**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide Heat, Ventilation, and Air Conditioning (HVAC) systems to maintain a comfortable temperature and failed to maintain flooring that was clean and free from damage. This failure resulted in R1 and R6 experiencing difficulty breathing and R5 and R7 experiencing difficulty sleeping, resulting in significant discomfort. This failure has the potential to affect all 58 residents residing in the facility.Findings include:1. On 7/30/25 at 10:03 AM, a digital metal stemmed thermometer used for taking temperatures for this survey was checked for accuracy using the ice-point method and was accurate within +/- 2 degrees Fahrenheit. R1's Resident Face Sheet documented an admission date of 12/12/24 and included diagnoses of morbid obesity, chronic respiratory failure with hypercapnia, chronic obstructive pulmonary disease, and congestive heart failure. R1's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14, indicating R1 was cognitively intact.On 7/30/25 at 10:33 AM, R1 was sitting on the side of her bed in her room wearing an oxygen nasal cannula connected to an oxygen condenser set at 3 liters per minute. The thermometer measured the ambient air temperature of R1's room to be 85.6 degrees Fahrenheit (F). R1's Packaged Terminal Air Conditioner (PTAC) unit was on but was not blowing out cold air. R1 said it was so hot in her room she was having difficulty sleeping. R1 stated we just sleep covered in sweat. R1 said due to the heat she was having increased difficulty breathing. R1 stated I'm on oxygen with COPD (Chronic Obstructive Pulmonary Disease). I can't hardly breathe with this heat. I'm struggling.R6's Resident Face Sheet documented an admission date of 1/30/23 and included diagnoses of morbid obesity, chronic obstructive pulmonary disease, and chronic respiratory disease. R6's MDS dated [DATE] documented a BIMS score of 14, indicating R6 was cognitively intact.On 7/30/25 at 10:59 AM, R6 was sitting in the dining room in her wheelchair wearing an oxygen nasal cannula connected to an oxygen concentrator set at 2 liters per minute. R6 stated It's so hot in here, and it has been like this for weeks. The heat makes it hard for me to breathe in here. The thermometer measured the ambient air temperature of the dining room to be 82.3 degrees F. Several residents were sitting in the dining room participating in a dice game activity and all said they were hot and uncomfortable.R5's Resident Face Sheet documented an admission date of 2/4/25 and included diagnoses of morbid obesity, hypertension, and edema. R5's MDS dated [DATE] documented a BIMS score of 14, indicating R5 was cognitively intact.On 7/30/25 at 10:40 AM, R5 stated it has been so hot in here for the past 3 to 4 weeks since the air conditioning stopped working. It's hard to sleep when it's this hot. I toss and turn all night sweating. This morning trying to get dressed I was already wet with sweat before I could get my clothes on. The thermometer measured the ambient air temperature in R5's room to be 83.6 degrees F.On 7/30/25 at 11:55 AM, the thermometer measured the ambient air temperature of R5's room at 86.1 degrees F. R7's Resident Face Sheet documented an admission date of 7/10/25 and included diagnoses of pneumonitis, atrial fibrillation, and insomnia. R7's MDS dated [DATE] documented a BIMS score of 13, indicating R7 was cognitively intact.On 7/30/25 at 10:52 AM, R7 stated It's plenty hot in here. The main problem is it's hard to sleep at night. It's uncomfortable day and night. The thermometer measured the ambient air temperature in R7's room to be 82.6 degrees F.On 7/30/25 at 11:43 AM, staff were passing noon time meal trays to several residents sitting in the dining room. The thermometer measured the ambient air temperature of the dining room to be 84.5 degrees F.On 7/30/25 at 11:49 AM, the Heating, Ventilation, and Air Conditioning (HVAC) unit farthest from the nurse's station on 300 hall was running but putting out a very small amount of cold air and was dripping condensation onto the floor and had ceiling tiles with greenish brown discoloration surrounding it.On 7/30/25 at 11:51 AM, the HVAC unit closest to the nurse's station on 300 hall was not working.On 7/30/25 at 11:53 AM, the HVAC unit above the nurse's station was not working and had 7 ceiling tiles with greenish brown discoloration.On 7/30/25 at 11:56 AM, the HVAC unit closest to the nurse's station on 200 hall was blowing out a small amount of cold air.On 7/30/25 at 11:57 AM, the HVAC unit farthest from the nurse's station on 200 hall was blowing out a small amount of cold air.On 7/30/25 at 11:59 AM, the HVAC unit closest to the nurse's station on 400 hall was not working.On 7/30/25 at 12:01 PM, the HVAC unit farthest from the nurse's station on 400 hall was blowing out a small amount of cold air. On 7/30/25 at 12:06 PM, V4 (Maintenance Director) said he had asked corporate for 33 PTAC units to replace the older PTAC units in resident rooms and corporate had only sent him 4 PTAC units. V4 said several of the PTAC units in resident rooms had been replaced during the winter of 2024 but the PTAC units that were not replaced could not keep up with cooling resident rooms. V4 said the facility did have portable air conditioners but if too many were plugged in it would pop the breaker and everything plugged into that electrical line would lose power. V4 verified most of the HVAC systems in the facility were not functioning or not functioning well. V4 said he had contacted the HVAC company to come to the facility and fix the HVAC units but was told they would not come to the facility until the facility paid the bill from the last time the HVAC company had been at the facility.On 8/1/25 at 2:26 PM, V1 (Former Administrator) said the air conditioning is a reoccurring theme every summer. V1 said he had done everything he could do but did not have the authority to change the HVAC units. V1 said in December of 2024 he had replaced all the PTAC units in resident rooms that needed changed but the PTAC units that needed replaced now are the older ones that were about 2 years old and are starting to fail. V1 said they needed to be replaced but corporate had only sent the facility 4 new PTAC units. V1 said he had emailed and called corporate several times about the HVAC systems and PTAC units not working but corporate still had not fixed them.On 8/1/25 at 12:14 PM, V7 (Medical Director) said he was aware the facility has had trouble with the HVAC system. V7 said with the temperatures being over 81 degrees F, it would not cause the residents to go into true respiratory failure but it would be more difficult to breathe with the high heat and high humidity. V7 said the combination of comorbidities and being elderly put the residents at high risk for dehydration, heat exhaustion, and heat stroke. V7 stated (V1) is passionate about it and has been trying to get it fixed. V7 said some of the resident rooms were very hot and that was not