**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assess and monitor a resident who had no recorded bowel movement for eight consecutive days who was experiencing abdominal discomfort. This failure resulted in R1 having acute rectal bleeding, requiring hospitalization for a blood transfusion and emergency intravenous medication administration to reverse the effects of her blood thinner. R1 also required the insertion of a rectal tube for the management of her fecal impaction. This applies to 1 out of 3 (R1) residents reviewed for constipation. The findings include: R1's EMR (Electronic Medical Record) showed R1 was admitted on [DATE] with multiple diagnoses including dementia, psychosis, severe protein caloric malnutrition, anxiety, depression, diabetes type 2, hypertension, and hyperlipidemia. R1's MDS (Minimum Data Set) dated 9/17/2024 showed R1 was moderately cognitively impaired. The MDS continued to show R1 was always incontinent of bowel and required substantial to maximal staff assistance with her toileting needs. On 12/26/2024 at 9:00 AM, V11 (R1's Family Member) stated she had a care plan meeting with V16 (Social Service Director) on 9/26/2024. V11 stated she inquired regarding R1's bowel movement because R1 expressed having rectal discomfort and had a history of constipation. V11 stated V16 informed her that the nursing staff reported R1 was having routine bowel movements. V11 stated then on 10/1/2024, she was informed R1 was transferred to the hospital for a rectal bleed. On 12/26/2024 at 12:20 PM, V16 (Social Worker Director) stated she reviewed R1's care plan meeting documentation which did not mention specifics regarding R1's bowel concern. V16 stated she did recall asking R1's nurse on duty about her nursing care but unfortunately did not recall specifics. V16 stated only the nursing team had access to review residents' documented bowel patterns. On 12/24/2024 at 1:15 PM, V10 (Certified Nurse Assistant/CNA) stated she routinely took care of R1 during her stay. V10 stated R1 was confused and combative at times. V10 stated she recalled informing the nurses on duty that R1 would routinely complain of abdomen discomfort. V10 stated R1 had also been incontinent of bowel at times. V10 stated she documents residents' bowel movements in their EMRs every shift. On 12/26/2024 at 1:10 PM, V18 (Licensed Practical Nurse/LPN) stated she took care of R1 on 9/29/2024 from 7 AM-7 PM and was concerned because R1 did not eat. V18 stated she notified the telehealth physician on call and continued to monitor R1. V18 stated she was unsure how to check for resident bowel movements in their EMRs. V18 said she depends on the CNAs to report unusual bowel issues such as constipation or diarrhea. On 12/26/2024 at 11:00 PM, V13 (CNA) said she took care of R1 on 10/1/2024 from 7 AM-7 PM. V13 stated R1 had a large putty-like mushy bowel movement during the day. V13 stated that during lunch she noticed R1 was tired and leaning forward in her chair. V13 stated R1 had refused to eat, and she then assisted her to bed. V13 stated she informed the nurse on duty because she was worried that R1 also appeared very fatigued and refused to eat during the shift. V13 stated she records bowel movements in the residents' EMRs and believed nurses review the documentation. On 12/24/2024 at 12:10 PM, V4 (Agency Registered Nurse/RN) stated she took care of R1 on 10/1/2024. V4 stated at 8:30 PM during her care, R1 was noted with a large amount of rectal bleeding and a low blood pressure. V4 stated R1 was then transferred to the hospital for further care. V4 said she recalled being informed during the shift report that R1 had a bowel movement during the prior shift but was unsure if R1 had been constipated or of her bowel patterns. V4 stated residents' EMRs alerts nurses when a resident has not had a bowel movement recorded for more than two-three days, which will prompt the nurses to further assess the resident. On 12/24/2024 at 10:20 AM, V2 (Assistant Director of Nursing/ADON) stated she reviewed R1's documented bowel activity report for her stay which showed that before her bowel movement on 10/1/2024 she had only one recorded bowel movement on 9/22/2024. V2 stated the computer system alerts the nurses when no bowel movement has been documented in a three-day look back for all residents. V2 stated the facility expects CNAs to document bowel activity every shift for