3. R135's face sheets shows he has diagnosis including respiratory failure, dehydration, emphysema, urine retention, and protein calorie malnutrition. On 1/27/25 at 9:43 AM, R135 was observed lying in bed. V8 (Certified Nursing Assistant-CNA) provided incontinence care. V8 removed his incontinent brief, his sacrum was red with an open area without a protective dressing in place. On 1/28/25 at 10:44 AM, V2 (DON) went to provide wound care to R135. V2 removed his incontinent brief R135's sacrum remained without a dressing in place, his sacrum was red with an open area. V2 said R135 has a pressure ulcer to his sacrum and should have a dressing in place. R135's admission Evaluation dated 1/21/25 documents an open area to his buttock measuring 0.8 cm (centimeters) x .5 cm. R135's Physician Order Sheets dated January 2025 shows orders including sacrum open area-cleanse with normal saline dry and cover with a foam dressing daily. Based on observation, interview, and record review the facility failed to follow the Wound Physician's recommendations, failed to identify, report, and obtain treatment for wounds and failed to provide pressure relieving intervention to prevent the development of pressure ulcers for 4 of 9 residents (R73, R45, R135, R35) reviewed for pressure ulcers in the sample of 20. This failure resulted in R73's MASD-Moisture Acquired Skin Disease to the left and right gluteal area developing into a left gluteal Stage 3 and right gluteal Stage 4 pressure ulcer. The findings include: 1. R73 Predicting Pressure Ulcer score risk dated 10/12/2024 (admission) shows, High Risk On 01/28/25 at 11:11 AM, V2 DON-Director of Nurse changed the dressing for R73's Stage 4 pressure wound to the left buttock and the Stage 4 pressure wound to the left heel. On 01/28/25 at 11:11 AM, V2 DON-Director of Nursing said, R73 did have redness to the right butt cheek upon admission but developed the pressure ulcer in the facility. R73 admission assessment dated , 05/10/24 at 7:18 PM, shows, Skin MASD in buttocks - very red but intact, Dry scab at Right foot 2 x 1 cm (centimeter), Dry scab at left shoulder - no drainage noted, scattered bruises and scabs at arms and legs due to fall. R73's Initial Wound Evaluation by V11 Wound Doctor dated 10/16/24 shows, unstageable Deep Tissue Injury of the Left Heel, etiology Pressure, Duration Less than 2 days. Size 8.3 cm x 4.1 cm. Skin intact with purple/maroon discoloration. Recommendations: Off-Load Wound; Float Heels in Bed; Pressure Off-Loading Boots. Stage 4 Pressure Wound of the Right Buttock Full thickness. Etiology Pressure Stage 4, duration greater than 14 days. Noted to be present on admission per staff. Wound size 2.6 cm x 1.1 cm x 0.5 cm centimeters. slough 10%. Stage 3 Pressure Wound of the Left Buttock Full Thickness. Etiology Pressure Stage 3, Duration greater than 14 days, noted to be present on admission per staff. Wound size 4.5 cm x 7.3 cm x 0.3 cm. 100% subcutaneous dermis. R73's Current Care Plan on 01/28/25 shows, V11's Recommendation to float heels in bed and to apply pressure off-loading boots has NOT been initiated as an Intervention in R73's Care Plan. R73's Wound Evaluation & Management Summary dated 11/27/24 by V11 Wound Doctor shows, Stage 3 pressure wound of the left buttock full thickness etiology pressure, stage 3, duration greater than 56 days noted to be present on admission per staff, 4.5 cm x 8.1 cm x 0.5 centimeters, 30% slough, 20% granulation, 50% subcutaneous dermis. Recommendations: Cipro 500 milligrams by mouth twice a day for 10 days started yesterday by primary care physician with positive cultures of wound and urinary tract infection. R73's MAR dated November 2024 and December 2024 shows, R73 did not receive the wound physicians recommended antibiotic of Ciprofloxacin 500 milligrams by mouth twice a day for 10 days between November 27, 2024, to December 6, 2024, for the Stage 3 Pressure Wound. On 01/28/25 at 1:43 PM, V2 DON said, the nurse that is given the Physician Order is responsible to ensure it is performed. This would be the