**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 35. The sample included five residents, with three residents reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observations, record review, and interviews, the facility failed to follow physician orders to implement preventative wound interventions for Resident (R) 1. On 06/09/25, Consultant GG assessed R1 for a left heel ulcer, ordered suspension boots, and directed staff to clean the wound daily. Staff were to call the provider if the resident's left heel ulcer opened. The facility failed to input the order for suspension boots into R1's Electronic Medical Record (EMR) and further failed to implement the order or apply boots to R1's left heel. A wound assessment on 06/18/25 revealed the resident's left heel wound had opened up, and R1's EMR lacked evidence the facility had notified the resident's physician. The facility's failure to implement physician-ordered interventions to prevent worsening of R1's left heel wound resulted in a decline in the status of the wound, development of an additional wound, and R1 requiring the use of a wound vac (treatment method that uses suction to promote healing in complex wounds).Findings included:- R1's EMR documented diagnoses of diastolic congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), pressure ulcer of the left heel, diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), and dementia (a progressive mental disorder characterized by failing memory and confusion) with agitation.The Quarterly Minimum Data Set (MDS) dated 06/13/25, documented R1 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. R1 had impairment on one side of the lower extremities. R1 was independent rolling left and right. R1 required partial/moderate assistance for sitting up in bed. R1 had one deep tissue injury (DTI- purple or maroon localized area of discolored intact skin or bloodfilled blister due to damage of underlying soft tissue from pressure and/or shear) and open lesions other than ulcers, rashes, or cuts. The MDS documented R1 did not have a pressure-reducing device for chair, a pressure-reducing device for bed, was not on a turning/repositioning program, had no nutrition or hydration interventions to manage skin problems, pressure ulcer/injury care, surgical wound care, and required no application of ointments/medications other than to the feet. The MDS documented R1 required application of nonsurgical dressings to areas of the body other than to the feet and application of dressings to the feet.The Significant Change MDS dated 09/05/25, documented R1 had a BIMS score of five, which indicated severe cognitive impairment. R1 had impairment on one side of the lower extremities. R1 required supervision or touching assistance with rolling left and right. R1 had one stage one pressure injury (area which appears reddened, does not blanche, and may be painful but is not open) and one unstageable (depth of the wound is unknown due to the wound bed being covered by a thick layer of other tissue and pus) with slough (dead tissue, usually cream or yellow in color) and/or eschar (dead tissue) pressure ulcer. R1 had other open lesions on the foot. The MDS documented R1did not have a pressure-relieving device for the chair, a pressure-relieving device for bed, was not on a turning/repositioning program, lacked any nutrition or hydration intervention to manage skin problems, surgical wound care, and application of nonsurgical dressings other than to feet. The MDS documented R1 required application of ointments/medications to areas of the body other than to the feet, and application of dressings to the feet (with or without topical medications).The Functional Abilities CAA dated 09/05/25, documented R1 experienced a decline in activities of daily living (ADL) function.The Pressure Ulcer/Injury CAA dated 09/05/25, documented staff assessed the location, size, stage, presence of drainage, presence of odors, condition of skin, and if eschar or slough was present to the resident's wound.R1's Care Plan dated 09/26/24, documented R1 was at risk for skin issues related to incontinence, impaired mobility, and DM.The Care Plan documented interventions, dated 09/26/24, that directed staff to follow facility protocols for treatment of injuries. The plan directed staff to identify and document potential causal factors of wounds and eliminate/resolve those factors where possible. The plan revealed staff would monitor/document location, size, and treatment of skin injuries and reported abnormalities, failure to heal, and signs/symptoms of infection to the resident's doctor.The Care Plan documented an intervention, dated 10/06/24 that was revised on 02/04/25, that directed staff to know R1 had a pressure-reducing mattress and he required substantial assistance from staff for turning/repositioning. The plan documented an intervention, dated 01/02/25 and revised on 02/04/25, that directed R1 had a cushion in his wheelchair, and he was able to offload while in his chair.The Care Plan documented an intervention, dated 08/15/25, noting R1 had an unstageable wound to his left heel, and hospice provided wound care orders.The resident's care plan failed to address the physician's order for heel protectors and/or interventions related to the resident's left heel wound identified on 05/28/25.R1's EMR revealed the following:On 05/28/25, a Skin and Wound assessment documented R1 had a DTI to his left heel that was 12 hours old and measured 0 centimeters (cm) by 0 cm.R1's EMR lacked evidence the facility notified Consultant GG of the DTI identified on 05/28/25.R1's EMR lacked evidence of any treatment to R1's left heel from 05/28/25 to 06/05/25.The Physician's Order dated 06/05/25 and discontinued on 06/09/25, directed staff to cleanse a wound to the resident's left heel with wound cleanser and pat dry. Staff would clean around (peri) the wound with skin prep (a solution when applied that forms a protective waterproof barrier on the skin) and apply a nickel thick amount of Santyl (a sterile enzymatic debriding ointment) to wound bed, cover with adhesive foam dressing, and float heels as tolerated. The order further directed staff to change R1's wound dressing daily and as needed (PRN).A Doctor's Progress Note dated 06/09/25 documented Consultant GG saw R1 for a left heel ulcer and noted black eschar tissue on the left heel. Consultant GG diagnosed R1 with a left heel decubitus (pressure) ulcer. Consultant GG ordered suspension boots, laboratory tests, and wound care orders to clean the pressure ulcer with betadine daily and call the provider if the area opened.A Health Status