**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and review of the facility's policy titled Change in a Resident's Condition or Status, the facility failed to ensure that two of 40 sampled residents (R) (R159 and R9), medical providers, and family were timely notified of a change in condition. R159's medical provider was not notified of any changes in the resident's condition, including the lack of pedal pulses. Additionally, R159's family was not made aware of the resident's condition from 8/28/2024 until 9/7/2024. On 9/7/2024, R159's family was concerned about the resident's condition and requested that the resident be transferred to the hospital; however, the facility denied the request. Additionally, on 5/15/2024, the facility identified a change in R9's diabetic foot ulcer; however, the facility did not notify the resident's wound practitioner, who was treating the wound, until 5/16/2024, when the resident was transferred to the hospital. In addition, the facility failed to notify R9's family of a wound that had been treated since 4/15/2024. R9's family did not become aware of the resident's wound until 5/16/2024, when the resident was emergently transferred to the hospital. These failures caused death to R159 and actual harm to R9. On 3/28/2025, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Regional Director of Clinical Operations (RDCO) were informed of the Immediate Jeopardy (IJ) for F580, F600, F658, F686, and F835 on 3/28/2025 at 6:27 pm. The facility was unable to provide an acceptable IJ Removal Plan before the survey team's exit on 3/30/2025, and the IJ remained ongoing. Findings included: A review of the facility's policy titled Change in a Resident's Condition or Status, revised February 2021, revealed .policy interpretation and implementation 1. The nurse will notify the resident's attending physician or physician on call when there has been a . d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly; .g. need to transfer the resident to a hospital/treatment center . i. specific instruction to notify the physician of changes in the resident's condition . 3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observation and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form . 5. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status . 1. A review of the electronic medical record (EMR) revealed that R159 was admitted to the facility on [DATE] with diagnoses including, but not limited to, angioneurotic edema, diastolic congestive heart failure (CHF), deep vein thrombosis (DVT), hypercholesterolemia, and type 2 diabetes without complications. A review of R159's N [Nursing] Adv [Advanced] Skilled Evaluations dated 8/26/2024 revealed, Skin warm and pink with brisk capillary refill (< (less than) three seconds. No Edema present. A review of R159's N Adv Skilled Evaluation dated 8/27/2024 revealed, Skin warm and pink with brisk capillary refill (< three seconds). No edema present. A review of R159's Progress Note dated 8/28/2024 revealed, visit type: Acute . Pitting edema to BLE (bilateral lower extremities, bruising to the left foot. History of Present Illnesses .Staff concerned regarding worsening edema to BLE for the past 2-3 days, +2 to 3 pitting edema bilaterally. The patient spends most of the day in a wheelchair with feet down, and discussed with staff elevating the patient's feet to help with edema reduction as well. Bruise to the left foot that was noticed yesterday. Unsure how the bruise was acquired. Patient does not elicit a painful response to the bruised area .Skin/Breast-Positive: Swelling, Bruises .Bruise to [NAME] surface of left foot .Edema .Pitting, Edema in lower left extremities, Edema in lower right extremities . A review of the resident's progress notes prior to 8/28/2024 revealed no documented evidence that the resident's medical provider was notified of any edema or bruising to the resident's foot. A review of R159's Physician's Order dated 8/29/2024 revealed an order for Lasix oral tablet [a diuretic medication] 20 milligrams (MG) give one tablet by mouth one time a day for CHF/fluid retention. A review of R159's N Adv Skilled Evaluation dated 8/30/2024 revealed .Skin warm and pink with brisk capillary refill (< three seconds). No edema present . Calf tenderness is not present. Negative bilaterally for Homan's sign. Left pedal pulse: +2 normal. Right pedal pulse: +2 normal A review of R159's N Adv Skilled Evaluation dated 8/31/2024 revealed Pain: Indicators of pain: None . Cardiovascular: Skin warm and pink with brisk capillary refill (< 3 seconds). No edema present . Calf tenderness is not present. Left pedal pulse: absent. Right pedal pulse: Absent . Skin: Skin warm & dry, skin color WNL [within normal limits] and turgor is normal . The evaluation was completed by Licensed Practical Nurse (LPN) 1. There was no documented evidence that the resident's medical provider was notified of the resident not having pedal pulses. A review of R159's N Adv Skilled Evaluation dated 9/1/2024 revealed . Skin warm and pink with brisk capillary refill (< three seconds). No edema present . Calf tenderness is not present. Negative bilaterally for Homan's sign. Left pedal pulse: +2 normal. Right pedal pulse: +2 normal A review of R159's N Adv Skilled Evaluation dated 9/3/2024 revealed . Pain: Indicators of pain: None . Cardiovascular: Skin warm and pink with brisk capillary refill (< 3 seconds). No edema present . Calf tenderness is not present. Left pedal pulse: absent. Right pedal pulse: Absent . Skin: Skin warm & dry, skin color WNL, and turgor is normal . There was no documented evidence that the resident's medical provider was notified that pedal pulses were absent. A review of R159's Progress Notes dated 9/4/2024 revealed Visit Type: Acute . Chief complaint . follow up on medication changes. History of Present Illnesses . patient napping in wheelchair, arouses to verbal stimuli . continued pitting edema of BLE . staff deny any current concerns or complaints . Positive: pitting, edema in lower left extremities, edema in lower right extremities . Lasix 40 mg tablet: Administer 1 tablet PO Q Day [every day] for edema. The evaluation was completed by LPN1. A review of the EMR revealed no documentation that the medical provider was made aware of the lack of pedal pulses identified on 8/31/2024 and 9/3/2024. A review of R159's Encounter Note dated 9/7/2024 revealed, Telehealth-Asynchronous . Nurse reports resident has a fluid-filled blister on the back of the left calf. She has a history of cellulitis. Denies redness and swelling of the left calf. However, the family is requesting the resident be transferred to the ED [Emergency Department]. Request denied. Resident asymptomatic. Vital signs are stable. Augmentin 875 mg every 12 hours for seven days, ordered, and wound culture. Follow up with wound care and rounding provider. A review of R159's Telehealth Notes dated 9/7/2024 revealed Situation: bilateral edema to lower extremities and left leg weeping. C/O [complaints of] pain. The nurse was notified the patient was moaning really loudly. - Treatment: Tylenol 325 MG two tablets PO [by mouth] BID [twice a day] PRN [as needed] for pain x [times] five days. Keep the left leg clean and dry. Will schedule rounding provider. A review of R159's N Adv - Skin Only Evaluation dated 9/7/2024 revealed . Skin Issue: #001: New. Issue type: Open lesion . Location: left lower leg . Painful: Yes - constant pain. #002: New. Issue type: Open lesion . Location: Left foot . Painful: Yes - constant pain. Skin note: +4 [plus 4] edema with two closed blisters to the left lower leg, and one opened blister to the left foot. Review of the EMR revealed no documented evidence that the medical provider was made aware of the increase in edema from 2-3+ bilaterally on 8/28/2024 to 4+ to the left lower leg on 9/7/2024 despite the Lasix being increased to 40mg every day on 9/4/2024. A review of R159's Nurses Note dated 9/7/2024 revealed CNA made this writer aware that the resident has swelling to BLLE. Resident assessed: Right leg +2 edema, left leg +4 edema with blisters and weeping noted. Resident c/o pain to LLE. PRN medication administered. Resident being treated for edema as of 9/5/2024 with Lasix. A review of R159's Nurses Note dated 9/7/2024 revealed [Nurse Practitioner (NP) 2], notified. N/o [new order] PRN Tylenol 650 MG PRN BID for pain. And cleanse LLE with NNS [normal saline], pat dry, cover with ABD [abdominal], and wrap loosely QD [every day]. A review of R159's N Adv Skilled Evaluation dated 9/7/2024 revealed . Cardiovascular: Circulation check: Extremities are warm and pink. Capillary refill: Sluggish, less than 3 seconds. Edema Issue #001: No change. Location: Left Lower leg. +2 pitting. New onset edema: No, Edema is not dependent on positioning. #002: NO change. Location: left foot . Calf tenderness is not present. Negative bilaterally for Homan's sign. Left pedal pulse: +2 normal. Right pedal pulse: +2 normal . Skin note: has a skin irritation on top of left foot, blister to back of the left calf . A review of R159's Infection Note dated 9/7/2024 revealed culture taken from top of left foot wound, serous drainage noted. A review of R159's N Adv Skilled Evaluation dated 9/8/2024 revealed .Cardiovascular check: extremities are warm and pink . Edema issue #001: no change. Location: left lower leg. +2 pitting . #002: no change. Location: left foot . Calf tenderness is not present. Negative bilaterally for Homan's sign. Left pedal pulse: +2 normal. Right pedal pulse: +2 normal . A review of R159's Progress Note dated 9/9/2024 revealed R159 had discolored areas to the digits of the right lower extremity (RLE), and pulses were not palpable due to edema. The note also indicated that an ankle brachial index (ABI) was ordered. R159's Progress Notes dated 9/9/2024, revealed . patient is noted to be moving RLE, edema to BLE has improved. Weeping edema to the left lower extremity noted. The patient started on antibiotics over the weekend by an on-call provider for concerns of cellulitis. Discolored areas to RLE, pulses not palpable due to edema. Order ABI [ankle brachial index test compares blood pressures in the upper and lower limbs to diagnose and assess the severity of peripheral artery disease (PAD). A review of R159's Encounter dated 9/10/2024, revealed . was seen and examined for a leg condition that apparently evolved over the course of 24 hours. Nursing had reported a rash over her lower extremities, and she was being treated with antibiotics for cellulitis. Discussed patient's condition with her family on Monday, 9/9/2024. Family had some grievances regarding care . Ext RLE, LLE a few black areas on toes, and lateral/medial aspect of both feet, DP pulses unpalpable B/L . Imaging: Doppler result c/w arterial occlusion bilaterally . in view of patients chronic debility, h/o [history of] sepsis, gangrene on both extremities, and rapid decline, it was decided to send her to the ED immediately. Family was informed accordingly and expressed agreement. During an interview on 3/27/2025 at 12:36 pm, the Director of Nursing (DON) stated she expected the nurses to notify the physician anytime there was a change in a resident's condition. The DON also stated there were agency nurses working in the facility, and they received the same training as the full-time nurses, which included change of condition notification and documentation of a change in condition on the Situation Background Assessment Recommendation (SBAR) communication form in the EMR. During an interview on 3/26/2025 at 1:28 pm, Family Member (F) 159, when