**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and staff interviews for one (1) of seven (7) sampled residents, the facility staff failed to ensure that a resident had adequate assistance while being transferred from the wheelchair to the bed in the resident's room and subsequently the resident sustained injuries and was transferred to the hospital emergency room. Resident #1. The findings included: Resident #1 was admitted to the facility on [DATE] with multiple diagnoses that included the following: Unspecified Dementia, Chronic Atrial Fibrillation and Muscle Weakness. A Facility Reported Incident (FRI) DC~13527 was submitted to the State Agency on 03/14/25 at 10:41 PM, that documented the following: On March 14, 2025, around 21:45 (9:45 PM), Nursing Assistant Ms. (Employee Name) was providing care for resident (Resident Name). After she transferred (Resident Name) on bed, she noted that he had blood coming from his mouth and nose. Once the nursing assistant observed the bleeding, she notified the nurse, nurses attempted to control the bleeding coming from the resident's nose. Nurse (Employee name) performed a complete body and noted a hematoma to (Resident's) right lower leg, which showed no discoloration. A review of Resident #1's medical record revealed the following: A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed that the facility staff coded the resident as having impairment on one side in the upper extremities and impairment on both sides in the lower extremities. The facility staff coded that the resident was dependent on staff with a helper doing all the effort for toileting, personal hygiene and to transfer from chair (wheelchair) to bed. The facility staff coded that the resident uses a manual wheelchair. A review of the State Minimum Data Set (MDS) assessment dated [DATE] showed that the facility staff coded the resident is sometimes understood- ability is limited to making concrete requests and for Cognitive skills for daily decision-making staff coded the resident as being severely impaired- never/rarely made decisions. The facility staff coded the resident as needing a 2-person physical assist and extensive assistance for Transfers-how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position. The facility staff coded that the resident does not have one or more unhealed pressure ulcers/injuries and as having no venous or arterial ulcers. The facility staff coded that the resident has no other ulcers wounds or skin problems present. It is noted that there was no significant change Minimum Data Set assessment in the resident's medical record dated from 11/25/2024 to 03/14/2025. A review of the documents titled Skin Monitoring: CNA (certified nurse aide) shower report dated 03/03/25 and 03/10/25 both show handwritten documentation that states skin intact and they are both signed by a charge nurse. A review of the document titled Skin Check dated 03/03/25 at 7:29 PM, which is the weekly skin assessment showed that the facility staff did not code any skin issues on either legs or feet for the resident. A review of the document titled Skin Check dated 03/10/25 at 10:08 PM, which is the weekly skin assessment showed that the facility staff marked no skin issues for the resident. It is noted that Resident #1 had no skin issues documented in the medical record in three months prior to 03/14/25. A review of a nursing progress note dated 03/14/25 at 11:44 PM documented the following This writer was called to room [ROOM NUMBER]A by the assigned CNA (certified nursing assistant) reporting resident is bleeding upon assessment resident was observed bleeding from the nose and mouth. Hematoma also noted to his right foot. The write (r) (sp) was unable to control the bleeding. Howevernosebleed (spelling - however nosebleed) was managed with pressure but unresolved. The hematoma to his right leg was swollen but no active bleeding noted. Resident show signs of pain when right foot was touched /moved. No signs of dizziness or distress noted. Breathing is normal. Gentle pressure applied to stop nosebleed (sp). Assessed hematoma for changes in size, color, or pain. right foot elevated and cold compress applied. MD (medical doctor) notified. Order given to transfer resident to the ER for further evaluation. 911 was called and arrived at 22:30 (10:30 PM). Resident was transfer to (hospital name abbreviation) at 23:10 (11:10 PM) via stretcher. RP (Resident Representative) made aware. A review of a nursing progress note dated 03/15/25 at 12:57 AM, documented the following: Observed the resident is sitting in bed without gown and the charge nurse and the CNA (certified nurse aide) at the bedside, assisting Mr. (resident name) and providing care to stop bleeding from the nose and mouth. provide assistance to the resident r/t (related to) nose bleeding by applying gentle pressure nostrils and Ice cubes on the forehead/nose bridge to stop active bleeding for the duration of 5 to 15 mint (minutes) (sp) between 9:30pm to 9: 45pm, able to redirect resident, effective to calm, but unable to stop bleeding. Moderate amount of bleeding from nose and mouth noted via apply 4X4 gaze (gauze) (sp) multiple time. The resident was unable to provide statement regarding. The resident repeated the same word aaaa aaaa aaaa upon assessment observed bump/hematoma to the right lower extremity, no s/s (signs symptoms) of pain or distress noted. Resident was able to move the right leg without any pain, but unable to provide further detail. Provide assistance with incontinent care A physician order dated 03/14/25 documented Transfer to ER (emergency room) A review of a hospital face sheet showed that the resident was admitted to the hospital on [DATE] with an admitting diagnosis of leg hematoma. A review of a hospital document titled Progress Notes-Physician dated 03/17/25 at 2:44 PM, documented the following: presents as Trauma [NAME] (SIC) after being found down. Primary survey revealed no acute life -threatening injury. Secondary survey revealed dried blood over the upper lip, hematoma on the right anterior shin, dried blood bilateral digits. All trauma imaging negative for acute traumatic injury except for a mesentry (mesentery) (sp) contusion on CT (computed tomography). Concerns for elder abuse, so admitted for safe discharge plan. Now w (with) (sp)/ concerns for infection of RLE (right lower extremity) hematoma, plan for OR (operating room) for debridement Wednesday. A review of a hospital document titled Operative Reports dated 03/20/25, documented the following: Indication for surgery RLE (right lower extremity) infected hematoma Operation right lower extremity wound debridement 3X5CM2 (centimeters), wound vac placement, right. Findings superficial necrotic eschar excised, approx (approximately) (sp) 25 cc of old hematoma evacuated, no frank purulence noted. Fibular exposed with intact periosteum. white sponge was attached to black sponge with staple, laid along wound base with white sponge toward exposed fibula. Wound size 3x5 cm (centimeters) at the end of case with some tunneling superiorly. It is noted that the resident was assessed with a right leg wound, identified by facility staff as a hematoma sustained during transfer from wheelchair to bed. The right leg wound was assessed by hospital staff with areas of necrosis and required surgical intervention. An observation was