**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the prevention of avoidable accidents for one of three sampled residents (Resident 1), when a Certified Nursing Assistant 1 (CNA 1) failed to perform a two-person transfer while using a Hoyer Lift (a mechanical lift used to transfer residents from their bed to a chair, or wheelchair, etc.) with Resident 1, and failed to use the appropriate Hoyer Lift sling with Resident 1 during a transfer from a bed to a wheelchair. These failures resulted in Resident 1 falling to the floor and sustaining a laceration (a break in the skin caused by blunt force trauma) to the back of the head, requiring evaluation and treatment at a hospital. Findings: During a review of Resident 1's admission Record (contains Resident 1's medical and demographic information), undated, the admission Record indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses that included quadriplegia (paralysis of the arms and legs), altered mental status, muscle weakness, and cachexia (weakness and wasting of the body due to severe chronic illness) and severe protein-calorie malnutrition (inadequate intake of calories from proteins, vitamins, and minerals). During a review of Resident 1's fall assessment titled, [name of facility] Fall Risk Evaluation, (a scored assessment of Resident 1's fall risk) dated March 3, 2023, the fall assessment indicated, Resident 1 was identified to be at high-risk for falls, with a score of 12. The document further indicated, .If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls . During a concurrent observation and interview on May 4, 2023, at 2:38 PM, with Resident 1, in Resident 1's room, Resident 1 was observed to be unable to move his arms and legs. Resident 1 appeared thin and frail (weak and delicate), and did not verbalize anything when spoken to, but when asked if he fell from a Hoyer Lift recently, Resident 1 nodded his head up and down. During an interview on May 23, 2023, at 2:25 PM, with the Assistant Director of Nursing (ADON), the ADON stated, she was working at the facility on April 20, 2023, at the time when Resident 1 fell from the Hoyer Lift. The ADON stated, she responded to the incident after Resident 1 had fallen to the floor, and because of the fall, Resident 1 sustained a laceration to the rear of his head, which bled and required evaluation at a hospital. The ADON further stated, Resident 1 fell from the Hoyer Lift sling, because CNA 1 had used the incorrect sling to transfer Resident 1 with the Hoyer Lift. The ADON further stated, CNA 1 had used the sling intended to be used with the sit-to-stand lift (a mechanical lift used to aid residents to rise from the seated position but does not support the resident's entire body weight) but should have instead used the full body sling meant to be used with the Hoyer Lift. The ADON further stated, the sit-to-stand sling was not supposed to be used at all with the Hoyer Lift. The ADON further stated, Resident 1 required the assistance of two staff members when the Hoyer Lift was used, but CNA 1 did not get the assistance of another staff member to assist with the transfer, and instead attempted the transfer by herself. During an interview on May 23, 2023, at 2:44 PM, with CNA 1, CNA 1 stated, on April 20, 2023, she attempted to transfer Resident 1 by herself from their bed to a wheelchair using the Hoyer Lift. CNA 1 further stated, she was aware Resident 1 required the assistance of two staff during transfers with the Hoyer Lift but stated Resident 1 was not very heavy, so she thought she could attempt to perform the transfer alone. CNA 1 further stated, she used the sit-to-stand sling instead of the Hoyer full body sling when she used the Hoyer device to transfer Resident 1, and at the time she performed the transfer, she was not aware that she was using the wrong sling. During a follow up interview on May 23, 2023, at 2:54 PM, with the ADON, the ADON stated, two staff members were required to transfer any resident when using the Hoyer Lift, because one person was supposed to stand by the Hoyer Lift while the other staff member was supposed to be by the resident in the sling, to guide the resident and make sure they don't bump their head or fall. During a concurrent interview and record review, on May 30, 2023, at 4:30 PM, with the Director of Nurses (DON), the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, undated, was reviewed. The P&P indicated, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities . Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards, and try to prevent avoidable accidents . Individualized, Resident-Centered Approach to Safety . 3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. 4. Implementing interventions to reduce accident risks and hazards shall include the following: . d. Ensuring that interventions are implemented . The DON stated, Resident 1 required two staff members during transfers with the Hoyer Lift, but the resident only had the supervision of one staff member at the time the resident fell. During a review of Resident 1's physician's orders, dated April 20, 2023, the physician ' s orders indicated the following: 1) Amoxicillin (An antibiotic used to treat bacterial infections) 875 mg (milligrams-a unit of measurements) - potassium clavulanate (an antibiotic used to treat bacterial infections) 125 mg 1 tablet by mouth every 12 hours x (times) 7 days .2) Sulfamethoxazole (an antibiotic used to treat bacterial infections) 800 mg-trimethoprim (an antibiotic used to treat bacterial infections) 160 mg 1 tablet by mouth every 12 hours x 7 days - head laceration/prophylaxis-(a medication or a treatment designed and used to prevent a disease or illness from occurring) .3. Back of head laceration treatment cleanse with normal saline wound cleanser, pat dry, cover with dry dressing wrap with kerlix (a type of gauze dressing), secure with tape daily & reevaluate in 7 days . During a review of the facility's Hoyer Lift [name of manufacturer] operator's manual titled, Owner's Operator and Maintenance Manual Electric Portable Patient Lift, undated, the manual indicated, Warning . [name of manufacturer] products are specifically designed and manufactured for use in conjunction with [name of manufacturer] accessories. Accessories designed by other manufacturers have not been tested by [name of manufacturer] and are not recommended for use with [name of manufacturer] products . Operating the Patient Lift . [name of manufacturer] slings and patient lift accessories are specifically designed to be used in conjunction with [name of manufacturer] patient lifts. Slings and accessories designed by other manufacturers are not to be utilized as a component of [name of manufacturer] ' s patient lift system . for the safety of the patient, DO NOT intermix slings and patient lifts of different manufacturers. Warranty will be voided . Operating the Patient Lift . [name of manufacturer] recommends that two assistants be used for all lifting preparation and transferring to/from procedures . WARNING . DO NOT use slings and patient lifts of different manufacturers . Injury or damage may occur . During a review of Resident 1's Minimum Data Set (MDS - a comprehensive assessment of the resident's functional capabilities), dated March 1, 2023, the MDS Section G (functional status) indicated, Resident 1 was total dependence (totally dependent on staff) for transfers [to and from bed, wheelchair etc.] and bed mobility. The MDS further indicated, Resident 1 required the assistance of two staff members during transfers. During a review of Resident 1's Physical Therapy Recertification and Updated Plan of Treatment (a summary assessment and plan of treatment for the resident), signed on April 20, 2023, the plan indicated, . Patient will safely perform functional transfers with TD [total dependence] . Comments: Hoyer transfers recommended for safety . During a review of Resident 1's care plan titled, ADL [activities of daily living] - care plan, dated January 23, 2023, the care plan indicated, Needs assistance with ADLs: Transfers - Total Assist Support . 2-3 staff assist . with interventions including, Assist with transfers, request extra help as needed . During a review of the facility's P&P titled, Policy and Procedure on Hoyer Lift Usage, dated August 2017, the P&P indicated, It is this facility ' s policy to help move, lift, and transfer heavy residents who are unable to assist mover . 1. Assess physical characteristics of the resident (i.e. weight size, height, age, physical limitations and abilities) and determine if assistance is needed from another caregiver . 5. DO NOT use Hoyer Lift equipment if unfamiliar with procedure . 7. Provide reassurance that precaution will be taken to prevent falls . During a review of the facility's P&P titled, Policy and Procedure on Fall Prevention and Reduction, dated October 2014, the P&P indicated, Policy. It is this facility ' s policy to prevent falls to the extent possible and within the control of the facility . 