she visited R159 on 9/7/2024, she notified the nursing staff that R159 had a blister on the back of her calf. F159 also stated she requested that R159 be sent out to the hospital because nursing staff were not aware of the blister on the back of the resident's calf, and so the resident could be treated for cellulitis because she knew it could lead to gangrene. F159 stated R159 was sent to the hospital on 9/10/2024 around 1:30 pm after she had an occlusion in her legs and was pronounced dead at 9:13 pm. F159 indicated the death certificate noted the cause of death was from acute hypoxic respiratory failure due to sepsis, acute renal failure, tubular necrosis, septic shock, and atherosclerosis of the native arteries of the extremities of gangrene. During an interview on 3/27/2025 at 8:42 am, NP1 stated that when R159's pedal pulses were absent on 08/31/24, the nurses should have informed the on-call provider and sent the R159 to the hospital since there was no in-house laboratory or imaging at the facility. NP1 stated she was not working at the facility at the time but confirmed that not notifying the provider timely could have led to the residents' demise from not getting enough oxygen to the brain and circulation to the feet due to the occlusion in the lower extremities. During an interview on 3/27/2025 at 11:01 am, NP2 confirmed nursing staff notified her on 09/07/24 that R159 had drainage to the top of the foot, so she ordered an antibiotic to prevent infection. NP2 also stated that had she been notified on 8/31/2024 that R159 did not have palpable pedal pulses, she would have requested a more thorough assessment of the resident. NP2 further stated she would have ordered the resident to be the hospital for more aggressive treatment of the resident's condition to prevent the condition from worsening. The NP did not explain why she did not ask the nurse any other questions about the resident's foot. During an interview on 3/27/2025 at 1:47 pm, the incoming Medical Director stated it was his expectation the nursing staff would have informed the provider on 8/31/2024 and 9/3/2024 of R159's change in condition when the resident was without pedal pulses so that a more thorough assessment could have been conducted, or so the resident could have been sent to the hospital for treatment. During an interview on 3/28/2025 at 10:37 am, the outgoing Medical Director stated it was his expectation that NP3 would have honored the family's request to send R159 to the hospital. The continuing interview revealed as the facility's Medical Director, he was responsible for the residents' care in the facility; however, he needed the nursing staff to communicate changes in conditions to him. An interview was attempted with NP3 on 3/27/2025 at 10:52 am, 11:25 am, and 11:30 am, however, a message could not be left to return the phone call. An interview was attempted with LPN1 on 3/25/2025 at 3:11 pm, 3:15 pm, and 3:30 pm. Voicemail messages were left, however, LPN1 did not return the phone calls. 2. A review of R9's admission Record revealed he was admitted to the facility on [DATE] and had a hospital stay from 5/16/2024 to 5/23/2024. He had diagnoses which included diabetes and Alzheimer's disease on admission. A review of R9's quarterly MDS with an ARD of 5/9/2024 revealed R9 had a BIMS score of six out of 15, which indicated severe cognitive impairment. It failed to document any diabetic foot ulcer or treatment. A review of R9's Order Recap Report dated 4/12/2024 to 5/16/2024 revealed an order dated 4/15/2024 for betadine to the right lateral foot from 4/15/2024 to 4/22/2024, when another order was entered for betadine daily to the right lateral foot, which continued until R9 was hospitalized on [DATE]. A review of a Skin/Wound Note dated 4/18/2024 at 2:34 pm revealed R9 was seen for wound care management of a diabetic ulcer to his right lateral foot. Betadine was ordered for the treatment of the area. A review of an Evaluation and Management Report with date of service 4/18/2024 revealed a note written by a contracted wound Nurse Practitioner, NP5. NP5 documented the right foot wound as a diabetic ulcer, which measured 4 centimeters (cm) x 4.5cm x 0.2cm. The wound was 100% necrotic (dead) tissue. This was the first description of the wound since Betadine was ordered as the treatment on 4/15/2024. Further review of the EMR revealed Wound Progress Notes with dates of service by the wound Nurse Practitioner of 4/25/2024, 5/2/2024, and 5/9/2024. Measurements of the diabetic ulcer were: On 4/25/2024 4cm x 4.5cm x 0.2cm of black, necrotic tissue and mild serous drainage On 5/2/2024 3.8cm x 4.1cm x 0.2cm of dermis tissue and no drainage On 5/9/2024 3.8cm x 4.1cm x 0.2cm of black necrotic tissue with no drainage. A review of a Nurse's Note dated 5/15/2024 at 11:08 revealed that during wound care for the diabetic ulcer, LPN2 observed that the side of R9's right foot and right pinky toe were black and bruised. R9 denied pain and was unaware of how the bruising occurred. R9 was educated to keep the foot elevated and to stay off the foot as much as possible. Writer will notify Wound Care [Doctor] in AM [morning] of observations. UM [Unit Manager] and Nurse made aware of findings. A review of a Nurse's Note dated 5/16/2024 at 12:38 pm revealed R9 was seen by NP5. R9's had discoloration on his right foot and pinky toe with slight bleeding. An arterial and venous Doppler was completed on the right foot. A review of a Wound Progress Note dated 5/16/2024 and located in the Misc tab of the EMR revealed his diabetic ulcer had increased in size to 13cm x 10cm x 0.2cm. It had 40% necrotic tissue, was 60% was deep tissue injury (DTI). An arterial and venous Doppler was ordered, and the primary nurse practitioner (NP4) was notified. A review of a Progress Note by NP4 with date of service 5/16/2024 revealed NP4 was unable to palpate a pedal (top of foot), posterior tibial (behind the ankle bone), or popliteal (behind the knee) pulse in the right lower extremity. The right lateral foot had a black eschar, had slightly malodorous drainage, and underneath the foot felt boggy. NP4 notified R9's representative, Family Member (F)9, by phone, that the foot was suspected to be gangrene. NP4 recommended immediate transfer to the ER for further evaluation. A review of R9's hospital records for 5/16/2024 to 5/23/2024 revealed R9 had an incision and drainage (I&D) completed on 5/17/2024, which showed the wounds tracked to the bone in all areas with significant tissue loss of the right foot. On 5/20/2024, a right below-the-knee amputation was completed. R9 was diagnosed with gangrene of the right foot and necrotizing cellulitis. A review of a facility provided statement by LPN2 dated 5/21/2024 revealed she saw R9 on 5/15/2024 and noticed his toe was discolored and the diabetic ulcer site to the right of his foot increased in size, measuring 13cm x 10cm x 0.2cm. LPN2 notified the unit manager and charge nurse but did not notify a practitioner until she rounded with NP5 on 5/16/2024 of the increase in size and spreading of discoloration to the right foot. During an observation on 3/25/2025 at 1:10 pm, R9 sat on the edge of his bed eating lunch. His right leg was amputated below the knee. R9 was unable to answer questions related to his leg or foot wound. During an interview on 3/26/2025 at 2:00 pm, F9, listed as R9's responsible party in his EMR, reported that her first knowledge of the foot wound was when she received the phone call that he was going out to the ER on [DATE]. F9 had no idea how long he had had the wound and was not involved in his care for it before 5/16/2024. During an interview on 3/27/2025 at 12:42 pm, the DON stated LPN2 should have completed an SBAR form and then called the doctor on 5/15/2024 when the change in condition occurred. The DON expected the family to be notified immediately of any wound or change in a wound.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the interviews, record review, and a review of the facility's policies titled Abuse Prevention Policy, Pressure Ulcer Treatment, and Prevention of Pressure Ulcers, the facility failed to ensure residents were free from abuse and neglect for three of six residents (R) (R159, R9, and R360) reviewed for abuse and neglect. (1) The facility neglected to emergently transfer R159 to the hospital per the family's request and failed to notify R159's physician after a change in condition, which resulted in a delay in treatment. (2) The facility failed to notify R9's wound treatment provider of the worsening of the resident's diabetic ulcer. (3) R360 was physically abused by her roommate (R46), who had a history of abusing other residents. These failures caused actual harm and death to the residents. On [DATE], R159 was emergently transferred to the hospital, where she expired from complications related to the facility's failure to notify the resident's physician of her change in condition. On [DATE], the facility failed to report the worsening of R9's diabetic ulcer, and on [DATE], the resident sustained a below-the-knee amputation. On [DATE], R360 was a victim of abuse when R46 had wrapped a call light cord around R360's neck and then tied the call light cord to the bedrail. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Regional Director of Clinical Operations (RDCO) were informed of the Immediate Jeopardy (IJ) for F580, F600, F658, F686, and F835 on [DATE] at 6:27 pm. The facility was unable to provide an acceptable IJ Removal Plan before the survey team's exit on [DATE], and the IJ remained ongoing. Findings included: A review of the facility's policy titled Abuse Prevention Policy, reviewed [DATE], revealed, It is the responsibility of all staff to provide a safe environment for the residents. Resident care and treatments shall be monitored by all staff on an ongoing basis so that residents are free from abuse, neglect, or mistreatment. Care will be monitored so that the resident's care plan is followed. Examples of ways to protect a resident from harm during an investigation of abuse, neglect and exploitation may include but are not limited to: a) Temporary (less than 24 hours) separation from other residents if a resident's behavior poses a threat of abuse or violence b) Temporary or permanent room or roommate change, where incompatibility creates the potential for abuse (follow change of room or roommate procedures) c) Safeguard valuables in a locked area (provide receipts to resident) d) involve family members to sit with resident e) Temporary one on one supervision of a resident f) Engage a resident in diversionary activities g) Reassignment of nursing staff duties h) Time off for nursing staff i) involve clergy, social services and counselors, as appropriate . A review of the facility's Pressure Ulcer Treatment policy dated [DATE] revealed that the staff, Measure wound weekly, to include a. Current measurements of the wound(s); b. Current visual stage(s) of the wound(s); c. Any drainage, odor, progress, or decline of wound(s). All pressure ulcers and other wounds should be listed weekly in the medical record. A review of the facility's Prevention of Pressure Ulcers policy dated [DATE] revealed that Any residents with wounds will be documented on the Weekly Wound Information Sheet. Weekly documentation should include: 1. Current measurements of the wound; 2. Current visual stage of the wound(s); 3. Any drainage, odor, progress, or decline of the wound; 4. Current treatment regimen: 5. Pain; 6. Wound bed; 7. Description of wound and surrounding tissue. 