**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 24 residents with three residents reviewed for abuse and neglect. Based on record review, observation, and interview, the facility failed to ensure staff immediately reported Resident (R)1's allegation of sexual abuse to the Licensed Nursing Home Administrator (LNHA) and further failed to report the sexual abuse allegation to the required state agencies including law enforcement. On 07/24/24 at 09:37 PM, R1 told her representative that a dirty old man came into her room and tried to get into her pants. At 10:00 PM R1's representative called the facility and reported the allegation to Licensed Nurse (LN). LN G told R1's representative there were no male staff working that night and said she had been down R1's hallway passing medications and had not seen anyone walking in the hall. LN G told R1's representative she would go down and talk to R1 and report the incident to Administrative Nurse D. At 11:00 PM, R1 asked LN G if she had told the nurse that she was molested. LN G did not report the abuse allegation until 07/25/24 at 09:03 PM. Administrative Staff A stated the allegation of sexual abuse was not reported to the appropriate state entities because LN G determined the resident had been dreaming. The facility failed to ensure staff reported an allegation of sexual abuse to the LNHA immediately and further failed to report the sexual abuse allegation to the required state entities including law enforcement. This placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), hypertension (high blood pressure), weakness, and macular degeneration (progressive deterioration of the retina). The Quarterly Minimum Data Set (MDS), dated 06/05/24, documented that R1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R1 was independent with eating and oral care and required moderate assistance from one staff for toileting, transfer, dressing, personal hygiene, and bathing. The MDS recorded R1 had no behaviors including hallucinations (sensing things while awake that appear to be real, but the mind created) or delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue). The Functional Abilities Care Area Assessment (CAA), dated 03/05/24, documented R1 was alert and oriented with a BIMS score of 15. The CAA documented R1 had macular degeneration but was able to see well enough to assist with her activities of daily living (ADLs). The CAA documented R1 was independent with mobility in her wheelchair and at times walked short distances in her room using her walker to go to the bathroom. The facility goal for R1 was for R1 to maintain her independence as much as possible and to provide R1 help when she needed it. The Visual Function CAA, dated 03/05/24, documented R1 had a diagnosis of macular degeneration. The CAA documented R1 was not able to see well enough to read a book but was able to see well enough to safely navigate the halls and feed herself. R1's Care Plan, documented R1 primarily used a wheelchair in the hall and self-propelled herself using her feet or the handrails. R1 could walk in her room with assistance from one staff and her walker. R1 chose to sleep in her recliner and could make position changes in the recliner. The care plan documented R1 required one staff's assistance for dressing, toileting, and transfers. On 07/30/24, a new focus was placed in R1's Care Plan which documented R1 had a behavior symptom related to dreaming. The plan documented R1 would have no evidence of behavior problems of dreaming of men being in her room and minimize the potential for R1's disruptive behaviors of feeling men in her room by having a second person in the room when a male is in the room with R1. The Mood/Behavior Note, dated 07/25/24 at 04:20 AM, documented LN G received a phone call from R1's representative at 10:00 PM on 07/24/24. R1's representative just got off the phone with R1 and R1 stated some man had come into her room, pulled off her covers while R1 sat in her recliner, and tried to get into her pants. R1's representative asked LN G if there were any male staff working and LN G stated no. R1's representative asked if it could have possibly been a male resident. LN G explained there were three male residents down R1's hall but they were at the end of the hallway and were all in bed and no other males were in the facility. R1's representative requested the incident be reported to Administrative Nurse D. LN G explained to R1's representative that she had been down R1's hall multiple times between 09:00 PM and 10:00 PM. LN G explained to R1's representative R1 seemed tired that evening when she received her night meds and breathing treatment and R1 had also been sleeping. R1's representative requested R1 be checked on throughout the night. LN G assured R1's representative staff would do so. LN G went down to check on R1. R1 was on the phone with her representative again. R1 seemed very confused. R1 asked her representative multiple times if it was August yet and R1 repeated the same topic over and over. Later at 11:00 PM, R1 asked LN G if she had told LN G that some man had molested her. R1 told LN G that some man came into her room and pulled on her butt hair. Later in the night, R1 rang for assistance to the bathroom and R1 asked LN G, Did I get molested by some man, or did I dream it? LN G documented R1 concluded that she had dreamt it. The Other Communication Note, dated 07/30/24, documented the ombudsman came to the facility to visit with R1 regarding R1's representative called and reported a man had been in R1's room and R1 claimed the man had pulled her pants down while she was in her recliner. R1 told the Ombudsman she was molested last night. The ombudsmen asked R1 if she felt safe at the facility. R1 said the staff were taking care of her and she felt safe. The ombudsman then asked R1 about men in her room and R1 said She did not want men in her room. Staff asked R1 about the bath house as the bath aide was a male and R1 said it was fine for him to give her a bath. The ombudsman and staff discussed R1's plan of care and staff stated R1's Care Plan had already been changed to not have males alone in R1's room. The facility was unable to provide an investigation, incident report, and/or witness statements related to the incident. The updated timeline of events provided by the facility on 07/31/24, documented on 07/25/24 (this initial call occurred on 07/24/24) at 10:00 PM, LN G received a phone call from R1's representative. R1's representative had just got off the phone with R1 and R1 had stated some man had come into her room and pulled off her covers while R1 sat in her recliner and tried to get into her pants. At 11:00 PM, R1 asked LN G if she had told LN G that some man had molested her. Later in the night, R1 rang for assistance to the bathroom