**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide care and services, according to professional standards of practice, to promote skin integrity and prevent the development and worsening of pressure injuries for 2 of 4 residents reviewed for pressure injuries, out of a total sample of 27 residents, (#5 and #7). The facility's failure to implement preventative interventions and ensure timely and adequate care and treatments for pressure injuries resulted in actual harm, for two dependent residents who were deemed at risk for development of wounds. Resident #5 acquired a pressure injury that was not thoroughly assessed when identified, to determine appropriate approaches to prevent the wound from worsening. Resident #7 developed two pressure injuries, suffered severe wound and bone infections that required hospitalization, and subsequently died on hospice services. Findings: 1. Review of the medical record revealed resident #7, an [AGE] year-old female, was admitted to the facility on [DATE] and re-admitted from the hospital on [DATE]. The Resident Information form listed her diagnoses including heart disease, osteoporosis, chronic pain, type 2 diabetes with a foot ulcer, and a Stage III sacral pressure ulcer. The document indicated resident #7 was discharged to an acute care hospital on [DATE]. The National Pressure Injury Advisory Panel (NPIAP) defines a pressure injury or pressure ulcer as localized damage to the skin and underlying soft tissue usually over a bony prominence. The injury is caused by prolonged pressure and can present as either intact skin or an open ulcer, usually at the site of bony prominences such as heels, hips, sacrum, and coccyx or tailbone. According to NPIAP, a stage I pressure injury is a localized area of non-blanchable redness on intact skin. However, blanchable redness may precede visual changes. Stage II pressure injuries show partial-thickness skin loss with an exposed pink or red wound bed. A Stage III pressure injury shows full-thickness skin loss with visible fat and/or granulation tissue. Slough and eschar (types of dead tissue) may be present but does not obscure the depth of tissue loss. A stage IV pressure injury involves full-thickness loss of skin and tissue that leaves muscle or bone exposed. A deep tissue pressure injury (DTI) is a persistent non-blanchable deep red, maroon or purple discoloration or a blood-filled blister that is covered with intact or non-intact skin. An unstageable pressure injury involves full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed as it is hidden by dead tissue (retrieved on [DATE] from https://cdn.ymaws.com/npiap.com/resource/resmgr/NPIAP-Staging-Poster.pdf). Review of the Minimum Data Set (MDS) Discharge Return Anticipated assessment with assessment reference date (ARD) of [DATE] revealed resident #7 had modified independence with cognitive skills for daily decision-making. The document indicated she did not exhibit any behavioral symptoms or reject evaluation or care necessary to achieve her goals for health and well-being. Resident #7 was totally dependent on staff for bathing, toileting hygiene, personal hygiene, bed mobility, and transfers. She was always incontinent of bowel movements. The MDS assessment showed resident #7 had one unhealed Stage III pressure ulcer not present on admission to the facility. Resident #7 had a care plan for bowel incontinence, initiated on [DATE]. The approaches indicated the resident used disposable briefs. The document instructed licensed nurses and Certified Nursing Assistants (CNAs) to check and change the resident as required after episodes of bowel incontinence. A care plan for diabetes, initiated on [DATE], instructed nursing staff to check the resident for breaks in skin integrity, treat promptly per physician orders, inspect her feet daily for open sores, pressure areas, or redness, and report any signs and symptoms of infections to open areas. A care plan for the potential for additional skin breakdown was initiated on [DATE]. The goals were resident #7 would show signs of healing and not develop skin infection. The interventions included an air mattress, heel protector pads to both feet when in bed, offloading boots, assist with bed mobility and repositioning on rounds during care and as needed, clean promptly after incontinence episodes, and treatment to right heel diabetic wound and non-pressure ulcer to the sacrum. A care plan for the potential for additional pressure ulcers, initiated on [DATE], instructed nurses to assist resident #7 with toileting tasks and incontinence care, observe skin during routine care, observe for signs and symptoms of infection, apply treatment to her pressure ulcer on the coccyx, and follow recommendations of the wound physician. Resident #7 had a care plan for antibiotic therapy for a wound infection, initiated on [DATE]. The goal was the resident's wound infection would resolve without complications. The interventions included give antibiotic therapy as ordered, obtain and monitor lab and diagnostic work as