informed verbally while doing rounds at the facility., The wound consult order remains as a standing order. The wound order was discontinued when the resident d/c from the facility on 9/20/204 [sic].The charge nurse communicates between the doctors regarding skin issues. 12/10 & 12/11/25 [sic] show in the nurses' notes that the charge nurse communicated skin issues with the MD. The charge nurses are responsible for communication; they complete skin assessments and notifications. Interview on 08/19/25 at 4:38 pm, MDS P stated she could not recall Resident #1 having a wound care order or pressure ulcer and once Resident #1 asked her to put cream around his face. She stated the expectations for when the residents had wound care referrals was for the nurses to contact the wound care Doctor. She stated not having wound care consults could cause a resident to have an adverse effect depending on the resident's orders. She stated the staff would not know what was going on with the resident and probably could not treat them properly. Interview on 08/19/25 at 4:51 pm, the Administrator stated the nurse management DON O and ADON G were responsible for scheduling wound care consults. Interview on 08/20/25 at 3:21 pm, CNA R stated she remembered Resident #1, he had a sore on his butt more like circular and sometimes would see just a little blood coming from it last year 2024. She stated she told the nurse after they lifted him and transferred him to the bedside commode and saw it initially in 2024. She stated in December 2024 she documented the redness of his wound in the EMR. She stated she never talked to nurse management because she just reported his sore to his nurse for that shift. She stated she told LVN S in 2024 about Resident #1's sore and she said okay and went to look at it. She stated the sore on his butt had its good days and bad days and did not always bleed and said the sore did not have any odor but was about 1/2 inch in size. She stated she saw LVN C, LVN S and LVN N doing treatments on it. She stated she worked nights and thought ADON G and DON O were aware of the sore on his butt because Resident #1 informed everybody about it. She stated she never spoke to ADON G or DON O about his butt sore because she talked the nurses about it. Interview on 08/20/25 at 11:28 am, CNA T stated she started working at this facility the spring of 2024 and saw Resident #1's butt sore but did not talk to anyone about it. She stated she was not sure if ADON G and DON O knew about his butt wound. She stated in October 2024 or November 2024, Resident #1's butt wound stuck to his pants because it bled a lot when they pulled down his pants. She stated she told LVN C and after Resident #1 was showered then LVN C came and cleaned and put cream on his butt wound. She stated he had the butt wound for a while and all the way up to the time he discharged this facility. She stated Resident #1 did not have any pain from the wound. She stated CNA L and herself gave him showers and CNA L also saw the sore bleeding. She stated after she finished Resident #1's shower she would fill out the shower sheet and sign it and then the nurse would put the shower sheet into the drawer at the nursing station. Interview on 08/20/25 at 11:49 am, CNA M stated she first noticed Resident #1 had a butt wound last year, last summer august or September 2024. She stated the nurses knew Resident #1 had a butt wound because after he showered the nurses had to put cream on it. She stated she saw LVN A, LVN C, LVN H put cream on it. She stated she documented his butt wound on the shower sheets and thought the nurses documented in the nurses notes. She stated Resident #1 had dry skin on the bottom of legs and his butt wound bled a little bit at times. She stated the last time Resident #1's butt wound bled was a couple of times before he discharged this facility. She stated the time his butt wound bled, she completed the shower sheet, then the nurse put the cream on it. She stated sometimes Resident #1 did not have a dressing on it and if it drained, a dressing was put on it. She stated she was not sure if the nurse managers were aware of his butt wound but the shower sheets were completed and the nurse put them in the drawer at the nurses station. Interview on 08/20/25 at 12:01 pm, LVN N stated Resident #1 had a sore with a dressing on his coccyx and was kind of not sure of the size. She stated she forgot because it had been so long ago last year 2024. She stated she was not aware he had a wound care consult. Interview on 08/22/25 at 4:16 pm, former CNA U stated Resident #1 had a wound and noticed it when she started working at that facility last September 2024 up until he discharged this facility. She stated when she would give him a shower, she would pat the area of his butt really softly. She stated she did not see Resident #1's butt sore healed. She stated at times his butt wound bled a little bit and was about the size of a quarter. She stated she spoke to the nurses and they put dressing and cream on it and added LVN C was good about putting the dressing on his wound. She stated she did not see other nurses doing the skin treatments after he showered but LVN C. She stated sometimes Resident #1 was in pain because of the butt wound. She stated DON O started working there and he was not too talkative and did not say hello to the CNA's and would just walk by them, so she never talked to him about anything. She stated she did not see ADON G to talk about Resident #1's wound but did talk to the nurses about it. Interviews on 08/21/25 b[TRUNC

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure they provided care included but was not limited to assessing, evaluating, planning and implementing resident care plan and responding to resident's needs for one (Resident #1) of 12 residents reviewed for Nursing services. 1.The facility failed to ensure ADON G referred Resident #1 to the Wound care Doctor after he was diagnosed with an open sacral wound on 09/27[BH1] [BH2] /24 and prior to discharge on [DATE]. 2.The facility failed when ADON G stated she was aware of the Physician's order dated 09/27/24 for a wound care consult for Resident #1 but felt he did not have a wound on his buttock so she did not follow the Doctor's order from 09/27/24 to 12/19/24. These failures could affect all residents by placing them at risk of continued wound issues and infections if Doctor's orders were not followed, which could result in a decrease in health and psycho-social well-being. Findings included: Record review of Resident #1's Quarterly MDS assessment dated [DATE] by RN W revealed, a [AGE] year-old male who admitted [DATE]. He had a BIMS score 15 (no cognitive impairment) and had upper and lower extremity impairment on both sides and dependent - helper did all effort for all ADL's. He was always incontinent with bladder and frequently incontinent with bowel and he had medically complex conditions. His diagnoses was Malnutrition, depression, Amyotrophic lateral sclerosis, adjustment disorder, GERD, other lack of coordination, chronic pain, dysphagia. Skin Conditions: At risk of developing pressure ulcers/injuries, no skin conditions. Record review of Resident #1's Order Recap Report printed 08/14/25 revealed, Resident may be seen by Wound care Dr. V, for evaluation and treatment. every 7 day(s) for open areas noted on baseline skin assessment Verbal 09/27/2024 start 09/28/2024 and DC 12/20/2024 by Doctor J. Apply zinc oxide to buttock as needed for Wound (started 05/26/24 - 12/20/24) by Doctor J. Ammonium Lactate External Cream 12 % (Lactic Acid (Ammonium Lactate)) Apply to both lower extremities topically two times a day for dry skin (start 12/12/24 - 12/20/24). Hydrocortisone External Lotion 2.5 % (Hydrocortisone (Topical)) Apply to Skin topically two times a day for itchy areas Resident able to state where itch is occurring (started 03/05/24 - 12/20/24). Mupirocin External Ointment 2 % (Mupirocin) Apply to affected areas to RLE topically two times a day for skin infection until 12/22/2024 Apply to RLE x 10 days (start 12/13/24 - 12/20/24). Record review of Resident #1's Care plans printed 08/21/24 and date initiated 03/18/23 revealed, Resident #1 have bowel incontinence related to immobility & Amyotrophic Lateral Sclerosis: Interventions: check resident every two hours and assist with toileting as needed, provide loose fitting, easy to remove clothing, provide pericare after each incontinent episode and see care plans on mobility, ADL's, Cognitive deficit, communication. And date initiated 04/24/23 - Resident #1 have potential impairment to skin integrity related to impaired mobility and incontinence; he prefers to have incontinent pad in recliner chair: Interventions: avoid scratching, and keep hands and body parts from excessive moisture. Educate resident/family/caregivers of causative factor and measures to prevent skin injury. Encourage good nutrition and hydration in order to promote healthier skin. Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Record review of Resident #1's Nurses Note dated 01/31/2024 at 09:41 am by LVN A revealed, Reopened area about resident Left buttock area about 0.2x0.2cm. NP B here notified. New order noted -apply zinc oxide QD until healed. RP notified. Record review of Resident #1's Nurses note dated 05/26/2024 at 10:17 pm by LVN C revealed, Resident said the buttocks wound are healed. MD notified and changed zinc oxide cream qd to PRN. Call light in reach. Record review of Resident #1's Nurses note dated 07/08/2024 at 09:22 am by Nurse D revealed, Nurse asked about buttocks abrasion and resident stated it is healing. Will continue to monitor. Record review of Resident #1's Nurses note dated 07/10/2024 1:17 pm by Nurse D revealed, Nurse asked resident about buttocks wound after his shower and resident verbalized it is healing. Record review of Resident #1's Nurses Notes dated 07/10/2024 at 10:09 pm by RN E revealed, Nurse cont. to monitor wound to buttocks, no s/s of infection noted. Resident stable, alert and oriented x 4 with no s/s of pain or distress noted at this time. Vitals within normal range. Call light within reach. Will continue with care plan. Record review of Resident #1's Nurses Notes dated 07/23/2024 at 2:36 pm by Nurse D revealed, Nurse did wound care treatment per residents request because both residents buttocks cheeks skin was irritating him. Record review of Resident #1's MARs/TARs dated 09/01/24 - 09/30/24 revealed, Hydrocortisone External lotion 2.5% topical apply to skin topically two times a day for itchy areas resident able to state where itch is occurring (start date 03/05/24 and DC date 12/20/24). Apply