**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to recognize an acute change in condition for a resident. This failure applied to one (R5) of three residents reviewed for nursing care and resulted in a delay in care for R5 who was hospitalized for respiratory failure. Findings include: R5 is [AGE] years old and admitted to the facility on [DATE] and has diagnoses that include hydrocephalus, g-tube placement, communication deficit weakness and lack of coordination. Minimum data set (6/28/24) indicates R5 to have severe cognitive impairment and unable to make needs known to staff. The assessment data also includes that R5 is incontinent of bowel and bladder and totally dependent on staff for turning, repositioning and all other activities of daily living. On 7/15/24 at 12:51PM R5 was in the facility, observed by the Surveyor to be in bed, and appearing to be in respiratory distress. R5 was visibly and audibly gasping for air and respirations were counted at 47 breaths per minute. At 12:55PM V7 Registered Nurse said that R5 has been breathing like that all morning. It's baseline. V7 said that vital signs were taken about 15 minutes prior and documented as: blood Pressure 111/44, Temperature 97.4F, Pulse 100 beats per minute, Respirations 24 breaths per minute and Oxygen 94% on room air. At 12:58PM V7 and V8 LPN (licensed practical nurse) went to the bedside of R5 at request of the Surveyor. V8 was orienting with V7 on this day and while at the bedside, V7 and V8 agreed that R5's presentation and assessment was unchanged since earlier that morning around 9AM. Surveyor requested an immediate set of vital signs which V7 and V8 obtained. The pulse oximeter measured a pulse of 110 beats per minute and an oxygen saturation fluctuating between 80% and 97% on room air. V9 Registered Nurse entered the room at 1:07PM physically assessed R5 and agreed that R5's presentation was normal for their baseline, and that R5 periodically gets like this. At 1:08PM V7 was asked for a respiration count and said it was 28 breaths per minute. V7 said that a normal respiration count should be between 12 and 25 breaths per minute. Surveyor requested to count again together out loud, and the result was 40 breaths per minute. V7 left the room to call the medical provider for further orders. At 1:33PM, R5 was observed in bed, condition unchanged. V7 said that the provider was notified that R5 has a rate of 40 respirations and did not give any further orders. At 1:58PM V2 Director of Nursing said that a respiration rate of 40 would not be considered normal, however co-morbidities should be considered overall. V2 said, that R5's family refused hospice services upon recommendation and R5 remained full code at the moment, meaning that all measures should be taken to sustain life. V2 went to personally assess R5 and follow up with V7. Emergency Paramedics were observed on site in the facility at 2:30PM. V7 said that they called 911 due to R5 experiencing a further increase of breathing and decreased blood pressure to 89/50. R5 was transferred via Fire Department to the hospital emergency room and admitted to the neurological intensive care unit for respiratory failure and treated for sepsis. The medical group representing R5's physician and Nurse Practitioner refused an opportunity to interview R5's providers during this investigation. The facility provided Notification for Change of Condition policy revised 6/6/24 which states in part: Policy Statement: The facility will provide care to residents and provide notification of resident change in status. Procedures 1. The facility must immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is: b. A significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); c. A need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or d. A decision to transfer or discharge the resident from the facility as specified in §483.15 (c ) (1) (ii) as in the continued presence of the resident poses a threat to the safety and health of the resident and other individuals in the facility. Per federal definition §483.1 0(g)(14 ), a need to alter treatment significantly means a need to stop a form of treatment because of adverse consequences (e.g., an adverse drug reaction), or commence a new form of treatment to deal with a problem (e.g., the use of any medical procedure, or therapy that has not been used on that resident before). Per federal guidance under §483.10(g)(14), physician also need to be notified if resident experiences symptoms such as chest pain, loss of consciousness, or other signs or symptoms of heart attack or stroke.