Based on observation, interview, and record review the facility failed to ensure interventions were placed when a pressure injury was identified and failed to ensure treatments and pressure reducing interventions were in place for 2 of 3 residents (R33, R21) reviewed for pressure in the sample of 12. This failure resulted in R33 sustaining a stage 3 pressure injury to her coccyx. The findings include: 1. On 3/3/25 at 10:15 AM, R33 was in bed sleeping. R33's air mattress was deflated, and R33 was laying on the bed frame. The air mattress controller said standby. Heel protection boots were observed in R33's wheelchair in the room. At 10:19 AM, V3 Certified Nursing Assistant came into the room and said the air mattress controller was not supposed to say standby. V3 tried to un-plug and re-plug the unit and the mattress did not inflate. V3 looked at the control unit again and discovered the unit was turned off. V3 turned on the unit, and the mattress inflated. V3 said the mattress needs to be turned on in order to relieve pressure and R33 is supposed to have the heel protection boots on when in bed. On 3/4/25 at 9:46 AM, V2 Director of Nursing said the floor nurses do weekly skin assessments and complete a progress note if there is a skin issue. V2 said the nurses are supposed to do an assessment with measurements, get treatment orders, and alert her if there is a wound. V2 said she checks the documented measurements and makes sure the doctor is contacted for treatment orders. V2 said, if necessary, the wound doctor can see them. R33's Skin/Wound Note dated 2/17/25 at 10:45 PM shows, Resident had shower this evening. Bilateral lower and upper (BL/UL) discolorations. Open sore on coccyx. R33's Skin/Wound Note dated 2/27/25 at 1:49 PM shows Pressure wound to sacrum measuring 2.1 x 1.5 x 0.3 cm [centimeters] found during cares. [V6 Wound Physician] in building and saw resident today. Will admit to wound care services. Area cleaned with wound cleanser. New treatment order from [V6] to cleanse wound with wound cleanser. Apply hydrocolloid sheet BID [twice per day] and PRN [as needed] for 30 days. On 3/4/25 at 1:52 PM, V2 said R33 has a facility acquired pressure injury. V2 said last Thursday (2/27/25) the Certified Nursing Assistants reported it to her after the wound was found while R33 was being changed. V2 said she looked at the wound and V6 was in the building, so she had him see R33. V2 said she was not aware that it was found on 2/17/25 according to the nurse progress note. V2 said the nurses should have notified her and got treatment orders. V2 said R33 has pressure reducing interventions including an air mattress and cushioned heel boots. V2 said the air mattress should be plugged in and the resident should not be laying on a deflated mattress. V2 said R33 should have her heel boots on when in bed. On 3/5/25 at 10:44 AM, V7 Licensed Practical Nurse said she was in training on 2/17/25 and recalled R33's open area but could not recall details of the wound. V7 said she did not take measurements, get treatment orders, or notify V2. On 3/5/25 at 2:25 PM, V6 Wound Physician said he saw R33 for the first time on 2/27/25 and was told they had found the wound that day. V6 said he classified the wound as a stage 3 pressure injury. V6 said his report shows duration of > (greater than) 3 days, which was based on his clinical judgement of how the wound looked to him. V6 said he saw granulation tissue in the wound and it takes more than 48 hours for granulation tissue to evolve, it doesn't show up right away. V6 said he would expect without treatment, a wound would decline further. V6 said a wound would not improve on its own. V6 said lack of treatment and pressure reducing interventions would contribute to the wound worsening. R33's Most recent Braden Scale for Predicting Pressure Ulcer Risk (provided by the facility) dated 7/27/24 shows R33 is at high risk for pressure injury. R33's Initial Wound Evaluation and Management Summary by V6 is dated 2/27/25 and shows, Stage 3 Pressure Wound Sacrum Full Thickness, duration: >3 days, measuring 2.1 x 1.5 x 0.3 cm. Recommendations off-load wound, reposition per facility protocol, group 2 mattress. R33's Physician Orders for February 2025 do not contain wound treatment orders or pressure relieving interventions for R33's coccyx wound until 2/27/25. R33's treatment order were started on 2/27/25 and show, air mattress to bed for proper weight distribution, check every shift and PRN for proper inflation. 