Based on observation, interview and record review, the facility failed to ensure a resident (Resident B) was free from staff to resident abuse for 1 of 3 residents reviewed for abuse. This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 7/8/23 when Resident B alleged the Social Services Director (SSD) kissed him. The SSD was banned from the resident's room on 7/8/23. Resident B had new negative behaviors of acting out, thrashing, and hitting his head on his bed mattress on 7/11/23. The SSD had sent the resident explicit photos of herself to an IPAD the resident had in his possession on 7/14/23 and 7/17/23. On 7/18/23, the resident had an increase in behaviors of cursing and yelling at staff with unsuccessful redirection. The Executive Director, Director of Nursing and Regional Director of Clinical Operations were notified of the Immediate Jeopardy on 7/27/23. The Immediate Jeopardy was removed on 7/28/23, but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: The clinical record for Resident B was reviewed on 7/25/23 at 12:39 p.m. The resident's diagnoses included, but were not limited to, traumatic subdural hemorrhage with loss of consciousness, ventilator dependent, acute and chronic respiratory failure with hypoxia, and fractures of the skull base, right sided zygomatic, right side lateral orbital wall, left tibia, right forearm and cervical. The quarterly MDS (Minimum Data Set) assessment, dated 7/13/23, indicated the resident's cognition was intact. The follow up incident report, dated 7/10/23, indicated during an investigation of an abuse allegation, Resident B alleged a new concern to Staff Member 7 that the SSD would come to his room and kiss him. The progress note, dated 7/11/23 at 2:13 p.m., indicated the resident had continued to display previously observed behaviors such as aggressiveness, yelling, and using profanity towards staff at numerous times throughout the day. (There were no other behavior notes prior to 7/11/23.) The care plan, dated 7/12/23, indicated Resident B had a behavior problem of acting out, thrashing and hitting his head on the mattress when he does not get what he wants; expects staff to spend extended amounts of time with him after care had been provided; attempts to manipulate staff to stay in his room longer; and had made allegations of sexual inappropriateness by staff yet denied the allegations. The interventions included, but were not limited to, approach/speak in a calm manner, consult behavioral health as needed, communicate with resident regarding behaviors, encourage family/girlfriend to visit more often and spend more time with resident to decrease behaviors, intervene as necessary to protect the rights and safety of others, minimize potential for disruptive behaviors by offering tasks that divert attention, encourage to express feelings, and notify physician of increased episodes of behaviors. The progress note, dated 7/18/23 at 7:48 a.m., indicated the resident had increased behaviors, cussed and yelled at the clinical staff. Re-direction of the resident was attempted but was unsuccessful. During an interview of 7/25/23 at 1:55 p.m., Resident B indicated no one had ever abused or mistreated him in any way. He denied any kind of relationship with the SSD. They were rumors and he was not sure why the rumors started. The SSD was better than all the other aides. The resident denied any texting, touching, or intimacy of any kind. The SSD was banned (on 7/8/23) from his room. He was sick of the aides as he had to wait on them. The rumors had upset him. He just felt like people were not listening to him. During a confidential interview on 7/25/23 at 3:58 p.m., the complainant indicated that the SSD and Resident B were having a relationship. It was reported to the complainant that a staff member witnessed Resident B and the SSD kiss. The SSD was in the resident's room a lot, and there was a lot of texting between the two. The SSD texted the resident's ex-girlfriend and the family called and had the SSD banned from his room. The resident received texts from the SSD that stated, I love you and Resident B responded with you make my d*** hard. During an interview on 7/25/23 at 4:10 p.m., Staff Member 7 indicated she had witnessed the text messages between Resident B and the SSD. The resident would ask Staff Member 7 to send texts for him because of the limited use of his hands. She recognized the number as a number she had in her phone, which was the number of the SSD. The resident saved the SSD's number under a different name to hide the communication. Before she realized she had been sending texts to the SSD for the resident, she was told by the resident that it was his wife. The resident texted on the IPAD and the texts are very big and several texts could be seen. There were texts that said I love you back and forth. There was a text with the word masturbating in it. She also saw a text to the resident from the SSD number that said when the SSD was rubbing lotion on his arms and legs, she did not know how she had the self-control to stop. The two were still texting. The resident made it clear to her that they were still in communication. The SSD used to never come down and help feed the residents on the 400 Hall. After Resident B admitted , the SSD would feed the resident at just about every single meal with the door closed. On this hall, the doors are not allowed to be closed due to the tracheotomies. Staff Member 7 had entered the resident's room one day when the door was closed to check on him. The SSD was in there feeding the resident and gave