B1. Resident C's clinical record was reviewed on 4/15/25 at 12:38 p.m. The diagnosis included, but was not limited to, Lewy Bodies dementia. The Elopement Risk Review form, dated 2/19/25, for Resident C indicated the resident was assessed as being a high risk for elopement. A care plan, initiated on 10/2/23, for Resident C indicated, .Focus: Resident is at risk for wandering . Goal: Resident will have no injuries related to wandering daily . Interventions: Document any wandering activity and interventions attempted . Notify and update MD/NP [medical doctor/nurse practitioner] and family of any changes in wandering activity . Provide resident with food, drink, offer toileting, walk with resident and offer other activities . A review of a State Reportable on Resident C indicated, on 3/26/25 at 11:01 a.m., staff observed the resident in a wheelchair immediately outside of the exit door. Staff immediately accompanied the resident inside the facility without incident. Resident was wearing appropriate clothing and footwear. The follow up on 4/4/25 indicated, the exit door mag lock failed and the resident was able to exit. A review of nursing progress notes on Resident C indicated, on 3/26/25 at 11:34 a.m., the resident was unable to be evaluated by the skin and wound team due to resident being out of the room and was unable to be located. The progress notes lacked documentation of an incident where Resident C was found outside of the exit door on 3/26/25. During an interview on 4/15/25 at 2:30 p.m., the DON indicated she was on vacation when Resident C eloped but she believed it to be in the daytime. He was in a wheelchair and rolled down the unit that was closed and not used for residents. The lock was not working and he was able to get out. She was unsure how long he had been outside but believed the weather to be nice that day. The facility did do an incident report but did not make a note in the nursing progress notes. During an interview on 4/16/25 at 9:30 a.m., Physical Therapist 1 indicated she found Resident C outside the door in the back on the hallway with no residents sometime before noon on 3/26/25. The wound care team had been looking for him and couldn't find him. She went looking and decided to try the back door on the closed unit. He was sitting outside unharmed. She was unsure how long he had been outside. During a tour on 4/16/25 at 10:26 a.m., the closed unit was observed to have two closed doors with a sign indicating the unit was closed. A door at the end of the hallway was observed to lead out to a porch with a ramp directly behind the backside of the smoking shack used by residents. No residents or staff were observed to be in the area at the time. During an interview on 4/16/25 at 11:02 a.m., the Administrator indicated she was unable to locate nursing progress notes related to Resident C's elopement on 3/26/25. During an interview on 4/16/25 at 11:25 a.m., LPN 1 indicated she had checked Resident C's blood sugar at approximately 9:00 a.m. on 3/26/25, and would have checked it again around 11:00 or 11:30 a.m., that same morning. She did not remember seeing him between those times. During an interview on 4/16/25 at 11:34 a.m., LPN 3 indicated she had been telling the facility for quite some time the back door lock was not working and she had seen Resident C attempting to get through the doors to the closed unit many times. He had indicated to her, I'm an escapee you know. On 4/16/25 at 11:11 a.m., the Administrator provided the policy, Policy and Procedure for Personal Safety Devices for Resident at Risk of Elopement, undated, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . It is the policy of this facility that all residents are provided adequate supervision to meet each resident's nursing and personal care needs . 6. All . exit doors alarms will be tested every shift to verify that each device and door alarm are functioning properly . This citation relates to Complaints IN00456323 and IN00456968. 