**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, review of the clinical record, and review of facility policy and procedure, the facility failed to ensure one resident (#18) was provided care and services, according to professional standards and physician orders, to prevent a new pressure ulcer and prevent worsening of existing pressure ulcers. The deficient practice could lead to physical harm of residents developing new or worsening wounds. -Findings Include: Resident #18 was initially admitted to the facility September 25, 2019, with diagnoses that included hyperlipidemia, chronic kidney disease, diastolic heart failure, neuromuscular dysfunction of bladder, ulcer of anus and rectum, and localized edema. A quarterly minimum data set (MDS) assessment dated [DATE], revealed the Resident #18 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident had intact cognition. Section GG revealed the resident was dependent on staff for bed mobility of sit to lying, and required substantial/maximum assistance with rolling in bed. Additionally, the resident had a diagnosis of paraplegia. A care plan dated May 24, 2021, revealed the resident was at risk for skin impairment, and had pressure ulcers on bilateral gluteal folds and sacrum, and a rectal fistula. Interventions included to assess/record/monitor wound healing weekly and as necessary. Measure length, width, and depth where possible, assess and document status of wound perimeter, wound bed, and healing progress. Report improvements and declines to the physician. If the resident refuses treatment, confer with the resident, interdisciplinary team (IDT), and family to determine the cause and try alternative methods to gain compliance. Document alternative methods. There was no evidence of a care plan update for a facility-acquired pressure ulcer on the resident's scrotum. A physician order dated August 28, 2024, and discontinued September 4, 2024, indicated to cleanse left ischium with Dakins, pat dry, apply calcium alginate, cover with ABD pad, and secure with tape, change daily and as needed, and notify provider of any concerns, two times a day every Mon, Wed, Fri, and Sun. A duplicate order indicated for two times a day every Tue, Thu, and Sat, and was also discontinued September 4, 2024. There was no evidence of wound care orders or treatment for the left ischium wound from September 4, 2024 until November 1, 2024. A physician order dated August 28, 2024, and discontinued November 1, 2024, indicated for wound care: cleanse sacral ulcer with WCS, pat dry, sprinkle collagen powder to wound bed, apply Maxorb Ag, cover with ABD pad and secure with tape, two times a day every Mon, Wed, Fri, and Sun. An additional duplicate order dated August 29, 2024, indicated for two times a day every Tue, Thu, and Sat. A physician order dated August 28, 2024, and discontinued November 1, 2024, indicated for wound care: cleanse right ischium with Dakins, apply Maxorb Ag and ABD pad, change two times a day every Mon, Wed, Fri, and Sun. A duplicate order indicated for two times a day every Tue, Thu, and Sat. A physician order dated October 25, 2024, indicated to clean wound with normal saline, pat dry, pack wound with 1/4 inch put ABD wrap with kerlix every night shift for wound care. There was no evidence of which wound the treatment was indicated for. A Pressure Ulcer Documentation assessment dated [DATE], revealed the resident had three pressure ulcers: -Right gluteal fold pressure ulcer, present on admission, Stage 4, measured as 3.2 x 0.8 x 1.2 cm, no tunneling -Left gluteal fold pressure ulcer, present on admission, Stage 4, measured as 2.2 x 2.3 x 0.7 cm, no tunneling -Sacral pressure ulcer, present on admission, Stage 4, measured as 2.0 x 2.3 x 0.6 cm, no tunneling Wound Care Visit Discharge Instructions dated September 3, 2024, revealed the resident had wounds on the right and left ischium, sacrum, and peri-anus. Discharge instructions included: -Right and Left Ischium: cleanse wound with wound cleaner, change ABD pad dressing 3 times per day and as needed -Midline Sacrum: cleanse wound with wound cleaner, change ABD pad and Maxorb Ag dressing 3 times per day and as needed -Peri-anus: cleanse wound with wound cleaner, change ABD pad dressing 3 times per day and as needed A Weekly Skin Check and Wound assessment dated [DATE], revealed the resident had right and left gluteal fold pressure ulcers, and a sacral pressure ulcer. There was no evidence of measurements or further details of the wounds. A Pressure Ulcer Documentation assessment dated [DATE], revealed the resident had four pressure ulcers: -Right gluteal fold pressure ulcer, present on admission, Stage 4, measured as 1.9 x 0.7 x 0.4 cm -Left gluteal fold pressure ulcer, present on admission, Stage 4, measured as 2.5 x 0.5 x 1.5 cm, tunneling noted with a depth of 1.6 cm -Coccyx pressure ulcer, present on admission, Stage 4, measured as 2.6 x 3.1 x 2.1 cm, tunneling from 12:00 to 3:00 noted with a depth of 2.1 cm -Scrotum, present on admission, Stage 4, measured as 2.7 x 1.6 x 0.5 cm A Pressure Ulcer Documentation assessment dated [DATE], revealed the resident had four pressure ulcers: -Right gluteal fold pressure ulcer, present on admission, Stage 4, measured as 2.5 x 3.1 x 1.4 cm -Left gluteal fold pressure ulcer, present on admission, Stage 4, measured as 2.5 x 0.5 x 1.5 cm -Coccyx pressure ulcer, present on admission, Stage 4, measured as 2.3 x 3.0 x 2.1 cm -Scrotum, facility-acquired with an onset date of September 23, 2024, Stage 4, measured as 2.7 x 1.6 x 0.5 cm There was no evidence of documentaion on the presence of tunneling on any of the wounds. The clinical record was reviewed and there was no evidence of notification to the physician of the new