good. V7 said the last few days had been very hot.On 8/6/25 at 11:40 AM, V6 (Licensed Practical Nurse/ LPN) said the air conditioning had not been working all summer. V6 said over the weekend (8/2/25 and 8/3/25), the HVAC units on the 400 hall were blowing out hot air and they could not shut them off. V6 stated it was miserable in here.The facility's undated Extreme Weather- Heat or Cold policy documented in part . The priority of this facility to minimize the stress our residents could experience from extreme temperatures related to weather events. To mitigate the risk, we rigorously maintain our systems of heating, ventilation and air conditioning and generator. Individuals are prone to heat illness when they remain in hot or humid weather for an extended period. If the facility reaches a heat index/ apparent temperature of 80 (degrees) Fahrenheit implement the following actions and/ or treatments. Move individual(s) to cool area. Utilize electric fans circulate air. Notify Director to ensure measures for air condition repair and resident care are being followed.The facility's December 2016 Hot Weather Plan documented in part .1. Monitoring: a. in the event of a loss of air conditioning, hallway temperatures will be monitored and recorded every hour on the Temperature Monitor Log. d. The administrator or DON should contact the Regional [NAME] President and Regional Nurse Consultant. f. Nursing will assure that each Resident's room has an operational fan. 3. Maintenance Department Response: a. Maintenance staff will be available 24 hours a day during any heat emergencies. Various heating and cooling companies will be utilized as necessary. b. Administrator, Maintenance Supervisor or designee will determine if any of the above providers should be called out. 6. Other: The Department of Health and Senior Services must be notified during serious heat emergencies. This would be defined as. when persistent heat related issues cannot be resolved by the Administrator and/ or Maintenance.On 8/12/25 at 11:40 AM, the website Weather Underground (https://www.wunderground.com/history/monthly/us/il/salem/KMWA/date/2025-7) historical data documents a maximum temperature of 91 degrees F on 7/30/25 with a maximum humidity of 100%.On 8/12/25 at 12:52 PM, the website https://southernillinoisnow.com/2025/07/28/more-than-130-million-people-brace-for-sweltering-conditions-across-most-of-the-us/ documented on 7/28/25 at 6:37 AM a report documenting in part .Extreme heat is also expected to continue on Monday and Tuesday in the Midwest, where over the weekend temperatures felt between 97 to 111 degrees from [NAME], Nebraska, up into Minneapolis . Looking ahead to the work week, potentially life-threatening heat and humidity are expected to continue across the eastern half of the country through Wednesday. Major cities including St. Louis, Memphis, [NAME], [NAME], [NAME], and [NAME], Mississippi, are all likely all see actual temperatures in the upper 90s to low 100s. A prolonged heat wave is forecast for those regions as an abundance of tropical moisture settling in is expected to drive the feels-like temperatures up to between 105 to 115 degrees over multiple consecutive days .2. On 8/1/25 at 10:14 AM, V8 (Family Member/Power of Attorney/POA) said she comes to visit R2 every Sunday, and the dining room floor is always dirty and in bad shape when she is in the facility.On 8/1/25 at 1:10 PM, the dining room floor appeared to be dirty with several tiles with blackish brown discoloration. The tiles lining the area where the flooring changes to tile were cracking and uneven with black discoloration on them from wall to wall. Several tiles by the sliding glass door were bubbled and had a blackish brown discoloration. Several tiles located around the kitchen entrance had a large amount of blackish brown discoloration with bubbling and cracking.On 8/1/25 at 1:35 PM, V10 (Housekeeping Supervisor) said the discoloration on the tiles was glue. V10 said the facility had tried to scrape it off but had not been successful. V10 said there was nothing housekeeping could do about the bubbling and cracking tiles.On 8/1/25 at 2:26 PM, V1 (Former Administrator) said he had the dining room floor professionally stripped and waxed and was told there was nothing more they could do for the floor. V1 said corporate was aware of the dining room flooring.On 8/7/25 at 10:20 AM, V4 (Maintenance Director) said he had started replacing bubbling tiles. V4 said the dining room floor had several layers of tile and as the tile below broke down it would cause the top tiles to bubble and crack. V4 said the only way to keep the top tiles from bubbling and cracking would be to replace the flooring. V4 said he had stripped the floors and had removed a large about of the discoloration. V4 said he was going to put 3 layers of wax on the floor to avoid discoloration but as the lower tiles broke down it would cause the glue to seep up between the top tiles and collect dirt and debris causing the discoloration.The facility's 7/30/25 Daily Census Report documented 58 residents residing in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to safely transport 1 (R1) of 3 residents reviewed for accidents. This failure resulted in R1 receiving a fracture to R1's fifth and sixth cervical vertebrae and right radius. This past noncompliance occurred between 1/29/2024 - 2/01/2024. The findings include: R1's face sheet documents R1 was admitted to the facility on [DATE], with diagnoses of Unspecified fracture of shaft of right tibia, subsequent encounter for closed fracture with routine healing, Unspecified fracture of the lower end of right radius, subsequent encounter for closed fracture with routine healing, Other nondisplaced fracture of fifth cervical vertebra, subsequent encounter for fracture with routine healing, Unspecified fracture of right femur, subsequent encounter for closed fracture with routine healing, Other nondisplaced fracture of sixth cervical vertebra, subsequent encounter for fracture with routine healing, Unspecified fracture of shaft of right fibula, subsequent encounter for closed fracture with routine healing, Morbid (severe) obesity due to excess calories, and Type 2 diabetes mellitus with diabetic nephropathy. R1's Minimum Data Set (MDS), dated [DATE], documents in Section C, a Brief Interview for Mental Status (BIMS) score of 15, indicating R1 is cognitively intact. Section GG, Functional Abilities and Goals, R1 is dependent with substantial assistance with activities of daily living. The facility's investigation report, dated 1/29/2024, documents at 4:10 PM on 1/29/24, V1 (Administrator) was notified by V3 (Transportation CNA) that while on the way to an appointment, a vehicle pulled out in front of them from the shoulder of the road. When V3 applied the brakes to avoid a collision, R1 fell forward and bumped her face on the floor of the van. R1 was immediately sent to the emergency room (ER) for evaluation. Investigation initiated