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement turning and repositioning to prevent the development of new pressure injuries and complete treatment orders. This failure affected two residents (R4 and R5) who were at high risk of developing pressure ulcers and resulted in R4 and R5 developing deep tissue injuries to the sacrum. Findings include: R4 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that included Protein-calorie Malnutrition, Heart failure, and metabolic encephalopathy. According to Skin Evaluation Assessment of 3/13/24, R4 was assessed to have one pressure ulcer of the right heel. Minimum Data Set (3/25/24) indicated R4 was cognitively impaired, incontinent of bowel and bladder and dependent on staff for turning, repositioning and toileting. R4 used a manual wheelchair, to which they were dependent on staff to transfer and maneuvers. R4 was able to feed self with set-up assistance from the staff. The mobility task for R4 was reviewed for March 2024. Turning and bed mobility were not documented night shift 3/17 and morning shift 3/18. According to nursing progress notes on 3/18 at 3:30PM, an open wound [was] noticed to the sacrum A significant change was noted on 3/19/24 and R4 was assessed to have a sacral deep tissue injury measuring 7cm (centimeters) length by 10cm width. The wound nurse practitioner assessed and treated R4 on 3/19 and orders were placed to cleanse with normal saline and apply bordered foam every three days. The Treatment Administration Record of March 2024 did not contain any signatures that this treatment was completed 3/22, 3/25 or 3/28. R4 was discharged from the facility on 4/1/24. R5 is [AGE] years old and admitted to the facility on [DATE] and has diagnoses that include hydrocephalus, g-tube placement, communication deficit weakness and lack of coordination. Minimum data set (6/28/24) indicates R5 to have severe cognitive impairment and unable to make needs known to staff. The assessment data also includes that R5 is incontinent of bowel and bladder and totally dependent on staff for turning, repositioning and all other activities of daily living. According to Skin Evaluation (6/22/24) R5 admitted to the facility with staple to a surgical scalp laceration and without any pressure ulcers. During assessment by the nurse practitioner on 7/10/24, R5 was noted with a sacral deep tissue injury (pressure wound) measuring 5cm length and 6.5cm width. Orders were placed to cleanse with normal saline and apply medical grade honey and silver alginate (for debridement) and secure with a hydrocolloid bandage every other day and as needed. Review of the Treatment Administration Record July 2024 indicated that this treatment was not signed as completed 7/14/24. On 7/15/24 R5 was in the facility, observed by the Surveyor to be in bed, and appearing to be in respiratory distress. Facility staff was notified, and R5 was transferred to the hospital emergency room and admitted to the neurological intensive care unit due to respiratory failure. A care plan for skin integrity was initiated 6/21/24 and included an intervention to check skin every shift and report abnormalities to the nurse. A skin observation report was requested from the facility and not provided. On 7/16/24 at 3:24PM V13 Wound Care Nurse was interviewed and said, the wound care team was alerted to R5's sacral wound after the nurse placed a wound consult. The nurses and CNA's are responsible for checking skin of high risk residents every shift and during incontinence care. R5 was high risk due to immobility, use of g-tube and general unresponsive presentation. Because of this, we ordered R5 to be on an alternating pressure relieving mattress to assist with prevention of skin breakdown, however it does not replace the need for turning, repositioning and routine skin care. By the time the wound care team assessed the sacral wound, it was a deep tissue injury with leathery eschar (dead tissue). V13 was unable to determine for certain how long the wound had developed but said that it was likely a full thickness wound under the dead tissues. V13 was not able to recall any information regarding R4's admission to the facility. Facility Policy Skin Care Regimen and Treatment Formulary revised 1/24/24 states in part: It is the policy of this facility to ensure prompt identification, documentation and to obtain appropriate treatment for residents with skin breakdown. Procedures 1. Charge nurses must document in the Electronic Health Record any skin breakdown upon assessment and identification. Furthermore, treatment must be obtained from the patient's physician. 2. Routine daily wound care treatment/ dressing change is administered by the wound care nurse or designee daily unless otherwise indicated by the patient's attending physician. a) Pressure Injuries/ Vascular Wounds (Stasis/ Arterial/ Diabetic) b) Surgical Wounds c) Other Skin Conditions 4. TAR [Treatment Administration Record] Nursing Documentation includes: a) Routine wound care completed by wound care nurse or designee. b) Ostomy care completed by the wound care nurse or designated nurse. 5. Refer any skin breakdown to the skin care team and physician including wound physician/NP (nurse pracitioner) for further review and management as indicated. 