Glenbridge Health And Rehabilitation

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to resolve and communicate actions taken on concerns and suggestions raised during Resident Council meetings over a period of 10 of 11 reviewed months. Resident Council minutes from February 2025 through January 2026 repeatedly documented resident complaints about showers not being provided as often as desired, food being served late, cold, raw, burnt, or of poor quality, beds not being made, and clothing not being taken to or returned from laundry. Although some Resident Council Concern forms were completed and assigned to departments such as nursing, dietary, and laundry, many forms lacked documentation of what was done to address the concerns, and several months had no concern forms at all despite documented complaints in the minutes. Across multiple months, the Resident Council minutes showed recurring issues without clear follow-up or documented resolution. In February 2025, residents reported late and cold meals, undercooked food, missed showers, unmade beds, and missing or unwashed clothing; concern forms were created for dietary and nursing, but one form had no description of actions taken and another only contained a signature and date. In March and April 2025, residents again voiced concerns about showers, bed-making, missing clothing, and poor or late meals, yet the facility could not provide any corresponding Resident Council Concern forms. In May 2025, residents added complaints about call bells not being answered for long periods, inadequate room cleaning, ill-fitting bed sheets, small or unappetizing food portions, and lack of requested sandwiches; while some concern forms were completed with general departmental responses, the minutes’ “Pending Updates” sections were often blank, and there was no documentation that specific resolutions were communicated back to residents. From June through November 2025 and into January 2026, the same categories of concerns—call light response times, staff turning off call lights without providing care, noisy or disruptive staff at night, insufficient showers, inadequate linens and towels, missing clothing, and dissatisfaction with food quality, variety, and timeliness—continued to appear in the Resident Council minutes. For several of these months (June, July, August, September, October, and November 2025), the facility was unable to produce any Resident Council Concern forms despite documented complaints. When concern forms were completed in January 2026 for laundry, nursing, and dietary issues, some contained only a generic statement that labeled clothing was returned daily, and others were left entirely blank for the department response, signature, and date. During a Resident Council group interview, multiple residents agreed that concerns about call bell response times, cold or late food, and missing clothing were recurring and ongoing, and they stated that Resident Council was never provided communication about what was done or being done to address these issues. The Activity Director and Administrator confirmed that concerns were frequently repeated month to month and acknowledged that the documented department responses often did not truly address the issues raised, and that the expected process of documenting and reporting back resolutions in the minutes was not consistently carried out. The deficiency centers on the facility’s failure to honor residents’ rights related to Resident Council by not effectively resolving and communicating the handling of concerns raised in these meetings. The Resident Council minutes repeatedly documented the same categories of complaints without clear evidence that the facility investigated, resolved, and reported back on these issues in a systematic way. Missing or incomplete Resident Council Concern forms, blank sections for pending updates, and resident reports that they were not informed of any actions taken demonstrate the inaction and lack of communication that led to the cited deficiency.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to implement an effective system to assess residents for the risk of entrapment from bed rails, to monitor and document the ongoing need for bed rails, and to obtain and document informed consent after discussing risks and benefits with residents or their representatives. For four sampled residents, the facility used various bed rails or grab bars without documented evidence of entrapment risk assessment or informed consent. The facility’s own Siderail Data Collection assessments were incomplete, with key sections such as comments and summaries left blank, and no documentation that entrapment risk was evaluated. Additionally, subsequent required reassessments were not completed after the initial dates noted in the records. For one resident with diagnoses including heart failure, acute kidney failure, chronic atrial fibrillation, and diabetes, a Siderail Data Collection assessment documented poor bed mobility, use of side rails for positioning, and a desire to have side rails raised, but contained no comments or summary and no evidence of entrapment risk assessment. A later Nursing Quarterly/Annual/Significant Evaluation assessment indicated the resident did not have any potential restraints, which automatically disabled the side rail review questions, leaving them unanswered. There was no documentation that risks and benefits of side rail use were discussed or that informed consent was obtained, even though observations showed half-length bed rails in the upright position on both sides of the bed, which the resident reported using for bed mobility. Another resident with fibromyalgia, rheumatoid arthritis, low back pain, Alzheimer’s disease with late onset, and dementia had a Siderail Data Collection assessment indicating poor bed mobility, use of side rails for support, and balance difficulties, but again with no comments, no summary, and no documented entrapment risk assessment. The Nursing Quarterly/Annual/Significant Evaluation similarly recorded that the resident had no potential restraints, disabling the side rail review section and leaving all related questions unanswered. No evidence was found that risks and benefits of bed rail use were discussed with the resident or representative or that informed consent was obtained, despite observations of a bed grab bar secured to the bedframe and in the upright position. A third resident with heart failure, COPD, and hypertension had a Siderail Data Collection assessment showing poor bed mobility, use of side rails for support, balance difficulties, and a history of falls, with assist rails/quarter rails selected as the device type. However, there were no comments, no summary, and no documentation of entrapment risk assessment, and no further Siderail Data Collection assessments after the initial date. The Nursing Quarterly/Annual/Significant Evaluation again marked that the resident had no potential restraints, disabling the side rail review questions, and there was no evidence of any discussion of risks and benefits or informed consent for bed rail use. Observations showed quarter-length bed rails in the upright position on