3.1-45(a)(2) A. Based on interview and record review, the facility failed to provide supervision to prevent repeated falls for a resident assessed to be a high risk for falls for 1 of 3 residents reviewed for accidents. This deficient practice resulted in a resident sustaining fractures of the wrist and hand and hospitalization for decreased mobility in lower extremities. (Resident B) B. Based on interview and record review, the facility failed to ensure a resident with an assessed behavior of wandering and a high risk of elopement was provided treatment and services to prevent an elopement which resulted in the resident going through an unlocked door and getting outside without staff knowledge for 1 of 3 residents reviewed for elopement. (Resident C) Findings include: A1. On 4/15/25 at 11:24 a.m., Resident B's clinical record was reviewed. The diagnoses included, but were not limited to, diabetes, osteoporosis (a condition where bones become weak and brittle), osteoarthritis (occurs when flexible tissue at the ends of bones wears down), and history of a healed traumatic fracture. A hospital history and physical, dated 3/6/25 at 7:27 p.m., indicated Resident B had a diagnosis of osteoporosis and compression fracture from a fall in February 2025. Documentation indicated resident had fall precautions. A physician's order for Resident B, dated 3/13/25, indicated up ad lib (able to move and mobilize freely) with assistance. The baseline care plan for Resident B, dated 3/13/25, lacked documentation of resident being at high risk for falls or interventions to prevent falls. The admission MDS (Minimum Data Set) assessment, dated 3/18/25, indicated the resident had moderately impaired cognition, had history of falls on admission and had falls since admission. A Progress Note, dated 3/13/25 at 10:15 p.m., indicated the resident slid off her bed while attempting to stand. The fall was witnessed and an assessment was completed with no injuries or reports of pain. The physician and family were notified. A Fall Risk Assessment, dated 3/13/25 at 10:26 p.m., indicated Resident B was assessed as high fall risk due to ambulation, elimination, gait and balance. A Progress Note, dated 3/14/25 at 2:42 p.m., indicated an IDT (interdisciplinary team) Fall follow up, indicated the resident slid off the bed while attempting to get up. The resident was assessed and not observed to be injured. The care plan was reviewed and updated and a new intervention for a scoop mattress was added. A Progress Note, dated 3/23/25 at 3:00 p.m., indicated the resident had an unwitnessed fall and complained of left arm pain. The on-call physician was contacted and new orders were received as follows: x-ray of left extremity (hand, wrist and elbow), fall precautions, assess pain, monitor neurological checks and notify a clinician of any change in condition. The x-ray report for Resident B, dated 3/23/25 at 8:04 p.m., indicated the following the left hand demonstrated an oblique fracture (break that occurs at an angle across the bone's length) of the midshaft of the fourth metacarpal (a break in the middle of the bone in the hand that connects to the ring finger). There was an acute fracture of the torus variety (causes one side of the bone to bend, but does not actually break through the entire bone) in the distal left radius (the lower end of the radius bone in the forearm, located nearest the wrist). No other fractures are noted. A Progress Note, dated 3/23/25 at 10:30 p.m., indicated the physician was notified of x-ray results. The clinical record lacked documentation of any new orders or interventions after x-ray results were received. A Progress Note, dated 3/24/25 at 3:30 a.m., indicated the resident was assisted to the restroom by CNA 1. The resident was incontinent and slipped on the wet floor. CNA 1 lowered the resident to floor and called for assistance. LPN 4 went to the resident's room to assist CNA 1. The resident was unable to stand from a seated position and they placed a sheet under her and transferred her back to bed. The resident had no complaints of pain and neurological checks were with in normal limits. A Fall Risk Assessment, dated 3/24/25 at 4:27 a.m., indicated Resident B was assessed as a high fall risk due to history of falls, ambulation, elimination, gate and balance. On 3/24/25 at 3:40 a.m., a Change in Condition Summary was sent to the provider due to the fall. The summary indicated the resident had weakness in bilateral lower extremities, was unable to stand, and recommend a physical therapy evaluation. The primary care feedback indicated that there were no new interventions, testing, or recommendations applicable. On 3/24/25 at 8:33 a.m., a Change in Condition Summary was sent to the provider due to altered mental status and new neurological signs. The provider recommended the resident be sent to the emergency room. On 