6. Residents who are not able to turn and reposition themselves will be turned and repositioned at least every 2 hours unless otherwise specified by the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that nursing staff had the required competencies when transcribing physician orders for newly admitted residents to ensure that care is being provided as ordered and to meet the needs of the residents; they also failed to ensure that standards of nursing practice were being followed during the administration of medication. This failure applied to three of three (R73, R103, and R504) residents reviewed for nursing services and resulted in (R73) receiving medication that was not ordered; (R103) not having a BiPap machine upon admission, that R103 was required to wear due to history of sleep apnea and respiratory failure; and (R504) did not receive medication that were needed for the prevention of blood clots upon admission to the facility. Findings include: R103 was a [AGE] year-old male initially admitted to the facility on [DATE] and expired on [DATE]. His medical diagnoses include but are not limited to the following: respiratory failure, sleep apnea, severe protein calorie malnutrition, muscle wasting, altered mental status, history of falling, hyperlipidemia, heart failure, dementia, depression, and absence of lung, HTN, and COPD. Transition of care report from (facility) state in part but not limited to the following: Reason for hospitalization: fall, altered mental status, acute respiratory failure, and COPD. 4 liters of oxygen. Per hospital discharge records dated [DATE] state in part but not limited to the following: BiPap QHS per pulmonary recommendations Settings: 15/5, 50% FiO2. Venous blood gas improved with BiPap. Fast track report: Oxygen: 3 liters, has a BiPap from home and will bring. Physician Order Sheet dated [DATE] at 2:04 PM states in part but not limited to the following: BiPap; Oxygen 4 liters per minute; Settings: 12/5, set rate 12 breathing 25; FiO2 40% with tidal volumes 448 every evening and night shift and as needed for sleep apnea while sleeping. On [DATE] at 12:50 PM, V2 (Director of Nursing) was interviewed regarding R103's BiPap machine and orders. V2 states admissions were notified at some point from the hospital liaison that R103 needed a BiPap. At this point, admissions did order a BiPap for R103, however when the resident arrived to the facility, we did not see an order on the discharge records for the BiPap, so the BiPap was not set for R103. R103 did not receive the BiPap on [DATE]. I know that the unit manager was made aware that R103needed a BiPap the following day on [DATE] and this is how the order was obtained. I am not sure if the BiPap was one from home or the one admissions had ordered for him. I am unsure of who set the BiPap machine up for R103. On [DATE] at 1:30 PM, V35 (Unit Manager) was interviewed regarding R103's care while at the facility. V35 states on [DATE] she spoke with V27 (Family Member) about concerns V27 had about R103's care. V27 told me at this time that R103 was previously found unresponsive and needs a BiPap when he sleeps. V27 satated she came to the facility and saw R103 sleeping without the BiPap. V27 was concerned this would happen again. I ensured her we were able to care for R103. This was the first time we were made aware that R103 required a BiPap while sleeping. After this conversation, I looked into the situation and found that R103 did not have an order for the BiPap in place. I contacted the doctor, confirmed the order, and obtained a written order. I talked with the nurses on his unit to ensure he is wearing the BiPap at all times while R103 is sleeping. I am unsure of where the BiPap came from, if it was brought in by the family or it was one that we had ordered for the resident. On [DATE] at 12:10 PM, V29 (Registered Nurse) was interviewed about R103's admission to the facility. V29 says she was the admitting nurse for R103 and believes he was admitted around 3:00 PM on [DATE]. We are made aware of new admission orders and status by both the hospital discharge records and by the hospital nurse's report. I remember he came in via transport with oxygen. I also received report from the hospital nurse that he was on oxygen. I did not get report from the hospital nurse that he was using a BiPap nor was it in his hospital discharge orders. Typically, if a resident is on a BiPap the hospital nurse will report to us the settings of the BiPap or the settings will be on the discharge paperwork. I did not have any interaction with his family when he admitted , he came by himself. Asked V29 how the admission orders are reviewed after the admitting nurse puts them in, in which V29 said two nurses verify the orders upon admission, the next day the unit manager would review the admission records. From there the physician typically shows up the following day to verify the orders, notes, and to see the resident. V29 