Note dated 06/09/25 at 07:24 AM, documented Consultant GG saw R1 and gave new orders to apply betadine to R1's left heel daily and to call the provider if the wound opened. The provider ordered laboratory tests for the next lab day. The note did not address the suspension boots ordered.R1's EMR lacked evidence staff placed the physician's order for suspension boots in R1's EMR and on the Treatment Administration Record (TAR) for staff to follow.R1's clinical record lacked evidence the facility implemented the suspension boots for R1 as ordered on 06/09/25.An order with a start date of 06/10/25 and discontinued date of 07/02/25 revealed staff were to apply betadine daily to the resident's left heel wound and to call R1's primary care provider if it opened.On 06/11/25, a Skin and Wound assessment documented R1 had a DTI to his left heel that was 14 days old and measured five cm by 3.92 cm.On 06/18/25, a Skin and Wound assessment documented R1 had an unstageable left heel pressure wound that was 21 days old and measured 4.83 cm by 4.36 cm.R1's EMR lacked evidence the facility notified Consultant GG of the change in condition of R1's left heel wound.On 06/25/25, a Skin and Wound assessment documented R1 had an unstageable pressure wound, with an onset date of 05/28/25, to his left heel that measured 3.9 cm by 3.85 cm. R1's EMR lacked evidence the facility notified Consultant GG of the change in condition of R1's left heel wound.On 07/02/25, a Skin and Wound assessment documented R1 had an unstageable pressure wound, with an onset date of 05/28/25, to his left heel. The assessment lacked measurements.A Physician's Order with a start date of 07/03/25 and discontinued date of 08/04/25, directed staff to clean the resident's heel with wound cleanser, clean stable surrounding tissue with skin prep, apply Santyl to the wound bed, and cover with silicone adhesive foam dressing every day.On 07/10/25, a Skin and Wound assessment documented R1 had an unstageable pressure wound, with an onset date of 05/28/25, to his left heel that measured 4.07 cm by 3.86 cm (an increase in size).On 07/16/25, a Skin and Wound assessment documented R1 had an unstageable pressure wound, with an onset date of 05/28/25, to his left heel that measured 3.97 cm by 2.97 cm.An Orders- Administration Note on 07/20/25 at 07:33 AM, documented the left heel was foul-smelling and produced brown drainage on the previous dressing. R1 verbalized pain.A Health Status Note on 07/21/25 at 07:00 AM, documented Consultant GG saw R1 and wrote new orders for a contract wound care company to evaluate and treat the resident's wounds.A Nutrition/Dietary Note on 07/21/25 at 03:49 PM, documented R1 had a stage two (partial-thickness skin loss into but no deeper than the dermis, including intact or ruptured blisters) pressure wound with treatment in place. R1's wound improved, and he continued on a regular diet.On 07/23/25, a Skin and Wound assessment documented R1 had an unstageable pressure wound, with an onset date of 05/28/25, to his left heel. The assessment lacked measurements.A N Adv (Nursing Advantage)- Skin Check note on 07/23/25 at 01:07 PM, documented R1 had a left heel pressure wound that measured 4.4 cm by 3.1 cm.A N Adv- Skin Check note on 07/27/25 at 09:01 AM, documented R1 had a stage two left heel pressure wound with orders in place. The note lacked measurements of the wound.A N Adv- Skin Check note on 07/30/25 at 03:05 PM, documented R1 had an unstageable left heel pressure ulcer that measured 4.1 cm by 2.9 cm.R1's clinical record lacked evidence the facility had notified or attempted to notify R1's representative of his left heel wound prior to 08/02/25.A Communication- with Family/NOK (Next of Kin)/POA (Power of Attorney) note on 08/02/25 at 02:03 PM, documented Administrative Nurse D attempted to call R1's POA to notify them of R1's change of wound status. Administrative Nurse D left a message after calling twice. She attempted to call R1's second point of contact with no answer as well.A Health Status Note on 08/03/25 at 01:46 AM, documented the nurse assisted the Certified Nurse Aide (CNA) with R1's bed change and observed white bugs crawling under R1's elevated left foot. R1 was not wearing heel protectors. The CNA lifted R1's leg slightly off the pillow so the nurse could view the dressing. R1's silicone dressing was not intact, and there were white bugs crawling out from under the section that was detached. The wound was not a new wound, but that was a change in wound status. The nurse notified Administrative Staff A and Administrative Nurse D at approximately 12:12 AM and administered PRN pain medication per R1's request at 12:15 AM. The nurse notified Consultant GG at 01:20 AM and received orders to clean with wound cleanser, apply Medihoney, then a wet-to-dry dressing. Consultant GG would evaluate for a wound vac on Monday morning when in the facility.A Health Status Note on 08/03/25 at 10:19 PM, documented the nurse changed R1's dressing per Consultant GG's orders and administered PRN pain medication. The nurse documented there was nothing moving at that time, and there was an odor present.A Doctor's Progress Note on 08/04/25 documented Consultant GG saw R1 for maggots in his stage four (a deep pressure wound that reaches the muscles, ligaments, or even bone) left heel wound. The plan of care included an order for wound care plus, an order for 125 millimeters of mercury (mmHg) continuous wound vac, an order for wet-to-wet (wound care technique where a moist gauze dressing is applied to a wound, allowing it to dry over time), with Medihoney (medical-grade honey used to aid wound healing) until wound vac started, an order for a low air-loss mattress, and a recommendation for hospice if he qualified.An order with a start date of 08/05/25 and a discontinued date of 08/08/25 directed staff to clean the resident's heel with wound cleanser, apply Medihoney, then wet-to-wet, cover with dressing daily for left heel wound.A Health Status Note on 08/05/25 at 11:27 AM, documented the nurse discussed with R1's representative that R1 was to have a wound vac placed on his left heel. R1's representative stated she was okay with the wound vac.On 08/06/25, a Skin and Wound assessment documented R1 had an unstageable pressure wound, with an onset date of 05/28/25, to his left heel that measured 3.06 cm by 2.7 cm.An order with a start date of 08/08/25 and discontinued date of 08/20/25, directed staff to clean the resident's heel with wound cleanser, apply Medihoney, then wet-to-dry (a wound care method used to mechanically debride wounds by removing dead tissue), cover with