**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews it was determined that the facility failed to ensure medications were administered as ordered. This was found to be evident for 1 (Resident #102) out of 1 Resident reviewed for a significant medication error during the re-certification survey. This deficient practice resulted in an actual harm cited as past compliance. The findings include: On 07/20/25 at 5:32 PM a review of the Facility Reported Incident (FRI) #348424 revealed a report that advised Resident #102 was mistakenly administered all of Resident #115's morning medications. As a result, the Resident experienced a significant adverse event and was admitted to the local hospital's Intensive Care Unit (ICU) for treatment. A review of Resident #115's Medication Administration Record (MAR) was conducted on 07/20/25 at 5:35 PM. The review of the MAR showed the following morning medications were scheduled to be administered on the day of the incident (8/19/24): Cyanocobalamin (vitamin B-12), Gabapentin capsule 900 mg, Ibuprofen tablet; 800 mg, MiraLAX (polyethylene glycol 3350) 17 gram/dose; MS Contin (morphine) extended release 30 mg, Nubeqa (darolutamide) tablet 300 mg (cancer medication), Senna - S (8.6- 50 mg), and Tamsulosin capsule; 0.4 mg. During an interview conducted on 07/20/25 at 5:49 PM, the Director of Nursing (DON) confirmed that Registered Nurse (RN) 16 administered Resident #115's morning medications to Resident #102. The DON reviewed the MAR with this Surveyor and confirmed that Resident #102 received the following medications: Cyanocobalamin (vitamin B-12), Gabapentin capsule 900 mg, Ibuprofen tablet; 800 mg, MiraLAX (polyethylene glycol 3350) 17 gram/dose; MS Contin (morphine) extended release 30 mg, Nubeqa (darolutamide) tablet 300 mg (cancer medication), Senna - S (8.6- 50 mg), and Tamsulosin capsule; 0.4 mg. A review of Resident #102's progress note dated 08/19/24 from the DON was conducted on 07/20/25 at 6:56PM. The note reported that RN #16 immediately reported her oversight that she administered Resident #102 incorrect medications during the AM (before noon) medication pass. The DON stated, this writer was called to the resident room approximately 0930, immediately after medication was given, resident was noted alert and verbal, and oriented x 2-3.The DON further stated that the Resident was able to follow commands, speech was clear, continued with O2 (oxygen) via nasal cannula for treatment of COPD, bilateral strong hand grasp, pushes, pulls, bilateral strong pedal pushes and pulls. The Physician was notified, gave new orders for neuro checks every 15 minutes, administer Narcan and send to the emergency room for decreased/change in mental status. The Physician also stated that he would be in today to assess the Resident.According to the World Health Organization (WHO) Chronic Obstructive Pulmonary Disease (COPD) is a common lung disease causing restricted airflow and breathing problems. It is sometimes called emphysema or chronic bronchitis. In people with COPD, the lungs can get damaged or clogged with phlegm.According to the National Institute of Drug Abuse Naloxone (Narcan) is a medicine that rapidly reverses an opioid overdose. It is an opioid antagonist. This means that it attaches to opioid receptors and reverses and blocks the effects of other opioids. Naloxone can quickly restore normal breathing to a person if their breathing has slowed or stopped because of an opioid overdose. The DON reported that at approximately 12:45 PM, Resident #102 was noted with decreased mentation, hard to arouse, 911 was called and arrived, Narcan was administered, and the Resident was transported to the local hospital emergency room. A review of Resident #102's hospital discharge summary was conducted on 07/20/25 at 7:04 PM. The discharge summary reported that in the ED (emergency department) the Resident was started on 1 milligram of Narcan infusion and placed on a BiPAP. The Resident was arousable to moderate sternal rub and was able to follow simple commands like moving legs and squeezing hand. The Resident was admitted to the ICU (Intensive Care Unit) for management of unintentional/accidental overdose, acute on chronic hypoxic hypercapnic respiratory failure due to drug overdose as well as hypotension/shock. The report showed that the resident was admitted to the hospital on [DATE] and discharged back to [NAME] Nursing and Rehabilitation on 08/24/24. Biphasic Positive Airway Pressure (BiPAP) is a type of noninvasive ventilation that helps you breathe. Providers can use it to treat you if you're not getting enough oxygen or can't get rid of carbon dioxide. A machine