says I have been disciplined in the past for transcribing medications incorrectly. Per facility One-On-One Inservice Record, V29 (Registered Nurse) was disciplined on [DATE], [DATE], [DATE], and [DATE] for medication reconciliation and medication/treatment guidelines. Findings include: R504 was an [AGE] year-old male admitted to the facility [DATE] with diagnoses that included cerebral infarction and hypertension. Immediately prior to transfer, R504 underwent a surgical laminectomy of the spine after sustaining a fall in the home. According to the Minimum Data Set assessment dated [DATE], R504 was assessed to be totally dependent on staff for all activities of daily living, requiring extensive 2-person assistance with bed mobility, turning and toileting. R504 mobilized with a wheelchair and was not ambulatory. According to nursing progress note dated [DATE] at approximately 1:00AM, R504 was assessed by nursing staff to have multiple episodes of yellow emesis at start of the shift. During emesis R504 was observed to have fixed stare. Nurse assessed vital signs: Blood Pressure: 67/39 Heart Rate: 89 and blood glucose: 299. The nurse on duty called 911 for transport to the nearest hospital. According to hospital records dated [DATE], several hours after arriving to the Emergency Department, R504 received life resuscitation measures and expired. Death Certificate dated [DATE] lists cause of death: Cardiopulmonary Arrest and Massive Pulmonary Embolism. On [DATE] at 10:06AM V2 Director of Nursing said, we were made aware that R504 went to the hospital and passed away. When the hospital called, they asked for a medication list and the unit manager grabbed the chart and reconciled the notes. That is when she found that there was a discrepancy with how the admission medication orders were transcribed. It is possible that this could have contributed to blood clot development, and I began an investigation based off of this concern. The medication, Heparin was missed (upon admission to the facility) and was not documented on the Physicians Order Sheet. R504 did not receive Heparin at any time while in the facility. The nurse that transcribed the orders was from an agency and was asked not to return after this incident. On [DATE] at 9:58AM, V30 Medical Director and primary physician of R504 said, when patients come from the hospital, we are supposed to follow all the hospital orders. I was told by the facility that the nurses have a system in place where they call the physician and go over the medication list, and then another nurse will verify that all the medications have been ordered in the system correctly according to the discharge medication list. I round at the facility, and I also will review the hospital discharge orders when I do the initial visit. I don't know how an error could have occurred with these systems in place. Heparin is used to help prevent blood clots, such as DVT (deep vein thrombosis) and pulmonary embolism. Heparin is used to help prevent blood clots of all kinds, particularly in high-risk patients. It is possible that without the Heparin being given as ordered, a patient who is at risk of developing blood clots has a higher chance of developing them if they are unable to walk or move on their own. V30's Physician progress note dated [DATE] indicated that R504 was assessed, and all hospital records were reviewed. Hospital discharge forms and Physician Order sheet reviewed for [DATE]. Hospital discharge medication list included Heparin 5,000 units to be given every 8 hours which was not transcribed to the Physician Order Sheet at the time of admission to the facility. There is no record of R504 receiving this medication while in the facility at any time. Physician progress note dated [DATE] documented that R504 was at risk for developing DVT (deep vein thrombosis). Facility policy titled, Admission, long-term care (Revised [DATE]) includes: Ensure that a complete list of the medications the resident was taking at home is documented in the resident's medical record. Compare this list with the resident's current medications. Reconcile and document any discrepancies in the resident's medical record to reduce the risk of transition-related adverse drug events. R73 is a [AGE] year-old male admitted to the facility [DATE] with diagnoses that include End Stage Renal Disease, Diabetes, Hypertension and Spinal Stenosis. R73 is alert and oriented as assessed on [DATE], with a BIMS (Brief Interview of Mental Status) score of 14 (cognitively intact). On [DATE] V6 (RN) wrote a progress note at 4:07PM that stated, Resident accidentally taken the wrong medication family aware and MD will continually monitor resident for side effect and reaction. Facility Witness statement for the incident of [DATE] states that V6 (RN) pulled medications for R73 and the roommate and entered the room with both medication cups in hand. When she set the medication in front of R73, he ingested