immediately. Power of Attorney (POA) and V9 (Primary Physician) both notified immediately after the fall. On 1/29/24, R1 was immediately seen after the fall at an out of state emergency room. R1 was discharged from the ER the same day with all scans and x-rays negative for any fractures. POA and MD notified. Neurological checks continued. At 8:50 AM on 1/30/24, facility received a call from ER stating possible C5/C6 fracture. R1 immediately sent to local hospital for further evaluation by emergency medical services (EMS) with a C Collar applied. POA and MD notified. While at the local hospital, an MRI (Magnetic Resonance Imaging) was completed and confirmed C5/C6 fracture. The local hospital transferred R1 to another out of state hospital for further evaluation. R1 returned to this facility with a (specialized collar) from the out of state hospital. POA and MD notified. On 2/2/24, R1 complained of increased pain to the right forearm. V9 notified. X-rays ordered. POA notified. On 2/3/24 at 10:16 AM, R1 requested to go to the hospital secondary to pain. V9 and POA notified. R1 left facility and was transferred to the local hospital. R1 returned from the local hospital same day at 4:10 PM with a right arm splint and orders to follow up with Ortho. X-rays showing right radial fracture. V9 and POA notified. On 2/3/24 at 10:30 PM, R1 requested to go to the hospital secondary to increase left knee pain. V9 and POA notified. R1 states she was sitting in the chair with all straps fastened. R1 states they were on the interstate headed to her appointment when a car pulled out in front of them. R1 states V3 hit the brakes to avoid an accident and she fell forward to the floor. R1 states it all happened so fast, but she believes it was a white car. R1 states she then went to the ER and had all different scans and x-rays completed. R1 states she does not want anyone to get in trouble and it was an accident. R1's hospital x-ray report, dated 1/30/2024, documents acute nondisplaced fracture of the right C6 superior articular faucet extending superiorly to the right C5 pedicle and right C5 lamina. R1's hospital x-ray report, dated 2/03/2024, documents no acute fractures in the pelvis or left hip, and documents that R1 has an acute intra-articular right distal radial fracture. On 2/21/2024, at 9:10 AM, V1 (Administrator) stated he was notified by V3 (CNA) regarding the auto incident that occurred on 1/29/2024 while transporting R1 to an appointment. V1 stated V3 stated a car pulled out in front of him and he immediately applied the brakes to avoid a collision. V1 stated V3 stated R1's chair tipped over causing R1 to bump her face on the floor of the van. V1 stated R1 was immediately taken to a local hospital emergency room for further evaluation. V1 stated R1 was returned from the emergency room that same day with all scans and x-rays negative for any fractures. V1 stated the facility received a phone call the next day, 1/30/2024, from the local emergency room that R1 has possible C5/C6 neck fracture. V1 stated R1 was immediately sent to the local emergency room for an evaluation and a C-collar was applied. V1 stated while at the emergency room it was confirmed R1 did have a C5/C6 fracture. V1 stated R1 returned from local hospital with a cervical collar in place. V1 stated on 2/2/2024, R1 complained of increased pain to her right arm and x-rays were ordered, but R1 was sent out to the hospital before local x-ray company made it to the facility. V1 stated that R1 requested to go out to the hospital on 2/3/2024 in the morning related to pain. V1 stated R1 was sent out to the local emergency room and returned the same day with a right arm splint and to follow-up with ortho. V1 stated x-rays showed a right arm fracture. V1 stated later that evening R1 requested to go back to the hospital related to increased left leg pain. V1 stated on 2/4/2024, the facility received report that R1 had been transferred to an outside hospital with electrolyte and hemoglobin imbalances, and continues to remain at the outside hospital at this time. On 2/21/2024, at 1:30 PM, V6 (Maintenance) stated he gave an in-service on van safety and resident transport to all the employees that transport residents. V6 stated V3 (Transportation CNA) transported R1 using a (specialized wheelchair) when he took her to her appointment on 1/29/2024. V6 stated after R1's auto incident, he checked the van over and found no mechanical problems noted. On 2/21/2024, at 2:10 PM, V3 (Transportation CNA) stated he transported R1 to her appointment on 1/29/2024 and they left around 1:00 PM. V3 stated before they left, he loaded R1 into the van with a (specialized wheelchair). V3 stated he fastened and locked all four wheels and placed one seat belt over R1's left side. V3 stated he was traveling around 15 -20 miles per hour (mph) in the far-right lane and he was going down a hill when a white, four door, car pulled out in front of him. V3 stated he slammed on his brakes to avoid a collision and when he did, R1 slid out from underneath the seat belt and the (specialized wheelchair) tipped over on the left side to the floor. V3 stated he immediately pulled over and assessed R1 for any injuries. V3 stated R1 was alert and answered questions appropriately. V3 stated R1 stated that her chin was hurting. V3 stated he saw a penny size red mark on her chin at that time. V3 stated he helped get R1 get positioned properly back into the (specialized wheelchair) and checked all fasteners and made sure all the wheels were locked in place. V3 stated he called V1 (Administrator) and V2 (Director of Nursing), and they advised him to take R1 to the emergency room. V3 stated he transported R1 to the emergency room where she got evaluated. V3 stated they spent about 2 1/2 hours there; CT (Computed Tomography) scans and x-rays were taken. V3 stated at that time, R1 did not have any new problems noted and he transported her back to the facility. V3 stated he has been transporting residents since last June 2023, and he usually has 2-4 appointments a week. V3 stated he has had no other auto incidents where residents have gotten hurt. V3 stated he has only transported a resident in a (specialized wheelchair) 2-3 times. V3 stated he does not like to transport residents in (specialized wheelchairs). V3 stated any little bump in the road, the (specialized wheelchair) will move easily. V3 stated R1 has bad knees and prefers to transport using a (specialized wheelchair) rather than her wheelchair. V3 stated R1's appointments usually take 2 hours at times and it is more comfortable for her to transport using a (specialized wheelchair). V3 stated he has been trained on van safety and transport of residents, and it is now recommended no residents be transported in (specialized wheelchairs) any further. On 2/22/2024, at 10:57 AM, R1 was observed lying in her bed with a C-collar in place to her neck. R1's right forearm was observed to have yellow-greenish colored bruising noted. R1's left leg