Based on observations, interviews, and record reviews, the facility failed to ensure that one (R504) resident who depends on staff assistance for ADL (Activities of Daily Living) care was provided incontinence care and transfer assistance in a timely manner, demonstrating inadequate care in a sample of 55 residents. This failure resulted in R504 suffering psychosocial harm stating feelings of humiliation and embarrassment. Findings include: On 06/02/25 at 11:00am, R504 was observed, in his (R504) room, sitting on the side of bed with a walker in front of him, and R504's call light was wrapped on the bedside table behind R504 not within reach of R504. Surveyor observed urine on the floor below R504 with his (R504) foot lying in the puddle of urine. R504 stated, It has been over an hour that I (R504) have been waiting for help to get to chair and get cleaned up. A nurse came in, helped me sit on the side of the bed, and said that he (nurse) would be back once he (nurse) could find another nurse to help him (nurse). I'm sorry. This is humiliating. I'm (R504) so embarrassed. R504's face sheet documents diagnoses that include but are not limited to need for assistance with personal care; muscle weakness; fall; other abnormalities of gait and mobility; unsteadiness on feet; and periprosthetic fracture around internal prosthetic left hip joint. R504's Brief Interview of Mental Status (BIMS) score, dated 5/16/25, documents, in part, a BIMS score of 15 which indicates R504 is cognitively intact. On 6/2/2025 at 11:05am, V11 (Certified Nurse's Assistant/CNA) stated, My resident's load is heavy because many of them require increased surveillance and two people assistance, and they are always short staffed. I (V11) already waited for over an hour for another CNA to help me (V11) to move the resident from bed to chair. There is only one nurse and one other CNA working this unit. I (V11) will not risk the resident falling by moving him (R504) by himself (V11). On 6/4/25 at 12:01pm, V2 (Assistant Director of Nursing/DON) said, Any staff can help a resident. Physical therapy, social workers. You (staff) do not have to be a nurse. An hour is too much for a resident to get assistance. Right away. Assist them (residents) right away. Waiting for an hour with sitting in urine would probably make a resident mad and sad. Facility policy titled, Activities of Daily Living (ADLs), Supporting, reviewed date 9/01/24, documents, in part, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene . Appropriate care and services will be provided for residents who are unable to carry out ADLs independently . including . hygiene; . mobility (transfer and ambulation, including walking); elimination (toileting) . Facility policy titled, Answering the Call light, reviewed date9/1/22, documents, in part, . When the resident is in the bed . be sure the call light is within easy reach of the resident .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that staff are aware of required LALM (Low Air Loss Mattress) settings, failed to ensure that LALM checks were conducted, failed to ensure the LALM is on the correct setting/mode, failed to implement care plan interventions, failed to turn/reposition dependent residents every 2 hours, failed to ensure that wound assessments were accurate & staged correctly, failed to follow physician orders, and/or failed to ensure that treatments were administered as ordered for four of four residents (R1, R2, R3, R4) reviewed for pressure ulcers. These failures resulted in R1 sustaining a (facility acquired) infected large sacrum decubitus which required surgical intervention and osteomyelitis (bone infection) of the sacrum/coccyx. These failures also resulted in R3's (stage 3) sacrum pressure ulcer declining to (stage 4). Findings include: 1. On 10/8/24 and 10/18/24, IDPH (Illinois Department of Public Health) received allegations that the facility failed to provide timely/adequate care to prevent stage 4 wounds. (R1) sustained a stage 4 infected wound that required surgery. R1's wound was down to the bone. R1's diagnoses include but not limited to obesity, generalized muscle weakness, hypertensive heart disease, and congestive heart failure. R1 was admitted [DATE] transferred to the hospital on 9/21/24 and did not return to the facility. R1's (12/22/23) risk for skin integrity impairment assessment determined a score of 12 (High Risk). R1's (9/13/24) functional assessment affirms resident is dependent on staff for toileting hygiene and requires substantial/maximal assistance for rolling left and right (turning/repositioning). R1's care plan includes (12/25/23) Resident has alteration of bowel & bladder functioning due to weakness and decreased mobility. (9/16/24) MASD (Moisture Associated Skin Damage) sacrum area. Interventions: perform skin at risk assessment per facility protocol. Notify MD (Medical Doctor) of significant changes. Identify potential causative factors and eliminate/ resolve when possible. Keep skin clean and dry. Turn and reposition every 2 hours. On 10/28/24 at 1:05pm, surveyor inquired about R1's (facility acquired) skin integrity impairment, V2 (Director of Nursing) presented R1's (2/23/24) initial skin alteration record and (3/21/24) weekly skin alteration record and stated 2/23 is when the MASD started and 3/21 is when the MASD got resolved. Then, the 9/16 (2024) MASD was identified next. R1's (9/16/24) initial skin alteration record states sacrum MASD. 7 x 4.5 x 0cm (centimeters). Wound margins/edges: erythema (redness). Peri -wound area erythema, warm to touch, cracked/excoriation. No pain verbalized or observed during treatment. Assist to reposition totally dependent. Preventive measures daily skin checks during CNA routine rounds, reposition every 2 hours and PRN (as needed), moisture barrier, incontinence care. R1's POS (Physician Order Sheets) include (3/7/24) Air loss mattress checks for function every shift. Turn and reposition every 2 hours. (9/16/24) Medihoney apply to sacrum daily for excoriating/MASD. Cover with foam dressing. R1's (9/16/24) progress notes state wound care provided. R1's (September 2024) TAR (Treatment Administration Record) affirms Medihoney to sacrum was not documented (blank spaces noted) on 9/17, 9/18, 9/19, 9/20, and 9/21 (5 days). R1's (9/13/24) BIMS (Brief Interview Mental Status) determined a score of 12 (cognition intact). R1's (9/21/24) ER (Emergency Room) progress notes state patient herself reports pain in her butt with pressure ulcer noted to her sacrum. Dressed with white substance and dressing on arrival [Medihoney which was prescribed - is not a white substance]. R1's (9/21/24) history and physical states patient presents to ER, patient is complaining of butt pain. Musculoskeletal: positive for back pain. Skin: Findings: Lesion present. Comments: Large sacral decubitus. Patient does endorse back pain near butt. Patient has large sacral decubitus. Differential diagnosis includes infection. R1's surgical consults state (9/24/24) wound appears likely to involve muscle and likely periostium (membranous tissue that covers the surface of bone). Recommend MRI (Magnetic Resonance Imaging) to evaluate bone involvement. (9/26/24) Patient was noted to have sacral decubitus ulcer on admission with imaging/MRI (Magnetic Resonance Imaging) confirming osteomyelitis of the sacrum and coccyx. Seen by surgery and plan for debridement today. R1's (10/3/24) discharge summary states wound cultures resulted pseudomonas (Bacteria) and VRE (Vancomycin-Resistant Enterococci) faecium (Bacteria). On 10/28/24, surveyor requested credentials for the facility Wound Care Nurse. At 12:05pm, V1 (Administrator) stated that the facility employs two wound care Nurses (V8 & V10) however only presented V10's (Wound Care Nurse) wound care certification. Surveyor inquired when V10 was hired V1 responded He (V10) started last Monday so that would be on October 21st [7 days prior]. On 10/28/24 at 12:47pm, V1 stated that (V8/Wound Care Nurse) Does not have wound care certification and subsequently affirmed in writing that V8 does not possess the WCC (Wound Care Certified) certification. This employee (V8) was hired on September 18, 2023 (over 1 year ago). On 10/29/24 at 12:11pm, surveyor inquired who's responsible for wound care at the facility V11 (ADON/Assistant Director of Nursing) stated I troubleshoot for the facility just to do the dressing when the wound care is not here and affirmed that when V8 (Wound Care Nurse) is not working she (V11) provides wound care. Surveyor inquired when V8 works at the facility V11 responded Friday, Saturday, Sunday