**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, staff education and Facility Assessment review, the facility failed to ensure the nursing staff were trained and demonstrated the competencies and skillsets 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 one Resident (#182), out of a total sample of 44 Residents. Resident #182 was admitted with a Stage 2 pressure ulcer that progressed and deteriorated to a Stage 4 pressure ulcer. Resident #182 developed a pressure ulcer to the midthoracic spine while in the facility. and; 2) Ensure 10 out of 10 staff education records reviewed, education and competencies were completed and documented annually, per Facility Assessment. Findings include: 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. Mental Health and Behavior: Manage the medical conditions and medication related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with things anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD, and other psychiatric diagnosis, intellectual or developmental disabilities. Medication: Awareness of any limitations of administering medications, administration of medications that residents need, by route; oral, nasal, buccal, sublingual, topical, subcutaneous, rectal, intravenous (peripheral or central lines), intramuscular, inhaled (nebulizer), vaginal, ophthalmic, etc. Assessment/management of polypharmacy. Pain management: Assessment of pain, pharmacologic and non-pharmacological pain management. 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. Therapy: PT, OT, Speech/Language, Respiratory, Music, Art, management of braces, splints. Other Special Care Needs: Dialysis, hospice, ostomy care, tracheostomy care, ventilator care, bariatric care, palliative care, end of life care. Nutrition: Individualized dietary requirements, liberalized diets, specialized diets, IV nutrition, tube feeding, cultural or ethnic dietary needs, assistive devices, fluid monitoring or restrictions, hypodermoclysis. Provide Person-Centered/Directed Care: Psycho/Social/Spiritual Support: Build relationship with resident /get to know him/her; engage resident in conversation. Find you what resident preferences and routines are; what makes a good day for the resident; what upsets him/her and incorporate this information into the care planning process. Record and discuss treatment and care preferences. Support emotional and mental well-being, support helpful coping mechanisms. Support resident having familiar belongings. Provide culturally competent care; learn about resident preferences and practices with regard to culture and religion; stay open to requests and preferences and work to support those as appropriate. Provide or support access to religious preferences, use or encourage prayer as appropriate/ desired by the resident. Provide opportunities for social activities/life enrichment (individual, small group, community). Support community integration if resident desires. Prevent abuse and neglect. Identify hazards and risks for residents. Provide family/representative support. Offer and assist resident and family caregivers (or other proxy as appropriate) to be involved in person-centered care planning and advanced care planning. Review of the Facility Assessment, dated as reviewed with the QAPI committee, in November 2022, indicated the following: Staff Training, education, and competencies: Staff receive training, education and competencies that are necessary to provide the level and types of support and care needed for our patient/resident population. Staff receive a comprehensive orientation program that is designed based on their job title and responsibilities. Additional training is required for specialty areas such as wound care, infection control, IV administration as examples. All staff are required to have an initial 8 hours of training on dementia care principles and four hours annually thereafter. The nurse practice educator is the leader of training and competencies in the center. An annual calendar is created that schedules required training for all staff. Training is conducted online, in the classroom, on the nursing units as appropriate. Clinical staff are CPR certified. Nurses obtain additional certification in areas of specialty required to care for our patient populations ex. IV certification, wound care certification etc. We also use collaboration within the interdisciplinary team for advancement of skills (example: PT Training staff on weight bearing restrictions or use of special equipment). [NAME] Hill also has a full-time Nurse Practitioner who is available for teaching and training staff. [NAME] Hill will also contract vendors or hospitals to provide additional training on new clinical programs. Facility has an extensive library of clinical policies and procedures that are developed through a shared governance model using clinical practice councils. Policies and procedures are based on federal regulations, standards from professional organizations (APIC, CDC, NPUAP, etc.) and professional clinical resources. ([NAME] and other evidence-based resources). An annual review is performed by the Practice Councils and the center Quality Improvement Committee to determine if updates are needed. However, policies and procedures are also updated throughout the year if practice standards