3/24/25 at 10:09 a.m., a late entry nursing note indicated, at 7:30 a.m., LPN 5 entered resident's room and noticed the resident was confused, had slurred speech and could not open her right eye all the way. Neurological checks were completed and the resident could not feel or move her legs. The resident complained of abdominal and low back pain. Emergency Medical Services were called and resident was transferred to the emergency room. The clinical record lacked documentation of an IDT note after Resident B's falls on 3/23/35 and 3/24/25. During an interview on 4/15/25 at 11:57 a.m., the DON indicated that resident was admitted to the facility due to a urinary tract infection and history of spinal injury from a previous fall. The DON indicated that Resident B was walking with a CNA on 3/24/25 when her legs became weak and the resident was lowered to the floor. The DON indicated that the resident was unable to stand, so the staff placed a sheet under Resident B to take her back to bed. The DON indicated they did not send the resident to the hospital due to she was lowered to the floor, her neurological checks were normal and she did not complain of pain. The DON indicated that the resident was now paralyzed. During an interview on 4/15/25 at 2:33 p.m., CNA 1 indicated she had assisted Resident B to the restroom on 3/24/25. CNA 1 indicated that Resident B had tingling and numbness occasionally in her legs. CNA 1 indicated she asked the resident if she was experiencing any tingling or numbness and the resident denied having any. CNA 1 indicated that Resident B ambulated with a walker. CNA 1 indicated while walking Resident B to the restroom, the resident complained of left leg pain and tingling, CNA 1 indicated she had resident sit on the seat of her walker and pushed her to the restroom. CNA 1 indicated the resident was able to stand and pivot to the commode but started to urinate while standing. CNA 1 indicated the resident's right foot was sliding and she lowered the resident to the floor. CNA 1 indicated she called for assistance and LPN 4 came to assist her, she indicated that they were unable to get a mechanical lift into the restroom, so they placed a sheet under Resident B and carried her back to bed. During an interview on 4/16/25 at 9:52 a.m., LPN 5 indicated she had received report on 3/24/25 at approximately 6:30 a.m. LPN 5 indicated it was reported that Resident B had a fall during the night. LPN 5 indicated that when LPN 5 went to Resident B's room to check her blood sugar LPN 5 noticed the resident was confused and not acting like herself. LPN 5 indicated the resident complained of low back pain and stomach pain. LPN 5 indicated the resident was unable to move her legs and could not feel the nurse touching them. LPN 5 indicated she called 911 and the ambulance arrived at approximately 8:00 a.m. During an interview on 4/16/25 at 10:58 a.m., LPN 2 indicated she had worked on 3/23/25 when Resident B had slid off her bed. LPN 2 indicated that Resident B complained of wrist and hand pain after the fall. LPN 2 indicated she called the provider on call and received an order for an x-ray. She indicated at approximately 10:30 p.m., LPN 2 notified the family, the DON and Executive Director (ED) of the results. LPN 2 indicated she placed the x-ray results in the provider binder at the nurses station. LPN 2 indicated she did not call the provider on call with the results. LPN 2 indicated she was unsure when the medical providers looked at the binder because she only worked Saturdays and Sundays. During an interview on 4/16/25 at 2:05 p.m., the ED indicated there was no IDT note or root cause analysis completed after falls on 3/23/25 or 3/24/25, for Resident B. On 4/15/25 at 12:53 p.m., the DON provided the facility's policy Guidelines for Incidents/Accidents/Falls, dated 6/30/23, and indicated it was the policy currently being used by the facility. A review of the policy indicated, .It is the policy of the facility to ensure that any incident/accident to include falls is reported immediately .a written report will be entered into Risk Management .information will be used to implement corrective actions to include any needed training to prevent reoccurrences when possible .6. The incident/accident report will be completed as soon as information is obtained .11. All falls will have a site investigation by appropriate staff in an effort to define the root cause of the fall .15. Based on results of the incident/accident/fall, the resident's care plan will be addressed .with appropriate interventions in place .