each side of the bed, which the resident stated were used for repositioning. A fourth resident with Parkinson’s disease, cerebral infarction, and dementia had a Siderail Data Collection assessment documenting poor bed mobility, use of side rails for support, balance difficulties, and a history of falls, with assist rails/quarter rails selected. As with the other residents, the assessment lacked comments and a summary, and there was no evidence of an entrapment risk assessment or any subsequent Siderail Data Collection assessments. The Nursing Quarterly/Annual/Significant Evaluation recorded no potential restraints, disabling the side rail review questions and leaving them unanswered. The record contained no documentation that risks and benefits of bed rail use were discussed with the resident or representative or that informed consent was obtained, even though repeated observations showed quarter-length bed rails in the upright position on both sides of the bed. Interviews with the DON and Administrator confirmed that the consolidated nursing assessment format caused the bed/side rail review questions to be skipped when staff selected that a device was not a restraint, and that informed consent had not been obtained for residents using grab bars, quarter-length, or half-length bed rails.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Failure to maintain effective systems for acquiring and refilling a controlled medication resulted in a resident missing four consecutive days of a prescribed drug. The resident, admitted with diabetes mellitus and neuropathy, had an order for Lyrica 25 mg once daily for neuropathy. Review of the MAR showed that the 9:00 AM dose of Lyrica was not administered on four specific days, each omission coded to refer to progress notes. Progress notes on each of those days, written by different nurses, documented that the Lyrica was "on order," indicating the medication was unavailable for administration. Multiple nursing staff reported they did not have the Lyrica available on their shifts and documented or reported that the medication was on order. One nurse stated she reordered the medication from the pharmacy and informed the Weekend Supervisor, who later did not recall being notified. Another nurse reported she requested a refill from the Unit Manager, contacted the pharmacy to attempt to pull the medication from the Pyxis, and was told there was no prescription on file, preventing access to the backup supply. She stated she notified the Unit Manager on two separate days that the resident was out of Lyrica and that it could not be pulled from the Pyxis. A third nurse reported she also did not have the Lyrica to administer and stated she informed the Unit Manager. The Unit Manager described a process in which nurses were to call the pharmacy for refills, and the pharmacy would either send the medication or indicate a new prescription was needed. She stated that full-time nurses typically informed her when a new prescription was required, but agency nurses often did not know how to do this, requiring repeated education. She reported being informed that the resident was out of Lyrica, contacting the pharmacy, and being told the medication would be sent, then later being told a new prescription was needed. The Nurse Practitioner stated he received email requests from the facility when controlled medications needed reordering and that he checked these multiple times daily. The Pharmacy Director reported that the last refill of 30 capsules had been delivered previously, that a more recent refill required a new prescription, and that there was no record of an early refill request; she stated that if facility procedures had been followed, there was no reason the medication should have run out. The DON and Medical Director both acknowledged awareness that the resident’s medication had run out, with the Medical Director stating that running out of residents’ medications should never happen.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to obtain and document informed consent for the initiation of a psychotropic medication. A resident with Lewy Body Dementia and severe cognitive impairment, as documented on the admission MDS, had no behavioral symptoms and was receiving antidepressant medications during the assessment look-back period. The December 2025 MAR showed a physician order dated 12/04/25 for risperidone 0.5 mg twice daily for a mood disorder. Review of the resident’s electronic medical record revealed no documentation that the resident’s Responsible Party was informed in advance of the risks and benefits of starting risperidone or that consent to this treatment was obtained. Staff interviews further clarified the breakdown in the facility’s process for obtaining informed consent for psychotropic medications. The Social Worker and Social Worker Assistant, both of whom started in August 2025, reported they were not responsible for obtaining informed consents and stated that the NP was responsible for this task. The NP reported that he had previously been given forms to sign monthly by the former Social Worker, but that this practice stopped when the former Social Worker left, and he acknowledged he was not obtaining informed consents before initiating psychotropic medications, instead only reviewing medications generally during rounds and documenting in progress notes. The DON explained that the prior system relied on the Social Worker to notify the NP when informed consent was needed for new psychotropic medications and stated that this system failed when the last Social Worker left, resulting in the lack of informed consent for the psychotropic medication initiated for this resident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to submit a request for a Level II PASRR evaluation for a resident with serious mental health disorders. Documentation showed the resident had a Level I PASRR determination with no expiration date, and the North Carolina PASRR Level I screen did not list major depressive disorder or bipolar disorder. However, the resident was admitted with diagnoses including metabolic encephalopathy, vascular dementia, anxiety disorder, major depressive disorder, and bipolar disorder. A quarterly MDS assessment documented active psychiatric/mood disorder diagnoses of non-Alzheimer’s dementia, anxiety disorder, depression (other than bipolar), and bipolar disorder, and indicated the resident was not currently considered by the state Level II PASRR process to have a serious mental illness or intellectual disability. The resident was also receiving antianxiety medication during the assessment period. Further record review and interviews revealed that psychiatry had been consulted to review the resident’s psychotropic medications, confirming diagnoses of dementia, insomnia, depression, anxiety, and bipolar disorder, with continuation of buspirone ordered twice daily. The facility was unable to provide documentation that a Level II PASRR evaluation request had been submitted for this resident. The Admission Coordinator stated he did not have access to the NC MUST system and relied on the hospital to initiate PASRR screenings and on the Social Work Assistant to provide PASRR determination letters. The Social Work Assistant reported she did not verify new residents’ diagnoses before providing the PASRR Determination Notification letter and had not been informed by the clinical team to request a Level II PASRR evaluation for this resident. The Administrator confirmed that residents were discussed in daily clinical meetings and acknowledged that a Level II PASRR request should have been submitted for this resident based on the mental health diagnoses.