1. A review of the electronic medical record (EMR) revealed that R159 was admitted to the facility on [DATE] with diagnoses including angioneurotic edema, diastolic congestive heart failure (CHF), deep vein thrombosis (DVT), hypercholesterolemia, and type 2 diabetes without complications. A review of R159's Progress Note dated [DATE] revealed R159 had pitting edema to the bilateral lower extremities (BLE) and a bruised area to the left foot. A review of R159's N [Nursing] Adv [Advanced] Skilled Evaluation dated [DATE] and [DATE] revealed R159 did not have palpable pedal pulses. A continued review of the evaluation revealed that there was no documented evidence of nursing intervention or that R159's physician was notified. The evaluation was completed by Licensed Practical Nurse (LPN) 1. A review of R159's Encounter Note dated [DATE] revealed the nurse reported R159 had a fluid-filled blister on the back of her left calf. R159's family requested R159 be transferred to the ED (emergency department) for treatment, which was denied by Nurse Practitioner (NP) 3. A review of R159's Progress Note dated [DATE] revealed R159 had discolored areas to the digits of the right lower extremity (RLE), and pedal pulses were not palpable due to edema. The note also indicated that an ankle brachial index (ABI) was ordered. However, there was no documented evidence that the resident's medical provider was notified that the resident was without pedal pulses. A review of R159's Encounter note dated [DATE] revealed that a few black areas were on the toes, and the lateral/medial aspect of both feet, pulses were unpalpable, and the Doppler imaging results were consistent with arterial occlusion bilaterally. The outgoing Medical Director was notified, and R159 was emergently transferred to the hospital. During an interview on [DATE] at 6:43 pm, the RDCO stated the facility's policy was to try to provide treatment to residents, but ultimately, the family decided to send the resident to the hospital. The RDCO also stated that NP3 should have sent R159 to the hospital as requested on [DATE]. During an interview on [DATE] at 12:36 pm, the Director of Nursing (DON) stated she expected the nurses to notify the physician when there was a change in the resident's condition to prevent the worsening of R159's skin condition. During an interview on [DATE] at 1:28 pm, F159 stated that on [DATE], she notified the nursing staff that R159 had a blister on the back of her calf. F159 indicated she asked the nursing staff and NP3 to send the R159 to the hospital because the nursing staff was not aware of the blister and was not receiving any treatment for the blister, but NP3 denied the request because she stated the resident could be taken care of at the facility. During an interview on [DATE] at 8:42 am, NP1 stated she expected the nursing staff to inform her when residents had a change in condition. NP1 also stated that when R159's pedal pulses were absent on [DATE], the nurses should have informed the on-call provider and sent the R159 to the hospital since there wasn't an in-house laboratory or imaging at the facility. During an interview on [DATE] at 11:01 am, NP2 confirmed nursing staff notified her on [DATE] that R159 had drainage to the top of the foot; however, the nursing staff did not report any other changes, which indicated worsening of the resident's foot. NP2 also stated that she would have requested a more thorough assessment of the resident and then sent her to the hospital for more aggressive treatment of the resident if she had been notified that R159 did not have palpable pedal pulses on [DATE] and [DATE]. During an interview on [DATE] at 1:47 pm, the incoming Medical Director stated he expected the nursing staff to be a medical provider on [DATE] when R159 had a change in condition when she was without pedal pulses. The incoming Medical Director also stated that the resident should have been sent to the hospital, where aggressive treatment could have been provided to prevent sepsis and gangrene of the resident's foot. During an interview on [DATE] at 10:37 am, the outgoing Medical Director stated he expected NP3 to honor the family's request to send R159 to the hospital. The Medical Director explained that he was responsible for residents' care in the facility, but to do that, he needed the nursing staff to communicate with him when residents had changes in their conditions. 2. A review of R9's EMR revealed he was admitted to the facility on [DATE] and had a hospital stay from [DATE] to [DATE]. He had diagnoses which included diabetes and Alzheimer's disease on admission. A review of R9's Order Recap Report dated [DATE] to [DATE] revealed an order dated [DATE] for betadine to the right lateral foot from [DATE] to [DATE], when another order was entered for betadine daily to the right lateral foot, which continued until R9 was hospitalized on [DATE]. The order dated [DATE] was written by a nurse and signed by the resident's physician. A review of an undated statement written by LPN 11 revealed that she was notified on [DATE] that R9 had a wound on the right lateral side of his foot. It was approximately three to four inches in length. It had hard eschar, black in color and dry. It was pink around the outside of the area. I cleaned it with normal saline, patted it dry, and painted it with betadine per facility protocol, and it was left open to air. He had pedal pulses, it was not hot to the touch. Arrangements that the wound care provider (NP5) to see the resident the next day. Cross Reference: F580 Notification. A review of a Skin/Wound Note dated [DATE] revealed R9 was seen for wound care management of a diabetic ulcer to his right lateral foot. Betadine was ordered for the treatment of the area. This was the first note written related to the wound being seen and assessed by a medical provider, three days after the wound was identified by nursing. A review of an Evaluation and Management Report with date of service [DATE] revealed R9 was seen by a contracted wound Nurse Practitioner, NP5. NP5 documented the right foot wound as a diabetic ulcer, which measured 4 centimeters (cm) x 4.5cm x 0.2cm. The wound was 100% necrotic tissue. Further review of the Misc tab revealed Wound Progress Notes with the following dates of service: * [DATE] Measurements of the diabetic ulcer were 4cm x 4.5cm x 0.2cm of black, necrotic tissue and mild serous drainage. * [DATE] measurements were 3.8cm x 4.1cm x 0.2cm of dermis tissue and no drainage. * [DATE] measurements were 3.8cm x 4.1cm x 0.2cm of black necrotic tissue with no drainage. In all three reports, the NP5 documented that R9's heels were not floated, nor were the heel suspension boots used, and for the facility to: Monitor patient for any clinical signs and symptoms of infection or any further skin breakdown. Notify myself or the PCP [primary care provider] of any changes. Make sure the patient is being turned and repositioned frequently to help with wound healing and to help prevent any further skin breakdown. On [DATE], NP5 added that he Educated treatment staff to use heel boots to relieve pressure to the heels and will aid in wound healing. This can also relieve pain from constant pressure. On [DATE], NP5 also instructed the resident not to apply any pressure to the wound area as this may cause further skin breakdown. A review of the Orders, Progress Notes, Care Plan, and Tasks tabs of the EMR revealed no order or documentation that heel boots or turning and repositioning were implemented. A review of R9's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of [DATE] revealed R9 had a Brief Interview of Mental Status (BIMS) score of six out of 15, which indicated severe cognitive impairment. It failed to document any diabetic foot ulcer or treatment. R9 needed partial/moderate assistance to roll and substantial/maximal assistance to transfer. A review of a Physician's Progress Note dated [DATE] revealed the physician saw R9 after staff reported he was not eating, was withdrawn, and was refusing medications. R9 stated he was not sick. Staff were directed to check labs if symptoms persisted, monitor closely, and provide wound care. The note did not document the observation of the wound by the physician. A review of a Nurse's Note dated [DATE] at 6:13 pm revealed the physician had been notified that R9 refused most of his meals over the weekend, refused his blood sugar check that morning, as well as his scheduled medications and insulin. The note further documented that the resident spent a lot of his day in bed, covered with a sheet; that he covers his head with a sheet; noted a jerking movement, and had a strange affect; and altered mental issues. There was no mention of the wound on R9's foot in this progress note. A review of a Nurse's Note dated [DATE] at 11:08 am revealed that during wound care for the diabetic ulcer, LPN2 observed that the side of R9's right foot and right pinky toe were black and bruised. R9 denied pain and was unaware of how the bruising occurred. R9 was educated to keep the foot elevated and to stay off the foot as much as possible. Writer will notify Wound Care [Doctor] in [morning] of observations. UM [Unit Manager] and Nurse made aware of findings. The note did not give wound measurements or a description/assessment to include any drainage, or if pedal pulses were palpable. Cross Reference: F580 Notification. A review of a Nurse's Note dated [DATE] at 12:38 pm revealed R9 was seen by NP5. R9's had discoloration on his right foot and pinky toe with slight bleeding. An arterial and venous Doppler was completed on the right foot. The Doppler results were not available prior to the resident being transferred to the hospital. A review of a Wound Progress Note dated [DATE] revealed his diabetic ulcer had increased in size to 13cm x 10cm x 0.2cm. It had 40% necrotic tissue, was 60% was deep tissue injury (DTI). An arterial and venous Doppler was ordered, and the primary nurse practitioner (NP4) was notified. A review of a Dietary Note on [DATE] at 1:01 pm revealed the Registered Dietitian noted a significant weight loss for one and six months. No pressure sores notes. No changes. There was no indication that the dietitian was made aware of the wound, and no supplements for wound healing were ordered. A call was made to the dietitian for an interview, with no response. A review of a Progress Note by NP4 with date of service [DATE] revealed NP4 was unable to palpate a pedal (top of foot), posterior tibial (behind ankle bone), or popliteal (behind the knee) pulse in the right lower extremity. The right lateral foot had a black eschar, had slightly malodorous drainage, and underneath the foot felt boggy. NP4 notified R9's representative, Family Member (F)9, by phone that the foot was suspected to be gangrene. NP4 recommended immediate transfer to the ER (emergency room) for further evaluation. A review of R9's hospital records for [DATE] to [DATE] revealed R9 had an incision and drainage (I&D) completed on [DATE], which showed the wounds tracked to the bone in all areas with significant tissue loss of the right foot. On [DATE], a right below-the-knee amputation was completed. R9 was diagnosed with gangrene of the right foot and necrotizing cellulitis. A review of R9's Care Plan revealed that a focus area was not added to R9's Care Plan for the diabetic ulcer until [DATE], after R9 was discharged to the hospital with gangrene. Interventions dated [DATE] included seeing a wound provider and monitoring/documenting the wound weekly, as well as ensuring appropriate protective devices are applied to affected areas and reporting