her a hateful look. The staff member did not understand why the SSD would look at her that way. During an interview on 7/25/23 at 4:22 p.m., Staff Member 8 indicated she did observe a number on Resident B's phone and recognized the number as the SSD, because all the staff had that number. She had not ever texted for the resident. During an interview on 7/25/23 at 4:25 p.m., Staff Member 10 indicated she could not say for sure whether there was a relationship between the SSD and Resident B. Resident B had told Staff Member 10 that he and the SSD were still in communication when there was not supposed to be any communication between them. During an interview on 7/25/23 at 4:29 p.m., Staff Member 11 indicated she had spoken with the SSD and asked why she was at the facility late every night. The SSD told her that she was told she had to. She had not seen any texts between Resident B or the SSD. Staff Member 11 told the SSD that if she was doing what she heard, she needed to stop. The staff had an obligation to the residents and that line cannot be crossed. During an interview on 7/26/23 at 11:28 a.m., Staff Member 12 indicated she reported the texting on 7/6/23. Prior to Resident B admitting to the facility the SSD was never on the hall. After Resident B came to the facility the SSD was on the hall and fed the resident breakfast, lunch and dinner. The resident would have Staff Member 12 and Staff Member 15 text for him. He asked Staff Member 15 to text someone for him. When both staff members asked the resident who the someone was, the resident just laughed. Resident B told both staff members that the SSD was not allowed in his room anymore. Staff Member 12 exited the room at that time and asked the DON (Director of Nursing) about the SSD not being allowed in the resident's room and about the texts. The DON asked her to look at the number next time. She did and she and the Unit Manager confirmed the number belonged to the SSD and reported it. Resident B asked Staff Member 12 and Staff Member 15 who they thought the person was the resident was having them text. Staff Member 12 responded with the SSD's name and Resident B stated yes. Resident B had Staff Member 12 send a text to the number that said, stick with the plan and are you coming down for lunch. Staff Member 12 could see previous texts due to the size of the IPAD screen. One text said, I love you and another good night, all from the number of the SSD. There was a message that Resident B had sent to the SSD number which said, you make my d*** so hard. This past Friday (7/21/23), there was a text sent from Resident B to the SSD number that said, you take such good care of daddy and then the response from the SSD number was I love you so much. Not long after that, food was delivered to the resident. Staff Member 12 was not sure if it was a coincidence or not but thought it strange that food was delivered to the resident not long after the text messages. During a telephone interview on 7/26/23 at 1:02 p.m., Staff Member 14 indicated the SSD had purchased clothes for Resident B. A delivery came with the SSD name on the box. Staff Member 14 asked who the clothes were for and was told Resident B. She was not sure whether the SSD had purchased the IPAD for Resident B. During an interview on 7/26/23 at 1:31 p.m., Staff Member 15 indicated that Resident B had called both she and Staff Member 12 to his room. Resident B told them both that he and the SSD had been texting and he had the SSD number saved as another woman. The only name Staff Member 15 had seen was the other woman with a heart emoji next to the name. During an interview on 7/27/23 at 9:45 a.m., the ED (Executive Director) indicated she had the SSD come in for an interview. The SSD let her look at her phone. There were no inappropriate messages that she could see. The SSD told her the IPAD was hers and she had purchased it during COVID for facetime visits with families. The SSD was letting Resident B use the IPAD until he got his cell phone and was better able to work the phone since he only had the use of one hand. Since the IPAD did not belong to the resident, they were going to ask to see the IPAD and give him the chance to delete his personal information in order not to violate his rights. The progress note, dated 7/27/23 at 10:14 a.m., indicated the DON and ED discussed with resident that the IPAD was loaned to him for short term use and that facility needed to retrieve the IPAD related to the ongoing investigation. The resident got upset and stated, No you cannot have it, I have personal stuff in there I do not want anyone to see. It was explained to the resident that he would have adequate time to remove anything personal that he did not want anyone to see. The resident agreed to 1 hour of time to remove his personal information. During an observation of the IPAD on 7/27/23 at 1:35 p.m., with the DON present, the IPAD showed no text messages between the resident and the SSD. Review of the history on the IPAD, under photos, there were 5 explicit photos sent to the resident on 7/14/23 and 7/17/23. The DON identified the person in the photos as the facilities SSD. One of the photos sent to the IPAD by the SSD while the resident had the IPAD in his possession was of the SSD without clothing. On 7/25/23 at 12:15 p.m., the Director of Nursing provided a current, undated copy of the document titled INDIANA Abuse & Neglect & Misappropriation of Properly. It included, but was not limited to, Mistreatment .In Indiana is defined as staff .exploiting a resident .Examples .romantic and/or inappropriate