dressing daily for the heel wound. The order did not specify which heel to provide wound care to.A Hospice Note on 08/10/25 at 01:23 PM, documented hospice visited with R1 that day and the nurse requested pressure-reducing boots and wound dressing supplies from hospice.On 08/13/25, a Skin and Wound assessment documented R1 had an unstageable pressure wound, with an onset date of 05/28/25, to his left heel that measured 3.05 cm by 3.9 cm.An order with a start date of 08/16/25 and discontinued date of 08/23/25, for wound vac to left heel 125 mmHg continuous, black sponge, until healed, one time only for wound.Review of R1's August 2025 TAR revealed the wound vac order was signed off as completed on 08/17/25.An order with a start date of 08/17/25 and a discontinued date of 08/23/25, to monitor wound vac every shift and ensure the battery is charged during the night for the day shift.A History and Physical- New Admit Note on 08/17/25 documented R1 had a pressure ulcer on his left heel, which the facility treated, and he had a foul odor per staff. Consultant HH documented hospice care was involved with R1. Consultant HH documented R1's left heel wound needed to be debrided (medical removal of dead, damaged, or infected tissue to improve the healing potential for the remaining healthy tissue) and that would be discussed with hospice.A Communication- with Resident note on 08/17/25 at 12:38 AM documented R1 picked the adhesive tape off of the wound vac. The nurse approximated the appliance and replaced the adhesive. R1 complained of anxiety and stated his pain was managed at that time.A Care Plan Note on 08/21/25 at 02:31 PM, documented the facility held a care plan meeting with R1, hospice, R1' representative, and facility staff. R1 was up for most meals and on a supplement. Hospice discussed with R1's representative that R1's wounds would not heal, and R1's representative agreed to have the wound vac discontinued.An order with a start date of 08/22/25 and discontinued date of 08/29/25, to cleanse left heel with wound cleanser, pat dry, skin prep wipe to periwound, sprinkle crushed metronidazole (antifungal medication) onto a calcium alginate (dressing which forms a soft, gel that absorbs when it comes into contact with wound exudate) pad and place over wound bed, cover with abdominal (ABD) pads and rolled gauze every Monday, Wednesday, and Friday for unstageable pressure ulcer of left heel.An order with a start date of 09/01/25, to cleanse the left heel with wound cleanser, pat dry, skin prep wipe to periwound skin, sprinkle crushed metronidazole onto a calcium alginate pad and place over wound bed, cover with ABD pads and rolled gauze every Monday, Wednesday, and Friday related to an unstageable pressure ulcer of the left heel.On 09/03/25, a Skin and Wound assessment documented R1 had a stage one [NAME] Terminal ulcer (KTU- a pressure-based injury that can develop quickly and is often a sign of terminal illness or impending death), location not set, that developed 05/28/25, and measured 3.42 cm by 2.53 cm.On 09/10/25, a Skin and Wound assessment documented R1 had a stage four left heel pressure ulcer that measured 2.59 cm by 2.28 cm.On 09/17/25, a Skin and Wound assessment documented R1 had a stage four left heel pressure ulcer that measured 2.57 cm by 2.02 cm.On 09/17/25 at 12:29 PM, R1 sat in his Broda chair (specialized wheelchair with the ability to tilt and recline) in the dining room. R1 wore bilateral heel protector boots.On 09/22/25 at 12:11 PM, R1's representative stated the facility had notified her about R1's left heel wound the first week of August. She stated she was unaware he had a sore until that point. R1's representative stated the facility wanted to put a wound vac on his left heel, and she knew that the wound had to have been there a while if it needed a wound vac. She stated that it was the first time they had reached out about R1's wound.On 09/17/25 at 01:20 PM, Administrative Nurse D stated R1 had heel protectors prior to going on hospice, and the Kardex (nursing tool that gives a brief overview of the care needs of each resident) should tell CNAs who needs heel protectors.On 09/17/25 at 03:10 PM, CNA M stated residents at risk for pressure wounds were those who were prone to being in bed, had heavy incontinence, or someone refusing cares. He stated he watched for signs of breakdown. CNA M stated the Kardex had prevention interventions in it and heel protectors would be on the Kardex. CNA M stated if he found a new skin issue, he reported it to the nurse or Administrative Nurse D. He stated he prevented skin issues with R1 by providing incontinence cares, checking him every two hours, repositioning R1, off-loading R1's feet, and, when in his Broda chair, leaning him back. CNA M stated he remembered back in June (2025), R1 had a DTI he noticed when getting R1 out of the recliner. He stated he was not sure if R1 had any heel protectors on his feet at that time. CNA M stated he did not know if R1 used heel protectors when the wound occurred, but knew he had heel protectors at the time of the interview.On 09/17/25 at 03:21 PM, Licensed Nurse (LN) G stated residents at risk for pressure wounds were those who had a weight decline, recent dehydration, any redness starting, were in bed more than usual, or had an acute illness. She stated the care plan should tell nursing any special interventions that were in place, such as repositioning every two hours, barrier creams, and heel protectors. She stated the CNA's Kardex would say if a resident used heel protectors. LN G stated if a provider ordered suspension boots, the order was placed in the computer and would go in the TAR for the nurses to sign off on. She stated any new skin issues were reported to the nurse, and the nurse did a skin assessment and then reported any changes to the provider for any new orders. She stated she reported any new change to the provider. She stated R1's left heel wound started out as a small opening, then it opened up. LN G stated the provider prescribed orders, made several changes, including adding a wound vac, then the facility discontinued the wound vac in agreement with the family. LN G stated R1 did not have an order in PCC for nurses to check on heel protectors. She stated she was not sure when the heel protectors were ordered.On 09/17/25 at 03:33 PM, Administrative Nurse D stated staff knew who was at risk for pressure wounds through communication and tasks for charting. She stated if a provider ordered suspension boots, she made sure the facility had them, and she put the order in PCC. Administrative Nurse D stated she expected