1. Residents, Upon admission, shall be assessed and evaluated for risk for falls or further falls. 2. Residents identified to be at risk for falls or further falls shall have plans of care developed to minimize or reduce risk factors for falls or further falls. 3. Plans of care shall include interventions on the following . Provision of monitoring and supervision to resident to prevent fall incident . During a review of the facility's job description for Certified Nursing Assistant titled, Certified Nursing Assistant, undated, the job description indicated, . Purpose of your job position. The primary purpose of your job position is to provide each of your assigned residents with routine daily nursing care and services in accordance with the resident ' s assessment and care plan, and as may be directed by your supervisors . Delegation of Authority. As a Certified Nursing Assistant you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties . Perform all assigned tasks in accordance with our established policies and procedures, and as instructed by your supervisors . Follow established safety precautions in the performance of all duties . Operate all equipment in a safe manner .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the facility's policy and procedure titled Policy and Procedure on Pressure Ulcers (wounds caused by prolonged pressure on a bony prominence that may be superficial (Stage 1) to involving damage which includes all layers of skin down to the bone (Stage IV), dated August 22, 2017, for two of two sampled residents (Residents 3 and 44) was followed when: 1. The facility did not provide documented evidence for Resident 3 who had a Stage 4 pressure (involves all layers of skin down to the bone) ulcer on the sacrum (located above the tailbone) and a Stage 3 pressure (Involves all layers of skin down to the muscle) ulcer on the left hip to show the resident had been repositioned at least every two hours to prevent further pressure on the wounds. 2. For Resident 44: the facility did not conduct a full assessment (includes: Type of Ulcer, Location, Stage of Pressure Ulcer, Measurements, Non-viable tissue, Odor, Amount of Exudate [fluid], Type of Exudate, Wound bed, Description of surrounding skin/tissue, Description of wound edges, Progress towards healing, Nature and frequency of Pain and Signs of Infection) of a Deep Tissue Injury (DTI- a form of pressure ulcer. Pressure ulcers are localized areas of tissue damage that develop because of prolonged pressure on areas of bone that are close to the skin's surface) on Resident 44's right heel at admission; the facility did not follow the physician's treatment order for the DTI for 64 days, the facility did not inform the wound care doctor of Resident 44's DTI for 40 days; the facility did not conduct weekly wound assessments for nine weeks and the Registered Dietician (RD) did not include the DTI in Resident 44's Nutritional Assessments from admission through to November 9, 2022. These failures had the potential to cause Residents 3 and 44, to suffer an increased risk of mortality (the state of being subject to death), infection, decline in function (a loss of independence in self-care capabilities and deterioration in mobility and in activities of daily living), and pain. Findings: 1. During a review of Resident 3's admission Record (contains demographic and medical information), undated, indicated Resident 3 was initially admitted to the facility on [DATE], and readmitted [DATE], with diagnoses that included metabolic encephalopathy (chemical imbalance in the brain), hemiplegia and hemiparesis following cerebral infarction (muscle weakness, inability to move one side of body as a result of blocked blood flow to the brain), dementia (a group of conditions affecting the ability to remember, think or make decisions), contracture of left and right knee (stiffening of the knee and inability to move the knee), blindness (inability to see), pressure ulcer of sacral region and pressure ulcer of left hip (localized damage to the skin on the hip). During a concurrent observation and interview on December 13, 2022, at 8:48 AM, with Resident 3, who was lying in bed covered up with her legs turned to the right, Resident 3 stated she did not know how her wound developed or when it occurred, and the facility staff had not explained that to her. Resident 3 stated the treatment nurse puts a dressing on her wound, and she did not know