and R1 asked LN G, Did I get molested by some man, or did I dream it? On 07/25/24 at 09:03 PM LN G notified Administrative Nurse D of R1's mood and behavior and her findings of LN G's investigation. On 07/25/24 at 09:05 PM, Administrative Nurse D notified Administrative Staff A of R1's mood and behavior and LN G's investigation and findings. On 07/29/24, sometime in the morning, Administrative Staff A and Administrative Nurse D gave the results of the investigation to R1's representative. On 07/30/24, sometime in the afternoon, the ombudsman visited with the resident and social services. R1's Care Plan was reviewed and updated. On 07/31/24 at 09:45 AM, observation revealed R1 resided in a double occupancy room and sat in a recliner closest to the door with her eyes closed. On 07/31/24 at 09:45 AM, R1 stated that she thought a dirty old man had come into her room and tried to get in her pants, but he was gone now, and it had all been taken care of. R1 stated at the time of the incident she had feared the man coming back into her room. On 07/31/24 at 10:00 AM, R1's representative stated that on 07/24/24 at 09:37 PM she called R1 and R1 told her a dirty old man came into her room and was trying to get into her pants. R1's representative reported R1 slept in her recliner and said she had been dozing when it happened. R1's representative stated she called LN G to report the complaint. R1's representative stated LN G confirmed the were no male employees working that night. LN G told R1's representative she had been down R1's hallway passing medications and had not seen any residents walking in the hall. R1's representative stated LN G told her she would go down and talk to R1 and report the incident to Administrative Nurse D. R1's representative stated she called R1 back and was on the phone with R1 until 10:32 PM and no one came into R1's room. R1's representative stated she drove six hours to the facility on [DATE] and arrived at 05:00 PM and personally talked to LN G. LN G told R1's representative she documented the phone call in R1's chart and said R1 may have been dreaming; LN G said she notified Administrative Nurse D. On 07/31/24 LN G was unavailable for an interview. On 07/31/24 at 10:45 AM, Certified Nurse's Aide (CNA) M stated R1 had brought up the incident to her on Saturday, the weekend after it happened. R1 told CNA M that she had been molested and some man had put his hand down her pants. CNA M asked R1 if she was sure that happened and R1 stated Yes. CNA M stated she could not believe that this really happened to R1, and it must have been a dream or something in R1's mind that she thought really happened. CNA M stated R1 continued to bring up the incident. On 07/31/24 at 11:00 AM, Administrative Staff A stated that she and Administrative Nurse D had reviewed LN G's nurse's note and reviewed her investigation. Administrative Staff A stated R1 later told LN G that it may have been a dream. Administrative Staff A stated LN G reported that she was up and down the hall all evening passing meds and the two men on the hallway were in bed. Administrative Staff A stated the facility had not reported the incident to the state agency. Administrative Staff A stated she and Administrative Nurse D were satisfied with the investigation LN G had performed. Administrative Staff A stated she talked with Administrative Nurse D about having ongoing contact with family members when allegations of this type were reported. Administrative Staff A stated she did not know if there was any investigative report with witness statements related to this incident. Administrative Staff A stated she was notified of R1's allegations on 07/24/24 at 09:05 PM. On 07/31/24 at 11:30 AM, Administrative Staff A presented a handwritten timeline of the events and questioned if the facility was supposed to investigate allegations of abuse if the allegations were just a resident's dream. The facility failed to ensure staff immediately reported R1's allegation of sexual abuse to the LNHA and further failed to report the sexual abuse allegation to the required state agencies including law enforcement. This deficient practice placed R1 in immediate jeopardy. On 07/31/24 at 12:46 PM Administrative Staff A received a copy of the Immediate Jeopardy [IJ] Template and was informed of the IJ for R1. On 07/31/24 at 03:00 PM, the facility submitted a plan with corrective actions to remove the immediacy. The corrective actions included: The facility initiated an investigation on 07/31/24 for allegations of abuse and neglect for R1. The abuse allegation was reported to the appropriate state agency, law enforcement, the facility's Medical Director, and R1's family. Immediate education was initiated for all nursing staff on recognizing and reporting abuse and neglect allegations. All interviewable residents were interviewed to identify any safety concerns. The onsite surveyor verified the implementation of the corrective actions and removal of the immediacy on 07/31/24. The deficient practice remained at a scope and severity of D.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 24 residents with three residents reviewed for abuse and neglect. Based on record review, observation, and interview, the facility failed to investigate an allegation of sexual abuse and initiate protective measures until an investigation was completed. On 07/24/24 at 09:37 PM Resident (R)1 told her daughter that a dirty old man came into her room and tried to get into her pants. At 10:00 PM R1's representative called the facility and reported the allegation to Licensed Nurse (LN). LN G told R1's representative there were no male staff working that night and said she had been down R1's hallway passing medications and had not seen anyone walking in the hall. LN G told R1's representative she would go down and talk to R1 and report the incident to Administrative Nurse D. At 11:00 PM, R1 asked LN G if she had told the nurse that she was molested. On 07/25/24 R1's representative arrived at the facility and spoke with LN G. LN G told R1's representative she felt R1 may have been dreaming. LN G did not report the allegation to administration for almost 24 hours. R1's representative returned to the facility on [DATE] and spoke with Administrative Nurse D. Administrative Nurse D told R1's representative LN G had already investigated the incident and determined the resident had been dreaming. Administrative Staff A confirmed no further investigation was conducted because she and Administrative Nurse D agreed with LN G's conclusion. The facility's failure to initiate protective measures to prevent further sexual abuse and failure to investigate the abuse allegation placed R1 and all other cognitively impaired residents in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), hypertension (high blood pressure), weakness, and macular degeneration (progressive deterioration of the retina). The Quarterly Minimum Data Set (MDS), dated 06/05/24, documented that R1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R1 was independent with eating and oral care and required moderate assistance from one staff for toileting, transfer, dressing, personal hygiene, and bathing. The MDS recorded R1 had no behaviors including hallucinations (sensing things while awake that appear to be real, but the mind created) or delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue). The Functional Abilities Care Area Assessment (CAA), dated 03/05/24, documented R1 was alert and oriented with a BIMS score of 15. The CAA documented R1 had macular degeneration but was able to see well enough to assist with her activities of daily living (ADLs). The CAA documented R1 was independent with mobility in her wheelchair and at times walked short distances in her room using her walker to go to the bathroom. The facility goal for R1 was for R1 to maintain her independence as much as possible and to provide R1 help when she needed it. The Visual Function CAA, dated 03/05/24, documented R1 had a diagnosis of macular degeneration. The CAA documented R1 was not able to see well enough to read a book but was able to see well enough to safely navigate the halls and feed herself. R1's Care Plan, documented R1 primarily used a wheelchair in the hall and self-propelled herself using her feet or the handrails. R1 could walk in her room with assistance from one staff and her walker. R1 chose to sleep in her recliner and could make position changes in the recliner. The care plan documented R1 required one staff's assistance for dressing, toileting, and transfers. On 07/30/24, a new focus was placed in R1's Care Plan which documented R1 had a behavior symptom related to dreaming. The plan documented R1 would have no evidence of behavior problems of dreaming of men being in her room and minimize the potential for R1's disruptive behaviors of feeling men in her room by having a second person in the room when a male is in the room with R1. The Mood/Behavior Note, dated 07/25/24 at 04:20 AM, documented LN G received a phone call from R1's representative at 10:00 PM on 07/24/24. R1's representative just got off the phone with R1 and R1 stated some man had come into her room, pulled off her covers while R1 sat in her recliner, and tried to get into her pants. R1's representative asked LN G if there were any male staff working and LN G stated no. R1's representative asked if it could have possibly been a male resident. LN G explained there were three male residents down R1's hall but they were at the end of the hallway and were all in bed and no other males were in the facility. R1's representative requested the incident be reported to Administrative Nurse D. LN G explained to R1's representative that she had been down R1's hall multiple times between 09:00 PM and 10:00 PM. LN G explained to R1's representative R1 seemed tired that evening when she received her night meds and breathing treatment and R1 had also been sleeping. R1's representative requested R1 be checked on throughout the night. LN G assured R1's representative staff would do so. LN G went down to check on R1. R1 was on the phone with her representative again. R1 seemed very confused. R1 asked her representative multiple times if it was August yet and R1 repeated the same topic over and over. Later at 11:00 PM, R1 asked LN G if she had told LN G that some man had molested her. R1 told LN G that some man came into her room and pulled on her butt hair. Later in the night, R1 rang for assistance to the bathroom and R1 asked LN G, Did I get molested by some man, or did I dream it? LN G documented R1 concluded that she had dreamt it. The Other Communication Note, dated 07/30/24, documented the ombudsman came to the facility to visit with R1 regarding R1's representative called and reported a man had been in R1's room and R1 claimed the man had pulled her pants down while she was in her recliner. R1 told the Ombudsman she was molested last night. The ombudsmen asked R1 if she felt safe at the facility. R1 said the staff were taking care of her and she felt safe. The ombudsman then asked R1 about men in her room and R1 said She did not want men in her room. Staff asked R1 about the bath house as the bath aide was a male and R1 said it was fine for him to give her a bath. The ombudsman and staff discussed R1's plan of care and staff stated R1's Care Plan had already been changed to not have males alone in R1's room. The facility was unable to provide an investigation, incident report, and/or witness statements related to the incident. The updated timeline of events provided by the facility on 07/31/24, documented on 07/25/24 (this initial call occurred on 07/24/24) at 10:00 PM, LN G received a phone call from R1's representative. R1's representative had just got off the phone with R1 and R1 had stated some man had come into her room and pulled off her covers while R1 sat in her recliner and tried to get into her pants. At 11:00 PM, R1 asked LN G if she had told LN G that some man had molested her. Later in the night, R1 rang for assistance to the bathroom and R1 asked LN G, Did I get molested by some man, or did I dream it? On 07/25/24 at 09:03 PM LN G notified Administrative Nurse D of R1's mood and behavior and her findings of LN G's investigation. On 07/25/24 at 09:05 PM, Administrative Nurse D notified Administrative Staff A of R1's mood and behavior and LN G's investigation and findings. On 07/29/24, sometime in the morning, Administrative Staff A and Administrative Nurse D gave the results of the investigation to R1's representative. On 07/30/24, sometime in the afternoon, the ombudsman visited with the resident and social services. R1's Care Plan was reviewed and updated. On 07/31/24 at 09:45 AM, observation revealed R1 resided in a double occupancy room and sat in a recliner closest to the door with her eyes closed. On 07/31/24 at 09:45 AM, R1 stated that she thought a dirty old man had come into her room and tried to get in her pants, but he was gone now, and it had all been taken care of. R1 stated at the time of the incident she had feared the man coming back into her room. On 07/31/24 at 10:00 AM, R1's representative stated that on 07/24/24 at 09:37 PM she called R1 and R1 told her a dirty old man came into her room and was trying to get into her pants. R1's representative reported R1 slept in her recliner and said she had been dozing when it happened. R1's representative stated she called LN G to report the complaint. R1's representative stated LN G confirmed the were no male employees working that night. LN G told R1's representative she had been down R1's hallway passing