delivers air through a mask on your face.Acute on chronic hypoxic hypercapnic respiratory failure is a serious condition where a patient with an existing chronic respiratory problem experiences a sudden worsening of their breathing, leading to dangerously low oxygen levels (hypoxia) and high carbon dioxide levels (hypercapnia) in the blood. This means the lungs are not effectively exchanging gases, and the body's organs are not getting enough oxygen while accumulating excess carbon dioxide. Hypotension, or low blood pressure, can lead to shock when it becomes severe enough to prevent the body's organs from receiving adequate oxygen and nutrients. Shock is a life-threatening condition characterized by circulatory failure and inadequate tissue perfusion. A review of the facility's mitigation plan was conducted on 07/20/25 at 7:49 PM. The plan consisted of an in-service to all permanent and agency licensed nurses and certified medication assistants (CMA) on education of medication administration on 08/20/24. Staff who were not present on 08/20/24 to receive the in-service could not start their shift until they received the medication administration in-service. The facility also conducted observations of all staff that administered medications on 08/20/24. Ongoing medication administration observations were conducted weekly for 6 weeks. The results of the 6 weeks of observations were reviewed at the monthly Quality Assurance and Performance Improvement (QAPI) meeting. This deficient practice was cited as past noncompliance with corrective measures completed on 08/20/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of complaints MD00196300, MD00194233, facility-reported incidents MD00196345, MD00193981, hospital records, medical record, facility documentation and interviews, it was determined the facility failed to protect a vulnerable resident ' s skin from injury resulting in harm to Resident #44, and failed to put measures in place to prevent further skin breakdown (Resident #38, #39, #23, #13). This was evident for 5 ( #44, #38, #39, #23, #13) of 43 residents reviewed during a complaint survey. The findings include: 1.) On 9/14/23 at 12:30 PM a review of facility-reported incident MD00196345 revealed that Resident #44 obtained a wound under the trach collar that was located on the back of the neck. The report documented that Resident #44 was sent to the hospital and was subsequently admitted for other symptoms not related to the area on the neck, but other preexisting conditions that the facility had been managing. On 9/14/23 at 12:30 PM a review of complaint MD00196300 revealed Resident #44 was taken to the emergency room for evaluation of a posterior (back) neck laceration due to a trach (tracheostomy) collar tie. On 9/14/23 at 12:35 PM a review of Resident #44 ' s medical record revealed a 4/20/23 physician ' s note which documented Resident #44, who was in their 30 ' s, was admitted to the facility for care following a cardiac arrest which resulted in an anoxic brain injury and was deemed unable to recover brain function. Resident #44 had a tracheostomy placed and was sent to the facility for further care. Review of an 8/26/23 at 11:00 PM nursing note documented that the nurse was called to the resident ' s room by a geriatric nursing assistant (GNA) for a wound on the back of the resident ' s neck. The note documented the resident was observed with an approximate 15 cm. (centimeter) laceration along the back of the neck. The respiratory therapist removed the trach collar, and the nurse applied a dressing over the area. The resident was sent to the emergency room. Review of the emergency room ' s triage note dated 8/26/23 at 23:36 (11:36 PM) documented chief complaint, pt presents to ED (emergency department) from facility due to laceration to back of pts. neck from trach collar strap. The patient ' s temperature was 99.1, blood pressure 97/62, and a heart rate of 142 beats per minute. The note documented the presenting problem as, positive for laceration, fever, redness and swelling. The ED disposition documented in the following order, diagnosis: pressure injury of skin, posterior neck, infected wound, tachycardia (rapid heart rate), hypotension (low blood pressure), leukocytosis (high white blood cell count), dehydration, and symptomatic anemia. The disposition was, admitted . Review of the ED provider disposition note dated 8/27/23 at 1:25 AM documented, medical decision making and included, Trach collar is in place. Patient with open wound posterior neck at the level the trach collar stye. Malodorous serous discharge. Macerated skin at the edges of wound. No bleeding no warmth no