relationship between staff and resident that does not involve physical intimacy .texting romantic notes to a resident .Policy .It is the policy of this facility to provide resident centered care that meets the psychosocial .and emotional needs .of the residents .It is the intent of this facility to prevent abuse, mistreatment .of residents The Immediate Jeopardy, that began on 7/8/23, was removed on 7/28/23, when the facility conducted the following: The DON/Designee completed a full house audit of all interviewable residents for any concerns of abuse (dated 7/27/23); skin assessments were completed on all residents unable to complete interviews and assessed for signs and symptoms of decline in psychosocial well-being (dated 7/27/23); all facility communication devices were reviewed and audited for any inappropriate communication between staff and residents (dated 7/27/23); all staff were educated on abuse with focus on types of abuse, inappropriate communications via in person or electronic communication devices, proper boundaries between staff and resident (dated 7/27/23); resident rights (dated 7/28/23); standard of conduct and cell phone policy (dated 7/27/23); change of condition with focus on behavior notification and follow up with the appropriate psychosocial evaluation and monitoring (dated 7/27/23). This Federal tag relates to Complaints IN00412690 and IN00413727. 3.1-27(a)(1)

Based on observation, record review, and interview, the facility failed to implement interventions to prevent the development and worsening of multiple facility acquired pressure ulcers resulting in three unstageable wounds, two Stage 3 pressure ulcers (PU) and a reopened Stage 2 PU. Two of the pressure ulcers worsened to a Stage 4; two of the pressure ulcers developed infections; and one Stage 4 PU worsened with osteomyelitis requiring IV antibiotics for 5 of 10 residents reviewed for Presure Ulcers. (Residents E, D, B, C, and F) The Immediate Jeopardy began on 1/13/22 when the facility failed to identify, prevent, and implement interventions to prevent and worsening of pressure ulcers. The Executive Director, Director of Nursing, and Clinical Director of Clinical Operations were notified of the Immediate Jeopardy on 8/12/22 at 3:30 p.m. The Immediate Jeopardy was removed on 8/16/22, but noncompliance remained at the lower scope and severity level of H. Findings include: 1. The clinical record for Resident E was reviewed on 8/9/22 at 11:08 a.m. The diagnoses included, but were not limited to, chronic respiratory failure, COPD (chronic obstructive respiratory disease), heart failure, anoxic brain injury, severe protein calorie malnutrition, other specified dermatitis, altered mental status, chronic pain syndrome, contracture of unspecified joint, neuromuscular dysfunction of bladder, and tracheostomy status. The Annual MDS (Minimum Data Set) assessment, dated 6/3/22, indicated the resident was cognitively intact, did not exhibit any refusal of care behaviors, required extensive assistance of two staff with bed mobility and personal hygiene, was completely dependent with toileting, was always incontinent of stool, was at risk for developing pressure ulcers, had a stage 3 pressure ulcer which was present on admission, a stage 4 pressure ulcer which was not present on admission, had a pressure reducing device for her bed, but did not have a turning or repositioning program, and received pressure ulcer care. The resident had impairments in functional range of motion to the bilateral upper and lower extremities. The care plan, dated 6/7/21, indicated the resident was at risk for altered skin integrity due to disease process, immobility, incontinence, tracheostomy, and g-tube (feeding tube) status. The interventions included, but were not limited to, administer treatments as ordered, apply appropriate pressure reducing appliances to bed and wheelchair, apply barrier creams post incontinent episodes, apply protective garments as ordered, avoid pressure from drainage tubes, orthotics, braces, and footwear, complete skin at risk assessment upon admission, readmission, quarterly and as needed, complete weekly skin checks, ensure residents are turned and repositioned, evaluate existing wound daily for changes, notify resident or representative and medical provider of any decline in wound healing, nutritional consult on admission, quarterly, and as needed, podiatry consult as ordered, provide appropriate off-loading cushion to chair, provide appropriate off-loading mattress, provide diet as ordered, and PT/OT to evaluate and treat as needed for positioning and wound care. The wound analysis, dated 5/18/21, indicated the resident had an area of MASD (Moisture-Associated Skin Damage) to the sacrum, acquired in house. No measurements were documented. The wound had scant sanguineous drainage, was debrided, and a treatment of daily wound cleanser, zinc paste, and bordered foam was put into place. The wound had been active since 4/27/21, and the clinical record indicated the wound later developed into two stage 3 pressure ulcers to the left ishium and coccyx on 1/13/22. The wound analysis, dated 1/13/22, indicated the resident had a stage 3 pressure ulcer to the coccyx, measuring 3.37 cm in length by 4.07 cm in width by 0.10 cm in depth which was worsening. It had 90% granulation and 10% epithelialization, the peri wound was fragile, there was scant serous drainage. Treatment included to cleanse with wound cleanser three times weekly and dress with medi-honey and bordered foam and ensure compliance with turning and