change. New policies and procedures are developed as new population trends and needs are identified. Provider recruitment, retention and training is a priority at the Facility: Each regional division is supported by a physician leader and a director of provider relations, who partners with operational leadership to ensure each center is appropriately staffed. Our [NAME] President for Medical Affairs meet with our medical directors regularly, individually and as a group to ensure coordination and collaboration in optimizing the car of our residents. [NAME] Hill collaborates with the Medical Practitioners/NP's regularly to ensure the policies and re-hospitalizations, pressure ulcers, weight loss and falls, to ensure the center has quality outcomes and measures necessary to provide high quality of life and quality of care standards that align with the facility mission and vision of the organization. Quarterly (QAPI) meeting, the medical director meets with the leadership team and consultants (pharmacist, lab/x-ray) to discuss outcomes and develop protocols necessary to achieve optimum clinical outcomes and customer service. The facility physician services provide training to medical practitioners that aligns with the expectations each year. The facility accepts residents with combinations of conditions that require complex care and management. The facility failed to provide training and demonstrated competency with Quality of Life, Quality of Care, Behavioral Health, Pharmacy Services, Food and Nutrition Services, Administration, and Infection Control in the following care areas: ADL Care Provided for Dependent Residents related to showers. Quality of Care related to wound treatment orders. Free of Accident Hazards/Supervision/Devices related to falls with fractures. Bowel/Bladder Incontinence, Catheter, UTI related to incorrect foley catheter size. Pain Management related to physician's order for pain patch. Trauma Informed Care related to PTSD care plan. Bedrails related to use and lack of assessment. Treatment and Services for Mental/Psychosocial Concerns related to use of psychotropic medication. Free from Unnecessary Psychotropic Medication /PRN use related to no stop date. Free from Medication Error Rate of 5% or more related to facility medication error rate of 9%. Residents are free from Significant Medication Errors Label/Store Drugs & Biologicals related to expired medication found in resident room. Resident Allergies, Preferences and Substitutes related to food allergies. Resident Records - Identifiable Information related to inaccurate documentation in medical records. Infection Prevention & Control related to tracking and implementation of contact precautions. 1. Resident #182 was admitted to the facility in November 2023, and had diagnoses which included a Stage 2 pressure ulcer (a break in the top two layers of skin as a result of pressure) and diabetes. Review of the Minimum Data Set assessment dated [DATE] indicated Resident #182 was admitted to the facility with a Stage 2 pressure ulcer on the coccyx, was at risk for skin breakdown, and was cognitively intact. Review of the medical record indicated that Resident #182's Stage 2 pressure ulcer, identified on 11/2/23 developed into a Stage 4 pressure ulcer on 11/8/23. The medical record failed to indicate Resident #182's coccyx pressure ulcer or midthoracic spine wound was evaluated,measured, or that staff notified the physician that the coccyx wound progressed from a Stage 2 pressure ulcer to a Stage 4 pressure ulcer. Further review of Resident #182's medical record indicated Nurse #1 signed off as completing the wound dressing to the Resident coccyx on 11/8/23, 11/10/23, 11/11/23 and 11/12/23. There were no evaluations or measurements of the wound indicated in the medical record. Further review of Resident #182's medical record indicated the measurements obtained on 11/18/23 documented by Nurse #11, was the first documented measurement of his/her coccyx wound since admission. The note did not reference wound depth. During an interview on 12/05/23 at 12:01 P.M., Nurse #1 said Resident #182 had a Stage 2 pressure ulcer on admission that progressed to a Stage 4, a pressure ulcer on the lower back, and said he/she documented it in the medical record as well as notified the unit manager of the change in condition. Nurse #1 said she had been a nurse for a long time and knows when a wound is not healing and getting worse. Nurse #1 said she notifies the NP if she has any concerns so the NP can visit the resident and make changes to medications or treatments. Nurse #1 said her training in the facility consisted of online videos that are assigned to nurses each year and that she had not completed any competencies in years. Nurse #1 said she does remember a training conducted by the rehabilitation department on the use of Hoyer lifts but reported no additional hands-on competencies completed. Review of Nurse #1 education files failed to include any demonstrated competencies necessary to provide the level and types of care needed for the resident population as required per the facility assessment. Review of the education files failed to include recognizing and reporting wound deterioration, evaluation, measurments, and hands on clinical competency evaluations. Nurse #1's education files indicated he/she did not have the nessecary skills to properly evaluate Resident #182's Stage 2 pressure ulcer that deteriroated to a Stage 4 pressure ulcer. Review of Nurse #11's education files failed to include demonstrated competencies necessary to provide the level and types of care needed for the resident population as required per the facility assessment. Review of the education files failed to include recognizing and reporting wound deterioration, evaluation, measurments, and hands on clinical competency evaluations.Nurse #2's education files indicated he/she did not have the nessecary skills to properly evaluate Resident #182's Stage 2 pressure ulcer that deteriroated to a Stage 4 pressure ulcer. 