conducted on 04/21/25 at approximately 11:00 AM, Resident #1 was observed in the day room on the first floor sitting in a wheelchair and looking out a large window. Resident #1 responded to his name and made incoherent speech and nodded head but otherwise not interviewable. A review of the facility's incident investigation which contained a typed telephone interview from Resident #1's assigned CNA (Employee #5). The typed telephone interview dated 03/17/25 at 2:15 PM, documented the following: On March 17, 2025, the DON (director of nursing) and ADON (assistant director of nursing) of (facility name) called (Employee #5 (certified nurse aide) to obtain her statement regarding the incident that occurred on March 14, 2025. She (Employee #5) mentioned that Resident #1 started to remove his brief and had feces all over himself and on the floor. Therefore when she transferred (Resident #1), she did not want to get her clothes soiled from the bowel movement. She then put her arms under his quickly transferred him to the bed. She did state that she held the resident a little further away from her body to prevent him from getting bowel movement onto her clothes. When she got to the bed, she placed him on the bed. Unfortunately, she stated that the resident hit his face. When asked what happened to the resident's leg, she mentioned that she forgot to take the foot rest off and that they were still up during transfer. (Employee #5) was asked why she continued to provide care if the resident was agitated and yelling. She stated that she felt she could transfer him to the bed quickly and get assistance to get him cleaned up. (Employee #5) stated that after she saw the resident's face bleeding, she called the nurse and began cleaning the blood noted on the bed. It is noted that Employee #5 attempted to transfer the resident on 03/14/25, without the assistance of at least 1 other staff member as required by the resident's State Minimum Data Set assessment dated [DATE]. Review of Employee #5's human resource record revealed a document titled Review Discussion Form dated 03/21/25 documented the following: Final written warning (performance) date of incident 03/14/25, Date of conversation 03/21/25, Description of incident: Employee transferred a resident from the wheelchair to the bed utilizing unsafe practices. As a result, the resident sustained facial and leg injuries. Because of this incident, the resident was hospitalized and will return to the facility with a wound vac for his leg injury. It is noted that the involved CNA Employee #5 was terminated from the facility on 03/25/25 and the last time Employee #5 clocked into work was 03/14/25 according to the time submission which was reviewed. During a telephone interview conducted on 04/23/25 at approximately 11:30 AM, Employee #9 (LPN licensed practical nurse supervisor) stated that the residents nurse called him to the room, and he saw that the resident was bleeding from his nose, and he had a bruise on his right leg. Employee #9 went on to state that Resident #1 was yelling words he could not understand. The EMS (emergency medical services) would not take the resident until the police got there. During a face-to-face interview conducted on 04/23/25 at 4:07 PM, Employee #1 (Administrator) stated that the CNA (certified nurse aide) (Employee #5) was taken off the unit on 03/14/25 and never returned. Employee #1 went on to state that the employee (Employee #5) was terminated for violation of safety rules. During a face-to-face interview conducted on 04/24/25 at 12:57 PM, Employee #2 (Director of Nursing) stated that the resident did not have any wounds prior to the incident that occurred on 03/14/25 when a CNA attempted to transfer the resident from the wheelchair to the bed. When the surveyor asked about the necrotic tissue debridement that was documented in the hospital documentation Employee #1 stated that They did an evacuation of the hematoma, they opened it (hematoma) in the hospital. He did not have any wounds prior to when he went to the hospital. Cross Reference 22B DCMR Sec. 3211.1 (d) *******************************************************

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, for one (1) of 41 sampled residents, facility staff failed to ensure that Resident #52 received care to prevent pressure ulcer development that was first observed at a Stage 3. This deficiency resulted in actual harm to Resident #52 on 02/28/2024. The findings included: Review of the facility's Wound Care Consultant Contract dated 09/14/22 documented,The Wound Care Consultant agrees to serve as the Wound Care Consultant to coordinate medical care in the facility and provide clinical guidance and oversight regarding wound care; provide diagnosis and treatment recommendations for wounds; and sign and date all orders, such as medications. Review of the facility's Pressure Ulcers, Prevention and Care policy revised on 11/10/22 documented: - Skin integrity alteration will be reported to the physician for treatment orders. - Classification of pressure ulcers: Stage 2: a partial thickness of skin is lost (epidermal layer has been lost, but dermis is at least partially intact); may present as blistering surrounded by an area of redness and/or indurations. Stage 3; a full thickness of skin is lost, exposing the subcutaneous tissues; present as a shallow crater (unless covered by eschar - thick brown, black or yellow crust); may be draining. There is also depth at this stage. - A specific plan of care must be developed by nursing and the interdisciplinary care team. Review of the Resident Assessment - Pressure Injuries policy revised on 11/10/22 documented, Accurate assessments addressing each resident's skin status will be conducted by qualified staff and correctly documented in the medical record; and a qualified health professional will document the presence, number, stage and pertinent characteristics of any pressure injury on the wound documentation form in the medical record. Resident #52 was admitted to the facility on [DATE] with diagnoses that included: Adult Failure to Thrive, History of Falling, and Muscle Weakness. Review of the resident's medical record revealed the following: A face sheet that showed Resident #52 had listed a legal guardian, substitute decision maker and emergency contact #1. Physician's orders dated 01/19/24 directed: Apply barrier cream to sacrum, buttocks and peri-area every shift for skin protection; weekly skin assessment, every evening shift every Friday; resident to have shower every day shift, every Monday and Thursday, Licensed nurse will validate and ensure skin assessment is completed. A Hospital Discharge summary dated [DATE] documented: - admission on [DATE] at 1:57 PM. - Chief complaint - altered mental status, low oxygen and blood pressure. - Physical exam at discharge - skin: warm and dry. A readmission Note dated 01/27/24 at 9:01 PM documented: - Resident readmitted into the facility. - Warm to touch skin, mass around the mid-arm and in the inguinal area was noted, IV (intravenous) related bruises on bilateral upper arm were noted. A readmission Braden Scale Evaluation dated 01/27/24 documented: - Resident's score 11. - Interpretation of score: 10-12 indicates high risk. - Continue current plan of care. A care plan documented: [Resident #52] has impaired skin integrity related to bilateral upper arm bruises/mass in the mid arm/inguinal area that was initiated on 01/27/24. A Focused Observation Note dated 01/30/24 at 11:21 PM documented, complete bed bath given, no new skin issue noted. A quarterly Braden Scale (a tool used to foster early identification of residents at risk for developing pressure ulcers) dated 02/01/24 at 5:42 PM documented: - Resident's score 11 (interpretation of score: 10-12 indicates high risk). - No referrals necessary. - Continue current plan of care A physician's order dated 02/02/24 directed, Turning and repositioning every 2 hours as tolerated and PRN (as needed) every shift. A Significant Change in Status Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff coded: a Brief Interview for Mental Status (BIMS) summary score of 07 indicating severe cognitive impairment; no rejection of care behaviors; required substantial/maximal assistance for toileting hygiene, shower/bathing; frequently incontinent of bowel and bladder; at risk for pressure ulcers/injuries; and had no unhealed pressure ulcers/injuries, wounds or other skin problems. A [nursing] Skin Observation Tool Assessment on Tuesday, 02/06/24, at 8:20 PM documented, complete bed bath given, no new skin issue noted. A [nursing] Skin Observation Tool Assessment on Tuesday, 02/13/24, at 10:53 PM documented, Complete bed bath given. A Skin Observation Tool Assessment on Friday, 02/16/24, at 11:55 PM documented, complete bed bath given, no new skin issue noted. A [nursing] Skin Observation Tool Assessment on Friday, 02/23/24, at 10:37 PM documented, complete bed bath given, no new skin issue noted. A care plan focus area: The resident has limited physical mobility r/t (related to) weakness, that was initiated on 02/23/24 had approaches/interventions that included, monitor/document/report any s/sx (signs and symptoms) of immobility: contractures forming or worsening, skin-breakdown. The Treatment Administration Record (TAR) for February 2024 showed that on Monday, 02/26/24, facility staff documented a check mark and their initials to indicate that Resident #52 had a shower and that the nurse validated and ensured that a skin assessment was completed. A Nursing Progress Note dated 02/26/24 at 2:24 PM documented: - Upon assessment, skin is dry and warm to touch. - Resident turned and repositioned every 2 hours for comfort and pressure relief. A care plan focus area: [Resident #52] is at risk for bladder incontinence related to deconditioning that was initiated on 02/26/24, that had approaches/interventions that included, weekly skin assessment. An Attending Physician's note on Tuesday, 02/27/24, at 10:58 AM documented: - Subjective: [Resident #52] spends most of her time in bed because she has become frailer. There have been no new issues regarding her care. - Objective: remains a well-developed thin black female, in no acute distress when seen. There are no new labs available for analysis. - Assessment: continues to do well and remains clinically stable. We will continue with the current management. A [nursing] Skin Only Evaluation Note on Tuesday, 02/27/24, at 10:50 PM documented: - Skin warm & dry, skin color within normal limits (WNL) and turgor is normal; complete bed bath given, no new skin issue noted. A Wound Care Physician's Note on Wednesday, 02/28/24, at 8:16 AM documented: Wound rounds: Stage 3 sacral decubitus ulcer, moderate drainage with necrotic tissue and slough; Plan: clean with Dakins solution (used to prevent and treat skin and tissue infections), apply collagenase Santyl (debridement agent used on dead tissue) ointment and dry dressing daily. Although the Wound Care Physician documented a treatment order for Resident #52's new Stage 3 sacral ulcer, the medical record lacked documented evidence that the resident's primary care physician was notified about Resident #52's new Stage 3 sacral pressure ulcer/wound on 02/28/24. As a result, no new orders or interventions were implemented until 03/01/24 (over 48 hours later). A Skin Only Evaluation Note dated 02/29/24 at 4:45 PM documented, Skin warm & dry, skin color WNL (within normal limits) and turgor is normal; no skin issues; complete bed bath given. Review of the February 2024 Treatment Administration Record (TAR) dated from 02/01/24 to 02/29/24 showed that facility staff documented a check mark and their initials to indicate that Resident #52: 1. Received a shower everyday shift on Mondays and Fridays and that a licensed nurse validated and ensured that the skin assessment was completed. 2. Received weekly skin assessments every Friday on the evening shift; and 3. Barrier cream was applied to the resident's sacrum, buttocks, and peri-area every shift for skin protection. A Health Status Note dated 03/01/24 at 2:25 PM documented: - Resident remains alert and verbally responsive with intermittent confusion and generalized weakness. - Upon assessment skin is dry and warm to touch. - Resident turned and repositioned every 2 hours for comfort and pressure relief. A [nursing] Skin Only Evaluation Note dated 03/01/24 at 3:06 PM documented, Skin warm & dry, skin color WNL and turgor is normal; no skin issues; complete bed bath given. A physician's order dated 03/01/24 at 3:32 PM directed, Dakin's 1/2 strength External Solution 0.25 % (Sodium Hypochlorite) cleanse sacral ulcer with Dakin's solution, pat dry, apply Santyl and cover with border gauze daily. A physician's order dated 03/01/24 at 3:38 PM directed, Santyl External Ointment 250 Unit/GM (gram), apply to sacral ulcer topically everyday shift for wound care. A Wound Care Physician Note dated 03/04/24 at 8:18 AM documented: - Late Entry: created on 03/07/24 at 8:21 AM. - [AGE] year-old female with cachexia - Stage 3 sacral decubitus ulcer. Decreased slough and drainage. 8 cm (centimeters) long by 6 cm wide by 2 cm deep. - Plan: Continue Santyl dressings daily. A Skin Observation Tool assessment dated [DATE] at 1:08 PM documented: - Site: Sacrum - Type: Pressure - Length: 8 cm - Width: 6 cm - Stage II (Stage 2) [It should be noted that wound care physician staged the resident's sacral wound as a Stage 3 on 02/28/24.] - Notes: Cleanse with [NAME] solution, apply Santyl. Cover with dry gauze. A Health Status Note dated 03/06/24 at 7:56 AM documented: - Fluids offered but poorly tolerated encouraged to take more fluids but refused after several attempts. - Resident on oxygen at 2 liters via nasal cannula for shortness of breath for shortness of breath. - A call was placed to medical doctor in reference to resident with poor intake with order to transfer resident to the nearest emergency room for evaluation and treatment. - A call was placed and spoke with the resident's representative. A Health Status Note dated 03/06/24 at 10:52 PM documented: - Call placed to [Hospital name] at 10:30 PM to check on resident status, resident has been admitted . During a face-to-face interview on 03/06/24 at 11:15 AM, Employee #2 (Director of Nursing/DON) stated, Skin assessments are done weekly in PCC (Point Click Care, the facility's electronic health record system). That form is used to assess the wound for any changes. Once a new wound area is observed, the process is to immediately call the medical doctor and get new orders. The nurse will write a progress note with a description of the wound that includes size, location, drainage, what the surrounding area looks like and then also indicate that the family was notified. A new care plan is either initiated or revised. During a face-to-face interview on 03/13/24 at 11:25 AM, Employee #6 (Medical Director/Resident #52's primary physician) stated, The wound doctor is allowed to put in orders. Any provider that provides services at this facility is credentialed and can put in orders. I can't answer as to why [Wound Doctor] did not directly put in the wound care orders. I did see the resident (on 02/27/24). The nursing staff did not communicate any skin issues to me, and I did not turn her over to do any assessment of her skin during my time with her. During a face-to-face interview on 03/20/24 at approximately 12:30 PM, Employee #1 (Administrator) and Employee #2 acknowledged the findings. Cross reference 22B DCMR Sec. 3211.1 (Facility staff failed to ensure that Resident #52 received sufficient nursing care and services to prevent pressure ulcer development that was first observed at a Stage 3.)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, for one (1) of 1 residents sampled for pain management, facility staff failed to ensure that Resident #243 received effective pain assessments/evaluation for a known left hip fracture. The findings included: According to National Institute of Health (NIH): - Assessment of pain is a critical step to providing good pain management. - Nurses working with patients with acute pain must select the appropriate elements of assessment for the current clinical situation. - The most critical aspect of pain assessment is that it is done on a regular basis (e.g., once a shift, every 2 hours) using a standard format. The assessment parameters should be explicitly directed. - To meet the patients' needs, pain should be reassessed after each intervention to evaluate the effect and determine whether modification is needed. The time frame for reassessment also should be directed. - Pain assessment should include intensity, location, and quality. https://www.ncbi.nlm.nih.gov/books/NBK2658/ Review of the facility's Pain Management policy (not dated) showed: - The facility will provide optimal pain control, assessment, and monitoring for all identified residents with pain. - Pain will be measured on a 0-10 scale. Cognitively impaired residents will be assessed utilizing behavioral or visual indicators. - Pain assessment will occur with the onset of new pain. Review of the facility's Documentation Criteria policy revised on 07/22/22 showed: - Clinical notes for pain control include location, severity, quality, duration, and cause. - Note when pain medication is given (very important) and note if/when pain relief is obtained and length of relief. Resident #243 was admitted to the facility on [DATE] with diagnoses that included: Muscle Weakness, Other Abnormalities of Gait and Balance and Age-Related Physical Debility. Review of the resident's medical record revealed the following: A care plan focus area: [Resident #243] has chronic pain to back and knees related to Osteoporosis, that was initiated on 05/16/19, had interventions that included: administer medications as ordered. Monitor and record effectiveness; monitor and record any complaints of pain: location frequency, intensity, effect on function, alleviating factors, aggravating factors; monitor and record any non-verbal signs of pain (guarding, withdrawal, crying, restlessness, etc.). A physician's order dated 05/24/19 directed: Turn and reposition every 2 hours, every shift. A care plan focus area: [Resident #243] has complaints of acute pain to right hip related to post fall, that was initiated on 07/07/21, had interventions of: administer medication routine and as needed, as ordered. Evaluate/record/report effectiveness. Monitor and record any complaints of pain: location frequency, intensity. Monitor and record any non-verbal signs of pain (guarding, restlessness). Handle gently and try to eliminate any environmental stimuli. A physician's order dated 08/16/21 directed: Tramadol (narcotic pain reliever), 100 mg (milligrams), 1 tablet, twice a day PRN (as needed) A physician's order dated 08/19/21 directed: Monitor pain every shift. A physician's order dated 03/23/23 directed: Tramadol 50 mg, twice a day. A physician's order dated 04/07/23 that directed, Acetaminophen (pain reliever) 500 mg, 2 tablets three times a day, as needed for pain. An Annual Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff coded: a Brief Interview for Mental Status (BIMS) summary score of 12, indicating mild cognitive impairment; received scheduled pain medication regimen; no falls since the prior assessment and did not receive any opioid medications. A Pain Assessment Note dated 05/29/2023 at 5:51 PM documented: - Pain site - left lower extremity. Received scheduled pain medication regimen. - Resident pain interview intensity rating on the Numeric Rating Scale (0-10) 3. - Resident pain interview: verbal descriptor scale severe. A Facility Reported Incident (FRI), DC~11996, received by the State Agency on 05/29/23 at 6:30 PM documented: - At 4:40 PM, the resident got up on her seat to give another resident a hug and she missed her step and fell on her left side. - Resident refused to be assessed by the nurse supervisor, she said she will be fine but verbalized feeling pain to the left thigh, 4/10. - The physician was called and gave an order for an x-ray of the affected leg. - Resident RP was called and was made aware of the fall accident. A physician's order dated 05/29/23 directed Left hip/left knee x-ray A Nursing Progress Note dated 05/30/23 at 6:50 AM documented: - Range of motion within normal limits bilateral upper and right lower extremities with limited mobility left lower extremity. - Denies any pain at rest but complained of moderate pain with guarding to left hip upon assessment. Given PRN Tylenol (Acetaminophen) 1000 mg with good effect. - X-ray to left hip to be done in the morning. Left knee x-ray result dated 05/30/23 at 1:21 PM documented: - No acute fracture, dislocation or degenerative disease. -There is soft tissue swelling and vascular calcification. Left hip x-ray result dated 05/30/23 at 1:21 PM documented: - There is a fracture of the neck of the proximal femur without significant displacement. - Clinical Correlation and follow-up imaging recommended as indicated. A Nursing Progress Note dated 05/30/23 at 2:01 PM documented: - X-ray for left hip/knee done this shift, results received: No acute fracture, dislocation or degenerative disease, there is a swelling tissue and vascular calcification. - Physician's Assistant (PA) made aware; no new order given. - Resident was able to get transferred from the bed to wheelchair with assistance. It should be noted that although Employee #7 documented that she received the results of the left knee/hip x-rays, she failed to inform the PA of the left hip fracture. The Restorative Point of Care documentation dated 05/30/23 showed that Resident #243 received 15 nursing minutes of walking on the day shift (7:00 AM - 3:30 PM). A Nursing Progress Note dated 05/30/23 at 11:37 PM documented: - Day 1 post fall, pain to left hip/knee. Routine pain medication administered as ordered. The Treatment Administration Record (TAR) showed that on 05/30/23, day shift (7:00 AM - 3;30 PM), facility staff documented their initials to indicate that they were turning and repositioning Resident #243 every two hours. The TAR for the same date and shift also showed that in the section that directed, monitor for pain every shift, Employee #7 documented her initials to indicate that this task was completed however, there is no evidence that the pain characteristics such as intensity, pattern, frequency, and duration were assessed even though the resident had a known left hip fracture. The TAR also showed that on 05/30/23, evening shift (3:00 PM - 11:30 PM), facility staff documented their initials to indicate that they were turning and repositioning Resident #243 every two hours. The TAR for the same date and shift also showed that in the section that directed, monitor for pain every shift, facility staff documented their initials to indicate that this task was completed however, there is no evidence that the pain characteristics such as intensity, pattern, frequency, and duration were assessed even though the resident had a known left hip fracture. A Night Shift (11:00 PM - 7:30 AM) Nursing Progress Note dated 05/31/23 at 6:56 AM documented: - Range of motion within normal limits bilateral upper and right lower extremities with limited mobility left lower extremity. - Complaints of pain upon assessment. Given Tramadol 50 mg with good effect. No visible injuries noted. - Received results of left hip x-rays with impression of non-displaced fracture of neck of left proximal femur. Clinical correlation and follow-up imaging indicated. Morning shift to follow-up with primary physician. It should be noted that although the employee documented that Resident #243's left hip x-ray results showed a fracture, he failed to notify the resident's primary care physician. The TAR showed that on 05/30/23, night shift, facility staff documented their initials to indicate that they were turning and repositioning Resident #243 every two hours. The TAR for the same date and shift also showed that in the section that directed, monitor for pain every shift, facility staff documented their initials to indicate that this task was completed however, there is no evidence that the pain characteristics such as intensity, pattern, frequency, and duration were assessed even though the resident had a known left hip fracture. A Night Shift Nursing Supervisor Note dated 05/31/23 at 8:47 AM, written by Employee #8 documented: - Status post fall, no bruise, no redness noted. - Resident guarding her left leg/hip. Medicated for complaints of pain to left upper leg with Tramadol 50 mg and effective. - Result of left hip x-rays received with impression of non-displaced fracture of neck of left proximal femur. Clinical correlation and follow-up imaging indicated. Please follow-up with primary medical doctor. It should be noted that although Employee #8 documented that Resident #243's left hip x-ray results showed a fracture, she failed to notify the resident's primary care physician. The Restorative Point of Care documentation dated 05/31/23 showed that Resident #243 received 15 nursing minutes of walking on the day shift. The TAR showed that on 05/31/23, day shift, facility staff documented their initials to indicate that they were turning and repositioning Resident #243 every two hours. A Nursing Progress Note dated 05/31/23 at 12:22 PM documented: - Status post fall, order given on 5/29/23 as follows: left hip/ Left knee x-ray to rule out fracture. X-ray result received and indicated a fracture of the neck of the left proximal femur without significant displacement. - [Physician's Name] made aware, new order given to transfer resident to the nearest emergency room for further evaluation of fracture of the neck of the left proximal femur. - 911 called at 10:40 AM, resident left at 11:20 AM via stretcher. Representative made aware of before and after transfer. A Hospital Discharge summary dated [DATE] at 6:00 AM documented: - 05/31/23 - Computed Tomography (CT) Scan of pelvis without contrast: acute appearing mildly impacted subcapital left femoral neck fracture. - Percutaneous fixation of left femoral neck fracture completed (the insertion of pins or wires through the skin to hold the bones in a proper position while they heal). During a face-to-face interview conducted on 03/12/24 at 12:20 PM, Employee #7 (Licensed Practical Nurse/LPN who worked on 05/30/23, day shift) stated, The process for when x-ray results are received is to call the medical doctor with the results. I don't think I received both results for [Resident #243] at the same time, or else I would have documented the results in my note. When asked if she received both x-ray results as documented in her progress note on 05/30/23 at 2:01 PM, she replied, I don't remember. I talked about the left knee, not both. So, I don't believe that I had both results at the time. During a telephone interview on 03/13/24 at 8:30 AM, Employee #8 (Night Shift Supervisor who worked on 05/30/23) was asked why there was no notification made to Resident #243's physician or their representative regarding the left hip x-ray result. The employee stated that the facility did not have a physicians on-call list [list of physicians to call on specific days and time frames]. The employe also said Since I have been working here, the instruction has been to not call the medical doctors during the night unless there's an emergency and the patient is at risk of dying. We wait until around 7:00-7:30 AM because most of the doctors get angry when we call them in the middle of the night. During a face-to-face interview on 03/13/24 at 11:25 AM, Employee #6 (Medical Director) stated, There is no on-call schedule for the medical providers at this facility, but I am available 24/7. During off shifts (evening and night), nursing staff are to contact the assigned medical provider and if they can't reach them, then they are to call me. If there's an abnormal result that is not critical, it makes sense to call in the morning and not at 3:00 AM. If there is an abnormal lab, x-ray, or incident, that should be reported to the provider during that shift when it happens. An x-ray result that comes back with a fracture, should not wait until morning, that should be reported immediately. Anything that affects the resident's well-being should be reported immediately. It has not been reported to me that there are any issues with reaching any of the medical providers during the evening or night shifts. During a face-to-face interview conducted on 03/13/24 at 12:25 PM, Employee #2 (DON) acknowledged the findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, for two (2) of 41 sampled residents, facility staff failed to ensure that Resident #26 received timely treatment and care in accordance with professional standards of practice and the physician's orders for her right foot; and facility staff failed to assess Resident #32's skin every shift per the care plan. Subsequently, the resident was observed with cellulitis of left lower limb with edema. These failures resulted in actual harm to Resident #26 when it was determined that the resident's reddened right big toe (first observed on 07/14/22) further declined and resulted in amputation on 10/26/22. The findings included: Review of the policy Documentation Criteria last reviewed on 07/22/22 directed, Clinical notes are written by a licensed nurse in the medical record. Clinical notes are randomly audited by registered nurse quarterly. Finding of audit are reported to QI (Quality Improvement) team with scheduled meeting . Clinical notes for decubitus/open wound include description of the area, size, drainage, presence of necrotic tissue, and condition of skin around the area . treatment was done as ordered . skin: note condition of feet even if no open areas exist .note for evidence of infection . Review of the 1st floor shower book showed a document titled, Skin Monitoring: CNA (Certified Nurse Aide) Shower Report that directed, perform a visual assessment or a resident's skin when giving the resident a shower. Report any abnormal looking skin to the charge nurse immediately . The form also had an area that directed, Charge nurse assessment followed by a designated space for the CNA's signature as well as the charge nurse's signature. 