one pill and then stated that the medications in the cup were not his meds. V6 took the remaining medicine from R73 and gave him the other prepared medications. Prior to going into the room, the medications were labeled with the resident's names. V6 (RN) could not be reached for interview during this investigation. Review of V6's Employee file reviewed and found to contain Employee Warning Notices that indicated V6 had received written notice of three additional medication administration related incidents since being hired in the facility in 2018. On [DATE] at 10:06AM V2 Director of Nursing said, I am aware that there have been multiple medication administration errors since I've been the Director of Nursing. Medication administration errors are avoidable by utilizing the 5 rights. When an incident like this occurs, the nurses are provided education in the form of an in-service that emphasizes the Rights of Medication Administration, such as right medication, right dose, right patient, right time, and right route. I was not aware that V6 (RN) had a history of documented medication errors or incidents. R73 did not require any hospitalization after the incident, and the physician was called with no further orders but to monitor for any reactions. Facility policy titled, Medication and Treatment Administration Guidelines, Long-Term Care (no revision date) includes: Medications are administered in accordance with the following rights of medication administration or per state specific standards: Right patient, right medication, right dose, right route, right time (including duration of therapy, right documentation, right of patient to refuse, right clinical indication).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately transcribe hospital discharge orders to ensure that a newly admitted resident received all medications needed for treatment and failed to prevent a medication administration error. These failures affected two residents (R504 and R73) reviewed for medication administration and resulted in one resident (R73) receiving medication that was not ordered and resulted in (R504) not receiving medication for the prevention of blood clots upon admission to the facility and then being emergently transferred to the hospital and subsequently expiring. Findings include: R504 was an [AGE] year old male admitted to the facility [DATE] with diagnoses that included cerebral infarction and hypertension. Immediately prior to transfer, R504 underwent a surgical laminectomy of the spine after sustaining a fall in the home. According to the Minimum Data Set assessment dated [DATE], R504 was assessed to be totally dependent on staff for all activities of daily living, requiring extensive 2 person assistance with bed mobility, turning and toileting. R504 mobilized with a wheelchair and was not ambulatory. According to nursing progress note dated [DATE] at approximately 1:00AM, R504 was assessed by nursing staff to have multiple episodes of yellow emesis at start of the shift. During emesis R504 was observed to have fixed stare. Nurse assessed vital signs: Blood Pressure: 67/39 Heart Rate: 89 and blood glucose: 299. The nurse on duty called 911 for transport to the nearest hospital. According to hospital records dated [DATE], several hours after arriving to the Emergency Department, R504 received life resuscitation measures and expired. Death Certificate dated [DATE] lists cause of death: Cardiopulmonary Arrest and Massive Pulmonary Embolism. On [DATE] at 10:06AM V2 Director of Nursing said, we were made aware that R504 went to the hospital and passed away. When the hospital called, they asked for a medication list and the unit manager grabbed the chart and reconciled the notes. That is when she found that there was a discrepancy with how the admission medication orders were transcribed. It is possible that this could have contributed to blood clot development and I began an investigation based off of this concern. The medication, Heparin was missed (upon admission to the facility) and was not documented on the Physicians Order Sheet. R504 did not receive Heparin at any time while in the facility. The nurse that transcribed the orders was from an agency and was asked not to return after this incident. On [DATE] at 9:58AM, V30 Medical Director and primary physician of R504 said, when patients come from the hospital, we are supposed to follow all the hospital orders. I was told by the facility that the nurses have a system in place where they call the physician and go over the medication list, and then another nurse will verify that all the medications have been ordered in the system correctly according to the discharge medication list. I round at the facility, and I also will review the hospital discharge orders when I do the initial visit. I don't know how an error could have occurred with these systems in place. Heparin is used to help prevent blood clots, such as DVT (deep