2) Review of 10 personnel files of actively working clinical nursing staff in the facility on 12/4/23 and 12/5/23 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 nessecary skills to evaluate, documenet, or recognize a change in condition related to skin integrity and proper wound management. Review of 10 out of 10 licensed nurses working in the facility, educational records, failed to indicate competencies were completed annually, per the Facility Assessment. Competencies reviewed included Skin and wound care, Medication Management, Pain Management, Infection Control, Basic Nursing Skills, Basic Restorative Services, Identification of Changes in Condition, Cultural Competency, Dementia Training, Person Centered Care, and Communication. 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 12/4/23 at 10:02 A.M., the Nursing Home Administrator (NHA) said the Assistant Director of Nursing (ADON) was filling in for the Nurse Practice Educator position from July 2023 providing education along with the Director of Nursing to provide clinical training. The NHA said the wound nurse who resigned in June 2023 completed competencies on nurses for the Swift Phone (Phone used to track wound evaluations and measurements). The NHA said the DON and ADON manage all required nursing competencies in the facility because they are clinical. The NHA said the DON is certified in wound care. The NHA said the DON, ADON and Unit Managers take on all responsibility of training, and weekly wounds rounds. The NHA said she met with the DON, ADON and Unit managers to come up with a plan when the wound nurse submitted her one-month notice. The NHA said the team would review plans to transition the management of wound rounds and competencies during that time. During an interview on 12/4/23 at 10:35 A.M., with the Nursing Home Administrator (NHA), the Director of Nursing (DON) and Regional Nurse #1, the DON said new clinical staff are assigned mentors and given an orientation checklist to tack trainings. The DON said the mentor is responsible for checking off the orientation checklist. The DON said staff utilize an online video training system to watch videos and that human resources assigns the training to staff. The DON said this packet is to track training and not a competency packet. During an interview on 12/04/23 10:59 A.M. with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), the DON said she is not certified in wound care and that she was trained on the use of the Swift Phone to evaluate wounds but does not use it because it is not user friendly, and she can't log into it. The DON said weekly wound rounds and wound evaluations needed to be addressed by all clinical staff. The ADON said wound rounds and evaluations were done by unit managers with swift phone access. The DON and ADON said they do not know what nurses have completed training with the use of the Swift phone. The DON said she expects documentation, evaluation including measurements of skin and wounds to be documented manually if the Swift Phone was not used. During an interview on 12/5/23 at 2:38 P.M., the Director of Nursing (DON) said the facility does not conduct training with competencies, only online video modules are assigned. The DON said they only do online videos for all new hires and no yearly training, just online training. The DON said wound basics is an online training that is not required and they just have staff do the online video's with no hands on competencies. The DON said human resources tracks the online modules. The DON said clinical staff come off orientation once the check list is completed and the mentor confirms the orientee is ready. The DON said she did not have any orientation checklists, competencies, or documented trainings for clinical staff aside from printed transcripts from the online video modules. During an interview on 12/5/23 at 12:42 P.M., the Medical Director said she expects new and existing clinical staff to be competent in resident care and complete the required training and competencies before providing care to residents. The Medical Director said she would expect staff to be competent in wound care needs including competency to assess, evaluate and measure skin issues. The Medical Director said she expects the facility to conduct weekly wound evaluations as indicated and expects clinical oversight by staff and management. The Medical Director said she would expect staff to document and report changes in condition right away and for clinical management to be notified. During an interview on 12/5/23 at 12:55 P.M., Unit Manager #1 said she would