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves failures to ensure medications were administered as prescribed, resulting in two separate medication errors. In the first incident, a nurse administered Adderall XR 20 mg that was prescribed for one resident to another resident with a very similar name. The nurse reported that she was interrupted by another staff member during the morning medication pass, inadvertently entered the wrong room, and gave the medications to the wrong resident. The resident who received the Adderall noticed that there were more pills than usual and stated that they did not look like his pills, but he had already taken the Adderall capsule by the time the nurse attempted to stop him. The resident who received the wrong medication had diagnoses including urinary retention, metabolic encephalopathy, and hypertension, and his cognition was documented as severely impaired. The Adderall XR 10 mg capsules, two by mouth in the morning, were ordered for a different resident with ADHD and moderately impaired cognition. The error was discovered when the nurse compared the remaining pills to the intended resident’s Medication Administration Record and medication cards and determined that Adderall had been given to the wrong resident. The nurse then reported the medication error to the unit manager. In the second incident, another nurse administered an incorrect dose of Lyrica to a resident with diabetes mellitus and neuropathy. The resident had physician orders for Lyrica 25 mg once daily and Lyrica 50 mg at bedtime. Review of the declining count sheet for the 50 mg capsules showed that two 50 mg capsules were removed at a single bedtime administration, resulting in a 100 mg dose instead of the prescribed 50 mg. The error was discovered the following morning by a different nurse when she attempted to administer the morning 25 mg dose, found no 25 mg capsules or count sheet, and noted that two 50 mg capsules had been signed out the previous night. The resident, whose cognition was moderately impaired, was described as drowsy in the morning, which staff stated was not unusual for him, and he was later assessed and monitored after the error was reported. The nurse who made the Lyrica error did not provide a statement, as multiple attempts to contact her were unsuccessful. Facility staff, including the weekend supervisor, unit manager, DON, and NP, confirmed that the resident had received a double dose of Lyrica 50 mg at bedtime instead of the ordered single 50 mg dose. The NP documented that the resident had accidentally received a higher dose of Lyrica than prescribed and that he was awake, alert, and interacting with family at the time of assessment. Both incidents demonstrate that medications were not administered in accordance with the physician’s orders, leading to residents receiving either another resident’s medication or an incorrect dosage of their own medication.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to complete timely and adequate skin and wound assessments, Braden Scale risk assessments, and prompt initiation of treatment for pressure ulcers for three residents. For one resident with hemiplegia, limited mobility, and hospice enrollment, the care plan identified risk for pressure ulcer development and called for weekly treatment documentation with measurements and detailed wound characteristics. However, there were no documented Braden Scale assessments in 2025 and no weekly skin assessments prior to mid-January 2026. Shower sheets from November documented a sacral pressure injury, but they were unsigned, and the ADON who recalled completing one sheet stated she assumed a dressing indicated the wound was already being treated and did not report it. Hospice notes from early November did not document a sacral ulcer, and there were no treatment orders or treatments for a sacral ulcer between the dates when the shower sheets noted a pressure injury and when the wound nurse documented a stage 3 sacral pressure ulcer with a new treatment order. The wound nurse later stated the ulcer was stage 3 when first identified and believed it might have been found earlier if routine nurse skin assessments had been completed. A second resident with type 2 DM, neuropathy, peripheral angiopathy, and a history of diabetic foot ulcers had a care plan requiring daily inspection of feet and full-body checks for skin breaks. A Braden Scale was completed in early 2025, but no additional Braden assessments were documented until December 2025, and there were no weekly skin assessments documented before mid-January 2026. In November, weekly wound assessments documented a suspected deep tissue injury on the left plantar foot and an unstageable pressure ulcer with black eschar on the right plantar foot, with treatment orders initiated and later revised. The Wound PA and wound nurse attributed the plantar ulcers to the resident’s feet resting against the bed footboard and noted that the resident, due to neuropathy, could not feel his feet or the wounds. The unit manager reported that an NA initially found the wounds and notified her, and she then brought in the wound nurse. She also stated that, at the time the wounds were identified, nurses were not doing formal skin assessments and that NAs were performing skin checks during baths and completing shower sheets, with no consistent nurse-led weekly skin assessment schedule documented for this resident. A third resident with hemiplegia, a history of a stage 4 pressure ulcer, peripheral vascular disease, and contractures had a care plan for potential pressure injury development that required monitoring and documenting changes in skin status, including wound size and stage. A Braden Scale in early January 2026 showed low risk, but there were no weekly skin assessments documented from late January to early February. On February 9, the wound nurse documented an ulcer to the posterior left knee with a history of recurrent yeast rash and noted that a recent course of nystatin powder had not healed the area. A treatment order for mupirocin and a clean dressing was started the next day. The wound nurse stated that during treatment on February 9 the resident reported pain behind the left knee, prompting a deeper inspection that revealed a white area she believed looked like an ulcer, with tendon exposed and yellow drainage, but no wound assessment with measurements or staging was documented at that time. A weekly wound assessment and Wound PA note dated February 18 documented a stage 4 pressure ulcer with exposed tendon at the left posterior knee, with the PA stating the wound had been present for about two weeks and was caused by the tight