the nurse to notify her of any new skin issues then notify the resident's representative and their provider. She stated R1's left heel wound started out as a DTI, and he had a treatment in place. She stated R1 did not have an order for heel protectors at that time. Administrative Nurse D stated she was not sure if the suspension boots were ordered by Consultant GG on 06/09/25 because if the order was not put in the computer, then she did not get notified of a new order. She stated she expected staff to document any notifications to the provider and family.The facility's Transcription of Orders/Following Physician's Orders policy, last revised 05/18/24, directed upon receiving a physician's order via telephone, fax, written order, verbal order, transcribed order, or other, the facility documented the order in the resident's EMR in the orders section.The facility's Pressure Injury Prevention and Management Policy, last revised 05/18/24, directed the facility established and utilized a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce, or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. The policy directed the facility implemented evidence-based interventions for prevention for all residents who were assessed at risk or who had a pressure injury present. Basic or routine care interventions included but were not limited to: redistribution of pressure; minimization of exposure to moisture; and providing appropriate, pressure-redistributing support surfaces. The policy directed the facility to document the interventions in the care plan and communicate the interventions to all relevant staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 23 residents. The sample included nine residents. Based on record review and interviews, the facility failed to provide Resident (R) 2 with wound care consistent with standards of practice when staff failed to ensure physician involvement for wound status changes and appropriate treatment orders, and failed to assess wound characteristics consistently and when treatment changes were made. These failures resulted in the deterioration of the wound and the worsening of the infectious process. This also placed R2 at risk for increased pain and other wound-related complications. Findings included: - R2's Electronic Medical Record (EMR) documented a diagnosis of cerebral infarction (stroke - the sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), pressure-induced deep tissue damage (pressure ulcer - localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) of the sacral region (sacrum - large triangular bone/area between the two hip bones), open wound of lower back and pelvis, weakness, systolic congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), type two diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel). The admission Minimum Data Set (MDS), dated 07/18/24, noted R2 had problems with short-term and long-term memory. The MDS further documented R2 had poor decision-making and required cues and supervision. The MDS documented R2 used a wheelchair and required substantial, maximal assistance for transition from lying to a seated position on the edge of a bed, sitting to stand, bathing, toileting hygiene, lower body dressing, and transfers. The MDS documented R2 was on antibiotics and had one stage four (a deep pressure wound that reaches the muscles, ligaments, or even bone) pressure ulcer. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 07/18/24, documented R2 had obvious long- and short-term memory deficits. The CAA documented R2 was admitted to the facility following a hospital stay secondary to a sacral wound with infection and was on intravenous (IV- administered directly into the bloodstream via a vein) antibiotics. The CAA further documented R2 required assistance with ADL completion and had a wound vacuum-assisted closure device (wound vac - a wound healing therapy that uses negative pressure to help wounds heal) in place to his sacral area. R2's Care Plan, with an initiated date of 07/23/24, documented R2 had a stage four pressure ulcer to his sacrum. An intervention with an initiated date of 07/23/24 documented R2 had a wound vac to his sacral wound. Staff were to change the resident's wound vac three times a week and as needed. An intervention with an initiated date of 07/23/24 directed staff to assess, record, and monitor wound healing weekly and as needed. Measure the wound length, width, and depth where possible. Assess and document the status of the wound perimeter, wound bed, and healing progress. Report improvements and declines to the doctor (MD). An intervention with an initiated date of 07/23/24 directed staff to administer treatments as ordered and monitor for effectiveness. An intervention with an initiated date of 07/23/24 directed staff to monitor the dressing every shift to ensure it was intact and adhering, report loose dressing to the treatment nurse, and replace wound vac as needed. An intervention with an initiated date of 07/23/24, documented weekly treatment documentation was to include measurement of each area of skin breakdown's width, length, depth, type of tissue, and exudate (the fluid that leaks out of body vessels and tissues). R2's Care Plan, with an initiated date of 07/23/24, documented R2 had an infection of his sacral wound. An intervention with an initiated date of 07/23/24, directed staff to change wound vac dressing three times a week and as needed. R2's Care Plan, with an initiated date of 08/08/24, documented R2 had actual impairment to skin integrity of the skin surrounding the pressure ulcer related to a possible reaction to Tegaderm (transparent, film dressing that can be used to protect wounds) that secured the wound vac. An incomplete intervention with an initiated date of 08/08/24 documented R2 needed (SPECIFY: pressure relieving/reducing mattress, pillows, sheepskin padding, etc.) to protect the skin while in bed. R2's EMR documented the following: An admission Note dated 07/12/24 documented R2 was oriented to his room and the facility. The note further documented R2 had a wound vac placed and medications ordered to start IV antibiotics in the morning. A Nursing: Weekly Skin Evaluation dated 07/14/24, documented R2 had an open wound to the sacrum. The evaluation description related to the sacral wound documented tunneling (a wound that's progressed to form passageways underneath the surface of the skin) pressure ulcer, with a wound vac in place. The evaluation lacked further sacral wound evaluation including peri-wound (skin surrounding the wound), drainage, odor, and other signs of infection, and wound measurements