zinc oxide to buttock as needed for wound (start date 05/26/24 and DC date 12/20/24). Record review of Resident #1's Nurses Notes dated 09/16/2024 at 8:07 pm by LVN E revealed, Resident requested for wound consult for pressure wound to buttock. MD notified, waiting for response. Resident stable, alert and oriented x 4 with no s/s of pain or discomfort noted at this time. Vitals within normal range, call light within reach, will continue with care plan. Record review of Resident #1's Nursing Notes dated 09/26/2024 at 10:47 pm by Former DON F revealed, Baseline skin assessment completed. Noted open areas to sacral area. Refer to wound care doctor to evaluate and treat. Continue to monitor. Record review of Resident #1's Nurses Note dated 09/27/2024 at 2:36 pm by Former DON F revealed, Follow up to baseline skin assessment findings. Resident was referred to [Wound care] Dr. for eval and treatment. Face sheet and medication list faxed, order is in the system. Record review of Resident #1's MARs/TARs dated 10/01/24 - 10/31/24 revealed, Hydrocortisone External lotion 2.5% topical apply to skin topically two times a day for itchy areas resident able to state where itch is occurring (start date 03/05/24 and DC date 12/20/24). Apply zinc oxide to buttock as needed for wound (start date 05/26/24 and DC date 12/20/24). Record review of Resident #1's MARs/TARs dated 11/01/24 - 11/30/24 revealed, Hydrocortisone External lotion 2.5% topical apply to skin topically two times a day for itchy areas resident able to state where itch is occurring (start date 03/05/24 and DC date 12/20/24). Apply zinc oxide to buttock as needed for wound (start date 05/26/24 and DC date 12/20/24). Record review of Resident #1's Nurses Notes dated 11/03/2024 at 1:30 pm by LVN C revealed, Apply zinc oxide to buttock as needed for Wound Full shower provided. Excoriation and peeling skin to buttocks. No bleeding. BP=115/80, P=76, T=97.6, O2SAT=98, ROOM AIR, R=18. Will monitor. Record review of Resident #1's MARs/TARs dated 12/01/24 - 12/19/24 revealed, Ammonium Lactate external cream 12% apply to both lower extremities topically two times a day for dry skin (start date 12/12/24 - DC date 12/20/24). Hydrocortisone External lotion 2.5% topical apply to skin topically two times a day for itchy areas resident able to state where itch is occurring (start date 03/05/24 and DC date 12/20/24). Apply zinc oxide to buttock as needed for wound (start date 05/26/24 and DC date 12/20/24). Mupirocin external ointment 2% apply to affected areas to RLE topically two times a day for skin infection until 12/22/24, apply to RLE x 10 days (start date 12/13/24 - DC date 12/20/24. Interview on 08/14/25 at 1:59 pm, LVN A stated Resident #1 did not have any wounds but he had redness on his buttock and zinc oxide cream was used to treat it last year 2024. Interview on 08/14/25 at 2:21 pm, CNA K stated Resident #1 the nurses applied cream on his left buttock because he had a small wound on it last year 2024. Interview on 08/14/25 at 2:38 pm, CNA L stated Resident #1 had scratches on his right buttock, it was a shear that started last year (2024) sometime. Interview on 08/14/25 at 2:55 pm, CNA M stated Resident #1 had a wound on his bottom, he developed a wound after his shower one day she noticed it. She stated his nurses would put some cream and covered with dressing. She stated Resident #1's wound on his bottom was the size of a quarter last year 2024. Interview on 08/15/25 at 3:20 pm ADON G stated Resident #1 had really dry scaly skin and he had a topical cream that was used. She stated when Resident #1 considered (thought) he had a wound, but he was told he did not have one on his buttock that she could remember. She stated she talked to him all the time through a computer he used because he was not able to verbalize his needs. She stated he had a chronic skin condition and his skin cream was applied after his showers. She stated he had a shearing of his buttocks that healed in two weeks last year 2024. She stated Resident #1 discharged the facility and he did not have any wounds. She stated LVN H was the nurse who discharged him and December 2024 and he had no skin issues. Interview on 08/18/25 at 10:21 am, NP I stated he was the NP for Doctor J and saw Resident #1 before he discharged the facility December 2024. He stated oh yes he remembered Resident #1 very well, he used a tablet to communicate with and had ALS because he could not talk (speak). He stated he discharged to another place. He stated he saw Resident #1 once or twice before he discharged this facility in December 2024. He stated he did a head to toe assessment and his legs were swollen and he ordered a water pill for him to start taking. He stated Resident #1 had a couple of skin issues, a wound on butt and rash on his lower leg. He stated the only issues Resident #1 had was his legs were swollen and he had the wound on his buttock. Interview on 08/19/25 at 9:44 am, NP I stated when he assessed Resident #1 in December 2024, he could not remember the size of his butt wound but there was no odor or draining. He stated Resident #1 had a wound in the crack of his butt area. He stated Resident #1 had wound care orders but said ‘Let's make changes to his orders' and added the mupirocin ointment for his butt crack wound. Interview on 08/19/25 at 1:01 pm, ADON G stated the staff needed to ensure the residents orders were followed through on. She stated it was the nurses responsibility to ensure the orders were done. She stated Resident #1 did not have a wound care consult because his wound healed before the Wound care Doctor came back to the facility for rounds. She stated the Wound care Doctor came once per week. She stated Resident #1 had an abrasion on his buttock that had healed because barrier cream was applied for his bottom. She stated they continued to put barrier cream on his bottom for his comfort and said Resident #1 had a skin disorder of dry and scaly skin. She stated she knew about Resident #1's wound care order but he did not have a wound so he did not need to be seen by the wound care Doctor, She stated Resident #1 had a rash in December 2024 and could not say where it was. Interview on 08/19/25 at 1:16 pm, Doctor J stated Resident #1 had some skin issues on his legs and a wound on his bottom January 2024 and sometime in May 2024. He stated Resident #1 was diagnosed with a pressure wound of his sacral area and that the Wound Care Doctor had treated it. He stated he did not know that Resident #1 had not been assessed by the Wound Care Doctor. He stated the staff had changed so much at the facility and was not sure who he spoke to about it. He stated he never discontinued Resident #1's wound care order because he needed to see the Wound care Doctor for his skin issues. He stated no one had ever said Resident #1 did not need the Wound consult. He stated he expected the resident's wound care consults to be done in order to keep their skin issues from getting worse. Interview on 08/20/25 at 11:28 am, CNA T stated she started working at this facility the spring of 2024 and saw Resident #1's butt sore but did not talk to anyone about it. Interview on 08/20/25 at 11:49 am, CNA M stated she first noticed Resident #1 had a butt wound last year, last summer august or September 2024. Interview on 08/20/25 at 12:01 pm, LVN N stated Resident #1 had a sore with a dressing on his coccyx and was kind of not sure of the size. She stated she forgot because it had been so long ago last year 2024. She stated she was not aware he had a wound care consult. Interview on 08/20/25 at 3:21 pm, CNA R stated she remembered Resident #1, he had a sore on his butt more like circular and sometime would see just a little blood coming from it last year 2024. Interview on 08/22/25 at 4:16 pm, former CNA U stated Resident #1 had a wound and noticed it when she started working at that facility last September 2024. Interview on 08/20/25 at 4:21 pm, DON O stated the physician orders were supposed to be followed and the nursing staff worked under the Doctors. He stated they could not do anything arbitrarily and do something different than what the Doctor ordered. Interview on 08/21/25 at 4:57 pm, the Administrator stated ADON G and DON O could not override what the Doctor's orders were. She stated the Doctors orders superseded what ADON G and DON O thought and they should also follow the Doctor's orders to ensure the residents received proper treatment. Interview on 08/21/25 at 5:42 pm, ADON G stated she had a training about wound care from DON O yesterday (08/19/25) and another wound care training by text from the RN Consultant today (08/20/25). She stated if it is a wound and the resident had a wound care consult order, she was going to make sure the referral was sent to the Wound Care Doctor. She stated she was going to send it to the Wound care Doctor regardless of what she thought because it was a Doctor's order. Record review of the Facility's QAPI policy dated February 2020 revealed, Policy Statement: This facility shall develop, implement, and maintain an ongoing, facility wide, data-driven QAPI Program that is focused on indicator of the outcomes of care and quality of life for our residents. Policy Interpretation and implementation: 1. Provide a means to measure current and potential indicators for outcomes of care and quality of life. 2. Provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators. Authority 1. The owner and/or governing board (body) of our facility is ultimately responsible for the QAPI program. Implementation:1. The QAPI Committee oversees implementation of our QAPI Plan, which is the written component describing the specifics of the QAPI program, how the facility will conduct its QAPI functions, and the activities of the QAPI Committee.