ordered, report the results to the physician, and follow up as needed. A care plan for activities of daily living (ADL) self-care performance deficit, initiated on [DATE], indicated resident #7 required assistance from two staff for transfers with a mechanical lift, assistance from one to two staff for bed mobility, and assistance of one staff for personal hygiene. The care plan instructed nursing staff to encourage the resident to use the call bell to call for assistance. In telephone interviews and conference calls on [DATE] at 10:32 AM, [DATE] at 11:05 AM, and [DATE] at 1:10 PM, resident #7's family explained she developed wounds on her heel and bottom while in the facility, which they believed were treated with only the bare minimum of care. The family stated staff did not provide necessary ADL care, such as regular turning and repositioning or prompt incontinence care to prevent development and worsening of their mother's wounds. During the months preceding their mother's transfer to the hospital, they recalled multiple conversations with the 1st Floor Unit Manager, Assistant Director of Nursing (ADON) F, during which they requested bloodwork, additional testing, and intravenous (IV) antibiotics. The family explained they were all in agreement regarding aggressive treatment of the wounds, but lab work was never ordered, and they were told wound culture samples were either lost, improperly tested, contaminated, or inaccurate. They said, We asked [name of ADON F] to get a [Computed Tomography (CT)] scan and they kept on saying they were treating her adequately in the facility. They never suggested hospitalization. The family stated the wounds on their mother's right heel and tailbone gradually worsened and the right heel wound became infected. They explained the facility finally arranged for an Infectious Disease specialist to assess her on [DATE] as different antibiotics and treatments were not effective. However, later that day, the family became more concerned about their mother's declining status and called 911 themselves. According to the family, their mother was diagnosed with right heel osteomyelitis (a bone infection), in the hospital and the physicians who treated her confirmed her wounds were avoidable and preventable if proper measures had been in place. They shared that diagnostic testing performed in the hospital showed her wounds were not caused by circulatory issues. The family members stated they attended a care plan meeting with the facility via telephone on Monday [DATE], while their mother was in the hospital. They informed the Director of Nursing (DON) and ADON F their mother had osteomyelitis and discussed how her care would be handled if she returned to the facility on IV antibiotics. The family recalled they informed the DON and ADON F of concerns related to their mother not being turned, repositioned, and cleaned adequately to prevent and heal her wounds. They stated they mentioned staff often ignored their mother or did not respond to the call light in a timely manner when she needed care. During the care plan meeting, the family complained that on two occasions a nurse who was in the room to do their mother's wound dressing refused to provide incontinence care as it was not her job. As a result, their mother had to wait for over an hour for the bowel movement to be cleaned from her skin. The family explained despite receiving IV antibiotics in the hospital, their mother's infection was so severe that she never recovered. They stated their mother died on hospice services two weeks later, on [DATE]. Review of an Order Summary Report revealed resident #7 had physician orders for three courses of oral antibiotics to treat her right heel wound infection. She received Doxycycline 100 milligrams (mg) twice daily from [DATE] to [DATE], and the drug was re-ordered from [DATE] to [DATE]. The physician then ordered Clindamycin HCl 300 mg every eight hours from [DATE] to [DATE]. The medical record showed no bloodwork was ordered between [DATE] and [DATE]. Review of the medical record revealed Wound Evaluation & Management Summary notes documented by the wound physician regarding his weekly visit assessment findings, treatment orders, and recommendations. A note dated [DATE] revealed resident #7 had a diabetic wound of the right heel of greater than a 106-day duration, that measured 1.0-centimeter (cm) x 0.9 cm x 0.7 cm. The area around the wound was red and there was a moderate amount of clear, watery drainage. The document indicated 15% of the wound tissue was slough. The wound physician wrote treatment orders and his recommendations included float heels in bed, off-load wound, reposition per facility protocol, turn from side to side in bed every one to two hours if able, offloading heel elevator cushion, and the oral antibiotic Doxycycline for ten days. The document indicated the resident's Stage III pressure wound on her coccyx, of duration greater than eight days, was resolved. A note by the wound physician dated [DATE] revealed resident #7's right heel