and Monday. Surveyor inquired if V11 is wound care certified V11 replied No, I'm not. Surveyor inquired about R1's cognitive and functional status V11 stated She is bedridden. She's incontinent both of urine and stool. She's alert 2-3, she can tell you change me, or I have poop. Surveyor inquired about R1's skin integrity impairment (prior to 9/21/24) hospital transfer V11 responded she (R1) has excoriation because she is incontinent of urine and stool. Surveyor inquired what causes excoriation V11 replied Urine and stool, urine is very corrosive and stool. Surveyor inquired what blank spaces on the TAR indicates V11 stated That they didn't do anything. Surveyor inquired if R1's Medihoney treatment/dressing was documented on the (August 2024 TAR) V11 reviewed R1's EMR (Electronic Medical Records) and responded Nobody sign it or it means it's not there 5 days, the blank one. The Nurses on the floor should be doing this. Surveyor advised that V11 affirmed that she (V11) and V8 were responsible for wound care (in prior statement) V11 replied I (V11) know, but if I cannot do it, I told them (assigned Nurses) that they have to do it. Surveyor inquired about potential harm to a resident if skin integrity impairments are not treated (as ordered) V11 stated Well, it will just deteriorate with the stool and urine there. You need to clean it and put another dressing. On 10/30/24 at 12:59pm, surveyor inquired about staff requirements for resident change in condition re: sacrum Decubitus V14 (Medical Director) stated I would expect that the staging is done properly, the dressing requirements are very clear in the wound care plan, and the offloading mechanisms such as the low air loss mattress is ordered, and as a Physician or in-house Nurse Practitioner, there's a rounding and we treat infection if there's infection. Surveyor inquired about potential harm to a resident if treatments are not administered as ordered V14 responded So there is potential for serious harm, the wound can become infected, and the resident can become septic. Surveyor inquired how osteomyelitis occurs V14 replied It is a progression of any skin or soft tissue infection or trauma, the deeper the wound goes there's muscle and facia. The deeper the wound goes; it can involve the bone and it can be an infection which is osteomyelitis. On 10/30/24 at 1:32pm, V13 (Agency Licensed Practical Nurse) affirmed that she was assigned to R1 on 9/21/24. Surveyor inquired about R1's sacrum skin integrity impairment V13 stated That I'm not too familiar with it because I know that someone is there doing wound care [R1's TAR affirms that wound care was not documented for 5 days]. I'm not sure what kind of wound that (R1) had. V13 affirmed that V15 (CNA/Certified Nursing Assistant) was also assigned to R1 on 9/21/24. On 10/30/24 at 2:15pm, surveyor inquired about R1's sacrum wound, V15 (Certified Nursing Assistant) stated When I changed her, (R1) had like a patch on her butt and we (staff) usually put the zinc on it, it was just red. Surveyor inquired if R1 reported pain V15 replied She might say that she is uncomfortable, so we just turn her side to side. 2. R3's diagnoses include Parkinson's disease and reduced mobility. R3's (9/3/24) risk for skin integrity impairment assessment determined a score of 12 (high risk). R3's (10/3/24) functional assessment affirms resident is dependent on staff for rolling left and right. R3's (4/4/24) initial skin alteration record (admission) includes (stage 3) sacrum pressure ulcer. R3's (10/24/24) weekly skin alteration record includes (stage 4) sacrum pressure ulcer [therefore wound declined]. R3's POS includes (4/5/24) turning and repositioning every 2 hours. (4/9/24) air loss mattress check function every shift. (7/23/34) Calcium Alginate apply to sacral daily for stage 4 pressure ulcer after cleansing with NSS (Normal Saline Solution) and cover with dry dressing. R3's care plan includes (4/5/24) high risk for alteration in skin integrity, Interventions: identify potential causative factors and eliminate/resolve when possible. LALM (Low Air Loss Mattress) check for function every shift. On 10/23/24 at 3:44pm, R3 was lying on a LALM, and the setting was on static mode (therefore providing a firm surface). Surveyor inquired about R3's current LALM