repositioning. The wound analysis, dated 1/13/22, indicated the resident had a new unstageable pressure ulcer to the left ischium, measuring 2.63 cm on length, 2.28 cm in width by 0.1 cm in depth. The wound had 2.71 cm of red tissue, 0.32 cm of pink tissue, and 0.45 cm of black tissue. There was scant serosanguinous drainage. The wound was 100% slough or eschar (dead tissue). The treatment indicated to cleanse with normal saline, apply medihoney, and a bordered foam dressing three times weekly. The clinical record indicated this wound healed on 2/8/22. The wound note, dated 1/13/22 at 9:14 p.m., indicated the resident was seen for a comprehensive skin and wound evaluation for a left ischium ulcer and coccyx pressure ulcer. The resident had a stage 3 pressure ulcer to the left ischium which was new, and a stage 3 pressure ulcer to the coccyx, which was previously MASD. Recommendations included pressure reduction and discussion with staff at the time of the visit of recommendations to include heel protection and pressure reduction to bony prominences, recommendations to provide frequent incontinent care. Due to the patient's comorbidities and risk factors for wound decompensation the patient required turning and repositioning every 1 hour and may consider avoiding sitting or lying directly flat at all times when possible. The care plan lacked documentation of any updates with interventions to turn and reposition the resident every hour. The wound analysis, dated 1/18/22, indicated the resident had a wound to the right ischium, which was first observed on 1/13/22. The wound was classified as an unstageable pressure ulcer. The wound measured 1.40 cm in length, 1.28 cm in width, and 0 cm in depth. The wound was 100% covered with slough or eschar. Treatment indicated to cleanse with normal saline and apply medihoney and a bordered foam dressing every 3 days. The wound analysis, dated 1/18/22, indicated the coccyx wound measured 7.43 cm in length, with a width of 9.69 cm and a depth of 0 cm. The wound was worsening, and had 70% granulation, 30% slough, moderate serosanguinous drainage with no odor, and the treatment was unchanged. Pressure reduction included mattress overlay, specialty bed, ensure compliance with turning protocol, and wedge/foam cushion for offloading. The wound note, dated 1/18/22 at 4:01 p.m., indicated the resident was seen for a comprehensive wound evaluation for left and right ischium ulcers and a pressure ulcer to her coccyx and her right back. The wounds were described as a stage 3 pressure ulcer to her left ischium and a stage 3 pressure ulcer to her coccyx with major overall worsening, which was previously MASD. She had a new area to the right upper back which was classified as a deep tissue injury. The resident had experienced an oral intake decline and often refused meals. The resident was severely contracted in almost every joint. Staff indicated the resident refused to turn many times to relieve pressure. The physician discussed pressure reduction and turning precautions with staff at the time of the visit, including heel protection and pressure reduction to bony prominences. The resident had extensive wound decline, culture and lab results were pending with a potential for diagnosis of opportunistic infection. The resident may need IV medications based on labs or cultures. The resident required turning and repositioning every hour and may consider avoiding sitting or lying directly flat at all times when possible. The wound analysis, dated 1/18/22, indicated the resident had a new suspected DTI to the right back, measuring 12.56 cm in length, 6.08 cm in width, and 0 cm in depth. Treatment included skin prep twice daily. The clinical record indicated this wound was healed on 3/15/22. The lab report, dated 1/19/22, indicated the resident had a basic metabolic panel (BMP) and a complete blood count (CBC). The resident's white blood cell count was high at 13.0 k/cmm with a normal value range of 4.5 to 10.8K/cmm. The resident's absolute neuts were high at 9.90 K/uL with a normal value range of 1.50 to 7.60 K/uL. The resident's monocytes were high at 1.20 K/uL with a normal value range of 0.15 to 1/10 K/uL. The resident's EOS were high at 0.10 K/uL with a normal value range of 0.20 to 0.80 K/uL. The nurse's note, dated 1/19/22 at 2:47 p.m., indicated the NP reviewed the resident's lab results and ordered doxycycline monohydrate 100 mg every morning and at bedtime for a wound infection for 10 days. The wound note, dated 1/26/22 at 8:23 p.m., indicated the resident had multiple scattered pressure ulcers with observed deep tissue injuries. She had increased moisture at the wound site. Staff were encouraged to keep the site always covered and avoid contamination with feces. She required turning and repositioning every hour. The wound analysis, dated 2/22/22, indicated the wound measured 9.13 cm in L x 8.69 cm in width x 0.02 cm in D (depth), improving, 60% granulation, 40% slough. Treatment unchanged. The wound was debrided. The wound note, dated 2/22/22 at 6:29 p.m., indicated the surgical debridement was performed to the resident's ulcer. Devitalized epidermis, dermis and subcutaneous tissue (tissue that impedes healing and acts as an origin for wound infection) including but not limited to biofilm were removed to keep the wound in an active state of healing. Nursing staff were given detailed ulcer care instructions and asked to monitor for any signs of prolonged bleeding or debridement intolerance. The wound note, dated 3/15/22 at 2:30 p.m., indicated the resident's wounds were now