all residents. V2 continued to say the facility also expects nurses to check the residents' triggered bowel alerts every shift and respond, to ensure residents are being appropriately assessed and treated for constipation. V2 stated she was unsure why R1's nurses did not respond to R1's triggered alerts for no bowel movements documented for multiple consecutive days. On 12/26/2024 at 3:00 PM, V14 (Physician) stated she had been overseeing R1's medical care during her stay at the facility but was not sure of her bowel documentation. V14 stated older residents usually have irregular bowel patterns due to slow bowel activity and poor intake, which then puts them at risk for constipation. V14 stated constipation can be treated at the facility with stool softeners, and residents can be further monitored for related complications. V14 stated she expected the facility staff to follow its process for bowel management to monitor those at risk for constipation. R1's Care Plan (initiated 9/21/2024) showed R1 was a risk problem for constipation related to decreased mobility and effects of medications. The care plan included the following interventions, Monitor medications for side effects of constipation. Keep physician informed of any problems, Monitor/document/report to MD PRN signs/symptoms of complications related to constipation: change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation, Bradycardia (slow, low pulse), Abdominal distention, vomiting, small loose or stools, fecal smearing, Bowel sounds, diaphoresis, Abdomen: tenderness, guarding, rigidity, fecal impaction, and Record bowel movement pattern each day. Describe amount, color, and consistency. R1's Documentation Survey Report for bowel movements dated 12/24/2024 showed the following: 9/16/2024-9/21/2024: R1 had 6 days with no bowel movement recorded and no interventions done. 9/22/2024: R1 had one large, formed stool. 9/23/2024-9/30/2024: R1 had 8 days with no bowel movement recorded and no interventions done. 10/1/2024: R1 had one small putty and another large putty stool. R1's Order Summary Report showed an order dated 9/30/2024 for GlycoLax Powder (Polyethylene Glycol 3350) gram by mouth one time a day for constipation. The report also showed an as needed order for constipation dated 9/30/2024 for Dulcolax Suppository 10 MG (Bisacodyl) insert 1 suppository rectally as needed for constipation Daily. R1's MAR (Medication Administration Record) from 9/1/2024-10/1/2024 showed R1 did not receive a Dulcolax Suppository for constipation. The MAR showed R1 received 1 dose of GlycoLax Powder on 10/1/2024. R1's Nurse's Progress Note dated 9/29/2024 at 2:44 PM, said Noted patient have a decreased appetite today. Patient refused breakfast and lunch .Efforts to offer drinks to hydrate and frequent small meals was also unsuccessful. The note said the telehealth physician was notified and orders were received to Continue to monitor patient and will let the primary provider follow up tomorrow with the patient. R1's Progress Note dated 10/1/2024 at 8:57 PM showed R1 had to be transferred to the hospital because resident had significant blood clots and bleeding noted from vaginal or rectal area. R1's emergency room hospital notes dated 10/1/2024 said, Pt (patient) with large amount of rectal bleeding in ED (emergency department). The notes said R1 was transfused with one unit of packed red blood cells and received Kcentra as an emergency intravenous medication to reverse the effects of R1's blood thinner medication to treat her blood loss. The notes continued to say R1 also had a rectal tube inserted to facilitate stool passage after receiving stool softeners for fecal impaction with stercoral colitis. R1's CT scan (computer tomography) of the abdomen dated 10/1/2024 said, A markedly heavy stool burden is seen throughout the colon, particularly in the rectosigmoid colon, with substantial distension of the rectal vault .These findings are concerning for fecal impaction with stercoral proctocolitis. The facility's policy titled Bowel Management dated 7/26/2024, said Policy Statement It is the facility's policy to record resident's bowel movement in the medical record. Procedure 1. The certified nurse aide on each shift will record the resident's bowel movements. 