was elevated slightly on a pillow. R1 was alert and oriented to person, place, and time. R1 stated she did not want to talk about the van incident at this time. On 2/21/2024, at 9:00 AM, V1 (Administrator) stated the facility had a Quality Assurance (QA) meeting on 1/31/2024 to discuss. V1 stated the following people attended the QA meeting: V1 (Administrator), V2 (Director of Nursing), V14 (Assistant Director of Nursing), V15 (Regional). V1 stated the measures put in place to ensure the deficient practice does not recur are: All transportation staff will be educated to pull over to a safe area and call EMS after an incident. All transportation staff will be in-serviced on proper procedure for install of wheelchair. No (specialized wheelchairs) will be used on the transportation van/bus. A wheelchair audit will be completed for all residents. On 2/21/2024, V1 (Administrator) provided their QAPI (Quality Assurance Performance Improvement) Ad Hoc Form outlining the actions taken by the facility prior to the survey date to correct the noncompliance. Prior to the survey date of 2/26/24, the facility took the following actions to correct the non-compliance: 1. A Quality Assurance and Performance Improvement meeting was held on 1/31/2024. In attendance - V1, V2, V14, V15 (Regional). Immediate corrective action for those affected by deficient practice: R1 sent to the emergency room and treated at the emergency room. Transportation vehicle checked to ensure all safety mechanisms properly functioning. An in-service for all transportation staff on van/bus safety and resident transport was given by V6 (Maintenance) on 2/01/2024. In attendance were: V1 (Administrator), V3 (Transportation CNA), and V16 (Activity Director). 2. Process/Steps to identify others having the potential to be impacted by the same deficient practice: All residents that utilize the transportation vehicle have the potential to be affected. 3. Measures put into place/systematic changes to ensure the deficient practice does not recur: All transportation staff were educated to pull over to a safe area and call EMS after an incident. All transportation staff will be in-serviced on proper procedure for install of wheelchair. No (specialized wheelchairs) will be used on the transportation van/bus. The facilities Transportation Policy was updated to reflect the changes. A wheelchair audit will be completed for all residents. All in-service education completed on 2/1/24. 4. Plan to monitor performance to ensure solutions are sustained: Facility Administrator responsible for ensuring ongoing compliance. Facility Administrator responsible for reporting to QA committee.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents are free from staff to resident abuse for one resident of four residents (R3) reviewed for abuse in the sample of 4. This failure resulted in R3, during care on 7/6/23, experiencing physical pain and emotional distress with continued feelings of intimidation, fear, sadness, anxiety and helplessness. Findings include: R3's Face Sheet documented an admission date of 3/7/23, and diagnoses including Quadriplegia, Tracheostomy, Pressure Ulcer of the Sacrum, Diabetes Type 2, Morbid Obesity, Hypertension, Anxiety Disorder, Insomnia, Unspecified Depressive Episodes, and Polyneuropathy. R3's Minimum Data Set, dated [DATE], documented R3 has no deficits in cognition, is totally dependent on at least two staff for transfers, bed mobility, dressing, eating, and toileting. Nurses Note, dated 7/6/23 at 11:54am, authored by V4, Registered Nurse, documented, Resident accused CNA (Certified Nursing Assistant) of being rough while completing care. Is cursing and yelling at staff. Attempted to console and allowed resident to vent. Administrator and Director of Nurses notified. There was no documentation in the record to indicate R3 was assessed for injuries by nursing staff, or that R3's Physician had been contacted. On 8/23/23 at 12:05pm, R3 was alert and oriented to person, place, and time. R3 denied she has ever been physically or verbally abused at the facility, stating, I'm not going to let anybody abuse me, and stated, Some of the staff are always rude, like they're having a bad day. R3 stated staff have not said anything racist to her, but she has heard from staff that V6 has made racist comments to them. R3 stated she does not like V6 because, She's (V6) probably bipolar. R3 stated she does not think V6 likes R3. R3 stated there was an incident in July 2023 where V6, Rolled me (R3) over and she wasn't very gentle about it and hurt me, but I can't say it was intentional. R3 stated V6 does not take care of her anymore, since July 2023. R3 stated she did not ask to not have care from V6, and thinks maybe V6 does not want to take care of her anymore. On 8/24/23 at 10:15am, R3 was tearful, and stated she had been reluctant to speak to the Surveyor on 8/23/23. R3 stated on 7/6/23, V5 and V6 were providing incontinence care prior to showering. R3 stated upon entering the room, V6 seemed to be short with her. R3 stated as V6 was rolling her to her side, R3's flaccid left arm was caught under her body, and due to Neuropathy, she was in extreme pain. R3 stated she yelled for V6 to stop because she was hurting R3, but V6 did not stop. R3 stated she was hollering and V6 was hollering right back at her. R3 stated when the mechanical lift sling was placed under her, V6 stormed out of the room and into the hall, yelling, I can't do this anymore, and making statements about how uncooperative R3 is. R3 stated R3, Felt like (expletive) and started crying because she thought R3 and V6 were friends. R3 stated she feels very scared and vulnerable because she can't move or take care of herself and is completely dependent on staff. R3 stated sometimes V6 is the only CNA working on the Phoenix Unit, and she is afraid if V6 is mad at R3, she might not go tell other staff she needs help or would not go in R3's room if there was an emergency. R3 stated she worries that V6's feelings about her will poison other staff's opinion of R3. R3 stated she had not wanted to tell the Surveyor this because she fears staff retaliation. R3 stated she has a history of experiencing domestic violence, including a former partner shooting her in the neck, causing her to be quadriplegic. R3 stated, I already have problems with being scared, especially at night, and I startle easy with an extreme reaction to noise. R3 stated other staff members have said things to her such as,This (Phoenix) is (V6's) hall, which R3 has interpreted to mean it's V6's hall, not R3's hall. On 8/23/23 at 10:55am, V7, Certified Nursing Assistant (CNA), stated she usually works on the Phoenix Unit, but at times will float to other halls. V7 stated she has witnessed V6, CNA, make racial slurs about R3 behind R3's back, including using the N word. V7 stated she reported this a few weeks ago to V2, Director of Nursing, and V3, Assistant Director of Nurses. V7 stated for a few days afterward, V6 worked