1. Facility staff failed to ensure that Resident #26 received timely treatment and care in accordance with professional standards of practice and the physician's orders for her right foot. Resident #26 was admitted to the facility on [DATE] with diagnoses that included: Idiopathic Peripheral Autonomic Neuropathy, Type 2 Diabetes Mellitus and Muscle Weakness. Review of Resident #26's medical record revealed the following: 05/10/19 [physician's order] Monitor for bruising/bleeding every shift 05/10/19 [physician's order] Turn and repositioning Q (every) 2 hrs (hours) every shift Care plan focus area, [Resident #26] is at risk for skin impairment r/t (related to) decreased mobility, incontinence, underweight initiated on 09/10/19 had the following approaches, Report any signs of skin breakdown (sore, tender, red, or broken areas). Provide diet and supplement as ordered. Dietary consult PRN (as needed) .Keep clean and dry as possible. Minimize skin exposure to moisture. The Annual Minimum Data Set (MDS) dated [DATE] showed facility staff coded the resident as: usually makes self understood; usually understands others; severe cognitive impairment; no behavior issues or refusal of care; required extensive assistance with two persons physical assist for bed mobility; required extensive assistance with one person physical assist for transfers, toilet use and personal hygiene; no functional limitations in range of motion; at risk for pressure ulcers; and no unhealed pressure ulcers or any other skin conditions. 06/27/22 Monthly Summary .No skin breakdown . no new skin issues noted . 07/14/22 at 11:48 AM [Physician's Assistant Note] .Pt's (patient's) nurse reported that pt complained of big toe pain and redness [right toe] .Pt admits to doing well and admits to pain to the foot .Plan: .Order Colchicine (decreases swelling) 0.6mg (milligrams) tablet, give 2 tablet x 1, then 1 tablet 1 hour later for [NAME] exacerbation. 07/14/22 at 10:55 PM [Nursing Note] .MD (medical doctor) in house, made aware of RT (right) great toe swollen, new order given for Colchicine 0.6mg tab (tablet), give 2 tabs x1, then 1 tab 1 hour later for [NAME] exacerbation. Order faxed, awaiting delivery .Will continue with POC (plan of care). 07/15/22 [physician's order] Colchicine tablet; 0.6 mg; amt (amount): 2 tabs x1; oral Special Instructions: give 2 tablet x 1, then 1 tablet 1 hour later for [NAME] exacerbation once - one time It should be noted the order for Resident #26 to receive Colchicine was written one day after she was assessed for the pain and redness of her right foot. A review of the 1st Floor Assignment sheet was conducted and showed that Resident #26 was scheduled to receive a shower every Monday and Thursday evening shift (3:00 PM - 11:00 PM). CNA documentation showed that on 07/17/22, evening shift, Resident #26 received a shower. However, there was no evidence that a skin report sheet was completed to show that a skin assessment was performed. Furthermore, as of 11/09/22, facility staff was unable to provide documented evidence that a shower report sheet had been completed on Resident #26 for any of her scheduled shower days from January 2022 to present. Treatment Administration Record (TAR) showed that from 07/15/22 to 07/22/22, facility staff documented: 0 or none noted in the area that directed, Monitor for bruising/bleeding every shift; and that Resident #26 was turned and repositioned q (every) 2 hours. From 07/15/22 to 07/22/22 (8 days), there was no documented evidence that facility staff performed an assessment (skin color, temperature, pain and swelling) of Resident #26's right foot. 07/23/22 at 8:58 PM [Physician's Note] .Patient seen at the request of nursing for ischemic [necrotic] foot and toe with surrounding cellulitis .Dark big toe dry and cellulitis .Begin Keflex (antibiotic) . 07/23/22 at 11:05 PM [Nursing Note] .New order given (1) Keflex 500mg po (by mouth) TID (three times a day) X 7 days for cellulitis of foot .and Gangrene [Dead tissue caused by an infection or lack of blood flow]. 07/26/22 [physician's order] Uric Acid [laboratory test that measures waste product found in blood ] 07/26/22 at 5:57 PM [American Health Associates] .Uric Acid . 3.9 . Reference range 2.3 - 6.6 mg/dL (deciliter) . 07/28/22 at 8:11 AM [Physician's Assistant Note] .MSc (musculoskeletal): Normal ROM (range of motion) to lower extremities, hyper pigmented discoloration of the foot, and no pedal edema .Plan 1. Continue with current treatment plan and level of care .Continue with Cellulitis medication regimen and treatment. 07/31/22 [Monthly Summary] . Resident recently completed antibiotic .for right foot cellulitis . 08/01/22 at 10:06 PM [Nursing Note] . [resident's] RT foot remains swollen, denies pain. 08/06/22 at 7:34 PM [Physician's Note] Follow up done regarding PVD (Peripheral Vascular Disease) with dry gangrene. Hyperpigmentation persists with skin warm to touch and dry . Continue current treatment . A Quarterly MDS dated [DATE] showed facility staff coded: required extensive assistance with two persons physical assist for bed mobility; required extensive assistance with one person physical assist for personal hygiene; at risk for pressure ulcers; and 1 venous/arterial ulcer present. It should be noted that the MDS is coded as the Resident having 1 venous/arterial ulcer present. However, there are no documented skin assessments/clinical notes for any open wound/ulcer for this time period. Care plan focus area, [Resident #26] is at risk for skin impairment r/t (related to) decreased mobility underweight showed it was revised on 08/16/22. However, there was no evidence that when facility staff first noted the change in the condition to the resident's right foot, that the care plan was updated to include person-centered care goals and approaches that addressed actions, treatments, procedures, or activities for the care of Resident #26's right foot. From 08/09/22 [date the MDS was coded for Resident #26 having one venous/arterial ulcer] to 08/23/22 (15 days), there was no documented evidence that facility staff performed an assessment (skin color, temperature, pain and swelling) of Resident #26's right foot. The August 2022 TAR showed that from 08/09/22 to 08/23/22 (15 days), facility staff documented: 0 or none noted in the area that directed, Monitor for bruising/bleeding every shift; and that Resident #26 was turned and repositioned q (every) 2 hours. 