reasonability of the Wound Nurse to input the order to pharmacy, obtain the wound culture, and notify the primary care physician. On 01/29/25 at 11:29 AM, V11 Wound Doctor said, R73 had a wound infection. I coordinate with the Infection Control Nurse and the Primary Doctor. The Infection Control Nurse ensures the order goes through appropriately and follows up on the wound culture results. On 01/29/25 at 12:54 PM, V2 DON said, the facility's Infection Control Nurse left in August of 2024. I have had a few different Wound Nurses off and on over the past year. My current Wound Nurse started 3 days ago. The Facility's Nursing Skin Integrity policy dated 03/20/23 shows, the licensed nurse using the EMR -electronic medical record observation tool, is to complete a Head-To-Toe Assessment to identify any/all areas of loss of skin integrity. The includes pressure injuries, non-pressure injuries, skin tears, bruises . Notify sites the wound nurse/DON of any skin integrity issues. Evaluate areas of loss of skin integrity and complete a wound consult as appropriate. If the wound doctor is following the resident's wound, their weekly assessment is sufficient for the week. It is the wound nurse/DON's responsibility to ensure all orders and/or recommendations from the Wound Physician are carried out timely. On 01/28/25 at 11:11 AM, V2 DON-Director of Nursing removed R73 right pressure reduction boot. R73 had a 1 centimeter by 1 centimeter black/purple area on the bony prominence of the medial ball of his right foot that looked like a deep tissue injury. On 01/28/25 at 11:11 AM, V2 DON said, the discoloration to the right medial ball of his right foot was not there last week when I assessed R73 with the wound doctor. On 01/28/25 at 11:11 AM, R73 denied any injury to the foot. On 01/28/25 01:49 PM, V2 DON, said, I have not documented on R73's discoloration. None of the staff reported the discoloration. R73 has no record of recent injury. The wound doctor will see R73 tomorrow. I will call it discoloration and allow the Wound Doctor to make the determination. On 01/29/25 at 9:43 AM, V10 Wound Doctor said, the wound on the right medial ball of R73's foot is a deep tissue injury. Deep tissue injuries are caused from the tissue resting against a surface for too long. R73 also has a diagnosis of diabetes which increases his risk for wound development. I will classify the wound as a pressure ulcer. The Facility's Nursing Skin Integrity policy dated 03/20/23 shows, evaluate areas of loss of skin integrity and complete a wound consult as appropriate. Complete the appropriate entry on the wound care log. 2. R45 Predicting Pressure Ulcer score risk dated 05/21/24 (admission) shows, At Risk On 01/27/25 at 10:00 AM, R45 observed lying on her back. On 01/28/25 at 1:48 PM, R45 observed lying on back, the positioning wedge was sitting on a chair in her room. On 01/29/25 at 9:55 AM, R45 observed laying on her back with the head of the bed up at 45 degrees. On 01/29/25 at 10:08 AM, V10 Wound Care Doctor said, R45's wound was acquired in the facility. It currently measures 1.8 cm (centimeters) x 1.4 cm x 0.2 cm deep. On 01/29/25 11:02 AM, V2 said, on 5/14/24, R45 was Care Planned that she prefers to lay on her back, identified on admission. On 09/07/24 it was observed that R45 had an open area to her coccyx, we added the pressure reducing mattress that day (09/07/24). On 01/29/25 at 11:29 AM, V11 Wound Doctor said, it is not normal for skin to progress from intact tissue to a stage 4 pressure ulcer, it can happen. Skin can break down quickly and then the muscle. Perhaps the air mattress would have prevented the opening of the wound. R45's admission Skin Observation Tool dated 05/14/24 shows, Skin is intact . R45's Care Plan initiated 05/14/24 shows, R45 likes to lay on her back that can further increase risk of skin breakdown. Care Plan Initiated 05/21/24 R45 is in need of assistance with ADL's-Activities of Daily Living. She insists to stay in bed and needs staff encouragement and substantial maximal assist from staff to roll left and right. R45's Initial Wound Assessment by V11 Wound Care Doctor dated 09/11/2024 shows, Stage 4 Pressure Wound Sacrum Full Thickness, Etiology Pressure, Duration greater than 4 days, Wound Size 3.5 cm x 2.6 cm x 0.4 cm. The facility's Nursing Skin Integrity policy dated 03/20/23 shows, validate a care plan with appropriate interventions initiated. R45's Physician's Orders dated 09/07/24 shows, R45's Pressure Redistribution Mattress was ordered 09/07/24. The facility did not provide R45 with a pressure reducing mattress until after she developed a Stage 4 pressure ulcer. 