settings V5 (RN/Registered Nurse) stated Usually it's preset. Surveyor inquired what static mode means V5 responded I'm not familiar with this machine. R3 was noted to be lying on a white flat sheet, a thick blue folded sheet (8 layers), and folded bath blanket (4 layers). V5 counted the layers beneath R3 (as requested) and affirmed that there were 13 excluding the brief (therefore a total of 14 layers placed beneath the buttocks). Surveyor relayed concerns with all the linens placed between R3 and the LALM V5 replied It should only be one, otherwise this one (LALM) won't work. V5 then proceeded to cover R3 with the blanket and left the room, V5 did not remove any of the sheets and/or blanket beneath R3 at this time. R3's (October 2024) TAR affirms for low air loss mattress checks (blank entries) were noted on 10/5, 10/6, 10/8, 10/19, 10/23, 10/24, 10/25, and 10/27. For Calcium Alginate treatments 9 is documented on 10/6, 10/14, 10/17, 10/20 and 10/28. For turning/repositioning every 2 hours blank spaces were noted on 10/3, 10/5, 10/6, 10/7, 10/8, 10/9, 10/19, 10/20, 10/23, 10/24, 10/25, 10/27 and 10/28. On 10/29/24 at 12:45pm, surveyor inquired why 9 was documented on R3's (October 2024) TAR, V11 (ADON) stated I don't know why they (Nurses) do this number nine. 10/6 (2024) it says done by wound nurse (referring to R3's progress notes). 10/8 says done by wound nurse. 10/14 says done by wound nurse. 10/20 is done by wound nurse. 10/24 will be done by wound nurse. Surveyor inquired if Nurses should be charting wound care for other staff V11 responded No, they have to chart when they are doing it, the dressing and everything. Surveyor inquired what mode the LALM should be in while a resident is lying in bed V11 replied The mattress should just stay in alternating because that is where the cell is alternating, go up and go down the bed, so the patient should be floating in the mattress. Surveyor inquired if several linen layers were placed under R3's buttocks while lying on a LALM is the mattress effective V11 stated No, it has to be one layer only because the air can go to the patients skin. 3. R4's diagnoses include Parkinson's disease, generalized muscle weakness, and protein calorie malnutrition. R4's (10/12/24) Braden determined a score of 11 (high risk). R4's (9/13/24) initial skin alteration record was signed on 9/15/24 (2 days after assessment). Site: Abdomen. Description: Sacral wound stage 4 [the description is incongruent with the site]. Preventive measures: redistribution mattress. R4's (10/12/24) re-admission skin alteration record states site: abdomen. Description: sacral wound stage 4. [again, the description is incongruent with the site]. R4's (10/24/24) weekly skin alteration record states sacrum stage 3 [therefore back staged]. R4's (9/13/24) POS states cleanse sacral wound with NS, apply Alginate, cover with dry dressing daily and as needed. R4's (October 2024) TAR affirms sacral treatment was not documented (blank entries) on 10/4, 10/5, 10/6, 10/7, 10/8, 10/9, 10/10, 10/11, 10/12, 10/15, 10/17, 10/18, 10/19, and 10/22. Low air loss mattress checks were initiated on 10/24 (1.5 months after implementation). On 10/23/24 at 3:55pm, inquired if R4 has a wound V6 (RN) stated It's on the back, he (R4) was just turned by the CNA. R4's (10/15/24) BIMS determined a score of 9 (moderate impairment). On 10/23/24 at 3:57pm, surveyor inquired if R4's dressing was changed today R4 replied Uh um nodded his head no and affirmed that it was not. R4 was lying atop of a LALM, surveyor inquired about the current settings on R4's LALM, V6 (RN) stated Unfortunately I (V6) was not told as to what setting he (R4) should be in. Right now, the setting is at 250 (pounds) I wound say however R4 appeared to be about half that weight. Surveyor inquired how much R4 weighs R4 responded 122 pounds. Surveyor requested to inspect R4 at this time. V7 (Certified Nursing Assistant) removed R4's incontinence brief which was dry however a dressing was not present and white cream was noted on the open sacral wound. Surveyor inquired about R4's exposed wound, V6 replied I see a wound on the tailbone, it is an open wound. Surveyor inquired what was on R4's (stage 4) sacrum wound V6 stated Zinc oxide. Surveyor inquired if a dressing was supposed to be on R4's sacrum