joining together. The re-admission skin grid pressure assessment, dated 4/1/22, indicated the resident had a stage 3 pressure ulcer to the sacrum measuring 6.5 cm in L x 6 cm in W x 0 cm in D. The treatment order, dated 4/1/22, indicated to apply calazime-zinc oxide lotion to sacrum twice daily for skin irritation. The wound analysis, dated 4/5/22, indicated the sacrum wound measured 6.48 cm in L, 7.33 cm in W, 0.02 cm in D. The wound was worsening and was now classified as a stage 4 with exposed bone. There was 60% granulation and 40% slough. The treatment for medihoney and a bordered foam was resumed on 4/5/22. The wound analysis, dated 4/5/22, indicated the resident had an unstageable pressure ulcer to the left upper sacrum which was previously grouped with the sacrum and had separated and made as it's own wound. The wound measured 2.62 cm in length, 1.57 cm in width, and 0 cm in depth. The wound was covered with 100% slough or eschar. The wound note, dated 4/5/22 at 9:40 p.m., indicated the resident had a comprehensive skin and wound evaluation for readmission to the facility. She had a stage 4 pressure ulcer to the sacrum which was previously a stage 3 and a stage 3 to the upper sacrum which was previously clustered with the sacrum. She had a right hip unstageable pressure ulcer. The physician recommended to keep the wound dry, to turn and reposition every 1 hour, and a nutrition consult. The nurse's note, dated 5/4/22 at 8:50 p.m., indicated the resident returned to the facility and was refusing all skin assessments, however had a wound to her sacrum. The wound analysis, dated 5/6/22, indicated the wound measured 4.27 cm in L x 5.58 cm in W x 0.01 cm in depth, improving, 90% granulation 10% slough, treatment unchanged. During an observation on 8/10/22 at 10:11 a.m., Resident E was resting abed. Her lower extremities were completely contracted and were positioned on a pillow, with her right foot and heel directly touching the pillow and were not offloaded. Her left heel was floating off the edge of the pillow. The resident did not have any pressure relief boots in place. The Respiratory Therapy Director removed the blanket and observed the resident, however, did not reposition the resident or place any pressure relief boots on her. During an observation on 8/10/22 at 11:47 a.m., LPN 7 and the Wound Nurse entered the resident's room to perform wound care. The blankets were removed and both of the resident's heels were observed to be lying directly on a pillow and were not properly offloaded. There were no pressure relief boots in place. A large portion of the resident's bottom was covered in scar tissue. The wound nurse indicated she believed the resident had a stage 3 pressure ulcer and the facility had a lot of pressure ulcers. Two open areas were observed to the coccyx which appeared to be fully granulating with less than 5% yellow tissue. The wound was cleansed, collagen with silver was applied to the wound bed with a foam border secondary dressing applied. The resident was repositioned with her heels again lying directly on the pillow and not floated. Staff indicated the care was completed and left the room. On 8/11/22, Resident E was observed to be lying turned to her right side in her bed. The resident's heels were resting directly on a pillow, with both heels touching and resting on the surface of the pillow. At 8:33 a.m., a nurse entered the room but did not reposition the resident. At 8:50 a.m., the Wounds Care nurse entered the room but did not reposition the resident. Staff did not reposition the resident until 10:42 a.m., when CNA 5 and CNA 6 entered the room and turned her to the left side. They replaced the pillow under the resident's feet, resting her heels directly on the pillow without allowing them to float. The resident did not appear to be resistive to turning or repositioning and did not refuse to allow staff to turn her. During an interview on 8/11/22 at 10:33 a.m., CNA 5 and CNA 6 indicated they had not turned the resident since before breakfast, which would have been prior to 8:00 that morning. During an interview on 8/11/22 at 10:42 a.m., CNA 5 and CNA 6 indicated they tried to turn the residents every 2 hours but, . we may be a little off . They were not aware of the resident requiring any more frequent turning schedules. They were unaware of the resident every wearing heel protector boots, and they had never seen any in her room. During an interview, on 8/12/22 at 8:42 a.m., the Wound NP indicated when she took over care for the resident, she had a lot of sacral and hip wounds. She at one point had an upper back wound, and now was dealing with a stage 4 wound to her sacrum. She was very contracted and underweight. If she were to put pressure on the pillows, there would be a concern for developing a pressure wound. If the resident had boots, she had not seen them on her. She recommended they off load and float the resident's heels, and she would have recommended heel protectors in the past. 2. The clinical record for Resident D was reviewed on 8/9/22 at 1:13 p.m. The diagnoses included but were not limited to, chronic respiratory failure, type 2 diabetes mellitus, anemia, neuromuscular dysfunction of bladder, peripheral vascular disease, overactive bladder, kidney failure, and chronic pain. The admission skin assessment, dated 5/4/22, indicated the resident had a stage 4 pressure ulcer to the coccyx which measured 10 cm in length, by 7 cm in width, by 0.5 cm in depth. The resident's sensory perception was completely limited, his skin was constantly moist, he was