on a different hall, but V6 is now working on the Phoenix Unit again. V7 stated as far as she knows,V2 and V3 didn't do any kind of investigation or say anything to V6 because V6 is continuing the behavior. On 8/23/23 at 11:35am, V3, Assistant Director of Nurses, stated on 7/18/23 or 7/19/23, V7 reported V6 was making racial slurs about R3 behind R3's back. V3 stated she did not investigate it, did not inform V1, Administrator, and did not question V6 or R3. V3 stated the decision to move V6 to a different hall for a few days had already been made based on programmatic needs. V3 stated V6 is again back on the Phoenix Unit, but V6 does not provide care for R3, because,(R3) doesn't like her. V3 stated R3 has previously told V3 that V6 is, A b***h. V3 stated when R3 made this statement, V3 did not ask R3 to elaborate. V3 stated there are other staff R3 does not like, for example new staff or younger in age staff. V3 stated R3 has never reported any abuse allegations toward any staff to V3. On 8/23/23 at 12:30pm, V4 stated on 7/6/23, she responded to R3's room to assist V5, CNA, in completing care for R3, after V6 had left the room. V4 stated R3 was crying and upset, and V4 stated V5 reported to V4 he had observed that V6, Had been rough with (R3) during care that day. V4 stated she immediately reported this to V1 and V2. V4 stated she did not know if they started an abuse investigation, but V6 was allowed to work the remainder of her shift that day. V4 stated V6 will now not go into R3's room, and V6 at times is the only CNA on Phoenix, and has to go get CNA staff from other halls if R3 turns on her call light or needs care. V4 stated she has not heard V6 make any racial statements. V4 stated she is concerned about whether or not R3 is getting proper care under these circumstances. On 8/23/23 at 12:45pm, V5 stated on 7/6/23, he was assisting V6 in caring for R3. They provided incontinence care, and V5 stated R3 always wants a certain perineal spray cleanser to be used, so staff always use the spray per R3's wishes. V5 stated R3 requested the spray be used, and V6 seemed upset and told R3 she wasn't getting the spray that day, but provided no rationale. V5 stated V6 then rolled R3 toward the side of the bed while V5 placed the mechanical lift sling under R3.V5 stated R3 has a lot of nerve pain and staff have to be extra careful when repositioning her, but V6 was not being careful, and R3 began yelling that she was in pain, and asked V6 to stop, but V6 continued rolling R3 over. V5 stated R3 was yelling, crying, and cursing, and V6 was being equally loud toward R3.V5 stated he is not sure if V6 was trying to hurt R3, or if it was accidental. V5 stated he told V6 to leave the room, V4 came in the room, and when R3 was comfortably positioned, V5 reported the incident to V4. V5 stated he then assisted R3 with showering, and R3 was crying as V5 tried to console R3. V5 stated he assured R3 the incident would be reported, so after the shower, V5 reported the incident to V1 and V2. V5 stated he is not sure if an investigation was started, but V6 worked the remainder of her shift. V5 stated since the incident, V6 has refused to take care of R3, so CNAs from other halls have been providing care. V5 stated he has not heard V6 make racial statements, but V6 has told V5, I don't hate her (R3), but I just don't care about her. On 8/23/23 at 2:05pm, V6 stated she works the 6am to 6pm shift, always on the Phoenix Unit. V6 stated she has been employed at the facility since February 2023, but had previously worked at the facility for a total of eleven years. V6 stated she has never been accused to any type of resident abuse and denied ever having abused any resident. When asked about the 7/6/23 incident, V6 stated R3 is,Hard to handle, and verbally abuses staff. V6 stated on that date, she and V5 were providing incontinence care for R3 before showering her. V6 denied there was an issue with perineal spray, and denied telling R3 she couldn't have it. V6 stated she was rolling R3 toward her as V5 was putting the lift sling under R3, when R3 suddenly started yelling,Get off me and stop hitting me. V6 stated she believed R3 was saying that because R3 had told another staff member who no longer works at the facility that R3 was trying to get V6 fired. V6 stated she did not say anything to R3, and did not yell back at her. V6 stated she told V5 she was going to leave the room so that R3 could calm down. V6 stated R3 was not crying and did not say anything about being in pain. V6 stated later that day, V2 and V3 told V6 they decided V6 should work a different hall for an undetermined amount of time to give V6 a break from R3, and to give R3 some time to cool off, because It seemed like there was a personality conflict. V6 stated she worked the rest of her shift that day, and then had a few days off. V6 stated she worked on another hall for a few days when she returned, but had to return to the Phoenix Unit because, All the residents there were upset and crying because I wasn't taking care of them anymore. V6 stated, She (R3) must have called (V10, Ombudsman) because she showed up last week and asked me a bunch of questions. V6 stated V10 felt it would be for the best if V6 did not work with R3, so administrative staff told V6 when R3 turns on her light or needs care, other CNA and/or nursing staff are to be summoned to provide the care. V6 stated if staff to resident abuse is witnessed or suspected, it should be immediately reported to V1, V2, or V3, and if they are unavailable it should be reported to the Charge Nurse. V6 stated if a resident is angry and upset with a staff member, the staff member should remove herself and get another staff member to approach the resident. V6 stated she has never witnessed any staff make racist comments about residents, and stated she has never made racist comments about residents. On 8/23/23 at 3:05pm, V10 stated on 7/7/23, R3 reported to her the incident with V6 that occurred on 7/6/23. V10 stated R3 reported V6, Was rolling her over and using more force than what was required. V10 stated R3 did not identify the incident as abuse, but R3 stated she did think V6's actions were intentional. V10 stated she discussed the incident with V1 and V2, who stated V6 had a few days off, and when she returned would not be back on the Phoenix Unit for an undetermined amount of time. V10 stated R3 called V10 on 8/11/23 to report V6 was working on the Phoenix Unit again. On 8/23/23 at 3:42pm, V2 stated on 7/6/23, V4 reported R3 said V6 was rough rolling her over, and R3 wanted to speak to V2. V2 said R3 stated her arm got caught under her as V6 was rolling R3 to the side during care. V2 stated R3 said she did not think V6 was intentionally trying to hurt R3. V2 stated V1 was off that day, but she communicated about the incident with him by phone. V2 stated there have been no previous complaints from residents about V6, and that V6 is a good employee. V2 stated she determined, Nothing inappropriate