medications and had not seen any residents walking in the hall. R1's representative stated LN G told her she would go down and talk to R1 and report the incident to Administrative Nurse D. R1's representative stated she called R1 back and was on the phone with R1 until 10:32 PM and no one came into R1's room. R1's representative stated she drove six hours to the facility on [DATE] and arrived at 05:00 PM and personally talked to LN G. LN G told R1's representative she documented the phone call in R1's chart and said R1 may have been dreaming; LN G said she notified Administrative Nurse D. On 07/31/24 LN G was unavailable for an interview. On 07/31/24 at 10:45 AM, Certified Nurse's Aide (CNA) M stated R1 had brought up the incident to her on Saturday, the weekend after it happened. R1 told CNA M that she had been molested and some man had put his hand down her pants. CNA M asked R1 if she was sure that happened and R1 stated Yes. CNA M stated she could not believe that this really happened to R1, and it must have been a dream or something in R1's mind that she thought really happened. CNA M stated R1 continued to bring up the incident. On 07/31/24 at 11:00 AM, Administrative Staff A stated that she and Administrative Nurse D had reviewed LN G's nurse's note and reviewed her investigation. Administrative Staff A stated R1 later told LN G that it may have been a dream. Administrative Staff A stated LN G reported that she was up and down the hall all evening passing meds and the two men on the hallway were in bed. Administrative Staff A stated the facility had not reported the incident to the state agency. Administrative Staff A stated she and Administrative Nurse D were satisfied with the investigation LN G had performed. Administrative Staff A stated she talked with Administrative Nurse D about having ongoing contact with family members when allegations of this type were reported. Administrative Staff A stated she did not know if there was any investigative report with witness statements related to this incident. Administrative Staff A stated she was notified of R1's allegations on 07/24/24 at 09:05 PM. On 07/31/24 at 11:30 AM, Administrative Staff A presented a handwritten timeline of the events and questioned if the facility was supposed to investigate allegations of abuse if the allegations were just a resident's dream. The facility failed to investigate R1's allegation of sexual abuse and initiate protective measures until an investigation was completed. This deficient practice placed R1 in immediate jeopardy and placed all cognitively impaired residents at risk for unidentified and ongoing abuse. On 07/31/24 at 12:46 PM Administrative Staff A received a copy of the Immediate Jeopardy [IJ] Template and was informed of the IJ for R1. On 07/31/24 at 03:00 PM, the facility submitted a plan with corrective actions to remove the immediacy. The corrective actions included: The facility initiated an investigation on 07/31/24 for allegations of abuse and neglect for R1. The abuse allegation was reported to the appropriate state agency, law enforcement, the facility's Medical Director, and R1's family. Immediate education was initiated for all nursing staff on recognizing and reporting abuse and neglect allegations. All interviewable residents were interviewed to identify any safety concerns. The onsite surveyor verified the implementation of the corrective actions and removal of the immediacy on 07/31/24. The deficient practice remained at a scope and severity of E.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 27. The sample included three residents reviewed for pressure injuries/ulcers. Based on record review and interview, the facility failed to ensure adequate treatment to prevent the worsening of a facility acquired pressure ulcer and failed to promote healing. On 12/15/23, Resident (R) 1, who required assistance from two staff for bed mobility, developed a facility acquired unstageable (depth of the wound is unknown due to the wound bed is covered by a thick layer of other tissue and pus) pressure ulcer to her left heel. The facility applied heel protectors but did not involve the provider until seven days later. The provider ordered a dressing to the wound, changed every seven days. The wound became stagnant and lacked any signs of healing from 12/22/23 through 03/23/24 when a new treatment was started. The facility also did not measure the wound for two weeks from 03/09/24 through 03/22/24. On 03/29/24, the facility spoke with the dietician and the telehealth wound nurse and received new orders for R1's deteriorating wound but did not involve the physician despite increased wound dimensions and the presence of signs of possible infection including increased drainage and pain, until 04/02/24 when the facility received a new order from the wound nurse and the facility's medical director. On 04/03/24, the facility identified drainage from the wound and a new open area on the inside of the left foot but did not notify the physician. On Saturday, 04/06/24, the facility documented R1 would go for a podiatry referral the following Tuesday. On 04/07/24, R1 was assessed by her provider and sent to the hospital for respiratory issues and wound care. Upon admission to the hospital, R1's left heel wound was necrotic (pertaining to the death of tissue in response to disease or injury) with purulent (producing or containing pus), foul-smelling drainage and had advanced to a Stage 4 pressure ulcer (a deep pressure wound that reaches the muscles, ligaments, or even bone) with exposed bone. Further testing revealed R1 had osteomyelitis (local or generalized infection of the bone and bone marrow) of her left heel bone. R1 was sent to a higher level of acute care for wound care and vascular evaluation. The surgeon recommended amputation (surgical removal) of the left lower extremity, above the knee. R1 and her family did not want the procedure. R1 was placed on palliative care and passed away on 04/27/24 at the local hospital. The facility's failure to notify and involve the physician and ensure physician assessment of an evolving, and progressively worsening, facility acquired pressure ulcer placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord), moderate protein calorie malnutrition, weakness, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The admission Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented R1 required moderate staff assistance for bed mobility, maximum staff assistance with sit to stand, chair to bed transfer, toileting, and bathing. The MDS documented R1 did not ambulate. The MDS documented R1 was admitted to the facility with intact skin and was at risk for pressure ulcer development. The MDS documented R1 had a pressure reducing device for her chair, a pressure reducing device