bedfast, he was completely immobile, his nutrition was very poor, and he had an identified problem with friction and shear. His Braden scale scoring was 6, which was classified as a very high risk for developing pressure ulcers. The care plan, dated 5/5/22, Indicated the resident had impaired skin integrity, including pressure ulcers to his coccyx, a stage 3 to his sacrum, a stage 2 pressure ulcer to his left heel, related to immobility. An intervention to elevate the resident's legs as he would allow was initiated on 8/3/22. The care plan indicated to ensure the resident was turned and repositioned but did not specify a schedule or instructions to turn every hour. The wound analysis, dated 5/6/22, indicated the resident had an unstageable pressure ulcer to the sacrum, which was present on admission, which measured 8.39 cm in L x 4.99 cm in W x 0 cm in depth. The treatment indicated to cleanse with normal saline, and dress with medi-honey and bordered foam every 3 days and as needed for soilage. The wound note, dated 5/11/22 at 4:05 p.m., indicated the resident had multiple wounds including an unstageable pressure ulcer to the sacrum, an unstageable pressure ulcer to the left heel and a deep tissue injury to the right heel. Recommendations included, but were not limited to, heel protection and pressure reduction to bony prominences, turning every 1 hours due to the patient's comorbidities and risk factors for wound decompensation and new wound development, avoid sitting or lying flat at all times when possible. A nutrition consult was recommended to optimize wound healing. The Wound Analysis, dated 6/3/22, indicated the resident's wound was worsening. The measurements were 7.63 cm in L x 9.1 cm in W x 0 cm in D. The resident's treatment was unchanged. The admission MDS assessment, dated 6/8/22, indicated the resident was severely cognitively impaired, was totally dependent on staff for bed mobility, toileting, and personal hygiene, did not exhibit any behaviors of rejection of care, was at risk for developing pressure ulcers. The resident had a pressure reducing device for the chair and bed and pressure ulcer care but did not indicate a turning and repositioning program. The wound analysis, dated 6/14/22, indicated the wound was reclassified as a stage 3 pressure ulcer. The wound analysis, dated 7/12/22, indicated the wound measured 6.88 cm in L x 8.51 cm in W x 2.5 cm in D, stable. The measurements were post debridement, treatment unchanged. The wound analysis, dated 7/22/22, indicated the resident developed a new unstageable pressure ulcer to the right elbow, measuring 1.38 cm in length by 1.02 cm in W by 0 cm in D. It was a suspected DTI. Treatment indicated to apply skin prep and leave open to air three times daily. Preventative measures included offloading the elbow on a pillow. The wound analysis, dated 8/5/22, indicated the resident developed a new stage 2 pressure ulcer to the right posterior leg measuring 6.45 cm in L x 4.2 cm in W x 0 cm in depth which was described as having intact epithelium which was serous filled (a blister). Treatment indicated to apply skin prep and leave open to air twice daily. During an observation on 8/10/22 at 11:13 a.m., the wound nurse and LPN 7 provided wound care for Resident D. The wound to the resident's coccyx appeared to be a large open wound with approximately 30% of the wound bed covered with yellow stringy tissue. The wound to the resident's right elbow was scabbed over and indicated as healed by the wound nurse. The wound to the resident's left heel was a superficial pink, healing wound with scant serosanguineous drainage. The wound to the right posterior leg was observed to be healing, with no drainage, there was a dry area of reddish discoloration. A new wound to the resident's right ankle bone was observed at this time which the Wound Nurse estimated was approximately 2 cm in length by 1 cm in width, with 25% of the wound presenting as a red open area, and 75% of the wound with a moist, darkened black-purple area. There was a scant amount of serosanguinous drainage as described by the Wound Nurse to the edge of the wound. The wound nurse indicated the resident often got blisters on his lower extremities. The Skin Grid Pressure note, dated 8/10/22 at 1:00 p.m., indicated the resident had a new area to the right outer ankle, which was classified as a stage one. The measurements of the wound were 2 cm in length by 1 cm in width, by 0.2 cm in depth. The IDT follow up note, dated 8/10/22 at 1:23 p.m., indicated the resident had developed a new stage 1 pressure ulcer to his right outer ankle, the root cause was pressure to the right outer ankle. The intervention put into place was heel lift boots, dietary consult on 8/10/22, and prostat twice daily. Observations of Resident D were conducted on 8/11/22. At 8:20 a.m., the resident was observed to be lying on his right side, with a purple wedge pillow under his right elbow, heel protector boots in place, and a pillow under his left side. At 8:56 a.m., the nurse entered the room and provided medications to the resident. She exited the room at 9:05 a.m., but did not reposition the resident during the time she was in the room. At 9:05 a.m., the Wound Nurse entered the room and administered the resident's tube feeding and replaced his water flush bag but did not turn or reposition the resident. She exited the room at 9:20 a.m. Staff did not enter the resident's room again until 10:20 a.m., when CNA 5 and CNA 6 entered the room to provide care and reposition the resident. They both indicated the last time they