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent the development and worsening of facility acquired pressure ulcers for 2 of 6 residents reviewed for pressure ulcers. This deficient practice resulted in worsening and possible infection of an unstageable pressure ulcer and the development of a Stage III pressure ulcer. (Resident 34, Resident 5) Findings include: 1. On [DATE] at 2:06 p.m., Resident 34's clinical record was reviewed. The diagnoses included, but were not limited to, dementia, overactive bladder, and diabetes mellitus. The Braden Scale for Predicting Pressure Ulcer, dated [DATE] at 7:52 a.m., indicated the resident was a mild risk for developing a pressure ulcer. The Annual Minimum Data Set (MDS) assessment, dated [DATE], indicated she had severe cognitive impairment; was always incontinent of urine; frequently incontinent of bowel movements; was at risk for skin breakdown; did not currently have any pressure ulcers; had no impairments for mobility with the left lower extremity; and was independent with moving in bed from left to right. A care plan, dated [DATE], indicated she required assistance with activities of daily living (ADLs) due to dementia. Her interventions were for staff to assist with transfers, toileting, and bed mobility as needed. A care plan, dated [DATE], indicated she was at risk for skin breakdown due to diagnosis of overactive bladder and decreased mobility. The interventions were Braden scale quarterly and as needed; keep resident clean and dry; pressure relieving mattress per facility policy; and skin assessment per facility policy. Wound 1: A weekly wound evaluation, dated [DATE] at 4:25 p.m., indicated a stage two (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising) wound was identified on the resident's left heel and measured 2.0 centimeters (cm) length (L) X (by) 1.0 cm width (W) X less than (<) 0.1 cm depth (D). The evaluation did not include documentation to indicate a new intervention to provide pressure relief to the left heel was initiated. A nursing progress note, dated [DATE] at 4:53 p.m., indicated a wound was identified to the left heel. The note did not include documentation to indicate a new intervention to provide pressure relief to the left heel was initiated. A nursing progress note, dated [DATE] at 4:18 p.m., indicated the facility-acquired stage two pressure ulcer on the left heel deteriorated to an unstageable (the stage of the wound is unclear, the base of the wound is covered by a layer of dead tissue that may be yellow, green, gray, brown or black) pressure ulcer and measured 1.5 cm L X 1.0 cm W X < 0.1 cm depth (D). The wound base was 75 to 99 percent eschar (dead tissue). The note indicated the Nurse Practitioner (NP) recommended for staff to initiate pressure relief interventions to the left heel and bony prominence's but did not include documentation to indicate pressure relief was provided to the left heel. A Care Plan, dated [DATE], indicated the resident had an unstageable pressure injury to the left heel with interventions for diet as ordered, low air loss mattress to resident bed, skin checks weekly and as needed, and treatments as ordered. The plan did not include documentation to show interventions for pressure relief were provided to the left heel. The care plan was not developed until eight days after the pressure ulcer was found. A weekly wound evaluation, dated [DATE] at 10:23 a.m., indicated the measurements of the wound did not change. The evaluation did not include interventions to provide pressure relief to the left heel were initiated. A nursing progress note, dated [DATE] at 6:37 a.m., indicated the facility-acquired unstageable pressure injury on the left heel was stable. A weekly wound evaluation, dated [DATE] at 11:33 a.m., indicated the measurements of the wound did not change. The evaluation indicated Medihoney (a debriding dressing) should be applied to the wound. The evaluation did not include interventions to provide pressure relief to the left heel were initiated. A nursing progress note, dated [DATE] at 6:39 a.m., indicated the NP identified the facility-acquired unstageable pressure injury on the left heel deteriorated and measured 2.0 cm L X 2.0 cm W X 0.1 cm D. The note indicated the NP recommended for staff to provide