symptoms of infection. It did not include avoiding pressure to the wound area, turning and positioning frequently, or using heel boots. No pressure-relieving interventions were implemented, even though recommended by the wound NP5. The area was resolved on [DATE] when R9 returned from the hospital with a right below-the-knee amputation. A review of a facility provided statement by LPN2 dated [DATE] revealed she saw R9 on [DATE] and noticed his toe was discolored and the diabetic ulcer site to the right of his foot increased in size, measuring 13cm x 10cm x 0.2cm. LPN2 notified the unit manager and charge nurse. On [DATE], LPN2 rounded with NP5 and informed him of the increase in size and spreading of discoloration to the right foot. Measurement was 13cm x 10cm x 0.2cm. NP5 ordered an arterial and venous Doppler of the right leg. During an observation on [DATE] at 1:10 pm, R9 sat on the edge of his bed eating lunch. His right leg was amputated below the knee. R9 was unable to answer questions related to his leg or foot wound. During an interview on [DATE] at 9:40 am, the Assistant DON stated the wound care provider made general recommendations when he rounded, such as floating heels, heel booties, turning every two hours, and applying an air mattress, and the facility followed them. The recommendations made for R9 were expected to be in his Care Plan. Assistant DON transcribed the measurements of R9's wound from NP5 to the Initial and Weekly Skin Assessments but did not recall that she visualized or assessed the wound. During an interview on [DATE] at 12:42 pm, the DON expected interventions to be in place, ordered, and care-planned to prevent further breakdown. The physician was unavailable for interview during the survey despite attempts to reach him via telephone. 3. A review of R46's EMR revealed R46 was admitted to the facility on [DATE] with multiple diagnoses of Alzheimer's Disease, dementia with behavioral disturbances, major depressive disorder, and generalized anxiety disorder. A review of R46's quarterly MDS assessment with an ARD of [DATE] revealed R46 had a BIMS score of 14 out of 15, which indicated she was cognitively intact. A review of R46's quarterly MDS with an ARD of [DATE] revealed the facility assessed that R46 had a BIMS score of four, which indicated she was severely cognitively impaired. A review of R46's comprehensive Care Plan dated [DATE] revealed a focus area for Risk for Harm: Self-directed or other directed with interventions of if resident poses a potential threat to injure self or others, notify provider and if safe allow resident personal space. A review of R46's comprehensive Care Plan dated [DATE] revealed a focus area for history of exhibiting manipulative behaviors and making false accusations toward staff, other residents, and family members . with interventions of [DATE] educate the resident and family/caregivers on successful coping and interaction strategies. The resident needs encouragement and active support to assist in developing more appropriate methods of coping and interacting. Encourage me to express feelings appropriately. Document behaviors and residents' responses to interventions. followed by Care Now services. A review of R46's Behavior Note dated [DATE] revealed Resident noted to be hiding roommates' call bell from resident and not allowing roommate to have lights on per roommate request. A review of R46's Nurses Note dated [DATE] revealed that R46 continued to track down her roommate's whereabouts and continued with her verbal abuse anytime staff were in the room to provide care for her roommate. She continued to put her roommate in a wheelchair every time her roommate wanted to go to the restroom and wheeled her to the toilet without requesting assistance from staff. She would come to the common area and demand that her roommate be taken back to her room, stating that she needs the resident in the room with her. She was upset that her roommate was taken for a shower or to eat in the dining room. It was documented that it is a toxic obsession that will cause harm to (the) roommate and will not allow (the) roommate to thrive in (a) social setting. At about 12:20 she came to common area and we thought she was ready for her shower, [sic] I went and to start wheeling her to shower and she swapped me with her hands and then at yelled for me to not hit her. I advised management to pull up cameras and ask all the CNAs and a resident that was right by her. The situation with this resident is completely out of control and is ramping up on a daily. A review of R46's Psychosocial/Social Service Note dated [DATE] revealed R46's roommate was offered a room change by multiple staff members and adamantly declines/refuses room change. A review of R46's Psychosocial/Social Service Note dated [DATE] revealed [behavioral health provider] notified of resident's behaviors. Med review to be conducted. A review of R46's admission Note dated [DATE] revealed Resident will be receiving a new roommate on [DATE]. Resident was notified in person on [DATE] and was in acceptance of new roommate. Resident's R/P was notified via telephone on [DATE] and was in acceptance of new roommate. A review of R46's Behavior Note dated [DATE] revealed Resident is exhibiting behaviors toward roommate that is making roommate tearful. Staff spoke with the resident to be mindful of the co-living situation and to respect the privacy of the roommate while staff are giving personal care. The resident has been observed pulling back the privacy curtain while staff is speaking with the roommate. Resident states, If she needs help, I just help her. Staff informed the resident that we are here to care for her and her roommate, but if her roommate needs help, she can help her by pushing her call light. Resident verbalized understanding. A review of R46's admission Note dated [DATE] revealed Resident will receive a new roommate on [DATE]. Resident was notified in person on [DATE] and was in acceptance of new roommate. Resident's R/P [Resident Representative] was notified via telephone, was unable to reach but VM [voicemail] was left notifying her that her mother was getting a new roommate and to contact me with any questions or concerns, if any. A review of R46's Nurses Note dated [DATE] revealed Resident noted to be standing over roommate. Resident noted to be verbally antagonizing roommate telling her 'you can't stay in here. You are going to have to go.' Nurse asked resident if R46 was bothering her and resident states 'yes she is. I'm just not feeling well and I don't want to talk to anyone right now.' Nurse advised R46 that her roommate did not wish to talk to her. R46 states this was my room first and you can't tell me what to do. Resident continued to be verbally aggressive towards staff and roommate while she was receiving her medications. Resident behaviors are reported to the proper administration. A review of R46's Patient At Risk Progress Note dated [DATE] revealed ([DATE]) Resident was observed standing over roommate after roommate verbalized that 'she did not want to talk to anyone right now.' ([DATE]) Staff observed the resident harassing the previous roommate and not letting her leave the room until she agreed to move back into her room. Action: IDT [Interdisciplinary Team] to discuss R46 behaviors toward other residents. The resident was reeducated on co-living situations, informed of other residents' right to privacy, and to make their own decisions. Response: Resident verbalized understanding of the privacy of others and co co-living situation. Staff will continue to redirect residents as needed and monitor/report any behaviors. A review of R46's admission Note dated [DATE] revealed Resident will receive a new roommate on [DATE]. Resident was notified in person of new roommate on [DATE], and the resident's R/P was notified via telephone on [DATE] and was in acceptance of the new roommate. A review of R46's Psychosocial/Social Service Note dated [DATE] revealed New admit into R46's room today. R46 stated that she was unhappy with the roommate and 'this was her room. SSD [social services director] explained the co-living situation with the resident and that she would have to move rooms if she was unhappy. R46 declined . A review of R46's Behavior Note dated [DATE] revealed R46 received a new roommate on [DATE]. The new roommate's granddaughter states that her grandmother told her she was very uncomfortable in the room because R46 would not stop touching her and kept turning the volume off on her phone. The granddaughter states that when she came to see the resident, R46 would not let them in the room and then began slamming her drawers shut and turning the TV volume up. She states that she then saw her grab her grandmother's phone and turn the volume off. Staff had a conversation with R46, and she denied touching her or her phone. The SSD informed the resident of their right to privacy and the co-living situation. She asked if the new roommate could move out and the rates for a private room. The Admissions Director was notified of interest in the private room. A review of R46's Psychosocial/Social Service Note dated [DATE] revealed SSD discussed with daughter resident's continuous behaviors. Daughter was informed of R46 making false accusations toward staff and exhibiting verbal behaviors toward previous and new roommates. Daughter states that she has always been controlling and manipulative. A review of R46's Nurses Note dated [DATE] revealed Resident returned from hospital via ambulance. No s\s [signs and symptoms] of distress or discomfort noted. The resident was transferred to the hospital related to behaviors. A review of R46's Psychosocial/Social Service Note dated [DATE] revealed [Hospital] accepted the referral on [DATE] . The resident was transferred to the hospital related to behaviors. A review of R46's Activities Note dated [DATE] revealed R46 was readmitted to the facility. A review of R46's admission Note dated [DATE] revealed Resident will receive new roommate on [DATE]. Resident was notified in person on ([DATE]) and resident's R/P, was notified via telephone on [DATE] and was in acceptance of new roommate. A review of R46's Behavior Note dated [DATE] revealed Resident is vocally upset with new roommate, stating that she believes clothing has been stolen. New roommate is bedbound. Resident is turning up heat in room and keeping main door closed. Roommate states she feels uncomfortable due to negative comments R46 made she was infringing on her space. A review of R46's Nurses Note dated [DATE] revealed Resident notified of new roommate and in agreement. A review of R360's undated admission Record revealed she was admitted to the facility on [DATE] with diagnoses of chronic respiratory failure, epilepsy, anxiety disorder, and major depressive disorder. A review of R360's quarterly MDS assessment with an ARD of [DATE] revealed she had a BIMS score of 15, indicating she was cognitively intact. A review of R360's Census Note revealed she was moved into the room with R46 on [DATE]. A review of R46's Behavior Note dated [DATE] revealed that the social worker (SW) was called to the resident's room due to a situation that was occurring. The resident was stating that the TV in her room was her personal TV. The note documented that the resident had taken the remote and hid it so the roommate could not watch television; the resident struck the SW and became angry during redirection. The SW then made a phone call to the resident's family, who validated that the TV was not the resident's and attempted to speak to