wound had increased in size and measured 1.1 cm x 1.1 cm x 0.7 cm, continued with peri wound redness, and had light purulent drainage or pus. The slough tissue was increased to 20% and the wound progress was not at goal. The wound physician obtained a sample of tissue and/or fluid from the heel wound for wound culture lab testing, to determine if there was an infection, to identify the causative organism, and to select the most effective antibiotic therapy if indicated. The wound physician's recommendations emphasized the importance of off-loading pressure to the wound. A wound progress note dated [DATE] revealed the size of the right heel wound had decreased slightly, but purulent drainage and slough was unchanged although she had completed ten days of oral Doxycycline. The wound physician wrote, Lab performed only aerobic culture, will send anaerobic culture. Aerobic bacteria are usually found in superficial wounds and anaerobic bacteria are usually found in deeper wounds and abscesses. A wound culture order is only for aerobic bacteria, and an anaerobic culture order must be requested separately (retrieved on [DATE] from www.biologyonline.com/dictionary). Review of a Health Status Note effective [DATE] revealed the facility called the lab to request an anaerobic culture as only an aerobic culture was requested. A wound progress note dated [DATE] read, Lab only performed aerobic culture again. Will send another culture for anaerobes; patient has moderate growth of skin flora from aerobic culture, will start Doxycycline. A wound progress note dated [DATE] revealed resident #7's wound measured 0.7 cm x 0.5 cm x 0.5 cm but was not at goal. The wound still had light purulent drainage, peri wound redness, and 20% slough tissue. The wound physician noted there was no growth in the wound culture, but due to the presence of pus and redness he would submit yet another culture for anaerobes and aerobes. The plan of care indicated resident #7 remained on oral Doxycycline 100 mg twice daily. Review of a Health Status Note dated [DATE] revealed resident #7 had an open area on her coccyx. The note indicated the assigned nurse called the hospice agency for treatment orders, and the area was cleansed, and a dry dressing applied. Review of the medical record revealed a treatment order was initiated two days later on [DATE]. A wound progress note dated [DATE] showed over the previous seven days, resident #7's wound increased in size to 1.1 cm x 1.4 cm x 0.9 cm. The surface area of the wound increased from 0.35 cm squared to 1.54 cm squared and the wound care physician noted moderate purulent drainage, peri wound redness, and that slough tissue increased from 20% to 40%. The note read, Wound progress exacerbated due to infection.Lab has lost cultures again; will send cultures for anaerobes and aerobes again. The physician ordered another oral antibiotic, Clindamycin 300 mg three times daily. The progress note indicated lab work related to the resident's blood sugar control over the previous months was pending as of [DATE], but review of the medical record revealed the test was never ordered. During the visit, the wound physician noted resident #7 developed a stage III pressure wound on her coccyx that measured 3.7 cm x 5.1 cm x 0.3 cm, with a surface area of 18.87 cm squared. The wound had a moderate amount or clear drainage, the edges were macerated, and it had 30% slough tissue. The physician noted resident #7 had an open area of moisture-associated skin damage on her sacrum, above the coccyx wound, that measured 4.7 cm x 6.5 cm x 0.1 cm. A wound progress note dated [DATE] revealed resident #7's right heel wound had significantly increased in size to 1.4 cm x 4.5 cm x 1.2 cm. During the week since the wound was last assessed by the wound physician, the wound's surface area increased from 1.54 cm squared to 6.3 cm squared. The peri wound redness remained, and the wound now had heavy purulent drainage, 40% thick necrotic tissue, and 20% slough. The note indicated the wound progress was exacerbated due to infection. The wound physician noted the facility's lab provided a culture result of moderate growth of normal skin flora with no specific organisms or antibiotic sensitivities. As a result, he decided to test the validity of the result by sending a culture to another lab as the condition of the wound continued to deteriorate. The wound physician obtained a sample by debriding the membrane that covered the heel bone and removed dead tissue. The note revealed he recommended a consultation with an Infectious Disease specialist for initiation of IV antibiotics. The document indicated over the previous week, resident #7's Stage III pressure ulcer on her coccyx had also increased in size to 4.5 cm x 6.5 cm x 0.3 cm, with a surface area that changed from 18.87 cm squared to 29.25 cm squared. Review of nursing progress notes from [DATE] to [DATE] revealed no documentation by facility nurses that reflected awareness of the worsening conditions of resident #7's wounds. There was no evidence nurses