Paul House & Health Cr Ctr

resident (R1) with skin breakdown was repositioned every two hours.

This failure has the potential to

including but not limited to: Hemiplegia and Hemiparesis following cerebral infarction, vascular dementia, pressure ulcer of sacral region stage three, frontotemporal neurocognitive disorder and hypertensive heart disease.On 3/23/26 at 3:26 pm, R1 was observed lying in bed on his right side and with the head of the bed elevated.At that time, V10 (R1's Family) stated the following, My brother has been lying on his right side since this morning around 10:00 am. I've been here with him (R1) and waiting on someone to come and help me turn him because he already has a pressure sore.On 3/23/26 at 3:45 pm, V7 (CNA/ Certified Nurse Assistant) stated the following, I'm assigned to R1 today. I've been here since 7:00 am. I believe the last time that I repositioned R1 was at 9:00 am. We have been really busy because we only have three CNAs on the unit (two west) and we usually have four. I cannot reposition him (R1) by myself and I cannot always find someone to help me reposition him. I didn't know that his sister (V10) would help reposition him. He should be repositioned every two hours to prevent pressure ulcers. He has a wound on his heel.On 3/23/26 at 3:50 pm, V6 (LPN/ Licensed Practical Nurse) stated the following, R1 is my patient today. I'm not sure when he (R1) was last turned. V7 (CNA) is the person that repositions R1.On 3/24/26 at 10:00 am, V2 (DON/ Director of Nursing) stated the following, He currently has one wound on the left heel that we are monitoring and trying to heal. It is expected that R1 is turned and repositioned every two hours to maintain his skin integrity. He (R1) is not able to turn himself.R1's Wound Report dated 3/24/26 documents a left heel wound.R1's care plan documents, R1 is at risk for alteration in skin integrity; R1 is at high risk for developing skin breakdown; R1 requires total care with dependent assistance for personal care and mobility; R1 should be repositioned every two hours and as needed.Facility Pressure Injury Prevention policy documents, reposition all residents with or at risk of pressure injuries on an individualized schedule, as determined by the interdisciplinary team.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE