**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and records review, the facility failed to assess and provide necessary services to one of twelve sampled residents (Resident 38) when the facility did not ensure Resident 38 was free from pain due to left foot pressure ulcer and Deep Vein Thrombosis (DVT - a blood clot forms in one or more of the deep veins in the body, usually in the legs) to left leg. This failure resulted to Resident 38's inability to relax when she repeatedly called out for help and moaned (to make a long, low sound of pain, suffering). (Reference F686) Findings: During a record review for Resident 38, the Face sheet (A one-page summary of important information about a resident) indicated Resident 38 was admitted on [DATE] with diagnoses including but not limited to Diabetes Mellitus (disease that result in too much sugar in the blood); Congestive Heart Failure (CHF - blood often backs up and fluid can build up in the lungs, causing shortness of breath); and Other Symptoms and Signs Involving Cognitive Functions and Awareness and Schizoaffective disorder (a mental health disorder). During a record review for Resident 38, the document titled Progress Notes dated 3/9/23 at 3:54 p.m. indicated Resident 38 had a change of condition. The Progress Notes indicated Resident 38 had left hand and left leg swelling. During a record review for Resident 38, the document titled Progress Note dated 3/10/23 at 5:37 p.m. indicated doctor assessed Resident 38's swollen leg and ordered ultrasound (an imaging test that uses sound waves to create a picture of organs, tissues, and other structures inside the body) to rule out DVT. The Progress Note also indicated Resident 38 was on monitoring for left heel blister (a painful skin condition where fluid fills a space between layers of skin). During an observation and concurrent interview with Resident 38 in her room on 3/13/23 at 3:21 p.m., Resident 38 was sitting on her wheelchair, awake wearing a Prevalon heel protection boot (help reduce the risk of pressure ulcer (also known as bedsore - damage to an area of the skin caused by constant pressure on the area for a long time)by keeping the heel floated) to her left leg. Resident 38's top of left foot appeared swollen. When Resident 38 was asked if she had any concern with her skin, Resident 38 stated she believed she had an open area to her left foot and stated, it hurts. During an observation in Resident 38's room on 3/14/23 at 8:57 a.m., Resident 38 was sitting on her wheelchair, appeared restless kept on saying hello. During a record review for Resident 38, the ultrasound report dated 3/14/23 indicated the ultrasound was performed on 3/14/23 at 4:23 p.m. The report indicated, There is extensive DVT involving left common femoral vein (a large blood vessel in your thigh), superficial femoral vein and popliteal vein (vein located behind your kneecap). During an observation in Resident 38's room on 3/15/23 at 8:52 a.m., Resident 38 was sitting on her wheelchair, appeared restless kept on saying hello, and help. During an interview with Licensed Staff F on 3/15/23 2:28 p.m. when asked about reason for delay of the left leg ultrasound for Resident 38, Licensed Staff F stated the Social Service Director (SSD) was responsible for scheduling all appointments for the residents. Licensed Staff F stated they sometimes had a hard time to schedule an appointment with the hospital. During an interview with the SSD on 3/15/23 at 4:10 p.m. when asked about the reason for the delay of the ultrasound for Resident 38's left leg, the SSD stated the hospital would not schedule Resident 38 for the ultrasound until they get an order that had the doctor's signature, so she had to return the request form to the nurses to obtain the doctor's signature. The SSD stated when she was able to arrange the appointment for Resident 38, there was no transportation available to take Resident 38 to the appointment. During an observation in Resident 38's room on 3/16/23 at 8:29 a.m., Resident 38 was sitting on her wheelchair with a diabetic shoe on her left foot. Resident had facial grimacing, moaning, and repeatedly saying hello and help me. During an interview with Licensed Staff F on 3/16/23 11:24 a.m. Licensed Staff F stated she was not sure if Resident 38 was in pain, she stated it was normal for Resident 38 to call out and count loudly. When Licensed Staff F was asked how she would determine actual pain from behavior, Licensed Staff F stated she would observe for nonverbal indications of pain like facial grimacing, fidgeting, and restless; Licensed Staff F stated she would try to console Resident 38 and if it did not work, then it could be an indication that Resident 38 was in pain. Licensed Staff F stated Resident 38 received Tylenol (pain reliever) for two consecutive days and had asked Resident 38's doctor for a routine pain medication to manage potential pain from the pressure ulcer and DVT. During an interview with Licensed Staff B on 3/16/23 at 1:45 p.m., Licensed Staff B stated Resident 38 was super restless and moved her feet all the time. When Licensed Staff B was asked if Resident 38 having the DVT and pressure ulcer on her left heel would experience pain, Licensed Staff B stated, she could. Licensed Staff B was asked how pain was assessed when resident had behavior, Licensed Staff B stated she would observe for physical signs of pain like facial grimacing, tensed muscle, moaning, and restlessness. Licensed Staff B stated although these signs of pain were observed from Resident 38, Licensed Staff B stated she could not tell if Resident 38 was in pain due to Resident 38's history of calling out in the past. During an observation in Resident 38's room on 03/17/23 at 9:29 a.m., Resident 38 was on her bed with eyes closed, moaning. During a record review for Resident 38, the Medication Administration Record (MAR) for March 2023 indicated Resident 38 was monitored for pain every shift. The MAR indicated from 3/01/23 to 3/16/23, Resident 38 had 4 out of 10 level of pain (score of 0 no pain; 1 to 3 mild pain; 4 to 6 moderate pain and 7 to 10 severe pain) on 3/05/23. The MAR indicated Resident 38 received Tylenol on the following days: 3/3/23 for 6 out of 10 level of pain; 3/5/23 for 4 out of 10 level of pain; and 3/15/23 for 4 out of 10 level of pain. Review of the Facility policy titled Skin and Wound Monitoring and Management revised on 1/2022 indicated, A resident who enters the facility without pressure injury does not develop pressure injury unless the individual's clinical condition or other factors demonstrate that a developed injury was unavoidable; and A resident having pressure injury(s) receives necessary treatment and services to promote healing, prevent infection, and prevent new, avoidable pressure injuries from developing. Procedure indicated, It is understood that a resident may experience pain associated with the presence of skin injury and/or any form of compromise. Therefore, the nursing staff shall be responsible to assess the resident for complaints of pain on assessment, prior to treatment, and as appropriate. Review of the Facility policy titled Recognition and Management of Pain dated 2/2023 indicated, It is the policy of this facility to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and records review, the facility failed to provide adequate supervision for two of twelve sampled residents (Resident 249 and 38) when: 1. The facility did not follow their Fall Care plan to provide staff supervision to Resident 249 when sitting on his wheelchair. This failure resulted to Resident 249's repeated falls requiring two hospitalizations due to nasal laceration (a deep cut or tear in skin) and bilateral nasal bone fractures (a break in the bone or cartilage over the bridge, or in the sidewall or septum [structure that divides the nostrils] of the nose) to which Resident 249 experienced pain. 2. The facility failed to follow the doctor's order for nectar thick liquid for Resident 38 who had difficulty swallowing and did not provide staff supervision when drinking liquid. This failure had the potential for Resident 38 to aspirate (to breathe a substance into your lungs by accident) which could lead to choking, respiratory complications, serious infections or even death. Findings: Resident 249 During a record review for Resident 249, the Face sheet (A one-page summary of important information about a resident) indicated Resident 249 was admitted on [DATE] with diagnoses including but not limited to Difficulty Walking; Muscle Weakness; and Hemiplegia and Hemiparesis (paralysis of one side of the body). During a record review for Resident 249, the document titled LN (Licensed Nurse) - Fall Risk Evaluation dated 6/09/22 indicated Resident 249 was high risk for fall. During a record review for Resident 249, the Fall Care Plan initiated on 6/11/22 indicated Resident 249 was at risk for falls related to generalized weakness. Care Plan interventions indicated: - Be sure the call light is within reach and encourage to use it to call for assistance as needed - Bed in lowest position with fall mat at bedside - Educate resident/family/caregivers about safety reminders and what to do if a fall occurs - Keep needed items, water, etc., in reach - Occupational, Physical Therapy evaluation and treatment per physician orders - Educate resident/ family/caregivers about safety reminders and what to do if a fall occurs - Monitor placement of wedge cushion and dycem (non-slip products) in reclining wheelchair During a record review for Resident 249, the Minimum Data Set (MDS -health status screening and assessment tool used for all residents) dated 6/16/22 indicated Resident 249 had a BIMS score of 4 out of 15 points (Brief Interview for Mental Status - a 15-point cognitive (involving conscious intellectual activity [such as thinking, reasoning, or remembering)]) screening measure that evaluates memory and orientation. A score of 13 to 15 is cognitively intact, 08 to 12 is moderately impaired, and 00 to 07 is severe impairment). The MDS indicated Resident 249 required extensive (resident involved in activity; staff provide weightbearing support) one-person physical