related to the sacral wound. A Physician's Order with a start date of 07/15/24, documented to change the sacral wound vac, settings: 150 (negative pressure) continuous. Three times weekly on the day shift and as needed. Every Monday, Wednesday, and Friday. (Order placed on hold 08/07/24) R2's EMR lacked an order or dressing instructions to staff in the event the wound vac malfunctioned or could not be placed. A Weekly Pressure Injury Skin Report dated 07/17/24, documented R2 had a stage four pressure wound to his sacrum with a length of 6.5 centimeters (cm), width of 4.6 cm, and depth of 2.3 cm. The assessment documented a moderate amount of serosanguineous (semi-thick blood-tinged drainage) exudate, with no foul odor documented. The note described the wound bed as dark pink or red tissue with slough (dead tissue, usually cream or yellow in color). The note further documented the surrounding skin as normal for skin, and the assessment was marked as no change from the previous assessment and directed to continue the current treatment as ordered. The comment box on the assessment was blank. A Weekly Pressure Injury Skin Report dated 07/24/24, documented R2 had a stage four pressure wound to his sacrum with a length of 6.5 cm, width of 4.6 cm, and depth of 2.3 cm. The assessment documented a moderate amount of serosanguineous exudate, with no foul odor documented. The wound bed was described as dark pink or red tissue with slough. The surrounding skin was documented as normal for skin, progress from the previous assessment was marked as no change and directed to continue the current treatment as ordered. The comment box on the assessment documented the site was beefy red with some minimal bleeding noted to the surrounding skin when the clear film dressing was removed. R2's EMR lacked evidence the changes and bleeding to the peri-wound was reported to the physician. A Weekly Pressure Injury Skin Report dated 07/26/24, documented R2 had a stage four pressure wound to his sacrum with a length of 6.5 cm, width of 4.6 cm, and depth of 2.3 cm. The assessment documented a moderate amount of serosanguineous exudate, with no foul odor documented. The wound bed was described as dark pink or red tissue with slough. The surrounding skin was documented as normal for skin, progress from the previous assessment was marked as no change and directed to continue current treatment as ordered. The comment box on the assessment was blank. A Weekly Pressure Injury Skin Report dated 07/31/24, documented R2 had a stage four pressure wound to his sacrum with a length of 6.5 cm, width of 4.6cm, and depth of 2.3cm. The assessment documented a moderate amount of serosanguineous exudate, with no foul odor documented. with the wound bed was described as dark pink or red tissue with slough. The surrounding skin was documented as normal for skin, progress from the previous assessment was marked as no change and directed to continue current treatment as ordered. The comment box on the assessment documented redness, with skin breakdown noted surrounding the wound. Skin-prep (liquid skin barrier) was applied. R2's EMR lacked evidence the physician was notified of the skin breakdown. A Nursing: admission Eval dated 08/03/24, under section C skin evaluation, documented R2 had an unstageable pressure ulcer to his sacrum with a length of 6.0 cm, width of 4.0 cm, and depth of 2.0 cm. No further description of the sacral wound was documented in the assessment. A Nursing: Weekly Skin Evaluation dated 08/04/24, documented R2 had an open wound to his sacrum. The evaluation description related to the sacral wound documented a continued tunneling pressure ulcer with a wound vac in place. The evaluation lacked further sacral wound description and lacked wound measurements related to sacral wound. An Infection Note dated 08/05/24 at 03:41 AM noted R2 remained on IV antibiotics for the treatment of a wound infection. R2 had a wound vac in place on his sacrum. R2 did not have any adverse reactions to his medication. A Nurse Note dated 08/07/24 at 02:55 PM, documented the skin surrounding R2's pressure ulcer that was covered with Tegaderm had become reddened with areas of breakdown. The note documented that staff was unable to attach and seal the wound vac due to the area of breakdown. The note further documented the writer consulted with a certified wound nurse who recommended a treatment to use until the physician gave further orders. A Physician's Order with a start date of 08/07/24, documented a sacral dressing and directed to cover the wound bed with calcium alginate antimicrobial silver (dressing with antimicrobial properties used on infected wounds or wounds that are at a high risk of infection), apply Xeroform gauze (sterile non-adhering fine mesh gauze treated with a bacteriostatic agent) dressing, cover with ABD (large pad to absorb drainage) and paper tape. Change twice weekly until the resident could be seen by Veterans Affairs (VA). (This order was discontinued on 08/12/24). R2's August 2024 Medication Administration Record /Treatment Administration Record (MAR/TAR) lacked evidence the dressing was applied on 08/07/24 when initially ordered. The MAR/TAR recorded the dressing was first applied on 08/10/24 and then discontinued on 08/12/24. R2's EMR lacked evidence physician was contacted or made aware of R2's complications related to the wound vac and new dressing change order until 08/12/24. A Nursing: Weekly Skin Evaluation dated 08/10/24, documented R2 had an open wound to the sacrum. The evaluation description related to the sacral wound documented a continued tunneling pressure ulcer. The evaluation lacked further sacral wound description and lacked wound measurements related to sacral wound. A Health Status Note dated 08/12/24 at 09:58 AM documented Consultant HH was at the facility and saw R2. The note documented the plan of care was reviewed, new orders noted, and the dressing to R2's sacral area was changed to saline wet to wet twice daily (BID). A Physician's Order with a start date of 08/12/24, documented a sacral dressing, cleanse with wound cleanser then apply saline wet to wet to the wound; cover and change BID every day and night shift for wound. (Order placed on hold 08/19/24) A Weekly Pressure Injury Skin Report dated 08/14/24, documented R2 had a stage four pressure wound to his sacrum with a length of 6.5 cm, width of 4.6 cm, and depth of 2.8 cm. The assessment documented a moderate amount of serosanguineous exudate, with no foul odor documented. The wound bed was described as dark pink or red tissue with slough. The surrounding skin was documented