pressure relief to the left heel using heel boots when the resident was in bed. A weekly wound evaluation, dated [DATE] at 11:54 a.m., indicated the measurement and treatment of the wound did not change. The evaluation did not include interventions for a heel boot or pressure relief to the left heel were implemented. A nursing progress note, dated [DATE] at 6:47 a.m., indicated the facility-acquired unstageable pressure injury on the left heel deteriorated and measured 2.0 cm L X 3.0 cm W X 0.1 cm D. The wound base was 50 to 74 percent slough (dead tissue) and 50 to 74 percent eschar. The note indicated pressure relief should be provided with heel boots. The nursing progress did not indicate the interventions for a heel boot or pressure relief to the left heel were implemented. A weekly wound evaluation, dated [DATE] at 11:37 a.m., indicated the measurement of the facility-acquired unstageable pressure injury did not change, but the treatment changed to Hydrogel (a primary dressing indicated for hydrating dry, necrotic, and sloughy wounds). A nursing progress note, dated [DATE] at 6:30 a.m., indicated the facility-acquired unstageable pressure injury on the left heel was stable and measured 1.5 cm L X 3.0 cm W X 0.1 cm D. The wound base was 100 percent eschar. The note indicated pressure relief should be provided with heel boots. The nursing progress note did not include documentation the interventions for a heel boot or pressure relief to the left heel were implemented. A weekly wound evaluation, dated [DATE] at 11:09 a.m., indicated the facility-acquired unstageable pressure injury measured 1.5 cm L X 1.0 cm W X 0.1 cm D, but the treatment changed to Hydrogel (a primary dressing indicated for hydrating dry, necrotic, and sloughy wounds). A nursing progress note, dated [DATE] at 6:41 a.m., indicated the facility-acquired unstageable pressure injury on the left heel improved and measured 1.5 cm L X 2.5 cm W X 0.1 cm D. The wound base was 75 to 99 percent slough and 25 to 49 percent eschar. The note indicated pressure relief should be provided with heel boots. The nursing progress note did not include documentation to indicate the interventions for a heel boot or pressure relief to the left heel were implemented. A weekly wound evaluation, dated [DATE] at 3:49 p.m., indicated the facility-acquired unstageable pressure injury measured 1.5 cm L X 2.5 cm W X 0.1 cm D. A nursing progress note, dated [DATE] at 6:34 a.m., indicated the NP identified the facility-acquired unstageable pressure injury on the left heel deteriorated, exhibited signs and symptoms of infection, and measured 3.0 cm L X 2.0 cm W X 0.1 cm D. The note indicated new orders for antibiotic (ATB) therapy, pressure relief with a heel boot at all times, a wound culture, and a low air loss mattress were received. The nursing progress note indicated the wound exudate was foul smelling, 1 to 24 percent slough and 75 to 99 percent eschar. They documentation did not indicate the interventions for a heel boot or pressure relief to the left heel were implemented. A weekly wound evaluation, dated [DATE] at 3:25 p.m., indicated the facility-acquired unstageable pressure injury measured 3.0 cm L X 2.0 cm W X 0.1 cm D and the treatment changed to Santyl (a medication for debriding necrotic tissue from wounds). On [DATE] at 12:16 p.m., Resident 34 was observed at the dining room table feeding herself. She was observed to be wearing socks on both feet with her feet resting on the floor. No pressure relieving devices were observed on the resident's feet or beside the wheelchair. During an observation on [DATE] at 12:16 p.m., Resident 34 was observed sitting at a dining table without a heel boot on the left foot. The left heel was resting on the floor and observed to not have pressure relief. A nursing progress note, dated [DATE] at 6:48 a.m., indicated the NP identified the facility-acquired unstageable pressure injury on the left heel deteriorated and measured 5.0 cm L X 3.5 cm W X 0.1 cm D. The wound bed was 1 to 24 percent and 75 to 99 percent eschar. The nursing progress note did not indicate the interventions for a heel boot, pressure relief to the left heel, or a low air loss (LAL) mattress were implemented. During a continuous observation on [DATE] from 10:14 a.m. through 12:16 p.m., Resident 34 was observed sitting in a wheelchair with a wound dressing on the left heel. The resident was observed to not have pressure