erythema. Appears to be approximately 1 centimeter at its deepest. Review of the hospital general admission note dated 8/27/23 at 4:16 AM documented, reason for admission: sepsis, cellulitis of the back of the neck, laceration back of neck, symptomatic anemia. The note documented, the patient has a tracheostomy collar and where it ties in the back there is now a deep laceration which is why the nursing home sent [him/her] here. The note continued, when [he/she] present to the ER [his/her] heart rate was found to be high at 142 and bp low at 97/62. The note documented a temperature of 99.1 and a white blood cell count at 14.31 and a hemoglobin of 6.8 with a hematocrit of 22.1. A central line was inserted, and the resident received IV (intravenous) fluids and IV vancomycin (antibiotic). Further review of the 9/5/23 at 6:40 AM hospital note documented, discharge - wound care active orders: type: pressure posterior neck, Schedule: Routine, Frequency: 3 times per week, as ordered, Additional instructions: wash with soap and water. Apply wound gel/hydrogel to wound bed, Aquacel Ag to wound bed, and secure with ABD. On 9/14/23 at 1:17 PM an interview was conducted with the respiratory program manager, Staff #11. Staff #11 was asked how often the straps were changed prior to the laceration. He stated weekly and prn (when necessary) if wet or dirty. Staff #11 stated they were changed out the Wednesday or Thursday before the laceration was found. Staff #11 stated, when they do trach are they release the trach collar and inspect. Staff #11 stated, the collar has a green strap, and we think when pulling it tight it caused a laceration. When asked how a strap could cause a laceration, he stated that sometimes there are rough edges from pulling and tightening up. Staff #11 stated that they removed all the green straps from the trachs and now put a soft collar on to provide cushioning, a softer gray collar. Staff #11 stated that they are now changed every 2 days and there was someone with the therapist to look at the back of the neck. Staff #11 was informed that documentation could not be found of the therapists signing off that the trach ties were changed. Staff #11 stated, they don ' t document changing the straps, that it is part of the respiratory protocol. Some do document for certain patients. On 9/14/23 at 1:29 PM an interview was conducted with respiratory therapist (RT) #10. Staff #10 stated, I worked with the resident that day and I did not change the trach ties. I look under as best as I can. I did not change the ties that day. They were not due to be changed that day. Originally the ties were changed weekly and as needed. Always on Monday and PRN. Now we change every 2 days. Now we do skin assessment every shift which are 12-hour shifts. Staff #10 was asked if there was any documentation that the ties were changed and she stated, it was not an outright order before so there was no documentation unless it was put in a note, but now it is an order, and we document. Staff #10 stated, the laceration was like a half-moon scar. I really did not look hard because the straps were not due to be changed. Staff #10 was asked if she would normally check the back of the neck. Staff #10 stated, when in school we were not taught specific skin conditions except for around the stoma. It was not on my radar before this happened and I have never seen it before. On 9/14/23 at 2:57 PM an interview was conducted with geriatric nursing assistant (GNA) #9. GNA #9 was asked if she typically would bathe the back of the neck when giving a bed bath. GNA #9 stated, I don ' t wash the neck. I wash the resident ' s back. We check to see if there are scratches under the straps. When asked if she lifted the trach straps, GNA #9 stated, I do not lift the strap up. When you turn the patient, you can see the back of the neck. On 9/14/23 at 4:23 PM GNA #8 was interviewed and stated that she always worked on the ventilator unit. GNA #8 was asked how she washed Resident #44, and she stated, I give a bed bath and I wash the whole body. When asked if she ever lifted the trach collar straps to wash, GNA #8 said, no. GNA stated that she washed the resident ' s hair a couple of weeks before and braided the hair, but it wasn ' t that day. GNA #8 stated, we change the sheets every other day and the pillowcases. I change the sheets frequently. There was nothing on the sheets or pillowcases. On 9/14/23 at 4:00 PM a review of the August 2023 Treatment Administration Record (TAR) was conducted. There was an order, weekly skin check by licensed nurse. The nurses initialed on the TAR when a skin check was done. A skin check was initialed on 8/3/23, 