for her bed, and was on a turning/repositioning program. R1 was not on a nutrition or hydration program to manage skin problems. The admission Function Abilities Care Area Assessment (CAA), dated 11/27/23, documented R1 presented to the facility with weakness, poor coordination, impaired balance, and pain related to her MS. The CAA documented R1 had occasional urinary incontinence which was likely due to her immobility. The CAA documented R1 was no longer able to ambulate and due to the progressive neurological nature of her disease process, R1 was not expected to improve. The admission Pressure Ulcer/Injury CAA, dated 11/27/23, documented R1 was at risk for skin breakdown due to her need for staff assistance for bed mobility, having an at risk Braden (assessment tool used to predict risk for pressure injuries) score, and being on psychotropic (alters mood or thought) medications. The CAA documented R1 had no skin issues oat the time of her admission on [DATE]. The CAA documented all residents of the facility had mattresses that helped with weight distribution to help prevent skin breakdown from occurring. The CAA documented R1 was on a turning/repositioning program and had a pressure reducing cushion in her wheelchair to help reduce her risk and help maintain her skin integrity. The CAA documented the goal was for R1 to remain free from skin breakdown. The Significant Change MDS, dated [DATE], documented R1's BIMS score was 12, which indicated moderately impaired cognition. The MDS documented R1 had one or more unhealed pressure ulcers. The MDS documented R1 had one unstageable pressure ulcer due to slough (dead tissue, usually cream or yellow in color) and/or eschar (dead tissue), and this pressure ulcer was not present on R1's admission. The CAA documented R1 had a pressure reducing device for her chair, a pressure reducing device for her bed, was on a turning/repositioning program, and was receiving pressure ulcer care. The CAA documented R1 was not receiving an application of any dressing to her feet with or without topical medications. The Significant Change Functional Abilities CAA, dated 02/27/24, documented R1 required assistance with her activities of daily living (ADL's), had an unstageable pressure ulcer to her left heel, and R1's decline was felt to be due to the progression of her MS; she was not expected to improve. The Significant Change Pressure Ulcer/Injury CAA, dated 02/27/24, documented R1 had an unstageable pressure ulcer to her left heel. She was incontinent, dependent on staff for mobility, and had an at risk Braden score. The CAA documented R1 had an air mattress, was on a turning/repositioning program, and had a cushion to her wheelchair. The CAA documented R1 had MS which was the biggest contributing factor that restricted her mobility. R1's Care Plan directed staff R1 required assistance from two staff for all bed mobility (11/23/23). The care plan directed staff to provide R1 a pressure reducing mattress and cushion and to float her heels (11/23/23). The care plan directed staff to notify the nurse immediately of any new areas of skin breakdown redness, blisters, bruises, or discoloration noted during baths or daily care (12/15/23). The care plan directed staff to provide R1 an air mattress due to R1 refused to get out of bed sometimes and was at risk for further skin breakdown (01/11/24). R1 was non-ambulatory and used a wheelchair with bilateral foot pedals propelled by staff (01/12/24). The care plan directed staff to place an Allevyn (foam dressing) heel dressing and change on bath days; the dressing could be left on for seven days and change as needed (01/24/24). The care plan directed staff R1 required two staff assistance with check and changes with position change (03/27/24). The care plan lacked direction regarding how often R1 was to be repositioned. The care plan directed staff to ensure heel protectors were on R1's feet (03/27/24). The care plan directed staff to perform a Wound Data Collection daily and to inform R1 and her family about any new area of skin breakdown (03/27/24). The care plan directed staff to apply a Xeroform (non-adherent dressing) foam dressing to the left heel and secure with Kerlix (cotton gauze) and paper tape and change daily (03/27/24). The care plan directed staff to avoid positioning R1 on her right side. R1 could be placed on her left side or on her back with heel protectors on and feet elevated as much as possible (04/06/24). The care plan directed staff to apply calcium alginate (a highly absorbent dressing for cavity wounds with moderate to heavy drainage), cover with bordered foam dressing, secure with Kerlix and paper tape and change every day (04/11/24). (This intervention was never performed in the facility as R1 never returned). The Kardex [nursing tool that gives a brief overview of the care needs of each resident] did not address any turning or repositioning program or directives for R1. The admission Braden Scale, dated 11/21/23, documented R1 a score of 16, which indicated mild risk. The Braden Scale intervention guide recommended frequent turning (e.g., every two hours), maximal remobilization, pressure reduction support surfaces if bed or chair bound, protect heels, manage moisture, manage nutrition, manage friction and shear (the separation of skin layers caused by friction or trauma). If other major risk factors were present advance to next level of risk. On admission, on 11/21/23, R1 had an order for thrombo-embolic deterrent hose (TED-compression stockings) to her bilateral legs, on in the morning and off at night. This order was discontinued on 12/19/23. Review of R1's clinical record lacked evidence the staff who signed off on the application and removal of the TED hose noted any skin changed to R1's left heel. R1's medication Review Report documented an order dated 11/29/23 for house shake nutritional supplements, 120 milliliters with meals. R1's EMR recorded a Physician's Order dated 12/01/23 to start on 12/08/23, for a weekly skin check every Friday. The Skin Observation Tool, dated 12/08/23, documented R1's skin check was completed and had no skin conditions observed. The Skin Observation Tool, dated 12/15/23, documented R1 had an unstageable pressure ulcer to the left medial (inner) heel. The Skin Observation Tool lacked evidence staff notified R1's primary care physician or family of the unstageable pressure ulcer. The Wound Data Collection Tool, dated 12/15/23, documented R1 had an unstageable pressure ulcer with eschar to her left heel that measure 2 centimeters (cm) by 3.5 cm with no depth. The wound bed was covered with 100 percent eschar. The surrounding skin was intact and pink. This was the initial data collection on the pressure ulcer and the pressure ulcer was not present on admission. There was no dressing