relieving devices on or near the bilateral lower extremities. The resident was observed to unsuccessfully make significant changes in position to relieve pressure from the left buttock or heel, was observed to bear weight directly on the left heel, and was observed to use the left heel to propel the wheelchair. RN 1 and CNA 1 were observed to help the resident without providing significant position changes or devices to relieve pressure to the left buttock and heel. During an observation on [DATE] at 1:40 P.M., Resident 34 was observed lying in bed with the left heel resting on the mattress. A pressure relieving device for the heels was observed in the recliner. During an observation on [DATE] at 9:30 a.m., Resident 34 was observed seated in the wheelchair without a heel boot or pressure relief to the left heel. During an interview on [DATE] at 10:16 a.m., CNA 4 indicated Resident 34 had a decline in her ADLs. She used to ambulate per self and now required extensive assistance with toileting, transfers, and bed mobility. She had a large pressure ulcer to her left heel. Her interventions were a heels-up cushion while in bed. During an interview on [DATE] at 10:20 a.m., LPN 1 indicated Resident 34's left heel pressure ulcer was worse. During an observation, on [DATE] at 10:27 a.m., Resident 34 was observed to not have a pressure relieving device on the left heel. CNA 3 and CNA 4 were observed to transfer Resident 34 from the wheelchair to the bed and the resident was observed to bear weight on the left heel during the transfer. The bed did not have a low loss air mattress. CNA 4 indicated Resident 34 had gotten up early and had been up for a while. During an observation on [DATE] at 10:30 a.m., the NP indicate the facility-acquired unstageable pressure ulcer on the left heel looked worse, was bigger in size, was approximately the size of a golf ball, was black in the center, and the peri wound was red. During an observation on [DATE] at 10:29 a.m., Resident 34 was seated in the wheelchair without a heel boot or pressure relief to the left heel. On [DATE] at 11:36 a.m., Resident 34's clinical record was reviewed. - A weekly wound evaluation, dated [DATE] at 9:25 a.m., indicated Resident 34 had an in-house acquired unstageable pressure ulcer to left heel. The length was 5 cm L X 3.5 W cm X 0.1 cm D. During an observation on [DATE] at 2:48 p.m., Resident 34 was observed to not have a heel boot on the left heel. Resident 34 was observed to propel the wheelchair using both feet. During an interview on [DATE] at 2:48 p.m., CNA 5 indicated Resident 34 propels the wheelchair using both feet all the time. During an interview on [DATE] at 10:45 a.m., the ADON indicated that wound culture ordered on [DATE] for Resident 34 was not completed due to the facility did not have culture supplies to collect. The ADON indicated the culture tube was expired. The facility called the lab to get another culture tube and the lab indicated they would bring on next lad day. During an interview on [DATE] at 11:15 a.m., LPN 1 indicated lab was here today but did not bring a culture tubes. Wound 2: A nursing progress note, dated [DATE] at 6:34 a.m. indicated the resident developed a new, facility acquired area of skin impairment on the left buttock (Wound 2) that measured 0.7 cm L X 1.5 cm W X 0.0 cm D. The wound base was 100 percent eschar. A weekly wound evaluation, dated [DATE] at 3:37 p.m., indicated Wound 2 was a facility-acquired unstageable pressure injury and measured 0.7. cm L X 1.5 cm W X 0.0 cm D and the treatment was Santyl (a medication for debriding necrotic tissue from wounds). The evaluation did not include sufficient documentation to show interventions for pressure relief to the left buttock were implemented. The pressure relief interventions were pressure redistribution mattress and wheelchair cushion A care plan for an unstageable pressure injury on the left buttock, dated [DATE], indicated interventions to administer medications and treatments as ordered, assess, record, and monitor wound healing weekly and report improvements and declines to the physician were implemented. The plan of care did not include documentation to indicate interventions to provide pressure relief to the left buttock were implemented until [DATE] that was when the low air loss mattress was added to the care plan. The care plan was not developed until six days after the pressure injury was discovered. During