8/10/23 and 8/17/23. On 8/24/23 there were initials, however they were in parenthesis. On 9/14/23 at 4:35 PM an interview was conducted with Licensed Practical Nurse (LPN) #7. The TAR was shown to LPN #7, and she was asked if those initials were her initials on 8/24/23 and what did the parenthesis mean. LPN #7 stated they were her initials and the parenthesis meant that she did not do the skin check. When asked why she did not do the skin check, LPN #7 stated, because I only had 1 GNA that night and had multiple admissions and I was on the floor by myself. I was the only nurse. I got 2 admissions that night. There were about 17 residents because I had to do both hallways. I had to do the vent hallway and the rehab hallway. When asked if they worked short-staffed, LPN #7 stated, we do work short often, sometimes we have 1 GNA and sometimes we have 2 GNAs. LPN #7 was asked when she did a skin assessment to describe how she did it. LPN #7 stated, a weekly skin check is a whole assessment head to toe. The GNAs help me roll the patient. I don ' t look under gauze, respiratory does that. When asked if respiratory was with her when she did a skin assessment, she said, no, the GNA is. On 9/14/23 at 4:48 PM an interview was conducted with the Assistant Director of Nursing (ADON) #6 who stated that she helped with the nursing scheduling. Staff #6 stated on the 500 unit, which was the ventilator and rehab unit, they have 1 nurse, 1 respiratory therapist and 2 GNAs for each shift, except the overnight shift has 1 GNA. Staff #6 stated she was working that evening and said, I became aware of the laceration about a half hour before we sent [him/her] out. It looked like a cut; no drainage and it was not bleeding. It did not smell. It did look kind of fresh, there was no drainage. The trach collar was clean, so I wasn ' t sure if it was fresh or had been there since there was no blood or drainage. Until you pushed [his/her] head forward you could not see it. If the head was kept back, you couldn ' t see it. It was red and beefy, was not actively bleeding. I was not the nurse on the unit. The GNA came and got me and asked me to look at it. The nurse on the unit was not certain if he should put a bandage on it and he was on the fence as to sending [Resident #44] out. I looked at it and I felt [he/she] should be sent out. Just eyeballing it about half a centimeter or more. You had to bend the head down to see it and I didn ' t want to do that and make it worse. Staff #6 continued, I would have expected the nurses to inspect the neck and look under the trach cover. [Resident #44] didn ' t have folds on [his/her] neck. I don ' t know if I would push the neck down because it would make [him/her] uncomfortable, but I would take the trach collar off. Respiratory therapy does it as far as changing. I would assume they do that. But during a skin check I would expect it and I would expect the GNA ' s to wash the neck. Staff #6 stated that since the incident, the respiratory therapist is doing more skin checks when doing the trach ties and when they put a new tie on. On 9/15/23 at 7:16 AM an interview was conducted with the Director of Nursing (DON), and she was asked if they did any education with the staff. The DON said, respiratory did their education and I know some nurses had skin education. When asked if they did any kind of QAPI (Quality Assurance and Performance Improvement), she stated, no, we did not do an AD hoc meeting. The DON provided the surveyor with a sign-in sheet for the 6 respiratory therapists that were educated. The DON stated they educated all the nurses verbally but did not have documentation of the education. The DON stated they did a whole building skin audit. On 9/15/23 at 7:43 AM an interview with the ADON revealed that an action plan was typed up but the only thing that had been started was the facility-wide skin sweep. The ADON said they verbally educated the nursing staff, especially on that unit, but there was no documentation of the education. 