2. The facility will assess the resident when a resident shows sign and symptom of abdominal distress like pain, tenderness upon palpitation, rigidity, vomiting, etc. 3. If there is a change in the resident's pattern of bowel movement, the facility will notify the physician. 4. The facility will follow up to ensure that the physician's order is implemented .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to safely transfer a resident who was identified as needing two staff assistance. This applies to 1 of 3 residents (R2) reviewed for fall incidents in the sample of 6. This failure resulted in one staff attempting to transfer R2 from bed to wheelchair and in the process R2 buckling her knees requiring the staff to lower R2 on her knees, to the floor. R2 was sent to the hospital and was diagnosed with closed subcapital fracture of the left femur and dislocation of the left knee. The findings include: R2 was admitted to the facility on [DATE]. R2 had multiple diagnoses which included dementia without behavioral disturbance and morbid (severe) obesity due to excess calories, based on the face sheet. R2's admission MDS (minimum data set) dated November 29, 2022, showed that the resident was moderately impaired with cognition and required extensive assistance from the staff with regards to bed mobility, dressing, toilet use and personal hygiene. R2's MDS showed that transfer activity only occurred once or twice with one staff physical assist. The MDS also showed that R2 was not steady and required staff assistance for stability during surface-to-surface transfer (transfer between bed and chair or wheelchair). The same MDS showed that R2 uses a wheelchair as mobility device. R2's documented weight on February 1, 2023, was 218 pounds with the height of 61.0 inches. R2's progress notes dated February 15, 2023 (9:46 AM) created by V5 (agency Nurse) showed, Resident was lowered to the floor during a transfer from bed to wheelchair. She was unable to stand and pivot and her knees began to buckle under. C/o [complained of] pain noted to bilateral knees after resident was put back to bed. New orders for X-Ray of bilateral knees and volteran gel to both shoulders twice daily. R2's progress notes dated February 15, 2023 (3:37 PM) created by V14 (Nurse Practitioner) showed in-part, Patient is seen per staff request for a fall this morning. Staff reports that the patient was eased to the floor when she was about to fall. Patient reports that her knees gave away and she fell. She reports much pain to [bilateral] knees. Patient has h/o [history of] knee pain and shoulder pain. Restorative care staff with patient. Patient is in bed, no bruises on knees, has some swelling, had some swelling in the past too. Patient calm and cooperative, denies chest pain, SOB [shortness of breath], headache, dizziness, abdominal pain, n/v/d [nausea/vomiting/diarrhea]. Still has some pain to shoulders too, which was also there before the fall. The progress notes showed, pain level: 10. The same progress notes showed under assessment/plan, [Bilateral knee pain, [status post] fall today. [Continue] Tramadol 50 mg PO [orally] q8h [every 8 hours], [continue] Lidocaine patch 5% to [bilateral knees daily, x-ray [bilateral knees, Call MD (Medical Doctor) with x-ray results. R2's progress notes dated February 16, 2023 (7:09 PM) showed in-part, Resident transferred to [hospital emergency room] per PCP (primary care physician) order due to fall last night and inability to have x-ray done to left knee. R2's progress notes dated February 17, 2023 (1:36 AM) showed that the resident was admitted to the hospital with diagnoses of closed subcapital fracture of the left femur and dislocation of the left knee. R2's fall incident report dated February 15, 2023 (9:30 AM) showed, During transfer from bed to wheelchair, this resident was unable to pivot, and the CNA (Certified Nursing Assistant) could no longer support her, so she lowered her to the floor. Resident knees buckled. The incident report showed no visible injuries were observed post fall incident, however R2 complained of pain, with pain level of 10. R2's fall investigation made by the facility after the resident's fall on February 15, 2023, at 9:30 AM showed under the root cause analysis, [R2] is alert and oriented x 3 and requires extensive assist x 1 person with ADL's (activities of daily living). On [February 15, 2023] resident was eased to the floor by the CNA upon transfer. CNA was interviewed and she reported that she assisted [R2] to the edge of the bed