2. R21's Wound Evaluation & Management Summary dated 1/23/25 shows R21 has a stage 2 pressure wound of her left, medial buttock (Site 10) with a duration greater than three days measuring 3.6 centimeters (cm) by 1.9 cm by 0.1 cm and is to receive wound treatment three times a week for 30 days. R21's Wound Evaluation & Management Summary dated 1/30/25 shows R21's Stage 2 pressure wound (Site 10) had increased in severity to a stage 3 pressure wound measuring 11.2 cm by 6.7 cm by 0.2 cm. R21's Treatment Administration Record (TAR) for 1/1/25 through 1/31/25 does not show any treatment scheduled for R21's pressure ulcer of her left, medial buttock. R21's current Order Summary Report for 1/20/25 through 3/31/25 and Order Summary Report for 1/20/25 through 3/31/25 for discontinued orders both show there are no orders for wound treatment of R21's pressure ulcer of her left, medial buttock from 1/23/25 through 2/5/25. On 3/4/25 at 1:52 PM, V2, Director of Nursing and Wound Care Nurse, said R21's pressure ulcer of her left medial buttock was identified when she was doing wound rounds with the Wound Care Physician, V6. On 3/5/25 at 10:19 AM, V2 said V6 does his progress notes of each resident wound right away after his wound rounds on Thursdays. V2 said she accesses V6's progress notes (Wound Evaluation & Manage Summary) and enters his treatment orders into their computer system and treatment orders are started the next day. On 3/5/25 at 2:22 PM, V6 said he would expect a wound to worsen/decline if wound treatment is not being provided. The facility's Assessment of Skin Alteration Policy dated 11/2017 shows residents with skin alteration will be assessed and treatment will be provided as ordered by the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to assess and monitor a resident (R7) with a history of pneumonia showing a change in condition. This failure resulted in R7 being admitted to the hospital in poor condition. The facility also failed to correctly apply elastic bandages to a resident (R29) with lower extremity edema. This applies to two of two residents (R7 and R29) in the sample of 12 reviewed for quality of care. The findings include: 1. The Physician Order Sheet (POS) for R7 shows diagnosis to include anemia, coronary artery disease and chronic obstructive pulmonary disease. The POS shows orders for oxygen at 2-4 liters via a nasal cannula as needed to keep the oxygen saturations above 90%. The facility assessment dated [DATE] shows R7 to be cognitively intact. On 5/23/23 at 9:21 AM, R7 was observed being taken from the bathroom by staff and placed in her wheelchair. R7 immediately fell asleep, and her breathing sounded congested. R7 would wake up when her name was said but would immediately fall back to sleep. R7 had an oxygen concentrator in her room but it was not being used. At 9:30AM, V3 Licensed Practical Nurse (LPN) was asked about R7's current condition and V3 said R7 has been like this lately due to her medications being changed. On 5/23/23 at 10:16 AM, R7 continued to sit in her wheelchair in her room asleep, leaning over to the right, with her right hand hanging down. R7's breathing sounds congested, and she was coughing. On 5/23/23 at 10:44 AM, R7 was still in her room asleep in her wheelchair, both hands are hanging down by her side. On 5/23/23 at 11:48 AM, R7 was moved to the dining room leaning over to the right, still sleeping, hands hanging down. The staff and other residents were saying her name and she would wake up for a very short period and immediately fall back to sleep. R7 was spilling her lunch on the floor. R7 could be heard coughing at times. At 12:48PM, R7 had been pushed into the activity room and was still asleep in her wheelchair with her hands hanging down by her side and leaning to the right side. At 1:16 PM, R7 was still in the activity room, asleep in her wheelchair. On 5/23/23 at 1:20PM, R7 was pushed down the hall by 2 Certified Nursing Assistants (CNA). One CNA was pushing the wheelchair and the other was holding her legs up. V3 came into R7's room and checked her blood pressure and oxygen saturations. V3 applied the oxygen nasal cannula to R7 and was observed adjusting the oxygen and rechecking her oxygen saturations. V3 left the room and returned with a oxygen mask which she then applied to R7 and continued to check R7's oxygen saturation. V3 left the room again and returned with a nebulizer treatment for R7. V3 said she had notified the Nurse Practitioner for a chest x-ray order. R7 continued to have a difficult time staying awake and following commands. On 5/23/23 at 1:55 PM, R7 was in bed asleep, and her oxygen is set at 8 liters using the mask. R7 was observed using her abdominal muscles to breath. On 5/23/23at 2:59 PM, R7 was asleep in bed with her oxygen at 8 liters per mask, using accessory muscles to breath. On 5/24/23 at 8:00AM, R7 was not in her room. R7's medical record shows a note dated 5/23/23 at 3PM by V3 that R7 was having a hard time staying awake, was lethargic and slept through lunch. V3 documented that R7's oxygen saturation was 81% and she had started oxygen at 6 liters via a mask. V3 wrote she had contacted the NP and an order was received for a chest Xray and cough syrup. The note also shows a nebulizer treatment was completed and R7's saturations went up to 