2) On 9/14/23 at 8:13 PM a review of facility-reported incident MD00193981 for Resident #38 revealed an allegation that the resident, who resided on the dementia unit, was found by a family member on 6/28/23 laying in urine and feces and also had sores. Review of a 6/30/23 at 4:43 PM note documented that the resident had an old discolored blister to the left heel measuring 6 x 4, a popped blister area to the left calf measuring 3 x 2 and also had a stage 2 to the sacral area. Review of wound notes dated 7/3/23 to 9/18/23 documented that Resident #38 had an unstageable pressure ulcer to the left heel. Further review of the 9/18/23 wound notes documented Resident #38 had a stage 3 pressure ulcer to the right medial ankle that was acquired in house on 9/18/23, a deep tissue injury (DTI) pressure area to the right lateral foot that was acquired in house on 9/18/23, and a stage 2 pressure ulcer to the left lateral foot acquired in house on 9/4/23. On 9/21/23 at 1:16 PM, Resident #38 was observed lying in bed on his/her back with legs and knees facing the side wall. On 9/21/23 at 4:07 PM the surveyor walked into Resident #38 ' s room and asked GNA #30 if she could lift Resident #38 ' s sheet so the surveyor could see Resident #38 ' s feet. GNA #30 walked over and lifted Resident #38 ' s sheet and said, look at the way [he/she] was left. Resident #38 ' s diaper was saturated, and Resident #38 had bowel movement on the buttocks. Resident #38 ' s legs were contracted sideways. The resident ' s heels were not floated on pillows. There was no pillow between the knees. There was no padding around the ankle area as both legs and feet were touching each other. The resident was not on an air mattress. Resident #38 had been in the same position as when the surveyor observed the resident at 1:16 PM. Review of Resident #38 ' s care plan, resident is at risk for skin breakdown r/t decline in cognition, decline in mobility and ADL function documented interventions, Keep clean and dry as possible. Minimize skin exposure to moisture, Use under pads/briefs. Check q 2 hrs. and change prn for soiling. There were no interventions on the care plan about applying an air mattress to the bed, floating heels, placing a pillow between the knees to keep them from rubbing together or pillows between the ankles to keep them from rubbing together and having pressure on them. On 9/20/23 at 4:58 PM LPN # 31 was interviewed and said the resident was total care. LPN #31 stated that Resident #38 got changed at least twice per shift, maybe 3 times per shift if a heavy wetter. On 9/21/23 at 3:47 PM the DON was interviewed and stated when the family complained on 6/30/23 she immediately did a full body assessment. The DON stated that the spouse stated the resident had some sores and one on the heel and leg from when the resident fell before admission. The DON stated, during my assessment [Resident #38] did have the wounds and had a stage 2 on [his/her] sacrum. The one on the bottom was new. The DON stated, during a shift they should be checked and turned every 2 hours. Approximately every 2 to 2 ½ hours they should be checked. It should be 3 to 4 times. They should be checked more than twice. On 9/25/23 at 3:01 PM an interview was done with the wound care NP, Staff #36 who stated that the resident had multiple areas on the feet and heel that had resolved as of 9/25/23. Staff #36 stated that they classified the pressure ulcers as unavoidable as the resident has had a decline in general condition, was made palliative care and had overall weight loss. Staff #36 was asked if there was an air mattress on the bed and she said, no air mattress prior to now. When asked if there were pillows between the resident ' s contracted knees, Staff #36 stated, normally I do not see with pillows between the knees. Sometimes I do and sometimes I don ' t. Staff #36 stated she would expect the resident to be turned every 2 hours and the heels elevated. The surveyor asked Staff #36 if she would expect nursing measures for a susceptible resident to have pillows between the heels and ankles and to be on an air mattress and turned and repositioned every 2 hours. Staff #36 stated, yes. Staff #36 was asked how she could determine the pressure ulcers were unavoidable if nursing measures were observed not in place. Staff #36 did not answer. On 9/26/23 at 2:40 PM an interview was conducted with LPN #35. LPN #35 was asked about staffing on the dementia unit and her response was, we are usually short. The other day I had 1 GNA. We do as best as our ability allows, especially dealing with behaviors. Residents are supposed to be turned and repositioned every 2 hours, but if we don ' t have the staff, it is 2 times per shift. On 9/26/23 at 2:42 PM GNA #32 was interviewed and asked how often they check and change residents on the unit. GNA #2 stated, twice per shift. Staffing is awful. We have baths, rounding, charting, behaviors, and feeders. We try our best. 3) On 9/18/23 at 10:30 AM a review of complaint MD00194233 revealed an allegation that Resident #39 obtained a stage 4 pressure sore on the buttocks while in the facility. On 9/18/23 at 10:30 AM a review of Resident #39 ' s medical record revealed that the resident was initially admitted to the facility on [DATE] for rehabilitation. A 5/1/23 at 12:10 PM nursing