V6 responded Yes. On 10/28/24 at 10:36am, surveyor inquired why R4's initial wound assessment states stage 4 and the current wound assessment states stage 3, V2 (Director of Nursing) stated Good question. Surveyor inquired about staging wounds, V2 responded When staging from a stage 4 going to a stage 3, if the wound is getting better by the week-by-week assessment of the wound nurse. Surveyor inquired if back staging of wounds is appropriate V2 replied Don't we indicate if its progressing or getting better? Surveyor inquired if V2 was familiar with staging wounds V2 stated No. [The National Pressure Ulcer Advisory Panel advises against reverse staging of pressure ulcers, or bedsores, because it doesn't accurately reflect the healing process]. On 10/29/24 at 1:07pm, surveyor inquired why R4's initial sacral wound assessment (dated 9/13/24) was documented/signed on 9/15 (3 days after admission). V11 (ADON) stated (R4) was admitted on the 12th and the assessment was done the next day. When you do it on the day it will give you the day that you did the assessment. If I do the assessment today, I have to sign the assessment for today. Surveyor inquired about concerns with R4's (9/13/24) initial wound assessment, V11 responded The site says abdomen how can you put abdomen when the site is sacrum. 4. R2's diagnoses include dementia, type II diabetes mellitus, protein calorie malnutrition, and generalized muscle weakness. R2's (10/12/24) risk for skin integrity impairment assessment determined a score of 10 (high risk). R2's (10/12/24) initial skin alteration record (admission) includes left buttock stage 4 pressure ulcer and sacrum MASD. R2's (10/24/24) weekly skin alteration record includes sacrum stage 4 [incongruent with the initial assessment] and buttocks MASD [incongruent with the initial assessment]. On 10/29/24 at 12:28pm, V11 (ADON) affirmed that (V8/Wound Care Nurse) documented R2's (10/12/24) and (10/24/24) wound assessments. Surveyor inquired why R2's (10/12/24) initial wound assessment includes left buttock stage 4 (black/eschar tissue) however the (10/24/24) assessment (conducted 12 days later) states buttocks MASD, V11 stated (R2) cannot have MASD because (R2) is not eating. That cannot be, you cannot come back and change that to MASD. Stage 4 cannot go back to MASD. The documentation was not entered properly. R2's (10/23/24) POS states cleanse sacral 1/2 strength Dakins, pat dry, apply metrocream, cover with dry dressing daily. R2's (October 2024) TAR affirms the sacral treatment was not documented (blank entry) on 10/26/24. The (7/2023) low air loss mattress policy states the purpose is to provide features of a mattress support system that provides a flow of air to assist in managing the heat and humidity of the skin. Low air loss mattresses will be utilized for residents with stage III and IV pressure ulcers of the trunk as well as residents with multiple stage II pressure ulcers. The low air loss mattress will be checked on a regular basis to ensure that all cells of the mattress are functioning appropriately. Any resident on a low air loss mattress will have a single non-fitted sheet which may be used for assistance with repositioning. The management of wounds policy (revised 12/31/23) states it is the policy of this facility to manage tissue load and improve tissue tolerance to pressure, friction, and shearing forces. This will be accomplished through the use of appropriate positioning practices, positioning devices, and support services. It is the policy of this facility to treat the wound according to the guidelines of the Agency for Healthcare Research and Quality (AHRQ), National Pressure Ulcer Advisory Panel, and current standards of clinical practice. According to the AHRQ, Care of the ulcer itself involves debridement of necrotic tissue, cleansing of the wound at initial examination and at each dressing change, and using a dressing that keeps the ulcer bed continuously moist but the surrounding intact skin dry. The following policies and procedures will be utilized: wound cleansing policy and procedure and wound dressing policy and procedure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to properly assess one resident (R1) for skin breakdown; and failed to prevent, recognize and treat a new wound that was