in a sitting position, then assisted her in a standing position to get in the chair, the resident knees buckled, and she assisted her to the floor. Nurse on duty and NP (Nurse Practitioner) were notified. Resident was assessed with no apparent injury noted at the time of the fall. Bilateral knee x-ray was ordered. While waiting for the x-ray to be performed; resident complained of increased pain, MD (Medical Doctor) was notified and ordered to send resident to [hospital] ER (emergency room) for further diagnostic testing where she was admitted with diagnosis of closed subcapital fracture of left femur and dislocation of left knee. Based on investigation, it was concluded that [R2] knees buckled while standing caused her to lose her balance and fell. On March 3, 2023, at 3:52 PM, V13 (Physical Therapist/Rehab Manager) stated that based on R2's PT (physical therapy) records, R2 was evaluated by the therapist on November 29, 2022. V13 stated that R2 presented with status post fall with diagnosis of right shoulder dislocation and pneumonia. R2 was referred to PT due to decline in her ADL (activities of daily) and non-weight bearing on her right upper extremity. According to V13, based on R2's evaluation on November 29, 2022, the resident was maximum assistance (requiring 75% help) with bed mobility, transfers from bed to chair and sit to stand. R2 was totally dependent (100% help) with toilet transfer, was non-ambulatory, was not able to do wheelchair mobility, was non-weight bearing on her right upper extremity and with decreased sitting balance, which meant that the resident was unstable when sitting on the edge of the bed. V13 stated that she compared R2's documented status from the evaluation date and the PT discharge notes dated January 16, 2023, and it showed that the resident had minimal improvement only with regards to transfers from bed to chair, while the rest of the ADL mentioned above remained the same. According to V13, based on the PT discharge notes, R2's transfers from bed to chair minimally improved from maximum assistance to moderate/maximum assistance due to non-weight bearing on the right upper extremity, persistent weakness and obesity. V13 stated that based on R2's discharge status from PT on January 16, 2023, the resident would require two staff assistance with use of a gait belt to safely transfer R2 and to prevent potential fall. V13 elaborated that to safely transfer R2 in the nursing unit, two staff should be assisting the resident, one on each side, both holding the gait belt (at the back side) and the staff positioned on the left side should hold R2's left arm for support. V13 added that since R2 was non-weight bearing on the right arm, the staff positioned on the right side of the resident cannot support/ hold that arm of R2. V13 stated that after R2 was discharged from PT, the nursing restorative nurse was given the status information of the resident. This status information included instructions of what device to use during R2's transfers and how many staff should assist the resident during transfer in the nursing unit. V13 further stated that it is the standard of practice that if a resident needs more than minimum assistance with transfer while in therapy, the resident would require two staff assistance with transfer in the nursing unit, adding the fact that a resident is morbidly obese, it is more important to transfer the resident with two staff assistance with the use of a gait belt for safety. During the same interview V13 stated that because of R2's obesity and the buckling of the resident's knees during the incident (February 15, 2023), it was possible that the resident twisted her left knee at some point that caused the closed subcapital fracture of the left femur and dislocation of left knee. On March 3, 2023, at 5:11 PM, V3 (agency CNA (Certified Nursing Assistant)) stated that she was the only staff assisting R2 on February 15, 2023, when the resident had the incident. According to V3, it was her first time being assigned to take care of R2 on February 15, 2023. V3 stated that prior to her attempting to transfer R2 on February 15, 2023, between 9:00 AM and 9:30 AM, she asked V5 (agency Nurse) how many staff assistance does R2 needed during transfer. V5 told her (V3) that R2 needed only one staff assistance with gait belt. V3 stated that she proceeded to provide care for R2 and attempted to transfer