note documented a new admission skin check was done from the wound care Nurse Practitioner (NP) which documented the resident had 2 scabs to the upper abdomen that were dry. There were no other noted skin alterations. The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident''s individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. Review of a 5/2/23 MDS note documented Resident #39 was extensive assistance with the help of 2 people for bed mobility on more than 1 or 2 occasions. According to the National Library of Medicine, The Braden Scale for Predicting Pressure Sore Risk was developed to foster early identification of patients at risk for forming pressure sores. The scale is composed of six subscales that reflect sensory perception, skin moisture, activity, mobility, friction and shear, and nutritional status. A score of 19 or higher is not at risk. A score of 15-18 is at risk, 13-14 is moderate risk, 10-12 is high risk and 9 or less is very high risk. A Braden scale was done on 5/8/23 and documented a score of 10 which indicated Resident #39 was at high risk to develop a pressure ulcer. A 6/7/23 note documented that Resident #39 was sent out to the hospital and a 6/9/23 note documented the resident returned on 6/9/23. There was no readmission assessment of the resident in the progress notes or under the assessments section of the medical record. There were no nursing notes after 6/9/23 until the next assessment which was on 6/11/23. There were no skin issues documented in that assessment. A review of the hospital Discharge summary dated [DATE] did not have any documentation of active skin issues. On 6/12/23 at 4:51 PM a wound assessment was done and revealed a Stage III pressure ulcer was discovered and it documented, present on admission. The pressure ulcer was 1.7 cm (centimeters) in length, 1.5 cm in width and 0.5 cm in depth. The note was documented by the Assistant Director of Nursing (ADON). Review of the June 2023 Treatment Administration Record (TAR) documented that a treatment to the pressure ulcer was not started until 6/15/23, 3 days after the pressure ulcer was found. On 6/19/23 at 3:37 PM the ADON documented the pressure ulcer was larger and the wound healing status was declining. The pressure ulcer was 5 cm. in length, 4 cm. in width. And 0.5 cm in depth. On 6/26/23 at 3:39 PM the ADON documented the pressure ulcer was now 9 cm. in length, 14 cm. in width and 0.5 cm in depth. The pressure ulcer was unstageable due to slough and necrotic tissue. On 6/26/23 at 10:28 AM a progress note documented, resident seen by wound NP (nurse practitioner) this morning. Sacrum wound worsening; area debrided at bedside by NP. Resident noted to feel warm to touch. VS (vital signs) taken by GNA, Temp 99.7. The resident was sent to the hospital and was admitted for sepsis. According to the Centers for Disease Control (CDC) sepsis is a life-threatening infection when an infection that someone already has triggers a chain reaction throughout the body. Continued review of the medical record revealed Resident #39 had precipitating risk factors for breakdown such as immobility, incontinence of bowel and bladder, albumin level of 1.9 (5/21/23 dietary note) (albumin is the most common protein found in the blood and is used by the body for growth and tissue repair. A normal albumin level is 3.4 to 5.4), chronic anemia, and frequent transfers to the hospital and physician ' s office via ambulance. Further review of the medical record demonstrated that the facility failed to put preventive measures in place to help reduce the risk of developing a pressure ulcer. The only intervention that was found was to elevate the heels. There was no turning and repositioning every 2 hours, no air mattress, no timing for changing of incontinence products. There was no altered skin/pressure ulcer care plan in place. On 9/26/23 at 7:22 AM the DON was interviewed and stated that Resident #39, eventually did get a pressure ulcer and I think it was in-house acquired initially but [he/she] was transferred back and forth to the hospital. Our wound team was seeing [him/her] and it was progressively getting worse. On 9/26/23 at 9:31 AM the ADON was interviewed and asked about the wound found on 6/12/23 as she was the one that documented on it in the medical record. The ADON stated she did not remember and that she just puts in what the wound nurse states. The ADON was asked about how they determined it was not a facility acquired pressure ulcer when there was no documentation that the resident was assessed on readmission to the facility on 6/9/23. When asked if there should have been a re-admission assessment, the