acquired in the facility for 1 resident (R1) out of 7 residents reviewed for nursing care. This failure resulted in R1 being sent out to the hospital on 5/29/24 for altered mental status in which it was discovered R1 had a unstageable wound to the sacrum and again R1 was evaluated in the hospital on 6/5/24 where R1's sacral wound extended to the anus and required surgical debridement. Findings include: R1 is an [AGE] year old with diagnosis including but not limited to: Muscle weakness, abnormalities of gait and balance, cognitive communication deficit, cerebral infarction, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side. On 7/01/2024 at 10:10 AM, V1 (Administrator) said, R1 has been discharged from the facility. He went to the hospital on 6/5/2024 and the family decided to take him home from the Hospital. (R1 was sent on 6/5/24 to the hospital for wound evaluation) On 7/1/2024 at 10:15 AM, V6 (R1's family) said, There have been times that I have gone to visit my dad (R1) and noticed that he smelled of urine and feces. He (R1) had a rash and wound on his scrotum. He (R1) had developed a wound on his back that spread to his anus. It was so deep that he had to have surgery and also had a colostomy bag placed. He (R1) had necrotic tissue that had to be removed and he also had formed infections in the wound. He (R1) is still not completely healed from the wound. My dad (R1) did not have any wounds when he was admitted to the facility on [DATE] and now he (R1) has an unstageable wound from which he (R1) is having many complications. The facility didn't prevent my dad's pressure wound from forming and did not treat my dad (R1's) wound until it was too late. He (R1) developed the pressure ulcer in the facility, before he was even hospitalized . He (R1) then got a wound infection in the facility and went back out to the Hospital for the infection. On 07/02/2024 at 1:12 PM, V14 (ADON/ Assistant Director of Nursing) said, I help with wounds sometimes when the wound nurse is not here. On 07/02/2024 at 1:12 PM, V14 said, R1 was incontinent. He (R1) was not alert and oriented and will not call for help if he is wet. For incontinent patients, they are usually rounded on every two hours to reposition and change. I was not in the facility on the day that R1 was readmitted to the facility. I live close by, so I have no problems coming into the facility to assess a wound. I was not aware of R1's wound. I (V14) am not sure why the wound care orders were not entered until 6/2/2024 because he (R1) came back to the facility on 5/31/2024. I was not aware of R1 having any skin breakdown. On 07/02/2024 at 1:12 PM, V14 (ADON) said, If a patient has a wound upon admission, wound care team is notified to assess the patient and implement treatment. We (wound team) will call the Doctor to get orders for a wound to ensure that it is treated. A patient can have skin breakdown within 24 hours because the skin is very tender and older patients are more prone to skin breakdown. For wound prevention, we use air mattresses, zinc oxide to protect the skin and we reposition and change the patients every two hours. The wounds can quickly worsen without treatment. My expectation is that there are no wounds developed or worsening in this facility. On 07/02/2024 at 1:14 PM, V14 (ADON) said, There can be many complications from a pressure ulcer including: sepsis (blood infection) or skin infections such as cellulitis. On 7/3/2024 at 1:50 PM, V18 (LPN/Licensed Practical Nurse) said, I re-admitted R1 back to the facility. I don't recall any further orders for wound care at the time of R1's admission. I'm sure that I notified the nursing manager and I did document my findings of the open area on the skin. I am not sure what was done after that. On 7/3/2024 at 2:24 PM, V19 (Nurse Practitioner) said, If I saw the patent (R1) after re-admission to the facility, I would have definitely entered orders for wound treatment. Ideally, the nurse would call the primary Doctor and the wound care consult is ordered for assessment on the next day. The purpose of the treatment would be to heal the wound and to prevent it from worsening. Facility Census report documents, R1 was admitted to the facility on [DATE]; R1 was admitted to the hospital on [DATE]; R1 was re-admitted to the facility from