contracture. The wound nurse acknowledged that the wound looked the same on February 9 and February 18 and that a full wound assessment with measurements should have been completed when the wound was first found. Across these three residents, multiple staff interviews described a prior process in which NAs performed skin checks during baths or showers, documented findings on shower sheets, and were expected to notify nurses of abnormalities, while nurses and unit managers did not consistently review shower sheets or perform routine weekly skin assessments. The wound nurse and unit managers reported that Braden Scales were supposed to be completed on admission, quarterly, and with changes in condition or new wounds, but acknowledged that Braden assessments were missed for extended periods for at least two residents, coinciding with a transition to a new combined quarterly nursing assessment. Staff, including the Wound PA, physician, DON, wound nurse, and unit managers, stated that skin assessments should be completed by nurses at least weekly and that wounds should be assessed, measured, staged, and documented when identified, but this did not occur consistently for the residents cited in the deficiency.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 26 opportunities (11.45%) during medication administration observations. For a resident admitted with constipation, a physician’s order dated 01/06/26 directed administration of 17 grams of polyethylene glycol powder by mouth once daily. On 03/24/26 at 10:00 AM, a nurse mixed the polyethylene glycol in water, brought it to the bedside, placed it on the over-bed table, and then administered other medications and a flavored liquid used to swallow pills. The nurse left the room without giving the polyethylene glycol. When questioned at 10:30 AM, the nurse acknowledged leaving the medication on the table and stated she forgot to administer it because she was nervous; the mixed medication remained on the table in the resident’s room. Another resident with constipation had a physician’s order dated 12/14/23 for polyethylene glycol, one packet by mouth every other day, dissolved in 4–6 oz of fluid. On 03/24/26 at 9:20 AM, a nurse prepared this resident’s medications, including dissolving the polyethylene glycol in water, administered the crushed medications, gave the resident one drink of the polyethylene glycol mixture, then placed the remaining mixture on the over-bed table and left the room. At 10:33 AM, when asked about this medication, the nurse stated she should not have left the drink in the room because it contained medication and that she should have ensured the resident drank all of it. A third resident, admitted with gastroesophageal reflux disease, had a physician’s order dated 03/19/26 for calcium carbonate 600 mg by mouth in the morning as a supplement. On 03/24/26 at 8:45 AM, a nurse prepared and administered calcium carbonate 1000 mg instead. Later that day, review of the medication bottle showed tablets labeled 1000 mg, and the nurse stated she did not think calcium carbonate came in 600 mg tablets and would inform the provider about the dosage.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to honor a resident's right to voice grievances without reprisal by not completing and providing a written grievance decision with all required components. Resident #67, who was cognitively intact, had a grievance form completed on 3/5/26 by the Social Worker (SW) regarding concerns about night shift staff not being attentive, not providing incontinence care during the night, and not checking on her every two hours. The grievance form only documented that education would be provided by the Staff Development Coordinator and did not include how the grievance was investigated, a summary of pertinent findings or conclusions, a statement as to whether the grievance was confirmed or not confirmed, or the date a written grievance decision was provided to the resident. During an interview, Resident #67 reported she continued to experience issues with incontinence care not being provided routinely on night shift and stated she had raised these concerns during a care plan meeting. She indicated she did not know whether her concern had been addressed and had not been verbally informed of any grievance decision or received a written grievance decision. The SW reported she was responsible for managing grievances and described a process in which she completed the grievance form, assigned it to the appropriate department, and verbally followed up with that department, but she did not document the investigation, findings, resolution, or dates on the grievance form. She also stated she did not follow up with the individual who filed the grievance to inform them of the investigation, findings, or resolution and did not provide written notification of the grievance outcome, indicating she was unaware these steps were required. The Administrator stated that grievances should include documentation of investigation, findings, corrective actions, resolution, and notification to the complainant, and was not aware that the SW was not completing these steps.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to maintain clean and orderly front and rear common hallways, which are heavily used by residents, visitors, and staff. On multiple observations, surveyors noted that the front common hallway floor between two resident wings had numerous stains, dirt, debris, and dried fluid or water spots too numerous to count, with dirt and debris pushed into wall corners and under a water fountain alcove. A repeat observation days later showed the same conditions persisted, with continued traffic by residents, staff, and visitors through the area. Similar conditions were observed in the rear common hallway between two resident wings, where surveyors again found multiple areas of stains, dirt, debris, and dried fluid or water spots, along with dirt and debris pushed into corners and along the walls. Follow-up observations later in the week showed that these unsanitary conditions remained unchanged, despite ongoing use of the hallway by residents and staff traveling to and from the activities room and resident rooms. Interviews with facility staff confirmed that housekeeping staff were scheduled seven days a week and were expected to clean common areas first, including sweeping and mopping floors. However, the Housekeeping Director reported that a maintenance staff member, who normally only buffed floors, had been mopping the common hallways that week. During a walkthrough, this staff member was observed mopping over dirty fluid spots without removing them; the spots were easily removed by rubbing with a shoe, demonstrating inadequate cleaning. Both the Housekeeping Director and the DON stated that the floors still appeared dirty after mopping and that the condition of the floors throughout the facility was unacceptable. The Administrator also acknowledged dissatisfaction with the floor conditions and confirmed that the maintenance staff member was responsible for keeping the floors clean, noting that the floors needed to be cleaner and that more effort was needed to remove dirt, debris, and fluid spots during mopping.