ADON said yes. It was pointed out to the ADON that the treatment was not started on 6/12/23 when the pressure ulcer was found. The ADON stated, we would do the treatment that day but not do anything else until the wound NP would email the orders and that may be a couple of days. The ADON stated, she (NP) is on top of it now because she did wound rounds on Monday, and they received the orders by the end of day on Monday. On 9/26/23 at 12:40 PM the DON was asked about the nurses not doing a re-admission assessment when a resident comes back from the hospital. The DON stated, we have an admission checklist and admission observation which is a total history and complete physical. The DON acknowledged that it was not done. The DON stated, a lot of documentation stuff that has been missing that we are trying to improve on. The DON acknowledged there was no care plan for skin/pressure ulcer prevention and there was no documentation of turning and repositioning every 2 hours and any other preventive measures. The DON was also informed that physician documentation could not be found for the pressure ulcer. When asked if she expected the wound care provider or nurse to notify the attending physician, the DON stated, yes. 4) On 9/20/23 at 8:16 AM a review of Resident #23 ' s medical record revealed a 8/26/22 progress note that documented that Resident #23 had a history of a sacral ulcer. Review of Resident #23 's admission MDS with an assessment reference date of 8/26/22 documented that Resident #23 was extensive assistance for bed mobility and total dependence on staff for personal hygiene and bathing. The MDS also documented that there was impairment on the upper and lower extremities on one side. Review of the Braden Scale Risk Assessment for Resident #23 on 8/19/22 at 7:07 PM documented Resident #23 ' s score was 10 which put the resident in a high-risk category. Review of a 9/15/22 at 6:56 PM dietician note documented Resident #23 had lost 9.6 pounds in 1 month since admission. Review of a 10/9/22 at 12:17 PM progress note documented that an approximate 4 centimeter (cm) crescent shaped open area was noted to the resident ' s left buttocks area by the GNA during morning care. The note documented, wound bed noted to be red/white in color. Review of a 10/10/22 at 6:50 PM dietician note documented, nurse reported today that open skin area on buttock is pressure ulcer. Review of Resident #23 ' s care plans failed to produce a care plan for prevention of pressure ulcers even though it was documented that the resident had a history of a sacral ulcer. A care plan was not developed until 10/10/22, after a pressure ulcer was found. There was no evidence in the medical record that Resident #23 was turned and repositioned every 2 hours or that any interventions were put into place to prevent the development of pressure ulcers. On 9/26/23 at 2:42 PM an interview was conducted with GNA #32 who stated that the resident would scream when turned, did not roll, and pretty much laid in bed. When asked how often Resident #23 was turned and checked on she said that the resident was rounded on twice per shift. GNA #32 stated that staffing was a problem, and with only 2 GNAs on the unit they could not get to baths, rounding, and charting. 5) The facility staff failed to provide treatment for Resident #13 ' s sacral pressure ulcer and failed to complete a weekly skin assessment with measurements. Review of Resident #13 ' s medical record on 9/19/23 revealed the resident's admission assessment conducted on 5/19/22 revealed the Resident had a sacral pressure ulcer measuring 2.1 cm by .2 cm by .1 cm and was coded on the Resident's MDS (Minimum Data Set) admission assessment on 5/24/22 as a Stage III pressure ulcer. Review of the Resident #13 's May 2022 Treatment Administration Record revealed the facility staff failed to document any treatment provided to the sacral pressure ulcer until 5/26/22, 7 days after the Resident was admitted . Further review of Resident #13& #39's medical record revealed no weekly assessment of the Resident & #39's sacral pressure ulcer on 5/26/23. Weekly assessments of pressure ulcers allow the facility staff to determine if the treatment needs to be changed. Interview with the Director of Nursing on 9/19/23 at 1:45 PM confirmed the facility staff failed to document if the facility staff provided treatment to Resident #13''s sacral pressure ulcer from 5/19/22 until 5/26/22 and failed to do a weekly assessment of the pressure ulcer on 5/26/22. On 9/26/23 at 5:15 PM the surveyors expressed their concerns to the Nursing Home Administrator, Director of Nursing, and the Director of Clinical Services.