vein thrombosis) and pulmonary embolism. Heparin is used to help prevent blood clots of all kinds, particularly in high risk patients. It is possible that without the Heparin being given as ordered, a patient who is at risk of developing blood clots has a higher chance of developing them if they are unable to walk or move on their own. V30's Physician progress note dated [DATE] indicated that R504 was assessed, and all hospital records were reviewed. Hospital discharge forms and Physician Order sheet reviewed for [DATE]. Hospital discharge medication list included Heparin 5,000 units to be given every 8 hours which was not transcribed to the Physician Order Sheet at the time of admission to the facility. There is no record of R504 receiving this medication while in the facility at any time. Physician progress note dated [DATE] documented that R504 was at risk for developing DVT (deep vein thrombosis). Facility policy titled, Admission, long-term care (Revised [DATE]) includes: Ensure that a complete list of the medications the resident was taking at home is documented in the resident's medical record. Compare this list with the resident's current medications. Reconcile and document any discrepancies in the resident's medical record to reduce the risk of transition-related adverse drug events. R73 is a [AGE] year old male admitted to the facility [DATE] with diagnoses that include End Stage Renal Disease, Diabetes, Hypertension and Spinal Stenosis. R73 is alert and oriented as assessed on [DATE], with a BIMS (Brief Interview of Mental Status) score of 14 (cognitively intact). On [DATE] V6 (RN) wrote a progress note at 4:07PM that stated, Resident accidentally taken the wrong medication family aware and MD will continually monitor resident for side effect and reaction. Facility Witness statement for the incident of [DATE] states that V6 (RN) pulled medications for R73 and the roommate, and entered the room with both medication cups in hand. When she set the medication in front of R73, he ingested one pill and then stated that the medications in the cup were not his meds. V6 took the remaining medicine from R73 and gave him the other prepared medications. Prior to going into the room, the medications were labeled with the resident's names. V6 (RN) could not be reached for interview during this investigation. Review of V6's Employee file reviewed and found to contain Employee Warning Notices that indicated V6 had received written notice of three additional medication administration related incidents since being hired in the facility in 2018. On [DATE] at 10:06AM V2 Director of Nursing said, I am aware that there have been multiple medication administration errors since I've been the Director of Nursing. Medication administration errors are avoidable by utilizing the 5 rights. When an incident like this occurs, the nurses are provided education in the form of an in-service that emphasizes the Rights of Medication Administration, such as right medication, right dose, right patient, right time and right route. I was not aware that V6 (RN) had a history of documented medication errors or incidents. R73 did not require any hospitalization after the incident, and the physician was called with no further orders but to monitor for any reactions. Facility policy titled, Medication and Treatment Administration Guidelines, Long-Term Care (no revision date) includes: Medications are administered in accordance with the following rights of medication administration or per state specific standards: Right patient, right medication, right dose, right route, right time (including duration of therapy, right documentation, right of patient to refuse, right clinical indication).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records reviewed the facility failed to document a dependent resident's (R1) skin condition when initially observed or reported. This failure affected 1 or 3 residents reviewed for pressure ulcer prevention. This failure resulted in R1 developing an unstageable pressure ulcer to R1's sacrum. Findings include: R1 is [AGE] years old with diagnosis including but not limited to Metabolic Encephalopathy, Dysphagia, Urinary Tract Infections, Reduced Mobility, and Altered Mental Status. R1 admitted to the facility on [DATE] and discharged to home on [DATE]. On 11/16/22 at 10:06 AM V7, Unit Manager Registered Nurse, stated R1 stayed in bed and was not active. V7 stated R1 was dependent on staff. V7 stated skin checks are done daily if a resident has wounds and weekly if the skin is clear. On 11/16/22 at 10:57AM V5, Director of Nursing, said the nurses do skin checks weekly or daily. V5 said we don't keep the skin sheets, they are not part of the medical record. V5 said the skin checks will be charted in the electronic treatment administration record (ETAR). V5 reviewed R1's ETAR and saw with the surveyor no skin checks are documented. At 12:03 PM V5 said she has no additional