assist from staff with transfers and walking. First Fall 6/25/22 During a record review for Resident 249, the document titled Progress Notes dated 6/25/22 at 10:10 a.m. indicated Resident 249 was found on the floor yelling for help. The Progress Note indicated Resident 249 claimed he had fallen from the wheelchair trying to get to restroom. The Progress Note indicated Resident 249 sustained small laceration outside right eye, inner area alongside nose and larger laceration to outer, lower area under right eye. During a record review for Resident 249, the document titled Progress Notes dated 6/25/22 at 12:34 p.m. indicated Resident 249 was sent to the emergency room for evaluation. During a record review for Resident 249, the document titled Progress Notes dated 6/25/22 at 6:13 p.m. indicated Resident 249 returned to the facility. During a record review for Resident 249, the document titled Progress Notes dated 6/27/22 at 10:59 a.m. indicated the Interdisciplinary Team (IDT - group of health care professionals who work together toward the goals of the resident) met to discuss Resident 249's fall incident. The Progress Note indicated, [Resident 249] must be within view of staff/family members when sitting up in wheelchair. During a record review for Resident 249, the Fall Care Plan indicated interventions initiated on 6/25/22 indicated, Staff will not place the resident on wheelchair without family/staff supervision. Second Fall 7/7/22 During a record review for Resident 249, the document titled Progress Notes dated 7/7/22 at 6:30 a.m. indicated, at 0612 [Resident 249] was heard hollering from room. Found on floor on left side curled around transfer pole. Bed was in lowest position and call light was within reach. Resident assisted back on the bed. Crescent shaped skin tear back of left hand ; bruising left elbow. Said hit head (pink mark to back of head to left side, but no swelling or broken skin), but that it only hurt a little. During a review of the Fall Care Plan for Resident 249 and concurrent interview with the DON on 03/17/23 at 3:01 p.m., the DON verified Resident 249's Fall Care Plan did not have new intervention to prevent Resident 249 from further fall. Third Fall 7/13/22 During a record review for Resident 249, the document titled Progress Notes dated 7/13/22 at 7:09 a.m. indicated Resident 249's roommate notified the nurse that Resident 249 was on the floor. The Progress Note indicated the nurse and the CNA (Certified Nursing Assistant) found Resident 249 next to the bed on floor laying on a pillow on his right side. The Progress Note indicated Resident 249 had redness to his right elbow and right shoulder. During a record review for Resident 249, the document titled Progress Notes dated 7/14/22 at 2:42 p.m., indicated, IDT met to discuss resident recent fall. Resident was found on floor at bedside Will do room change closer to nurses' station, to monitor resident closer. Will provide floor mat at bed side. During an interview and concurrent record review with the DON on 03/17/23 at 3:07 p.m. when asked what interventions were put in place after the 7/13/22 fall incident to prevent Resident 249 from falling, the DON stated Resident 249 was moved to 18B which is closer to the nurse's station. The DON stated they also used regular mattress on the floor at bedside to prevent Resident 249 from sustaining fall related injury. The DON verified the fall care plan did not indicate floor mattress was used. Fourth Fall 9/11/22 During a record review for Resident 249, the document titled Progress Notes dated 9/11/22 at 4:32 p.m. indicated, 0800 at the Hallway [Resident 249] was in his wheelchair eating breakfast. The Progress Note indicated the housekeeper observed Resident 249 from afar leaning on his right side all the way to the floor and saw Resident 249 fell down. The Progress Note indicated staff immediately responded to the incident and found Resident 249 with blood coming from his nose and some blood coming from his mouth. The Progress Notes indicated Resident 249 possibly bit his right cheek with 2 small openings, right eyebrow laceration, right side of nose has laceration. The Progress Note indicated staff was assisting the resident across the room when the incident occurred. The Progress Note indicated Resident 249 was transferred to the hospital at 8:21 a.m. During a record review for Resident 249, the document titled ED (Emergency Department) Physician Notes dated 9/11/22 at 8:47 a.m. indicated, [Resident 249] was apparently complaining of neck pain after the fall. The Physician Note indicated a rhino rocket (designed for the treatment of nosebleed) was placed which was initially avoided due to Resident 249 nasal bone fractures, discomfort, and deviated septum, however Resident 249 had ongoing profuse bleeding. The Physician Note indicated Resident 249 received a dose of Fentanyl (a powerful pain medication). During a record review for Resident 249, the document titled Computerized Tomography (diagnostic imaging that shows detailed images of any part of the body, including the bones) dated 9/11/22 indicated, New