who completed daily wound care notified ADON F, the DON, the attending physician, the hospice physician, the hospice nurse, or the wound physician when the wound drainage changed from clear to light purulent and then moderate purulent during the 6-week period preceding the resident's hospitalization. The progress notes showed no evidence of cohesive and comprehensive care planning discussions that involved all stakeholders including the resident, hospice staff, family members, facility staff, and the physicians, to determine the goals and extent of treatment, as the status of the infected heel wound worsened. On [DATE] at 4:49 PM, ADON F stated resident #7 had a pressure ulcer on her coccyx and a diabetic ulcer on her right heel. She recalled on [DATE], the resident's heel wound was deteriorating and had quite a lot of purulent drainage. ADON F stated the wound physician recommended a more aggressive approach, an Infectious Disease consult and IV antibiotics. She added, There was always a conflict with hospice. ADON F stated the resident was sent to the hospital on [DATE], at the family's request, and on [DATE], the family informed the facility that resident #7 had right heel osteomyelitis. On [DATE] at 10:24 AM, in a telephone interview, the wound physician explained heel wounds were usually caused by either trauma or pressure. He stated resident #7's diabetic right heel wound was actually secondary to pressure, but the terminology indicated her diabetes diagnosis affected wound healing. The wound physician stated the primary preventative measure for these types of wounds was to alleviate pressure on bony prominences. He stated he placed a strong emphasis both in his documented recommendations and verbal discussions with staff regarding the importance of offloading and skin care in preventing and healing pressure ulcers. The wound physician acknowledged resident #7's heel wound started to decline in [DATE] and worsened significantly after brewing for weeks. When asked about his assessment and treatment of the resident's wound, he said, The problem I had with escalating things was that her family had her on hospice, and families are not always aware of how that affects care and services. The feeling I got from the facility was that she was on hospice so aggressive treatment was not the goal. The wound physician acknowledged he only visited the facility once a week, but the attending physician(s) should be made aware of any significant decline between his visits. He explained for concerns related to osteomyelitis, he would usually order additional testing, but he was always told that hospice needed to approve aggressive care. The wound physician said, I would have ordered much more if she was not on hospice. If Infectious Disease was engaged, she would have been on IV broad-spectrum antibiotics. In the last two weeks, hospice was the huge reason for delay in care. The wound physician added he had significant concerns regarding the facility's lab provider, as the entity lost numerous samples for multiple residents and provided possibly inaccurate results over the last eight to twelve months. He stated he reported his concerns to the Administrator and DON. When the wound physician was informed resident #7 was diagnosed with osteomyelitis in the hospital, he said, I am not surprised at all. You only have so much soft tissue between skin and [the heel bone]. On [DATE] at 11:00 AM and 4:57 PM, ADON F stated she rounded weekly with the wound doctor and always reminded him if residents received hospice services. She explained under those circumstances, she would have to notify the hospice agency if the wound physician wanted to consult other specialists or proceed with aggressive treatments. ADON F stated she spoke to the hospice nurse about IV antibiotics for resident #7, but she could not recall the date of the conversation. ADON F stated during rounds, the wound physician described the wounds and discussed treatments with her. She explained after he left, she reviewed the sections of his notes that pertained to new orders, the treatment plan, and wound measurements. ADON F was informed the wound physician's progress notes repeatedly indicated he did not receive requested lab results in a timely manner and/or was not confident the results were accurate. She acknowledged the lab did not initially perform anaerobic wound cultures as the physician was not specific, and she requested only aerobic cultures. ADON F stated to her knowledge, the lab provided the results requested from later samples. She said, I don't look at the entire note or read anything else. I did not know that he was writing that he did not have the culture results. ADON F could not explain why she was unaware of the wound physician's concerns related to wound cultures if she rounded with him weekly and participated in discussions specific to the status of each resident's wound(s). On [DATE] at 11:34 AM, the DON stated she did not recall any conversations with the wound physician regarding his dissatisfaction with