body audits to support that R1's skin was checked before the development of R1's pressure ulcer. At 2:45 PM V5 said the purpose of nurse documentation is for communication. V5 said I would expect a description of the alteration, if a resident had a new skin alteration, to be found in the nurses' notes. On 11/16/22 at 1:08PM V11, Certified Nursing Assistant, said she gave R1 a bed bath, when she worked on 10/31/22. V11 said after a resident receives a shower, we complete a shower sheet and the nurse will sign it. V11 said when we give a bed bath, we don't complete a shower sheet. V11 said I never saw a skin problem with R1. On 11/16/22 at 2:09PM V10, Wound Nurse Practitioner, said on 11/1/22 I was told to see R1 for a skin alteration. V10 said R1 had comorbidities that contribute to skin breakdown including limited mobility, Hypertension, Diabetes, and history of a stroke. V10 said skin checks would be a beneficial intervention. V10 said if the nurse knew of a skin alteration the nurse should have written a note. V10 said a note would have been beneficial to know what kind of wound the resident had or the progression of the wound from when it was first seen to the current time. On 11/16/22 at 2:32 PM V15, Nurse, said when a wound is reported to me, I let the wound care team know and call the doctor. V15 said for a skin impairment I make a progress note. V15 said the purpose of documenting a wound is so the facility has documentation of the skin condition. V15 was unable to recall R1's wound or why she obtained the treatment order on 10/30/22 for R1's intergluteal crease. On 11/17/22 at 10:00 AM V19, Nurse, said if she signed off a treatment on eTAR for R1, then she provided the ordered treatment. V19 was unable to remember what R1's skin or alteration looked like. R1's Braden Scale assessment dated [DATE] notes R1 is at risk for pressure ulcers, with a score of 15. R1's care plan initiated on 9/27/22 states R1 is at risk for alteration in skin integrity related to Diabetes, Urinary Tract Infection, Hypertension, Impaired Mobility, and Cerebral Vascular Accident. The goal for R1 is to decrease/minimize skin breakdown risks. Review of R1's Order Recap Report notes an order dated 10/30/22 to cleanse intergluteal crease and cover with dry dressing daily. R1's Progress Notes reviewed 10/26/22 to 11/1/22 do not have documentation related to physician order for intergluteal crease dressing. There is no skin assessment documented for R1's intergluteal crease on the day the order was received. Review of R1's Order Recap Report notes the order for the intergluteal crease was ended on 11/1/22. A new order dated 11/1/22 states Sacrum: cleanse, apply Thera-Honey and cover with dry dressing. A Medical practitioner Wound Progress Note written by V10 on 11/1/22 documents R1 needs assistance with bed mobility. Acute unstageable pressure ulcer noted to sacrum. A Skin and Wound Evaluation written by V18, Registered Nurse, documents on 11/1/22 R1 has an unstageable pressure alteration. The alteration has slough and or eschar present. The alteration is in house acquired. The alteration is 5.1 cm in length and 8.0 cm in width. It is documented noted 30% purple discoloration. [A picture of R1's wound is attached to this evaluation.] R1's Functional Status assessment dated [DATE] notes R1 requires extensive assistance with bed mobility. Skin Conditions assessment dated [DATE] notes R1 has no pressure ulcers but is at risk. R1's Functional Status assessment dated [DATE] notes R1 requires extensive assistance with bed mobility. Skin Conditions assessment dated [DATE] notes R1 has an unstageable pressure ulcer. The facility provided a document revised on 8/19/22 titled Change in Status, Identifying and Communicating, Long-Term Care. Documentation states identifying and communicating change in resident's status includes other assessment findings in the appropriate areas in the medical record, nursing interventions, and resident response. The facility provided a document titled Skin Management Guidelines dated 3/2022 which documents, in part: Skin alterations and pressure injuries are evaluated and documented by the nurse. Body audits are completed by the nurse daily for patients with pressure ulcers and documented on the eTAR; new findings are documented in a progress note. By the nurse weekly for patients without pressure injuries and documented on the eTAR; new findings are documented in a progress note. By the nursing assistant during baths/showers, and if indicated during routine daily care and documented on the Skin Worksheet. The Skin Worksheet is used by the nursing assistant to document skin observations. The worksheet is completed at least twice per week with the patient's bath/shower. Completed worksheets are given to the nurse for validation and action planning as indicated. In the event a patient experiences a new pressure injury, complete Braden Scale, PUSH Tool, and Skin Progress Note.