as reddened, progress from the previous assessment was marked as deteriorated and noted to continue the current treatment as ordered. The comment box on the assessment documented dark red, and purple tissue surrounding the wound. R2's EMR lacked evidence the physician was notified of the changes in the wound and/or peri-wound. A Nursing: Weekly Skin Evaluation dated 08/17/24, lacked documentation related to R2's sacral wound and contained no wound measurements. An Order Note dated 08/19/24, documented R2 had a decline in alertness, his blood pressure had decreased, and his pulse increased from his normal range. The note documented R2 refused to eat or drink much and his wound to the coccyx was black in color with a strong foul smell. Staff placed a call to the provider, and they gave an to send R2 to the emergency room. A Nurse Note dated 08/19/24 documented an ambulance arrived at the facility and transported R2 to the emergency room at 01:10 PM. R2's Emergency Department Note dated 08/19/24 recorded R2 presented to the emergency department for possible sepsis (a life-threatening systemic reaction that develops due to infections that cause inflammation throughout the entire body). The note further documented R2's sacral wound measurements were approximately 10 cm by 14 cm, and the wound was necrotic (pertaining to the death of tissue in response to disease or injury) with tunneling present. On 08/21/24 at 03:40 PM, in a phone interview with Consultant JJ, a nurse for Consultant HH, Consultant JJ stated she reviewed all the call logs from 08/07/24 and stated that there were no logged calls from the facility on that day related to R2 at all. On 08/21/24 at 04:23 PM, Hospital Nurse II stated R2 admitted for sepsis. Hospital Nurse II stated R2's sacral wound was in very bad condition when he arrived. Hospital Nurse II stated R2's wound was really bad and showed signs of neglect. Hospital Nurse II confirmed R2 had transferred to another hospital for a higher level of care. On 08/22/24 at 03:33 PM, Licensed Nurse (LN) H stated she was unsure why R2's wound vac was removed, but said she believed it was related to the tape used on the wound vac and R2's skin breakdown around the site where the wound vac dressing was placed. LN H stated wound assessments were supposed to be completed weekly and that included assessing the wound and taking measurements. LN H further stated staff were supposed to measure the wounds to know if they were changing in size, assess tissue to note if the wound had worsened or improved, and know if the physician needed to be notified. LN H stated the last time she saw R2's wound, it was horrible and was deep enough to see his tailbone. LN H stated she would reassess a wound if new treatments or dressings were ordered. LN H stated she believe R2's wound began deteriorating after the wound vac was removed. She stated at first the site around the wound was pink; however, as time went on, staff believed the dressing was irritating R2's skin, and it gradually got worse, and the wound vac was removed. LN H stated she saw the wound when R2 first arrived at the facility and the wound had some small necrotic tissue around the opening; however, she stated it was much smaller and was not as severe. LN H stated she was off work for a week, and when she returned R2's wound had worsened. She stated she had been a nurse for 30 years and this was the first time she gagged after seeing the wound without the wound vac. LN H stated if staff notice a breakdown in a wound, especially after a new treatment was ordered, they should notify the provider. On 08/26/24 at 12:15 PM Administrative Nurse D stated if staff noticed a wound was worsening, she expected staff to notify her or their wound nurse as they handle the wound care for the facility. Administrative Nurse D stated she expected staff to assess wounds, which included taking measurements and documenting them weekly. Administrative Nurse D stated she believed the wound vac dressings for R2 were done three times per week. Administrative Nurse D stated if there was a change in dressing types, she expected staff to at least document a progress note as to why the wound vac could not be put back in place while waiting for the doctor to notify staff of a change in treatment. Administrative Nurse D stated R2's skin was breaking down; it was raw and would not stick to the dressing to form a seal. Administrative Nurse D stated staff believed the wound vac dressing would have caused more damage if put back on. Administrative Nurse D stated their wound nurse attempted to use barriers to help with the seal; however, it did not work. She stated she believed the cause of R2's issues were related to the tape, or Tegaderm and not the staff's competency. Administrative Nurse D stated Administrative Nurse E was in the facility the day the wound vac was removed and Administrative Nurse E was a certified wound nurse. Administrative Nurse D stated they followed Administrative Nurse E's recommendation to change the wound dressing twice weekly while waiting for the doctor to decide how he wanted to address it. Administrative Nurse D stated the doctor changed the dressing to a wet to wet while the facility awaited a response from the VA for approval. Administrative Nurse D stated no one had mentioned to her that R2's wound had worsened prior to him being sent out to the ER. On 08/26/24 at 01:44 PM Administrative Nurse E stated she was asked to assess R2's sacral wound, and that she understood the wound was previously debrided (medical removal of dead, damaged, or infected tissue to improve the healing potential for the remaining healthy tissue) at a hospital prior to admission. Administrative Nurse E stated R2's wound was a wicked wound with slough and eschar (dead tissue) and a wound vac could not be done on a wound with eschar. Administrative Nurse E stated she believed R2 should have had his wound debrided again at the hospital; however, they had to await approval through the VA. Administrative Nurse E stated the doctor was called to get a new dressing order to get by until R2 could be seen at the VA. Administrative Nurse E stated there was 80% slough and eschar in R2's wound when she saw it. Administrative Nurse E stated she believed Administrative Nurse D contacted Consultant HH for the dressing order. Administrative Nurse E stated if staff contacted a physician, then that staff should document that. Administrative Nurse E stated if it was not documented, then it was not done. On 08/26/24 at 02:02 PM Administrative Nurse D stated she consulted with Administrative Nurse E regarding R2's wound and