91% on 6 liters of oxygen. No further nursing notes were made by V3 that day for R7 regarding her change in condition. On 5/24/23 at 9:15 AM, V5 NP said she would have expected the nurse on duty to intervene and assess her earlier in the day since you informed her of the lethargy, cough and congestion. V5 said earlier intervention does have better outcomes. On 5/24/23 at 1:53 PM, V7 CNA said R7 does act more tired in the morning and will fall asleep quickly but yesterday was different, she spilled food on her for breakfast and for lunch. She usually [NAME] up after breakfast but yesterday she did not. That was different I told the nurse she was acting differently that day. On 5/25/23 at 8:17 AM, V6 LPN said she was the nurse who sent R7 out to the hospital. V6 said she was told in report at 6 PM that R7 was very sleepy, her oxygen saturations were in the 70's and was having a hard time breathing, hard to arouse. When I went in around 8PM to give meds, her skin was gray, she was having a hard time breathing and was hard to arouse, she would not take her meds, she was short of breath and had crackles in her lungs and was spitting up green sputum. V6 said she called the NP and was told to send her to the emergency room. V6 said she later called the hospital to check on R7 and was told she had to be transferred to another hospital for high flow oxygen. On 5/25/23 at 9:54 AM, V3 said when this surveyor approached her about R7, she felt it was just the usual behavior for R7. She did not feel the need to go check her. V3 said when she saw the CNA's bring her down the hall holding up her feet, she decided to go check her. Her oxygen saturations were 71 % at that time. V3 said she started the oxygen and gave R7 a breathing treatment and notified the NP that R7 was unresponsive, had low oxygen saturations and was coughing. I received an order for a chest x-ray and cough syrup. V3 said R7 had just had pneumonia last month and getting a chest X-ray was standard protocol for shortness of breath. The nursing progress notes for R7 shows V6 documented at 8PM that R7's color was gray, she was very lethargic, short of breath and R7 could not tell V6 where she was. R7 was coughing up green phlegm. The chest X-ray report came back showing R7 had pneumonia. The NP was notified and R7 was to be sent to the emergency room. There were no nursing notes showing R7 was monitored or assessed between 3 PM and 8PM on 5/23/23. The emergency room note from the local hospital R7 was first sent to shows R7 was brought to the hospital by ambulance for shortness of breath and pneumonia. The note shows the report they received from the nursing home was R7 had been short of breath that day and her oxygen saturations were in the 70's and that no call had been made earlier for a patient evaluation. R7's temperature was recorded as 100.7 and oxygen saturations were 86%. The note also shows R7 was transferred to another hospital in poor condition. The records for R7 shows a COBRA transfer record to send R7 to another hospital for a higher level of care due to her unstable condition. The hospital notes from the second hospital R7 was sent to shows a plan to treat her bilateral pneumonia, respiratory failure and sepsis. The X-ray obtained at the facility dated 5/23/23 showed a right basilar pneumonia. R7's facility care plan shows for chronic obstructive pulmonary disease (COPD) with interventions to include: instruct and monitor for early signs of COPD exacerbation such as confusion or excessive sleepiness, shortness of breath and coughing. The facility policy with a revision date of 12/7/17 for notification for change in resident condition or status shows the facility shall promptly notify appropriate individuals such as NP or the residents attending physician when there has been a marked change in relation to usual signs or symptoms. 2. On 5/23/23 at 9:35 AM, V3 was observed doing wound care on R29. R29's both lower leg were edematous and discolored. V3 wrapped R29's legs with ace wrap for his edema. V3 started at the knee and wrapped the ace wrap down to the toes. On 5/25/23 9:00AM, V2 LPN said when wrapping a residents lower legs, always start at the bottom and work your way up. On 5/25/23 at 9:11 AM, V4 Registered Nurse (RN) said when wrapping ace wraps to a residents legs for edema, always start at the bottom and work your way to the top to promote venous return. On 5/25/23 at 2:00PM, V11 Wound Physician said to promote venous return to lower legs for edema, always wrap from the toes to about 2 inches below the knees. The Physician Order Sheet (POS) for R29 shows diagnosis to include hypertension and type 2 diabetes. The POS shows an order for ace elastic bandages to affected areas daily. The care plan for R29 shows alteration in circulation to both lower legs and causing stasis ulcer/wounds. The facility stated they had no policy for application of elastic bandages.