on old bilateral nasal bone fractures with a new fracture of the bony nasal septum (the cartilage and bone in your nose) since 06/25/2022. During a record review for Resident 249, the document titled Progress Notes dated 9/11/22 at 4:33 p.m. indicated Resident 249 returned to the facility with rhino rocket clamp in right nose in place. During a record review for Resident 249, the document titled Progress Notes dated 9/11/22 at 5:35 p.m. indicated Resident 249 had some grimacing. During a record review for Resident 249, the Medication Administration Record (MAR) indicated Resident 249 received two tablets of Tylenol 325 mg (milligram) for pain level of 7 out of 10 on 9/11/22 at 5:31 p.m. The MAR indicated a score of 0 was no pain; 1 to 3 was mild pain; 4 to 6 was moderate pain; and 7 to 10 was severe pain During a record review for Resident 249, the MAR indicated Resident 249 received two tablets of Tylenol 325 mg (milligram) for pain level of 5 out of 10 on 9/12/22 at 1:56 p.m. During an interview with Unlicensed Staff J on 3/17/23 at 09:29 a.m., Unlicensed Staff J stated Resident 249 required extensive assist with transfers and toilet use, Resident 249 was non-ambulatory. During an interview with Unlicensed Staff E on 3/17/23 at 2:03 p.m., Unlicensed Staff E stated Resident 249 required two-person total assist with transfer and non-ambulatory. Unlicensed Staff E stated Resident 249 had at least 2 to 3 fall incidents since he was admitted to the facility. When Unlicensed Staff E was asked about interventions put in place to prevent Resident 249 from further fall, Unlicensed Staff E stated Resident 249 was put on frequent check, lowered his bed, and placed fall mat at bedside right after the first fall incident. Unlicensed Staff E was asked if Resident 249 had complained of pain after he sustained a nasal fracture from the 9/11/22 fall incident, Unlicensed Staff E stated Resident 249 spoke Spanish; however, he stated he knew Resident 249 was in pain because his body language indicated he was in pain like grimacing and guarding. During an interview with Licensed Staff A on 3/17/23 at 2:08 p.m., Licensed Staff A stated Resident 249 had complained of pain a few times after he sustained the nasal fracture and was medicated with Tylenol. Licensed Staff A was asked what interventions were put in place to prevent Resident 249 from further fall, Licensed Staff A stated Resident 249 could not be left alone in wheelchair without supervision because he moved a lot. During an interview and concurrent record review with the DON on 03/17/23 at 3:19 p.m. when asked about Resident 249's 9/11/22 fall, the DON stated the incident happened in the morning when Resident 249 was sitting on his wheelchair outside of his room. The DON stated staff were providing oversight supervision to Resident 249 while passing breakfast tray; however, fall incident happened. The DON verified the fall care plan for Resident 249 initiated on 6/25/22 indicated, Staff will not place the resident on wheelchair without family/staff supervision. The DON concurred they did not follow the care plan to provide supervision when Resident 249 was up on his wheelchair. Review of the Facility policy titled Fall Management System revised on 2/2023 indicated This facility is committed to promoting resident autonomy by providing an environment that remains as free of accident hazards as possible. Each resident is assisted in attaining or maintaining their highest practicable level of function through providing the resident adequate supervision, assistive devices, and functional programs as appropriate to prevent accidents. Resident 38 During a record review for Resident 38, the Face sheet (A one-page summary of important information about a resident) indicated Resident 38 was admitted on [DATE] with diagnoses including but not limited to Diabetes Mellitus (disease that result in too much sugar in the blood); Congestive Heart Failure (CHF - blood often backs up and fluid can build up in the lungs, causing shortness of breath); and Other Symptoms and Signs Involving Cognitive Functions and Awareness and Schizoaffective disorder (a mental health disorder). During a record review for Resident 38, the MDS dated [DATE] indicated Resident 38 required supervision (oversight, encouragement, or cueing) with eating. During a record review for Resident 38, the document titled Order Summary Report indicated an order for Resident 38 with a start date on 2/24/23 for CCHO diet (consistent, constant, or controlled carbohydrate [food consisting of or containing a lot of sugars, starch]) mechanical soft texture, nectar thick consistency. During a record review for Resident 38, the document titled SLP (Speech Language Pathologist - also known as a Speech Therapist, is a health professional who diagnoses and treats communication and swallowing problems) Evaluation and Plan of Treatment with certification period from 1/17/23 to 2/12/23 indicated, Resident 38 was referred to Speech Therapy for Dysphagia (difficulty swallowing) services due to decline, risk for aspiration and oral/pharyngeal