expect competencies to be completed by all staff before working with residents. The unit manager said she has not completed or signed off on any competencies and that the only training completed is online video modules. Unit Manager #1 said competencies were done a long time ago, but the facility no longer does them. The Unit Manager said new hires have a check off sheet to indicate when they are ready to come off orientation. During a follow-up interview on 12/5/23 at 1:40 P.M, the Director of Nursing (DON) confirmed that the facility had no orientation packets or clinical competencies for the Nursing Department, indicating staff were not assessed for hands on competency. The DON said clinical staff should have documented hands on competencies and training before patient care. During an interview on 12/5/23 at 1:45 P.M, the Nurse Practitioner (NP) #1 said treatments are based on the nurse's assessment, he doesn't look at the documented assessments, and he goes by what the nurses tell him verbally. NP #1 said staff would tell him if there was a change, and said the nurses should assess the area. NP #1 said it doesn't matter if they come to him with specifics and measurements and that he goes by if he is told the area is worse, not by measurements, color, or drainage. NP #1 said if nurses change the dressing orders, ninety nine percent of the time he will say it's good. NP #1 said these are good nurses; they do a good job and he has faith their order changes are for good reason. NP #1 said the facility gets a ton of wound vac and dressing changes. The NP said he is not aware of any training, education, or hands on competencies the nursing staff have completed and said he couldn't care less about continuing education. NP #1 said online video crap doesn't mean anything and is a waste of time. NP #1 said he would expect the nurses to complete hands on training and he would expect them to have competencies to know what they are doing. The NP said he has not conducted any teaching or training to staff. Review of Nurse #1 education files failed to include demonstrated competencies necessary to provide the level and types of care needed for the resident population as required per the facility assessment. Review of Nurse #11's education files failed to include demonstrated competencies necessary to provide the level and types of care needed for the resident population as required per the facility assessment. 2) Review of 3 personnel files of actively working clinical nursing staff in the facility on 12/11/23 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 for 1 out of 3 actively working clinical nursing staff. Review of Nurse #8's education files failed to include demonstrated competencies necessary to provide the level and types of care needed for the resident population as required per the facility assessment. During an interview on 12/11/23 at 11:49 A.M., Nurse #8 said skin and wound training was conducted in the conference room last Wednesday and he/she watched videos on the television and answered questions as a group. The surveyor asked Nurse #8 if there was any hands-on training conducted and he/she said no. Nurse #8 said there were no supplies in the conference room at the time of his/her training and that only videos were shown on the television. Nurse #8 said he/she did not complete a hands-on competency and said I haven't done that part yet. He/she has only watched videos. Other staff did the competency part later when they brought supplies in to measure, but he/she wasn't there for that part. Nurse #8 said they still need to do it. Nurse #8 said after his/her video training he/she was told staff did complete a hands on competency later in the day with the use of supplies and a mannequin, but he/she did not and still needs to complete the hands on competency. Nurse #8 said he/she did not conduct any measuring, or wound dressing change competencies as there were no supplies or competency equipment set up during the video training he/she attended. Nurse #8 said he/she was instructed to sign in to the facilities online learning portal to conduct additional training. Nurse #8 said he/she would complete the hands-on competency portion this week. During an interview on 12/11/23 at 11:56 A.M., Nurse #7 said, he/she completed skin and wound training last Thursday in the conference room and then completed a hands-on competency with a mannequin. Nurse #7 said he/she completed the competency on dressings changes and wound measurements. Nurse #7 said she was trained on the use of the Swift Phone by Unit Manager #2. During an interview on 12/11/23 at 11:59 A.M., Unit Manager #2 said skin and wound training was conducted in the conference room last week and the competency portion included hands on measurements and dressing changes. UM #2 said all Nurses have completed trainings including competencies for skin assessment and wounds. During an interview on 12/11/23 at 10:35 A.M., Regional Nurse #1 said all clinical staff must complete online training and complete demonstrated competency prior to treating residents. Regional Nurse #1 said hands-on competency demonstration is documented by the evaluation conducted, and once completed the training and competency is tracked online. Regional Nurse #1 said clinical staff must pass the competency evaluation