on R1's left heel wound. The Wound Data Collection Tool, lacked evidence staff notified R1's primary care physician or family of the pressure ulcer. The Wound Data Collection Tool, dated 12/16/23, documented R1 had an unstageable pressure ulcer to her left heel. The wound was 100% covered with eschar. No dressing had been placed to the left heel wound. A pressure relieving gel heel protector was placed to R1's left heel. The Wound Data Collection Tool, lacked evidence staff notified R1's primary care physician or family. The Wound Data Collection Tool, dated 12/17/23, documented R1 had a pressure ulcer to her left heel with pink blanchable surrounding skin. No dressing was present to the left heel wound. Blue heel protectors were placed to R1's heels. The Wound Data Collection Tool, lacked evidence staff notified R1's primary care physician or family. The Wound Data Collection Tool, dated 12/19/23, documented R1 had a pressure ulcer to her left heel which measured 1.5 cm by 2 cm. Eschar covered 100 % of the wound bed. The surrounding skin was pink, intact, and macerated (softening and breaking down of skin as a result from prolonged exposure to moisture, such as sweat, urine, feces, or wound drainage for extended periods). There was no dressing to R1's left heel. The Wound Data Collection Tool, lacked evidence staff notified R1's primary care physician or family. The Communication/Visit with Physician Note, dated 12/22/23, documented a new order for Allevyn heel dressing to R1's left heel. Change every seven days or as needed. This Communication/Visit with Physician Note was the first documented evidence of notification to the physician of R1's unstageable pressure ulcer to her left heel, dated 12/22/23, seven days after staff discovered the pressure injury. The Wound RN Assessment, dated 12/22/23, documented R1 had an unstageable pressure ulcer to her left heel. The wound was covered with eschar and had minimal drainage. R1's physician was notified regarding the wound status and a new order for Allevyn heel dressing was ordered. Modifications to R1's interventions were repositioning/turning, support surfaces, nutrition, friction/shear management, and wound treatment. R1's Treatment Administration Record (TAR), dated December 2023, documented an order for Allevyn dressing to the left heel; may be on up to seven days, change as needed, and check twice daily, with a start date of 12/22/23. The Wound Data Collection Tool, dated 12/29/23, documented R1 had an unstageable pressure ulcer to her left heel which measured 3.5 cm by 3.2 cm. The wound bed was covered with 95% eschar and 5% granulation (new tissue formed during wound healing). The record lacked evidence staff notified R1's primary care physician of the increased size of R1's wound. The January 2024 TAR, documented an order for an Allevyn dressing to the left heel. The dressing could stay on up to seven days. Change as needed. Check twice daily with a start date of 12/22/23. The Wound Data Collection Tool, dated 01/03/24, documented R1 had an unstageable pressure ulcer which measured 2.5 cm by 2.5 cm. The wound bed was covered with 95% of eschar and 5% of granulation. The wound had a moderate amount of purulent drainage. The record lacked evidence staff notified R1's primary care physician of the purulent drainage. The Wound RN Assessment, dated 01/03/24, documented R1 had an unstageable pressure ulcer to her left heel. The top layer of the wound was peeling back with pink tissue noted underneath. The note documented to continue the current plan of treatment. The Health Status Note, dated 01/03/24, documented R1 was not safe to transfer with the sit-to-stand lift and would be transferred with a full body lift from then on. The Wound Data Collection Tool, dated 01/09/24, documented R1 had an unstageable pressure ulcer to her left heel which measured 3 cm by 3 cm. There was no dressing present. The wound bed was covered with 100% eschar. The record lacked evidence staff notified R1's primary care physician. The Care Plan Change Note, dated 01/11/24, documented an air mattress was added due to R1 refused to get out of bed some of the time and risk for further skin break down. The Care Plan Change Note, dated 01/12/24, documented the mobility bars were removed from R1's bed. The Wound RN Assessment, dated 01/12/24, documented R1 had an unstageable pressure ulcer to her left heel. The left heel wound was documented as a deep tissue injury (DTI- purple or maroon localized area of discolored intact skin or blood?filled blister due to damage of underlying soft tissue from pressure and/or shear) and the area was hard, with skin flaking off. The underneath skin was healed. The record lacked evidence staff notified R1's primary care physician. The 1-16-24 Clinic Visit documented R1 was seen by her physician with a chief complaint of none recorded. The visit recorded a reviewed problem of a left heel wound with an onset date of 10/27/22 [sic]. The HPI [history of present illness] section recorded the resident was calmy sitting in a chair. She initially voiced no concerns. She did then remark that she had some swelling in her legs and feet. Nursing reported she had recurrent urinary tract infections. The resident denied shortness of breath. The Musculosketal section documented R1 had normal muscle strength and poor tone; she had two plus edema (swelling) to her lower extremities. The document noted R1 had heel protector boots on and a dressing to the right [sic] heel. The note followed this with not removed. The Assessment/Plan section did not address or mention the wound. The Wound RN Assessment, dated 01/19/24, documented R1 had a non-pressure wound with partial thickness tissue loss. The note documented to continue with the current treatment. The record lacked evidence staff notified R1's primary care physician. The Wound Data Collection Tool, dated 01/19/24, documented R1 had an unstageable pressure wound to her left heel that measured 4 cm by 3.5 cm with dry flaky skin. The wound bed was covered with 100 % eschar. The record lacked evidence staff notified R1's primary care physician. The Wound RN Assessment, dated 01/22/24, documented R1 had a non-pressure wound with partial thickness tissue loss. The noted documented to continue with the current treatment plan. The record lacked evidence staff notified R1's primary care physician. The Wound RN Assessment, dated 01/29/24, documented R1's left heel wound was a non-pressure wound with partial thickness tissue loss. The nurse documented to continue the current plan of treatment. The record lacked evidence staff notified R1's primary care physician. The Wound Data Collection Tool, dated 01/30/24, documented R1 had a pressure ulcer to her left heel which measured 3.75 cm by 3.25 cm and was a deep tissue injury. The