the resident, but the resident was not listening. The resident's behavior has escalated, and the SW documented that she would continue to monitor the resident and follow up with the medical director for further intervention. A review of R46's Physician's Orders dated [DATE] revealed an order for Haldol Injection Solution (Haloperidol Lactate) Inject 2 mg intramuscularly STAT [immediately] for anxiety. There was no nursing note indicating the behavior exhibited for this medication. A review of R46's Nurses Note dated [DATE] revealed CNA7 reported that the call light cord was around her neck. I immediately went into the room, and the cord was lying across her chest. Upon inspection, the neck was normal in color. No redness, pain, bruising, swelling, or indentations of any kind were noted. The resident denied any pain. Resident continued with her normal ADLs [activities of daily living] throughout the day. A review of R46's Nurses Note dated [DATE] revealed that the CNA reported that the call light cord was lying across the resident in bed A. The two roommates exchanged profanities back and forth this (morning). A review of R46's Behavior Note dated [DATE] revealed SW informed by CNA7 of R360 that she removed the call light cord from around her, stating that R46 allegedly placed the cord around her. Profanity was exchanged between both residents. Follow up with MD [physician] to clinically intervene. A review of R46's Psychosocial/Social Service Note dated [DATE] revealed that the SW met with the resident in the room to interview after the CNA stated she had removed the call light cord from the resident's neck in the room. The SW asked the resident to tell her about what happened. The resident stated that (pointing fingers at she did it), referring to the roommate in the room. The SW restated, Are you sure? SW stated to the resident, You guys were getting into it, [360's Name] She stated, But I would not hurt anyone. She further asked, Are you going to do anything about it? SW then left the room and continued to follow through with necessary interventions. A review of R46's Behavior Note dated [DATE] revealed Resident was 1013 [legal form used to initiate involuntary hospitalization for mental health evaluation] by Medical Director. 911 was called and transported to [the hospital] for medical clearance and a second signature for commitment. A review of R46's Hospital Discharge Record dated [DATE] revealed that R46 had no recollection of the incident involving the roommate or past incidents; there were no observed behavioral disturbance while in ER; given level of nursing needs and medical acuity, R46 would not be a safe candidate for a psychiatric facility, and given dementia etiology of behaviors, would likely gain minimal therapeutic benefit; there were no recommended changes to current medications at that time; they strongly encouraged environmental augmentation to assist with behaviors; the family was aware of private room recommendations; no further psychiatric interventions were recommender at that time; R46 was discharged back to the facility. The Record was signed by the Consultation Liaison Psychiatry. A review of a facility document dated [DATE] revealed interviews with LPN10 and the SSD indicated R46 was observed by staff until she was transported to the ER for evaluation. The document also revealed that an interview with CNA7 revealed she entered R360 and R46's room on [DATE] at 8:30 am and observed the call light cord wrapped once loosely around R360's neck, and R360 pointed towards R46 when asked what happened, and then R46 started cursing at R360. During an interview on [DATE] at 2:20 pm, the Administrator confirmed he began employment after the incident occurred, but knew R46 had roommates and did not get along with them in the past, and since then, had been in a p[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and review of the facility's policy titled Change in a Resident's Condition or Status, the facility failed to ensure the nursing staff used their clinical skills and judgement to identify and notify the resident's medical provider of the worsening of skin condition for one of three sampled residents (R) (R159). On [DATE] and [DATE], R159 had a change in condition when pedal pulses were unpalpable; however, nursing staff did not identify this as a change in condition, and the resident's medical provider was not notified. On [DATE], R159 was emergently transferred to the hospital, where she expired hours after arriving at the hospital due to complications from the worsening of her skin condition. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Regional Director of Clinical Operations (RDCO) were informed of the Immediate Jeopardy (IJ) for F580, F600, F658, F686, and F835 on [DATE] at 6:27 pm. The facility was unable to provide an acceptable IJ Removal Plan before the survey team's exit on [DATE], and the IJ remained ongoing. Findings included: A review of the facility's policy titled Change in a Resident's Condition or Status, revised February 2021, revealed policy interpretation and implementation 1. The nurse will notify the resident's attending physician or physician on call when there has been a(an). d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly; g. need to transfer the resident to a hospital/treatment center; i. specific instruction to notify the physician of changes in the resident's condition. 3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form. 5. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. A review of R159's undated admission Record revealed she was admitted on [DATE] with multiple diagnoses, including angioneurotic edema, diastolic congestive heart failure (CHF), deep vein thrombosis (DVT), hypercholesterolemia, and type 2 diabetes without complications. A review of R159's medical provider Progress Note revealed R159 had pitting edema to the bilateral lower extremities (BLE) and a bruised area to the left foot. The Progress Note documented that the nursing staff reported that the edema had been worsening for two to three days prior to the provider's visit and evaluation of R159. A review of the resident's EMR revealed no documented evidence that the resident's medical provider was notified of the worsening edema or the bruising before [DATE]. A review of R159's N [Nursing] Adv [Advanced] Skilled Evaluations, dated [DATE] and [DATE], revealed that Licensed Practical Nurse (LPN) 1 documented that R159 did not have palpable pedal pulses. The evaluation did not reveal any documented evidence of any nursing interventions, including the notification of R159's physician about the worsening of the resident's condition. A review of R159's Encounter Note, dated [DATE], revealed the nurse reported F159 had a fluid-filled blister on the back of her left calf. R159's family requested the resident be transferred to the emergency department (ED) for treatment; however, the request was denied by Nurse Practitioner (NP)3 even though the provider ordered an antibiotic for the treatment of cellulitis. A review of R159's Progress Note dated [DATE] revealed R159 had discolored areas to the digits of the right lower extremity (RLE), and pulses were not palpable due to edema. The note also indicated that an ankle brachial index (ABI) was ordered. A review of R159's medical provider Encounter dated [DATE], revealed was seen and examined for a leg condition that apparently evolved over the course of 24 hours. Nursing had reported a rash over her lower extremities, and she was being treated with antibiotics for cellulitis. Discussed the patient's condition with her family on Monday, [DATE]. Family had some grievances regarding care . a few black areas on toes, and lateral/medial aspect of both feet, DP pulses unpalpable B/L . Imaging: Doppler result c/w [consistent with] arterial occlusion bilaterally . in view of the patient's chronic debility, h/o [history of] sepsis, gangrene on both extremities, and rapid decline, it was decided to send her to the ED immediately. The family was informed accordingly and expressed agreement. During an interview on [DATE] at 12:36 pm, the Director of Nursing (DON) stated nurses who worked at the facility had been educated on changes of conditions, documenting changes in resident conditions, and notifying medical providers of the changes in conditions. The DON stated it was her expectation that the nurses would have identified the resident's change in condition and would have notified the physician when the change in condition was identified. During an interview on [DATE] at 1:28 pm, the Family Member (F)159 stated [DATE], she notified the nursing staff that R159 had a blister on the back of her calf. F159 stated nursing was not aware of the blister, and she requested the resident be sent to the hospital for treatment, in fear that the cellulitis would progress to gangrene. F159 also stated the facility denied the request for the resident to be transferred to the hospital; however, on [DATE], the facility emergently transferred the resident to the hospital at approximately 1:30 pm. F159 further stated it was determined R159 had an occlusion in her leg and was pronounced dead at 9:13 pm, hours after she was transferred to the hospital. During an interview on [DATE] at 8:42 am, Nurse Practitioner (NP)1 stated that had she been notified on [DATE] when R159's pedal pulses were absent, she would have requested the nurse to conduct a further assessment of the resident for circulation in the legs and feet. NP1 indicated the nurses should have informed the on-call provider when the R159's pulses were unpalpable and/or sent the R159 to the hospital for treatment. During an interview on [DATE] at 11:01 am, NP2 confirmed nursing staff notified her on [DATE] that R159 had drainage to the top of the foot, and she ordered an antibiotic to prevent infection. NP2 also stated she was not made aware by nursing of the other worsening conditions, such as the absence of pedal pulses. She stated that had she been made aware of these changes, she would have requested a more thorough assessment of the resident and then sent her to the hospital for aggressive treatment. During an interview on [DATE] at 1:47 pm, the incoming Medical Director stated he expected that the nursing staff would have notified the provider when R159 had a change in condition on [DATE]. The incoming Medical Director also stated that R159 should have been transferred to the hospital for aggressive treatment in the early phase of the resident's medical condition. During an interview on [DATE] at 10:37 am, the outgoing Medical Director explained that he was responsible for the residents' care in the facility, but to do that, he needed the nursing staff to communicate changes in residents' conditions to him. The Medical Director stated he saw R159 on [DATE] and due to her chronic debility, gangrene on both extremities, and rapid decline, it was decided to send her to the ED immediately. Cross Reference F580

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and a review of the facility's policies titled Prevention of Pressure Ulcers and Pressure Ulcer Treatment, the facility failed to ensure that three of three sampled residents (R) (R104, R2, and R307) did not develop facility-acquired pressure ulcers. The facility failed to prevent the development of significant pressure ulcers for two of the three residents reviewed (R104 and R2). The facility failed to provide oversight, ensuring pressure ulcer assessments were completed, and ensure pressure ulcer treatment was provided in a timely manner and per the physician's orders. 