wound vac issue. Administrative Nurse D stated she did not know who contacted Consultant HH to get an order for the dressing change on 08/07/24 when the wound vac was removed. Administrative Nurse D stated she was with Administrative Nurse E when Administrative Nurse E recommended the dressing change and gave it to the nurse. Administrative Nurse D stated she entered the dressing order into the system; however, she believed LN I was supposed to have contacted Consultant HH to get permission for the order. On 08/26/24 at 02:07 PM LN I stated she went to change R2's wound vac and his skin was broken down under the Tegaderm. LN I stated she cleaned and dried the site; however, the dressing would not adhere. LN I stated she did not have a lot of wound experience, so she got Administrative Nurse E and Administrative Nurse D for assistance. LN I stated Administrative Nurse E and Administrative Nurse D were going to get a hold of Consultant HH for an order until Consultant HH could come to see R2. LN I stated Administrative Nurse E recommended the twice-weekly order, and then Administrative Nurse D got ahold of Consultant HH to obtain the order. LN I said the following Monday, Consultant HH changed the dressing order to a wet-to-wet dressing twice daily. LN I stated she changed the dressing on 08/07/24. LN I stated she saw the wound when the wound vac was removed and was the nurse who sent R2 out to the ER on [DATE]. LN I stated R2's wound looked worse. She stated R2's wound did not have necrotic skin when they removed the wound vac and the wound bed was a dark, deep red. LN I stated R2's wound later had blistering around the edges of the wound, was peeling, and had black spots in the wound bed. She further stated the wound had a stronger odor the day he was sent out. The facility's Wound Care policy with a revised date of 07/15/24, documented the following information should be recorded in the resident's medical record: the type of wound care given, the date and time the wound care was given, the name and title of the individual performing the wound care, any changes in the resident's condition, all assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound, any problems or complaints made by the resident related to the procedure, if the resident refused the treatment and he reasons why and the signature and title of the person recording the data. The facility failed to provide R2 wound care consistent with standards of practice when staff failed to ensure physician involvement for wound status changes and appropriate treatment orders, and failed to assess wound characteristics consistently and when treatment changes were made. These failures resulted in the deterioration of the wound and the worsening of the infectious process. This also placed R2 at risk for increased pain and other wound-related complications.

The facility identified a census of 23. The sample included nine residents. Based on record review and interviews, the facility failed to ensure Resident (R) 1 remained free from preventable accidents during a Hoyer lift (full body mechanical lift) transfer. This deficient practice resulted in impaired psychosocial well-being and placed R1 at risk for further complications. Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses of acquired absence (amputation) of left leg above knee, heart failure (a condition with low heart output and the body becomes congested with fluid), and hemiplegia (paralysis of one side of the body) affecting the right dominant side. The Annual Minimum Data Set (MDS) dated 11/03/23, documented R1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R1 required staff dependency for chair/bed-to-chair transfers. The Quarterly MDS dated 07/19/24, documented R1 had a BIMS score of 14, which indicated intact cognition. R1 required staff dependency for chair/bed-to-chair transfers. The Functional Abilities Care Area Assessment (CAA) dated 11/17/23, lacked an analysis of findings. The Falls CAA dated 11/15/23, documented R1 required assistance with activities of daily living (ADLs). R1's Care Plan, dated 01/12/21, documented R1 had an ADL self-care performance deficit and directed R1 required total assistance with a Hoyer lift to move between surfaces and as necessary. Certified Nurse Aide (CNA) M's Investigation Statement of Facts, dated 08/13/24, documented she and Certified Medication Aide (CMA) R hooked R1 up to the Hoyer lift to transfer him to the shower chair. She stated one of R1's lift sling leads came unattached, and they thought it had ripped. CNA M stated R1 fell out of the sling, and they quickly got him off of the Hoyer lift leg to make sure he was okay while CMA R notified the nurse. The nurse assessed R1 and called EMS. CMA R's Investigation Statement of Facts, dated 08/13/24, documented she and CNA M put R1 in the Hoyer lift and as she started to turn around to put him in the shower chair, one side of the Hoyer lift sling snapped and R1 tipped while another sling loop slid off. R1 fell to the ground and his back landed on the Hoyer lift. R1's right arm bled, and CNA M covered it as she ran to get the nurse. R1 complained of back pain but they did not move him until the ambulance arrived. R1's medical record revealed the following: An Incident Note on 08/13/24 at 02:07 PM documented at approximately 12:45 PM, two CNAs were in R1's room preparing him for his shower. They had R1 up in the air with the Hoyer lift when the sling came loose, causing R1 to fall to the floor. The CNAs stated R1 hit the lower part of his back on one of the lift legs. When the nurse entered the room, R1 laid flat on his back and voiced extreme low back pain. R1 had abrasions and several skin tears noted to the top of his right forearm. The nurse did not assess R1's back due to waiting for paramedics to arrive. R1 transferred to the emergency room (ER) for evaluation and treatment at approximately 01:30 PM. A Nurse Note on 08/13/24 at 10:28 PM documented R1 returned to the facility. Computed Tomography (CT scan- test that used x-ray technology to make multiple cross-sectional views of organs, bone, soft tissue, and blood vessels) scan of R1's lumbar and thoracic spine were negative. Staff received no new orders. A Psychosocial Note on 08/14/24 at 11:32 AM documented Social Services X spoke to R1. R1 stated his whole body hurt after the Hoyer lift fall. R1 expressed fear of using the Hoyer lift in the future. Social Services X noted R1 appeared tearful when speaking about the incident. Social Services X planned to follow up on a daily basis as long as R1 needed. A Nurse Note on 08/14/24 at 02:08 PM documented R1 