to meet the requirements to receive an online portal certificate. Regional Nurse #1 said she expects all clinical staff to be educated and have hands-on demonstrated competencies as required to meet the clinical needs of the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to ensure its administration used its resources effectively to provide appropriate wound care. Specifically, the facility administration failed to: 1) provide nursing staff education and training to provide competent, safe, and effective wound care management; 2) provide continuation of the wound care program following the resignation of its Wound Nurse and implement an effective wound care program 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. These failures resulted in the development of a Stage 4 pressure ulcer with purulent drainage and odor for one Resident (#182) out of a total sample of 44 residents. 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 in the absence of a wound nurse 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 an odor. Review of the Facility Assessment Tool, dated as reviewed with the QAPI committee in November 2022, indicated the facility offers pressure ulcer prevention and care, skin care, wound care (surgical, other wounds). Further review of the Facility Assessment Tool indicated, but was not limited to, the following: -The team also discusses current termination/resignations of staff and develops a plan on how to meet the staffing needs of the center proactively. -Staff receive training/education and competencies that are necessary to provide the level and types of support and care needed for our patient/resident population. Staff receive a comprehensive orientation program that is designed based on their job title and responsibilities. Additional training is required for specialty areas such as wound care, for example. Training is conducted online, in the classroom, and on the nursing units as appropriate. Nurses obtain additional certification in areas of specialty required to care for our populations ex: IV certification, wound care certification etc. The facility also has a full-time Nurse Practitioner who is available for teaching and training of staff. The facility will also contract vendors or hospitals to provide additional training on new clinical programs. The governing body has an extensive library of clinical policies and procedures that are developed through a shared governance model using clinical practice councils. Policies and procedures are based on federal regulations, standards from professional organizations (APIC, CDC, NPUAP, etc.) and professional clinical resources. ([NAME] and other evidence-based resources). An annual review is performed by the Practice Councils and the center Quality Improvement Committee to determine if updates are needed. However, policies and procedures are also updated throughout the year if practice standards change. New policies and procedures are developed as new population trends and needs are identified. 1) The facility failed to provide nursing staff education and training to provide competent, safe, and 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. Resident #182 was admitted to the facility in November 2023, and had diagnoses which included a Stage 2 pressure ulcer (a break in the top two layers of skin because of pressure), diabetes and congestive heart failure (a heart disease resulting in poor blood circulation). Review of the Minimum Data Set assessment dated [DATE] indicated Resident #182 was admitted to the facility with a Stage 2 pressure ulcer on the coccyx, was at risk for skin breakdown, and had a Brief Interview for Mental Status score of 15, indicating intact cognition. Review of the Hospital Discharge summary dated [DATE], indicated Resident #182 was discharged to the facility with a Stage 2 coccyx wound. Review of the nursing note dated 11/2/23, indicated Resident #182 was admitted with a Stage 2 pressure ulcer located on the coccyx. Further review of the medical record indicated on 11/8/23, the wound progressed to a Stage 4 pressure ulcer (Stage 4 ulcers are defined as deep wounds that may impact muscle, tendons, ligaments, and bone, which indicates Resident #182's wound deteriorated since admission) and that on 11/18/23 the wound had purulent drainage and an odor. Review of the nursing notes, physician notes and wound evaluations failed to indicate staff evaluated and monitored the wound, implemented preventative interventions and treatments, or notified the physician of a change in condition to prevent the worsening of Resident #182's wound. 