happened, I felt it was a personality conflict, and that was the end of it. V2 denied any staff had approached V2 about V6 making racial comments about residents. V2 stated V6 was again assigned to the Phoenix Unit with the understanding V6 would not go into R3's room and would have other staff provide her care. On 8/23/23 at 4:07pm, V1 stated he acts as the facility's Abuse Coordinator. V1 stated in his absence, V2 acts as the Abuse Coordinator. V1 stated the facility's Abuse Policy states abuse is to be immediately reported to him, and if he is unavailable, it is to be reported to V2 or the Charge Nurse, who will immediately report it to him. V1 stated he is to then come immediately to the facility and begin an investigation.V1 stated the accused employee is to be walked out immediately, and is to remain off until the investigation is completed. V1 stated he was off on 7/6/23 when V2 called and told him that (R3) said (V6) was rough with her during rolling her side to side, that (V2) talked to (R3), (R3) said it wasn't abuse, and that was the end of it. V1 stated V2 said V6 denied being rough with R3. V1 stated when he returned to work, he spoke with R3 and R3, Apologized for lashing out at (V6) and said she wanted (V6) to start taking care of her again. V1 stated since the Surveyor arrived on 8/23/23 asking questions about staff to resident abuse, he decided to start asking staff if they had witnessed abuse, and V2 had, immediately before this interview, told him staff have said V6 has made racial slurs about people of color, but has not made them in front of residents. V1 stated he does not feel this is abuse, but he will be filling out a disciplinary action form on V6. V1 stated V6 takes care of several residents of color, but he does not feel that is a potential problem. V1 stated V10 is in the building a lot, but he does not recall her speaking to him about R3. V1 stated if V10 had reported abuse, he would have immediately followed up on it. V1 stated there have been no previous allegations of abuse against V6. V1 stated V6 is again working on the Phoenix Unit, but other staff are to be taking care of R3, because V6 is, Scared to go back in there for fear (R3) will accuse her of something. The Surveyor informed V1 there had been allegations V6 made racist comments about R3, and hurt R3 physically and emotionally during care on 7/6/23. V1 stated he would begin an immediate investigation, and would call V6 at home to advise her she would be off until the investigation was completed. An 8/23/23 Long Term Care Facility Serious Injury Incident and Communicable Disease Report documented, Alleged abuse-involving (R3). Staff involved: (V6). At 4:45pm, (V1) was notified of an allegation of verbal and physical abuse. Investigation initiated immediately.(V6) suspended immediately. Law enforcement notified. Final reportable will be sent within five business days. On 8/24/23 at 8:10am, V2 stated V1 still acts as the Abuse Coordinator even when off, and is to be immediately notified of abuse, but V2 is to communicate with him and start an immediate investigation and walk out accused staff. V2 stated the residents nurse is to do head to toe skin check to check for signs of injury. V2 acknowledged there was no documentation in V4's Nurses Note to indicate an assessment for injuries was done, and V2 stated, (R3) gets a daily skin check anyway. V2 stated the 7/6/23 skin check was not timestamped, so there is no way to know if it was done before or after the above referenced incident. V2 stated she did not contact R3's Physician about the allegations of staff to resident abuse. . On 8/24/23 at 8:30am, V4 stated nursing staff should do a full body assessment on the resident after an abuse allegation has been made. V4 stated she doesn't remember if she assessed R3. V4 stated V2 did not instruct her to do one, nor is she aware of V2 doing one. V4 stated she did not contact R3's Physician. 8/24/23 9:20am, V11, Social Services Designee, stated she has been in the position since May 2023. V11 stated R3 is Quadriplegic as a result of a gunshot wound she sustained during a domestic dispute. V11 stated R3 has recently stated she will accept pastoral counseling for help in dealing with her issues. On 8/24/23 at 11:50am, V1 was told about R3's allegation of physical and verbal abuse and verbalization of fearing staff retaliation. V1 stated the initial notification of staff to resident abuse had been submitted to the Illinois Department of Public Health and the investigation was ongoing. The facility's undated Resident Rights Policy documented, Your facility must provide services to keep your physical and mental health, and sense of satisfaction. You must not be abused by anyone-physically, verbally, mentally, financially, or sexually. Your facility may not threaten or punish you in any way for asserting your rights or presenting grievances. The facility's Abuse Prevention Program Policy, dated 9/29/22, documented, Abuse is the willfull infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods and servicesthat are necessary to attain or maintain physical, mental, and psychological well-being. The facility desires to prevent abuse, neglect, or misappropriation of property by establishing a resident sensitive and resident secure environment. 5. Employees are required to report any incident, allegation, or suspicion of potential abuse, neglect, or misappropriation of property they observe, hear about, or suspect immediately to the Administrator. Upon learning of the report, the Administrator shall initiate an incident investigation. Upon report of such occurrences, the Nursing Supervisor is responsible for assessing the resident, reviewing documentation, and reporting to the Administrator. Employees of the facility who have been accused of abuse will be removed from resident contact immediately until the results of the investigation have been reviewed by the Administrator or designee. Employees accused of possible abuse shall not complete the shift as a direct care provider to residents. Any incident or allegation involving abuse, neglect, or misappropriation will result in an abuse investigation. 