the lab provider's services. She stated accuracy of the wound culture was outside the facility's scope and they trusted the lab to do its testing properly. The DON explained the facility continued to treat resident #7 with oral antibiotics while awaiting culture and sensitivity results from the lab. She acknowledged five weeks was a long time to wait for lab results while a wound infection worsened despite antibiotic therapy. The DON confirmed there was an interdisciplinary team process and the facility could have arranged a meeting with hospice staff, the resident's children and invited the wound physician to participate in discussions regarding approaches to wound treatment. She verified there was no documentation in the resident's medical record prior to [DATE] that showed consideration of transfer to the hospital for advanced testing and/or IV antibiotic therapy. In a telephone interview on [DATE] at 9:22 AM, in response to a telephone call made on [DATE] at 2:50 PM, resident #7's hospice Registered Nurse Case Manager (CM) stated she visited the facility regularly to assess the resident and ensure her comfort related to pain and anxiety. The CM reviewed the hospice medical record and stated hospice nurses visited the resident on [DATE], [DATE], [DATE], [DATE], and [DATE]. She stated the progress notes for those dates did not include documentation of discussions with or requests by the facility regarding more aggressive wound treatment such as an Infectious Disease physician consult, IV antibiotics, diagnostic testing, or hospitalization. The hospice agency's Executive Director (ED) explained the process was that recommendations by the facility's wound physician or Infectious Disease physician would be reviewed by the hospice's medical officer. She confirmed hospice authorized administration of IV antibiotics on a case-by-case basis. The CM and ED verified the facility never informed them of the possible need for IV antibiotics or advanced testing for resident #7's wound infection. On [DATE] at 1:46 PM, in a return telephone call received from the wound physician, he reiterated the facility was aware of his concerns about their lab provider as he had mentioned the issues to, several people, more than once. He confirmed his progress notes reflected the information he had regarding the cultures at the time the documents were completed. The wound physician checked resident #7's lab results in the facility's electronic medical record and stated the samples collected on [DATE] and [DATE] were processed for aerobic cultures only. He explained a culture collected on [DATE] showed no anaerobes were isolated, but due to the purulent wound drainage, he sent another sample for a repeat culture. The wound physician stated the sample collected on [DATE] showed an anaerobic organism, streptococcus intermedius. He read from the document, Susceptibilities are not routinely performed on this organism and explained that antibiotic sensitivities should have been determined by the lab. The wound physician indicated the next sample, collected on [DATE], showed no anaerobes were isolated. He explained he decided to seek confirmation from an outside lab as resident #7's wound continued to exhibit signs of infection although she remained on oral antibiotics. Resident #7's hospital record revealed she was admitted to the hospital with right heel and sacral pressure ulcers. Lab work done in the Emergency Department on [DATE] showed an elevated white blood cell count of 15.79 (normal range 4.4 to 10.5), which confirmed she had an infection, and she was started on IV antibiotics. A Wound/Ostomy Care Consult Note dated [DATE] revealed resident #7 had a sacral pressure ulcer that was present on admission to the hospital. The wound was described as an evolving DTI with slough. The provider noted the resident's right heel pressure ulcer was also present on admission to the hospital, the heel wound was described as unstageable, with mostly yellow slough, and redness to the peri wound area. A CT scan of the right foot with IV contrast, done on [DATE], revealed the resident had soft tissue swelling in the ankle and foot, an open wound, and osteomyelitis. The hospital record showed a wound culture was collected on [DATE] and resulted on [DATE]. The document indicated the organism Streptococcus intermedius was present in resident #7's heel wound, as noted in the lab culture collected in the facility on [DATE]. However, in contrast to the report from the facility's lab, the document included recommendations for antibiotics to which the organism was susceptible. The lab report indicated the organism was resistant to Clindamycin, the oral antibiotic that had been prescribed for resident #7 in the facility, thereby making the drug ineffective in treating the wound infection. A Podiatry Consult dated [DATE] revealed resident #7 was not a candidate for surgical intervention and would require IV antibiotics for six weeks. The hospital record showed the resident's infection progressed and she developed sepsis, a life-threatening complication of the body's extreme response to an infection (retrieved on [DATE] from ww.cdc.gov/sepsis/index.html). The Discharge Summary revealed resident #7 was transferred to an inpatient hospice unit on [DATE]. 