repositioned the resident was before 8:00 that same morning. The area to the resident's right ankle was observed to be about nickel sized, with a dark, black hardened tissue covering the wound bed. The surrounding skin was reddened. The wound appeared larger than the day before. The CNA's removed the pillows from the resident's left side, and moved it to his right side, and removed the wedge from the resident's right side and moved it to his left side. The resident was not turned and remained positioned on his right side. The CNAs did not attempt to reposition the resident onto his back or his right side. The resident did not make any independent movement or attempts to reject or resist care. During an interview on 8/11/22 at 9:20 a.m., CNA 5 and CNA 6 both indicated they tried to turn the resident every 2 hours, from his right side to his back, or his left side, however the resident preferred his right side and usually ended up going back there so they moved the pillows and wedges to the opposite side of whatever side they were on. They were not aware of the resident needing to be turned any more frequently than every 2 hours. During an interview on 8/11/22 at 11:24 a.m., the DON indicated usually a stage 1 pressure ulcer was not open. It was a non-blanchable reddened or discolored area. If it were open, it would be a stage 2, 3, or 4. If the wound was moist and dark, it sounded like it would be a DTI. She was informed of the resident developing a new pressure wound on 8/10/22 by the Wound Nurse, who informed her it a stage 1 pressure ulcer and it wasn't opened. She had described it to her as discolored and it was a stage 1. With the resident's comorbidities, things could happen very quickly for him. His skin assessment was due either 8/10/22 or 8/11/22. It had been several days since he'd had a true skin assessment. The Wound Nurse told her it looked like a scab, but she wasn't sure if it was scab. She told the wound nurse if it was opened it was a stage 2, 3, or 4. The Wound NP may change the staging. During an interview on 8/12/22 at 8:40 a.m., the Wound NP indicated she saw the resident on 8/12/22 for a new wound to his ankle. She was not able to stage it and classified it as an unstageable pressure ulcer. The perimeter of the wound had opened. The facility told her they thought it was a DTI, but because the skin had broken open and she could not see the wound bed it was unstageable. The resident had admitted with a wound to his sacrum. He had developed a lot of DTIs since admission to the facility. He was very overweight, and very hard to move in bed. It was hard to get him in a decent position. He liked to cross his legs and ankles so she could see how he got the ankle wound. Staff should be turning him every 2 hours, but if they could do more that would be great. Their system automatically recommended turning every 1 hour, but that was not very feasible. She recommended they turn at least every 2 hours. It was hard for her to say the wounds to either Resident D or Resident E were unavoidable. They were both at a very high risk for developing new wounds. She would have to see both residents daily to know if they were unavoidable. The Wound Analysis, dated 8/12/22, indicated the resident was seen by the Wound NP. He had a new unstageable pressure ulcer to the right lateral ankle. The wound measured 1.68 cm in length, by 1.58 cm in width, by 0.01 cm in depth. There was 1.14 squared cm of black tissue to the wound bed and scant serous drainage. The recommended treatment was to cleanse with normal saline, apply medihoney, and a bordered foam daily. The pressure reduction interventions included to float the resident's heels and apply soft offloading boots. 3.The clinical record for Resident B was reviewed on 8/10/22 at 1:32 p.m. The diagnoses included, but were not limited to, cerebral infarction, history of traumatic brain injury, paraplegia, polyneuropathy, neuromuscular dysfunction of the bladder, blindness in one eye and low vision in the other eye, localized edema, repeated falls, osteoarthritis, muscle weakness, and dysphagia. The Quarterly MDS assessment, dated 10/23/21, indicated the resident had impairments to the bilateral lower extremities. The annual MDS assessment, dated 7/29/22, indicated the resident was cognitively intact, did not exhibit any refusal of care behaviors, required extensive assistance of two staff with bed mobility and personal hygiene, was completely dependent with toileting, was always incontinent of stool, was at risk for developing pressure ulcers, had a stage 4 pressure ulcer which was not present on admission, had a pressure reducing boot for his right heel, but did not have a turning or repositioning program, and received pressure ulcer care. The resident had impairments to the bilateral lower extremities. The care plan, dated 11/24/21 and revised on 6/22/22, indicated the resident had the potential and actual impairment to skin integrity related to impaired mobility with paraplegia. The right heel pressure ulcer was unstageable on 11/23/21 and resolved on 5/18/22. On 6/22/22 the pressure wound reopened at a stage 4. The bottom of the right foot deep tissue injury on 12/14/21 and resolved on 1/4/22. The interventions included, but were not limited to, educate the resident, family and caregivers of causative factors and measures to prevent skin injury, elevate legs and float heels as resident will allow, encourage good nutrition and hydration in order to promote healthier skin, encourage resident to turn and reposition every 1 to 2 hours as resident will