an observation on [DATE] at 1:40 P.M., Resident 34 was observed lying in a supine position (on the back) on the bed with the left buttock resting on the mattress without pressure relief of low loss air mattress A nursing progress note, dated [DATE] at 6:48 a.m., indicated the NP identified the facility-acquired unstageable pressure injury on the left buttock measured 1.0 cm L X 1.8 cm W X 0.0 cm D. The note did not indicate the interventions for pressure relief to the left buttock or a low air loss (LAL) mattress were implemented. During an observation on [DATE] at 10:30 a.m., the NP indicated the facility-acquired pressure ulcer on the left buttock looked better and was about the size of a quarter. The pressure ulcer was observed to be white surrounding the area and a pink center. During an interview on [DATE] at 10:16 a.m., CNA 4 indicated Resident 34 had a decline in her ADLs. She used to ambulate per self and now required extensive assistance with toileting, transfers, and bed mobility. Resident 34 required assistance from staff to relieve pressure of her buttocks while in the wheelchair. Her interventions were to be checked every hour and half for incontinence. During an interview on [DATE] at 10:20 a.m., LPN 1 indicated Resident 34's left buttock pressure ulcer was better. On [DATE] at 11:36 a.m., Resident 34's clinical record was reviewed. A weekly wound evaluation, dated [DATE] at 9:23 a.m., indicated the facility-acquired unstageable pressure injury on the left buttock measured 1.0 cm L X 1.8 cm W X 0.0 cm D and the treatment did not change. During an interview on [DATE] at 11:37 a.m., CNA 6 indicated Resident 34 had a health decline for the last 2 weeks and had spent a lot of time in bed. Resident 34 did not have any pressure relieving devices on her feet while she was in her wheelchair. During an interview on [DATE] at 12:45 p.m., the Assistant Directors of Nursing (ADON) indicated on [DATE] they had completed skin assessments on all the residents. At that time, they found the pressure ulcer to Resident 34's left buttock. Since the pressure ulcer on left heel had gotten worse, they started the Santyl. She did not indicate any pressure relieving interventions to the left heel while the resident was in the chair or during transfers. On [DATE] at 3:45 p.m., the Director of Nursing (DON) provided the facility's policy, Guidelines for Prevention/Treatment of Pressure Injuries, dated [DATE], and indicated it was the policy being used by the facility. A review of the policy indicated, .Turn and reposition resident who are at risk for pressure injury often unless contraindicated. At least every 2 hours is recommended .Pressure ulcers/Pressure injuries are most common on the heels and sacrum 2. During an interview on [DATE] at 10:15 a.m., Resident 5 indicated she had an open area on her left upper back from her bra strap. She indicated she had bought new bras, the straps were too tight, and it caused a wound on her left upper back. Resident 5's clinical record was reviewed on [DATE] at 12:04 p.m. The diagnosis included, but was not limited to, chronic diastolic congestive heart failure. The Quarterly MDS assessment, dated [DATE], indicated Resident 5 had mild cognitive impairment, rolled from left to right independently, and was at risk for developing pressure ulcers. A Weekly Skin Check, completed by the nurse, dated [DATE] at 3:58 p.m., indicated the resident did not have loss of skin integrity new or existing. A Skin and Wound Progress Note, from the Nurse Practitioner (NP), dated [DATE] at 4:58 p.m., indicated the NP identified a facility-acquired Stage III pressure ulcer on the left upper back size 0.5 cm (centimeters) x 1 cm x 0.1 cm. The NP nurse debrided necrotic tissue from the area, provided wound care, and placed a dressing. The plan for Resident 5 indicated to cleanse with normal saline, apply collagen to the base of the wound, secure with bordered gauze, and change three times per week and prn (as needed). The nursing staff were given detailed ulcer care instructions and asked to monitor the ulcer for any signs or symptoms of prolonged bleeding or debridement intolerance. Recommend ongoing pressure reduction and turning and repositioning precautions per protocol including pressure reduction to the heels and all bony prominences. All prevention measures were discussed with staff at the time of visit. A Care Plan, initiated [DATE], indicated a