2. Review of the medical record revealed resident #5, a [AGE] year-old female, was admitted to the facility on [DATE] and re-admitted on [DATE]. Her diagnoses included metabolic encephalopathy (brain disorder), altered mental status, non-traumatic bleeding inside the brain, right carotid artery occlusion, left side weakness and paralysis, and generalized muscle weakness. The Resident Information sheet had been updated to show the resident acquired a Stage III pressure ulcer during her stay in the facility. Review of the MDS admission assessment with ARD of [DATE] revealed resident #5 had severely impaired cognitive skills for daily decision-making. The document indicated she had no behavioral symptoms and did not reject evaluation or care that was necessary to achieve her goals for health and well-being. Resident #5 had functional limitation in range of motion related to impairments of one arm and both legs, and she used a wheelchair for mobility. The resident was totally dependent on staff for toileting hygiene, bathing, dressing, and personal hygiene. She required substantial to maximal assistance for bed mobility and was dependent for transfers between the bed and wheelchair. The MDS assessment revealed resident #5 had an indwelling urinary catheter and was always incontinent of bowel movements. The resident was determined to be at risk for developing pressure ulcers, but the document showed she had no wounds, ulcers, or other skin problems on the date of the assessment. Review of the medical record revealed resident #5 had a care plan for bowel incontinence, initiated on [DATE]. The interventions instructed CNAs to provide peri care after each incontinence episode. A care plan for potential for impairment to skin integrity related to impaired mobility, incontinence, weakness, and protein-calorie malnutrition was initiated on [DATE]. The goals were resident #5 would show signs of healing and be free from skin infection. The interventions included assist with repositioning on rounds and as needed, follow facility protocols for treatment of injury, keep skin clean and dry, ensure placement of offloading boot on both feet when in bed. The document was updated on [DATE] to reflect application of a skin treatment to her sacral/coccyx open area. A care plan for risk for pressure ulcers was initiated on [DATE]. The goal was resident #5 would not develop any pressure ulcers. The interventions included apply topical preventative treatment if ordered, assist with bed mobility and repositioning on rounds and as needed, provide incontinence care promptly, observe the resident's skin condition during care, report any new findings, and perform skin assessments as indicated. Review of a Scale for Predicting Pressure Sore Risk form dated [DATE] revealed resident #5 had a score of 16. The legend indicated scores between 15 and 18 deemed residents at risk for developing pressure ulcers. Review of a Weekly Skin Inspection form dated [DATE] revealed resident #5's skin was intact. A form dated [DATE] indicated the resident's skin was not intact, due to a new area of skin breakdown. A Skin/Wound Note dated [DATE] at 11:34 PM, read, Resident was observed to have [an] open wound on her coccyx found by CNA. I cleansed with normal saline, applied skin protectant and bordered gauze. The document indicated the note was added to the facility's Shift Report and the 24-Hour Report. Review of the Order Summary Report for [DATE] revealed a physician order dated [DATE] to cleanse the open area with normal saline, pat dry, apply a Hydrocolloid, and cover with a border dressing twice daily. A Hydrocolloid dressing is usually used for superficial wounds with minimal drainage and is changed about every three days (retrieved on [DATE] from www.woundsource.com/blog/what-hydrocolloid-dressing). The order was discontinued on [DATE]. A new physician order dated [DATE] instructed nurses to apply Collagenase ointment 250 units per gram to the wound twice daily for slough, then apply collagen powder, Calcium Alginate, and cover with a dry dressing. Collagenase is used to treat skin ulcers by removing dead skin tissue from wounds to promote healing (retrieved on [DATE] from www.drugs.com/mtm/collagenase-topical.html). Alginate dressings are very absorbent and are often used in wounds with heavy drainage (retrieved on [DATE] from www.woundsource.com/blog/what-alginate-dressing). The Order Summary Report included physician orders dated [DATE] for a wound physician consult and an air mattress to promote wound healing. Review of the Initial Wound Evaluation & Management Summary dated [DATE] revealed the wound physician assessed resident #5 and discovered a Stage III pressure ulcer on her coccyx. The wound measured 4.0 cm x 1.0 cm x 0.3 cm and had a moderate amount of clear drainage. He noted 40% of