allow, followed by wound consult, and identify and document potential causative factors and eliminate or resolve where possible, keep the skin clean and dry. Staff were to monitor and document location, size and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection, maceration etc. to the physician, use pressure relieving and reducing cushion to protect the skin while the resident was up in the chair. Treatments as ordered. The wound analysis, dated 11/23/21, indicated the resident had a suspected deep tissue injury the right heel. The measurements included length 4.45 cm (centimeters), width 4.35 cm, and depth 0. The pressure wound was acquired in house. The periwound was macerated (when the skin was in contact with moisture for too long). Treatment included betadine dressing with a secondary kling or kerlix dressing. The dressing was to be changed 2 times a day and elevate the resident legs to level of his heart or above for 30 minutes one time a day. Pressure reduction and offloading, elevate legs regularly using a wedge or foam for offloading. The wound analysis, dated 1/25/22, indicated the resident's right heel was a stage 4 with exposed tendons. The measurements included length 4.58 cm, width 4.62 cm, and depth 1.00 cm. The wound had a heavy amount of serosanguinous drainage and had a malodorous odor. The peri wound was erythema. Treatments included cleanse the wound with normal saline, Dakin's moist to dry dressing, and cover with a border dressing. The wound analysis, dated 3/01/22, indicated the right heel wound was a stage 4. The measurements included length 3.84 cm, width 4.07 cm, and depth 0. The wound had 60 % (percent) granulation tissue and 40% slough or eschar. There was a moderate amount of serosanguinous drainage with no odor. The peri wound had erythema. The treatments included cleanse the wound with normal saline and apply a collagen dressing 1 time per day and cover with a boarder dressing. The wound analysis, dated 2/8/22, indicated the resident's right heel was a stage 4 and the wound bed had exposed tendons. Measurements included length 4.84 cm, width 5.88 cm, and depth 0.30 cm. The wound has 90% granulation tissue and 10% slough or eschar. There was a moderate amount of serosanguinous drainage with no odor. The Peri wound had erythema. Treatments included cleanse the wound with normal saline, apply a Santyl dressing and cover with a bordered dressing 1 time a day. The wound analysis, dated 3/8/22, indicated the resident's right heel wound measurements included length 3.98 cm, width 4.26 cm, and depth 0.01 cm. The wound had 80% granulation tissue and 20% slough or eschar. Moderate amount of serous drainage with no odor. The peri wound had erythema. Treatments included a collagen dressing and covered with a secondary bordered gauze 1 time per day. The wound analysis, dated 5/24/22, indicated the residents right heel had heeled. The wound analysis, dated 6/24/22, indicated the right heel pressure wound reopened at a stage 4. Measurements included length 3.25 cm, width 4.35 cm, and depth 0.30 cm. The wound had 20% granulation tissue and 80% slough or eschar. Moderate amount of serosanguinous drainage with no odor. The peri wound was intact. Treatments included cleanse the wound with normal saline and apply a hydrogel dressing covered with a bordered gauze dressing. The NP progress note, dated 7/5/22, indicated she recommend continuation of elevation of legs while in bed as well as floating bilateral heels. Wound culture was ordered by medical nurse practitioner and still awaiting results. The X-ray obtained showed osteomyelitis, but medical provider was awaiting culture for specified antibiotic orders. The labs were reviewed, and the white blood cell count is within normal limits. Additional Recommendations included, the resident had a pressure injury, pressure reduction and turning precautions discussed with staff at time of visit, including heel protection and pressure reduction to bony prominences. The resident was at a moderate to severe risk of significant complications, morbidity and/or mortality due to comorbidities and wound. The culture and lab results are pending with a potential for diagnosis of opportunistic infection. The patient may potentially need IV medications based on pending labs or cultures. The NP progress note, dated 7/13/22, indicated a follow up to the resident's right heel pressure wound osteomyelitis. The right heel x-ray showed possible osteomyelitis on 7/1/22 and the wound culture results. The resident was started on IV (Intravenous) antibiotics for 10 days and a prevalon boot to the right foot. The resident's right heel wound had reopened with drainage and swelling. The resident was paraplegic and could not feel his bilateral lower extremities. During an observation on 8/11/22 at 1:00 p.m., the wound care nurse donned gloves and removed the resident's prevalon boot and old dressing. She cleaned the wound with NS (Normal Saline). She removed her gloves and donned a clean pair of gloves and applied the collagen with silver nitrate dressing. A boarded foam dressing was applied over the collagen dressing. The wound had a scabbed area approximately three and a half inch long. The wound had a small dark area in the middle of the scab. No drainage or foul odor. During an interview on 8/10/22 at 1:32 p.m., Resident B indicated he was paralyzed from the chest down. The only time staff would turn him was when he got a bath. He tried to turn himself by holding onto the handrail and pushing back but was unable to turn himself. During an inter[TRUNCATED]