if they [wounds] are getting better. Resident 3 stated the certified nursing assistant (CNA) would come twice a day to check the dressing on her wound. Resident 3 stated that she did not have pain in the wounds, but the wounds would sometimes itch and I know I shouldn't scratch them. Resident 3 stated the certified nursing aides did not come in every two hours to assist with repositioning and that they used to come in more often but not so much anymore. Resident 3 was observed three times on December 13, 2022, at 8:48 AM, 10:30 AM, and 12:25 PM lying in her bed, in the same position, on her back with legs turned to the right and under her blanket. During a review of Resident 3's Braden Scale - For predicting pressure sore risk (Braden scale), dated October 21, 2022, the Braden Scale indicated Resident 3 was at high risk for pressure sore development with a score of 9 out of 23. The lower the score, indicated the increased risk for pressure sore development. During a review Resident 3's Long term care plan, Impaired skin/tissue integrity, chronic wound (care plan) dated October 21, 2022, indicated the plan/approach included assist with and/or encourage turning/repositioning at least every 2 hours and as needed. During a review of Resident 3's MDS (minimum data set, a clinical assessment of all residents in nursing homes) 3.0 Section G (MDS) dated [DATE], indicated Resident 3 required total assistance (full staff performance every time) with one-person physical assist for bed mobility (how the resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture). During a review of Resident 3's IDT (interdisciplinary team- a group of clinical staff such as nursing, dietary, and activities), wound care committee (IDT notes), dated November 11, 2022, the IDT notes under IDT recommendations was to reposition/turn every 2 hours. During an interview with a Certified Nursing Assistant (CNA 2) on December 13, 2022, at 3:20 PM, CNA 2 stated documentation for certified nursing assistants was written on the facility's nurse assistant additional notes. CNA 2 stated this documentation would include every 2-hour turning or those cares that are completed outside of the ADL (Activities of daily living such as eating, bathing, and walking) charting. During a review of Resident 3's Nurse assistant additional notes, dated October 25, 2022, through November 27, 2022, the notes indicated zero documentation of every 2-hour turning or repositioning of Resident 3. During a review of the facility's policy and procedure titled, Policy and Procedure on pressure ulcers (P&P), dated August 22, 2017, the P&P indicated, in section 1.8 If bedbound, reposition every two hours; if chairbound reposition every hour. Section 5.3 indicated, A resident who is dependent on staff for repositioning should have repositioning schedule to maintain skin integrity. Repositioning schedule may range from every 2 hours or more frequently depending on tissue tolerance. Section 5.7, indicated Document implementation of repositioning schedule in the resident's medical chart, e.g., licensed progress notes, ADLS charting or medication administration record (MAR). During an interview on December 13, 2022, at 5:06 PM, with the Director of Nursing (DON), the DON stated the intervention for pressure ulcers was expected to be every 2-hour turning and/or repositioning, which was not documented. The DON stated she made observations of residents' positions while lying in bed, throughout the day to ensure they were repositioned every two hours. The DON stated staff used a badge card to tell staff which way a resident should be facing at various times during the day while in bed. The DON stated that the CNAs and all staff have the same badge. The DON stated only observations were completed, there was no paper documentation to show that repositioning and/or every 2-hour turning was completed. 