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). Further review of the medical record indicated Nurse #1 signed off as completing Resident #182's coccyx wound dressing on 11/8/23, 11/10/23, 11/11/23 and 11/12/23. There were no wound measurements in the medical record for these dates. Further review of the medical record indicated Nurse #11 obtained the first documented wound measurement for Resident #182's coccyx wound on 11/18/23. The note did not reference wound depth. During an interview on 12/05/23 at 12:01 P.M., Nurse #1 said Resident #182 had a Stage 2 pressure ulcer located on the coccyx. Nurse #1 said this wound progressed to a Stage 4 pressure ulcer and that she documented the Stage 4 wound in the nursing notes and notified the unit manager of the change in condition. Nurse #1 said she had been a nurse for a long time and knew when a wound was not healing and getting worse. Nurse #1 said she notifies the Nurse Practitioner (NP) if she has any concerns so the NP can visit the resident and make changes to medications or treatments. Nurse #1 said her training in the facility consisted of online videos that are assigned to nurses each year and that she had not completed any competencies in years. Nurse #1 said she does remember a training conducted by the rehabilitation department on the use of Hoyer lifts but reported no additional hands-on competencies completed. Review of Nurse #1's education files failed to include demonstrated competencies necessary to provide wound care needed for the resident population as required per the facility assessment. Review of Nurse #11's education files failed to include demonstrated competencies necessary to provide wound care for the resident population as required per the facility assessment. Resident #65 was admitted to the facility in March 2023, and had diagnoses which included dementia, cellulitis, cerebral ischemia, and dysphagia. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #65 scored a 7 out of 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. Review of Resident #65's nursing skin check note dated 3/10/23, indicated he/she was admitted with a left lower extremity abrasion, pressure area to coccyx, and Prevalon heel protectors (a device used to reduce the risk of pressure injuries by keeping the heel floated, relieving pressure), applied to bilateral lower extremities. His/her skin was warm and dry. Review of Resident #65's nurse practitioner note dated 3/20/23, indicated the presence of pressure area to the Right buttock but failed to indicate the wound was evaluated or measured. There was no documentation of the left lower extremity abrasion and had no documented evaluations including measurements or observations of the Residents skin. Review of Resident #65's admission documentation failed to indicate measurements or further description of the pressure area to coccyx or left lower extremity. Review of Resident #65's nursing note dated 9/26/23, indicated the presence of a new unstageable wound to mid back measuring 7 centimeters (cm) x 7 cm, mostly white/yellow slough. Review of Resident #65's physician notes, nurses notes and wound evaluations failed to indicate staff completed wound evaluations and assessments to include measurements and description of wound status. Review of physician's orders dated 3/6/23 indicated the following: BUTTOCKS WOUND: Cleanse wound with soap and water. Apply skin prep to peri wound, apply TRIAD nickel thickness to open wound. every day and evening shift. L HEEL PRESSURE INJURY: Cleanse with normal saline and apply skin prep to wound. Leave open to air. Every evening shift. Moisture Barrier - Apply every shift and as needed to peri-area and buttocks every shift. L HEEL PRESSURE INJURY: Cleanse with normal saline and apply skin prep to wound. Leave open to air. Every evening shift. Moisture Barrier - Apply every shift and as needed to peri-area and buttocks every shift. Off-load heels with Prevalon boots or pillows while in bed. Every shift. On 11/16/23 at 10:38 A.M., the surveyor observed Resident #65 lying supine in bed. Resident #65 said his/her bottom and back were painful and that staff will sometimes place pillows behind his/her back or legs for comfort. Resident #65 did not have any pillows placed behind his/her back, under his coccyx area, legs and heels were flat on the bed and Resident #65 was not wearing Prevalon boots. During an interview with Nurse #10 on 11/16/23 at 10:21 A.M., she said Resident #65 has a wound to his/her thoracic spine, and a deep tissue injury on his/her heel, and moisture area to the coccyx that is treated daily. Nurse #10 said the facility had a dedicated wound nurse, but they resigned over the summer and weekly wound rounds are no longer conducted. Nurse #10 said she would expect heels to be offloaded, should not be flat on bed, pillows are to be placed for offloading pressure and Resident #65 should be wearing Geri sleeves and using Prevalon boots to both feet. Nurse # 10 said she would expect the orders and care plan interventions to be updated and followed to prevent skin issues. Resident #97 was admitted to the facility in November 2023, and had diagnoses which included fractures with multiple trauma, kidney disease and diabetes. Review of the Minimum Data Set assessment dated [DATE], indicated Resident #97 was cognitively intact, at risk for skin breakdown, and admitted with an unhealed Stage 2 pressure ulcer. Review of the Nurse Practitioner note dated 11/4/23, indicated Resident #97 had a Stage 2 pressure ulcer located on the right buttock. Review of Resident #97's physician orders indicated: * Comprehensive skin check to be completed by licensed nurse weekly, every day shift every Sunday for skin check, dated 11/5/23. Review of the care plan for skin breakdown dated 11/12/23, indicated Resident #97 had skin breakdown located on the left side of the back and buttocks. Interventions included: * Provide wound treatment as ordered. * Weekly skin check by licensed nurse. * Weekly wound assessment