4. On 01/27/25 at 01:15 PM, R35 observed in bed. There was an air mattress pump hanging on the foot of the bed. The power switch to the air mattress pump was in the off position. The green power button was not lit up. On 01/28/25 at 08:54 AM, V3 (Registered Nurse) confirmed the air mattress pump on R35's bed was off. V3 added that the pump should be on while R35 was in bed. R35's Order Summary Report printed on 1/28/25 showed an order for an air mattress. R35's Care Plan with an initiated date of 9/11/24 showed R35 was at risk for developing pressure injuries. Listed under interventions was for R35 to receive a pressure relieving/reducing mattress. On 01/28/25 at 01:39 PM, V4 (Certified Nursing Assistant) said an air mattress/pump is a pressure relieving intervention.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R5's care plan dated 11/20/23 showed R4 was at risk for choking or aspiration due to her diagnoses of dysphagia and dementia. The care plan showed R5 had a history of pneumonitis due to aspirating food and/or fluids. The care plan showed R5 will be assisted by CNAs (certified nursing assistant) if she eats in her room .Needs supervision during meals, cut foods into small pieces and redirect the resident to chew and swallow one at a time, slowly . R5's hospital records showed R5 was hospitalized on [DATE] with a diagnosis of gastrointestinal bleeding. R5's hospital speech therapy evaluation dated 12/8/23 showed R5 required a mechanical soft with nectar thick liquids due to her risk of choking. The evaluation showed R5 must be fed by staff to ensure R5 was eating slowly and was following the recommended feeding cues. The evaluation showed R5 was not to have straws in her drinks due to her choking risk. R5 was discharged from the hospital, back to the facility, on 12/14/23. On 2/5/24 at 11:56 AM, R5 was in bed, eating lunch. No staff were present in R5's room. R5 swiftly scooped food into her mouth; occasionally dropping food onto her lap. No coughing was noted from R5. Two Styrofoam cups with lids and straws, one containing thickened coffee and the other thickened water, were noted on the tray, directly in front of R5. On 2/5/24 at 1:03 PM, R5 remained in bed. One Styrofoam cup, with a lid and straw, was noted in front of R5 on her bedside table. The contents of the cup appeared to be non-thickened water. V8 Licensed Practical Nurse (LPN) entered R5's room. She picked up the cup, opened the lid and shook the cup, and stated, That's regular water. That's not thickened. V8 closed the cup and placed it back down in front of R5. V8 exited the room. On 2/6/24 at 9:39 AM, V9 Speech Therapist (ST) stated R5 has dysphagia that is chronic and ongoing. V9 stated R5's last speech therapy session was 12/5/23. V9 had not evaluated R5 since she had been readmitted from the hospital on [DATE]. V9 stated, I saw her in December because staff had reported she was coughing during meals. Upon evaluation, I downgraded her diet to mechanical soft and regular liquids. Upon her discharge from me, I said she needed direct, 1:1, supervision when eating due to her dysphagia and tendency to eat to fast. It looks like her fluids were changed to nectar thick in the hospital . I also see the (physician) order for no straws. She has a tendency to drink and eat too fast. Straws have a tendency to make people gulp and drink faster. That's why she probably shouldn't be using straws. 