pressure wound was present to resident left upper back, The interventions included, but were not limited to, treatments as ordered, pressure reducing mattress/cushion in chair, skin checks weekly and as needed. A Weekly Wound Evaluation, dated [DATE] at 4:24 p.m., indicated . Current Treatment: Collagen. Date Treatment Ordered: [DATE] . The MAR (Medication Administration Record) and the TAR (Treatment Administration Record), dated from [DATE] through [DATE] did not include documentation to show the wound treatment was administered in accordance with the NP orders until [DATE]. During an interview on [DATE] at 11:25 a.m., CNA 2 indicated Resident 5 did not have a wound on her back. During an interview on [DATE] at 11:54 a.m., LPN 2 indicated Resident 5 did not have a pressure on her back. She recently had a biopsy done which was why she had a dressing on. The clinical record lacked any indication Resident 5 had a biopsy to the left upper back. During an interview on [DATE] at 12:53 p.m., the Assistant Director of Nursing (ADON) indicated she did not know much about the wound on Resident 5's upper left back. The NP came in and found it. She did not know what it was from and thought possibly it was from the bra or the back of the chair and had been unsure what the interventions were to prevent the wound from getting worse. An email from the NP to the facility provided by the ADON on [DATE] at 3:15 p.m., was reviewed. The e-mail, dated [DATE] at 6:02 p.m., indicated, . [Resident name] . Stage III pressure injury on left upper back. See orders: Order date [DATE], cleanse with normal saline, collagen, bordered gauze, 3 times per week and as prn . During an interview, on [DATE] at 3:30 p.m., the DON indicated the treatment order for the facility-acquired unstageable pressure injury on the left upper back was received, on Friday, [DATE] at 4:22 p.m. and the receiving nurse scheduled the treatment to be administered on Monday, Wednesday, and Friday day shifts. The DON indicated the facility did not ensure the treatment was initiated between [DATE] and [DATE]. Active physician orders, dated [DATE] at 9:38 a.m., for Resident 5 indicated . Left upper back: cleanse with normal saline. Apply collagen to wound bed only. Cover with bordered gauze every day shift every Monday, Wednesday, Friday for wound healing . The order date was [DATE] and the start date was [DATE]. During an interview on [DATE] at 10:17 a.m., the NP indicated she found a Stage III pressure ulcer on Resident 5's left upper back, on [DATE], while performing rounds with LPN 3. The NP indicated a verbal order was given to LPN 3 and instructions were provided to LPN 3 for the care of the Stage III pressure ulcer. The NP sent an email with written orders in the evening of [DATE], for Resident 5's wound care treatment to the upper left back. The NP did not send anything on [DATE], as the DON indicated. The facility was responsible for inputting the information from the email into their system so orders can be started. During an interview on [DATE] at 10:42 a.m., LPN 3 indicated she rounded with the NP on [DATE], when the Stage III wound was found on Resident 5's upper left back. The NP showed her how to do the dressing change and gave her a verbal order. The NP sent an email later that evening, but she was not sure what time she received it. The facility was responsible for putting the order in the computer when the e-mail comes. She was not sure why the order said [DATE] at 4:22 p.m. During an interview on [DATE] at 11:54 a.m., the ADON and Minimum Data Set (MDS) Coordinator indicated the facility did not do an IDT meeting nor a Root Cause Analysis when a resident gets a pressure ulcer. The clinical record lacked documentation of an IDT meeting nor a Root Cause Analysis to determine how Resident 5 sustained a Stage III pressure ulcer on her upper left back. On [DATE] at 10:15 a.m., the Registered Nurse Consultant provided the facility's policy, Wound Nurse: What to do for New Skin issues and Week to Week Monitoring undated, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . Obtain all physician notes from rounds . Information related to wounds must be taken to the weekly SWAT meeting for review with the IDT team . Upon notification of the physician, obtain a treatment order . A copy of the Interdisciplinary Team Meeting (IDT) notes were asked for from the ADON and not received by survey exit. 3.1-40(a)(1) 3.1-40(a)(2)