to include measurements and description of wound status. Review of Resident #97's nursing progress notes, treatment administration record, and provider notes for the month of November 2023 indicated there were no measurements obtained or documented descriptions of Resident #97's Stage 2 pressure ulcer. Resident #101 was admitted to the facility in September 2023, and had diagnoses which included heart disease, diabetes, and dementia. Review of the admission Nursing Documentation dated 9/29/23, indicated Resident #101 had a Stage 2 pressure ulcer located on the coccyx, and redness to the skin in the area of the coccyx. The admission Nursing Documentation failed indicate measurements for Resident #101's wound. Review of the Skin and Wound Evaluation dated 12/8/23, indicated Resident #101 had a Stage 2 pressure ulcer located on the coccyx, which measured 3.5 centimeters (cm) x 0.6 cm. The evaluation indicated the wound was covered with a foam dressing, and no secondary dressing, and the wound was stable. Review of Resident #101's physician orders from admission through 12/10/23 failed to indicate an order for a dressing to be placed on his/her Stage 2 coccyx wound. Review of Resident #101's nursing, nurse practitioner and physician progress notes from his/her admission through 12/10/23 indicated there were no references to nursing staff notifying any providers that he/she had a Stage 2 coccyx wound or a discussion of wound treatment. Review of these notes indicated there was no reference to the NP or Physician examining Resident #101's coccyx wound. Review of the physician orders and nursing progress notes indicated that on 12/11/23 (day of survey) an order was placed for cleansing and a dressing to be applied to Resident #101's Stage 2 coccyx wound. During an interview with Regional Nurse #1 on 12/11/23 at 12:30 P.M., she said she had reviewed the medical record and interviewed nursing staff and determined staff had not informed Resident #101's Nurse Practitioner (NP) or Physician that he/she had a Stage 2 pressure ulcer on the coccyx, until today (12/11/23). Regional Nurse #1 said there had been no order for a dressing to be placed on the coccyx wound until today. Regional Nurse #1 said staff should have notified either the NP or Physician of Resident 101's wound and obtained orders wound treatment when he/she was admitted to the facility with the wound. Resident #67 was admitted to the facility in February 2023 with diagnosis including cancer. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #67 scored a 10 out of 15 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. Further review of the MDS indicated the Resident is on hospice services. Review of the wound nurse progress note dated 6/27/23, indicated Resident #67 had a Stage V (sic.) coccyx wound and recommended packing the wound with Aquacel Ag rope (an antimicrobial wound dressing which controls the development and growth of biofilms to better manage infection and absorb exudate). Review of the medical record including the Nurse Practitioner notes and nursing notes failed to indicate the wound nurse recommendation was reviewed. Review of personnel files for 10 of 10 licensed nurses actively working in the facility on 12/4/23 and 12/5/23 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. Competencies were not completed annually, per facility assessment. Competencies reviewed included Skin and Wound care, Medication Management, Pain Management, Infection Control, Basic Nursing Skills, Basic restorative services, Identification of Changes in Condition, Cultural Competency, Dementia Training, Person Centered Care, and Communication. There was no documented evidence these or other competencies were completed as required by the facility assessment. During an interview on 12/5/23 at 2:38 P.M., the Director of Nursing (DON) said the facility does not conduct training with competencies, only online Vital Learning video modules are assigned. The DON said the facility only does online videos for all new hires and no yearly trainings, just online stuff. Wound basics is online and not required. We just have them do the online stuff with no competencies. The DON said human resources tracks the online modules. The DON said clinical staff come off orientation once the check list is completed and the mentor confirms the orientee is ready. The DON said she did not have any orientation checklists, competencies, or trainings for clinical staff aside from printed transcripts from the online video modules in Vital Learning. The DON said there was no evidence of return demonstration practice for nursing staff. During an interview on 12/5/23 at 12:42 P.M., the Medical Director said she expects new and existing clinical staff to be competent in resident care and complete the required training and competencies before providing care to residents. The Medical Director said she would expect staff to be competent in wound care needs including competency to assess, evaluate and measure skin issues. The Medical Director said she expects the facility to conduct weekly wound evaluations as indicated and expects clinical oversight by staff and management. The Medical Director said she would expect staff to document and report changes in condition right away and for clinical management to be notified. During