wound bed was 100% covered with eschar. The record lacked evidence staff notified R1's primary care physician. R1's February 2024 TAR, documented an order for an Allevyn dressing to the left heel. May be on up to seven days. Change as needed. Check twice daily with a start date of 12/22/23. The Wound Data Collection Tool, dated 02/13/24, documented R1 had a deep tissue unstageable pressure ulcer to her left heel that measured 4.5 cm by 3 cm. The wound bed was 100% covered with eschar and had minimal sanguineous (bloody drainage) drainage. The description of the dressing was a Medihoney (medical-grade honey used to aid wound healing) patch to the wound bed, covered with an Allevyn heel dressing, and secured with paper tape. The record lacked evidence staff notified R1's primary care physician. R1's EMR lacked orders regarding the use of Medi-honey to the wound. The Wound Data Collection Tool, dated 02/19/24 documented R1 had a deep tissue unstageable pressure ulcer to her left heel that measured 3.5 cm by 4.0 cm. Drainage was present on the dressing and leaking around the dressing. The wound bed was 100% covered with eschar. The surrounding skin was pink and macerated. The dressing description described Medihoney pad with an Allevyn dressing secured with tape. The record lacked evidence staff notified R1's primary care physician. The Wound RN Assessment, dated 02/19/24, documented R1 had an unstageable pressure ulcer to her left heel. The note documented the wound had smaller measurements with new tissue growth after the eschar sloughed off. The note documented to continue the current plan of treatment. The record lacked evidence staff notified R1's primary care physician. The Late Entry Communication with Dietitian Note, dated 02/19/24 but created on 04/06/24, documented the dietitian was notified via email of R1's deep tissue injury and recommended to continue current protein supplement with no other recommendations given. The Health Status Note, dated 02/20/24, documented the dressing was changed to R1's left heel due to the dressing being soiled. The 2-20-24 Clinic Visit documented R1 was seen by her physician with a chief complaint of NH [nursing home] 2nd 30 day visit The visit recorded a reviewed problem of a left heel wound with an onset date of 10/27/22. The HPI section recorded the resident was doing better feeding herself and asked how long she will be there. She denied pain. She was wearing heel protectors and denied pain or other concern. Her husband continued to help her. She had gotten over recent pneumonia (inflammatory condition of the lungs). The Musculosketal section documented R1 had normal muscle strength and poor tone; her joints, bones, and muscles showed no contractures (abnormal fixation of joints or muscles), malalignment, tenderness, or bony abnormalities. She had normal movement of all extremities. Extremities: edema (tr to LE but feet in heel protectors.). The document noted R1 had edema and wore heel protectors. The Assessment/Plan section did not address or mention the wound. The Other Progress Note, dated 02/23/24, documented a fax was sent to the clinic to request an order for Vitamin C 500 milligrams (mg) daily for wound healing. The medication was received from the pharmacy. The Wound RN Assessment, dated 02/26/24, documented R1 had an unstageable pressure ulcer. The note documented to continue the current treatment. The record lacked evidence staff notified R1's primary care physician. The Wound Data Collection Tool, dated 02/27/24, documented R1 had a deep tissue injury unstageable pressure ulcer to her left heel that measured 4 cm by 4 cm with 0.1 cm in depth. The wound bed was covered with 95% of eschar and 5% epithelial (denoting the tissue forming the outer layer of the of the body's surface) tissue. The wound had a moderate amount of serosanguineous (semi-thick blood-tinged drainage) drainage. The dressing description was Medihoney with an Allevyn dressing. The record lacked evidence staff notified R1's primary care physician. The MDS Note, dated 02/27/24, documented the facility had changed R1's Quarterly MDS to a Significant Change MDS due to recent behaviors noted, a decline in the BIMS score, and a 5% weight loss over 30 days. R1 had a long-standing history of MS with complaints of frequent pain. R1 had a pressure ulcer to her left heel and slept on an air mattress. The March 2024 TAR, documented an order for an Allevyn dressing to the left heel. May be on up to seven days. Change as needed. Check twice daily with a start date of 12/22/23. This order was discontinued on 03/22/24. The Wound RN Assessment, dated 03/05/24, documented R1 had an unstageable pressure ulcer to her left heel. The note documented to continue with the current plan of care. The record lacked evidence staff notified R1's primary care physician. The Wound Data Collection Tool, dated 03/08/24, documented R1 had a full thickness pressure ulcer to her left heel that measured 4.4 cm by 4 cm by 0.1 cm. The wound bed was 75% covered with eschar and 25% covered with granulation. There was a moderate amount of serosanguineous drainage present. The noted documented the wound was very tender to the touch. The record lacked evidence staff notified R1's primary care physician. The Wound RN Assessment, dated 03/13/24, documented R1 had an unstageable pressure ulcer to her left heel. The note documented to continue the current plan of treatment. The record lacked evidence staff notified R1's primary care physician. R1's clinical record lacked evidence of staff measuring the unstageable left heel ulcer from 03/09/24 through 03/22/24. The 3-19-24 Clinic Visit documented the physician saw R1 with a chief complaint of NH 30 day visit. The visit recorded a reviewed problem of a left heel wound with an onset date of 10/27/22. The HPI section recorded she had a visit with another doctor and had severe dementia based on the results of the Mini-Mental State examination (MMSE). The Physical Examination section lacked assessment the musculosketal or skin. The Assessment/Plan section did not address or mention the wound. The Wound Data Collection Tool, dated 03/22/24, documented R1 had a deep tissue injury that was a full thickness wound to her left heel which measured 5 cm by 4 cm by 0.2 cm. The wound had a moderate amount of serosanguineous drainage that was foul smelling and had leaked out of the dressing. The wound bed was covered with 95% eschar and 5% epithelial tissue. The skin around the wound was denuded (skin that has had the first protective layer removed). The dressing was described as Xeroform with an Allevyn heel dressing. The tool lacked evidence staff notified R1's primary care physician. The Wound RN Assessment, dated 03/22/24, documented R1 had an unstageable pressure ulcer to her left heel. The note