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide Registered Nurse (RN) coverage for at least 8 consecutive hours on six specific days during a 53-day review period. Review of daily posted staffing sheets and schedule books revealed that on these days, there were no RNs listed as working, and no RN hours were recorded for the required shifts. The Director of Nursing (DON) was aware of the requirement for 8 consecutive hours of RN coverage daily but was only able to provide documentation for one of the days in question, leaving the remaining days without evidence of compliance. Interviews with the current and previous schedulers indicated a lack of awareness regarding the specific requirement for 8 consecutive hours of RN coverage each day. Both schedulers acknowledged difficulties in scheduling RNs, particularly on weekends, due to limited staff availability. The DON assisted with scheduling and was aware of the days without RN coverage. The Administrator confirmed awareness of the requirement and acknowledged that there were days without RN coverage during the reviewed period.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors observed that the facility failed to remove expired food and failed to date perishable food items stored in the walk-in cooler. During the initial kitchen tour, several food items were found either past their expiration date or lacking proper labeling and dating. Specifically, containers of chicken breasts, chicken noodle soup, and creamed corn were found with dates indicating they were expired, and a tray of tuna salad sandwiches was not dated at all. Additionally, a tray of bologna sandwiches was found with a date, but it was not specified if it was current or expired. These observations were made in the presence of the Assistant Dietary Supervisor, who acknowledged the presence of expired and undated perishable food items. Interviews with the Assistant Dietary Supervisor and the interim Dietary Manager confirmed that the facility's process requires all food to be sealed, labeled, and dated with both an opened date and a discard date. Both staff members stated that dietary staff are responsible for regularly checking food items and discarding any that are expired or not properly labeled. The Administrator also confirmed that all dietary staff had been educated on these procedures, but the deficiency was observed during the survey.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to notify the provider when a resident did not receive multiple doses of prescribed medications, specifically Metoprolol Succinate ER and Quetiapine Fumarate, due to the medications not being available. Documentation showed that over several days, the resident missed doses of both medications, but there was no evidence in the nursing progress notes that the provider had been notified of these missed doses. Interviews with nursing staff revealed that some nurses did not notify the provider, with one nurse stating it was the resident's first night and another indicating that weekend on-call providers would attribute the issue to pharmacy delivery rather than requiring intervention. The nurse practitioner confirmed only partial notification and was not informed of all missed doses. The resident involved had a complex medical history, including chronic systolic heart failure, type 2 diabetes with peripheral angiopathy, hypertensive heart disease with heart failure, and unspecified dementia with agitation. The facility's Director of Nursing and Administrator both stated that they would expect nurses to notify the provider of missed doses of these medications. Despite this expectation, the lack of timely provider notification for missed medication doses was confirmed through record review and staff interviews.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A significant medication error occurred when a resident did not receive five consecutive daily doses of Metoprolol Succinate, prescribed for heart failure, and Quetiapine Fumarate, an antipsychotic medication. The resident was admitted with multiple diagnoses, including chronic systolic heart failure, diabetes with peripheral angiopathy, hypertensive heart disease, and dementia with agitation. Upon admission, the Assistant Director of Nursing (ADON) entered and reactivated medication orders in the electronic medical record, but the process used did not result in the pharmacy being notified to send the medications. Documentation in the Medication Administration Record (MAR) and electronic MAR progress notes showed that the medications were consistently not available for administration over several days. Multiple agency nurses documented the missed doses, citing unavailability of the medications. Interviews revealed that agency nurses did not have access to the facility’s pyxis (backup medication supply) and were unaware of the process to obtain medications from it or to contact staff with access. The ADON, who was new to long-term care, believed that reactivating old orders in the system would suffice, but this did not trigger the pharmacy to deliver the medications. The resident’s vital signs remained within normal limits during the period of missed doses, and assessments by the Nurse Practitioner indicated no acute distress or behavioral issues. However, both the facility pharmacist and Nurse Practitioner confirmed that missing multiple doses of Metoprolol Succinate could be significant for a resident with heart failure. The Director of Nursing stated that all new admission orders should be entered as new orders and that the pyxis contained general medications for all residents, but agency nurses did not have access. The deficiency resulted from a combination of improper order entry, lack of pharmacy notification, and insufficient communication and access to backup medication supplies among agency staff.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to employ a director of food and nutrition services who met the minimum required qualifications, affecting 108 of 111 residents. The Assistant Dietary Supervisor, who was overseeing the kitchen, did not possess certification as a dietary manager or food manager, national certification for food service management and safety, an associate's or higher degree in food service management or hospitality, nor did he have two or more years of experience as a Director of Food and Nutrition Services in a nursing facility. He stated that he had been working in the facility's kitchen for a little over six months and relied on a dietician for consultation as needed. An interim Dietary Manager from a sister facility, who was certified, was only present once weekly to assist and did not have regular scheduled meetings with the Assistant Dietary Supervisor. The interim manager had recently resigned and was scheduled to leave the company. The facility administrator acknowledged the lack of a certified Dietary Manager and described ongoing efforts to hire a qualified individual, but at the time of the survey, the position remained unfilled, and oversight was limited to intermittent visits from the interim manager and consultation with a Registered Dietician.