function. Resident 38referred to Speech Therapy due to decline in safety awareness, ability to use compensatory strategies and ability to effectively communicate needs/preferences. During an observation in Resident 38's room on 3/13/23 at 3:16 p.m., an unidentified CNA (Certified Nursing Assistant) offered a diet ginger ale to Resident 38. The CNA was observed opening the soda can, poured in a cup and assisted Resident 38 to drink. During an observation in Resident 38's room on 3/15/23 at 8:52 a.m., Resident 38 was up on her wheelchair. Kept on saying hello, cherry and help. Resident 38 had half full cup of thick clear liquid in front of her on top of the bedside table and a quarter full cup of thin consistency coffee. During an observation and concurrent interview with Director of Staff Development (DSD) on in Resident 38's room on 3/15/23 at 8:58 a.m., the DSD verified the cup of water in front of Resident 38 was thicker than the coffee. The DSD stated the coffee should be thick and took coffee away. During an observation and concurrent interview with the Director of Nursing (DON) in Resident 38's room on 3/16/23 at 3:11 p.m. DON verified Resident 38 had an almost empty container and an approximately 40 ml (milliliter - one thousandth of a liter) of Boost (nutritional supplement) in a cup on top of Resident 38's bedside table. The DON verified Resident 38 had an order for nectar thick liquid. The DON stated Resident 38 would be at risk for aspiration pneumonia when drinking thin liquid. During an interview with the Dietary Manager on 3/16/23 at 3:18 p.m. when asked about their process of preparing liquid consistency for residents prior to sending food trays out to the unit, the Dietary Manager stated they would put one pump of thickener for thin liquid, 2 pumps for honey thick and 3 pumps for nectar thick. The Dietary Manager stated they would send the nutritional supplements like boost with the resident's meal tray unopened and it was the nurse's responsibility to mix the drink according to the doctor's order before serving it to the residents. During an interview and concurrent observation with on 3/16/23 at 3:27 p.m., the Speech Therapist (ST) stated Resident 38 received speech therapy services due to difficulty swallowing and risk for aspiration. The ST verified Resident 38 should have nectar thick liquid. When ST was asked to check the boost on top Resident 38's bedside table, the ST stated the boost consistency was thin and it should have been thickened before it was served to Resident 38. The ST stated Resident 38 required supervision during meals and drinking due to Resident 38's fluctuating mentation (process of reasoning and thinking). During an interview with Licensed Staff F on 3/16/23 at 3:31 p.m. when asked how she prepared the boost for Resident 38, Licensed Staff F stated there was no need to thicken the boost because it was already thick.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and records review, the facility failed to assess two of twelve sampled residents (Resident 23 and 38) who were identified at risk for pressure ulcer when: 1. The facility did not assess Resident 23's skin integrity under the left lower extremity (part of the body that includes the leg, ankle, and foot) immobilizer (removable devices that maintain stability of the knee) for a period of two weeks when nursing and therapy staff were providing care and treatment. This failure resulted to the development of a Suspected Deep Tissue Injury (SDTI - Intact or non-intact skin with localized area of persistent non-blanchable [when the skin is pushed and the area stays red, that means that there is little or no blood flow going to that area] deep red, maroon, purple discoloration, or epidermal separation revealing a dark wound bed or blood-filled blister [(a painful skin condition where fluid fills a space between layers of skin]) to Resident 23's left heel. 2. The facility did not assess Resident 38's skin integrity to her left heel after an old pressure ulcer resolved. This failure resulted to the development of a stage two (Partial-thickness loss of skin with exposed dermis [middle layer of skin]) pressure ulcer in a form of a ruptured blister to Resident 38's left heel to which Resident 38 experienced pain and inability to relax when she repeatedly called out for help and moaned (to make a long, low sound of pain, suffering). Findings: Resident 23 During a record review for Resident 23, the Face sheet indicated Resident 23 was admitted on [DATE] with diagnoses including but not limited to Fracture of Shaft of Left Fibula (a break in the small bone that runs along the outside of the lower leg); Diabetes Mellitus (disease that result in too much sugar in the blood); Protein Calorie Malnutrition (when a person is not consuming enough protein and calories) and COVID (Corona Virus Disease - an infectious respiratory disease). During a record review for Resident 23, the document titled LN (Licensed Nurse) - Braden Scale for Predicting Pressure Sore Risk dated 2/07/23 indicated Resident 23 scored 13 indicating she was moderate risk for