facility-acquired scrotum wound, or any treatment orders. Additionally, there was no evidence of any weekly wound assessments, including measurements or descriptions of the pressure wounds, between September 26 - October 14, 2024. A Pressure Ulcer Documentation assessment dated [DATE], revealed the following: -Coccyx pressure ulcer, present on admission, Stage 4, measured as 2.3 x 3.0 x 0.5 cm -Right gluteal fold pressure ulcer, with the measurement left blank and no descriptors -Pressure Ulcer #3: no evidence of location or any measurement or descriptors A Weekly Skin Check and Wound assessment dated [DATE], revealed the resident had right and left gluteal fold pressure ulcers, a coccyx pressure ulcer, and a medial testicular pressure ulcer. There was no evidence of measurements or further details of the pressure ulcers. Review of the MAR for September 2024 revealed there was no right ischium and sacral wound care treatment completed either shift on September 11, 13, and 15, and the clinical record revealed there was no evidence of the resident refusing the missed wound care treatments. A Medication Administration Note dated September 23, 2024, revealed the resident did not want to lay down to have wounds measured at the time. There was no evidence that alternatives were coordinated with the resident. The MAR for October 2024 and the clinical record were reviewed, and the resident missed sacral and/or right ischium wound care treatments for the following reasons, with no evidence of coordination of alternatives per the care plan: -October 9: refused -October 10; resident was up in chair, and at dialysis -October 12: at dialysis -October 14: had visitors -October 15: refused, and at dialysis -October 19: up in chair for dinner -October 22: at dialysis -October 23: refused -October 27: refused -October 28: refused -October 29: up in wheelchair A Discharge Summary note dated November 5, 2024, revealed the resident was transferred to the hospital via ambulance for difficulty breathing. A physician progress note from the hospital admission dated November 12, 2024, revealed the resident was treated for sepsis present on admission secondary to sacral wound, pneumonia, and urinary tract infection. Additionally, sacral decubitus wound with a wound culture positive for Proteus mirabilis. The resident was treated with antibiotics. An interview was conducted with a Registered Nurse, (RN / Stff #50) on April 16, 2025, at 1:09 pm, who stated if a treatment is ordered every shift, then it should be completed at some time during the shift, for day shift and night shift. Staff #50 stated that she was familiar with Resident #6, and that he had pressure wounds on the buttocks and sacral area. Staff #50 reviewed the clinical record and stated that the resident had orders for weekly skin and wound assessments. Staff #50 also reviewed the gap in weekly assessments from September 26 - October 14, 2024, and stated that the impact on a resident of missing the weekly assssments could be worsening wounds, missing new wounds or onset of infection. On April 16, 2025, at 1:35 PM, an interview was conducted with an RN / unit manager (Staff #96), who stated if a treatment is ordered every shift and as needed, then the treatment should be done anytime during that shift as well as any additional times that are needed. Staff #96 stated that if a treatment was not completed as ordered, then the resident's condition could worsen. Additionally, Staff #96 stated that if a resident was ordered weekly skin checks, then the nurse should complete the assessment and document in the weekly skin assessment. Also, if a resident was not assessed weeekly as ordered, then the wound could worsen or become infected and lead to delayed care. Staff #96 stated she was familiar with Resident #6 and that he had wounds on the hips and coccyx. The clinical record was reviewed and Staff #96 stated that there's a week missing in there for the weekly skin assessments between September and October 2024. Additionally, the missing sacral wound care treatments from September 2024 were reviewed in the record, and Staff #96 stated that there was no documentation that the treatments were done on September 11, 13, and 15. An interview was conducted with the Director of Nursing (DON / Staff #48) on April 16, 2025, at 2:52 PM. The DON stated that if a treatment is ordered every shift then it should be completed during that shift. If a resident was at a dialysis appointment, or was in a wheelchair and did not wanted to be treated at that particular time, then the nurse should communicate with the resident to find an alternate time to provide the treatment, or if it was at the end of the shift to communicate to the next shift that the treatment was not done so that the next nurse could address it. The DON stated that she was aware that Resident #6 had pressure ulcers to the coccyx and right and left buttocks, and that she was notified that the resident had bleeding from the scrotum but when assessed, did not see a pressure ulcer on the scrotum. The clinical record was reviewed and the DON stated that she could not see any evidence of notifiction to the provider for the documented new onset of the scrotal pressure ulcer. The missing weekly wound assessments for September-October 2024 and the missing wound care treatments were reviewed together and the DON stated this would not meet her expectation and that the facility had already been taking steps to correct the issue. An interview was conducted with the [NAME] President of Clinical Operations (Staff #4) on April 16, 2025, at 3:17 PM. Staff #4 stated that for residents with pressure ulcers, at least once a week, the wound size and descriptors should be documented. Staff #4 