Penalty

Fine: $41,15556 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to exercise the rights of a resident's representative when a resident had unsupervised visits with her son, despite restricted visitation instructions from the legal guardian. The legal guardian had informed the Admission's Director and the Resident Concierge that the resident was not to have visits from her son without supervision due to a history of inappropriate sexual interactions. However, the Admission's Director only left a note for the Social Worker, who was not informed until several days later, allowing the son to have unsupervised visits during that time. The resident, who was cognitively impaired and adjudicated incompetent, was admitted to the facility with a history of dementia, anxiety, and major depressive disorder. The baseline care plan did not include any interventions regarding supervised visitation, and the legal guardian's instructions were not communicated effectively to the necessary staff. The Admission's Director and Resident Concierge did not take immediate action to ensure the resident's safety, and the Social Worker was not made aware of the situation until after the unsupervised visits had occurred. Interviews with staff revealed a lack of communication and understanding of the legal guardian's directives. The Admission's Director and Resident Concierge did not notify the Director of Nursing or the Administrator about the need for supervised visitation, and the Social Worker was not informed until days later. This resulted in the resident's son having unrestricted access to the resident, which was against the legal guardian's wishes and posed a risk to the resident's safety.

Removal Plan

• Education was performed by the Regional Admissions Director with the Admissions Director and Resident Concierge regarding proper notification to Administrator and/or Director of Nursing when admitting residents and the resident's guardian/resident representative made request including restricted/supervised visitation.
• Regional Director of Admissions implemented a new form, Guardian/resident representative or Power of Attorney Documentation Form, this form is to be completed for all new admissions prior to admission by the Admissions Director.
• Guardian/resident representative wishes will be reviewed quarterly or as needed by care plan coordinator and renewed.
• Education was provided to the Care plan Coordinator and social worker by Administrator and Director of Nursing that during baseline care plan and/or quarterly care plan meetings the guardian/resident representative wishes are reviewed and ensured the wishes are reflected on the Resident's care plan which will add the information to the KARDEX.
• The Social Worker was educated by the Administrator on the process for supervised visits and to ensure to respect and follow the guardian/resident representative wishes as though the resident is making the decision themselves.
• All certified nursing assistants were educated by the Staff development Nurse on supervised visitation process, where to identify on the KARDEX visitation restrictions, to notify administrative on call number if restrictions are not followed, and that facility is to adhere to any guardian/resident representative wishes.
• All Nurses were educated by the Staff development Nurse on supervised visitation process, where to identify on the KARDEX visitation restrictions, where the visitation restriction will be located on the Resident profile chat under special instructions, and to ensure to respect and follow the guardian/resident representative wishes as though the resident is making the decision themselves.
• All Administrative Nurses were educated by the Director of Nursing on the process for supervised visitation, how to add to the KARDEX on visitation restrictions, where the visitation restriction will be added on the Resident profile chart under special instructions, and to ensure to respect and follow the guardian/resident representative wishes as though the resident is making the decision themselves.

Penalty

Fine: $41,15556 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to employ a director of food and nutrition services who met the minimum qualifications, affecting 106 of 109 residents. During an interview, the Dietary Manager admitted to lacking certification as a dietary manager or food manager, national certification for food service management and safety, an associate's or higher degree in food service management or hospitality, and two or more years of experience in the position of Director of Food and Nutrition Services in a nursing facility setting. Although he mentioned having a dietician for consultation, he was unable to provide her name. The Dietary Manager had been working in the facility's kitchen for a total of six months, with a break in between. Additionally, a Certified Dietary Manager from a sister facility was interviewed and stated she was available to assist but did not have regular meetings with the facility's Dietary Manager. The facility's Administrator was aware of the certification requirements but mistakenly believed her personal food safety certification was sufficient.

Penalty

Fine: $41,15556 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure proper labeling and secure storage of drugs and biologicals, as evidenced by observations of two medication carts containing loose and unsecured pills. On the 100/200 hall split medication cart, 41 loose pills of various shapes, sizes, and colors were found, along with debris such as paper shavings and rubber bands in the cart drawers. Nurse #2 acknowledged the responsibility of keeping the medication carts clean and orderly, admitting that the cart should have been vacuumed prior to the observation. Unit Manager #1 confirmed that the condition of the cart was unacceptable and reiterated that nurses were responsible for cleaning the carts weekly. Similarly, the 300 hall medication cart was observed to have 12 loose and unsecured pills. Nurse #3 admitted that it was her responsibility to maintain the cart's cleanliness but had not had the opportunity to clean it on the day of the observation or the previous day. The Director of Nursing (DON) explained that it was the nursing staff's responsibility to clean the medication carts weekly and had recently assigned specific nurses to this task. The DON also indicated that nurses should remove loose pills from the carts daily.

Penalty

Fine: $41,15556 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility was found to have several deficiencies in food storage and handling practices. During an observation of the dry goods storage room, a mesh bag of onions and a wrapped package of water bottles were found sitting on the floor, which is against professional standards. Additionally, an old mixer with a split plastic bag was also on the floor. The Dietary Manager acknowledged these items should not be on the floor. In the walk-in freezer, an expired bag of iceberg lettuce and a container of wilted lettuce covered in plastic wrap were found. A bin marked as pureed beef without a year was also present, and the Dietary Manager admitted it should not be in the freezer. Further observations in the 100 Hall nourishment room revealed five vanilla ice cream packages that appeared melted and refrozen, indicated by a darker yellow color on the tops inside each container. The Dietary Manager was informed and agreed that these items should not be there. An interview with the Administrator confirmed that the storage practices for beef, lettuce, onions, and ice cream were incorrect. These deficiencies in food storage and handling could potentially affect the quality of food served to residents.

Penalty

Fine: $41,15556 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide food that was appetizing in temperature, texture, and palatability for three residents. Resident #59, who was cognitively intact, expressed dissatisfaction with the quality of meals, describing them as cold, runny, and lacking in variety. He mentioned that the eggs were cold and runny, the bread was hard, and the chicken patties were unpalatable. Resident #59 also noted that the nutrition room was inadequately stocked, forcing him to keep snacks in his drawer. Resident #15, also cognitively intact, had previously filed a grievance about incorrect meal tickets and cold food. Despite a resolution being signed, she continued to report issues with the food being tasteless, cold, and unappealing. Her visitor corroborated these observations, noting that the food appeared unappetizing and poorly prepared during visits over the past six months. Resident #15 described meals as dry, hard, and unwashed, with brown salad and tasteless bread. Resident #57, who was cognitively intact, had also filed grievances about the quality and temperature of the food. Despite a resolution to incorporate his preferences, he continued to express dissatisfaction, stating that he had to rely on food purchased by family members. He described the meals as cold, dry, and unappealing, with runny slaw and unidentifiable meat. A test tray conducted with the Dietary Manager confirmed issues with food temperature and quality, with the manager acknowledging that improvements were needed.

