**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident #103 was admitted to the facility in August 2024 with diagnoses that include depression, diabetes, and pressure ulcer of the pressure region, unspecified. Review of Resident #103's Minimum Data Set (MDS) assessment dated [DATE] indicated one stage 3 and one stage 2 pressure ulcer that were present on admission. Review of Resident #103's most recent MDS Assessment, dated 11/12/24, indicated a Brief Interview for Mental Status score of 14 out of 15, indicating that the Resident is cognitively intact. The MDS further indicated that the Resident has a pressure ulcer/injury over a bony prominence and is at risk for developing pressure ulcers. Further, the MDS indicated one stage 4 pressure ulcer that was present on admission or reentry to the facility, indicating worsening of the buttock wound from previous MDS assessment. Review of Resident #103's Braden Scale for Predicting Pressure Score Risk, dated 8/21/24, indicated a risk score of 14 indicating moderate risk for skin breakdown. Review of Resident #103's Braden Scale for Predicting Pressure Score Risk, dated 9/4/24, 9/12/24 and 9/19/24 indicated a risk score of 15 indicating mild risk for skin breakdown. Review of initial admission paperwork dated August 2024 indicated wound care orders to cleanse buttock with sterile saline daily and apply alginate AG (a highly absorbent silver alginate dressing for moderately to heavily exuding wounds at-risk of infection) and foam. Review of the medical record indicated that the facility changed the recommended treatment orders on admission to the following: -Left/right buttocks, cleansed with wound cleanser, pat try, apply Manuka honey (a specialized honey used in wounds due to its antibacterial properties and tissue regeneration effects) and cover with 9x9 foam dressing every day for unstable wound, dated 8/21/24 and effective through 9/23/24. Review of the August 2024 Treatment Administration Record (TAR) indicated that the treatment to the buttock was not signed off as completed until 8/23/24. Review of the medical record failed to indicate daily buttock wound assessments were completed with dressing changes. Review of Resident #103's Wound Observation Tool, dated 8/21/24, indicated the following: Location: rt (right) buttock Type: Pressure Stage: Unstageable Specify: slough/eschar Overall Impression: First Observation, no reference Drainage amount: small Wound measurements: 5.0 x 5.0 centimeters (cm) with no depth No signs of infection Current Treatment plan: Manuka honey and foam dressing Review of a second Wound Observation Tool dated 8/21/24 indicated the following: Location: lt (left) buttock Type: Pressure Stage: Unstageable Specify: slough/eschar Overall Impression: First observation, no reference Drainage amount: small Wound measurements: 3.0 x 6.0 cm with 0.1 cm depth Current Treatment plan: Manuka honey and foam dressing Review of Resident #103's Wound Observation Tool, dated 8/28/24 indicated the following: Location: left and right buttock Type: Pressure Stage: Unstageable Specify: slough/eschar Overall Impression: Unchanged. Epithelial tissue present (pink), slough tissue present (yellow, tan, white, stringy). 75% slough in wound bed Drainage amount: moderate Wound measurements: 10 x 14 cm with 0.1 cm depth. Additional Comments: left and right buttocks wounds merged. Current Treatment Plan: Manuka honey and foam dressing MD (Medical Doctor) notified Review of the medical record failed to indicate any changes to Resident #103's wound treatment plan when the physician was notified that two buttock wounds merged to become one larger wound . Review of Resident #103's Wound Observation Tool, dated 9/11/24, indicated the following: Location: left and right buttock Overall Impression: Worsening. Granulation tissue present, slough and necrotic tissue present also. 94% slough in wound bed, 1% necrosis in wound bed. Drainage: large amount of purulent drainage Wound measurements: 8.8 x 9.6 cm with 0.1 cm depth Additional Comments: Left and right buttock wounds merged. Odor noted, redness surrounding, warm to touch, purulent drainage surrounding wound bed blistering, 1% necrotic between 11-12 o'clock and 5% granulation, rest of wound bed is slough. Infection: yes, redness surrounding, odor, purulent drainage, warm to touch Current Treatment: Manuka honey and foam dressing Physician notified on 9/11/24 Review of the medical record failed to indicate that changes were made to Resident #103's wound treatment plan when the physician was notified that the sacral wound had worsened and had signs and symptoms of infection including being warm to touch and having large amounts of purulent drainage. Review of the lab results since Resident #103's admission indicated admission labs drawn on 8/22/24 and no further labs drawn until 9/23/24, 12 days after nursing documented signs of infection in a buttock wound and notified the physician. Further review of the laboratory results indicated a white blood cell (WBC) count (a laboratory result used to determine presence of infection with normal results reading between 4 and 11) on admission of 10.1 and a result of 24.1 on 9/23/24, which could indicate infection. Review of a Nurse Practitioner (NP) Progress note dated, 9/12/24, indicated the following: 9/12/24: Patient seen today in follow-up of coccyx wounds, on assessment patient was in bed, wounds to coccyx area noted to have sloughy tissue scant amount of serosanguinous drainage and redness to surrounding area. Wounds appear to be getting worse, patient will be referred to wound clinic. Patient will continue with current medications and treatment plan. Review of Resident #103's medical record failed to indicate that prior to requiring hospitalization on 9/23/24 for a worsening buttock wound, the Resident had been referred to the wound clinic as indicated in the NP progress note dated 9/12/24. During an interview on 11/21/24 at 9:13 A.M., Unit Manager #1 and Unit Manager #2 said that they are the wound nurses at the facility. They said that Resident #103 was not referred and did not go to the wound clinic during his/her admission. Review of Physician's progress note dated 9/13/24 indicated the following: Follow-up for wound care and diabetes. Patient's decubitus ulcer was evaluated 2 days ago had significant sloughing and might benefit from debridement. Decubitus ulcer was examined at the bedside the patient has been getting saline debridement. Performed with nurse as she did before it is not worse if not slightly better. Further Review of Resident #103's progress notes indicated the following: -A physician's progress note dated 9/20/24 which indicated in part, the patient has had no recent labs. -A nursing progress note, dated 9/21/24 which indicated in part, while applying treatment to buttock it was noted resident has odor, warmth, redness, and slough was green to wound. On-call doctor notified and ordered stat labs . (10 days after the sacral wound was documented as having signs and symptoms of infection) -A nursing progress note dated 9/22/24 which indicated in part, wound dressing to coccyx this shift- areas present with significant redness, slough to open areas and purulent drainage. This writer called laboratory to revisit stat labs order placed on 9/21/24, stated nobody is available to come out today. On-call provider notified, instructed labs to be scheduled for tomorrow. -A physician's progress note dated 9/23/24 which indicated in part, Patient being seen in follow-up. Some concern that his coccygeal wound may have become more infected over the weekend. Patient was put in for labs currently blood pressure pulse stable no documented fever weights have been stable glycemic control has been stable await labs from today. Otherwise no chest pain shortness of breath fevers or chills specifically reported over the weekend significant redness. Sloughed open areas and purulent drainage. Labs came back with a white count going from 10-24 and a creatinine of 1.26-3.24. Looks that his decubitus ulcer is the redness had significantly expanded. I told the patient that he needed to go to the [emergency room] and he agreed. 9-23 patient clearly has sepsis from skin and soft tissue infection particularly with the end organ dysfunction from the elevated creatinine. He agrees to ER [sic] Review of the September 2024 TAR failed to indicate that the dressing change to buttocks was completed on 9/15/24, 9/17/24 and 9/19/24. Review of Nursing progress notes on 9/15/24, 9/17/24 and 9/19/24 also failed to indicate a dressing change was completed to Resident #103's buttocks. Review of the medical record indicated that the Resident was hospitalized from [DATE] through 11/6/24. Review of Resident #103's hospital Discharge summary, dated [DATE] indicated the following: -Patient was seen from nursing facility for ongoing sacral decubitus ulcers that were worsening. -Discharge Diagnoses included: Deep multiloculated (with many cavities) coccygeal decubitis ulcers with significant tissues loss probing to bone, creation of loop ileostomy for fecal diversion, VRE enterococcal sepsis from UTI (Urinary Tract Infection), acute on chronic anemia of chronic disease and could also be related to sepsis and increased depressive symptoms. -The Care Timeline indicated an incision and drainage of the sacral wound, followed by 5 further debridement treatments of the sacral wound, the need for ileostomy formation to divert stool away from the wound, and recommendations for negative pressure wound therapy upon readmission to the facility on [DATE]. Review of an Infectious Disease Follow up note dated 10/29/24 indicated the Resident with need to continue with long-term IV [intravenous] antibiotic therapy for osteomyelitis (a bone infection) from his/her wounds. Review of Resident #103's current active care plan indicated the following upon return from hospitalization: -The resident has Stage IV pressure ulcer on his sacrum r/t malnutrition, immobility, diabetes, dated 11/20/24. -The resident has osteomyelitis of his sacrum necessitating IV antibiotics., dated 11/20/24 - Ileostomy due to stage IV sacral wound and need for fecal diversion, initiated 11/6/24 and revision 11/20/24. Resident #103's medical record did not indicate that the Resident refused care or dressing changes. Review of Resident #103's Wound Observation Tool, dated 11/7/24, indicated the following: Location: sacrum Wound Measurements: 15 x 18 cm with depth of 5 cm. During an interview on 11/26/24 at 7:13 A.M., Nurse #2 said she admitted Resident #103 in August 2024, she said he/she came with treatment recommendations for his/her buttock wounds, but it was changed by the in house wound team on admission. Nurse #2 said that Resident #103's wound got worse, and it got worse fast following admission. Nurse #2 recalled the wound to be warm with redness and signs of infection. Nurse #2 felt like the treatment that was in place for the duration of Resident #103's first admission was not appropriate to continue for that long. Nurse #2 said that Resident #103 did not go to the wound clinic prior to his/her rehospitalization. Nurse #2 said wounds and wound management are a concern in the facility and one factor is that there is no wound doctor on staff to monitor the wounds. Nurse #2 said that a wound doctor monitoring the wounds may have prevented the progression and worsening of Resident #103's wounds. Nurse #2 said she has expressed concern with wound management in the facility before. Nurse #2 further said that if a resident comes into the facility with a wound or develops a wound in the facility she sees the wounds worsening, not generally improving. She said the wound team most often recommends Manuka honey as treatment for wounds and it is not always working for the wounds. During an interview on 11/21/24 at 9:13 A.M., Unit Manager #1 and Unit Manager #2 said that they are the wound nurses in the facility, and both are Licensed Practical Nurses. They said they took an online course through the facility and an online test which took approximately 8 hours total. They said once completed they are considered effective on their own for wound care in the facility. They said no one comes in or completes with them an in-person competency for wound care. Unit Manager #1 and Unit Manager #2 said that at this time they are the only ones rounding as the wound team on the wounds in the facility. Unit Manager #1 and Unit Manager #2 said that they observe the wounds weekly and make recommendations for treatments to the physician or nurse practitioner. Unit Manager #1 and Unit Manager #2 said they make their recommendations based of assessment of the wound. If the current treatment is working, then they will continue it but if it isn't working, the wound is stagnant or not changing or improving, then they will change the treatment. They said if they change a treatment recommendation, they do not specifically document why they are changing the treatment recommendations. Unit Manager #1 and Unit Manager #2 said that a worsening wound would be one with more drainage, redness, signs of infection, and would expect a dressing recommendation to change based on an assessment of a worsening wound as mentioned. When asked about referring residents to a wound clinic, they said they do not often refer residents to the wound clinic and manage them in house. They also said that in general they don't see wounds worsening in the facility or wound infections occurring. They said nurses on the floor should be documenting wound assessment on the TAR each time they complete the dressing. During an interview on 11/21/24 at 11:43 A.M., the Director of Nurses (DON) said that sometimes the wound nurses will go to her if they are having trouble determining if a wound is getting worse or looking infected. The DON also said the wound team could reach out to corporate support when there is a concern about a wound, this would be a phone call with verbal description given. The DON said she is not sure how frequently the physician or Nurse Practitioner are observing wounds but that she knows neither one is wound certified. The DON said that when the wound nurses' round, unless the wound has drastically worsened the recommendation would usually be to leave the current treatment in place, if there is no improvement, they may change the recommendation. Regarding referrals to the wound clinic if a recommendation is made, she would expect that an appointment is made, however, the facility has trouble getting transportation to and from appointments at this time. The DON said signs that a wound is infected would include redness, swelling, odor and drainage that is green or yellow. Regarding Resident #103, the DON said that on admission his/her treatment orders may have been changed due to formulary to a similar treatment. When asked if Alginate AG was similar to Manuka honey, she was unsure. When reviewing the Wound Observation Tool from 9/11/24 indicating