stated that the oucome for Resident #6 was that although the resident had a guarded condition and several comorbidities, that there were some missed wound treatments and a newly acquired pressure ulcer. Staff #4 stated that within the past several months, it was identified by the facility that there were issues in the wound care of Resident #6 and that corrective steps were taken such as partnering with a new wound provider. Review of the facility policy titled Assessments/Care Planning: Care Plans, Comprehensive Person-Centered, dated January 1, 2024, revealed 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. Review of the facility policy titled Assessments/Care Planning: Change in a Resident's Condition or Status, dated Janaury 1, 2024, revealed the facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. The nurse will notify the resident's attending physician or physician on call when there has been a significant change in the resident's physical condition, need to alter the resident's medical treatment significantly, refusal of treatment two (2) or more consecutive times, and/or specific instruction to notify the physician of changes in the resident's condition. Review of the facility policy titled Assessments/Care Planning: Resident Examination and Assessment, dated January 1, 2024, revealed the purpose of this policy is to examine and assess the resident for any abnormalities in health status, which provides a basis for the care plan. The assessment process shall be systematic, comprehensive and multidisciplinary based on the individual resident's needs, acuity and priorities in accordance with physician orders. Orders are to be completed in accordance with physician orders determined at a resident's time of admission or throughout the resident stay. A change in order for assessment is based upon the resident's acuity at the time of the order. Notify the supervisor if the resident refuses the examination. Notify the physician of any abnormalities, including but not limited to wounds or rashes on the resident's skin.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, the facility failed to ensure care and services related to wound was provided one resident (#57). The deficient practice resulted in the wound becoming necrotic and resident's transfer to the hospitalization. Findings include: Resident #57 was admitted to the facility on [DATE] with a diagnoses of Atrial Fibrillation, acute kidney failure, type II diabetes mellitus, systemic inflammatory response syndrome and bilateral lower extremity amputations. The admission note dated June 21, 2024 included the resident was admitted from a short-term general hospital, was confused as to situation and place and had bilateral lower extremity amputations. Per the documentation, the resident had pain of 10/10 from foley catheter; and, interventions to alleviate pain was to secure cathether and good peri/catheter care. An encounter note dated June 23, 2024 included a history of present illness that at the hospital, the resident's urinalysis was negative but a Foley catheter was placed for unknown reasons. Assessment included benign prostatic hyperplasia (BPH) with lower urinary tract symptoms. Per the documentation, the resident was noted to have a Foley catheter; and that, the provider will order bladder training and then removal of Foley catheter. The daily skilled evaluation dated June 23, 2024 revealed that the resident was oriented x 3 and had catheter use. The progress note dated June 24, 2024 at 4:59 p.m. included that the resident had a Foley catheter in place and was complaining of discomfort to his penis. Per the documentation, the nurse removed the Foley catheter and the Nurse Practitioner (NP) was notified. Further, the documentation included that resident will be monitored for spontaneous urination. The physician order dated June 24, 2024 included may replace Foley if not urinating every shift for 3 days. The daily skilled evaluation dated June 24, 2024 7:59 p.m. revealed the resident had catheter. However, there was documentation of the reason for the continued use and reinsertion of the Foley catheter. An encounter note dated June 25, 2024 included the resident did not have suprapubic tenderness; and that, the resident had Foley catheter. An admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 99 indicating the resident was unable to complete the interview. The assessment included that the resident had short-term and long-term memory problem and had severely impaired cognitive skills for daily decision making. Further, the MDS coded that the resident had an indwelling catheter. The CAA (Care Area Assessment) summary revealed that indwelling catheter was triggered for care planning. However, the clinical record revealed no evidence that a care plan related to the use of a Foley catheter and implemented interventions. The weekly skin check note dated June 28, 2024 included that the penis had slough noted at the meatus. Per the documentation, the resident was uncircumcised; and, the foreskin needed to be pulled back to note area of inflammation from previous catheter insertion. It also included that treatment was applied. The shower sheets dated June 28, 2024 revealed no documentation of any issues identified on the resident's penis The care plan dated July 2, 2024 included the resident had bladder incontinence related to dementia, history of CVA (cerebrovascular accident) and impaired mobility. Goal was that the resident's risk for septicemia will be minimized/prevented via prompt recognition and treatment of symptoms of UTI (urinary tract infection). Interventions included to use disposable briefs and to check and change as needed. The physician order dated July 3, 2024 included