Penalty

Fine: $41,15556 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain the bed remote in good repair for a resident in room 205-B, as observed during a survey. The bed remote's coiled cord was missing approximately 8 inches of its rubbery outside covering, exposing the wire inside. This condition was noted while the bed was occupied by a resident. Despite multiple observations over several days, the condition of the bed remote remained unchanged. Interviews with staff revealed that the resident was unable to utilize the bed remote, and staff members, including a nurse and nurse aides, acknowledged the exposed wire but did not report it to the maintenance department. The Maintenance Supervisor, during an interview, stated that he did not notice the exposed wire during his routine monthly checks and would have replaced it if he had. He assessed the exposed wire as a low hazard potential due to the low voltage but acknowledged it needed replacement for cosmetic reasons. The Administrator and Director of Nursing indicated that nurse aides should have alerted the maintenance department about the faulty equipment, highlighting a lapse in communication and reporting procedures within the facility.

Penalty

Fine: $41,15556 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in the documentation of Gradual Dose Reduction (GDR) and significant weight loss. Resident #93, diagnosed with schizophrenia, was receiving risperidone, an antipsychotic medication, twice daily. The MDS assessment did not reflect any attempt at GDR or documentation of it being clinically contraindicated, despite a psychiatry progress note indicating that a reduction was not recommended due to the risk of decompensation. The oversight was acknowledged by MDS Nurse #1, who admitted to overlooking the relevant documentation. Resident #92, with diagnoses including alcoholic cirrhosis, chronic kidney disease, heart failure, and protein-calorie malnutrition, experienced significant weight loss, dropping from 191.6 pounds to 157.6 pounds over a two-month period. However, the quarterly MDS assessment inaccurately indicated no significant weight loss, despite the resident's nutritional assessment and weight records showing otherwise. The MDS Nurse acknowledged the error, stating it was missed despite notes indicating the weight loss. The Director of Nursing and the Administrator both expressed expectations for accurate and thorough MDS assessments to reflect residents' care needs.

Penalty

Fine: $41,15556 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to request a Preadmission Screening and Resident Review (PASARR) Level II evaluation for a resident who was diagnosed with a new mental health condition. Resident #23, who was initially admitted with a PASARR Level I evaluation, was readmitted with diagnoses including Type 2 diabetes mellitus, vascular dementia, and cognitive communication disorder. Despite being cognitively intact as per a quarterly Minimum Data Set (MDS) assessment, the resident was later diagnosed with depression and subsequently with major depressive disorder and psychosis by a Psychiatric Nurse Practitioner. The resident's medication regimen was adjusted to include antidepressants and a mood stabilizer. Interviews with facility staff revealed a lack of clarity and communication regarding the responsibility for requesting PASARR Level II evaluations. The Social Worker Aide, who was responsible for PASARR, indicated that she relied on meetings or reports from the MDS Coordinator to be informed of changes necessitating a Level II evaluation. However, the Administrator, who ultimately held the responsibility for requesting these evaluations, acknowledged that the evaluation should have been requested following the resident's new diagnosis of depression. This oversight led to the deficiency identified by the surveyors.

Penalty

Fine: $41,15556 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop a person-centered comprehensive care plan for a resident who required supervised visitation. The resident, who was moderately cognitively impaired, was placed on supervised visitation after an incident where a family member was found handing the resident a pill from the family member's prescription bottle. Despite the initiation of supervised visitation, the resident's care plans did not reflect this need. Interviews with the Social Worker and the Director of Nursing revealed that the supervised visitation was initiated following the incident, but the care plan was not updated to include this requirement. The Care Plan Coordinator was new to the role and was not in the position when the care plan should have been updated.

Penalty

Fine: $41,15556 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement a treatment for an area of skin impairment for a resident reviewed for pressure ulcers. The resident was admitted with multiple diagnoses, including end-stage renal disease, diabetes mellitus, severe protein-calorie malnutrition, dysphagia, and cerebral infarction, which placed them at risk for pressure ulcers. The care plan included interventions for preventing and treating skin breakdown, but there was no treatment order for skin breakdown prevention on the resident's sacrum, and the Treatment Administration Record (TAR) did not include a treatment order to monitor or apply a foam dressing. The Wound Nurse documented a localized area of blanching erythema on the resident's sacrum and applied a protective foam dressing, but this was not communicated to other staff through the TAR. Interviews with various nursing staff revealed that they were unaware of the need to check or change the dressing because it was not listed on the TAR. The Wound Nurse confirmed that she would have set up a treatment on the TAR to check the sacrum daily, but this was not done, leading to a lack of monitoring by other staff. The Director of Nursing (DON) acknowledged that a treatment should have been set up to monitor and replace the foam dressing weekly and as needed. The lack of a treatment order meant that the resident's sacrum was not monitored when the Wound Nurse was not on duty, resulting in a failure to implement the necessary treatment for the resident's skin impairment.

Penalty

Fine: $41,15556 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to secure an oxygen cylinder stored in a resident's bathroom and ensure an oxygen vent was free from dust and debris for two residents requiring respiratory care. Resident #19, who was admitted with hypoxia, had an unsecured oxygen cylinder in her bathroom, which was observed multiple times on 01/28/25. Staff interviews revealed that the oxygen cylinder should have been attached to the resident's wheelchair or stored in the oxygen storage room. The unsecured cylinder posed an accident hazard, as it was half full of oxygen. Resident #1, diagnosed with chronic obstructive pulmonary disease (COPD), was observed on multiple occasions with a dusty external vent on her oxygen concentrator. Despite being ordered to receive oxygen at 2 liters per minute, the concentrator's vent was not cleaned, as confirmed by staff observations and interviews. The staff development coordinator and other nursing staff were unsure of the cleaning responsibilities for the oxygen concentrator vents, indicating a lack of clarity in the facility's procedures. Interviews with the Director of Nursing (DON) and other staff members highlighted inconsistencies in the facility's practices regarding oxygen equipment maintenance. The DON was unaware of the dusty filter on Resident #1's concentrator and stated that the vents should be cleaned by nursing or housekeeping staff. The lack of clear responsibility and oversight contributed to the deficiencies observed in the respiratory care provided to the residents.