2. A review of Resident 44's face sheet (a document that gives a summary of resident's information), undated, indicated Resident 44 was admitted to the facility on [DATE], with diagnoses of dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with external reality), difficulty with walking, muscle weakness and lack of coordination. During an observation and interview with Resident 44 and Resident 44's family member on December 5, 2022, at 11:23 AM, Resident 44 was in a wheelchair positioned beside her bed in her room. Sitting on Resident 44's bed was her family member. The family member stated she found out today Resident 44 had a blister on her right heel. Resident 44's right ankle had a cushion fastened around the ankle and there was a sock on the right foot. Resident 44's family member stated she was upset because it seemed Resident 44 had gone downhill since being admitted to the facility. Resident 44's family member stated Resident 44 could no longer use the bathroom on her own, wore a diaper and had a sore on her right foot. Resident 44 began to speak to her family member however Resident 44's sentences did not make sense and did not relate to the subject being discussed. A review of Resident 44's Comprehensive Resident admission Assessment, dated September 27, 2022, indicated Resident 44's skin was intact. Resident 44's Body Reassessment, dated September 28, 2022, indicated Resident 44 had a DTI to her right heel. The Body Reassessment, did not indicate measurements of the DTI, condition, or appearance of the skin in and around the DTI, presence of pain or signs of infection if any. A review of Resident 44's ADL [Activities of Daily Living] Care Plan, dated September 28, 2022, indicated, Bed Mobility: extensive assist, Transfers: extensive assist, Walk in Room/Corridor: extensive assist and Locomotion On/Off Unit: extensive assist. Pressure Ulcer/Skin Integrity Care Plan, dated September 28, 2022, indicated, Pressure ulcers/skin breakdown, delayed/poor wound healing related to impaired mobility, impaired cognition, urinary incontinence and chairfast/bedfast most of the time. A review of Resident 44's Long Term Care Plan titled, Impaired Skin/Tissue Integrity, Chronic Wound, dated September 28, 2022, indicated, Related to: DTI (R) [right] heel . Plan/Approach: . Assess and Document wound characteristics/dimensions initially, q [every] week and PRN [as needed] decline, Monitor wound progress; reevaluate wound Tx [treatment]/interventions q week and PRN, Use proper infection control procedures @ [at] all times to prevent cross contamination, Assess infection risk. Monitor for s/s [signs and symptoms] of wound infection and notify Dr. [doctor] . Assess for pain [secondary] to wound or its treatment and manage appropriately, . Monitor those dressings remain clean and intact between changes, replace PRN, . Avoid pressure, friction, and shear to involved area(s) @ all times, . Suspend Feet/Heels(s) off bed surface w/ [with] pillow under calf as tolerated, . A review of Resident 44's treatment orders for the DTI indicated: a. September 28, 2022, (R) heel DTI clnse [cleanse] c [with] NS [normal saline], pat dry, paint c iodine [antiseptic], cover c dry drsg [dressing], Qday [every day], x [times] 21 days, reeval [reevaluate] PRN [as needed]. b. November 4, 2022, (R) heel blood filled blister. Cleanse c N/S [normal saline] pat to dry. Apply betadine [an antiseptic], ABD [abdominal] pad & [and] wrap c kerlix [brand name] wrap. Then re-eval x 21 days . c. December 5, 2022, D/C [discontinue] previous orders to R [right] heel . [change] in etiology [the cause of the condition]. R heel st [stage] 3 [three-full thickness skin loss involving damage or necrosis (dead tissue) of subcutaneous tissue (innermost layer of skin) that may extend down to, but not through, underlying fascia (connective tissue)] PR [pressure] injury clnse [cleanse] c [with] NS [normal saline], pat dry, apply Medi Honey [a brand name for an ointment that supports autolytic (destruction of cells by their own enzymes) debridement (removal of damaged tissue) and a moist wound healing environment], cover c dry drsg [dressing], Qday [every day] & [and] PRN [as needed] x [times] 21 days, then reeval [reevaluate]. A review of Resident 44's Treatment Administration Record (TAR) from September 28, 2022, to November 3, 2022, indicated Resident 44's right heel DTI was being treated by cleanse with normal saline, pat dry, apply Medi Honey, cover with dry dressing every day and as needed. Not with the order dated September 28, 2022, (R) heel DTI clnse c NS, pat dry, paint c iodine, cover c dry drsg, Qday, x 21 days, reeval PRN. A review of Resident 44's physician's orders did not indicate a Medi Honey treatment during this time period. Thirty-seven days had passed without following the correct physician's order for wound treatment. A review of Resident 44's Treatment Administration Record (TAR) from November 4, 2022, to November 30, 2022, indicated Resident 44's right heel DTI was being treated by cleanse with normal saline, pat dry, apply Medi Honey, cover with dry dressing every