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure they provided pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one (Resident #1) of 12 residents reviewed for Pharmacy services. The facility failed to ensure LVN H and LVN X gave Resident #1 his Ammonium Lactate ointment on his lower legs as prescribed by his doctor on [DATE], [DATE], [DATE], [DATE] and [DATE][BH1] prior to discharge on [DATE]; Subsequently, the nurses stated it was unavailable with no documentation as to why. This failure could affect all residents by placing them at risk of going without their medications which could cause a resident to have a decline in health and psycho-social well-being.Findings included: Record review of Resident #1's Quarterly MDS assessment dated [DATE] by RN W revealed, a [AGE] year-old male who admitted [DATE]. He had a BIMS score 15 (no cognitive impairment) and had upper and lower extremity impairment on both sides and dependent - helper did all effort for all ADL's. He was always incontinent with bladder and frequently incontinent with bowel and he had medically complex conditions. His diagnoses was Malnutrition, depression, Amyotrophic lateral sclerosis, adjustment disorder, GERD, other lack of coordination, chronic pain, dysphagia. Skin Conditions: At risk of developing pressure ulcers/injuries, no skin conditions. Record review of Resident #1's Order Recap Report printed [DATE] revealed, Apply zinc oxide to buttock as needed for Wound (started [DATE] - [DATE]) by Doctor J. Ammonium Lactate External Cream 12 % (Lactic Acid (Ammonium Lactate) Apply to both lower extremities topically two times a day for dry skin (start [DATE] - [DATE]). Hydrocortisone External Lotion 2.5 % (Hydrocortisone (Topical)) Apply to Skin topically two times a day for itchy areas Resident able to state where itch is occurring (started [DATE] - [DATE]). Mupirocin External Ointment 2 % (Mupirocin) Apply to affected areas to RLE topically two times a day for skin infection until [DATE] Apply to RLE x 10 days (start [DATE] - [DATE]). Record review of Resident #1's Care plans printed [DATE] and date initiated [DATE] revealed, Resident #1 have bowel incontinence related to immobility & Amyotrophic Lateral Sclerosis: Interventions: check resident every two hours and assist with toileting as needed, provide loose fitting, easy to remove clothing, provide pericare after each incontinent episode and see care plans on mobility, ADL's, Cognitive deficit, communication. And date initiated [DATE] - Resident #1 have potential impairment to skin integrity related to impaired mobility and incontinence; he prefers to have incontinent pad in recliner chair: Interventions: avoid scratching, and keep hands and body parts from excessive moisture. Educate resident/family/caregivers of causative factor and measures to prevent skin injury. Encourage good nutrition and hydration in order to promote healthier skin. Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Record review of Resident #1's MARs/TARs dated [DATE] - [DATE] revealed , Ammonium Lactate external cream 12% apply to both lower extremities topically two times a day for dry skin (start date [DATE] - DC date [DATE]). Hydrocortisone External lotion 2.5% topical apply to skin topically two times a day for itchy areas resident able to state where itch is occurring (start date [DATE] and DC date [DATE]). Apply zinc oxide to buttock as needed for wound (start date [DATE] and DC date [DATE]). Mupirocin external ointment 2% apply to affected areas to RLE topically two times a day for skin infection until [DATE], apply to RLE x 10 days (start date [DATE] - DC date [DATE]. Record review of Resident #1's MAR/TARS dated [DATE] revealed, Ammonium Lactate External Cream 12 % (Lactic Acid Ammonium Lactate) Apply to both lower extremities topically two times a day for dry skin apply ammonium lactate -Start Date- [DATE] 6:00 pm -D/C Date- [DATE] 10:09 am. It was coded other/see nurses notes: unavailable for the dayshift on [DATE], [DATE], [DATE], [DATE] and [DATE] and night shift on [DATE] was coded hold/see nurses notes. Record review of Resident #1's Nurses Note dated [DATE] at 1:32 pm by LVN H revealed, Several dry yellow crusted over areas to BLE observed MD made aware will continue to implement current plan of care. Record review of Resident #1's Nurses Note dated [DATE] 10:15 am LVN H revealed, New order furosemide 20 mg 1 tab x 10 days Bactroban apply to affected area to RLE BID x 10 days ammonium lactate cream apply to BLE - NP I. Record review of Resident #1's Nurses Note dated [DATE] at 1:41 pm by LVN H revealed, Ammonium Lactate External Cream 12 % Apply to both lower extremities topically two times a day for dry skin apply ammonium lactate NA. Record review of Resident #1's Nurses Notes dated [DATE] at 8:36 pm by LVN X revealed, Ammonium Lactate External Cream 12 % Apply to both lower extremities topically two times a day for dry skin apply ammonium lactate medication unavailable. Record review of Resident #1's Nurses note dated [DATE] at 11:52 am by LVN H revealed, Ammonium Lactate External Cream 12 % not available. Record review of Resident #1's Nurses note dated [DATE] at 12:51 pm by LVN H revealed, Ammonium Lactate External Cream 12 % Apply to both lower extremities topically two times a day for dry skin apply ammonium lactate not available. Record review of Resident #1's Nurses noted [DATE] at 10:09 am by LVN H revealed, Ammonium Lactate External Cream 12 % not available to administer noted. Record review of Resident #1's Nurses note dated [DATE] at 9:09 am by LVN H revealed, Ammonium Lactate External Cream 12 % Apply to both lower extremities topically two times a day for dry skin apply ammonium lactate not available. Interview on [DATE] at 10:21 am, NP I stated he was the NP for Doctor J and saw Resident #1 before he discharged the facility [DATE]. He stated oh yes he remembered Resident #1 very well, he used a tablet to communicate with and had ALS because he could not talk (speak). He stated he discharged to another place. He stated he saw Resident #1 once or twice before he discharged this facility in [DATE]. He stated he did a head to toe assessment and his legs were swollen and he ordered a water pill for him to start taking. He stated Resident #1 had a couple of skin issues, a wound on butt and rash on his lower leg. He stated the only issues Resident #1 had was his legs were swollen and he had the wound on his buttock. Interview on [DATE] at 9:44 am, NP I stated when he assessed Resident #1 in [DATE], he could not remember the size of his butt wound but there was no odor or draining. He stated Resident #1 had a wound in the crack of his butt area. He stated Resident #1 had wound care orders but said ‘Let's make changes to his orders' and added the mupirocin ointment for his butt crack wound. Interview on [DATE] at 10:00 am, LVN H stated honestly she could not remember if Resident #1 had a wound care consult or treatment order because he was here a while ago in 2024. She stated she could not remember if she put any dressings on his lower leg but something was being put on it. She stated she never talked to the Wound care Doctor about Resident #1 and he was not seen by the Wound care Doctor. She stated for the ammonium lactate it was a possibility the pharmacy was saying it was an over the counter or cost too much and was not really sure. She stated Resident #1 probably had some ammonium lactate that was expired she was not really sure. She stated the NP back when Resident #1 was here was NP I. Interview on [DATE] at 12:24 pm, the Administrator stated the DON and Pharmacist did the monthly medication reconciliation of the resident's Doctor's orders to determine if there were any discrepancies. She stated if a resident was prescribed medication, the nurses needed to call the Doctor if it was unavailable. She stated the nurses needed to see if there was an alternate medication they could get or be put on hold. She stated If a resident were prescribed medication and not given she was not sure what could happen to the resident. Interview on [DATE] at 12:31 pm, DON O stated after review he stated there was no documentation on why the ammonium lactate was unavailable. He stated he was not sure why the ammonium lactate was not given to Resident #1 in [DATE]. He stated he would check to see why it was not given and unavailable. Interview on [DATE] at 1:01 pm, ADON G stated the staff needed to ensure the residents orders were followed through on. She stated it was the nurses responsibility to ensure the orders were done. She stated every month nurse management reviewed all of the residents physician orders that was then signed by the doctors sign. She stated the facility's Pharmacist came to the facility monthly to review the resident's medications and signed off on review of the medications. She stated the Pharmacist reviewed the medication findings with DON O of any concerns. She stated Resident #1 had a skin disorder of dry and scaly skin and had a rash in [DATE] and could not remember where it was. She stated she was not sure why Resident #1's ammonium sulfate was unavailable and would have to look in the computer. Interview on [DATE] at 1:16 pm, Doctor J stated Resident #1 had some skin issues on his legs and a wound on his bottom [DATE] and sometime in [DATE]. He stated none of the staff called him about any issues with Resident #1's ammonium lactate order being unavailable and it was not discontinued. He stated typically if the nurses could not get a medication was because it was not in stock or not covered by the insurance, then they would get another medication for the residen. Interview on [DATE] 3:47 pm, DON O stated for the ammonium lactate, he spoke to the dayshift nurse LVN H and she said it was not available. He stated he was not sure why LVN H did not contact Resident #1's Doctor/NP or pharmacy. He stated LVN H said she did not contact the Doctor or pharmacy because she felt like Bactroban and ammonium lactate were the same. He stated if the medication was not available the nurse should have called to see if it was a hold and ask the pharmacy for an alternate medication. He stated the nurses should have talk to him if they didn't have the ammonium lactate. Interview on [DATE] 4:15 pm, ADON G stated Resident #1 discharged this facility [DATE]. She stated the nurse said Resident #1's ammonium lactate was unavailable and after she spoke to LVN H she said it was not available. She stated LVN H should have notified Doctor J to get a substitute medication and let nurse management aware to assist with ensuring the resident received his medication. Record review of ADON G's email dated [DATE] at 3:52 pm revealed, I'm unaware of the resident not receiving ammonia lactate medication. The mar shows the other shifts administered cream except for the 6-2 shift with LVN H. The charge nurse communicates between the doctors regarding skin issues. 