the resident from bed to wheelchair on her own. According to V3 she applied the gait belt on R2's waist area, assisted R2 to sit on the edge of the bed, assisted R2 to stand up and attempted to assist R2 to walk towards the wheelchair. During the mentioned procedure, V3 cannot remember on which side of the resident she was positioned but stated that during the said process she was holding R2's gait belt at the back area and guiding the resident. V3 stated that R2 only took one step towards the wheelchair from the bed area when the resident said, wait I can't do it. During that time V3 stated that she positioned herself in-front of R2 while holding the gait belt on the front side of the resident. It was during that time that she noticed that R2's bilateral knees buckled, so she lowered the resident to the floor while holding the gait belt on the front side of the resident. According to V3 the incident happened so fast and because R2 was heavy and her (R2) knees had buckled, when she lowered R2 to the floor, the resident was on a kneeling position. V3 stated that when R2 was on the floor in a kneeling position she called V5 for assistance. After V5 saw R2 on the floor, they (V3 and V5) repositioned R2 from kneeling position to a sitting position on the floor. While R2 was in the sitting position on the floor, V5 assessed R2. V3 stated that after V5 had assessed R2, another CNA came in the room, and they placed R2 in bed using the full body mechanical lift. During the same interview, V3 stated that after the incident with R2, V2 (Director of Nursing) showed her a binder containing all of the residents transfer assistance. V2 pointed to her (V3) that based on the transfer assistance information (inside the binder), R2 should be transferred with the assistance of two staff using a gait belt. According to V3, she was not aware of the said binder, that is why she asked V5 prior to assisting R2. On March 4, 2023, at 9:10 AM, V5 (agency Nurse) stated that she was the assigned nurse for R2 on February 15, 2023 when the resident had the incident, and it was only her second time taking care of R2. V5 stated that she had worked on February 14, 2023 and was the assigned nurse for R2. According to V5 she was informed by a nursing staff (does not remember the name) during endorsement on February 14, 2023, that R2 is a one staff transfer with gait belt, so when V3 (agency CNA) asked her on February 15, 2023, about the transfer status of R2, she told V3 that the resident only needed one staff assistance using a gait belt. V5 admitted that she did not look at the binder containing each resident's transfer status which was available in the unit, to verify R2's transfer status before telling V3 on February 15, 2023. According to V5, when she was called by V3 to R2's room on February 15, 2023, around 9:30 AM, she saw R2 on the floor, about a step or two away from the bed. V5 described R2's position on the floor as, she was on a twisted position not fully sitting on the floor due to her weight but was partially kneeling on the floor. Her right knee was touching the floor, while her left knee was partially touching the floor. She had a gait belt around her waist. According to V5, R2 verbalized that she was okay and because of R2's uncomfortable position, they (V5 and V3) assisted the resident into a sitting position and had R2 extend her bilateral legs forward. V5 stated that during her assessment of R2, no visible injuries such as redness, bruising, swelling, rotation, or warmth were noted on the resident's legs and knees. R2 also did not complain of any pain at the time. After assessment, V5 stated that they (V5, V3 and another CNA who she does not remember the name) assisted R2 to the bed using the full body mechanical lift. According to V5, after transferring R2 in bed, the resident complained of bilateral knee pain and at that time R2 had pain patches on her knees. V5 stated that because the Nurse Practitioner was in the building, R2 was immediately seen with orders for voltaren gel (topical pain relief) to both shoulders and x-ray of the bilateral knees. On March 4, 2023, at 10:02 AM, V6 (Restorative Nurse) stated that after R2 was discharged from physical therapy she was informed by the therapist that two nursing staff should assist R2 during transfers with the use of a gait belt to ensure safety, prevent fall and prevent injury. V6 stated that R2's