pressure ulcer. During a record review for Resident 23, the document titled LN - Initial admission Record dated 2/07/23 indicated Resident 23 had an immobilizer to her left lower extremity. During a record review for Resident 23, the Care Plan initiated on 02/08/23 indicated, [Resident 23 had the potential for pressure ulcer development related to immobility, incontinence, and use of brace (a device used to immobilize a joint or body segment) to LLE (Left Lower Extremity). Care Plan interventions indicated, Monitor/document/report to MD (Medical Doctor) PRN (as needed) changes in skin status: appearance, color, wound healing, signs and symptoms of infection, wound size and stage; and Notify nurse immediately of any new areas of skin breakdown: Redness, Blisters, Bruises, discoloration noted during bath or daily care. During a record review for Resident 23, the Minimum Data Set (MDS -health status screening and assessment tool used for all residents) dated 2/14/23 indicated Resident 23 had a BIMS score of 01 out of 15 points (Brief Interview for Mental Status - a 15-point cognitive screening measure that evaluates memory and orientation. A score of 13 to 15 is cognitively intact, 08 to 12 is moderately impaired, and 00 to 07 is severe impairment). The MDS indicated Resident 23 required extensive (resident involved in activity; staff provide weightbearing support) two-person physical assistance with bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed). The MDS indicated Resident 23 was at risk for developing pressure ulcers. The MDS indicated Resident 23 did not have unhealed pressure ulcers during the assessment period. During a record review for Resident 23, the document titled SBAR (Situation, Background, Assessment and Recommendation - a tool used by health care professionals to communicate with each other about critical changes in patient's status) communication form dated 2/25/23 indicated Resident 23 was noted to have discoloration to her left heel that measured 7.5 cm (centimeter - a metric unit of length, equal to one hundredth of a meter) in length and 2.5 cm. in width. The document indicated Resident 23 was wearing immobilizer to her left foot. During a record review for Resident 23, the document titled Progress Note dated 2/28/23 at 11:17 a.m. indicated Resident 23 had a non-blanchable purple tissue with some dry well adherent eschar to her left heel. During a review of the Certified Nursing Assistant (CNA) job description dated 12/17/21 indicated essential duties and responsibilities for CNAs include but not limited to observe and report the presence of pressure areas and skin breakdowns to prevent pressure ulcers. During an interview with Licensed Staff G on 3/14/23 at 11:28 a.m., Licensed Staff G stated Resident 23's left leg was on immobilizer which caused a pressure ulcer to Resident 23's left heel. When Licensed Staff G was asked how often did nursing staff check the skin integrity under Resident 23's LLE immobilizer, she stated dressing to Resident 23's left knee was left untouched until the doctor said it was okay to remove the dressing. When Licensed Staff G was asked if there was an order to not remove the immobilizer, she stated there was no order. Licensed Staff G concurred Resident 23' LLE under the immobilizer should be checked daily for skin changes. During an interview and concurrent record review with Licensed Staff F on 3/15/23 at 10:13 a.m., when Licensed Staff F was asked how often did nursing staff check Resident 23's skin integrity under the LLE immobilizer, Licensed Staff F stated Resident 23's entire left leg was checked daily for skin changes and would document findings in Resident 23's record. Review of the document titled Nursing Weekly skin assessment for Resident 23 dated 3/14/23 with Licensed Staff F indicated the check box for current pressure ulcer was not checked. Licensed Staff F verified Resident 23 was receiving treatment to her left heel pressure ulcer. During an interview and concurrent record review with the Director of Rehabilitation (DOR) on 3/15/23 at 2:42 p.m. when asked whose responsibility to ensure, skin integrity under the immobilizer of Resident 23's left leg was not compromised, the DOR stated Physical Therapist (PT - A health professional trained to evaluate and treat people who have conditions or injuries that limit their ability to move and do physical activities) had to make sure Resident 23's skin under the left lower immobilizer did not have any skin problem every time PT provided treatment. The DOR stated PT would document their skin observation to Resident 23's record. During an interview and concurrent records review with the DON (Director of Nursing) on 3/15/23 at 2:51 p.m. when asked about her expectation from the nurses for resident who came with an immobilizer, the DON stated if the doctor gave an order to leave the immobilizer in place, then nurses were not allowed to remove the immobilizer; however, nurses could check for circulation like pulse and skin temperature. Review of the physician's order for February 2023 with the DON and verified there was