12/10 & [DATE] show in the nurses' notes that the charge nurse communicated skin issues with the MD. The charge nurses are responsible for communication; they complete skin assessments and notifications. Interview on [DATE] at 4:51 pm, the Administrator stated she was not aware Resident #1 was not given his ammonium lactate for several days before he discharged [DATE], because it was unavailable. She stated the pharmacist reviewed the medication and doctors reviewed the documentation. She stated the clinical team was responsible for ensuring the medications were accurately being given. She stated she was not sure who was ultimately responsible for ensuring the medications were accurate. Interview on [DATE] at 4:21 pm, DON O stated if a resident's medication was not available the nurse needed to call the Doctor and pharmacy for further guidance. He stated if the medication was not in stock the nurses should call the Doctor to see if there was an equivalent available. He stated he was not able to determine why Resident #1 did not get the ammonium lactate twice per day. He stated LVN H said the ammonium lactate was not available and said he was not sure if LVN H did not look in the medication cart if the ointment was missing she should have called the Doctor and/or pharmacy to see if there was some type of insurance issue. He stated they did a 1:1 training with LVN H because of this issue. He stated he could see RN E gave the ammonium lactate to Resident #1 at night and LVN H was aware if the medication were not available she should have made an attempt to get it then told himself or the ADON about it to address. He stated the physician orders were supposed to be followed and the nursing staff worked under the Doctors. He stated they could not do anything arbitrarily and do something different than what the Doctor ordered. Interview on [DATE] at 4:57 pm, the Administrator stated she was not sure why Resident #1 did not get the ammonium lactate ointment for his legs. She stated some nurses gave Resident #1 the ointment and others did not.[ She stated for Medication administering the ADON and DON were responsible for ensuring the services were being done. Record review of LVN H's Record of in-service dated [DATE] by DON O revealed, If medications aren't available, it is the charge nurses responsibility to call pharmacy. Meds (Medications) can be pulled from E-kit if not available. MD notification must be made so med (medication) can be placed on hold and/or change to an alternative. and this document was signed by LVN H. Record review of the facility's Medication and Administration Policy Revised [DATE] revealed, Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 2. The Director of Nursing Services supervises and directs all personnel who administer medications and/or have related function. 4. Medications are administered in accordance with prescriber orders, including any required timeframe.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete and accurately documented for one (Resident #1) of 12 residents reviewed for Medical records. The facility failed to ensure the IDT or MDS Coordinator added Resident #1's Pressure Injury on buttocks, unstageable diagnosis to his EMR profile, after he was [BH1] diagnosed on [DATE] with it and prior to his discharge on [DATE]. This failure could affect all residents by placing them at risk of getting missed care and treatments if no one were aware of their diagnosis, which could lead to decreased health and psycho-social well-being. Findings included: Record review of Resident #1's Quarterly MDS assessment dated [DATE] by RN W revealed, a [AGE] year-old male who admitted [DATE]. He had a BIMS score 15 (no cognitive impairment) and had upper and lower extremity impairment on both sides and dependent - helper did all effort for all ADL's. He was always incontinent with bladder and frequently incontinent with bowel and he had medically complex conditions. His diagnoses was Malnutrition, depression, Amyotrophic lateral sclerosis, adjustment disorder, GERD, other lack of coordination, chronic pain, dysphagia. Skin Conditions: At risk of developing pressure ulcers/injuries, no skin conditions. Record review of Resident #1's MARs/TARs dated 12/01/24 - 12/19/24 revealed, Ammonium Lactate external cream 12% apply to both lower extremities topically two times a day for dry skin (start date 12/12/24 - DC date 12/20/24). Hydrocortisone External lotion 2.5% topical apply to skin topically two times a day for itchy areas resident able to state where itch is occurring (start date 03/05/24 and DC date 12/20/24). Apply zinc oxide to buttock as needed for wound (start date 05/26/24 and DC date 12/20/24). Mupirocin external ointment 2% apply to affected areas to RLE topically two times a day for skin infection until 12/22/24, apply to RLE x 10 days (start date 12/13/24 - DC date 12/20/24. Record review of Resident #1's Order Recap Report printed 08/14/25 revealed, Resident may be seen by Wound care Dr. V, for evaluation and treatment. every 7 day(s) for open areas noted on baseline skin assessment Verbal 09/27/2024 start 09/28/2024 and DC 12/20/2024 by Doctor J. Apply zinc oxide to buttock as needed for Wound (started 05/26/24 - 12/20/24) by Doctor J. Ammonium Lactate External Cream 12 % (Lactic Acid (Ammonium Lactate)) Apply to both lower extremities topically two times a day for dry skin (start 12/12/24 - 12/20/24). Hydrocortisone External Lotion 2.5 % (Hydrocortisone (Topical)) Apply to Skin topically two times a day for itchy areas Resident able to state where itch is occurring (started 03/05/24 - 12/20/24). Mupirocin External Ointment 2 % (Mupirocin) Apply to affected areas to RLE topically two times a day for skin infection until 12/22/2024 Apply to RLE x 10 days (start 12/13/24 - 12/20/24). Record review of Resident #1's Care plans printed and date initiated 03/18/23 revealed, Resident #1 have bowel incontinence related to immobility & Amyotrophic Lateral Sclerosis: Interventions: check resident every two hours and assist with toileting as needed, provide loose fitting, easy to remove clothing, provide pericare after each incontinent episode and see care plans on mobility, ADL's, Cognitive deficit, communication. And date initiated 04/24/23 - Resident #1 have potential impairment to skin integrity related to impaired mobility and incontinence; he prefers to have incontinent pad in recliner chair: Interventions: avoid scratching, and keep hands and body parts from excessive moisture. Educate resident/family/caregivers of causative factor and measures to prevent skin injury. Encourage good nutrition and hydration in order to promote healthier skin. Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface.(Resident #1 did not have a Care plan for pressure injuries anywhere in his EMR profile). Record review of Resident #1's Progress Note by NP B dated 01/31/25 revealed, Diagnosis, Assessment and Plan - Assessment ICD Codes L89.300 Pressure injury of buttock, unstageable. Plan Discussed with Nursing & patient Apply zinc oxide in area and cover with dressing. Try to offload pressure to area. Record review of Resident #1's Nurses Note dated 01/31/2024 at 09:41 am by LVN A revealed, Reopened area about resident Left buttock area about 0.2x0.2cm. NP B here notified. New order noted -apply zinc oxide QD until healed. RP notified. Record review of Resident #1's Nurses note dated 05/26/2024 at 10:17 pm by LVN C revealed, Resident said the buttocks wound are healed. MD notified and changed zinc oxide cream qd to PRN. Call light in reach. Record review of Resident #1's Nurses note dated 07/08/2024 at 09:22 am by Nurse D revealed, Nurse asked about buttocks abrasion and resident stated it is healing. Will continue to monitor. Record review of Resident #1's Nurses note dated 07/10/2024 1:17 pm by Nurse D revealed, Nurse asked resident about buttocks wound after his shower and resident verbalized it is healing. Record review of Resident #1's Nurses Notes dated 07/10/2024 at 10:09 pm by RN E revealed, Nurse cont. to monitor wound to buttocks, no s/s of infection noted. Resident stable, alert and oriented x 4 with no s/s of pain or distress noted at this time. Vitals within normal range. Call light within reach. Will continue with care plan. Record review of Resident #1's Nurses Notes dated 07/23/2024 at 2:36 pm by Nurse D revealed, Nurse did wound care treatment per residents request because both residents buttocks cheeks skin was irritating him. Record review of Resident #1's Nurses Notes dated 09/16/2024 at 8:07 pm by LVN E revealed, Resident requested for wound consult for pressure wound to buttock. MD notified, waiting for response. Resident stable, alert and oriented x 4 with no s/s of pain or discomfort noted at this time. Vitals within normal range, call light within reach, will continue with care plan. Record review of Resident #1's Nursing Notes dated 09/26/2024 at 10:47 pm by Former DON F revealed, Baseline skin assessment completed. Noted open areas to sacral area. Refer to wound care doctor to evaluate and treat. Continue to monitor. Record review of Resident #1's Nurses Note dated 09/27/2024 at 2:36 pm by Former DON F revealed, Follow up to baseline skin assessment findings. Resident was referred to [Wound care] Dr. for eval and treatment. Face sheet and medication list faxed, order is in the system. Record review of Resident #1's Nurses Notes dated 11/03/2024 at 1:30 pm by LVN C revealed, Apply zinc oxide to buttock as needed for Wound Full shower provided. Excoriation and peeling skin to buttocks. No bleeding. BP=115/80, P=76, T=97.6, O2 SAT (saturation)=98, ROOM AIR, R=18. Will monitor. Record review of Resident #1's Weekly Skin Observation Tool dated 12/03/24 revealed, Does the resident have any observed skin issues? Yes- 3.Excoriation to buttocks: Dry skin to lower extremities, shoulders, thighs, abdomen, shoulders, calves; Eczema on abdomen. Healing blister to right inner thigh. Interview on 08/18/25 at 10:21 am, NP I stated he was the NP for Doctor J and saw Resident #1 before he discharged the facility December 2024. He stated oh yes he remembered Resident #1 very well, he used a tablet to communicate with and had ALS because he could not talk (speak). He stated he discharged to another place. He stated he saw Resident #1 once or twice before he discharged this facility in December 2024. He stated he did a head to toe assessment and his legs were swollen and he ordered a water pill for him to start taking. He stated Resident #1 had a couple of skin issues, a wound on butt and rash on his lower leg. He stated the only issues Resident #1 had was his legs were swollen and he had the wound on his buttock. Interview on 08/19/25 at 9:44 am, NP I stated when he assessed Resident #1 in December 2024, he could not remember the size of his butt wound but there was no odor or draining. He stated Resident #1 had a wound in the crack of his butt area. He stated Resident #1 had wound care orders but said ‘Let's make changes to his orders' and added the mupirocin ointment for his butt crack wound. Interview on 08/19/25 at 12:24 pm, the Administrator stated she would have to review Resident #1's records and was not aware the pressure injury diagnosis was not