1. R104 did not have preventive interventions in place before [DATE], when a pressure ulcer to the sacrum was identified. There were no treatment orders until [DATE] for the sacrum, at which time the wound was to be cleansed, and a honey cover with border dressing was to be applied. R104 was admitted to hospice on [DATE]. There was no assessment of the pressure ulcer on R104's sacrum with a description of the wound and with measurements until [DATE] (23 days after it was first noted). The first assessment of the sacrum pressure ulcer revealed it was unstageable due to necrosis and was 3 centimeters (cm) by (x) 1.2 cm x 0.2 cm, and R104 was also noted with a left heel unstageable pressure ulcer 2.2 x 1.8 in size at this time. On [DATE], the sacrum pressure ulcer was assessed by the wound care provider to be a stage 4, 3 cm x 3 cm x .02 cm depth. The left heel pressure ulcer was 2.2 cm x 2.8 cm. A review of the quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of [DATE] did not document pressure-reducing devices being in effect. The Wound Care Provider continued to treat R104's sacrum and left heel wounds on [DATE] and [DATE]. Then there was a 21-day gap between [DATE] through[DATE] when there was no assessment or measurements taken of the pressure ulcers by either the Wound Care Provider or facility nursing staff. On [DATE], the sacrum wound (which combined with a laceration) was 7.4 cm x 7.5 cm, by 2.2 cm, with 4.3 cm of undermining, and the deep tissue injury (DTI) of the left heel was 0.7 x 0.4 cm. The last Wound Care Provider note on [DATE] revealed the sacrum pressure ulcer had further deteriorated and was 7 cm x 16.2 cm x 2.2 cm with 6.3 cm of undermining, and the left heel DTI was 0.9 x 0.8 x 0.1 cm. The resident passed away on [DATE]. Although the Wound Care Provider recommended protective boots for the left heel DTI, this was not implemented, and there was no evidence of a specialty pressure relief mattress being provided. R104's pressure ulcer to the sacrum progressed to a stage 4 within the first month and got larger, deeper, and more severe with undermining and infection during her stay. According to R104's Physician, the pressure ulcer likely contributed to her death on [DATE]. 2. R2 developed a new open area on her sacrum on [DATE], and treatment orders were obtained from a wound doctor for medical honey. R2 had a hospital stay from [DATE] to [DATE]. When R2 returned from the hospital, there were no evaluations of the coccyx/sacral wound until [DATE], when the wound was documented as a stage two buttock wound. R2 had no treatment orders from [DATE] until [DATE] when calcium alginate was ordered. A review of R2's Misc tab revealed notes from the physician with the facility-contracted wound company dated [DATE], [DATE], and [DATE] with wound assessments completed to areas other than a sacral/coccyx/buttock wound. There was no documentation of a sacral/coccyx/buttock wound. The assessment completed by the wound doctor on [DATE] for R2 documented an unstageable sacral ulcer measuring 3.5cm x 4.5cm x 0.1cm with 100 percent necrotic tissue. A surgical excisional debridement was completed, and on [DATE], the wound measured 5cm x 5cm x 0.1cm and had 100 percent necrotic tissue. A review of the hospital Discharge Summary, dated [DATE], revealed R2 was hospitalized for an infected sacral decubitus ulcer. Surgical debridement was done, and R2 was discharged on an intravenous (IV) antibiotic. The failures to implement preventive interventions, assess pressure ulcers once identified, provide treatment per the physician's orders, and provide oversight of wound care contributed to R104's death and put R2 at risk of additional infection, worsening of the pressure ulcer, and potentially death. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Regional Director of Clinical Operations (RDCO) were informed of the Immediate Jeopardy (IJ) for F580, F600, F658, F686, and F835 on [DATE] at 6:27 pm. The facility was unable to provide an acceptable IJ Removal Plan before the survey team's exit on [DATE], and the IJ remained ongoing. Findings included: A review of the facility's Prevention of Pressure Ulcers policy, dated [DATE], revealed, The purpose of this procedure is to provide guidelines for residents identified to be at risk. Any residents with wounds will be documented on the Weekly Wound Information Sheet. Weekly documentation should include: (1) Current measurements of the wound (L [length]x [by] W [width] x D [depth]); (2) Current visual stage of the wound(s); (3) Any drainage, odor, progress or decline of wound; current treatment regimen; (5) pain; (6) Wound bed; (7) Description of wound and surrounding tissue . Preventive Protocol . Turn and reposition as needed . Pressure reduction mattress to the resident's bed . Assess dietary and hydration needs. A review of the facility's Pressure Ulcer Treatment policy, dated [DATE], revealed that the purpose of the policy was to provide guidelines for the treatment of pressure ulcers to facilitate healing and to prevent further deterioration. It was recorded, Assess the pressure ulcer(s) for location, size . sinus tracts, undermining, tunneling, exudate/odor, necrotic tissue, peri wound, pain, and the absence of granulation tissue and epithelialization. Determine the ulcer's current stage of development . Stage II - Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed . Stage III - Full thickness tissue loss. Subcutaneous fat may be visible . May include undermining or tunneling . Stage IV full thickness tissue loss with exposed bone, tendon, or muscle. Slough [non-viable yellow, tan, gray, green or brown tissue . may be adherent to the base of the wound or present in clumps] or eschar [dead or devitalized tissue . usually black, brown, or tan in color, and may appear scab-like] may be present on some parts of the wound bed. Often includes undermining and tunneling . Unstageable - Deep Tissue Injury - Purple or maroon area of discolored intact skin due to damage of underlying soft tissue . Use protective pressure-reducing devices as ordered . The following information may be documented in the resident's electronic medical record: If the resident refused the treatment and the reason(s) why . Weekly documentation in the medical record for resident-specific wounds. All pressure ulcers and other wounds will be listed weekly in the medical record. 1. A review of R104's electronic medical record (EMR) revealed R104 was admitted to the facility on [DATE] with diagnoses that included atherosclerotic heart disease, hypertension, and dementia. A review of the significant change MDS assessment with an ARD of [DATE] revealed R104 was intact in cognition with a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating that the resident was cognitively intact; that R104 was always incontinent of bowel and bladder; that R104 was identified with medically complex conditions; and that R104 was coded as not being at risk for pressure ulcers and none were present at this time. A review of R104's Care Plan initiated on [DATE] revealed a problem of I have an ADL [activities of daily living] self-care performance deficit r/t [related to] fatigue, impaired balance. The goal was to improve the level of ADL function. Interventions included explaining all procedures/tasks before starting, one-to-two-person assistance with toileting, transfers, repositioning, and turning in bed, and one-person assistance with personal hygiene. A review of R104's Care Plan initiated on [DATE] revealed R104 had the potential/actual impairment to skin integrity related to fragile skin. The goal was for R104 to have no complications. Interventions included, Encourage good nutrition and hydration to promote healthier skin . Follow facility protocols for treatment of injury . Keep skin clean and dry, use lotion on dry skin. The care plan did not specifically address pressure ulcer risk. A review of the significant change MDS, with an ARD of [DATE], revealed that R104 did not have preventive interventions in place to prevent the development of pressure ulcers before [DATE]. A review of the Nurse's Note dated [DATE] revealed, two small openings to sacrum. NP [Nurse Practitioner] made aware . The writer asked NP to assess the resident's sacrum. A review of the NP's Progress Note dated [DATE] revealed, New breakdown to sacrum noted. No description of the breakdown was documented, or treatment prescribed. The NP indicated discussing the plan of care and hospice with the R104's family. R104 was also noted with dark stool in her brief, and an order was placed for an occult stool test, which was positive. A review of the Nurse's Note dated [DATE] revealed, DON [Director of Nursing] notified writer via telephone that resident was testing positive for blood in her stool. Writer notified [family member]/emergency contact and 911 to have resident sent to hospital for evaluation . Resident left facility around 2010 [8:10 pm] on [DATE]. It was recorded that R104 returned to the facility on [DATE]. A review of the Nurse's Note dated [DATE] revealed, Nurse and NP noted two small open areas to sacrum, area cleansed, and protective dressing applied, to be evaluated by wound care MD [Medical Doctor] on Friday There was no description of the open areas to the sacrum by nursing or the NP. A review of the Medicaid Hospice Election Form dated [DATE] revealed R104 was admitted to hospice on [DATE] with a diagnosis of senile degeneration disease. A review of the Order Summary Report dated [DATE] and the Treatment Administration Record (TAR) for [DATE] revealed there were no treatment orders until [DATE], a total of nine days after the sacral pressure ulcer was first observed. A review of the Order Summary Report revealed an order to cleanse the sacrum wound with cleanser/saline, pat dry, apply honey, and cover with border dressing to be completed every shift (there were two shifts daily from 7:00 am - 7:00 pm and from 7:00 pm to 7:00 am) on Monday, Wednesday, and Friday. This order ran from [DATE] through [DATE]. A review of the Treatment Administration Record (TAR) for [DATE] and [DATE] revealed that the treatment was missing on both shifts on [DATE] and [DATE]. A review of the significant change MDS with an ARD of [DATE] revealed R104 exhibited a cognition decline, presenting with a BIMS score of nine, indicating moderate cognitive impairment. Even though the sacral pressure ulcer was first noted on [DATE], the MDS did not document the presence of any pressure ulcers and indicated R104 was at low risk for developing pressure ulcers. A review of the Order Summary Report dated [DATE] revealed 30 milliliters (ml) of Liquid Protein supplement was prescribed twice a day and was continued until [DATE]. A review of the Care Plan dated [DATE] revealed a care plan was initiated for R104 due to having an actual impairment to skin integrity related to a [DATE]- sacral wound; [DATE]-DTI [deep tissue injury]. The goal was to be free from injury to her skin. New interventions included application of skin prep to the right heel and covered with dressing, added on [DATE]; sacral wound: Medi honey and dressing added on [DATE]. There were no interventions related to turning and repositioning, keeping the sacrum clean and dry, or floating R104's right heel with the advent of the DTI. A review of the Order Summary Report dated [DATE] revealed an order to cleanse the right heel with normal saline/wound cleanser, to pat dry, apply skin prep, cover with abd, and secure with Kerlix one time a day every Monday, Wednesday, and Friday for the right heel