no doctor's order to not remove Resident 23's LLE immobilizer. The DON stated if there was no order to leave the immobilizer in place, nurses should definitely check the skin integrity for changes under the immobilizer at least once a day and document. Review of Resident 23's Progress notes with the DON did not show any documentation from nursing staff indicating Resident 23's left heel was checked at least once a day for skin changes prior to the identification of the SDTI. During a review of the bathing record for Resident 23 with the Infection Preventionist (IP) on 3/16/23 at 2:29 p.m., the IP verified the bathing record from 2/15/23 to 3/16/23 indicated Resident 23 received bed bath once on 3/14/23 and no record of shower given. The IP stated CNAs would document skin changes to the shower sheet and give to the nurse for follow-up. IP was asked to provide shower sheets for Resident 23 from February 2023 to present; however, this writer did not receive shower sheets for Resident 23 at time of exit from the facility. Resident 38 During an observation and concurrent interview with Resident 38 in her room on 3/13/23 at 3:21 p.m., Resident 38 was sitting on her wheelchair, awake wearing a Prevalon heel protection boot (help reduce the risk of pressure ulcer by keeping the heel floated) to her left foot. Resident 38's top of left foot appeared swollen. When Resident 38 was asked if she had any concern with her skin, Resident 38 stated she believed she had an open area to her left foot and stated, it hurts. During a record review for Resident 38, the Face sheet (A one-page summary of important information about a resident) indicated Resident 38 was admitted on [DATE] with diagnoses including but not limited to Diabetes Mellitus (disease that result in too much sugar in the blood); Congestive Heart Failure (CHF - blood often backs up and fluid can build up in the lungs, causing shortness of breath); and Other Symptoms and Signs Involving Cognitive Functions and Awareness and Schizoaffective disorder (a mental health disorder). During a record review for Resident 38, the document titled LN - Braden Scale for Predicting Pressure Sore Risk (a tool to help health professionals, especially nurses, assess a patient's risk of developing a pressure ulcer) dated 12/22/22 indicated Resident 38 had a total score of 14 (Total Score of 9 or less was Very High Risk; 10 to12 was High Risk; 13 to 14 was Moderate Risk; 15 to 18 was Mild Risk and 19 to 23 was No Risk). During a record review for Resident 38, the document titled Initial Care Plan dated 12/22/22 indicated Resident 38 had left heel pressure ulcer and potential for pressure ulcer. Care Plan intervention include but not limited to: daily body skin checks; Notify nurse immediately of any new areas of skin breakdown: Redness, Blisters, Bruises, discoloration noted during bath or daily care. During a record review for Resident 38, the MDS dated [DATE] indicated Resident 38 was at risk for developing pressure ulcers. The MDS indicated Resident 38 had an unstageable pressure ulcer (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough (dead tissue that separates from living tissue in a wound) or eschar (dead tissue that sheds or falls off from the skin) that was present upon admission. During a record review for Resident 38, the document titled LN - Skin Pressure Ulcer Weekly dated 1/11/23 at 6:20 a.m. indicated Resident 38 had an unstageable pressure ulcer to left heel. During a record review for Resident 38, the document titled Skin Wound Note dated 1/17/23 at 1:22 p.m. indicated Resident 38's pressure ulcer to left heel was resolved. During a record review for Resident 38, the Care plan initiated on 1/18/23 indicated Resident 38 had the potential for pressure ulcer development related to Resident 38's history of pressure ulcer. Care Plan interventions include: Notify nurse immediately of any new areas of skin breakdown: Redness, Blisters, Bruises, discoloration noted during bath or daily care. During a record review for Resident 38, the document titled Progress Notes dated 3/9/23 at 3:54 p.m. indicated Resident 38 had a change of condition. The Progress Notes indicated Resident 38 had left hand and left leg swelling. During a record review for Resident 38, the document titled Progress Note dated 3/10/23 at 5:37 p.m. indicated doctor assessed Resident 38's swollen leg and ordered ultrasound (the standard imaging test for patients suspected of having acute DVT [Deep Vein Thrombosis - a blood clot forms in one or more of the deep veins in the body, usually in the legs]) to rule out DVT. The Progress Note also indicated Resident 38 was on monitoring for left heel blister. During a record review for Resident 38, the ultrasound report dated 3/14/23 indicated the ultrasound was performed on 3/14/23 at 4:23 p.m. The report indicated, There is extensive DVT involving left common femoral vein (a large blood vessel in your thigh), superficial femoral vein and popliteal vein (vein located behind your kneecap). During an observation in Resident 38's room on 3/14/23 at 8:57 a.m., Resident 38 