transfer status information requiring two staff assistance with gait belt was placed in a binder along with the other residents transfer status, which is available in the nursing unit. According to V6, she updates the transfer status information every week to reflect any changes. V6 presented the transfer status information forms dated February 9 and February 15, 2023, which showed the transfer status of multiple residents including R2. The same transfer status information forms showed under transfer type for R2, 2-Person Gait Belt. On March 6, 2023, at 1:28 PM, V14 (Nurse Practitioner) stated that she expects the nursing staff to follow the transfer status information during transfer of any resident. According to V14, if the facility had assessed R2 to be needing two staff assistance during transfer with the use of a gait belt, it should be followed for safety and to prevent fall incidents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to identify, assess, monitor and treat a pressure ulcer. The facility also failed to implement interventions to provide pressure relief modalities and prevent developing facility acquired pressure ulcer. This failure resulted in R1 developing a facility-acquired stage 3 pressure ulcer to the right buttock and was left untreated for unknown prolonged time. This applies to 1 of 3 residents (R1) reviewed for pressure ulcers in the sample of 4. The findings include: The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE]. R1's most recent hospitalization was on January 12, 2023, for evaluation of low blood pressure. R1 was back to the facility on 1/13/2023. R1, a [AGE] year-old, with multiple diagnoses including diabetes mellitus type 2, hemiparesis and hemiplegia due to cerebral infarction, major depressive disorder, dementia, peripheral vascular disease and amputee or absence of tight great toe and partial of the right foot. The MDS (Minimum Data Set) dated 1/13/2023 shows R1 has moderately impaired cognition (BIMS-Brief Interview Mental Status- a score of 11/15). R1 requires extensive assistance with two plus person physical assist for transfer, supervision with one-person physical assist for bed mobility, dressing, hygiene. R1 required physical help with bathing. R1 is usually incontinent of bladder function and has colostomy bag for bowel elimination. R1 shows a score of 0 /none for pressure ulcer. The MDS under behavior shows a score of 0 for no behavior and 0 for rejection of care. The MDS dated [DATE] shows that R1 required limited assistance with 1-person physical assist for transfer, toileting, hygiene, and bathing. There were 0 scores for behaviors and rejection of care. R1 has limited range of motion bilateral lower extremities. There was 0 score for no pressure ulcer. The skin evaluation dated 1/10/2023 shows R1 as high risk (Braden Score of 20) for developing pressure ulcer. Further review of skin evaluation shows that R1 has current skin alteration to the left lower leg, and right dorsal foot due to history of arterial insufficiency. This evaluation shows that R1 had no pressure ulcer. The quarterly dietician evaluation dated 12/12/2022 shows that R1's skin was intact. The evaluation also shows that the goal for R1 was to prevent skin breakdown. The care plan dated 1/13/2023 shows skin alteration that addressed R1's foot open wound due to the arterial circulation. There was no specific preventative measure in place to prevent R1 from acquiring a facility acquired pressure ulcer. The facility's shower schedule shows that R1 was scheduled to shower twice a week (Wednesdays and Saturdays-7:00 A.M.-7:00 P.M.). The Shower Sheet/Skin Audit Form of R1 dated December 15, 2022, through January 18, 2023, were reviewed. The shower sheets shows that R1 was given a 2 shower/skin audited for a period of a month. On 1/18/2023 at 4:00 P.M., R1's shower sheets from December 15, 2022, through January 18, 2023, was reviewed with V6 (CNA- Certified Nursing Assistant/CNA Preceptor/scheduler). V6 said that she collects the shower sheets provided to residents and files them in the shower book. V6 said that R1 was only given 2 out of 10 showers for one month period (December 15,2022 through January 18,2023). V6 also added that during shower day, skin check was done by the CNA that provided the shower and the nurse that was assigned to the resident. V6 further added that R1 can be difficult as he preferred V13 (CNA) to provide shower to him. V6 further stated that based on the shower sheet/skin audit, and electronic documentation for showers, R1 was only provided shower and skin audit on 12/25/2022 and 1/9/2023. V6 added that there were no alternate measures provided to R1 in case he would prefer other CNA in addition to V13. These shower sheet dated 12/25/2022 shows that R1 was noted with skin alteration to the left leg. There was no other skin alteration such as pressure ulcer. The shower sheet of 1/9/2023 shows that shower/skin audit was done and did not show any skin alteration. The progress notes dated 1/12/2023 at 4:45 P.M. shows that R1 was sent to the hospital for evaluation due to low blood pressure. The progress notes dated 1/13/2022 shows that R1 had returned to the facility at 12:30 A.M. The notes also show that R1's skin intact. The notes did not reflect on the open wound to the dorsal portion of right food documented on 1/10.2023. There was no Skin Evaluation/Assessment upon R1's returned to the facility on 1/13/2023. On 1/18/2023 at 4:30 P.M., V2 (Director of Nursing) stated that facility's standard of practice was to perform thorough Skin Evaluation/Assessment when a resident has returned back to the facility either a hospital visit or readmission. On 1/18/2023 at 10:00 A.M., V14 (RN- Registered Nurse/Emergency Department at acute hospital) stated that she remembers R1 because R1 was very unkempt, with very dry discolored almost to blackish discoloration of the left lower leg, and an open wound of the right dorsal foot. V14 stated that R1's skin especially to the lower extremities were very dry that when R1's pants was removed, skin was peeled off with the pants with skin flakes all over. V14 added that R1 was at the ED on 1/12/-13/2023. V14 stated that R1 has a stage 2 or 3 pressure ulcer to the right lower buttock. V14 stated that there was blood oozing from R1's pressure ulcer and no dressing was noted. On 1/18/2023 at 3:00 P.M., V10 (Wound Care Nurse) stated that together with V8 (Wound Care Nurse) they both manage skin alteration including wounds that are either pressure ulcers or arterial /venous wounds. V10 stated that R1 currently has no pressure ulcer and only has the right dorsal foot wound which was arterial in nature. On 1/18/2023 at 10:30 A.M., V11 (LPN/License Practical Nurse from agency staffing) who was assigned to R1 on 1/18/2023 stated that R1 has no pressure ulcer. V11 stated that R1 left the building on 1/18/2023 around 9:30 A.M. for dialysis treatment. On 1/18/2023 at 10:40 A.M., V5 (CNA/Certified Nurse Assistant from staffing agency) stated that R1 has no pressure ulcer and does his own ADL (Activities of Daily Living) by himself. On 1/19/2023 at 4:58 P.M., V15 (Registered Nurse from staffing agency) stated that he had taken care of R1 at least three times prior to sending him out to the hospital on 1/12/2023 at around 5:55 P.M. V15 described R1 being alert and oriented 2-4 spheres with bouts of forgetfulness, was able to propel own wheelchair but needs assistance from staff for dressing, and meal set up. V15 added that she did not check R1's skin integrity for presence of pressure ulcers. On 1/18/2023 at 3:45 P.M., R1 was observed when he returned to the facility from his dialysis treatment. R1 was sitting in his wheelchair. R1 was alert and oriented times 3. R1 has weakness to the left side of his body and was noted leaning to the left side. R1 stated because of his stroke it was hard for him to move around. With R1's permission, R1 allowed for skin check and was taken to his room. Multiple staff including V2, V4 and V5 (CNAs), V9 (Wound Care Technician), V8 (Wound Care Nurse) were observed trying to encourage R1 to transfer self from wheelchair to bed. R1 was observed barely able to move his feet (right foot partially amputated) for transfer. The staff present encouraged him to scoot to bed and pull himself out from the wheelchair. However, R1 was not able too. The staff attempted to assist him and transfer R1 manually, however R1 was to stand up for short period. During this time, R1 agreed to have his sacral area observed. R1 was not wearing an incontinence pad, and fresh blood was oozing from the pressure ulcer of the right lower buttock. The blood just oozed from the right buttock down to the floor. R1 could not tolerate standing so the staff placed his pants back on and returned R1 to his wheelchair. R1's