wound. This order was discontinued on [DATE]. A review of the TARs dated [DATE], [DATE], and [DATE] revealed that the treatment was not completed (no documentation) numerous times as follows: -[DATE]: The treatment was not completed on any of the four dates it should have been ([DATE], [DATE], [DATE], and [DATE]). -[DATE]: The treatment was not completed on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. -[DATE]: The treatment was not completed on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. A review of the EMR revealed there was no assessment of the pressure ulcer on the sacrum with a description of the wound and with measurements or DTI to the heel until [DATE] (23 days after the pressure ulcer to the sacrum was first noted) at which time the wound care provider was notified and assumed primary oversight of the wound with weekly visits. A review of the Wound Care Physician's Wound Evaluation & Management Summary dated [DATE] revealed this was the first assessment of the sacrum pressure ulcer with a description and measurements. The sacral pressure ulcer was unstageable due to necrosis and was 3 cm x 1.2 cm x 0.2, with light, serious exudate. The sacral pressure ulcer was debrided. R104 was also noted with a left heel unstageable pressure ulcer (2.2 x 1.8 in size). The dressing treatment plan included Leptospermum honey applied three times a week for 24 days; gauze island with bdr applied three times per week for 24 days. In addition, recommendations of limiting sitting to 60 minutes, off-loading the wound, floating heels in bed, and repositioning per facility protocol were made; however, these interventions were not added to the care plan at this time or any time before her death. A review of a Dietary Note dated [DATE] revealed No weight this month due to refusal. Last month was 138 (pounds), which was relatively stable from her wt [weight] history. She receives tx [treatment] for unstageable wounds to her L [left] heel and sacrum. Diet is Regular. Liquid Protein provided at 30 cc BID [twice daily] for 200 kcals [calories] and 30 gm [grams] protein. Her meal intake is 45-70% average. We will continue with the current diet and supplement. Continue to make efforts to obtain weight. FU [follow up]as needed. A review of the Wound Care Physician's Wound Evaluation & Management Summary dated [DATE] revealed the sacrum pressure ulcer had progressed to a stage 4 and was 3 cm x 3 cm x 0.3 cm in depth with light serous exudate. Surgical debridement was conducted on the sacrum, and a single-use PICO dressing (single-use negative pressure wound therapy) was applied. The left heel was an unstageable DTI, 2.2 cm x 2.8 cm, intact with purple/maroon discoloration. Treatment for the heel included skin prep application three times per week for 10 days. Recommendations of limiting sitting to 60 minutes and offloading the wound, floating heels in bed, and repositioning per facility policy continued; these interventions were not care planned. A review of the Order Summary report dated [DATE] revealed an order for Cleanse left buttock wound cleanser/saline pat dry apply honey cover with border dressing every shift (twice a day) every Mon, Tue, Wed, Thu, Fri, Sat, Sun for wound. The order was discontinued on [DATE]. A review of the TAR for [DATE] revealed the treatment was not completed (no documentation) in [DATE] at all on [DATE], [DATE], or [DATE]. A review of the quarterly MDS with an ARD of [DATE] revealed R104's cognition had declined, with a BIMS of nine out of 15 showing moderate cognitive impairment. R104 was coded as having two DTIs (the stage 4 pressure ulcer was not identified), pressure ulcer care was being provided with turning and repositioning; however, no pressure reducing devices or nutritional interventions were coded as being in place. A review of the Wound Care Physician's Wound Evaluation & Management Summary dated [DATE] revealed a pressure ulcer stage 4 to the sacrum with measurements of 2.5 cm x 2 cm x 0.3 cm with light serous exudate, 80% necrotic tissue. The wound was treated with ultrasound mist therapy due to it being a non-healing wound and a lack of improvement in surface area or depth over the past 30 days. The left heel continued to be an unstageable DTI 2.5 cm x 1.8 cm x not measurable, intact with purple/maroon discoloration. A non-pressure wound of the left buttock with etiology of trauma/injury was also documented on the left buttock that was 3.1cm x 5.5 cm x 0.3 cm, noted to have 100% necrotic tissue. Recommendations of floating heels in bed, offloading the wound, and repositioning continued. A review of the Wound Care Physician's Wound Evaluation & Management Summary dated [DATE] revealed a pressure ulcer stage 4 to the sacrum, measurements were 2 cm x 1.6 cm x 0.3 cm with light serous exudate. Surgical debridement was conducted. Treatment and recommendations remain unchanged from the prior assessment, and the wound was identified as improved. The unstageable DTI to the left heel was 1 cm x 0.9 cm x not measurable. It was intact with purple discoloration and was also noted to have improved by having a decreased surface area. A review of the Wound Care Physician's Wound Evaluation & Management Summary dated [DATE] revealed a pressure ulcer stage 4 to the sacrum had combined with the non-pressure wound of the left buttock that was measured to be 6 cm x 7 cm x 2.2 cm, with undermining of 4.3 cm and light serous exudate. Single-use PICO was applied; negative pressure wound therapy was provided, and surgical debridement was completed. The unstageable DTI of the left heel was measured at 1 cm x 0.5 cm x not measurable. The heel was noted to be undergoing autolytic debridement. Evaluation was to continue weekly, or sooner as needed, with further intervention, which would be based on response to current treatment. A review of the EMR revealed that following the Wound Care Physician's visit on [DATE], a three-week (21-day) period elapsed until the Wound Care Physician made his next visit. Neither the facility nursing staff nor the Wound Care Physician assessed R104's pressure ulcers until [DATE]. During the timeframe, the Wound Care Physician and the nursing facility failed to assess the pressure ulcers. The Hospice Physician's Order showed an order dated [DATE], for Pack wound with Dakins damp gauze-calamine cream on edges, change daily. Pre-medicate with Ativan (anti-anxiety medication) and hydrocodone (narcotic pain medication) before care, daily. The order was discontinued on [DATE]. A review of the TARs for [DATE] and [DATE] revealed that the treatment was not completed (no documentation) as follows: -[DATE]: The treatment was not completed on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. -[DATE]: The treatment was not completed on [DATE], [DATE], and [DATE]. A review of a Hospice Nurse's Note dated [DATE] revealed R104 was reported to be sleeping during the day and night, refusing most meals but drinking one to two protein shakes throughout the day. Staff reported to the hospice nurse that R104 refused bed baths and wound care. Ativan was to be given before care. The sacral wound was noted to be significantly worse. The facility no longer has a treatment nurse available. MD contacted, and wound care orders were left with the facility. Patient was premedicated, and HRN [Hospice Registered Nurse] did wound care today. There were no wound measurements or a description of the condition of R104's pressure ulcers. A review of a Hospice Nurse's Note dated [DATE] revealed R104's coccyx dressing was changed and noted Area is approximately 8.0 x 8.0 and down to the bone. Inside the wound is pink with some slough that is yellowish white. The dressing was partially off and saturated with drainage or urine. The odor is foul. The area is cleaned with wound cleanser and packed with gauze soaked with sterile water and med honey gel. Dry 4x4 on top and apply dressing. Patient tolerated well. A review of the Order Summary report dated [DATE] revealed that House Supplement, 120 ml, was prescribed two times a day and continued until [DATE]. A review of the Wound Care Physician's Wound Evaluation & Management Summary dated [DATE] revealed the pressure ulcer stage 4 to the sacrum (which combined with a laceration) was 7.4 cm x 7.5 cm, by 2.2 cm with 4.3 cm of undermining and light serous exudate. Treatment of low-frequency ultrasound was provided, and a fresh bandage was applied. The DTI of the left heel was 0.7 x 0.4 cm. A review of a Hospice Nurse's Note dated [DATE] revealed R104's sacrum dressing was changed by the Hospice Nurse on this date. A review of the Order Summary report dated [DATE] revealed Wound care to sacral wound once a day to include cleaning the wound with wound cleanser or Dakins solution. Wound bed to be coated with Triad cream and contents of charcaps (for odor). Pack with roll gauze, cover with ABD pads, foam dressing, and secure with tape one time a day for Wound care and odor control. The order was discontinued on [DATE]. A review of the TAR for [DATE] revealed the treatment was not completed (no documentation) on [DATE], [DATE], and [DATE]. A review of the last Wound Care Physician's Wound Evaluation & Management Summary dated [DATE] revealed the pressure ulcer stage 4 to the sacrum had further deteriorated and was 7 cm x 16.2 cm x 2.2 cm with 6.3 cm of undermining, and the left heel DTI was 0.9 x 0.8 x 0.1 cm. The resident passed away on [DATE]. During an interview on [DATE] at 8:57 am, NP1 stated R104's pressure ulcer treatment was directed by the Wound Care Physician, who was not the same person who currently provided wound care at the facility. NP1 stated that the Wound Care Physician came in weekly. NP1 stated R104 was also a hospice patient, and she had seen R104 twice during her stay. NP1 stated that the facility nurses were responsible for completing wound care/dressing changes. NP1 stated that the Assistant Director of Nursing (ADON) performed wound care for R104. During an interview on [DATE] at 9:57 am, the ADON/Infection Preventionist (IP)1 stated that in [DATE], there were no nursing Unit Managers. The ADON/IP1 stated that typically, the Unit Manager went with the Wound Care Physician on the weekly skin rounds. The ADON/IP1 stated that before [DATE], when Unit Managers were hired and in place, she documented the weekly nursing wound assessments but did not see R104's pressure ulcers herself. ADON/IP1 stated she obtained the measurements from the Wound Care Physician's documentation. The ADON/IP1 verified that the first nursing documentation of the sacral pressure ulcer was dated [DATE]. The ADONIP1 verified the first pressure ulcer assessment with staging measurements, and a description for R104 was on [DATE]. ADON/IP1 verified a lack of weekly pressure ulcer/wound assessments after [DATE] until wound care was initiated by the Wound Care Physician. The ADON/IP1 stated that the LPNs could not measure wounds and stage them; the doctor staged wounds. The ADON/IP1 stated that the initial and weekly wound form should be completed weekly by nursing from the start of the wounds and should track all of them throughout the course of the wound/s. The ADON/IP1 stated R104 refused care, and it was documented in EMAR notes; however, the EMAR notes did not indicate what was refused, for example, a medication or treatment. The ADON/IP1 verified that the EMAR Notes and Progress Notes did not document that wound care had been refused. The ADON/IP1 stated the EMR showed a lot of medication refusals, but there was a lack of documentation of refusing dressing change on specific dates and