documented R1's wound was deteriorating evidenced by the wound continued to have a layer of eschar over the top of the wound. The note documented to continue the current plan of treatment. The record lacked evidence staff notified R1's primary care physician. Review of the Order Audit report for R1 revealed on 03/22/24 Licensed Nurse (LN) I entered an order for Xeroform, foam border dressing, secured with Kerlix and paper tape for pressure ulcer to left heel. Change every dayshift. The order was entered as a prescriber written order by Consultant HH. R1 clinical record lacked documentation when Consultant HH was contacted and lacked a provider visit note regarding the wound or a written order. The March 2024 TAR documented a new dressing order started on 03/23/24 for Xeroform, foam border dressing, secured with Kerlix and paper tape for pressure ulcer to left heel. Change every dayshift. A Late Entry Health Status Note, dated 03/23/24 but created on 04/12/24, documented Xeroform was started to help with wound management. A Clinic Referral (used for Visits to Doctor or Hospital Outpatient) dated 03/26/24 recorded a follow up for R1's upper respiratory infection; imaging of R1's chest and laboratory values were reviewed. The documentation lacked any mention of R1's wound and lacked evidence the wound was visualized or assessed by the provider. The Wound Data Collection Tool, dated 03/29/24 documented R1 had an unstageable pressure ulcer to her left heel that was a full thickness wound and in the middle of the wound was an area of hard eschar tissue. The wound measured 4.5 cm by 4 cm by 0.5 cm. There was heavy purulent foul-smelling drainage which had leaked out of the dressing. The collection tool noted there was the presence of possible complication to the wound as evidenced by a deep tissue injury surrounded the upper part of the left heel wound. R1 grimaced during the dressing change. The wound bed was 100% covered with eschar. The skin surrounding the wound was macerated and erythematous (red). The dressing description was Xeroform foam dressing secured with kerlix and paper tape. The record lacked evidence staff notified R1's primary care physician. The Wound RN Assessment, dated 03/29/24, documented R1 had an unstageable pressure ulcer to her left heel that was deteriorating due to non-healing eschar. The note documented staff notified the wound nurse and the dietitian of the non-healing wound. The note lacked documentation staff notified R1's primary care physician. The Late Entry Health Status Note, dated 03/29/24 but created on 04/12/24, documented the facility staff spoke with the wound nurse and she recommended to continue with the Xeroform with an Allevyn heel protector and secure with tape. The note lacked documentation staff notified R1's primary care physician. R1's April 2024 TAR, documented an order for Xeroform foam border dressing, secured with Kerlix and paper tape for pressure ulcer to left heel, started on 03/23/24 and discontinued on 04/02/24. The Communication with Dietitian Note, dated 04/01/24, documented an email was sent to the dietitian regarding R1's non-healing wound. R1 continued house shakes three times a day with meals. The Communication/Visit with Physician Note, dated 04/02/24, documented new orders were received to add Santyl (an ointment to removed damaged tissue from chronic skin ulcers) to the wound bed, cover with Xeroform and foam bordered dressing, per the wound nurse and the facility's medical director. The Nutrition Status Note, dated 04/02/24, documented the dietitian was consulted regarding a non-healing wound on R1's left heel. R1 was receiving soft and bite sized diet with mildly thickened liquids and health shakes three times a day. Intake was good and R1 was eating greater than 50% of her meals 73% of the time over the past two weeks. R1's current weight was 100 pounds and weight had trended up since her admission in November 2023. R1's previous diagnosis was resolved: inadequate oral intake related to decreased appetite and adjustment to living situation. The dietitian documented R1's current diet and supplements should have been adequate to meet her estimated needs. R1 received a daily multivitamin supplement to optimize micronutrient intake for wound healing. The dietitian recommended to continue the current plan of care. R1's April 2024 TAR documented a new dressing order started on 04/03/24 to cleanse the wound to the left heel with wound cleanser, pat dry, place Santyl ointment on the wound bed; cover with Xeroform and wrap in gauze. Change daily. This order was discontinued on 04/05/24. The Nursing Services Note, dated 04/03/24, documented R1's dressing to her left heel had to be changed due to the dressing being saturated with drainage and the drainage going all the way through all the dressing and Kerlix. The dressing order was followed, left heel protectors were applied, and R1's left heel was floated on two pillows. A new sore was noted on the inside of R1's left foot. The nurse documented she would pass along the information to the day shift. The record lacked evidence staff notified R1's primary care physician. The Wound RN Assessment, dated 04/04/24, documented R1 had an unstageable wound to her left heel and deterioration of the wound was evidenced by eschar tissue covering the top of the wound. The note documented R1's primary care physician was notified of the wounds status and the care plan was updated. Santyl was started to debride the dead tissue. The Wound Data Collection Tool, dated 04/05/24, documented R1 had an unstageable pressure ulcer to her left heel which measured 5.5 cm by 6 cm by 0.4 cm. The wound bed was covered with 75% eschar, 10% slough, and 5% epithelial tissue. There was a moderate amount of serosanguineous drainage. The surrounding skin was macerated and erythematous. The note documented a new treatment of calcium alginate to the wound bed covered with foam border, secured with kerlix and paper tape. R1's April 2024 TAR documented a new dressing change order dated 04/06/24 to cleanse the wound to the left heel with wound cleanser, pat dry, place calcium alginate on wound bed, cover with an Allevyn heel dressing, and secure with tape. (This order was placed on hold after R1 was admitted to the hospital.) The Communication Note, dated 04/06/24, documented due to R1's non-healing wound on her left heel and R1 was being referred to podiatry (foot doctor). An appointment was scheduled for Tuesday, 04/09/24, at the local hospital. The Health Status Note, dated 04/07/24, documented R1 was running a fever and her oxygen saturations were dropping into the low 80 percentiles (normal saturation are 93 percent or above). R1's oxygen was increased to 3.5 liters (L) and R1's oxygen saturation was still low. A mask was placed on[TRUNCATED]