8. External Reporting of Potential Abuse: In response to allegations of abuse, are reported immediately, but not two hours later than the allegation is made, to the Administrator and other officials (including the State Survey Agency). The allegation shall be either called or faxed to the Regional Public Health Office. The Administrator or designee will also also inform the resident or resident's representative and attending physician of the report of an occurrence of potential mistreatment and that an investigation is being conducted. The facility shall immediately contact local law enforcement authorities in the following situations: 1. Physical abuse involving physical injury inflicted on a resident by a staff member or visitor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify a resident's Primary Care Physician of a worsening wound, failed to ensure ordered weekly wound care physician visits were done, and failed to notify the resident's Primary Care Physician of the lack of a wound care physician for 1 of 3 residents (R1) residents reviewed for pressure wounds in the sample of three. These failures resulted in R1's wound worsening to a Stage 4 that developed an infection requiring hospitalization, Intravenous (IV) antibiotic therapy, and surgical debridement. Findings include: R1's Face Sheet documented an admission Date of 5/1/23, and Diagnoses including Hemiplegia/Hemiparesis following a Subarachnoid Hemorrhage affecting the non-dominant left side, Aphasia, Morbid Obesity, a pressure ulcer to the sacrum, and Diabetes Type 2. R1's Minimum Data Set, dated [DATE], documented R1 was totally dependent on at least two staff for transfers, toileting, and bed mobility, had an indwelling urinary catheter, a gastrostomy tube with enteral feedings, a tracheostomy with mechanical ventilation, and a Brief Interview for Mental Status Score of Zero, indicating R1 had severe deficits in cognitive functioning. R1's Care Plan, with a start date of 5/1/23, documented a problem area, Resident is at risk of skin breakdown or pressure ulcers, with a corresponding intervention, Report changes to MD (Medical Doctor) and obtain treatments as ordered as indicated. R1's Braden Scale for Predicting Pressure Sore Risk, dated 6/19/23, documented R1 was at moderate risk for the development of pressure ulcers. R1's June 2023 Physicians Order Sheet documented an order, Cleanse coccyx wound with wound cleanser, apply (trade name alginate dressing) and cover with bordered gauze dressing daily. R1's Nursing Wound Assessments documented the following (all the following measurements are in centimeters): 5/1/23: Initial wound observation: (Wound location) Coccyx, two open areas, (area) measures 2 by 4 with a depth of 0.1, light clear serous drainage, well defined edges, with 100 percent of the wound covered by granulation tissue, (stage not documented). 5/10/23: (Wound measures) 6.2 by 6.5 by 0.1, moderate serous drainage, stage 3, 20 percent epitheliazation tissue, 80 percent granulation tissue. Wound status: Stable. 5/15/23: 4.5 by 5.6 by 0.1, stage 3, 20 percent epitheliazation tissue, 80 percent granulation tissue. moderate serous clear drainage. Wound status: Improving. 5/22/23: 4.3 by 5.5 by 0.1, stage 3, 30 percent epitheliazation tissue, 70 percent granulation tissue, moderate serous clear drainage. Wound status: Improving. 5/30/23: 4.3 by 5.5 by 0.1, stage 3, 20 percent epitheliazation tissue, 80 percent granulation tissue, moderate serous amber clear drainage. Wound status: Declining. 6/5/23: 4.5 by 5.5 by 0.1, stage 3, 70 percent epitheliazation tissue, 30 percent granulation tissue, moderate serous amber clear drainage. Wound status: Stable. 6/12/23: 4.3 by 5.5 by 0.1, stage 3, 70 percent epitheliazation tissue, 30 percent granulation tissue, moderate serous amber clear drainage. Wound status: Stable. 6/19/23: 4.3 by 5.5 by 0.1, stage 3, 70 percent epitheliazation tissue, 30 percent granulation tissue, moderate serous amber clear drainage. Wound status: Stable. 6/26/23: 4.3 by 5.4 by 0.1, stage 3, 70 percent epitheliazation tissue, 30 percent granulation tissue, moderate serous amber clear drainage. Wound status: Stable. Physician Wound Evaluation and Management Summaries, authored by V5 (Wound Care Physician), documented the following: 5/10/25: At the request of the referring provider (V7, R1's Primary Care Physician), a thorough wound care assessment and evaluation was performed today. Stage 3 pressure wound to the sacrum for at least 45 days duration. Wound size (in centimeters) 6.2 by 6.5 by 0.1. (Follow up) in seven days. 5/15/23: Stage 3 pressure wound to the sacrum. Wound size: 4.5 by 4.6 by 0.1. Wound progress: Improved. Follow up .within seven days. 5/22/23: Stage 3 pressure wound to the sacrum. 4.3 by 5.5 by 0.1. Wound progress: Improved evidenced by decreased surface area, increased epitheliazation. Follow up .within seven days. 5/29/23: The patients visit has been rescheduled. No nurse available for rounds. There was no further documentation by V5 in the record. R1's TAR (Treatment Administration Record) for May and June 2023 documented from 5/1/23 to 5/9/23, the coccyx wound was treated every 48 hours with moistened (trade name collagen matrix) covered with a (trade name foam dressing). From 5/10/23 to 6/19/23, the wound was treated daily with calcium alginate with a trade name bordered gauze dressing. From 6/20/23 to 6/28/23, which included the day R1 was sent to the hospital, the area was treated daily with hydrogel followed by (trade name calcium alginate) covered with (trade name bordered gauze dressing). Nursing Progress Notes for R1 documented the following: 6/20/23 at 3:45pm: Wound Doctor attempted to be contacted multiple times the last few days .regarding residents worsening wound to coccyx. Wound Nurse finally contacted (V6-Physician/Medical Director) for further instruction, (new treatment order obtained.) 6/26/23 at 5:36pm: Wound Nurse assessed and completed residents prescribed treatment order with no issues .Wound edges look to be rejuvinating much better than previous treatment that was prescribed. Wound Nurse attempted to contact Wound Doctor once again regarding (the) center area of the wound that is still not appearing to improve Still no answer. 6/28/23 at 8:10am: Night nurse reported .this resident had 104 (degrees Fahrenheit) fever .rechecked at 7:30, still 103.8. Urine in (indwelling catheter) bag noted to be dark and cloudy with small clots observed. (V7) notified at 7:38am and orders are given to send to the hospital. A Hospital admission Record for R1, dated 6/28/23, documented, admitted (to the ICU (Intensive Care Unit)) with Urosepsis .(Admission) white blood cell count 18.6 (cells per microliter)(reference range: Normal 5-10). Culture from sacrum: Light Proteus miralibis, light polymorphonuclear cells, heavy gram-positive cocci, moderate gram variable bacilli. Assessment: Septic shock secondary to sacral wound. Cefipime 2000 milligrams in 0.9 percent sodium chloride in 50 milliliter IV piggyback given. A Hospital Encounter note dated 6/30/23 documented, Debridement of infected, necrotic, stage 4 sacral wound .necrotic tissue (present) all the way to the coccyx, fascia, and muscle .Possible need for multiple serial debridements. On 7/13/23 at 7:35am, V4 (R1's Power of Attorney) stated R1 was admitted to the facility on [DATE]. V4 stated R1 was admitted to the facility with a coccyx wound. V4 stated on 6/28/23, R1 developed a temperature of 103 degrees Fahrenheit, and was sent to the hospital, where it was discovered R1 had a Urinary Tract Infection and R1's coccyx wound was so deep the bone was exposed, and the wound was infected. V4 stated R1 will need multiple surgical interventions to close the wound. V4 stated R1 will also have to be on intravenous antibiotics, for weeks. On 