spent the day in bed per his normal. R1 voiced occasional back pain and received as needed (PRN) Tylenol (pain medication) and PRN Oxycodone (pain medication). R1 stated he felt shakier than usual, and he felt tired. A Psychosocial Note on 08/15/24 at 01:03 PM documented Social Services X spoke to R1 in his wheelchair. Staff moved R1 from his bed to his chair via Hoyer lift. R1 complained of pain but he no longer voiced fear of using the lift. The facility's Investigation, dated 08/19/24, documented on 08/13/24 at approximately 12:40 PM, CMA R and CNA M entered R1's room to perform a Hoyer lift transfer from his bed to the shower chair. One operated the lift while the other held the shower chair steady. As the staff lifted R1 up with the Hoyer lift, R1 requested them to check his weight. CNA M told R1 they would obtain his weight after his shower. As staff turned the Hoyer lift from the bed to the shower chair, R1 slid out of the Hoyer sling and onto the floor. CNA M and CMA R noted two of the Hoyer sling loops had popped off of the lift hooks. Staff immediately notified Licensed Nurse (LN) I. LN I called the ambulance and reported the incident to Administrative Nurse D and Administrative Staff A. Both CNA M and CMA R reported R1 hit his back on the leg of the lift and R1 complained of back pain. Staff noted R1 had a skin tear to his right arm. The facility received an order to send R1 to the emergency room (ER) for evaluation. The hospital performed a CT scan on R1's back with no negative results. The hospital discharged R1 back to the facility with a diagnosis of mechanical low back pain. During the investigation, Administrative Nurse D, the Regional Nurse Consultant, and Administrative Staff A re-enacted the incident with CMA R and CNA M. During the re-enactment, CNA M and CMA R did not widen the Hoyer lift legs after they cleared the bed per manufacturer's instructions. As a result, the Hoyer lift became unsteady and R1 slid out of the Hoyer lift during the transfer. On 08/21/24 at 04:40 PM, Social Services X stated she went to R1's room on 08/14/24 to follow-up with him after the fall from the Hoyer lift. She stated R1 voiced being scared of the Hoyer lift and he appeared tearful and in pain. She stated on 08/15/24, she went to talk to R1 because he had been transferred to his wheelchair. She stated R1 was sometimes confused and because he did not mention being scared of the Hoyer lift, she did not remind him that he stated he was previously. On 08/21/24 at 05:16 PM, CNA N stated to prevent accidents with the Hoyer lift, staff placed the lift sling hooks and made sure the secondary hooks were in place too. She stated one staff operated the lift while the other stayed with the resident. CNA N stated the lift legs were closed under the bed and staff opened them up when moving the lift out from under the bed to steady the lift. She stated she completed lift competencies recently. On 08/22/24 at 02:24 PM, LN H stated two staff operated the Hoyer lift at all times and hooked up the same color loops of the lift sling to the Hoyer lift. She stated one staff operated the lift while the other guided the resident and staff opened the lift legs during the transfer for more support. On 08/22/24 at 05:35 PM, Administrative Nurse D stated she expected staff to use two people during Hoyer lift transfers, one to spot while driving the lift and the other to open the lift legs once they were clear of the bed. She stated she expected staff to have the correct sling size and correct sling placement. Administrative Nurse D stated she expected staff to use the appropriate sling lift loops and to make sure to use the back up loop on the sling. She stated staff used a shower lift sling with the Hoyer lift for R1's transfer. She stated one of the failures during R1's transfer included the staff's failure to widen the lift legs and one staff did not stay with R1 while the other operated the lift. On 08/26/24 at 02:57 PM, CMA R stated on 08/13/24, she and CNA M used the Hoyer lift to transfer R1 into the shower chair but as soon as she turned the lift to place R1 in the shower chair from his bed, one of the straps came off and as he fell, another loop came off. She stated it was R1's left side loops that came off. She stated R1 fell onto the floor and his back hit the lift leg. She stated CNA M tried moving the lift out of the way while she got the nurse. CMA R stated they did not use the last loop during Hoyer lift transfer because it did not lift the resident high enough. She stated R1 complained of his back hurting really badly and that he voiced being scared. CMA R stated she completed lift competencies after the incident. On 08/26/24 at 03:03 PM, CNA M stated on 08/13/24, she and CMA R got R1 ready to transfer to the shower chair. She stated they hooked up R1's lift sling to the Hoyer lift and made sure the loops were hooked up correctly. CNA M stated as soon as they lifted R1 and turned the lift toward the shower chair, they thought the lift strap broke. She stated it was his left side that came off, so she assumed his shift in weight caused it because of his left leg amputation. CNA M stated after the incident, Administrative Nurse D pulled her, and the other staff involved in the incident from the floor and went over what happened and did education on how to run the lift properly. She stated during the re-enactment, the Regional Consultant told her they did not open the legs of the lift when moving it and told them the legs needed to be opened for stability. CNA M stated she received lift competencies after the incident. The facility's Safe Resident Handling/Transfers policy, dated 2023, directed all residents required safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them. The policy directed two staff members utilized a mechanical lift and staff received education on the use of safe handling/transfer practices to include the use of mechanical lifts upon hire and as the need arose. The facility failed to ensure R1 remained free from preventable accidents during a Hoyer lift transfer. This deficient practice resulted in impaired psychosocial well-being and placed R1 at risk for further complications. The facility put the following corrections into place: The facility updated R1's care plan on 08/13/24. Maintenance U inspected the Hoyer lift on 08/13/24. Physical Therapy (PT) evaluated R1 on 08/14/24. Direct care staff received mechanical lift, fall prevention, and abuse education on 08/14/24. Because the facility implemented and completed the corrections prior to the onsite survey, this deficient practice was cited as past noncompliance.