signs of infection the DON said that the facility could have considered an alternate dressing at that time. The DON said that Resident #103 was eventually hospitalized for a worsening sacral wound and would have expected that if the Manuka honey was not working and there were documented signs of infection and worsening of the wound a new intervention or treatment should have been attempted. The DON continued to say she cannot say if a change would have made a significant different in the wound progression but that she would expect that with worsening or no improvement documented that something else would have been attempted. During an interview on 11/22/24 at 9:38 A.M., Physician #1 said that his expectation is that nurses who are competent in wound care perform wound rounds and make recommendations to him about what resident's need are and what residents he needs to visualize the wounds of himself. He said he is not a wound expert, and he relies on the wound team to be assessing and implementing the correct orders for wound management. Physician #1 said that he does not believe he is always notified when the wound team changes a treatment order for a resident. He said it is possible that with sooner action to Resident #103's wound worsening the need for hospitalization and ileostomy formation could have been prevented but he can't say with certainty. During an interview on 11/25/24 at 8:08 A.M., Nurse Practitioner (NP) #1 said that she has been involved in Resident #103's wound care in the facility. She said that treatment did not change because it was not draining a lot during his/her admission. NP #1 said that she did recommend having Resident #103 seen at the wound clinic, but was not aware that it was never implemented, or that the facility was having trouble with securing transportation to appointments. Upon discharge from the hospitalization from 9/23/24 - 11/6/24 for treatment of worsening and infected sacral wounds, Resident #103 had a scheduled appointment at the wound clinic on 11/21/24. Review of the office visit note from his/her visit on 11/21/24 indicated but was not limited to the following: The patient arrives to the clinic from [facility] by ambulance. [Doctor] was called upon the patient's arrival. When the blankets were pulled down a towel was placed on the patient's abdomen. He/She reports he/she has been having issues with leaking from his/her ileostomy site and they have been placing towels to absorb the watery stools. The appliance was completely filled. The medication list shows the patient has been receiving colace stool softener. [Doctor] reports he will contact the facility to change medications. The abdomen had dried and new watery stool everywhere. Upon removal of the Negative Pressure Wound Therapy (NPWT) dressing the foam that was applied within the wound was 2/3 the size of the wound and not sufficient enough to cover the wound bed. Once the granufoam was removed it was revealed the patient has been passing stool from his rectum which has been circulating throughout the wound due to the NPWT. [Doctor] reports he had not been contacted by the facility to be made aware of this new finding. The wound is now covered in 100% devitalized tissue of slough with malodorous seropurulent drainage. The wound clinic recommended stopping the NPWT and initiating a new treatment as follows: For the coccyx wound- cleanse with vashe (a wound cleanser containing Hypochlorous Acid: a molecule produced by the human body ' s own immune system when fighting harmful bacteria and infection). Apply drawtex (wound dressing that removes debris, exudate and bacteria from the wound surface), to the wound bed and cover with a foam dressing with adhesive border. Change every day and as needed. Review of the medical record indicated that the newly recommended treatment was initiated on 11/21/24 and then changed by the facility on 11/23/24 to cleanse with vashe apply aquacel Ag to wound bed, pack with drawtex, then cover with foam dressing with adhesive border daily and as needed. Review of progress notes failed to indicate a reason for changing the recommendations from the wound clinic and failed to indicate communication with the wound clinic about the changes. The facility neglected to respond to and make changes to the plan of care for Resident #103's sacral wound when on 9/11/24 it was documented as worsened and with signs and symptoms of infection including being warm to touch and having large amounts of purulent drainage. The facility also neglected to arrange for a wound clinic appointment as indicated in the NP progress note dated 9/12/24. Lastly, the facility failed to implement the treatment recommendations made regarding the sacral wound following the 11/21/24 wound clinic follow up. Refer to F686 2a. Resident #97 was admitted to the facility in October 2023 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, muscle weakness, dysphagia, cognitive communication deficit, and anxiety. Review of Resident #97's Minimum Data Set (MDS) assessment, dated 9/4/24, indicated that Resident #97 had severely impaired cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 0 out of 15, and is dependent on staff for all activities of daily living tasks. The MDS indicated Resident #97 was at risk for developing pressure injuries and indicated the use of a pressure reducing device for chair and pressure reducing device for bed. Review of Resident #97's Braden Scale for Predicting Pressure Injury Risk, dated 11/5/24, indicated a score of 11 indicating the Resident is at high risk for developing pressure injuries. Review of the initial admission paperwork from October 2023 indicated one R (right) medial foot blister surrounding skin red and blanching. Resident #97 was admitted to the facility in October 2023 and developed an unstageable right buttock wound on 11/22/23 and a Left Heel DTI on 11/28/23 with recommendations for heel booties. Review of the medical record failed to indicate physician treatment orders or care plan interventions were implemented. Review of Resident #97's Wound Observation Tool, dated 11/22/23, indicated: Right buttock Worsening, granulation tissue, slough tissue, necrotic Tissue present (eschar) present (brown, black, leather). Length 1.5cm. x Width 1.0cm. Depth 0.1cm. Encourage offloading. Treatment orders: Wound care to right buttocks. Clean with ns (NS), pat dry. Apply manuka honey to wound bed and cover with allevyn or equivalent foam dressing. Every day shift and as needed. Dated 11/22/23. Review of the physician progress note dated 11/24/23 indicated no skin rashes or pressure ulcers. Review of the November 2023 Treatment Administration Record (TAR) indicated that the physician order for manuka honey treatment to the right buttock was not documented until 11/24/23 and failed to indicate the treatment order was completed as ordered on 11/26/23, the TAR was left blank and contained no documentation. Review of the physician progress note dated 12/6/23 indicated, coccygeal ulcer with mild redness around it. Possible wound infection based on patient's decreased energy level and foul odor. During an interview on 11/22/24 at 9:36 A.M., Physician #1 (Also the facility Medical Director) said the right buttock wound is referenced as the coccygeal ulcer in the visit note. Review of the medical record indicated that on 12/6/23 the wound to the right buttock deteriorated and required antibiotic therapy and a physician order for Keflex (an antibiotic) 500 mg. (milligrams), 3 times per day for 7 days was ordered on 12/6/23. Further review of Resident #97's medical record indicated the following physician orders: -Wound care to right buttocks. Clean with ns (NS), pat dry. Apply Santyl (collagenase ointment for wounds) to wound bed and cover with allevyn (highly absorbent foam dressing) or equivalent foam dressing. Every day shift every other day and PRN (as needed). Dated 12/8/23. Review of the December 2023 Treatment Administration Record (TAR) indicated that the physician order for Santyl treatment to the right buttock was not documented as completed on 12/8, 12/11 or 12/13, the TAR was left blank and contained no documentation. Review of the Nurse Practitioner Progress note dated 12/12/23 indicated Resident #97's wound is not improving per wound team. Coccyx decubiti. No improvement with recent Keflex. Last dose will be 12/13/2023 continue wound team consult and daily dressings with Santyl for debridement. Review of the weekly wound observation tool dated 12/13/23, indicated the unstageable right buttock pressure wound was showing signs of infection with purulent drainage and order. Resident #97 was documented to have pain and was yelling out. Length 4.5 cm. x Width 1.5 cm. x Depth 1.5 cm. Slough, Eschar. Extent of necrosis is 80% thin light brown. Necrotic tissue peeling up from 4-8 o'clock. Thin light brown color. Red irritation/rash scattered around. Moderate serosanguineous drainage. Treatment in place: Wound care to buttocks. Clean with NS, pat dry. Apply Santyl to wound bed and cover with allevyn or equivalent foam dressing. Encourage offloading. MD not notified, not new area. The wound observation tool indicated the physician was not notified of the of the wound observation tool assessment on 12/13/23. Review of the care plan failed to indicated there was evidence that offloading of the coccyx wound was implemented. Review of Resident #97's medical record indicated he/she was hospitalized on [DATE] through 12/20/24 due to worsening mental status and fever. Review of the hospital Discharge summary dated [DATE] indicated the following: admitted for treatment of cellulitis at the sacral wound and osteonecrosis of the left femoral head. CT (Computed Tomography medical imaging scan) showing air in soft tissue of the right medial buttock consistent with sacral ulcer. Incidental finding of left hip avascular necrosis with mild degenerative change noted. Patient to follow-up with [NAME] wound care. Referral sent at discharge, please follow up for making and attendance to that appointment. Avoid direct pressure to the area, frequent pressure offloading. Discharge Wound Care Recommendations included: BID (twice daily) dressing changes. Santyl, Dakins (antiseptic solution used for wound cleaning) soaked wet to dry, cover with 4x 4 gauze. Turn q2h (every 2 hours) hob (head of bed) <30 (less than). No sitting in chair >1hr (greater than one hour) use cushion. Air mattress. Avoid direct pressure to the area, frequent pressure offloading. Review of the re-admission facility physician progress note dated 12/20/23, indicated: Patient hospitalized with fever, CT done which showed hematoma. MRI showed cellulitis but no osteomyelitis, had a bedside debridement by plastic surgery on December 17th. He/she is in for twice daily dressing changes with Dakin's. Osteonecrosis of the left femoral head. Further review of the medical record failed to indicate a physician treatment order for Santyl, Dakins soaked wet to dry, cover with 4 x 4 gauze was ordered, and contained no treatment documentation. Review of Resident #97's medical record failed to indicate that a follow up appointment at the wound clinic was arranged by facility staff. Review of Resident #97's skin integrity care plan dated 10/5/23, and last revised 9/18/24, indicated the following interventions: -Weekly skin checks -Treatments as ordered -Clean and dry skin after each incontinent episode. -Assess location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx of infection, maceration etc. to MD. -Follow facility protocols for treatment of injury. -Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Review of Resident #97's care plan failed to indicate the following interventions were implemented: heel booties, head of bed <30 degrees or less, no sitting in chair greater than one hour, use of cushion, and an air mattress. Review of Resident #97's Weekly Skin Integrity Data Collection form dated 12/21/23, indicated the following: Skin intact: No, discolorations scattered to bilateral arms, open coccyx wound, open left heel wound. DTI (Deep Tissue Injury) Left Heel dark purple boggy, no open areas, 5.5 cm diameter. NP and family notified. The medial record failed to indicate any assessment or measurement data on 12/21/23 related to the open coccyx wound. Review of the NP progress note dated 12/26/23, indicated: Sacral wound infection. Wound enlarging with increased yellow drainage. Painful on dressing change is now on scheduled Tylenol 1g 3 times a day and tramadol as needed. May need to schedule tramadol especially half hour before dressing change. Continue aggressive pain management continue twice a day sacral decubitus dressing changes. {SIC} Review of Resident #97's Wound Observation Tool, dated 12/27/23, indicated the following: - Worsening Right buttock Pressure Unstageable, Length 6.4 cm. x Width 7.0 cm. x Depth 2.5 cm. Slough, Eschar. Extent of necrosis is 50% thin light brown. Yes, Undermines at 5. Necrotic tissue peeling up from 4-8 o'clock. Thin light brown color. Red irritation/rash scattered around. Moderate serosanguineous drainage. Yes -signs of infection with purulent drainage and odor- not new onset. Yes- has pain, yelling out. MD not notified, not new area. Encourage offloading. Further review of the medical record failed to indicate Resident #97 had documented wound measurements assessed upon re-admission to the facility and indicated the first wound measurements did not occur until 12/27/23. Review of the nursing progress note dated 12/27/23, indicated: Patient sent to hospital via ambulance per NP orders for abnormal lab values, lethargy and question of decubiti infection. Resident #97 was admitted to the hospital from [DATE] - 2/7/23. Review of Resident #97's hospital Discharge summary dated [DATE] indicated he/she was admitted due to fever, hyponatremic secondary to dehydration and a Stage 4 infected sacral decubitus ulcer/Osteomyelitis and proteus mirabilis bacteremia. Patient underwent multiple courses of antibiotics with resolution of sepsis. During an interview on 11/21/24 at 10:17 A.M., Unit Manager #2 (one of the wound nurses) said Resident # 97 had a blister to the foot and needed interventions with an air mattress and heel booties because he/she is at high risk of developing pressure areas. Unit Manager #2 said the new pressure area to the lower back should have been reported, treatments updated and followed, and the infections should have been reported to the physician or NP. During an interview on 11/21/24 at 10:22 A.M., the Regional Director of Clinical Services said she would expect orders to be implemented on admission and care plan interventions updated. Infections should have been documented, treated and reported to the NP or physician when identified. The Regional Director of Clinical Services said I do not know how many wounds are currently in the building. In the past I have been a part of wounds but I can barely Stage a wound. We rely on the wound nurses to do that