day and as needed. Not with the order dated November 4, 2022, (R) heel blood filled blister. Cleanse c N/S pat to dry. Apply betadine, ABD pad & wrap c kerlix wrap. Then re-eval x 21 days . A review of Resident 44's physician's orders did not indicate a Medi Honey treatment during this time period. Twenty-seven days had passed without following the correct physician's order for wound treatment. A review of Resident 44's Wound Care Doctor's Progress Notes was conducted. There was no documented evidence to show the Wound Care doctor had assessed Resident 4's DTI from September 27, 2022, to November 6, 2022, for a total of 40 days. A review of Resident 44's Weekly Wound Assessments from September 27, 2022, to December 4, 2022, was conducted. There was no documented evidence to show weekly wound assessments had been conducted, for a total of nine weeks. A review of Resident 44's Nutritional Assessments dated October 5, 2022, October 12, 2022, October 19, 2022, and November 9, 2022, indicated Resident 44's skin was clear and intact, and no breakdown documented. During an interview and record review with a Registered Dietician (RD) on December 13, 2022, at 10:56 AM, a review of Resident 44's weights from September 27, 2022 (weight 124 pounds) to October 24, 2022 (weight 117 pounds) was conducted. The RD verified Resident 44 lost 7 pounds in one month, a negative 5.65% [percent] significant weight change, which impacted the body's ability to heal. During an observation of Resident 44's wound on December 13, 2022, at 5:20 PM with a Treatment Nurse (TN 1), Resident 44's right and left heels were floated (pressure is relieved by not having the heel touch any surface) on pillows. Resident 44's right heel was wrapped in gauze. TN 1 stated Resident 44's stage III pressure sore measured 3 (three).9 (nine) cm (centimeters-a unit of measurement) x (by) 4 (four).9 cm about the size of a baseball. TN 1 cut the dressing away. Resident 44 became agitated stating be careful, be careful, no, no, no, Resident 44 reached toward her right foot in a protective gesture. TN 1 reassured Resident 44 and was very gentle with Resident 44's right foot. Resident 44 relaxed back onto her pillow. Resident 44's stage III pressure ulcer looked like hard, black necrotic (dead) tissue covering the entire wound's surface with one very small open area to the lower right corner of the wound. No oozing or weeping was observed coming from the wound. There was no odor. During a concurrent interview with the Wound Care Doctor (WCD) on December 13, 2022, at 5:42 PM, in the presence of TN 1, the WCD stated he came to the facility every Monday and evaluated all the residents with wounds. The WCD stated he was not told about Resident 44's wound until November 7, 2022. The WCD reviewed Resident 44's TARS from September 28, 2022, to November 3, 2022. The WCD stated he would not have ordered a Medi Honey treatment for a DTI and the treatment nurses knew this. TN 1 stated she would not have used the Medi Honey because she knew the WCD liked the betadine treatment for DTIs. The WCD stated Resident 44's wound was covered by a scab which was eschar (dead tissue). The WCD stated the wound was stable at this time and he was monitoring it for signs of infection. The WCD stated if the wound started oozing pus, he would debride (removal of dead tissue with a scalpel) the scab. The WCD stated he was hopeful the scab would eventually fall off and healthy tissue would be underneath. The WCD stated Resident 44 could not turn or reposition herself and it was very important that the staff kept the pressure off the resident's heels. The doctor stated he recommended a boot, but the facility did not want the boot they liked floating the heels with pillows. During a continued concurrent interview on December 13, 2022, at 6:07 PM with TN 1 and in the presence of the WCD, TN 1 stated she had not been informed about Resident 44's wound until November 4, 2022. TN 1 stated the Charge Nurses would let her know about resident wounds. TN 1 stated she used the betadine treatment in November 2022 and did not start the Medi Honey treatment until December 5, 2022. TN 1 reviewed Resident 44's TARs for September 2022, October 2022, and November 2022. TN 1 stated her initials on the TARS were made by someone else, because she had not documented her initials on the September 2022, October 2022, and November 2022 TARS presented to her. TN 1 stated she did not know where the TAR was which indicated the treatment