the hospital on 5/31/2024; R1 was discharged from the facility on 6/5/2024. Facility admission Summary note dated 4/26/2024 documents, head to toe assessment done with no skin issue noted. Facility admission Screener dated 4/26/2024 documents, R1 does not have impaired skin integrity upon admission. R1's Interim Care Plan dated 4/26/2024 documents, R1 is at risk for altered skin integrity related to incontinence and decreased mobility. R1's MDS (Minimum Data Set) - Section M dated 5/1/2024 documents, the resident (R1) is not at risk for developing pressure injuries/ulcers; the resident (R1) has no unhealed pressure injuries/ulcers. R1's MDS (Minimum Data Set) - Section H dated 5/1/2024 documents, R1 has occasional urinary and bowel incontinence; trial of a toileting program has not been attempted; No toileting program currently being used. Hospital Emergency Department Nurse note dated 5/29/2024 and written by V17 (Hospital Nurse) documents, Patient (R1) has wound on the sacrum, partial thickness. R1's (6/5/24) hospital record documents in part: R1 was sent for sacral wound evaluation. Wound measured 9 cm x 9 cm, base: moist, necrotic, extends to the anus. Hospital Discharge instructions dated 5/31/2024 documents a new order for miconazole nitrate ointment. Facility Nurse Progress note dated 5/31/2024 documents, body assessment completed, patient (R1) has open area on sacrum, dressing is covering the area, and R1 has noted irritation to penis area. Medical Doctor made aware R1 has returned. Orders are to stay the same. Facility admission Screener dated 5/31/2024 documents, R1 has impaired skin integrity upon admission (R1 was readmitted to the facility from the hospital). R1's MDS (Minimum Data Set) - Section H dated 5/29/2024 documents, R1 is always incontinent. R1's MDS (Minimum Data Set) - Section M dated 6/5/2024 documents, R1 has one or more unhealed pressure ulcers. R1's Physician Order Summary Report documents wound care orders for treatment of buttock and sacrum entered on 6/2/2024; orders for LALM (Low Air Loss Mattress) entered on 6/3/2023; orders for treatment of perianal/ scrotum entered on 6/5/2024; turn and reposition orders entered on 6/5/2024; and order for wound cream entered on 6/5/2024. R1's Physician Order Summary Report documents no order for miconazole nitrate ointment. R1's Treatment Administration Record (TAR) documents, no treatments implemented for R1's wounds on 5/31/24, 6/1/24 or 6/2/2024. Hospital summary dated 6/12/2024 documents, R1 was seen for sacral wound cellulitis and osteomyelitis; R1 will also need a diverting colostomy, sharp excisional debridement of sacral decubitus on 6/7/2024, post operation day one. Facility policy titled Pressure Ulcer Treatment and Management documents, Residents with pressure ulcers will have a physician's order for treatment; residents with pressure ulcers will be determined to be at high risk for pressure ulcer prevention and all components of the At Risk Protocol will include; pressure relieving devices, nutritional support, assistance with mobility including repositioning and ROM (range of motion) as outlined in the At Risk Protocol. Facility policy titled Pressure Ulcer Prevention protocol documents, Daily skin checks conducted by either the CNA (Certified Nurse Assistance) or Licensed Nurse to ensure early identification of potential problem areas. Facility policy titled Pressure Ulcer Risk Assessment documents, to implement a standardized plan of pressure ulcer prevention based upon a reliable and valid assessment of pressure ulcer risk.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure ADL (Activities of Daily Living) care was provided for dependent residents who required assistance with bladder and bowel incontinence for four of four residents (R1, R2, R3, R4) reviewed for ADL care. Findings include: On 10.21.2023 at 11:33 AM, R1 was observed awake, alert, lying in bed. R1 said he was soiled. 1) R1's medical record (Face Sheet) documents R1 is a [AGE] year-old admitted to the facility on 2.20.2020 with diagnoses including but not limited to: Parkinson's Disease, Venous Insufficiency (Chronic) (Peripheral), Acute Kidney Failure, and Weakness. R1's MDS (Minimum Data Set of 7.23.2023) documents R1 is cognitively intact, requires extensive assistance/two + persons physical assist with bed mobility, transfers, and toilet use; R1 is frequently incontinent of urine and stool. 