because they are the ones who are wound certified. During an interview on 11/21/24 at 11:58 A.M. the Director of Nursing (DON) said that she would expect wound treatment orders and recommendations to be followed and said care plan interventions should have been implemented on admission including turning and repositioning every 2 hours, use of a chair cushion, frequent offloading and an air mattress. The DON said Resident #97 was admitted as high risk for skin break down and said an air mattress and heel booties should have been ordered to prevent skin breakdown and said the care plan should have been implemented. During an interview on 11/21/24 at 12:45 P.M., the DON said staff will notify her if a wound is worsening or infected and said she will contact the Nurse Practitioner (NP), and make a referral for the resident to be seen at the outside wound clinic. During a follow up interview on 11/21/24 at 12:45 A.M., The DON said she was not aware of the wounds in the facility and said she would expect Resident #97 to be seen at the wound clinic for infected and worsening wounds. The DON said physician orders must be followed and said the order for Santyl with Dakins should have been implemented. The DON said green slough, redness, swelling warmth, odor are signs of infection and needs to be reported and assessed by the NP or MD. During an interview on 11/22/24 at 8:43 A.M., the Regional Director of Clinical Services said if residents are admitted from the hospital with wound orders, they need to be implemented by the physician[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #103 was admitted to the facility in August 2024 with diagnoses that include depression, diabetes, and pressure ulcer of the pressure region, unspecified. Review of Resident #103's Minimum Data Set (MDS) assessment dated [DATE] indicated one stage 3 and one stage 2 pressure ulcer that were present on admission. Review of Resident #103's most recent MDS Assessment, dated 11/12/24, indicated a Brief Interview for Mental Status score of 14 out of 15, indicating that the Resident is cognitively intact. The MDS further indicated that the Resident has a pressure ulcer/ injury over a bony prominence and is at risk for developing pressure ulcers. Further, the MDS indicated one stage 4 pressure ulcer that was present on admission or reentry to the facility. Review of Resident #103's Braden Scale for Predicting Pressure Sore Risk, dated 8/21/24, indicated a risk score of 14 indicating moderate risk for skin breakdown. Review of Resident #103's Braden Scale for Predicting Pressure Sore Risk, dated 9/4/24, 9/12/24 and 9/19/24 indicated a risk score of 15 indicating mild risk for skin breakdown. Review of initial admission paperwork from August 2024 indicated wound care orders to cleanse buttock with sterile saline daily and apply alginate AG (a highly absorbent silver alginate dressing for moderately to heavily exuding wounds at-risk of infection) and foam. Review of the medical record failed to indicate that this wound treatment was implemented while in the facility, and on the day of admission, the order was changed to indicate: -Left/right buttocks, cleansed with wound cleanser, pat try, apply Manuka honey (a specialized honey used in wounds due to its antibacterial properties and tissue regeneration effects) and cover with 9x9 foam dressing everyday for unstable wound, dated 8/21/24 and effective through 9/23/24. Review of the August 2024 Treatment Administration Record (TAR) indicated that the treatment to the buttock was not signed off as completed until 8/23/24. During an interview on 11/21/24 at 9:13 A.M., Unit Manager #1 and Unit Manager #2 said that nurses should document daily dressing changes on the TAR. They said the TAR gives you an assessment template to document a description of the drainage from the wound as well as appearance of wound bed among other things. Further review of Resident #103's TAR failed to indicate the assessment template for wound documentation had been implemented. Review of Resident #103's Wound Observation Tool, dated 8/21/24, indicated the following: Location: rt (right) buttock Type: Pressure Stage: Unstageable Specify: slough/ eschar Overall Impression: First Observation, no reference Drainage amount: small Wound measurements: 5.0 x 5.0 centimeters (cm) with no depth No signs of infection Current Treatment plan: Manuka honey and foam dressing Review of a second Wound Observation Tool dated 8/21/24 indicated the following: Location: lt (left) buttock Type: Pressure Stage: Unstageable Specify: slough/eschar Overall Impression: First observation, no reference Drainage amount: small Wound measurements: 3.0 x 6.0 cm with 0.1 cm depth Current Treatment plan: Manuka honey and foam dressing Review of Resident #103's Wound Observation Tool, dated 8/28/24 indicated the following: Location: left and right buttock Type: Pressure Stage: Unstageable Specify: slough/ eschar Overall Impression: Unchanged. Epithelial tissue present (pink), slough tissue present (yellow, tan, white, stringy). 75% slough in wound bed Drainage amount: moderate Wound measurements: 10 x 14 cm with 0.1 cm depth. Additional Comments: left and right buttocks wounds merged. Current Treatment Plan: Manuka honey and foam dressing The assessment indicated that the physician was notified Review of Resident #103's Wound Observation Tool, dated 9/4/24 indicated the following: Location: left and right buttock Type: Pressure Stage: Unstageable Specify: slough/ eschar Overall Impression: Improving. Slough tissue present, 75% slough in wound bed, Drainage Amount: moderate Wound measurements: 7.4 x 9.5 cm with 0.1 cm depth No signs of infection Current Treatment: Manuka honey and foam dressing Review of Resident #103's Wound Observation Tool, dated 9/11/24, indicated the following: Location: left and right buttock Overall Impression: Worsening. Granulation tissue present, slough and necrotic tissue present also. 94% slough in wound bed, 1% necrosis in wound bed. Drainage: large amount of purulent drainage Wound measurements: 8.8 x 9.6 cm with 0.1 cm depth Additional Comments: Left and right buttock wounds merged. Odor noted, redness surrounding, warm to touch, purulent drainage surrounding wound bed blistering, 1% necrotic between 11-12 o'clock and 5% granulation, rest of wound bed is slough. Infection: yes, redness surrounding, odor, purulent drainage, warm to touch Current Treatment: Manuka honey and foam dressing The assessment indicated that the physician was notified The surveyor requested all laboratory results during Resident #103's admission to the facility. Review of Laboratory results indicated admission labs drawn on 8/22/24 and no further labs drawn until 9/23/24, 12 days after nursing documented signs of infection in a buttock wound. Further review of the laboratory results indicated a white blood cell (WBC) count (a laboratory results used to determine presence of infection with normal results reading between 4 and 11) on admission of 10.1 and a result of 24.1 on 9/23/24. Review of a Nurse Practitioner Progress note dated, 9/12/24, indicated the following: 9/12/24: Patient seen today in follow-up of coccyx wounds, on assessment patient was in bed, wounds to coccyx area noted to have sloughy tissue scant amount of serosanguinous drainage and redness to surrounding area. Wounds appear to be getting worse, patient will be referred to wound clinic. Patient will continue with current medications and treatment plan. Review of the medical record failed to indicate that treatment was adjusted or changed to the buttock wound when on 9/11/24 it was documented as worsening and with signs and symptoms of infection. Review of Resident #103's medical record failed to indicate that an appointment at the wound clinic was arranged by facility staff as indicated in the Nurse Practitioner's progress note on 9/12/24. During an interview on 11/21/24 at 9:13 A.M., Unit Manager #1 and Unit Manager #2 said that they are the wound nurses at the facility. They said that Resident #103 was not referred and did not go to the wound clinic during his/her admission. Review of Physician's progress note dated 9/13/24 indicated the following: Follow-up for wound care and diabetes. Patient's decubitus ulcer was evaluated 2 days ago had significant sloughing and might benefit from debridement. Decubitus ulcer was examined at the bedside the patient has been getting saline debridement. Performed with nurse as she did before it is not worse if not slightly better. Further Review of Resident #103's progress notes indicated the following: -A physician's progress note dated 9/20/24 which indicated in part, the patient has had no recent labs. -A nursing progress note, dated 9/21/24 which indicated in part, while applying treatment to buttock it was noted resident has odor, warmth, redness, and slough was green to wound. On-call doctor notified and ordered stat labs. -A nursing progress note dated 9/22/24 which indicated in part, wound dressing to coccyx this shift- areas present with significant redness, slough to open areas and purulent drainage. This writer called laboratory to revisit stat labs order placed on 9/21/24, stated nobody is available to come out today. On-call provider notified, instructed labs to be scheduled for tomorrow. -A physician's progress note dated 9/23/24 which indicated in part, Patient being seen in follow-up. Some concern that his coccygeal wound may have become more infected over the weekend. Patient was put in for labs currently blood pressure pulse stable no documented fever weights have been stable glycemic control has been stable await labs from today Otherwise no chest pain shortness of breath fevers or chills specifically reported over the weekend significant redness. Sloughed open areas and purulent drainage. Labs came back with a white count going from 10-24 and a creatinine of 1.26-3.24. Looks that his decubitus ulcer is the redness had significantly expanded. I told the patient that he needed to go to the [emergency room] and he agreed. 9-23 patient clearly has sepsis from skin and soft tissue infection particularly with the end organ dysfunction from the elevated creatinine. He agrees to ER Review of the September 2024 TAR failed to indicate that the dressing change to buttocks was completed on 9/15/24, 9/17/24 and 9/19/24. Review of Nursing progress notes on 9/15/24, 9/17/24 and 9/19/24 also failed to indicate a dressing change was completed to Resident #103's buttocks. During an interview on 11/21/23 at 11:43 A.M., the Director of Nursing said that she would expect that STAT labs be completed within 4 hours of being ordered but said that there have been issues with that happening. Review of the medical record indicated that the Resident was hospitalized from [DATE] through 11/6/24. Review of Resident #103's hospital Discharge summary, dated [DATE] indicated the following: -Patient was seen from nursing facility for ongoing sacral decubitus ulcers that were worsening. -Discharge Diagnoses included: Deep multiloculated (with many cavities) coccygeal decubitis ulcers with significant tissues loss probing to bone, creation of loop ileostomy for fecal diversion, VRE enterococcal sepsis from UTI (Urinary Tract Infection), acute on chronic anemia of chronic disease and could also be related to sepsis and increased depressive symptoms. -The Care Timeline indicated an incision and drainage of the sacral wound, followed by 5 further debridement treatments of the sacral wound, the need for ileostomy formation to divert stool away from the wound, and recommendations for negative pressure wound therapy upon readmission to the facility on [DATE]. Review of an Infectious Disease Follow up note dated 10/29/24 indicated the Resident with need to continue with long-term IV [intravenous] antibiotic therapy for osteomyelitis (a bone infection) from his/her wounds. Review of Resident #103's current active care plan indicated the following upon return from hospitalization: -The resident has Stage IV pressure ulcer on his sacrum r/t malnutrition, immobility, diabetes, dated 11/20/24. -The resident has osteomyelitis of his sacrum necessitating IV antibiotics., dated 11/20/24 - Ileostomy due to stage IV sacral wound and need for fecal diversion, initiated 11/6/24 and revision 11/20/24. Review of Resident #103's care plan failed to indicate behaviors related to refusal of care or treatments. Review of Resident #103's Wound Observation Tool, dated 11/7/24, indicated the following: Wound Measurements: 15 x 18 cm with depth of 5 cm. During an interview on 11/26/24 at 7:13 A.M., Nurse #2 said she admitted Resident #103 in August 2024, she said he/she came with treatment recommendations for his/her buttock wounds, but it was changed by the wound team at admission. Nurse #2 said that Resident #103's wound got worse, and it got worse fast following admission. Nurse #2 recalled warmed and redness and signs of infection in the wound. Nurse #2 felt like the treatment that was in place for the duration of Resident #103's first admission was not appropriate to continue for that long. Nurse #2 said that Resident #103 did not go to the wound clinic prior to his/her rehospitalization. Nurse #2 said wounds and wound management are a concern in the facility and one factor is that there is no wound doctor on staff to monitor the wounds. Nurse #2 said that a wound doctor monitoring the wounds may have prevented the progression and worsening of Resident #103's wounds. Nurse #2 said she has expressed concern with wound management in the facility before. Nurse #2 further said that, generally speaking, if a resident comes into the facility with a wound or develops a wound in the facility she sees the wounds worsening, not generally improving. She said the wound team most often recommends Manuka honey as treatment for wounds and it is not always working for the wounds. During an interview on 11/21/24 at 9:13 A.M., Unit Manager (UM) #1 and Unit Manager #2 said that they are the wound nurses in the facility, and both are Licensed Practical Nurses. They said they took an online course through the facility and an online test which took approximately 8 hours total. They said once completed they are considered effective on their own for wound care in the facility. They said no one comes in or completes with them an in-person competency for wound care. UM #1 and UM#2 said that at this time they are the only ones rounding as the wound team on the wounds in the facility. UM #1 and UM #2 said that they observe the wounds weekly and make recommendations for treatments to the physician or nurse practitioner. UM #1 and UM #2 said they make their recommendations based of assessment of the wound. If the current treatment is working, then they will continue it but if it isn't working, the wound is stagnant or not changing or improving, then they will change the treatment. They said if they change a treatment recommendation, they do not specifically document why they are