was sitting on her wheelchair, appeared restless kept on saying hello. During an observation in Resident 38's room on 3/15/23 at 8:52 a.m., Resident 38 was sitting on her wheelchair, appeared restless kept on saying hello, and help. During an interview and concurrent record review with the DON on 3/15/23 at 3:12 p.m. when asked about facility process with skin assessment for residents who had previous pressure ulcers, the DON stated nurses were to do a weekly skin assessment and CNAs providing daily care like shower to residents would be able to identify any skin issues and would be reported to the nurse for further assessment. The DON verified there was no documentation from nursing staff indicating Resident 38's left heel was checked at least once a day for skin changes since Resident 38's old pressure ulcer resolved. During an observation in Resident 38's room on 3/16/23 at 8:29 a.m., Resident 38 was sitting on her wheelchair with a diabetic shoe on her left foot. Resident had facial grimacing, moaning, and repeatedly saying hello and help me. During an interview with Unlicensed Staff E on 3/16/23 at 9:11 a.m. when asked about resident's shower schedule, Unlicensed Staff E stated they give shower twice a week for all residents. Unlicensed Staff E stated they would do head to toe skin check when giving shower to residents; any skin changes would be documented to the shower sheet and would be given to the nurse. When Unlicensed Staff E was asked if he checked Resident 38's left heel when providing care, Unlicensed Staff E stated, no because her left leg was always wrapped. During an interview with Licensed Staff F on 3/16/23 11:24 a.m. Licensed Staff F stated she was not sure if Resident 38 was in pain, she stated it was normal for Resident 38 to call out and count loudly. When Licensed Staff F was asked how she would determine actual pain from behavior, Licensed Staff F stated she would observe for nonverbal indications of pain like facial grimacing, fidgeting, and restless; Licensed Staff F stated she would try to console Resident 38 and if it did not work, then it could be an indication that Resident 38 was in pain. Licensed Staff F stated Resident 38 received Tylenol (pain reliever) for two consecutive days and had asked Resident 38's doctor for a routine pain medication to manage potential pain from the pressure ulcer. During an interview with Licensed Staff B on 3/16/23 at 1:45 p.m., Licensed Staff B stated Resident 38's left heel blister would be a stage 2 pressure ulcer (Partial-thickness loss of skin with exposed dermis [middle layer of skin]) because it was a ruptured blister, and the location of wound was on a bony prominence. Licensed Staff B stated Resident 38 was super restless and moved her feet all the time. When Licensed Staff B was asked if Resident 38 having pressure ulcer on her left heel would experience pain, Licensed Staff B stated, she could. During a review of the bathing record for Resident 38 with the IP on 3/16/23 at 2:29 p.m., the IP verified the bathing record from 2/15/23 to 3/16/23 indicated Resident 38 received shower once on 3/11/23. The IP stated CNAs would document skin changes to the shower sheet and give to the nurse for follow-up. IP was asked to provide shower sheets for Resident 38 from February 2023 to present however, there were only two shower sheets received for 2/15/23 and 3/15/23. During an observation in Resident 38's room on 03/17/23 at 9:29 a.m., Resident 38 was on her bed with eyes closed, moaning. During a telephone interview with the Medical Director on 3/21/23 at 12:09 p.m. when asked about his expectation for resident skin assessment, the Medical Director stated daily skin assessment was very important for pressure ulcer prevention especially for residents who were at risk for pressure ulcer. Review of the Facility policy titled Skin and Wound Monitoring and Management revised on 1/2022 indicated, A resident who enters the facility without pressure injury does not develop pressure injury unless the individual's clinical condition or other factors demonstrate that a developed injury was unavoidable; and A resident having pressure injury(s) receives necessary treatment and services to promote healing, prevent infection, and prevent new, avoidable pressure injuries from developing. Procedure indicated: - It is understood that a resident may experience pain associated with the presence of skin injury and/or any form of compromise. Therefore, the nursing staff shall be responsible to assess the resident for complaints of pain on assessment, prior to treatment, and as appropriate. - Monitoring indicated Skin inspection on showering: On shower days, CNAs to observe resident skin; identify any areas of skin breakdown, discoloration, tears, or redness. Review of the Facility policy titled Pressure Ulcer dated 2/2023 indicated The purpose of this policy is that the resident does not develop pressure ulcers unless clinically unavoidable and that the facility provides care and services to: Promote the prevention of pressure ulcer development . Procedures indicated monitoring daily.