3. R7's care plan dated 12/4/23 showed R7 required the use of a sit-to-stand (mechanical) lift, with the assistance of two staff, for all transfers and toileting due to her unsteady balance and generalized weakness. On 2/5/24 at 11:41 AM, V10 CNA transferred R7, via sit-to-stand lift, from a wheelchair to the toilet. R7 was hanging onto the lift with her hands. R7's knees were bent as she was unable to bear weight and stand. No other staff were noted in R7's room. On 2/6/24 at 9:31 AM, V2 Director of Nursing (DON) stated all resident transfers, via a sit-to-stand, are to be performed by two staff members, not one. The facility's Lifting Machine, Using a Mechanical policy dated July 2017 showed, At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift. 4. R44's care plan dated 12/20/23 showed R44 required the substantial assistance of one staff when being transferred from bed to wheelchair. On 2/5/24 at 10:35 AM, V16 CNA transferred R44, from her bed to a wheelchair, by lifting R44 up, under her armpits, and pivoting her into the chair. R44 was unable to bear weight during the transfer or hold onto V16. No gait belt was used during the transfer. On 2/6/24 at 9:31 AM, V2 DON stated gait belts are to be used to transfer any resident that requires staff assistance. The facility's Gait Belt policy dated 6/1/23 showed, Gait belts are to be used for all transfers that require staff assistance and when assisting residents to ambulate. Based on observation, interview and record review the facility failed to ensure residents were transferred in a safe manner. This failure resulted in R432 being sent to the hospital for 8 days due to increased pain after a transfer. The facility also failed to ensure a resident with a diagnosis of dyspagia was supervised during meals and failed to ensure a resident was provided nectar thick liquids as ordered. This applies to 4 of 18 residents (R5, R7, R44 and R432) reviewed for safety in the sample of 18. The findings include: 1. R432's Face Sheet shows that he originally admitted to the facility on [DATE]. R432's Physical Therapy Evaluation dated 1/8/24 shows that he was referred to therapy for strengthening and decrease level of assistance in bed mobility and transfer. The report shows, Patient exhibiting difficulty performing bed mobility, transfer, sitting balance and ability to stand. The assessment shows that he needs maximum assistance of 2 people for transfer and is dependent on staff for bed-to-chair transfers and has no reports of pain. The assessment shows that R432 is alert and oriented to person, place and time. On 2/5/24 at 1:50 PM, R432 said that he had to go to the hospital due to severe back pain after an incident with a transfer. R432 said that he was using the slide board to transfer from his wheelchair to his bed. R432 said that once he got to the side of the bed, the aide that was behind him came to the front of him and he fell back in bed because no one was supporting his upper half and he hurt his back. R432 said that the pain was a 12 out of 10. R432 said that it was horrible. R432 said that before the incident he would have back pain when he moved but it was only at a 6 out of 10. R432 stated, I had to go to the hospital after that. I could not even lay in the MRI machine, it hurt so bad. They had to sedate me. R432's History and Physical dated 1/8/24 shows, admitted with spinal stenosis with lumbar myelopathy .lumbar fusion and spinal cord stimulator. He is feeling better. R432's Rehabilitation Practitioner Note dated 1/9/24 shows that his pain is 4-5 out of 10 Bed mobility maximal assistance x 2. Slide board transfers-maximal to total assist of 2 . R432's Nursing Note dated 1/10/24 at 5:36 PM shows, Resident complained of severe pain 10/10 stated that he had never felt this bad before and was very concerned. Given norco as ordered with relief. Called [Physician] and made aware. New order received for stat x-ray of the lumbar spine and lidocaine patch . R432's Nursing Notes dated 1/13/24 at 10:00 PM shows, patient complained of pain while sitting in his wheelchair. He is scheduled for PT Norco 5/325 1 