7/13/23 at 2:30pm, V6 (Physician/Medical Director) stated staff had contacted him once in the past few weeks to report R1's pressure ulcer was not improving and they had been unable to reach V5. V6 stated he did not evaluate R1, but did give orders to change the treatment. V6 stated he had heard nothing further about R1. On 7/13/23 at 2:50pm, V2 (Director of Nursing) stated R1 was admitted with she believed three pressure areas to the sacrum, two of which have healed. V2 stated R1 was getting daily skin checks documented with a check off on the Treatment Administration Record (TAR), with a documented full evaluation of the skin done weekly. V2 stated R1's wound care treatment was being done daily with a check off on the TAR. V2 stated V5 was to see all residents with wounds every Monday. V2 stated over the course of several weeks in April and May 2023, V5 became less and less available and difficult to reach. V2 stated V5 last saw R1 on 5/22/23. V2 stated she is not sure why any of V5's notes would read, No nurse available to round, as any of the nurses may round with V5. V2 stated V3 (Licensed Practical Nurse/Wound Care Nurse), tried contacting V5 on multiple occasions after 5/22/23. V2 stated V3 was measuring and staging V5's residents wounds weekly, and was continuing to treat the wound according to V5's 5/22/23 orders. V2 stated about two weeks ago, V2 reached out to V5's contractual employer to ask that they send a different provider, and a Wound Care Nurse Practitioner started at the facility on Monday, 7/10/23. V2 stated on 6/28/23, R1 developed a 103 degree fever and was sent to the hospital for Urosepsis. V2 stated at the time of hospitalization, R1 did not have a wound infection. On 7/14/23 at 9:40am, V3 stated R1 was admitted with an area to the coccyx, primarily covered with granulation tissue, with two small unhealed areas within it. V3 stated the coccyx was being treated daily, with V3 doing the treatment on Mondays and Fridays and floor nurses doing the treatment on the remaining days. V3 stated R1 was being seen weekly by V5. V3 stated one area resolved, but V3 did not believe the other area was improving with the treatment V5 prescribed. V3 stated she brought this to V5's attention every time he rounded, but V5 still would not change the treatment orders. V3 stated V5 last evaluated R1 on 5/22/23, and did not show up or call to cancel the following week. V3 stated she kept calling V5, as well as his contractual employer, and about three weeks after 5/22/23, the employer told V3 that V5, was on an extended medical leave and was not available. V3 stated at that point, she called V7 to ask if V7 could evaluate the wound, but V7 did not return V3's call. V3 stated on 6/20/23, she contacted V6 to report the wound was declining, and V6 did not evaluate the wound, but did prescribe new treatment orders. V3 stated she last observed and treated the wound on 6/26/23, and she felt the wound was improving. V3 stated around that time, V2 called V5's employer and asked they send a different provider since V5 was not dependable. V3 stated she heard on the morning of 6/29/23 that R1 had been sent to the hospital on 6/28/23 and, (V1, Administrator) and (V2) said they heard from the hospital that when they got (R1), the wound looked really bad, the wound was infected, bone was exposed, (R1) would have to be on IV antibiotics for four weeks, and she would need to have surgery on the wound. V3 stated she was very surprised to hear this report. V3 stated R1 is the only resident whose wound deteriorated while the facility was without a wound care provider. V3 stated on 7/10/23, V5's employer sent a new mid-level wound care provider, who followed up on all V5's residents, and will see them weekly every Monday. On 7/14/23 at 12:45pm, V1 stated he heard from a nursing staff member, he could not remember which one, a nurse at the hospital where R1 was, called voicing concerns about the appearance of the wound and questioning the quality of wound care she was receiving at the facility. V1 stated the last staff member to provide R1's wound care prior to her hospitalization was V8 (Licensed Practical Nurse/LPN) on 6/27/23. On 7/14/23 at 12:50pm, V8 (Licensed Practical Nurse/LPN) stated she did not specifically recall doing R1's dressing change on 6/27/23, but if it had showed signs of infection or if the bone was exposed she most certainly would have contacted V7. V8 stated she and V3 had discussed the wound several times, and she was aware V3 had been trying to get a hold of V5. On 7/14/23 at 1:20pm, V9 (Registered Nurse) stated she had discussed R1 with hospital staff during transfer report, but nothing was said about her wound being infected. On 7/14/23 at 1:30pm, V2 stated she,Heard in passing at the 6/29/23 Department Head Meeting, that hospital staff called to voice concern about the condition of the wound and the quality of wound care she received at the facility, but she did know who took the call, and she did not follow up with the hospital. On 7/14/23 at 1:45pm, V10 (Hospital Nursing House Supervisor) stated R1 was admitted on [DATE] with an admitting diagnosis of Sepsis due to Urinary Tract Infection versus Osteomyelitis from an infected sacral wound. V10 stated on admission, staff noted the wound was unstageable with necrotic tissue present. V10 stated R1 was on IV antibiotics throughout her stay. V10 stated during the hospitalization the wound had to be surgically debrided. V10 stated R1 was discharged from the hospital on 7/7/23 to a hospital in Missouri, where R1 will get more surgical intervention for the wound. V10 stated R1's hospital chart contained no documentation to indicate their staff talked to the facility about R1's wound specifically. On 7/14/23 at 2:00 pm, V7 (R1's Primary Care Physician) stated she was aware R1 had been sent to the hospital due to Urosepsis and an infected pressure ulcer. V7 stated she had no idea V5 had not been visiting the facility due to being on an extended medical leave. V7 stated the facility did not call to tell her R1 was not being seen, nor that R1's pressure area had worsened. V7 stated she is always available by phone, and additionally she is in the facility rounding every week and nobody said anything to her about this issue. V7 stated had she been aware, she would have evaluated the wound herself. V7 stated R1 has multiple serious health concerns which complicated her care. V7 stated she had counted on the facility to ensure R1's wound was being treated by a specialist. A Wound Management Program Policy dated 1/20/23 documented, It is the policy of (the facility) to manage resident skin integrity through prevention, assessment, and implementation of evaluation and interventions .Physician orders should be obtained and followed for each resident. The facility will assess residents weekly for current skin conditions .Physician .(will be) called weekly .with an update of the current wound condition. These calls are documented in the nursing notes.