08/24/22 at 9:56 PM [Nursing Note] .Vascular Consult for RT lower extremity. [Duplex (test examines the blood flow in the major arteries and veins in the arms and legs)] for diagnosis follow up. DX (diagnosis) (1) Toe pain great toe (2) Wound great toe RT nacrotic (sp). (2) Wound care cleansing RT great toe and light dressing pending vascular consult. 08/24/22 [physician's order] Vascular consult for rt lower extremity [Duplex] for diagnosis and follow up . 08/24/22 [physician's order] Wound care cleansing RT great toe and light dressing pending vascular consult - once a day 09/03/22 at 1:00 PM [Nursing Note] .Seen today by wound doctor . 09/03/22 [physician's order] Bacitracin (topical antibacterial) ointment; 500 unit/gram; ribbon size; apply ointment to right toe once daily. Leave open to air dry . 09/08/22 at 11:02 AM [Physician's Assistant Note] Pt seen at bedside on routine visit appears alert and stable Pt appears to be doing well and denies to pain to the foot MSc: Normal ROM to lower extremities, hyperpigmented discoloration of the foot, and no pedal edema .continue with current treatment and level of care . From 09/09/22 to 09/21/22 (13 days), there was no documented evidence that facility staff performed an assessment (skin color, temperature, pain and swelling) of Resident #26's right foot. September 2022 TAR showed that from 09/09/22 to 09/21/22, facility staff initialed in the area that directed, Bacitracin .apply ointment to right toe once daily. Leave open to air dry . indicating that the task was completed and documented: 0 or none noted in the area that directed, Monitor for bruising/bleeding every shift; and that Resident #26 was turned and repositioned q (every) 2 hours. 09/22/22 at 7:34 PM [Physician's Assistant Note] Pt's nurse reported that pt's right foot toes are changing color with gangrene . Pt was communicated through phone translator . Order bilateral duplex arterial/venous US (ultrasound) to rule out occlusion. 09/23/22 [physician's order] Duplex Doppler arterial\venous right leg and left leg . 09/23/22 at 11:24 PM [Nursing Note] Dynamic mobile called that Doppler will be done tomorrow and not today, to be done on 09/24/22 . 09/24/22 at 9:20 PM Dynamic Mobile Imaging . procedure: venous Doppler bilateral . findings: the venous ultrasound is normal .no evidence of venous clot . 09/26/22 at 2:54 PM [Nursing Note] [Resident #26] was seen today by .wound specialist and the wound team in house for dry gangrene perfusing (sp) right toes ischemic 1st, 4th and 5th toe continue Bacitracin ointment and leave open to air . No new order at this time. 09/29/22 at 6:35 PM [Physician's Assistant Note] Pt's nurse reported that pt had Doppler Scan results that need to be reviewed and addressed . Imaging: Venous Doppler bilateral LE (lower extremities) shows no evidence of venous clots .Plan Continue with current treatment plan and level of care . 10/01/22 [physician's order] Bilateral lower extremities arterial Doppler . 10/01/22 at 10:00 PM [Nursing Note] .Total care provided, turned and repositioned [every] 2 hours . Bilateral lower extremities arterial Doppler done this shift, result pending . 10/02/22 at 1:06 AM [Dynamic Mobile Imaging] . procedure: arterial legs bilateral venous . findings: right: moderate plaque is noted within visualized arteries . Findings consistent with moderate PVD without occlusion, right lower extremity .Moderate stenosis between right proximal femoral artery and mid SFA (superficial femoral artery). Moderate stenosis of the right distal SFA . It should be noted that the duplex test was first ordered on 08/24/22. A venous duplex test was not completed until 09/24/22 (31 days later), that showed no evidence of venous clots. Within this timeframe), Resident #26 had additional toes that became ischemic (4th and 5th toes). An arterial duplex was then done on 10/01/22 that showed PVD with moderate stenosis of the right lower extremity. The October 2022 TAR showed that from 10/02/22 to 10/16/22, facility staff initialed in the area that directed, Bacitracin .apply ointment to right toe once daily. Leave open to air dry . indicating that the task was completed and documented: 0 or none noted in the area that directed, Monitor for bruising/bleeding every shift; and that Resident #26 was turned and repositioned q (every) 2 hours. From 10/02/22 to 10/16/22, (15 days), there was no documented evidence that facility staff performed an assessment (skin color, temperature, pain and swelling) of Resident #26's right foot. 10/17/22 at 1:47 PM [Nursing Note] [Resident #26] was seen today by .wound specialist and the wound team in house for dry gangrene perfusing right toes ischemic 1st, 4th and 5th to continue Bacitracin ointment and leave open to air. 10/22/22 at 5:37 PM [Nursing Note] Resident .seen by PCP (primary care physician) .on shift. Orders given to send resident to the hospital for progressive gangrene, needs revascularization vs (versus) amputation . 10/23/22 [Hospital Discharge Summary] .presenting to the ED (emergency department) with dry gangrene of [right] foot . Per vascular surgery, no urgent surgical intervention is warranted at this time . recommended Betadine and dry dressing for patient's wounds . 10/23/22 at 10:27 PM [Nursing Note] Resident back on the unit from ER (emergency room) visit at 3:45pm . Resident discharged from ER with recommendation for right foot gangrene treatment with Betadine daily and to follow up with . wound center and scheduled vascular surgery appointment on 10/26/22 . 10/23/22 [physician's order] Cleanse right foot gangrene with Betadine and leave open to air daily once a day 10/26/22 at 1:15 PM [Vascular Consult Note] . presents with gangrene of the right foot . extending to the midfoot . no realistic chance of healing . The only choice her would be below-knee amputation . The patient and family do not wish to have major amputation . During a tour of the 1st floor on 10/31/22 at 12:15 PM, Resident #26 was observed in bed, covered with a sheet, with both her feet exposed. The right foot was observed to be necrotic from midway of the foot, extending to all five of her toes. Review of Resident #26's comprehensive care plan showed that from 07/14/22 to 11/03/22 there was no evidence that facility staff developed a patient-centered care plan with goals, approaches to address care of Resident #26's right foot. There was no evidence that facility staff provided Resident #26 with the necessary care and required services to meet the resident's needs as evidenced by: A. Failure to develop a patient-centered care plan to address care of Resident #26's right foot B. Failure to conduct ongoing skin assessments as directed by the facility's policies and Skin Monitoring Shower Report C. Failure to assess and document skin color, temperature, pain and swelling of Resident #26's right foot in order report any changes and deterioration in the residents condition to the physician from 07/15/22 to 07/22/22 (8 days), 08/09/22 to 08/23/22 (15 days), 09/09/22 to 09/21/22 (13 days) and 10/02/22 to 10/16/22 (15 days) D. Failure to obtain ordered duplex and vascular consult in a timely manner. Duplex and Vascular consult were ordered on 08/24/22. A venous duplex test was not completed until 09/24/22 (totaling 31 days later), that showed no evidence of venous clots. Within this timeframe (31 days), Resident #26 had additional toes that became ischemic (1st, 4th and 5th toes). An arterial duplex was then done on 10/01/22 that showed PVD with moderate stenosis of