tab given at 3:26 PM. He refused to go to therapy due to pain. Patient was put back to bed with 2 assist using the sliding board pain is getting worse per patient 10/10 and unbearable want to go to hospital requesting to call 911 picked up the patient at 4:48 PM. R432's Hospital Notes dated 1/13/24 shows, Presents to ED (Emergency Department) chief c/o (complaint of) low back pain; today while in PT (Physical Therapy), fell backwards onto mattress .Patient requiring multiple doses of narcotics to manage his pain; doesn't feel safe returning to rehab. Plan for admission for pain control, symptom stabilization. R432's Hospital Notes dated 1/14/24 shows, Patient reports he had been doing fair at SNF (Skilled Nursing Facility), but still with significant weakness. Patient reports he had a fall/injury to his back earlier this week while working with PT, for which he was started on a medrol dose pack (steroids) on 1/11. Then today patient was again working with PT and fell backwards on to the bed and had acute worsening of his left sided low back pain of which he presents today .pain control-oxycodone (narcotic pain medication), flexeril (muscle relaxer), lidocaine and diclofenac patches, hydromorphone (narcotic pain medication) for breakthrough . On 2/6/24 at 11:18 AM, V7 (Nurse Supervisor) said that R432 was a slide board transfer and was complaining of increased pain after a transfer. R432 was sent to the hospital for a few days and came back with an increase in pain medication and is now a mechanical lift transfer. On 2/6/24 at 1:18 PM, V21 (Nurse Practitioner) said that R432 was re-admitted to the hospital for severe back pain but she was unaware of any incidents that happened that caused the pain. On 2/7/24 at 8:58 AM, V23 (Occupational Therapist) said that when R432 was first admitted , he was able to use the slide board for transfers with two people. V23 said that when R432 first came in, he was unable to sit on the side of the bed independently. V23 said that for a two person assist slide board transfer, the patient should be assisted from the wheelchair to the bed by placing the slide board between the bed and the chair. V23 said that once the resident is in bed, one person should assisted with his trunk due to poor trunk control and one person should assist with his legs and move him to a laying positron in one swift movement so there would be no strain on the back especially with his history of back problems. V23 said that R432 needs assistance with trunk support at all times unless he would fall over in bed. On 2/7/24 at 9:24 AM, V24 (Certified Nursing Assistant) said that himself and another aide put R432 to bed on the evening of 1/10/24. V24 said that they used the slide board. V24 said that after a resident is assisted to the side of the bed with the slide board, one person would direct the resident's feet and one person would direct their trunk. V24 said that he did not remember if he was assisting with the feet or trunk. V24 said that he did not remember if R432 fell back in bed or not and V24 said that he did not remember if R432 complained of pain after the transfer. R432's Face Sheet shows that he was readmitted to the facility on [DATE]. R432's Physical Therapy Evaluation dated 1/22/24 shows he requires maximum assistance of two persons for bed mobility and totally dependent on staff for transfers and is in severe pain. R432's Medication Administration Record (MAR) for January shows that between 1/7/24 and 1/10/24 he was taking a lidocaine patch to his lower back daily and norco 5/325 milligrams (mg)-1 tablet every 4 hours as needed for pain. R432 took the norco five times for pain of 4 to 7 out of 10. After 1/10/24, R432 took norco 5/325 mg-1.5 tablets every 4 hours as needed for pain 12 times between 1/10/24 and 1/13/24 for pain of 3 to 10 out of 10. R432's MAR shows that when re-admitted from the hospital on 1/21/24 he was ordered oxycodone 5 mg every 4 hours as needed for pain and flexeril 5 mg every 8 hours as needed for muscle spasms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assess