changing the treatment recommendations. UM #1 and UM #2 said that a worsening wound would be one with more drainage, redness, signs of infection, and would expect a dressing recommendation to change based on an assessment of a worsening wound as mentioned. When asked about referring residents to a wound clinic, they said they do not often refer residents to the wound clinic and manage them in house. They also said that in general they don't see wounds worsening in the facility or wound infections occurring. They said nurses on the floor should be documenting wound assessment on the TAR each time they complete the dressing. During an interview on 11/21/24 at 11:43 A.M., the Director of Nurses (DON) said that she is not part of the wound team who rounds weekly on wounds, and she has not completed the wound course that the wound nurses have completed. She said that sometimes the wound nurses will go to her if they are having trouble determining if a wound is getting worse or looking infected. The DON also said the wound team could reach out to corporate support when there is a concern about a wound, this would be a phone call with verbal description given. The DON said she is not sure how frequently the physician or Nurse Practitioner are observing wounds but that she knows neither one is wound certified. The DON said that when the wound nurses' round, unless the wound has drastically worsened the recommendation would usually be to leave the current treatment in place, if there is no improvement, they may change the recommendation. Regarding referrals to the wound clinic if a recommendation is made, she would expect that an appointment is made, however, the facility has trouble getting transportation to and from appointments at this time. The DON said signs that a wound is infected would include redness, swelling, odor and drainage that is green or yellow. Regarding Resident #103, the DON said that on admission his/her treatment orders may have been changed due to formulary to a similar treatment. When asked if Alginate AG was similar to Manuka honey, she was unsure. When reviewing the Wound Observation Tool from 9/11/24 indicating signs of infection the DON said that the facility could have considered an alternate dressing at that time. The DON said that Resident #103 was eventually hospitalized for a worsening sacral wound and would have expected that if the Manuka [NAME] was no working and there were documented sign of infection and worsening of the wound a new intervention or treatment should have been attempted, she said she cannot say if a change would have made a significant different in the wound progression but that she would expect that with worsening or no improvement documented that something else would have been attempted. During an interview on 11/22/24 at 8:43 A.M., the Regional Director of Clinical Services said that there is not as wound physician who currently rounds in the facility and up until three weeks ago, an Occupational Therapist who is also wound certified was rounding with the wound nurses on wounds but has since stopped. During an interview on 11/22/24 at 9:38 A.M., Physician #1 said that his expectation is that nurses who are competent in wound care perform wound rounds and make recommendations to him about what resident's need are and what residents he needs to visualize the wounds of himself. He said he is not a wound expert, and he relies on the wound team to be assessing and implementing the correct orders for wound management. Physician #1 said that he does not believe he is always notified when the wound team changes a treatment order for a resident. He said it is possible that with sooner action to Resident #103's wound worsening the need for hospitalization and ileostomy formation could have been prevented but he can't say with certainty. During an interview on 11/25/24 at 8:08 A.M., Nurse Practitioner (NP) #1 said that she has been involved in Resident #103's wound care in the facility. She said that treatment did not change because it was not draining a lot during his/her admission. NP #1 said that she did recommend to have Resident #103 seen at the wound clinic, but was not aware that it was never implemented, or that the facility was having trouble with securing transportation to appointments. Upon readmission to the facility Resident #103 had scheduled wound clinic appointment. Review of the office visit note from his/her visit on 11/21/24 indicated but was not limited to the following: The patient arrives to the clinic from [facility] by ambulance. [Doctor] was called upon the patient's arrival. When the blankets were pulled down a towel was placed on the patient's abdomen. He/She reports he/she has been having issues with leaking from his/her ileostomy site and they have been placing towels to absorb the watery stools. The appliance was completely filled. The medication list shows the patient has been receiving colace stool softener. [Doctor] reports he will contact the facility to change medications. The abdomen had dried and new water stool everywhere. Upon removal of the Negative Pressure Wound Therapy (NPWT) dressing the foam that was applied within the wound was 2/3 the size of the wound and not sufficient enough to cover the wound bed. Once the granufoam was removed it was revealed the patient has been passing stool from his rectum which has been circulating throughout the wound due to the NPWT. [Doctor] reports he had not been contacted by the facility to be made aware of this new finding. The wound is now covered in 100% devitalized tissue of slough with malodorous seropurulent drainage. The wound clinic recommended stopping the NPWT and initiating a new treatment as follows: For the coccyx wound- cleanse with vashe. Apply drawtex to the wound bed and cover with a foam dressing with adhesive border. Change every day and as needed. Review of the medical record indicated that the newly recommended treatment was initiated on 11/21/24 and then changed by the facility on 11/23/24 to cleanse with vashe, apply aquacel Ag to wound bed, pack with drawtex, then cover with foam dressing with adhesive border daily and as needed. Review of progress notes failed to indicate a reason for changing the recommendations from the wound clinic. 3a. Resident #97 was admitted to the facility in October 2023 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, muscle weakness, dysphagia, cognitive communication deficit, and anxiety. Review of Resident #97's Minimum Data Set (MDS) assessment, dated 9/4/24, indicated that Resident #97 had severely impaired cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 0 out of 15, and is dependent on staff for all activities of daily living tasks. The MDS indicated Resident #97 was at risk for developing pressure injuries and indicated the use of a pressure reducing device for chair and pressure reducing device for bed. Review of Resident #97's Braden Scale for Predicting Pressure Injury Risk, dated 11/5/24, indicated a score of 11 indicating the Resident is at high risk for developing pressure injuries. Review of the initial admission paperwork from October 2023 indicated one R (right) medial foot blister surrounding skin red and blanching. Resident #97 was admitted to the facility in October 2023 and developed an unstageable right buttock wound on 11/22/23 and a left heel DTI (deep tissue injury) on 11/28/23 with recommendations for heel booties. Review of the medical record failed to indicate a physician treatment orders or care plan interventions were implemented. Review of Resident #97's Wound Observation Tool, dated 11/22/23, indicated: Right buttock Worsening, granulation tissue, slough tissue, necrotic Tissue present (eschar) present (brown, black, leather). Length 1.5cm. x Width 1.0cm. Depth 0.1cm. Surrounding tissue macerated. Encourage offloading. Review of Resident #97's medical record indicated the following physician orders: -Wound care to right buttocks. Clean with ns (NS), pat dry. Apply manuka honey to wound bed and cover with allevyn or equivalent foam dressing. Every day shift and as needed. Dated 11/22/23. Review of the physician progress note dated 11/24/23 indicated no skin rashes or pressure ulcers. Review of the November 2023 Treatment Administration Record (TAR) indicated that the physician order for manuka honey treatment to the right buttock was not documented until 11/24/23 and failed to indicate the treatment order was completed as ordered on 11/26/23, the TAR was left blank and contained no documentation. Review of the physician progress note dated 12/6/23 indicated, coccygeal ulcer with mild redness around it. Possible wound infection based on patient's decreased energy level and foul odor. During an interview on 11/22/24 at 9:36 A.M., Physician #1 (Also functions as the Medical Director) said the right buttock wound is referenced as the coccygeal ulcer in the visit note. Review of the medical record indicated that on 12/6/23 the wound to the right buttock deteriorated and required antibiotic therapy and a physician's order for Keflex 500 mg (milligrams), 3 times per day for 7 days was ordered on 12/6/23. Further review of Resident #97's medical record indicated the following physician orders: -Wound care to right buttocks. Clean with ns (normal saline), pat dry. Apply Santyl (collagenase ointment for wounds) to wound bed and cover with allevyn (highly absorbent foam dressing) or equivalent foam dressing. Every day shift every other day and PRN (as needed). Dated 12/8/23. Review of the December 2023 Treatment Administration Record (TAR) indicated that the physician order for Santyl treatment to the right buttock was not documented as completed on 12/8, 12/11 or 12/13, the TAR was left blank and contained no documentation. Review of Resident #97's risk for skin integrity care plan dated 10/5/23, and last revised 9/18/24, indicated the following interventions: -Weekly skin checks -Treatments as ordered -Clean and dry skin after each incontinent episode. -Assess location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx (signs/symptoms) of infection, maceration etc. to MD. -Follow facility protocols for treatment of injury. -Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Review of the Nurse Practitioner Progress note dated 12/12/23 indicated Resident #97's wound is not improving per wound team. Coccyx decubiti. No improvement with recent Keflex. Last dose will be 12/13/2023. Continue wound team consult and daily dressings with Santyl for debridement. Review of the physician orders failed to indicate a physician order for daily dressing changes with Santyl. Resident #97's treatment order is every day shift every other day and PRN. Review of the weekly wound observation tool dated 12/13/23, indicated the unstageable right buttock pressure wound was showing signs of infection with purulent drainage and order. Resident #97 was documented to have pain and was yelling out. Length 4.5cm. x Width 1.5cm. x Depth 1.5cm. Slough, Eschar. Extent of necrosis is 80% thin light brown. Necrotic tissue peeling up from 4-8 o'clock. Thin light brown color. Red irritation/rash scattered around. Moderate serosanguineous drainage. Interventions - pre medicate. Wound care to buttocks. Clean with NS, pat dry. Apply Santyl to wound bed and cover with allevyn or equivalent foam dressing. Encourage offloading. MD not notified, not new area. Review of the wound observation tool indicated the physician was not notified of the assessment on 12/13/23 indicating signs of infection with purulent drainage and odor. Review of the care plan failed to indicate offloading was added to the care plan. Review of the nursing progress note dated 12/14/23, indicated, This writer Notified NP (Nurse Practitioner) that resident was continuing to have a decreased appetite, decreased level of awake time, decreased calling out, and ability to tolerate being out of bed for long periods of time, even after finishing a course of ABX (antibiotic) for a wound infection. NP stated to get labs. Labs were drawn, resident did not open his/her eyes or yell out during lab draw. This writer went in to assess the patient and give medications. Resident opened his/her eyes for a second when his/her name was called but would not stay awake. Resident unable to take meds due to decreased level of alertness. Resident noted to have a respiratory rate of 15 with 20-30 second periods of apnea, an apical heart rate of 113 with bounding beats, oxygen saturation rate bounced from 88-93 based on apneic periods, manual BP (blood pressure) was 152/94, noted to be clammy with a rectal temperature of 103.2. NP notified of changes, recommended to send to ER [SIC] (emergency room) for evaluation Review of Resident #97's medical record indicated he/she was hospitalized on [DATE] to 12/20/23 due to worsening mental status and fever. Review of the hospital Discharge summary dated [DATE] indicated the following: admitted for treatment of cellulitis at the sacral wound and osteonecrosis of the left femoral head. CT (Computed Tomography medical imaging scan) showing air in soft tissue of the right medial buttock consistent with sacral ulcer. Incidental finding of left hip avascular necrosis with mild degenerative change noted. Patient to follow-up with [NAME] wound care. Referral sent at discharge, please follow up for making and attendance to that appointment. Avoid direct pressure to the area, frequent pressure offloading. Discharge Wound Care Recommendations included: BID (twice daily) dressing changes. Santyl, Dakins (antiseptic solution used for wound cleaning) soaked wet to dry, cover with 4x 4 gauze. Turn q2h (every 2 hours) hob (head of bed) <30 (less than). No sitting in chair >1hr (greater than one hour) use cushion. Air mattress. Avoid direct pressure to the area, frequent pressure offloading. Review of the re-admission facility physician progress note dated 12/20/23, indicated: Patient hospitalized with fever, CT done which showed hematoma. MRI showed cellulitis but no osteomyelitis, had a bedside debridement by plastic surgery on December 17th. He/she is in for twice daily dressing changes with Dakin's. Osteonecrosis of the left femoral head. Review of the medical record failed to indicate hospital discharge wound clinic follow up recommendations were implemented. Further review of the medical record failed to indicate a physician treatment order for Santyl, Dakins soaked wet to dry, cover with 4 x 4 gauze was ordered, and contained no treatment documentation. Further review of Resident #97's medical record indicated the following physician orders: -Wound care to sacrum. Clean with NS, pat dry. Apply Santyl to wound bed and cover with allevyn or equivalent form dressing every day and evening shift. Dated 12/20/23. -Santyl Ointment 250 UNIT/GM (Collagenase). Apply to sacrum topically every day and evening shift for wound care. Dated 12/20/23. Review of Resident #97's re-admission care plan failed to indicate care plan interventions were