times. The ADON/IP1 verified that there were many blanks on the TARs for pressure ulcer treatment, such as dressing changes. The ADON/IP1 stated that a blank meant the nurses did not document providing the treatment, and she could not say if it was a failure to document or a failure to complete the treatment. The ADON/IP1 looked through Progress Notes and stated that on [DATE], a refusal of R104's sacrum dressing change was documented in notes. The ADON/IP1 was unable to find any additional documentation of wound care refusals for specific dates/times. During an interview on [DATE] at 10:57 am, Unit Manager/Infection Preventionist (IP)2 stated she took over at the end of [DATE] as Unit Manager. She stated R104's pressure ulcer to the sacrum advanced, and she went into hospice. Unit Manager/IP2 stated R104's refusals of treatment should have been documented, and there was a code of 2 on the TAR that should have been used. Unit Manager/IP2 stated Hospice could do dressing changes and should verbally alert the nurse if that was the case. Unit Manager/IP2 reviewed the EMR and stated the hospice nurse changed the dressing on [DATE]. She stated that Hospice and the Wound Care Physician should have had communication regarding R104's pressure ulcer care. Unit Manager/IP2 stated there was an EMAR Note dated [DATE] indicating R104's sacral wound was packed; however, this was not documented on the TAR. During an interview on [DATE] at 12:04 pm, Certified Nursing Assistant (CNA)6 stated she worked at the facility with R104 one day in [DATE] and one day in [DATE]. She stated that the first time she was assigned R104, she could smell her odor from the pressure ulcer coming down the hall. CNA6 stated R104 did not want to be changed, but she was able to do it. CNA6 stated that when she turned R104 to her side, there was a hole, golf ball size, deep hole. CNA6 stated it was stuffed with gauze and had not been changed in a while. She stated the gauze was black and falling out. CNA6 stated she was so concerned that she went to find the wound care nurse. CNA6 was told by a different nurse that there was no wound care nurse. CNA6 stated she saw a doctor and asked him to look at the wound, but neither the doctor nor any other nurse came to assess it as she worked with R104 for 12 hours that day. CNA6 stated she came back to the facility a couple of weeks later (approximately [DATE]) and was assigned to R104 and saw the same thing. She stated R104 had not been changed, and her brief was soaked with fluid from the wound, and the wound did not have any packing or a dressing. CNA6 stated R104 was bedridden and was unable to do anything for herself. CNA6 stated R104 allowed her to provide care to her on those two days. CNA6 stated there was nothing in place for R104's left heel, but she elevated her feet with pillows and knew to reposition her every two hours. CNA6 stated R104's sacrum wound was the worst bedsore she had ever seen, and it smelled worse the second time. During an interview on [DATE] at 1:21 pm, the DON stated that pressure ulcer prevention consisted of educating staff on repositioning. She stated preventive interventions were utilized, such as boots to float heels or pillows. The DON stated these interventions should be care-planned. The DON stated there were weekly meetings called PAR in which residents with wounds or at risk were discussed by the care team. The DON stated that a treatment order should have been put into place immediately after R104's pressure ulcer to the sacrum was noted on [DATE]. The DON stated R104 should have been turned every two hours, and if a boot was needed for a heel wound, it was ordered, and pillows were used to float the heels. The DON stated that weekly skin assessments should be completed. The Wound Care Nurse completed the initial and weekly pressure ulcer form. She stated a referral would be made for the Wound Care Physician to see the resident on weekly rounds. The DON stated LPNs could not assess pressure ulcers, but they could describe and document their observations. The DON stated blanks on the TAR could indicate that treatment was not provided or was not documented. The DON stated nurses should document with a code on the TAR if there was a wound care refusal and should not leave it blank. The DON stated she had observed R104's pressure ulcer to the sacrum and stated it had become infected. During an interview on [DATE] at 10:16 am, R104's Physician (Outgoing Medical Director (OGMD)) stated treatment should have been initiated right away ([DATE]) with the development of R104's pressure ulcer to the sacrum, and it should have been assessed with measurements right away as well. OGMD stated interventions such as boots for the left heel pressure ulcer would be initiated by the wound team or the Director of Nursing (DON). OGMD stated that a repositioning schedule should have been implemented with repositioning as frequently as possible. OGMD stated the facility had staffing issues preventing repositioning from being done. OGMD stated he noticed R104's pressure ulcer treatments were not being completed by the nursing staff. OGMD stated he was concerned that the facility did not have a Wound Care Nurse to oversee wound care during the time R104 developed and had pressure ulcers. OGMD stated he insisted to the Administrator that the facility hire a Wound Care Nurse. OGMD stated weekly assessment of pressure ulcers by nursing staff was very important; nurses should notify the Wound Care Physician of any changes. OGMD stated the Wound Care Physician was responsible for assessing and providing treatment and orders once they assumed care. OGMD stated he had not been aware of the three-week gap in the Wound Care Physician's not evaluating R104's wounds. OGMD stated that if there were blanks on the TARs for wound care by nursing staff, chances were it was not getting done. OGMD stated it was his expectation for nurses to document the provision of wound care. OGMD stated he did not remember R104 refusing treatment, but she might have. OGMD stated R104's death was likely a result of the pressure ulcer to her sacrum; he stated she had a deep wound that could lead to sepsis and infection. OGMD stated R104 was also over [AGE] years old, was frail, and had pneumonia in [DATE] of which could have also contributed to her death. During an interview on [DATE] at 12:36 pm, Unit Manager/IP2 verified the three-week period when the Wound Care Physician did not come and oversee R104's pressure ulcers. Unit Manager/IP2 stated that the nurses called, but the Wound Care Physician did not come, and that was why the facility got a different Wound Care Physician. Unit Manager/IP2 also verified the initial gap of 23 days following R104's pressure ulcer being discovered until it was assessed on [DATE]. She stated the nurses could not have completed the nursing pressure ulcer form without the Wou[TRUNCATED]

Based on interviews, facility policy review, and job description review, the facility administration failed to use resources to ensure residents attained and maintained their highest physical well-being. The facility's Administrator and the Director of Nursing (DON) failed to identify failures from nursing and other facility staff, which caused the actual harm and/or death of residents. 1. The facility's administration failed to ensure that residents' physicians and/or other medical providers were notified after R159 and R9 had changes in conditions related to the worsening of their skin conditions. Cross Reference F580-J 2. The facility's administration failed to ensure residents were free from neglect and abuse. Nursing staff neglected to identify and/or report the worsening of R159's and R9's skin conditions, which led to actual harm and death. Additionally, the facility failed to protect R360 from being abused by R46, even though the facility documented copious notes where R46 abused multiple other residents. Cross Reference F600-J 3. The facility's administration failed to ensure licensed nurses used their professional standards of nursing practices to identify the worsening of R159's skin condition. The facility's nurses failed to appropriately assess, intervene, and notify the resident's physician on several occasions of changes in the resident's skin condition. Cross Reference F658-J 4. The facility's administration failed to ensure nursing services were provided to prevent the development of a serious pressure ulcer. Cross References F686-J 5. Additionally, Substandard Quality of Care (SQC) was identified at §483.12, Free from Abuse and Neglect F600, and at §483.25 Quality of Care, Treatment/Services to Prevent/Heal Pressure Ulcers. On 3/28/2025, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Regional Director of Clinical Operations (RDCO) were informed of the Immediate Jeopardy (IJ) for F580, F600, F658, F686, and F835 on 3/28/2025 at 6:27 pm. The facility was unable to provide an acceptable IJ Removal Plan before the survey team's exit on 3/30/2025, and the IJ remained ongoing. Findings included: A review of the facility-provided job description titled Administrator revealed Summary The primary purpose of your job position is to direct the day-to-day functions of the facility in accordance with current federal, state and local standards, guidelines and regulations that govern long-term care facilities to ensure that the highest degree of quality care can be provided to our residents at all times. A review of the facility-provided position description titled Director of Nursing revealed Overview: Provides leadership and direction for the nursing staff while being responsible for the overall management of the Nursing Department. Ensures nursing staff's compliance with all facility and nursing policies and procedures as well as compliance with regulatory requirements. During an interview on 3/28/2025 at 8:57 am, the DON confirmed she started the position in May 2024 and was responsible for the overall management of the nursing staff. The DON stated the nurses did not follow the change in condition policies, but had received training on the policy during in-services held in 2024. The DON stated the Assistant Director of Nursing (ADON) was responsible for training the agency and full-time staff on the policies during orientation and in-services provided throughout the year. The DON stated she expected the nurses to complete alert charting when a change in condition was identified, to notify the provider, to perform a thorough assessment of the resident, and document a change in condition by completing an SBAR (situation, background, assessment and recommendation) form in the electronic medical record (EMR). During an interview on 3/28/2525 at 9:32 am, the Administrator confirmed he was responsible for the overall management of the facility, and the DON was responsible for the management of the nursing staff, and the ADON for the education of nursing staff. The Administrator stated that the nurses' failure to identify a change in condition and report it to the provider was not per the change in condition policy. During an interview on 3/28/2025 at 10:00 am, the ADON verified that she was responsible for training the nursing staff on nursing policies. ADON stated she trained the nurses on the change in condition policy last year, and she held a skills fair in 2025. The ADON stated there was a change in condition policy at each nurse's station in a binder and posted by the time clock. The ADON stated that the nurses who have been working should also be able to identify a change in conditions because it was not new to them.