the wound was nonviable tissue, which he removed surgically. The plan of care included recommendations to .Limit sitting to 60 minutes; Off-Load Wound; Reposition per facility protocol; Turn side to side in bed every 1 - 2 hours if able.Upgrade offloading chair cushion; Gel cushion. The note indicated the wound physician discussed the plan of care with nursing staff. Review of Progress Notes from [DATE] to [DATE] revealed no documentation regarding the size, characteristics, or stage of resident #5's wound either when it was identified or during the 7-day period prior to the wound physician's assessment. Changes in the types of treatments ordered indicated within four days, the wound worsened from an open area that required only a skin protectant cream to a pressure ulcer with slough and drainage. The medical record did not reflect follow up by nursing management on [DATE], although the new wound was documented on the Shift Report and the 24-Hour Report, to thoroughly assess the wound and ensure appropriate treatments and interventions were initiated in a timely manner. On [DATE] at 10:13 AM, resident #5 was seated upright in a high-back wheelchair in the 1st floor common area. The resident's body was centered in the chair and there were no positioning devices noted on either side of her body. On [DATE] at 1:39 PM, after the lunch meal, the resident remained seated upright in the wheelchair in the common area. She was still centered in the wheelchair, with her buttocks flat on the seat cushion, and there were no positioning devices beside or under[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to permit a resident to return to the facility after being transferred to the emergency room for 1 of 3 residents reviewed for discharge of a total sample of 4 residents, (#1). Findings: Resident #1's medical record revealed he was admitted to the facility for long term care on 10/06/22 with diagnoses of Corona Virus Disease 2019 (COVID-19), atrial fibrillation, and schizoaffective disorder. The resident was discharged to the hospital on [DATE]. The resident's physician orders included Tramadol for pain, Depakote for mood and behavior, and Seroquel for schizoaffective disorder. Resident #1's admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/11/22 indicated his Brief Interview for Mental Status (BIMS) score was 14 out of 15 indicating intact cognition. The assessment reflected he required extensive assistance of one person for bed mobility, walking, dressing, toilet use and hygiene. He required extensive assistance of 2 persons for transfers. On 1/30/23 at 8:38 AM, during a telephone interview, resident #1's sister stated the resident had been in the hospital for a month because the facility refused to take him back. She stated the Admissions Director told her the facility gave his bed away on 12/27/22 and they were unsure when the facility would have a bed available. On 1/30/22 at 3:40 PM, the Unit Manager stated resident #1 was very different after he contracted COVID-19. She said prior to COVID-19, he was friendly, laughed and joked. He was friendly with a group of residents who he socialized and ate his meals with. He always checked on this group of residents to see how they were doing. The Unit Manager stated after COVID-19, he completely changed. He stopped eating with his little group, he did not interact with the other residents. He would not look you in the eyes when he spoke. He was just different. On 1/30/23 at 5:15 PM, the Director of Nursing (DON) stated when resident #1 was admitted to the facility he adapted very well, was active in activities and seemed to make friends. The DON recalled the resident contracted COVID 19,and was placed on isolation precautions. The resident went into isolation acting like himself but when he came out of isolation, he was different. He did not make eye contact, he wandered in his wheelchair, and he could not be redirected immediately. The DON stated the resident raced up and down the halls in his wheelchair and got on elevators. He became difficult to redirect and became very agitated. The DON explained he was sent to the hospital for evaluation and possible adjustment of medications. We wanted the hospital to evaluate him, regulate his medications and send him back. A progress note sent from the hospital Case Manager dated 12/27/22 at 3:52 PM read, Per the family the patient was on the unlocked side of the facility and tried to go down the elevator by himself. Due to this, the nursing home sees patient as a risk for elopement. However, currently, patient has been calm and unrestrained chemically or physically in the hospital bed. He has not tried to elope. Pt. (patient) has a Pre-admission Assessment and Resident Review (PASRR) PASRR II that was started over the weekend, but since the pt has been hydrated, had antibiotics, and stabilized he is not a threat to self or others. Psych assessed and cleared the resident and no holds are being placed on the patient. Case Management to follow as patient is long term care at Winter