added to Resident #1's EMR profile. Interview on 08/19/25 at 1:16 pm, Doctor J stated Resident #1 had some skin issues on his legs and a wound on his bottom January 2024 and sometime in May 2024. He stated Resident #1 was diagnosed with a pressure wound of his sacral area and that the Wound Care Doctor had treated it. He stated he did not know that Resident #1 had not been assessed by the Wound Care Doctor. Interview on 08/19/25 3:47 pm, DON O stated he was not sure why his pressure injury was not added to his medical records because he was not working here at the time. Interview on 08/19/25 at 4:38 pm, MDS P stated she was the person who updated the resident's diagnosis in the EMR. She stated when the Facility Doctors diagnosed a resident they should be added to the resident's medical record. She stated she looked at the residents progress notes from the facility doctors and outside doctors to add diagnoses. She stated she was responsible for ensuring the diagnoses were added to the EMR. She stated if the diagnoses were not added to the EMR the staff wound not know what was going on with the resident. She stated not adding the diagnoses could cause anything to happen like infections and hospitalizations. Interview on 08/20/25 at 12:46 pm, MDS P stated she went over the resident's documentation weekly by using a calendar to check five residents per day to review their nurses notes, doctor's notes and hospital records and psychiatric records for any new additions to the resident's EMR profile. She stated if the diagnosis were not added, the resident could have a change of condition and need to go to the hospital or get infections. She stated the resident might receive improper care or not get the right treatment for a skin issue. Interview on 08/20/25 at 4:21 pm, DON O stated not being sure why Resident #1's pressure Ulcer of buttock diagnosis was not added to his medical record and if the doctor put it on a progress note, it should have been added. He stated Resident #1's pressure ulcer diagnosis should have been added to his diagnosis profile and been care planned. He stated not having a diagnosis added to a resident records runs the risk of the diagnosed condition not being treated. Interview on 08/21/25 at 4:57 pm, the Administrator stated the MDS Coordinator was responsible for ensuring medical records were accurate. Interview on 08/21/25 at 5:42 pm ADON G stated she was not sure why Resident #1's pressure ulcer of buttock diagnoses was not added to his EMR profile. She stated she was not sure of the timeframe diagnosis should be add and would assume within a couple of days depending on what it is. Record review of the Facility's Medical records policy was requested 08/19/25 at 5:14 pm and 08/21/25 at 5:24 pm and the Administrator stated the facility did not have one.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive assessment and quarterly review assessments for one (Resident #1) of four residents were reviewed for comprehensive care plans. The facility failed to review and revise Resident #1's care plan quarterly and after each assessment. This failure could affect residents by placing them at risk for not having their individual needs met. Findings included: Record review of Resident #1's Face Sheet printed 01/07/2025, reflected a [AGE] year-old male who was admitted to the facility initially 09/29/2017 and readmitted on [DATE] with diagnoses to include but not limited to end stage renal disease (gradual loss of kidney function), history of open wound left foot, type 2 diabetes with mellitus with foot ulcer (is a chronic condition that happens when you have persistently high blood sugar levels), peripheral vascular disease (slow and progressive disorder of the blood vessels). Record review of Resident #1's annual MDS, dated [DATE], reflected a BIMS score of 11 which indicated moderate impairment. Review of section GG indicated Resident #1 was dependent on staff for ADL's. Review of section M0150 indicated Resident #1 was at risk for pressure ulcers. Record review of Resident #1s care plan revised 01/9/2024 reflected, Resident #1 resisted care, taking medications, eating food from facility kitchen at times, showers/ADL care and attending dialysis. Resident #1 refused therapy on several occasions. Interventions included encourage as much participation/interaction by the resident as possible during care activities and give clear explanation of all care activities prior to and as they occur. Review of Resident #1's care plan conference revealed the last care plan was held 06/13/2024. Interview on 01/07/2024 at 2:17 PM with the Social Worker revealed care plan conferences were conducted every 3 months. The Social Worker stated the last care plan meeting should have been in September however was not completed due to an oversight. The Social Worker stated he was not working at the facility in September however would review resident files to ensure care plan meetings were being held quarterly. The Social Worker stated care plan meetings needed to be completed so that residents or responsible party would be updated on resident care. The Social Workers stated he was working on ensuring care plan conferences were done at the same time as the MDS. Interview on 01/08/2024 at 2:30 PM with the Administrator revealed the Social Worker was responsible for ensuring the care plan meetings were held quarterly. The Administrator stated the care plan meeting was likely missed due to the facility being in transition between Social Workers. The Administrator stated she was not sure if other care plan meetings were missed during that time. The Administrator stated she did not think there was a risk to residents due to care plan meetings not being completed due to any changes of condition being discussed in morning and evening meetings. Review of the policy Care Plans, Comprehensive person- Centered revised December 2016 The Interdisciplinary Team must review and update the care plan. At least quarterly, in conjunction with the required quarterly MDS assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews, the facility failed to obtain from hospice the most recent hospice plan of care specific to each patient needs for 1 of 3 residents (Resident #59) reviewed for hospice services. The facility failed to ensure Resident #1' s hospice care was care planned. This failure could place residents at risk of needs not being met. Findings include : Record review of Resident #1's electronic face Sheet, dated 02/29/24, revealed she was a 73 -year-old female admitted on [DATE] with diagnosis that included malignant neoplasm of corpus uteri (endometrial cancer), chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs. Review of Resident #1's Comprehensive Care Plan dated on 11/21/23 reflected no care plan for hospice care. Record review of Resident #1's doctor order dated 1/22/24 revealed patient admitted to hospice on 1/22/24. Interview on 02/29/24 at 2:40PM with the DON revealed hospice care plans are kept in PCC and it would be the MDS nurse who would make sure the care plan included hospice services. Interview on 02/29/24 on 2:56 PM with the MDS coordinator revealed IDT meetings were conducted daily to discuss changes to resident care. She stated the care plan was updated as needed and quarterly and annually. She stated if a resident was receiving hospice services it should be documented on the care plan. The MDS Coordinator stated the risk of not updating the care plan would be staff would not have a full picture of the resident care. Interview on 02/29/24 at 3:30PM with the administrator revealed the IDT team discusses needs of the residents daily and stated if a resident was on hospice it would need to be documented on the care plan. The Administrator was not sure why Resident #1's care plan did not contain the hospice information. The administrator stated there was not a risk to the resident due to hospice services not being documented on the care plan due to hospice being in the building 3-5 times a week and there being a hospice binder. Review of the facility policy Charting and documentation revised July 2017 All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the transfer or discharge was documented in the resident's medical record and appropriate information was communicated to the receiving health care institution or provider for one (Resident #1) of 4 residents reviewed for facility-initiated discharges. The facility failed to provide documentation for an immediate facility-initiated discharge for Resident #1 that the resident's needs could not be met and attempted to meet the resident's needs. The failure could affect residents by placing them at risk of not having access to adequate care in a nursing home facility. Findings included: Review of Resident #1's admission record, dated 01/07/24, revealed the resident was a [AGE] year-old male, admitted to the facility on [DATE], and discharged on 01/02/24, with the diagnoses of hemiplegia (brain damage or spinal cord injury leading to paralysis), dementia, epilepsy (seizure), and acute kidney failure. Review of Resident #1's Quarterly MDS Assessment, dated 10/01/23, revealed Resident #1 had a BIMS score of 6, which indicated severe cognitive impairment. Review of Resident #1's care plan, revised on 01/05/24, revealed Resident #1 had a history of substance abuse and cannabis usage with interventions of observe for signs and symptoms of impairment. There were no other interventions listed. Interview on 01/06/24 at 10:15 AM with the Administrator revealed Resident #1 was admitted to the hospital on [DATE] for a possible seizure. Upon admission to the hospital, the resident tested positive for illegal substances (methamphetamine and cocaine). The Administrator stated APS was contacted and that based on the facility's drug policy, the resident was provided a notice to move. She stated that she suspected the family was bringing drugs to the resident. Interview on 01/06/24 at 10:33 AM with the DON revealed Resident #1 was sent to the hospital on [DATE] due to the family stating he was choking. She stated Resident #1 was verbal, even if his BIMS score was 6 (which indicated severe cognitive impairment). The DON stated the resident had been to the hospital before on 11/22/23 due to a stroke and tested positive for cannabis and methamphetamine. The second time the resident went to the hospital on [DATE], the resident was found with cocaine in his system. Interview on 01/06/24 on 4:17 PM with Resident #2, Resident #1's roommate, revealed he used to smoke marijuana and would know if anyone smoked it. Resident #2 stated Resident #1 had a g-tube and Resident #2 would