the right lower extremity. The vascular consult was completed on 10/26/22 (totaling 63 days later) where it was documented, gangrene of the right foot . extending to the midfoot . no realistic chance of healing .The only choice [for] her would be below-knee amputation . During a face-to-face interview on 11/04/22 at 12:21 PM, Employee #10 (1st Floor Charge Nurse) reviewed Resident #26's comprehensive care plan, acknowledged the findings, and made no further comments. During a face-to-face interview conducted on 11/07/22 at 12:09 PM, Employee #10 stated, When the doctor's order a consult, the nurse reviews it and lets the unit secretary know so it can be scheduled. Once it is scheduled, arrangements are made for transportation and the consult date is documented. When asked why Resident #26's vascular consult was never scheduled as ordered, the employee stated, I don't know. A face-to-face interview was conducted on 11/07/22 at 3:30 PM with Employees #2 (Director of Nursing/DON) and #11 (Clinical Educator). Employee #11 stated, Nurses are supposed to do a weekly skin assessment on all residents whether they have wounds or not. When the CNA's give a shower, they look for any new areas and report that to the nurse. The nurse then documents it in Matrix Care (facility's electronic health record system) and makes the doctor aware. There's a shower sheet that both the CNA and nurse have to sign off on. The shower sheets are kept in a binder. There's one for every unit. When asked who audits the shower sheets or Matrix Care to ensure compliance with resident skin assessments, Employee #11 stated, I can't answer that question. Employee #2 stated, Unit Managers are supposed to check that the shower sheets and weekly skin assessments are being done and report back to me. There have not been any audits done lately on whether the skin assessments are being completed and I have not audited or reviewed to make sure that the forms [shower report] are getting completed. When asked about the care plans either not getting developed or not being patient-centered, Employee #2 stated, Only the RNs (registered nurses) can start or revise care plans. That's the charge nurses, evening and night supervisors and myself. Employee #2 acknowledged that licensed staff have not been developing or revising the care plans with patient-centered goals and approaches. When asked about the facility's process is for when the physician orders laboratory (lab) or any other test. Employee #2 stated, If the doctor orders a test, we call the lab or the x-ray and tell them. Once the results are in, we call the doctor and make him aware of the results. The nurse then signs and dates the form and puts it in the doctor's binder for them to sign when they come in. The night shift is supposed to check to see if tests that were ordered were obtained, if the results are back and if they were reported to the physician. When asked about the delay of Resident #26's ordered duplex test, Employee #2 stated that he doesn't know how it was missed the first time [08/24/22]. During a face-to-face interview conducted on 11/09/22 at 11:08 AM, Employee #2, #11, and #12 (Director of Quality Improvement) were made aware of the findings that Resident #26 did not receive the necessary care and required services for her right foot, causing a negative outcome. They all acknowledged the findings. 2. Facility staff failed to assess Resident #32's skin every shift per the care plan. Subsequently, the resident was observed with cellulitis of left lower limb with edema. During an observation and interview on 11/01/22 at 3:41 PM, Resident #32 stated that her left leg had started to swell and would sometimes leak. She said she had compression stockings at one time but believed they were taken with her laundry to be cleaned and never replaced. The surveyor noted that the resident's left leg was edematous from the knee to the ankle. The skin on the resident's leg appeared dark with light pink areas at the outer knee. The resident also stated that no facility staff had looked at her leg because she had not mentioned her concern to them. Resident #32 was admitted to the facility on [DATE] with diagnoses including Peripheral Vascular Disease, Cellulitis of the Left Lower Limb, Diabetes Mellitus, and Absence of Right Leg below the Knee. Review of Resident #32's medical record revealed: 06/17/21 at 5:42 PM [physician's order]: Monitor for Bruising/Bleeding every shift. 06/17/21 at 8:46 PM: [physician's order]: Emollient topical lotion, apply 2x/day as needed for dry skin. Care plan initiated on 01/10/22: Category: Skin integrity .[Resident #32] is at risk for skin breakdown r/t (related to) lower extremity cellulitis .Approach: Assess Resident for the presence of risk factors .Keep clean and dry as possible .Report any signs of skin breakdown (sore, tender, red or broken areas), skin every shift . 05/14/22 at 2:55 PM [physician's order]: Leg wrap with non-stretch leg wrap daily to left leg for venous insufficiency. A Quarterly MDS dated [DATE] showed that facility staff coded: a Brief Interview for Mental Status (BIMS)Summary Score of 15, indicating intact cognition; required extensive assistance for bed mobility, transfers, locomotion on the unit, dressing, toilet use, personal hygiene, bathing; functional impairment on one side for lower extremity; and was at risk for developing pressure ulcers. 09/19/22 at 1:45 PM [Nursing Progress Note]: .Complaint of dryness and scaling of the left leg .ordered Furosemide 40 mg (milligrams) and Spironolactone 25 mg once a day (to reduce edema caused by fluid accumulation). Also advised to continue the use of Cetaphil (emollient topical lotion) for dryness of the leg . Care plan initiated on 09/19/22 Category: Skin integrity .[Resident #32] has dryness/scaling/discoloration to left leg .Approach: Assess skin every shift . From 09/20/22 to 11/03/22, Resident #32's Treatment Administration Record (TAR) showed that facility staff initialed to attest that they Monitor[ed] for bruising/bleeding every shift and applied leg wrap with non-stretch leg wrap daily to left leg for venous insufficiency. From 09/20/22 to 11/03/22, Resident #32's Medication Administration Record (MAR) showed that facility staff initialed to attest that they applied emollient topical lotion 2x/day for dry skin. From 09/20/22 to 11/03/22 (45 days), there was no evidence that facility staff implemented a daily assessment and the condition of Resident #32's left lower extremity to include color, temperature, pain and swelling in order to identify and report changes and deterioration. During a face-to-face interview conducted on 11/07/22 at 1:10 PM, Employee #2 (Director of Nursing/DON) acknowledged the finding and made no further comments. During a face-to-face interview on 11/07/22 at 3:30 PM, Employee #11 (Clinical Educator) reviewed the findings for Resident #32 and stated that when the licensed nurses do the skin assessments, they should document the any new skin areas and the condition of the other existing areas. During a face-to-face interview conducted on 11/09/22 at 11:08 AM, Employee #2, #11, and #12 (Director of Quality Improvement) were made aware of the findings that facility staff failed to assess Resident #32's left leg daily per the resident's comprehensive care plan and they all acknowledged the findings. Cross reference: DCMR 3211.1