10.21.2023 at 11:33 AM, R1 was observed sitting up in bed. A blue brief was observed sticking out from the top of R1's yellow brief. R1 said staff double diapered him (on the night shift). R1 said, I don't like it. They do that so that they don't have to change me so much. It's my fault because I wet so much. R1 appeared sad (sad facial expression) as he told the Surveyor about the double diapering. At 11:37 AM, V5 (Agency CNA-Certified Nursing Assistant) entered R1's room to provide incontinent care. R1's blue brief and back of R1's yellow brief were saturated with urine; a pungent odor was noted. R1's draw sheet was saturated with urine; a dark ring was noted on R1's fitted sheet. 2) R2's medical record (Face Sheet) documents R2 is a [AGE] year-old admitted to the facility on 1.16.2020 with diagnoses including but not limited to: Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Type 2 Diabetes Mellitus with Hyperglycemia, Chronic Diastolic (Congestive) Heart Failure, and Hyperlipidemia, Unspecified. R2's MDS (Minimum Data Set of 7.11.2023) documents R2 is severely cognitively impaired, requires extensive assistance/two+ persons physical assist with bed mobility, total dependence/two+ persons physical assist with transfers and toilet use; R2 is always incontinent of urine and stool. 10.21.2023 at 10:38 AM, R2 is sitting up in bed with eyes closed, non-verbal. V4 said this is the first time I'm seeing him (to provide incontinent care); I did feed him earlier. V4 lowered the head of R2's bed and undid his brief. Surveyor observed a blue brief (with flaps removed) inside R2's outer brief. R2's blue brief was saturated with urine, the back of R2's yellow brief was saturated with urine. V4 said the line down the front of R2's yellow brief will change color when the resident is wet, however because R2 was double diapered (blue brief inside of yellow brief) the line on the outer brief will not change color even though resident is wet. 3) R3's medical record (Face Sheet) documents R3 is an [AGE] year-old admitted to the facility on 2.10.2022 with diagnoses including but not limited to: Radiculopathy, Lumbar Region; Muscle Weakness (Generalized), Fusion of Spine, Lumbar Region, and Thoracoabdominal Aortic Ectasia. R3's MDS (Minimum Data Set of 8.13.2023) documents R3 is severely cognitively impaired, requires extensive assistance/one-person physical assist with bed mobility and transfers, total dependence/two+ persons physical assist with toilet use; R3 is always incontinent of urine and stool. 10.21.2023 at 10:50 AM, with V4 (CNA-Certified Nursing Assistant) and V5 (Agency CNA-Certified Nursing Assistant), R3 was observed awake and alert lying in bed, R3 did not respond to Surveyors questions. R3's brief was saturated with urine. R3's incontinent pad was wet with urine; a dark ring was noted as well. R3's fitted sheet was wet with urine. 4) R4's medical record (Face Sheet) documents R4 is a [AGE] year-old admitted to the facility on 2.20.2018 with diagnoses including but not limited to: Chronic Combined Systolic (Congestive) and Diastolic (Congestive) Heart Failure, Hyperlipidemia, Unspecified; Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris, and Major Depressive Disorder, Single Episode, Unspecified. R4's MDS (Minimum Data Set of 8.13.2023) documents R3 is cognitively intact, requires extensive assistance/two+ persons physical assist with bed mobility, total dependence/two+ persons physical assist with transfers, total dependence/one-person physical assist with toilet use; R4 is always incontinent of urine and stool. 10.21.2023 at 11:06 AM, with V4 (CNA-Certified Nursing Assistant), R4 was observed awake and alert, sitting up in bed. R4 said she was changed once on the night shift but was currently wet. Surveyor observed a blue brief with flaps removed) inside R4's outer brief. R4's blue brief was saturated with urine, the back of R4's yellow brief was saturated with urine. The line down the front of R4's brief had not changed color. A folded bath blanket and an incontinent pad were observed under R4. The bath blanket was wet with dark urine; dark rings were noted on the bath blanket, incontinent pad, and fitted sheet.