she had provided. TN 1 stated the charge nurses were responsible for conducting the weekly wound assessments and she filled out the wound progress report with the WCD on his Monday visits. During an interview with the RD on December 13, 2022, at 6:35 PM, the RD stated she reviewed the residents' admission assessments to obtain information on the residents and check for the presence of wounds. The RD stated Resident 44's admission assessment indicated Resident 44's skin was clear and intact. The RD stated she had missed the Body Reassessment, that indicated the right heel DTI. The RD stated Resident 44's Nutritional Assessments dated October 5, 2022, October 12, 2022, October 19, 2022, and November 9, 2022, did not include considerations for the right heel DTI. During an interview with the Director of Nursing (DON) on December 13, 2022, at 7:41 PM, the DON verified a full assessment of Resident 44's DTI was not documented at admission and should have been. The DON verified there was no physician's order for the Medi Honey treatment indicated on Resident 44's TARs dated September 2022, October 2022, and November 2022. The DON stated a Treatment Nurse conducted the recapitulation (orders are reviewed and verified as accurate against the physician's initial orders, subsequent telephone orders and compared to the medication and treatment administration records monthly) of wound care orders and should have caught the error and did not. The DON stated the nurses should have followed the physician's treatment orders dated September 28, 2022, and November 4, 2022, and did not. The DON stated a Treatment Nurse should have informed the WCD of Resident 44's DTI on October 3, 2022 (the first weekly WCD visit following admission) and did not. The DON verified weekly wound assessments had not been documented and Resident 44's nutritional assessments should have included the right heel DTI and did not. A review of the facility's policy and procedure titled, Policy and Procedure on Pressure Ulcers, dated August 22, 2017, indicated, Policy: .A resident, who enters the facility with pressure ulcer and/or develops unavoidable pressure ulcers being in the facility, must receive treatment and services necessary to promote healing, prevent infection and prevent new ulcers from developing. Procedures: .All residents shall be assessed on admission or readmission of their skin condition and integrity, using the prescribed Nursing admission Assessment form. Licensed nurse must also refer resident to the Registered Dietitian at the new onset of a pressure ulcer for possible adjustments in his/her nutritional needs (caloric, protein and fluid) .Physician and other healthcare professional .shall have inputs in the assessment and identification of the type of ulcer. Assessments of Pressure Ulcers: Licensed charge nurse or treatment nurse shall conduct basic assessment and data collection on the following: Type of Ulcer . Location .Stage of Pressure Ulcer . Measurements . Non-viable tissue . Odor . Amount of Exudate [fluid] . Type of Exudate . Wound bed . Description of surrounding skin/tissue . Description of wound edges . Progress towards healing . Nature and frequency of Pain . Signs of Infection. Assessment of pressure ulcers shall be done at least once every week or as wound condition changes. Document general findings in the weekly skin and wound progress report. Choice of treatment and dressings should be based on the characteristics of the wound, relevance of the specific product to the identified pressure ulcer, treatment goals and manufacturer's recommendations for use. Pressure ulcer treatment orders shall be evaluated for effectiveness every 2 [two] - [to] 4 [four] weeks . The licensed nurse or treatment nurse shall also evaluate treatment plan, documenting whether or not to continue or modify the current interventions. Weekly/Monthly Special Skin Care Report - report containing progress on each resident identified with pressure ulcer, whether in-house or community acquired, shall be completed by the licensed nurse or treatment nurse on a weekly basis. A review of the facility's policy and procedure titled, Policy and Procedure on ReCapping of Physician Orders, dated August 22, 2017, indicated, Policy: It is the policy of this facility to review and provide recapitulation of physician's orders on a monthly basis. Physician Order Sheets will be reviewed and recapped to include necessary changes, corrections and updates made via telephone orders.