updated and did not include heel booties, turning and repositioning every two hours, head of bed <30 degrees or less, no sitting in chair greater than one hour, use of cushion, and an air mattress. Review of the medical record failed to indicate hospital discharge wound clinic follow up recommendations were implemented and did not include a physician treatment order for Santyl, Dakins soaked wet to dry, cover with 4 x 4 gauze. Further review of the medical record failed to indicate an order for an air mattress. Review of Resident #97's Weekly Skin Integrity Data Collection form dated 12/21/23, indicated the following: Skin intact: No, discolorations scattered to bilateral arms, open coccyx wound, open left heel wound. DTI Left Heel dark purple boggy, no open areas, 5.5cm diameter. NP and family notified. Review of the NP progress note dated 12/26/23, indicated: Sacral wound infection. Wound enlarging with increased yellow drainage. Painful on dressing change is now on scheduled Tylenol 1g (gram), 3 times a day and tramadol as needed. May need to schedule tramadol especially half hour before dressing change. Continue aggressive pain management continue twice a day sacral decubitus dressing changes. CMP (comprehensive metabolic panel- set of blood samples) in AM. Review of Resident #97's medical record failed to indicate that an appointment at the wound clinic was arranged by facility staff. Review of Resident #97's Wound Observation Tool, dated 12/27/23, indicated the following: - Worsening Right buttock Pressure Unstageable, Length 6.4cm. x Width 7.0cm. x Depth 2.5cm. Slough, Eschar. Extent of necrosis is 50% thin light brown. Yes, Undermines at 5. Necrotic tissue peeling up from 4-8oclock. Thin light brown color. Red irritation/rash scattered around. Moderate serosanguineous drainage. Yes -signs of infection with purulent drainage and odor- not new onset. Yes- has pain, yelling out. Interventions - pre medicate. Wound care to buttocks. Clean with NS, pat dry. Wound care to right buttocks. Clean with ns, pat dry. Aquacel (sterile foam dressing) to wound bed and cover with allevyn or equivalent foam dressing. Encourage offloading. MD not notified, not new area. Further review of the medical record failed to indicate Resident #97 had documented wound measurements assessed upon re-admission to the facility and indicated the first wound measurements did not occur until 12/27/23. Review of the nursing progress note dated 12/27/23, indicated: Patient sent to hospital via ambulance per NP orders for abnormal lab values, lethargy and question of decubiti infection. Resident #97 was hospitalized from [DATE] - 2/7/23. Review of Resident #97's hospital Discharge summary dated [DATE] indicated he/she was admitted due to fever, hyponatremic secondary to dehydration and a Stage 4 infected sacral decubitus ulcer/Osteomyelitis and proteus mirabilis bacteremia. Patient underwent multiple courses of antibiotics with resolution of sepsis. Review of the facility re-admission physician progress note dated

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, staff education review, and Facility Assessment review, the facility failed to ensure the nursing staff were trained and demonstrated the competencies and skill sets necessary to provide the level and types of care and services needed as outlined in the Facility Assessment. Specifically, the facility failed to: 1. Ensure the licensed nursing staff were trained and demonstrated competency to identify, assess, evaluate, intervene, and respond to a significant change in condition of a wound, for four Residents (#264, #97, #60, #103), out of a total sample of 30 Residents. 2. Ensure that 31 out of 36 staff education records reviewed, had completed education and competencies and were completed and documented annually, per the Facility Assessment. As a result of these failures, three Residents (#264, #97, #60, and #103) developed pressure injuries that worsened, became infected, required hospitalization, required intravenous antibiotics with surgical intervention and for one of the three Residents, resulted in death. Findings include: 1. According to the Board of Registration in Nursing, 244 CMR 9.00 &10.00: Standards of Conduct, Definitions and Severability; a competency is defined as the application of knowledge and the use of affective, cognitive, and psychomotor skills required for the role of a nurse licensed by the Board and for the delivery of safe nursing care in accordance with accepted standards of practice. Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. Competency in skills and techniques necessary to care for residents' needs includes but is not limited to competencies and training in areas as indicated in the facility assessment: - Activities of Daily Living: Bathing, showers, oral/denture care, dressing, eating, support with needs related to hearing/vision/sensory impairment, supporting resident independence in doing as much of these activities by himself/herself. - Mobility and fall/fall with injury prevention: Transfers, ambulation, restorative nursing, contracture prevention/care, supporting resident independence in doing as much of these activities by him or herself. - Bowel/bladder: Bowel/bladder toileting programs, incontinence prevention and care, intermittent or indwelling or other urinary catheter, ostomy, responding to requests for assistance to the bathroom/toilet promptly in order to maintain continence, and promote resident dignity. - Skin Integrity: Pressure injury prevention and care, skin care, wound care, surgical and other skin wounds. - Infection Prevention and Control: Identification and containment of infections, prevention of infections. - Management of Medical Conditions: Assessment, early in identification of problem/deterioration, management of medical and psychiatric symptoms and conditions such as heart failure, diabetes, chronic obstructive pulmonary disease (COPD), gastroenteritis, infections such as UTI and gastroenteritis, pneumonia, hypothyroidism. - Nutrition: Individualized dietary requirements, liberalized diets, specialized diets, IV nutrition, tube feeding, cultural or ethnic dietary needs, assistive devices, fluid monitoring or restrictions, hypodermoclysis. Review of the Facility Assessment, dated as reviewed with the QAPI committee, in [DATE], indicated the following: - Part 1 Facility Profile Wound Care Manual Annual Review Date [DATE] - Part 5 Training and Competencies Competent Support and Care for our Resident Population Every Day and During Emergencies: Infection control - a facility must include as part of its infection prevention and control program mandatory training that includes written standards, policies, and procedures for the program. Identification of resident changes in condition, including how to identify medical issues appropriately, how to determine if symptoms represent problems in need of intervention, how to identify when medical interventions are causing rather than helping relieve suffering and improve quality of life. All staff during orientation, annually and as needed. Competency: Person Centered Care Resident Assessment Medication Administration - Part 6- Facility Resources- Medical Equipment Low-air Loss Mattress. Required -Yes. Wound Vac-. Required - No. - Part 7- Healthcare Related Contracts, [NAME], or Other Agreements. Medical Director Contract Working with Medical Practitioners Describe your plan to recruit and retain enough medical practitioners e.g., physicians, nurse practitioners) who are adequately trained and knowledgeable in the care of your resident/patients, including how you will collaborate with them to ensure the facility has appropriate medical practices for the needs and scope of your population: - The facility is in contract with Post Acute EMS which provides the facility with medical practitioners 5 days a week on-site and on call services. Describe how the management and staff familiarize themselves with what they should expect from the medical practitioners and other healthcare professionals related to standards of care and competencies that are necessary to provide the level and type of support and care needed for your resident population. For example, do you share expectations from providers that see residents in your nursing home on the use of standards, protocols, or other information developed by your medical director? Do you have discussions on what providers and staff expect of each other in terms of the care delivery process and clinical reasoning essential to providing high quality? - Management team and staff are well trained on long term care/skilled nursing facility regulations. The staff have opened dialogue with medical practitioners about residents' current needs and how prescribed interventions are working for the resident, or not providing the desired outcomes. The medical directors oversight and attendance at monthly QAPI provides a platform for discussion of trends and patterns. Describe process for overseeing these services and how those services will meet resident needs and regulatory, operational, maintenance, and staff training requirements. - Clinical outcomes are measured and tracked at the monthly QAPI meeting. Policies and procedures are updated as needed according to regulatory requirements and are reviewed by the IDT on an annual basis or as needed. List health information technology resources such as systems for electronically managing patient records and electronically sharing information with other organizations. - The electronic health record the facility uses are Point Click Care (medical and administrative) and Optima/Net Health (therapy). The facility also utilizes hardware such as laptops, Wi-Fi servers, telephones, iPads, fax. The facility failed to provide training and demonstrated competency in Quality of Care related to wound treatment orders. Skin Integrity: Pressure injury prevention and care, skin care, wound care, surgical and other skin wounds. Resident #264 developed multiple pressure ulcers at the facility, specifically a sacral pressure ulcer that worsened in presentation of size and symptoms of infection which included gangrene and necrosis. The wound worsened at the facility despite being treated with antibiotics for multiple infections and eventually required hospitalization on [DATE] where the Resident underwent surgical debridement due to osteomyelitis of the coccygeal and ultimately died on [DATE] as a result of neglect. Resident #97 developed a Stage 4 pressure injury to the sacrum resulting in the development of osteomyelitis requiring antibiotics treatment, surgical debridement, and multiple hospitalizations. Resident #97 then developed one Deep Tissue Injury, and failed to arrange a wound clinic follow up for deteriorating wounds. Resident #60, developed a Stage 3 pressure injury to the lower back requiring antibiotic treatment and hospitalization, and failed to respond to and implement new interventions when Resident #60 developed a Stage 2 pressure injury to the right buttock, Stage 1 pressure injury to the right lateral foot, Unstageable DTI to the right outer calf, Unstageable DTI to the right heel, and failed to arrange a wound clinic follow up as indicated by the Physician. Resident #103 was admitted with a sacral pressure ulcer wound that worsened in the facility. Despite documentation of a worsening wound and signs of infection in the wound, treatment and interventions in the place for the wound remained the same, eventually resulting in hospitalization from [DATE] through [DATE] for worsening wounds, treatment with intravenous (IV) antibiotics and multiple surgical debridements for osteomyelitis (A bone infection) and the need for ileostomy formation for fecal diversion away from the wound. Resident #103 was discharged back to the facility with Negative Pressure Wound Therapy (a medical technique used to accelerate wound healing by applying negative pressure to the wound site) for wound management. 2. Review of 18 personnel files of actively working clinical nursing staff in the facility on [DATE] and [DATE] indicated the facility failed to conduct training that included an evaluation of demonstrated competencies necessary to provide the level and types of care needed for the resident population as required per the facility assessment. Further review of the education files indicated licensed clinical staff did not have the necessary skills and competency to evaluate, document, or recognize a change in condition related to skin integrity and proper wound management. Review of 31 out of 36 licensed nurses working in the facility, educational records failed to indicate competencies were completed, per the Facility Assessment. Competencies reviewed included Skin and Wound Care. There was no documented evidence that licensed clinical staff had the required clinical training or that competencies were completed as indicated in the facility assessment. Review of the Facility Wound Care Manual - Life Care Center Wound Care Tool Box, indicated the following: CWC-Certified Wound Care Champion The Facility's Wound Care Program utilized professional standards from both organizations, the NPIAP (National Pressure Injury Advisory Panel) and WOCN (wound, ostomy, and continence nurse), and has developed a national wound certification and credentialed program designed as CWC (Certified Wound Care-Champions). The certification program is accredited by ANCC (American Nurses Credentialing Center) and consists of five plus hours of didactic lesson with knowledge validation of online examination. Awards 7 CE's (continuing education) for nursing and may be accepted for Therapy. Competency and skills is validated on site in simulated or resident care situations. The facility failed to ensure clinical competency was demonstrated as indicated in per the facility assessment and Wound Care Manual. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, indicated: Title: Accepting, Verifying, Transcribing and Implementing Prescriber Orders According to The Massachusetts Board of Registration in Nursing (Board) is created and authorized by Massachusetts General Laws (M.G.L.) c. 13, §§ 13, 14, 14A, 15 and 15D, and M.G.L. c. 112, §§ 74 through 81C to protect the health, safety, and welfare of the citizens of the Commonwealth through the regulation of nursing practice and education. In addition, M.G.L. c. 30A, § 8 authorizes the Board to make advisory rulings with respect to the applicability to any person, property or state of facts of any statute or regulation enforced or administered by the Board. Each nurse is required to practice in accordance with accepted standards of practice and is responsible and accountable for his or her nursing judgments, actions, and competency. The Board's regulation at 244 CMR 9.03(6) requires all nurses to comply with any other law and regulation related to licensure and practice. -The nurse is accountable for ensuring that any orders he or she implements are reasonable based on the nurse's knowledge of that particular patient's care needs at that time and must also ensure that the orders (whether written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) originate from an authorized prescriber, pursuant to established protocols of the organization. - It is not within the scope of Licensed Practical or Registered Nurse practice to alter or change the directions provided for in orders from a duly authorized prescriber. Licensed nurses are not authorized to prescribe, renew/refill, or extend a prescription that has expired prior to receipt of an order from duly authorized prescriber. Standing Order / Protocol: Standing orders/protocols include written authorization from a duly authorized prescriber that indicates evidence based practice standards for a specific medication or activity to be implemented by the nurse. Standing orders/protocols are applicable to a specific patient or specific situation and directions remain consistent during implementation. Standing orders / protocols cannot authorize the nurse to: -alter the standing order / protocol once initiated (e.g., independently initiate new medications); -determine choice of intervention based upon a menu of medications, dosing instructions or actions; and/or -prescribe, renew/refill, or extend a prescription that has expired. In 3.04(1): A licensed practical nurse bears full responsibility for the quality of health care she or he provides to patients or health care consumers. (2) A licensed practical nurse participates in direct and indirect nursing care, health maintenance, teaching, counseling, collaborative planning and rehabilitation, to the extent of his or her generic and continuing education and experience in order to: (a) assess an individual's basic health status, records and related health data; (b) participate in analyzing and interpreting said recorded data, and making informed judgments as to the specific elements of nursing care mandated by a particular situation; (c) participate in planning and implementing nursing intervention, including appropriate health care components in nursing care plans that take account of the most recent advancements and current knowledge in the field; (d) incorporate the prescribed medical regimen into the nursing plan of care; (e) participate in the health teaching required by the individual and family so as to maintain an optimal level of health care; (f) when appropriate, evaluate outcomes of basic nursing intervention and initiate or encourage change in plans of care; and (g) collaborate, cooperate and communicate with other health care providers to ensure quality and continuity of care. During an interview on [DATE] at 11:42 A.M., The Director of Nurses (DON) said the facility has two Licensed Practical Nurses (LPN) with wound certification and said clinical demonstrated competency is required after the Wound Tool 7 hour certification course (The facility's wound care program which provides staff the title of Certified Wound Care-Champion). The DON said all staff upon hire and annually must have clinical wound competencies completed. The DON said the LPN's (wound nurses) manage weekly wound rounds and collect assessment data. The DON said the facility does not have anyone to interpret data and no other clinical oversight of the wound program and said they did have a Registered Nurse on the team but she left four months ago. The DON said clinical competency is provided by the Staff Development Coordinator (SDC) and said it is the expectation for all nurses to have training and clinical wound competency upon hire and annually. During a follow up interview on [DATE] at 12:33 P.M., the DON said she is made aware of infections and worsening wounds and said if a wound looks infected, the wound nurses will update the physician. The DON said, I had concerns with wounds, and I had the infection preventionist do oversight with the wound team and other staff because we had residents hospitalized with infections. The DON continued to say she did not complete the seven hour wound training certification and said just the two nurses are certified in the facility. The DON said the facility follows the Wound Care Manual - Life Care Center Wound Tool Box and staff complete training and wound competencies following this program. Review of the education files for two out of two designated wound nurses indicated there was no documented evidence that competencies were completed as indicated in the Wound Care Manual - Life Care Center Wound Tool Box. Unit Manager #1 had documented Certified Skin Champion certificate on file dated [DATE] but failed to complete the required clinical competency for skills validation. Unit Manager #2 had documented Certified Skin Champion certificate on file dated [DATE] but failed to complete the required clinical competency for skills validation. Further review of the education files indicated Unit Manager #1 and Unit Manager #2 were Licensed Practical Nurses. During an interview on [DATE] 8:43 A.M., Regional Director of Clinical Services said the facility's philosophy is to have wound certified nurses and rehabilitation person in the building and said they have two wound nurses that are LPNs. The Regional Director of Clinical Services said the LPN's can assess wounds because it is within the nurse practice act for the state of Massachusetts. The Regional Director of Clinical Services said wound nurses need to complete and pass the seven hour facility wound care certification course and have clinical competency to assess the wounds. The Regional Director of Clinical Services said nursing staff must have training and clinical competency to do wound care upon hire and annually said nurses can reach out to her and the DON with wound questions. The Regional Director of Clinical Services said the wound tool box protocol should be followed and said a competency is required after completion of the online course. During an interview on [DATE] at 1:38 P.M., Staff Development Coordinator (SDC) said, she manages the orientation process and reviews a nursing checkoff list verbally to ensure staff are competent. The SDC said not everyone will have a hands-on nursing competencies and said she will verbalize what needs to be done. The SDC said she will sign off the competency packet before they work on the unit but she will not complete the hands on competency with each nurse, she will verbalize only. The SDC continued to say she started working in the facility four months ago and said a lot of competencies were not done for a lot of clinical staff so she was playing catch up. During an interview on [DATE] 8:56 A.M., Unit Manager #1 said she took an online wound course and said she is one of the certified wound nurses who completes weekly wound rounds. Unit Manager #1 said each unit follows the Wound Tool Box and said she will assess and document the healing progress and said if a wound is not improving or is getting infected, the wound nurses will use their professional judgement for new treatment options and run it by the doctor, and he usually approves it. Unit Manager #1 said she did not complete a wound competency after the online course in person or in a simulated setting. During an interview on [DATE] at 9:14 A.M. Unit Manager #2 said she completed the online wound course and is one of the wound nurses who conducts weekly wound rounds in the facility. Unit Manager #2 said she and the other wound nurse will give wound recommendations based on the training and seminars and enter new treatment orders based off what they see during wound rounds. Unit Manager #2 said up until recently I did not know how to stage wounds. Unit Manager #2 said once the course is completed the wound nurses were effective on their own and said no one completed an in person competency or observation during any wound rounds. Unit Manager #2 said she did not complete a wound competency after the online course in person or in a simulated setting. During an interview on [DATE] at 9:38 A.M., Physician #1 (who is also the Medical Director of the facility) said he does not visualize many wounds and said if the wound nurses tell him a wound is getting worse, the wound nurses put in new treatments. Physician #1 said I let them decide. I do not know what they order, they are the wound team. I do not know about wounds. Physician #1 continued to say I feel they can accurately assess them. They determine what is needed and put orders in. I don't review the orders they put in. Physician #1 said he expects the wound team to be certified and competent in wounds and said I don't know the rules for what certification is needed. I am assuming the facility takes care of that and they are competent in their wound skills as wound certified nurse's doing the wound rounds. During a follow up interview on [DATE] at 10:16 A.M., Physician #1 said I am not a wound care expert and he is really relying on the wound care team to utilize the best treatment option. During an interview on [DATE] at 9:20 A.M., The Nursing Home Administrator said it is her expectation that clinical staff have the necessary training and clinical competencies per the facility assessment, to care for the residents in the facility and the wound team has been reconstructed and educated on wound care tool box. During an interview on [DATE] at 10:12 A.M., with the Nursing Home Administrator, Director of Nurses (DON) and Regional Director of Clinical Services said staff competencies are based off the requirements outlined in the facility assessment and it is the expectation upon hire and annually that staff have training and competencies completed. The DON said all Nurses must have clinical competencies completed upon hire and annually to assess and provide care. During an interview on [DATE] at 10:50 A.M., the Massachusetts Board of Registration in Nursing said Licensed Practical (LPN) Nurses can function independently, however a Registered Nurse (RN) is responsible for a systemic evaluation and the LPN at a minimum must have documented training and demonstrated clinical competency in wound care. LPN, although bearing full responsibility, does not bear ultimate responsibility. LPN regulations under 3.04, the word participate is used. The RN bears the ultimate responsibility for the quality of nursing care he or she provides to individuals and groups. Although the LPN works under his or her own license and bears responsibility and accountability for their judgments and actions, the RN would need to be involved in the aspects outlined in 3.02 (2) and 3.04 (2). Refer to F686, F835, F837, and F841

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure it was administrated in a manner that enabled the facility to ensure that systems were in place to provide competent clinical care and clinical oversight for the treatment to prevent the development and worsening of pressure injuries. Specifically, the facility administrator failed to: 1. Provide nursing staff education, training and competencies to demonstrate competency in providing safe and effective wound care management. 2. Identify concerns outlined by the Medical Director in the Quality Assurance and Performance Improvement (QAPI) program related to documentation, wound dressings, lab services and wound staging and documentation. 3. Implement an effective wound care program that is supervised by a physician for pressure ulcer (wounds that occur when the skin and tissue are damaged by prolonged pressure, usually on bony areas like the hips, heels, or elbows) prevention and care per the Facility Assessment Tool. As a result of these failures, three Residents (#264, #97, #103) developed pressure injuries that worsened, became infected, required hospitalization, required intravenous antibiotics with surgical intervention and for one of the three Residents, resulted in death. Findings include: During the survey process it was identified that the Administration's failure to perform wound care competencies for nursing staff that were delegated to assume the responsibilities of wound care management resulted in a failure to perform skin checks and wound evaluations, implement physician orders, updated the physician and plan of care when significant changes occurred, and the development of a stage 4 pressure ulcer with purulent drainage and odor. Review of the Facility Assessment Tool, dated and revised [DATE], as reviewed with the QAPI committee, indicated the facility last reviewed the Wound Care Manuel on [DATE]. The section Action needed by committee to ensure policies meet professional standards for the Wound Care Manuel was blank. Further review of the Facility Assessment Tool under the section Services and Care We Offer Based on our Residents' Needs indicated the following: - General Care: Skin Integrity - Specific Care of Practices: Pressure injury prevention and care, skin care, wound care (surgical, other skin wounds). - Is the facility able to perform all care activities mentioning in column B (General Care: Skin Integrity): Yes The Facility Assessment Tool continues to say that the facility employs a Wound Care Nurse for each of the three Resident units in the facility. The staffing data for the Wound Care Nurse position is blank for all three units outlined. 1. The facility failed to provide nursing staff guidance in which staff are expected to demonstrate competency with the activities listed in the training requirements for effective wound care management. According to the Board of Registration in Nursing, 244 CMR 9.00 &10.00: Standards of Conduct, Definitions and Severability; a competency is defined as the application of knowledge and the use of affective, cognitive, and psychomotor skills required for the role of a nurse licensed by the Board and for the delivery of safe nursing care in accordance with accepted standards of practice. Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. Review of 18 personnel files of actively working clinical nursing staff in the facility on [DATE] and [DATE] indicated the facility failed to conduct training that included an evaluation of demonstrated competencies necessary to provide the level and types of care needed for the resident population as required per the facility assessment. Further review of the education files indicated licensed clinical staff did not have the necessary skills to evaluate, document, or recognize a change in condition related to skin integrity and proper wound management. Review of 31 out of 36 licensed nurses working in the facility, educational records failed to indicate competencies were completed, per the Facility Assessment. Competencies reviewed included Skin and Wound Care. There was no documented evidence that licensed clinical staff had the required clinical training or that competencies were completed as indicated in the facility assessment. Review of 18 personnel files of actively working clinical nursing staff in the facility on [DATE] and [DATE] indicated the facility failed to conduct training that included an evaluation of demonstrated competencies necessary to provide the level and types of care needed for the resident population as required per the facility assessment. Further review of the education files indicated licensed clinical staff did not have the necessary skills to evaluate, document, or recognize a change in condition related to skin integrity and proper wound management. Review of 31 out of 36 licensed nurses working in the facility, educational records failed to indicate competencies were completed, per the Facility Assessment. Competencies reviewed included Skin and Wound Care. There was no documented evidence that licensed clinical staff had the required clinical training or that competencies were completed as indicated in the facility assessment. Review of the education files for two out of two designated wound nurses indicated there was no documented evidence that competencies were completed as indicated in the Wound Care Manual - Life Care Center Wound Tool Box. Unit Manager #1 had documented Certified Skin Champion certificate on file dated [DATE] but failed to complete the required clinical competency for skills validation. Unit Manager #2 had documented Certified Skin Champion certificate on file dated [DATE] but failed to complete the required clinical competency for skills validation. During an interview on [DATE] at 1:38 P.M., Staff Development Coordinator (SDC) said, she manages the orientation process and reviews a nursing checkoff list verbally to ensure staff are competent. The SDC said not everyone will have hands-on nursing competencies and said she will verbalize what needs to be done. The SDC said she will sign off the competency packet before they work on the unit, but she will not complete the hands on competency with each nurse, she will verbalize only. The SDC said she started working in the facility four months ago and said a lot of competencies were not done for a lot of clinical staff, so she was playing catch up. The SDC did not observe nursing staff completing the neccessary skills to perform clinical nursing care as it relates to wound management and pressure ulcers, therefore was unable to ensure the competencies were demonstrated effectively. During an interview on [DATE] at 9:20 A.M., The Nursing Home Administrator said it is her expectation that clinical staff have the necessary training and clinical competencies per the facility assessment, to care for the residents in the facility and the wound team has been educated on wound care tool box (a wound care manual developed by the facility used for wound care treatment). During an interview on [DATE] at 10:12 A.M., the Nursing Home Administrator, Director of Nurses (DON) and Regional Director of Clinical Services said staff competencies are based off the requirements outlined in the facility assessment and it is the expectation upon hire and annually that staff have training and competencies completed. The DON said all Nurses must have clinical competencies completed upon hire and annually to assess and provide care. 2. Review of the facility policy titled QAPI - Program Design and Scope, dated and revised [DATE], last reviewed [DATE], indicated the following: Policy: - The facility will have a QAPI program that is ongoing, comprehensive and capable of addressing the full range of care and services it provides. - At a minimum, the QAPI program will: - Address all systems of care and management practices - Include clinical care, quality of life and resident choice - Utilize the best available evidence to define measure indicators of quality and facility goals that reflect the processes of care and facility operations that have been shown to be predictive of desired outcomes for residents - Reflect the complexities, unique care and services that the facility provides. Procedure: - The facility will ensure QAPI programs address systems of care and management practices. Systems of care are the processes in place to achieve an expected clinical outcome. For example, the system for prevention of pressure ulcers also involves the system for ensuring adequate nutrition, as well was the systems for identification of changes in condition and infection prevention. Review of the facility policy titled Quality Assurance & Performance Improvement (QAPI) Plan for the Facility 2024 signed by the Facility Executive Director on [DATE] and the Medical Director on [DATE] indicated the following: - Purpose: The QAPI program is to utilize an ongoing, data driven, proactive approach to advance the quality if life and quality of care for all residents at our facility. QAPI principles will drive our facility decisions to promote excellence in all resident and staff-related areas. All facility associates will be encouraged to be involved in identifying opportunities for improvement, partake in QAPI teams, imbed QAPI activities in all core processes and providing ongoing feedback. - Governance and Leadership: The governing body is ultimately responsible for overseeing the QAPI Committee. The Executive Director has direct oversight responsibility for all functions of the QAPI committee and reports directly to the governing body. The QAPI Committee, which includes the medical director, is ultimately responsible for assuring compliance with federal and state requirements and continuous improvement in quality of care and customer satisfaction. Review of the facility's QAPI plan indicated monthly documentation titled Medical Director Oversight Committee (MDOC) Meeting Minutes completed by the Medical Director of the facility which included the following discussion points: - Dated and signed by the Medical Director and Executive Director [DATE]: - Based on the topics reviewed in QAPI, are there additional quality of care areas that should be reviewed? This was checked yes with the following documentation Assessment documentation, communication, timely intervention. - Are there any compliance or regulatory concerns? This was checked yes with the following documentation Documentation. - Are there any opportunities or changes needed to education programs for staff? This was checked yes with the following documentation orientation enhancement. - Are there any issues based on consultant reports (pharmacy, nutrition, wound), this was check off yes with the following documentation Dressings & compliance. - Dated and signed by the Medical Director and Executive Director on [DATE]: - Based on the topics reviewed in QAPI, are there additional quality of care areas that should be reviewed? This was checked yes with the following documentation Lab services. - Are there any opportunities or changes needed to education programs for staff? This was checked yes with the following documentation documentation. - Any concerns with Event Management Program (e.g. incident reports, falls, skin tears)? This was checked yes with the following documentation thoroughness of investigation and immediate implementation of new interventions. - Dated and signed by the Medical Director and Executive Director on [DATE]: - Are there any issues based on consultant reports (pharmacy, nutrition, wound)? This was checked yes with the following documentation Wounds - staging, documentation. - Any concerns with Event Management Program (e.g. incident reports, falls, skin tears)? This was checked yes with the following documentation need improved detail and investigation root cause. Further review of the MDOC Meeting Minutes failed to indicate that any of the areas that were checked off as yes were addressed through the QAPI process to indicate that the facility developed, implemented, and maintained a comprehensive QAPI plan when these concerns were identified. During an interview on [DATE] at 10:49 A.M., the Nursing Home Administrator (NHA) said she has noticed trends with wounds in the facility. During an interview on [DATE] at 11:43 A.M., with the NHA, the QAPI program was Reviewed. The NHA said she looks for patterns and trends of what is going on in the facility for what to include in QAPI to improve the quality of the facility. The NHA said any plans that are put in place as a result of QAPI are monitored over time to see what is effective and if they are not improving we discuss as a team. The NHA did not mention that wound care has been a part of QAPI this year. The NHA continued to say the facility's wound nurses have not been a part of QAPI. The surveyor showed the NHA the Medical Director Oversight Committee (MDOC) Meeting Minutes that was in the QAPI plan. When asked if there has been any follow up to the identified concerns, especially related to wounds in the facility, the NHA said no and the Medical Director's concerns should have been addressed with follow up QAPI plans. The surveyor asked the NHA if there was any other documentation in the QAPI plan related to pressure ulcers or skin wounds and the NHA said there was not. The surveyor reviewed the QAPI plan and did not identify any information related to wounds including the identification of a problem or any improvement activities. 3. According to the Mayo Clinic, complications and outcomes of Stage 4 pressure ulcers include: - Osteomyelitis, which is characterized by a mixture of inflammatory cells, fibrosis, bone necrosis, and new bone formation. It is associated with nonhealing wounds, surgical flap complications, and an increased length of hospitalization. It may develop within the first 2 weeks of pressure ulcer formation and despite treatment may require amputation in lower extremity cases. - Joint infections (septic arthritis) can damage cartilage and tissue. - Bone infections (osteomyelitis) can reduce the function of joints and limbs. - Long-term, nonhealing wounds can develop into a type of squamous cell carcinoma. - Sepsis (blood infection). During Resident #264, #97 and #103's stay in the facility, the Administrator failed to ensure that the physician provided oversight to ensure the appropriateness and quality of medically related care and recommendations made by facility staff were provided to the residents which resulted in worsening pressure wounds which further resulted in hospitalization, osteomyelitis, and for one resident, death. Resident #264 developed multiple pressure ulcers at the facility, specifically a sacral pressure ulcer that worsened in presentation of size and symptoms of infection which included gangrene and necrosis. The wound worsened at the facility despite being treated with antibiotics for multiple infections and eventually required hospitalization on [DATE] where the Resident underwent surgical debridement due to osteomyelitis of the coccygeal and ultimately died on [DATE] as a result of neglect. Resident #97 developed a Stage 4 pressure injury to the sacrum and development of osteomyelitis requiring antibiotics treatment, surgical debridement, and multiple hospitalizations. Resident #97 then developed two Stage 2 pressure injuries, one Deep Tissue Injury, and failed to arrange a wound clinic follow up for deteriorating wounds. Resident #103 was admitted with a sacral pressure ulcer wound that worsened in the facility. Despite documentation of a worsening wound and signs of infection in the wound, treatment and interventions in the place for the wound remained the same, eventually resulting in hospitalization from [DATE] through [DATE] for worsening wounds, treatment with intravenous (IV) antibiotics for osteomyelitis (A bone infection), and the need for ileostomy formation for fecal diversion away from the wound. Resident #103 was discharged back to the facility with Negative Pressure Wound Therapy (a medical technique used to accelerate wound healing by applying negative pressure to the wound site) for wound management. During an interview on [DATE] at 8:43 A.M., the Regional Director of Clinical Services said that there is not a wound physician who currently rounds in the facility. During an interview on [DATE] at 9:38 A.M., Physician #1 said that his expectation is that nurses who are competent in wound care perform wound rounds and make recommendations to him about what resident's need are and what residents he needs to visualize the wounds of himself. He said he is not a wound expert, and he relies on the wound team to be assessing and implementing the correct orders for wound management. Physician #1 said that he does not believe he is always notified when the wound team changes a treatment order for a resident. He said it is possible that with sooner action to Resident #103's wound worsening the need for hospitalization and ileostomy formation could have been prevented but he can't say with certainty. For Resident #264, Physician #1 said he treated the Resident with multiple courses of antibiotics. He said if the wound got bigger with slough, systemic fever the resident would have been sent to the hospital for debridement. He said Resident #264 should have been sent to the hospital sooner. For Resident #97, Physician #1 said he/she was treated with antibiotics at the end of December but he/she probably should have gone out sooner to the wound clinic for debridement and said he goes by what the wound nurses tell him and he was not aware of the situation as he did not visualize the wounds during that time. During a follow up interview on [DATE] at 10:16 A.M., Physician #1 said, I am not a wound care expert and he is really relying on the wound care team to utilize the best treatment option. During an interview on [DATE] at 11:43 A.M., the NHA said she should have addressed the physician's concerns regarding wound care that he mentioned in QAPI. Refer to F837