Penalty

Fine: $41,15556 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure accurate medical records and proper wound care for a resident with a sacral pressure injury. The resident, who was admitted to the facility with a stage 2 pressure ulcer on the sacrum, had a physician's order for a foam dressing to be applied and checked daily. However, on the day in question, the Treatment Administration Record inaccurately documented that the dressing was applied during the dayshift, despite observations and staff interviews indicating otherwise. During an observation, it was noted that the resident's sacral area was not covered with a dressing and was bleeding, causing the resident discomfort. Interviews with staff revealed that the Wound Care Nurse was responsible for the dressing application but failed to do so, despite having documented it as completed. The Wound Care Nurse admitted to intending to return to apply the dressing but forgot to update the documentation or enter a progress note. The Director of Nursing confirmed that the Wound Care Nurse should not have charted the wound care as completed if it had not been done, highlighting a lapse in following proper documentation and care procedures.

Penalty

Fine: $41,15556 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to treat a dependent resident with dignity when a nurse aide did not change the resident's soiled brief upon request before the resident's lunch meal. The resident, who was severely cognitively impaired and dependent on staff for toileting, reported having a bowel movement before lunch and requested assistance from the nurse aide who was delivering lunch trays. The nurse aide refused to change the brief at that time, citing concerns about cross-contamination while distributing meal trays. The resident expressed feeling belittled and treated like a child due to this interaction. The surveyor observed the situation and intervened by notifying a nurse, who, along with the nurse aide, provided incontinence care to the resident. During the care, a significant amount of feces was found in the resident's brief, which had been soiled for an extended period. The nurse aide, a travel aide new to the facility, explained her actions by stating her practice of avoiding incontinence care during meal distribution to prevent cross-contamination. The unit manager and the director of nursing later acknowledged that the nurse aide's handling of the situation was inappropriate and not in line with the facility's standards of care.

Penalty

Fine: $41,15556 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect a resident's right to be free from misappropriation of controlled medications, specifically Oxycodone/Acetaminophen, for a resident who was cognitively intact and regularly received pain medication. The issue arose when a card of narcotics was reported missing, and it was discovered that the medication was signed for by a nurse but was not accounted for in the medication cart. The nurse had handed the medications to a medication aide responsible for the cart, but the aide did not verify the contents properly. The investigation revealed that the medication aide, who was responsible for the cart, tested positive for oxycodone and was unable to provide a prescription, leading to her termination. The nurse who signed for the delivery confirmed handing over the medications to the aide, but the aide claimed not to have received the specific narcotics for the resident. The facility's Director of Nursing conducted a thorough search and confirmed the narcotics were not in the facility, prompting an investigation and notification to relevant authorities. The facility's failure to ensure proper handling and documentation of controlled substances led to the misappropriation of the resident's medication. The incident highlighted lapses in the facility's procedures for managing narcotics, including the lack of verification and accountability during the handover of medications between staff members.

Penalty

Fine: $41,15556 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide timely incontinence care to a resident who was unable to manage toileting independently. Resident #39, who had severe cognitive impairment and was always incontinent of bladder and bowel, requested assistance to change a soiled brief before lunch. However, the nurse aide (NA #2) did not provide the necessary care, citing concerns about cross-contamination while distributing meal trays. The resident remained in a soiled brief for an extended period, leading to a strong odor and the need for a complete bed change when care was finally provided. Another deficiency involved the failure to assist a resident with shaving. Resident #27, who had intact cognition but required assistance with shaving due to impaired mobility and vision, was observed with several days' growth of facial hair. Despite being scheduled for showers and shaves on specific days, the resident did not receive a shave during the shower on 01/29/25. The nurse aide responsible for the shower did not offer a shave, citing discomfort with shaving men and forgetting to ask for assistance. The resident expressed dissatisfaction with the lack of shaving, indicating a need for assistance that was not met. These incidents highlight the facility's failure to adhere to care plans and provide necessary assistance with activities of daily living (ADLs) for residents who are dependent on staff for personal care. The lack of timely incontinence care and failure to assist with shaving reflect deficiencies in the facility's ability to meet the basic care needs of its residents.

Penalty

Fine: $41,15556 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide a physician-ordered treatment for a resident with a stage 2 pressure ulcer. The resident, who was severely cognitively impaired, was admitted with wounds to her lower extremities and a blister on her heel, which had improved. However, she developed a stage 2 pressure ulcer on her sacral area. Observations revealed that the ulcer was not covered with a dressing, despite an active order for a foam dressing. The resident expressed discomfort and requested a dressing, indicating that the ulcer was causing her pain. Interviews with staff revealed a breakdown in communication and responsibility. Nurse #3 acknowledged the absence of a dressing and stated that the Wound Care Nurse was responsible for applying it. NA #5, who cared for the resident earlier in the day, noticed the absence of a dressing but did not report it, assuming the Wound Care Nurse would address it. The Wound Care Nurse admitted to not applying the dressing earlier due to the resident's distress and intended to return later. The Director of Nursing confirmed that the Wound Care Nurse was responsible for wound care during weekdays, and the hall nurse on weekends, emphasizing that the dressing should have been applied as ordered.