and identify a resident's pressure injury to her right lower leg until it was a stage 3 acquired pressure injury from a medical device. This applies to 1 of 3 residents (R2) reviewed for acquired pressure injuries in the sample of 3. This resulted in R2 sustaining a facility acquired stage 3 pressure injury. The findings include: R2's face sheet shows R2 is [AGE] year old who was originally admitted to the facility on [DATE], with diagnoses that include right femur fracture that had undergone hip surgery, history of falling, and diabetes. , R2's Braden scale (predicting pressure score risk), dated 10/30/23, shows R2 is at risk for developing pressure. R2's skin admission assessment, dated 10/11/23, shows R2 had no pressure injury except a surgical incision to right hip. R2's hospital Discharge summary, dated [DATE], shows an order for R2's right lower extremity to be non weight bearing, and the knee immobilizer to be on at all times. R2's care plan, dated 10/12/23, shows R2 was at risk to develop further skin breakdown, but did not include R2's use of the immobilizer or any care that needs to be done when wearing a knee immobilizer. R2's Wound Evaluation Management Summary, dated 11/1/23, was when R2's pressure injury was discovered to her right lower lateral calf that was a stage 3 measuring 6.5 centimeters (cm) x 2.5 cm x 0.1 cm. The Facility Wound Report, dated 1/3/23, provided to this surveyor shows R2's facility acquired pressure injury to her right lower lateral calf was now a stage 4 measuring 3.5 cm x 1.0 cm x 0.1 cm . On 1/3/24 at 10AM, R2 was in bed on a low air loss mattress. R2's right leg was suspended with a pillow. R2 said she fell at home, hurt her right leg, and had surgery. R2 said she now has a wound at the back of her right leg, but cannot recall what happened. V4 (Wound Nurse), who was also in R2's room, showed this surveyor R2's pressure injury to right lower lateral calf. A huge open wound was noted at the back of R2's right lower leg. V4 said R2's acquired pressure injury came from R2's knee immobilizer (medical device) she was using before. V4 then opened a closet, took a knee immobilizer, and showed this surveyor that this was R2's knee immobilizer. The knee immobilizer has velcro on the side. V4 pointed a hard area at the back part of the immobilizer, and said R2's right lower leg was laying directly on the hard part of the immobilizer; that had caused pressure injury on R2's right lower leg (calf). V4 said R2 was complaining of discomfort to that area. V4 said when the immobilizer was removed to check the skin, V4 had a stage 3 open area to her right lower leg V4 said the order was for R2 to use the immobilizer at all times, but typically, the skin can be checked during care. On 1/3/24 at 10:20 AM, V6 (Wound Doctor) said she took over R2's wound care for the past 4 weeks now. V6 said, (R2) has fragile skin and is also a diabetic. Wearing a knee immobilizer has the potential risk to cause the development of pressure injury. Slight movements can cause the immobilizer to move that can cause skin frictions. V6 said it was important to check the placement of the immobilizer and inspect the skin underneath. On 1/3/24 at 2PM, V2 (Director of Nursing) said since the order of the knee immobilizer was on at all times, no one was checking the skin underneath. V2 also said the order was not clarified to the Ortho if it can be removed for skin checks. V2 also confirmed R2's immobilizer was not part of R2's Physician Order Sheets (POS). On 1/3/24 at 2:15 PM, V7 ( R2's previous Wound Doctor) said, (R2) had an order of wearing the immobilizer at all times from Orthopedic, but generally speaking, when a resident wears an immobilizer, staff has to check the skin from time to time as immobilizer can cause pressure or skin irritations. The facility presented a document entitled Unavoidable Pressure Injury clinical condition, dated 1/4/24. The facility also presented a document from the Orthopedic MD, dated 1/4/24, that R2 has to wear the knee immobilizer until 11/13/23.