know if anyone put medications or drugs into his feed. Interview on 01/06/24 at 6:15 PM with the Administrator and the DON revealed the facility could not readmit Resident #1 to the facility because the facility would not have been able to meet the resident's needs. She stated with the resident unpredictably taking illegal substances from the resident's family, the facility would not be able to ensure the resident did not have adverse effects to the medications the resident was already prescribed. The Administrator and the DON stated with substance abuse, the facility would then be required to constantly adjust the medications, which placed the resident at risk for side effects the facility would be liable for. Review of Resident #1's hospital records, dated 11/27/23, revealed toxicology urine drug screen positive for cannabis and benzodiazepines. Review of Resident #1's hospital records, dated 01/03/24, revealed toxicology urine drug screen positive for polysubstance abuse, positive for methamphetamines, and positive for cocaine. Hospital record reviewed that patient's wife who reports she is concerned that his sister may have brought elbow brownies to him at the local skilled nursing facility. Resident #1 was monitored for withdrawal symptoms. Review of Resident #1's electronic record revealed no evidence of a 30-day notice provided to Resident #1, a discharge summary, documentation of contact with the resident's physician to indicate transfer or discharge was necessary. Review of the facility's Transfer or Discharge Notice, revised 03/2021, revealed no mention of immediate discharge due to drug use. Documents and related policy supporting Resident #1's immediate discharge with the rationale that the resident's needs could not be met was requested on 01/06/24 at 6:15 PM. The facility did not provide any documentation at exit .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain medical records that were complete and accurately documented for 1 (Resident #1) of 6 residents reviewed for accurate charting. The facility failed to ensure nursing staff accurately documented controlled substance administration for Resident #1. This failure placed residents at risk of receiving incorrect dosages of prescribed medication. Findings included: Review of Resident #1's admission record revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included: major depressive disorder (mood disorder), panic disorder, muscle spasms, and paraplegia (paralysis of legs). Review of Resident #1's quarterly MDS assessment, dated 03/29/23, revealed Resident #1 had a BIMS score of 15, which indicated he was cognitively intact. His Functional Status revealed he required limited or extensive assistance with most of his ADLs. Review of Resident #1's care plan, dated 01/31/23, revealed Resident #1 used a mood stabilizer/anticonvulsant medication related to unspecified convulsions. Record review of Resident #1's order summary, dated 04/27/23, revealed he had an order to receive 1 tablet of Clonazepam 1 mg three times a day for anxiety. Record review of Resident #1's Controlled Substance Record (CSR), supplied from the pharmacy at time of delivery, revealed Resident #1 had 20 Clonazepam 1 mg on 05/14/23, and MA B signed off for doses #1 and #2 on 05/15/23; indicating that she only administered 2 tablets of Clonazepam 1 mg on that date. MA B did not document the balance of tablets remaining after neither dose administered. She only documented the date, time, and her signature. Record review of Resident #1's CSR, recreated by the DON, revealed Resident #1 had 20 Clonazepam 1 mg on 05/14/23. The DON signed off on one wasted dose on 05/14/23 and printed MA B's name for the first three doses on 05/15/23, indicating that MA B had administered 3 tablets of Clonazepam 1 mg on that date, with 17 tablets remaining. Record review of Resident #1's May 2023 MAR revealed Resident #1 received: 3 doses of Clonazepam 1 mg at 9:00 AM, 3:00 PM, and 9:00 PM on 05/15/23, signed off with initials of a staff who was not identified; however, it was not the initials of MA B. Interview on 05/30/23 at 9:50 AM, MA B stated she worked at the facility through an agency and 05/15/23 was her first day ever working there. She stated she was not properly oriented to the facility when she arrived. However, she had knowledge on administering medications, including controlled substances, through her education, trainings, and experience. MA B stated she was given a login to access the system and a key to the medication cart. She stated that she did not count the controlled medications with the off-going nurse and was unsure of how many medications were in the cart before taking over. MA B stated a nurse was taking her key throughout the shift and going in her medication cart. She stated she knew it was not good practice to hand off her key. However, she was new at the facility and did not want to cause problems with the staff. MA B stated she administered 2 doses of Clonazepam to Resident #1 during her shift, at 8:00 AM and 8:00 PM. She stated she was aware that Resident #1 was ordered to receive 3 doses. However, she did not have her key for the afternoon dose and was informed that the medication had been administered. MA B stated she signed off on the CSR for the two doses of medication that she administered and could not recall if she documented the remaining balance of medication. She stated her shift ended at 10:00 PM, and while counting the medications they found that there were missing controlled mediations for Resident #1. She could not recall how many medications were missing. Interview on 05/30/23 at 10:35 AM, the DON stated there was one MA scheduled to work the entire facility on 05/15/23 with a census of about 40 residents. The DON stated agency staff completed a competency and skills check-off before being scheduled for a shift, and they were aware of the expectations before their shift. The DON stated once the medication cart key was handed off to the MA or nurse, it should not be shared between staff. She stated administration of controlled substances should be documented in the MAR and on the CSR to ensure accuracy and prevent medication errors. The DON stated she was informed at approximately 11:00 PM on 05/15/23 that the CSR and medication count did not add up. She stated when she arrived on the morning of 05/16/23, she and LVN A investigated and found that there were no missing medications. The DON stated MA B had filled out the CSR incorrectly, which caused the count to be off. She stated MA B had only signed off for administering 2 doses when 3 doses were given. The DON stated she created a new CSR and added the additional dose, which indicated that the Clonazepam 1 mg was administered three times on 05/15/23 as it was ordered, and that corrected the count. The DON stated she later realized that she should not have created a new CSR to add the additional dose herself, and that she should have had the staff who administered the medication to sign for it on the original CSR provided by the pharmacy. The DON stated the importance of accurately documenting the administration of controlled substance was to ensure that residents received the correct dosages of medications. She stated the risk of inaccurate documenting could be underdosing or overdosing the resident Interview on 05/30/23 at 10:55 AM, LVN A stated he worked on 05/15/23 with MA B. He denied taking the medication cart key during the shift or hearing about other staff taking it. LVN A stated that protocol for taking over a medication cart was to verify the count of all narcotics before receiving the key, and once you have the key it should not be given to anyone else until the end of shift. LVN A stated he assisted the DON with investigating the medication error from the previous night and they found that no medications were missing. However, the CSR was inaccurate. Interview on 05/30/23 at 11:10 AM, Resident #1 stated he had not missed any doses of medications. He stated that he was familiar with his medications and could tell if a dose was missed by how he felt. He stated that he had not experienced any increased spasms or pain. Review of the facility's current, undated policy titled Policies and Procedures for Pharmaceuticals Services, reflected in part the following: .Schedule Medication Inventory Sheets: The pharmacy will send scheduled medication sign off sheets for each scheduled medication. The scheduled inventory medication sheet should be completed for each dose administered. .Drug Diversion: The facility must have a system that records receipt, usage, and disposition of all controlled substances in sufficient detail that permits for an accurate reconciliation. .Following Medication Administration: Following resident medication administration, facility staff should appropriately document medication administration .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to review and revise the person-centered care plan to reflect the current condition for 2 (Residents #8 and #27) of 6 residents reviewed for care plan revisions. The facility failed to ensure Resident #8's care plan was updated to reflect her desire for positioning while eating and taking medications. The facility failed to ensure Resident #27's care plan was updated to reflect his refusal for treatment concerning his diabetic ulcers on his feet. This deficient practice could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs. Findings included: Record review of Resident #8's face sheet dated 05/02/2023, indicated a [AGE] year-old female who initially admitted on [DATE] and readmitted on [DATE] with diagnoses which included Multiple Sclerosis (a disease of the muscles and nerves) and atherosclerotic heart disease (a disease of the heart and the heart valves being stopped up). Record review of Resident #8's quarterly MDS dated [DATE], indicated she was always understood and always understood others. Resident #8 had a BIMS of 12 (Indicated she is moderately impaired for decision making). Section G reflected Resident #8 required no assistance to eat. Record review of Resident #8's comprehensive care plan dated 12/02/2022 reflected a potential swallowing problem but failed to indicate the position for eating and taking medications that the resident preferred. Observation on 05/01/23 at 12:15 p.m., revealed Resident #8 lying in her bed with the head of the bed no greater than 30 degrees eating her lunch that was placed on the left side of the bed. Resident #8 stated that she always lies in bed with her head this low or lower and eats, that is what she prefers. Observation on 05/02/23 at 7:41 a.m. with MA E revealed