for Santyl ointment (topical wound treatment) 250 unit/gram, apply to penis meatus topically at bedtime for wound care for small amount of slough area of the meatus. The weekly skin check notes dated July 4, and 12, 2024 included that the penis had slough noted at the meatus. Per the documentation, the resident was uncircumcised; and, the foreskin needed to be pulled back to note area of inflammation from previous catheter insertion. It also included that treatment was applied. The shower sheet dated July 8, 2024 revealed no documentation of any issues identified on the resident's penis. The clinical record revealed no evidence that Foley catheter care was administered or provided to the resident. It also did not include a reason why Foley catheter care was not provided; and that, the physician was notified. The encounter note dated July 11, 2024 revealed the resident was seen for penile abscess; and that, there was significant amount of smegma noted. Per the documentation, it inflamed but did not appear to be infected. It also included that the resident had Foley catheter; and, smegma was noted on the tip of the penis. Further, the documentaton included that the resident will be referred to the wound clinic as he might need debridement. The shower sheet dated July 11, 2024 revealed no documentation of any issues identified on the resident's penis. The encounter note dated July 16, 2024 revealed that the skin was warm and dry; and smegma was noted on the tip of the penis. The encounter note dated July 18, 2024 included that Foley catheter was noted. Despite documentation that the provider recommended referral to wound clinic, the clinical record revealed no evidence that the resident was referred to the wound clinic from July 11 through July 21, 2024. The progress note dated July 22, 2024 revealed that the resident had an appointment set at the wound clinic for July 31, 2024. The weekly skin check notes dated July 19 and 28, 2024 included that the penis had slough noted at the meatus. The documentation did not include whether or not treatment was administered. The shower sheet dated July 29, 2024 revealed no documentation of any issues identified on the resident's penis. The Santyl order was transcribed onto the medication administration record (MAR) for July 2024 and was documented as administered. The discharge and transfer assessment dated [DATE] included that the resident was transfered to the hospital. Per the documentation, the resident went to the wound clinic for his appointment for his penile wound; and , the wound clinic sent the resident to the ER (emergency room) straight from the clinic. The report of consultation note dated July 31, 2024 revealed that the resident had a penile ulcer at the tip of the penis; and that, there was need to retract the foreskin. Per the documentation, wound clinic performed wound culture and biopsy of the penile lesion. Further, the documentation included that the resident was sent to the ER for STAT urology consultation and possible I&D (incision & drainage) A phone interview with the wound clinic registered nurse (RN/staff #8) conducted on August 19, 2024 at 2:03 p.m., the RN stated that resident #57 was sent to the wound clinic for consultation of the penile wound. The RN said that on examination, the resident had quite a bit of necrosis at the tip of his penis which was usually seen in residents who were actively dying. The RN said that the wound clinic sent the resident out to the ER; and, if we are sending a resident out, then it was pretty bad. She stated that in the case of resident #57, the wound clinic biopsied the wound beneath the necrotic tissue at the tip of the penis. The RN said that the resident should have been seen and evaluated much sooner; and that, the facility could have done a culture and sensitivity test on resident #57. Further, the RN stated that the wound care provider documented that resident #57 may need removal of the penis and it was bad; but, she was not sure that happened. An interview was conducted on August 19, 2024 at 2:00 p.m. with the director of nursing (DON/staff #26) who stated that the facility did not have a wound care nurse for the past year. The DON said that a head to toe skin assessment was completed and reviewed by staff when a resident is admitted at the facility. The DON said the resident was then placed on weekly skin assessment schedule for issues. Regarding resident #57, the DON said that there was a definite problem here. The DON said that staff cannot have the same exact note every time staff were looking at a wound; and, she would have followed up with the resident after it was identified by staff. Further, the DON stated that it was problem that the provider recommended for the resident to see the wound clinic on July 11; but this was not even made until July 22, 2024. In a later interview with the DON conducted on August 19, 2024 at 3:05 p.m., the DON said that based on the clinical record, staff did everything they could. She also stated that review of the clinical record revealed the resident had slough in his penis and this was the same as necrosis. An interview on August 19, 2024 at 4:20 p.m. with a certified nursing assistant (CNA/staff #35) who stated he noticed that resident #57 had a penile issue; and he notified the administrator and charge nurse each time. He said that they told him that they knew about the issue and things were being done to correct it. He stated that the penile issue continued to look worse; and, when staff were cleaning the penis staff had to pull back the foreskin which did not come back easily. Further, he stated that some of the female nurses/staff were not comfortable pulling foreskin back and cleaning it like they should.