lower body, including hip and buttocks area was so stiff so the staff was unable to maneuver R1. R1 was then transferred to bed with the use of the mechanical lift. V8 and V9 assessed the pressure ulcer that was oozing. V8 said Oh my I am so surprised with this pressure ulcer, no one had informed us about this. This is a stage 3 pressure ulcer of the right lower buttock. This pressure ulcer did not just happen to stage 3, it would have started at stage 1 and progressed to stage 3 which was the stage now. Nobody told us, the direct staff should had let me and (V10) know, if they were checking his skin, this pressure ulcer would have not missed and had progressed this far. We could have monitored and provided treatment before it got this far. Not sure how long he has this pressure ulcer, but have we known, we would have provided wound treatment. V2 was present during this time and was also surprised with the stage 3 pressure ulcer acquired by R1. They concur that R1's current bed mattress was not a pressure relieving device and the wheelchair pad was also just a vinyl pad and has no pressure redistribution modality. V4 stated that R1 always sleep in his lounge reclining chair. The reclining chair was made of vinyl and has no pressure relieving device/cushion. It was also noted that R1's wheelchair pad and edge of the wheelchair seat was with dried blood. R1 stated I have bedsores on my buttocks because I am sitting in my wheelchair, and it is not comfortable. I know I have bedsores on my buttocks because I was told when I went to the hospital last January 12, a week ago. I came back here, no one gave me treatment, cream and dressing on my bedsores. I always sleep in my reclining chair because my back hurts when I sleep in my bed. The mattress was just uncomfortable and did not help and I have also back injury from long time ago. Prior to R1 being placed to bed, it was noted that the bed mattress was slightly sunken at the middle part of the mattress. This was pointed to the staff present and one of them said even the bed frame is not functioning, it does not go up or down. V8 (Wound Care Nurse) measured R1's right lower wound and classified it a stage 3 pressure ulcer, with measurement of length as 11.5 cm x 4.5 cm in width, 0.20 cm in depth. V8 described also the pressure ulcer with 5 % slough tissues. After V8 provide the treatment to R1's pressure ulcer to the right buttock, V4 and V5 removed R1's pants totally off of him. R1's left lower extremities was severely discolored with blackish/leathery appearance. There were multiple spots of heavy accumulations of dry scabs and skin flakes coming out from his legs and noted on his pants. V8 said he could definitely use a treatment lotion and hygiene. The facility's policy for Wound Care with revision date of 8/12/2021 and a reviewed date of 8/2022 shows that the purpose of the wound policy was to prevent development of pressure ulcer and purpose of treatment to promote pressure ulcer healing. 1. PROCEDURE: 1. Timely identification of resident assessed to be at risk for skin breakdown. a) The Braden Scale must be completed by license nurse on admission /readmission. c) Each risk factor and potential causes should be identified and reviewed individually and addressed to resident care plan. d) Facility should decide a plan of care and implement intervention. 3. Prevention of skin breakdown a) Daily regular hygiene c) inspection of the skin every shift with care for signs of breakdown f) Moisturize skin with lotion to hydrate skin soft and pliable h) Administer scheduled shower /bath and completion of Shower & Skin Audit Form and document findings. 4. Activity, Mobility and Positioning b) Establish an individualized turning and repositioning of resident is with impaired functioning. c) While in bed or wheelchair, resident should be turned and repositioned at least every 2 hours d) While in sitting position, resident should repositioned every 2 hours e) While in sitting position, if resident is capable of repositioning self, resident should be encourage to shift weight regularly to help relieve pressure on the sacral/ischial and or pressure point areas. The facility policy for Shower & Hygiene with revised date of 7/28/2022 shows ensure that residents shower/hygiene care is provided by the nursing staff to promote cleanliness, provide comfort to the resident and observe condition of skin.