Resident #8 taking her medications lying on her side with the head of the bed lower than 30 degrees. MA E stated this was how she always takes her morning medications, Resident #8 said yes it was that what I want. Record review of Resident #27's face sheet dated 05/02/2023, indicated a [AGE] year-old male who initially admitted on [DATE] and readmitted on [DATE] with diagnoses which included Diabetes Mellitus (inability to control blood sugar), heart disease, and hypertension (elevated blood pressure). Record review of Resident #27's quarterly MDS dated [DATE], indicated he was always understood and always understood others. Resident #27 had a BIMS of 13 (indicated he had normal cognitive functioning). Record review of Resident #27's comprehensive care plan dated 07/14/2022, with revisions on 09/28/22, and 03/17/23 reflected a diabetic ulcer but failed to indicate the refusal of the resident to wear podus boots and refusal to wear appropriate socks that prevent edema to the legs. Review of the Physician orders dated 03/2023 reflected a physician order dated 03/21/23 Podus Boots to bilateral (both) feet while in bed. Observation and interview on 05/01/23 at 11:00 a.m., revealed Resident #27 during wound care for his diabetic ulcers. The resident was wearing socks that were to his knees. LVN F stated to resident you are supposed to wear your low socks, the resident said he would not wear them, he liked these socks. LVN F stated you are supposed to wear your podus boots (pressure relieving boots) when you are in the bed also, the resident replied, I will not wear those things, I hate them. During an interview on 05/02/2023 at 2:00 p.m., the DON stated there was no MDS nurse working at the facility at this time. The DON stated the facility was still having the care plan meetings, and she was updating the care plans. The DON stated she was aware the care plans were not resident specific, as the MDS nurse that was here was not doing that, she [previous MDS nurse] did not think it was necessary. The DON stated this could be a problem for the residents, their desires might not be followed and if you had a new nurse then they would not know how to care for the residents. The DON was not aware that Resident #8 and #27's plan of care was not specific to their needs and desires. During an interview on 05/03/2023 at 2:56 p.m., the Administrator said she expected Resident #8 and #27's care plan to reflect the desired care of the residents. The Administrator said the care plan should reflect a picture of the resident's care needs. The Administrator said the nursing managers and the MDS nurse, were responsible for updating and monitoring the care plan for needed revisions. Record review of the policy and procedure Care Plans, Comprehensive Person-Centered dated March 2022 reflected: A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident . 4. Each resident's comprehensive person-centered care plan is consistent with the resident's' rights to participate in the development and implementation of his or her plan of care, including the right to .d. request revisions to the plan of care; e. participate in establishing the expected goals and outcomes of care; f. participate in determining the type, amount, frequency, and duration of care; . 11. Assessments for resident are ongoing and care plans are revised as information about the residents and the residents' condition change . 12. The interdisciplinary team reviews and updates the care plan . b. when the desired outcome is not met

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for one (400 Hall) of two halls reviewed for environment. The facility failed to ensure windows, furniture, beds, were in good repair for Rooms #411, #409, #405, #408, and the nurse's station. This failure could affect residents and the staff by placing them at risk for diminished quality of life due to the lack of a well-kept environment. Findings included: An observation on 05/08/19 at 07:00 a.m., revealed room [ROOM NUMBER]'s windowsill had wood chipping from the windowsill, and the paint is peeling off halfway across the top and bottom of the window. An observation and interview on 05/02/23 at 7:05 a.m., revealed room [ROOM NUMBER]'s the bed on the B side of the room had a foot board that was on the bed crocked and the side of the foot board was cracked. Resident #19 stated that she felt like she was titling to the side when she looks down there, the resident stated she had not told anyone about the end of her bed, she thought it was up to the facility to see it was crooked and fix it. An observation on 05/02/23 at 7:15 a.m., revealed room [ROOM NUMBER] A the overbed table had all the veneer missing from around the entire edge that surrounds the overbed table. An observation on 05/02/23 at 7:30 a.m., revealed room [ROOM NUMBER] the chest of drawers on the right side of the wall next to the bathroom door had the veneer missing between the first drawer and the second drawer. An observation on 05/02/23 at 8:06 a.m., revealed the only nurse's station in the facility had the Formica (desk top cover) with large areas broken off on the edge with sharp edges along the entire edge of the nurse's station. Interview on 05/02/23 at 12:55 p.m., LVN A revealed if something was broken or needed to be repaired, he would just tell the maintenance man. LVN A stated the maintenance man is usually here and if he was not then he would tell the DON or ADON about the need of repair. LVN A stated that there was no logbook to document in for maintenance repairs and there was no communication system for repairs. Interview on 05/02/23 at 2:00 p.m., the Maintenance Director revealed the staff was to use TELS (computer information system for communicating with maintenance) to communicate the need for repair in the facility, but most of the staff still just stop me and tell me what needs to be fixed. The Maintenance Director said when this happens, I tell the staff member to put it in TELS, so I fix what is in TELS. The maintenance director said he was responsible for the repairs. Interview on 05/02/23 at 2:13 p.m. with the DON revealed the facility staff was supposed to use TELS to communicate the need of repair for anything in the facility, including wheelchairs. The DON stated that the staff stop her and tell her about facility and maintenance needs. The staff has been told they are supposed to use TELS, but I am not sure if they really know how to use it, I do not really know how to use the system. Interview on 05/03/23 at 4:00 p.m., the Regional Director of Operations revealed the facility had no policy and procedure for physical environment. He stated they use TELS for guidance on repairs and communication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable and homelike environment for seven (Resident #2, #10,#15, #23, #44, #99 and #100) of 34 residents observed for wheelchairs, in that: The facility failed to properly maintain wheelchairs for Residents #2, #10, #15. #23, #44, #99 and #100. The wheelchair arm rest pads were torn and cracked with exposed interior foam. The arm rest pads could not appropriatley be cleaned due to the cracked and exposed foam. There was posed a safty problem as the cracked arm rest pads could cause injury to the resdients. These failures could place residents at risk for diminished quality of life and at risk for skin issues and discomfort due to the lack of a well-kept wheelchairs. Findings included: 1.Review of Resident #2's quarterly MDS assessment, dated 03/06/2023, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with the following diagnoses: contracture of muscle right ankle and foot, lack of coordination, and muscle weakness. Resident #2 was moderately impaired for decision making. Review of the Resident #2's plan of care dated 03/10/20/23 with updates reflected goals and approaches to include wheelchair mobility. An observation on 05/01/23 at 12:12 p.m., revealed Resident #2's right side arm rest on the wheelchair was cracked with jagged edges, and the interior padding was exposed. The arm pads were not appropriatley clean. 2.Review of Resident #10's quarterly MDS assessment, dated 04/15/2023, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with the following diagnoses: muscle weakness and lack of coordination. Resident #10's was cognitively intact. Review of the Resident #10's plan of care dated 04/20/23 with updates reflected goals and approaches to include wheelchair mobility. An observation on 05/01/23 at 12:05 p.m., revealed Resident #10's right arm rest was cracked with jagged edges on the wheelchair with the interior padding exposed, with [duct-tape] over the right arm rest. The arm pads were not apporiatley cleaned the [duck tape] was dark with collected dirt. 3. Review of Resident #15's quarterly MDS assessment, dated 03/29/2023, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with the following diagnosis: Alzheimer's. An observation and interview on 05/01/23 at 11:05 a.m., revealed Resident #15 was standing behind a wheelchair in the hallway, that right arm rest was cracked jagged edges on the wheelchair with the interior padding exposed. Resident #15 stated that the wheelchair was not her wheelchair and walked off down the hallway. 4. Review of Resident #23's quarterly MDS assessment, dated 03/29/2023, reflected he was a [AGE] year-old male admitted to the facility on [DATE], with the following diagnoses: difficulty in walking, lack of coordination, and muscle weakness. Resident #23 was severely impaired for decision making. Review of the Resident #23's plan of care dated 03/29/20/23 with updates reflected goals and approaches to include wheelchair mobility. An observation on 05/01/23 at 12:15 p.m., revealed Resident #23's right side and left side arm rest on the wheelchair was cracked with jagged edges, and the interior padding was exposed. The arm pads were not appropriately clean, they were stained with a dark substance. 5. Review of Resident #44's admission MDS assessment, dated 04/26/2023, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with the following diagnoses: chronic obstructive pulmonary disease (difficulty breathing), and rhabdomyolysis ( a condition that causes muscle breakdown). Review of the Resident #44's plan of care dated 04/22/20/23 with updates reflected goals and approaches to include wheelchair mobility. An observation on 05/01/23 at 10:00 a.m., revealed Resident #44's right side and left side arm rest on the wheelchair was cracked with jagged edges, and the interior padding was exposed. The arm rests had a dark dried substance on the top. 6. Review of Resident #99's admission MDS assessment, dated 03/31/2023, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with the following diagnoses: Osteoarthritis of both knees, and repeated falls. Resident #99 was severely impaired for decision making. Review of the Resident #99's plan of care dated 04/20/20/23 with updates reflected goals and approaches to include wheelchair mobility. An observation on 05/01/23 at 10:15 a.m., revealed Resident #99's right side arm rest on the wheelchair was cracked with jagged edges, and the interior padding was exposed. The arm rest could not be cleaned. 