Park. Addendum 5:28 PM, The Manager for the Case Management Department spoke to supervisors at Winter Park who confirmed and agreed that patient will be accepted back and there will be a resolution by 10 AM tomorrow. Family is aware. A PASRR is a federally mandated evaluation process per the Nursing Home Reform Act . A Level I Pre-admission Screening is required for all applicants to Medicaid certified nursing facilities, regardless of payor. A Level II Evaluation and Determination must be completed prior to admission if a serious mental illness and /or intellectual disability or related condition is identified through the Level I screening. A Level II evaluation must also be completed when there is a significant change in the resident's physical or mental condition. (Retrieved from Myflfamilies.com). On 1/31/23 at 9:40 AM, during a telephone interview, the hospital Case Worker stated at first the facility stated they needed a PASRR Level II before the resident could return to the nursing home. She said, They requested that we complete the form because their Social Worker did not have a master's degree and that is required for the PASRR II. We had the PASRR II completed. Then we got an email stating the resident could come back on 1/03/23. When we tried to send him back, the Admissions Director told me the facility would not be taking the resident back because the family called AHCA (Agency for Health Care Administration). She stated she spoke to him about discharge regulations and he stated he would talk their corporate office. The Case Worker said, I did not hear back from the Admissions Director, so I called their corporate office myself and I received an email stating the facility would not be taking the resident back because the facility had vulnerable population. While the resident was in the hospital the Case Worker stated she spoke with the family almost every day. She stated the hospital had a difficult time finding a bed and at one point they found a facility that was about three hours away. She said the resident's family was horrified because they would not be able to visit him frequently. The Case Worker said, The resident was very sad and could not understand why he was not going back to Westminster Winter Park. On 1/31/23 at 12:16 PM, during a telephone interview, the Ombudsman's Assistant stated she received a phone call from resident #1's sister who said she was waiting to hear if Westminster Winter Park was going to allow the resident to return to the facility. She stated the facility did not want to take him back after they sent him to the hospital for behaviors. The Assistant recalled she spoke to the Administrator of Westminster who confirmed the facility would not be taking the resident back. She said she suggested the facility allow the resident to return and give a 30-day discharge notice if needed. The Administrator seemed confused about the 30-day discharge notice. She stated he told her this was his first time for this situation and thanked her for the information. She said she explained to him that even if a resident was transferred to the hospital on [NAME] Act, you need to take them back and give the 30-day discharge notice. On 1/31/23 at 2:00 PM, the Administrator acknowledged he was aware their corporate office sent a letter informing the hospital the facility would not allow the resident to come back to the facility. He also acknowledged he spoke to the Ombudsman's Assistant regarding resident #1. On 1/31/23 at 10:04 AM, during a telephone conversation, resident #1's sister said, It has been like a nightmare since my brother was transferred to the hospital. He was very sad in the hospital because he missed his friends from Westminster Winter Park. He could not understand why he couldn't go back there to his home. He was worried and sad about where he would go. She said when the facility refused to take him back, the hospital had a hard time finding a facility with available beds. She said they found a few facilities but they were hours drive away and that would have made it difficult for the family to visit. When my brother was in the hospital, I would wake up at 4:00 AM worrying about where he was going to be placed . I could not eat or sleep properly. She explained their [AGE] year old mother was traumatized because she did not know where he would be placed. She talked about it every day and was very upset because he was not going back to Westminster. She stated the hospital finally found a bed in a local facility on 1/16/23 but her brother did not like the facility as much as he did Westminster. She said he told her the food was not as good and he couldn't choose his meals from a menu like he used to do at Westminster Winter Park. She explained he told her most people at this facility ate their meals in their rooms and he had a group of friends he used to eat with at Westminster. She noted her brother told her he missed his friends and talked about them all the time. She said he keeps telling her he wants to back to Westminster Winter Park.