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and the Facility Assessment, the facility failed to ensure the Governing Body provided oversight and accountability for quality of care related to comprehensive wound care management. Specifically: 1. The Governing Body failed to ensure the facility provided consistent and effective nursing staff education and training to provide competent quality of care and effective wound care management as outlined per the Facility Assessment. 2. The Governing Body failed to ensure the facility had implemented an effective wound care program that is supervised by a physician for pressure ulcer (wounds that occur when the skin and tissue are damaged by prolonged pressure, usually on bony areas like the hips, heels, or elbows) prevention and care. As a result of these failures, three Residents (#264, #97, #103) developed pressure injuries that worsened, became infected, required hospitalization, required intravenous antibiotics with surgical intervention and for one of the three Residents, resulted in death. Findings include: Review of the facility policy titled QAPI - Program Design and Scope, revised [DATE], last reviewed [DATE], indicated the following: - The authority for the planning and implementation of the Quality Assurance Performance Improvement (QAPI) program is delegated by the Board of Directors to the Divisional/Regional teams and the Executive Director at the facility. - The Executive Director assumes responsibility for the implementation and coordination of the Quality Assessment and Assurance (QAA) activities as defined in the facility's QAPI plan. The QAPI program is designed to sustain during times of transitions in leadership or staffing. - The Executive Director will assure the QAPI plan is reviewed annually by the QAA Committee. The QAA committee will make any necessary revision to the plan on an ongoing basis as indicated. Any changes to the plan will be communicated to the residents/patients, families, and associates through meetings and other means that are agreed upon by the QAA committee as they occur. Review of the facility policy titled Governing Body, revised [DATE], last reviewed [DATE], indicated the following: - Policy: The facility has an active (engaged and involved) governing body that is responsible for establishing and implementing policies regarding the management of the facility. - At least quarterly or more often if needed, the Executive Director reports to the governing body including, how the governing body responds back to the Executive Director and what specific types of problems and information (i.e., survey results, allegations of abuse or neglect, complaints, etc.) are reported or not reported directly to the governing body. - The Executive Director is held accountable and reports information about the facility's management and operation (i.e., audits, budgets, staffing, supplies, etc.) which is reviewed during facility visits from the regional/division team. 1. Review of the Facility Assessment Template, dated and last revised [DATE] included but was not limited to the following: Persons involved in completing the facility assessment: Executive Director (Nursing Home Administrator), Director of Nursing, Medical Director, Regional [NAME] President and the Regional Director of Clinical Services. - Review of the Facility Assessment Tool indicated the facility last reviewed the Wound Care Manuel on [DATE]. The section Action needed by committee to ensure policies meet professional standards for the Wound Care Manuel was blank. Further review of the Facility Assessment Tool under the section Services and Care We Offer Based on our Residents' Needs indicated the following: - General Care: Skin Integrity - Specific Care of Practices: Pressure injury prevention and care, skin care, wound care (surgical, other skin wounds). - Is the facility able to perform all care activities mentioning in column B (General Care: Skin Integrity): Yes The Facility Assessment Tool continues to say that the facility employs a Wound Care Nurse for each of the three Resident units in the facility. The staffing data for the Wound Care Nurse position is blank for all three units outlined. - Under the section Competent Support and Care for our Resident Population Every Day and During Emergencies: - Topic: Identification of resident changes in condition, including how to identify medical issues appropriately, how to determine if symptoms represent problems in need of intervention, how to identify when medical interventions are causing [sic] rather than helping relieve suffering and improve quality of life. - Which Staff are Training and what frequency: Direct care staff during orientation, annually and as needed. Under the section Working with Medical Practitioners, indicated the following: - the management team and staff are well trained on long term care/skilled nursing facility regulations. The staff have an open dialogue with medical practitioners about residents' current needs and how prescribed interventions are working for the resident, or not providing the desired outcomes. The medical director's oversight and attendance at monthly QAPI provides a platform for discussion of trends and patterns. - clinical outcomes are measured and tracked at the monthly QAPI meeting. Policies and procedures are updated as needed according to regulatory requirements and are viewed by the IDT on an annual basis or as needed. Review of the Facility Wound Care Manual - Life Care Center Wound Care Tool Box, indicated the following: CWC-Certified Wound Care Champion - The Facility's Wound Care Program utilized professional standards from both organizations, the NPIAP (National Pressure Injury Advisory Panel) and WOCN (wound, ostomy, and continence nurse), and has developed a national wound certification and credentialed program designed as CWC (Certified Wound Care-Champions). The certification program is accredited by ANCC (American Nurses Credentialing Center) and consists of five plus hours of didactic lesson with knowledge validation of online examination. Awards 7 CE's (continuing educations) for nursing and may be accepted for Therapy. Competency and skills is validated on site in simulated or resident care situations. Review of 18 personnel files of actively working clinical nursing staff in the facility on [DATE] and [DATE] indicated the facility failed to conduct training that included an evaluation of demonstrated competencies necessary to provide the level and types of care needed for the resident population as required per the facility assessment. Further review of the education files indicated licensed clinical staff did not have the necessary skills to evaluate, document, or recognize a change in condition related to skin integrity and proper wound management. Review of 31 out of 36 licensed nurses working in the facility, educational records failed to indicate competencies were completed, per the Facility Assessment. Competencies reviewed included Skin and Wound Care. There was no documented evidence that licensed clinical staff had the required clinical training or that competencies were completed as indicated in the facility assessment. During an interview on [DATE] at 9:20 A.M., The Nursing Home Administrator said it is her expectation that clinical staff have the necessary training and clinical competencies per the facility assessment, to care for the residents in the facility and the wound team has been educated on the facility's wound care toolbox (a wound care manual developed by the facility used for wound care treatment). During an interview on [DATE] at 8:43 A.M., the Regional Director of Clinical Services said we have a QAPI process for the wounds in the facility and the wound nurses provide data for QAPI and it allows us to track what is going on in the facility. The Regional Director of Clinical Services continued to say QAPI is the biggest tool for monitoring wound progress and treatment, she said she does not attend QAPI, but she will review QAPI discussions after the fact. During an interview on [DATE] at 10:12 A.M. with the Regional Director of Clinical Services, the Director of Nursing (DON) and the Nursing Home Administrator (NHA) they said the Governing Body is very involved in the building. The DON said if concerns are identified through the QAPI process the facility would do their part in the building and if they feel like they need more support whether it is equipment or something else they would reach out to the Governing Body. Additionally, they said staff competencies are based off the requirements outlined in the facility assessment and it is the expectation upon hire and annually that staff have training and competencies completed. The DON said all nurses must have clinical competencies completed upon hire and annually to assess and provide care. During an interview on [DATE] at 10:45 A.M., the Director of Nursing said the governing body of the facility is involved with wound care in the facility and if there were any issues, we would identify them in QAPI and make a plan from the results. During an interview on [DATE] at 10:49 A.M., the Nursing Home Administrator (NHA) said she has noticed trends with wounds in the facility. During an interview on [DATE] at 11:43 A.M., with the NHA, the QAPI program was reviewed. The NHA said she looks for patterns and trends of what is going on in the facility for what to include in QAPI to improve the quality of the facility. The NHA said any plans that are put in place as a result of QAPI are monitored over time to see what is effective and if they are not improving, we discuss as a team and these results should be in the QAPI plan. When asked what has the facility been working on this part year for QAPI the NHA did not mention that wound care has been a part of QAPI this year. The NHA continued to say the facility's wound nurses have not been a part of QAPI. The surveyor and the NHA reviewed the attendance sheets for each month of QAPI and the wound care nurses were not in attendance. The surveyor showed the NHA the Medical Director Oversight Committee (MDOC) Meeting Minutes that was in the QAPI plan. When asked if there has been any follow up to the identified concerns, especially related to wounds in the facility, the NHA said no, and the Medical Director's concerns should have been addressed with follow up QAPI plans. The surveyor asked the NHA if there was any other documentation in the QAPI plan related to pressure ulcers or skin wounds and the NHA said there was not. The surveyor reviewed the QAPI plan and did not identify any information related to wounds including the identification of a problem or any improvement activities. 2. According to the Mayo Clinic, complications and outcomes of Stage 4 pressure ulcers include: - Osteomyelitis, which is characterized by a mixture of inflammatory cells, fibrosis, bone necrosis, and new bone formation. It is associated with nonhealing wounds, surgical flap complications, and an increased length of hospitalization. It may develop within the first 2 weeks of pressure ulcer formation and despite treatment may require amputation in lower extremity cases. - Joint infections (septic arthritis) can damage cartilage and tissue. - Bone infections (osteomyelitis) can reduce the function of joints and limbs. - Long-term, nonhealing wounds can develop into a type of squamous cell carcinoma. - Sepsis (blood infection). During Resident #264, #97 and #103's stay in the facility, the Governing Body failed to ensure that the facility and physician provided oversight to ensure the appropriateness and quality of medically related care and recommendations made by facility staff were provided to the residents which resulted in worsening pressure wounds which further resulted in hospitalization, osteomyelitis, and for one resident, death. Resident #264 developed multiple pressure ulcers at the facility, specifically a sacral pressure ulcer that worsened in presentation of size and symptoms of infection which included gangrene and necrosis. The wound worsened at the facility despite being treated with antibiotics for multiple infections and eventually required hospitalization on [DATE] where the Resident underwent surgical debridement due to osteomyelitis of the coccygeal and ultimately died on [DATE] as a result of neglect. Resident #97 developed a Stage 4 pressure injury to the sacrum and development of osteomyelitis requiring antibiotics treatment, surgical debridement, and multiple hospitalizations. Resident #97 then developed two Stage 2 pressure injuries, one Deep Tissue Injury, and failed to arrange a wound clinic follow up for deteriorating wounds. Resident #103 was admitted with a sacral pressure ulcer wound that worsened in the facility. Despite documentation of a worsening wound and signs of infection in the wound, treatment and interventions in place for the wound remained the same, eventually resulting in hospitalization from [DATE] through [DATE] for worsening wounds, treatment with intravenous (IV) antibiotics and surgical debridement for osteomyelitis (A bone infection), and the need for ileostomy formation for fecal diversion away from the wound. Resident #103 was discharged back to the facility with Negative Pressure Wound Therapy (a medical technique used to accelerate wound healing by applying negative pressure to the wound site) for wound management. During an interview on [DATE] at 10:34 A.M., the Regional Director of Clinical Services said Residents with wounds can be sent out to a wound clinic if needed but transportation has been an issue lately. She continued to say the Physician or Nurse Practitioner will look at the wounds if needed. During an interview on [DATE] at 11:43 A.M., the Director of Nurses said if a recommendation is made to be seen in the wound clinic, she would expect that an appointment is made, however, the facility has trouble getting transportation to and from appointments at this time. During an interview on [DATE] at 8:43 A.M., the Regional Director of Clinical Services said that there is not a wound physician who currently rounds in the facility. She continued to say transportation has been an issue and if needed, the facility has an affiliation with doctor who specializes in wounds, but he has not come to the facility. She then said the facility does not have any contracts with outside wound companies. During an interview on [DATE] at 9:38 A.M., Physician #1 said that his expectation is that nurses who are competent in wound care perform wound rounds and make recommendations to him about what resident's need are and what residents he needs to visualize the wounds of himself. He said he is not a wound expert, and he relies on the wound team to be assessing and implementing the correct orders for wound management. Physician #1 said that he does not believe he is always notified when the wound team changes a treatment order for a resident. He said it is possible that with sooner action to Resident #103's wound worsening the need for hospitalization and ileostomy formation could have been prevented but he can't say with certainty. For Resident #264, Physician #1 said he treated the Resident with multiple courses of antibiotics. He said if the wound got bigger with slough, systemic fever the resident would have been sent to the hospital for debridement. He said Resident #264 should have been sent to the hospital sooner. For Resident #97, Physician #1 said he/she was treated with antibiotics at the end of December but he/she probably should have gone out sooner to the wound clinic for debridement and said he goes by what the wound nurses tell him and he was not aware of the situation as he did not visualize the wounds during that time. During a follow up interview on [DATE] at 10:16 A.M., Physician #1 said, I am not a wound care expert and he is really relying on the wound care team to utilize the best treatment option. During an interview on [DATE] at 8:08 A.M., the Nurse Practitioner said she has not been notified of the facility having trouble getting transportation for Residents who need to leave the facility for wound care. During an interview on [DATE] at 11:43 A.M., the Nursing Home Administrator said she should have addressed the physician's concerns regarding wound care that he mentioned in QAPI.