7. Review of Resident #100's admission MDS assessment, dated 04/13/2023, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with the following diagnoses: Muscle weakness and reduced mobility. Resident #100 was severely impaired for decision making. Review of the Resident #100's plan of care dated 04/20/20/23 with updates reflected goals and approaches to include wheelchair mobility. An observation on 05/01/23 at 9:45 a.m., revealed Resident #100's right side arm rest on the wheelchair was cracked jagged edges, and the interior padding was exposed with [duct-tape] over the right-side arm rest. The duct tape had a dark gummy substance stuck to it. Interview on 05/02/23 at 12:55 p.m., LVN A revealed if something was broken or needed to be repaired, like a wheelchair he would just tell the maintenance man. LVN A stated the maintenance man is usually here and if he was not then he would tell the DON or ADON about the need of repair. LVN A stated that there was no logbook to document in for maintenance repairs and there was no communication system for repairs. The LVN stated the maintenance man repaired the wheelchairs. LVN A was not aware of any wheelchairs requiring repair. Interview on 05/02/23 at 1:24 p.m., CNA B revealed if something was broken, she would tell the maintenance director or the nurse. CNA B sad she was not aware of any place to document the need for something to be repaired if was broken. CNA B sated she was not aware of any wheelchairs that required repair. Interview on 05/02/23 at 2:00 p.m., the Maintenance Director revealed the staff was to use TELS (computer information system for communicating with maintenance) to communicate the need for repair in the facility, but most of the staff still just stop me and tell me what needs to be fixed. The Maintenance Director said when this happens, I tell the staff members to put it in TELS, so I fix what is in TELS. The maintenance director said he was responsible for the repairs to the wheelchairs; the staff had not communicated to him that there was a need of repair to the wheelchairs. Interview on 05/02/23 at 2:13 p.m., the DON revealed the facility staff was supposed to use TELS to communicate the need of repair for anything in the facility, including wheelchairs. The DON stated that the staff stop her and tell her about facility and maintenance needs. The staff has bee told they are supposed to use TELS, but I am not sure if they really know how to use it, I do not really know how to use the system. The DON said she was aware that the Maintenance director was supposed to repair, wheelchairs. The DON said she was not aware of any wheelchairs that needed repair. Interview on 05/02/23 at 3:20 p.m., the Maintenance Director revealed, when he approached the surveyor and stated now that he was aware of the wheelchair problem, he had made rounds and identified all the wheelchair that required repair and had ordered new arm rest for them, and he had a reminder in TELs now so he would not forget to make rounds and check the wheelchairs in the future. Interview on 05/03/23 at 3:00 p.m., the Administrator revealed that the residents did require wheelchairs that were good repair, and she knew that if the resident did not it could affect their ability to have mobility. Review of the TELs log report reflected for the months of March and April, of 2023, there was no documentation related to the condition of the wheelchairs. Review of facility's policy Assistive Devices and Equipment, dated January 2020 reflected Our facility maintains equipment for residents 1. Certain devices and equipment that assist with resident mobility, safety and independence are provided for residents .these may include .mobility devices (wheelchairs ) 6.device condition-devices and equipment are maintained on schedule .defective or worn devices are discarded or repaired

Based on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for three residents (Residents #17, #38 and #148) of thirteen residents reviewed for palatable food. The facility failed to provide palatable food served at an appetizing temperature to residents who complained the food was cold or not hot during breakfast on 5/1/23 and 5/2/23. This failure could place residents who ate food from the kitchen at risk for weight loss, altered nutritional status and diminished quality of life. Findings included: Review of the facility's temperature log dated 5/2/23 for the breakfast meal revealed that the temperature for eggs was recorded at 179 degrees, the temperature for oatmeal was left blank. In an interview with DA C on 5/2/23 at 11:20 AM, DA C stated that she had forgotten to write the temperature for the oatmeal that morning but thought that it may have been around 198 degrees. She stated that food should be served hot so that residents enjoyed eating the food. In an interview with Resident #17 on 5/1/23 at 10:50 AM, Resident #17 revealed that she generally liked the food at the facility, but that her breakfast was always cold. In an interview with Resident #38 on 5/1/23 at 3:03 PM, Resident #38 revealed that the breakfast would often be served cold, especially the eggs. In an observation on 5/02/23 at 8:08 AM it was observed that the cart containing breakfast trays for residents' rooms was brought to the first hall and all trays had been served by 8:10 AM. In an observation on 5/2/23 at 8:17 AM, the second hall breakfast cart was delivered to the second hall, all breakfast trays were observed to be delivered to the residents' rooms at 8:22 AM. A test tray for the survey team was taken from the second hall breakfast cart at 8:23 AM. In an observation and interview with DON on 5/2/23 at 8:23 AM, the test breakfast tray from the second hall cart was tasted by the surveyors and the DON. The tasting revealed that the scrambled eggs were cold on the edges and tepid in the middle, the toast was found to be cold, and the oatmeal was found to be cold. DON stated that the breakfast food from the test tray was cold and did not taste good. In a private interview with a group of ten residents on 5/2/23 at 11:20 AM, the ten residents all revealed to the surveyor that the food was good at lunch and dinner and was served at a good temperature, but that breakfast was always served cold whether they were served in the dining room or in their rooms. The ten residents all revealed that the eggs and oatmeal were always cold. In an interview with Resident #148 on 5/3/23 at 10:20 AM, Resident #148 revealed that the breakfast was always cold and that she generally waited for lunch and dinner to really eat. A review of the facility policy entitled Test Trays, Policy Number 10.004 and dated 2018 revealed that under the heading Policy it stated that, The facility recognizes the importance of routine assurance monitoring to ensure that its residents are provided food that is appealing, palatable and served at the correct temperatures. Under the heading Procedure' the policy stated that, .evaluation will be conducted at each meal to ensure that food temperatures, portion sizes and diet orders are followed.

Based on observations, interviews and record review the facility failed to store, distribute, and serve food in accordance with professional standards for food safety in the facilities only kitchen. The facility failed to ensure food items past their expiration date were discarded. The facility failed to ensure different types of thawing meats were kept separate to reduce the risk of cross contamination. These failures could place residents at risk for food-borne illness. Findings include: In an observation on 5/1/23 at 10:30 AM several containers of food were stored on the shelves of the walk-in refrigerator, there were a container of pineapple bits dated 4/17/23, a container of applesauce dated 4/18/23, a zip-lock bag containing what appeared to be sausage chunks with no date, a container of tomato soup dated 4/18, and a container of peaches dated 3/25/23. In an observation on 5/1/23 at 10:32 AM a large stainless-steel container was discovered on the bottom shelf of the walk-in refrigerator. The container was observed to have a large ham, a large bag of premade beef/pork meatballs, a large Ziplock bag containing raw ground beef, and another bag containing a turkey breast. In an interview with DM C on 5/02/23 at 8:17 AM, DM C stated that all of the expired food items that were in the walk-in refrigerator the previous day had been discarded. She stated that leftover foods should be discarded after 72 hours from the time the food was placed into the refrigerator and that if residents consumed leftovers that were past their discard date the residents could become ill. In an interview with DA D on 5/02/23 at 11:00 AM, DA D stated that leftover foods had to be dated with the date that it was put into the walk-in refrigerated space. DA D stated that all leftover foods had to be discarded after 72 hours and that if residents ate expired foods, it could cause the residents to become sick. In an interview with DON on 5/03/23 at 2:07 PM, DON stated that if foods were served to residents that were past their respective expiration dates the residents could possibly contract a food borne illness. Review of the facility's policy dated 2018 entitled Food Storage, policy number 03.003, page 2 , section 2 entitled Refrigerators, section e stated that Use all leftovers within 72 hours. Discard items that are over 72 hours old. section f stated that, Store raw meats and eggs on the bottom shelf to prevent contamination of other foods. To avoid cross-contamination, store raw or uncooked food and produce away from and below prepared or ready-to-eat foods. The Food and Drug Administration Food Code dated 2017 reflected, 3-305.11 Food Storage. (A) .food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination .(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking . Date marking is the mechanism by which the Food Code requires active managerial control of the temperature and time combinations for cold holding. Industry must implement a system of identifying the date or day by which the food must be consumed, sold, or discarded.