an interview on 12/5/23 at 12:55 P.M., Unit Manager #1 said she would expect competencies to be completed by all staff before working with residents. Unit Manager #1 said she has not completed or signed off on any competencies and that the only training completed is online video modules. Unit Manager #1 said competencies were done a very long time ago, but the facility no longer does them. Unit Manager #1 said new hires have a check off sheet to indicate when they are read to come off orientation. During a follow-up interview on 12/5/23 at 1:45 P.M, the DON confirmed the facility had no orientation packets or clinical competencies for the Nursing Department, indicating staff were not assessed for competency. During an interview on 12/05/23 at 9:28 A.M., NP #1 said he does not look at a wound unless there is a change because his expectation is that nurses are assessing the wound and will tell him if there is a change. NP #1 said that his trust for nursing assessments of wounds is based, in part, on the assumption that nurses have completed hands-on training/competencies related to wound care and evaluation. The NP said he has not provided wound care or wound evaluation training to the nursing staff. 2) The facility failed to provide continuation of the wound care program following the resignation of its Wound Nurse and implement an effective wound care program for pressure ulcer prevention and care per the Facility Assessment Tool. During an interview on 12/4/23 at 10:02 A.M., the Administrator said the facility had employed a full-time wound nurse who was responsible for oversight of wounds in the building and training nurses how to treat and evaluate wounds. The Administrator said a Nurse Practice Educator was hired to replace the Wound Nurse but went on a leave of absence shortly after starting and did not return. The Administrator provided documentation stating the wound nurses' last day was 6/28/23, and that the Nurse Practice Educator hired to replace the Wound Nurse started on 7/11/23 and went on leave of absence on 8/1/23. The Administrator said that in the absence of the Wound Nurse her responsibilities, as outlined in the wound nurse job description, were delegated to the DON, Assistant Director of Nursing (ADON), and Unit Managers. The Administrator said the Wound Nurse gave a month's notice for her resignation which left the facility enough time to plan a transition of responsibilities. The Administrator said there was nothing on paper about specific divided responsibilities, and that no outside services were consulted or contracted to facilitate the wound care management program in the facility. Review of the Wound Nurse Job Description indicated, but was not limited to, the following responsibilities: 1) The Skin Health Lead develops and facilitates a person-centered team approach to prevention and management of wounds among the center leaders, the patient and family, the nursing team, CRC, providers, therapists 2) Coordinates and leads weekly team wound rounds and post-meet-ups for follow-up discussions. 3) Communicates and coordinates readiness for any potential admissions with skin/wound needs; with CAD and center leadership, as indicated. 4) Lead and/or ensure team review of all new admissions/readmissions for skin integrity needs. a. Identifies skin risk factors and discusses interventions. b. Identifies actual skin impairments. c. Facilitates team discussion to recognize patient/family skin/wound related needs, including but not limited to psychosocial, physical, nutritional, medical, and others. d. Coordinates skin, wound, and incontinence related to supplies with central supply and or DME companies, as indicated. e. Coordinates and or provides any needed skin/wound education with patient/family and staff, as indicated. 5) Ensures and/or leads team evaluation of all new skin/wound conditions for any new admissions within 48 hours. a. Reviews skin check, wound evaluation/documentation, risk assessment, orders, and care plan for completion and accuracy. b. Provides actual inspection of wounds (in-person or via wound app) to ensure accuracy of wound type. c. Reviews and/or coordinates team discussion to determine patient-wound goal. d. Ensures that the patient/responsible party/family has information regarding benefits and risks of interventions. During an interview on 12/4/23 at 10:58 A.M., the DON said she does not have a wound care certification. The DON said that in the absence of the wound nurse the unit managers should be completing weekly wound rounds and as the Orchard unit has not had a unit manager for around six weeks they have been trying to schedule an extra nurse to complete weekly wound rounds. The DON said the facility implemented a Swift Phone (a clinically calibrated wound imaging system) to track wounds when the Wound Nurse started, but the swift phone is not user friendly and that the DON is unable to use it. The DON said the Wound Nurse was responsible for training staff how to use the Swift Phone, but nobody has been designated for providing Swift Phone training since the Wound Nurse left in June. The DON also said that the Swift Phone has been malfunctioning intermittently. During an interview on 12/5/23 at 12:55 P.M., Unit Manager #1 said there have been no weekly wound rounds since the Wound Nurse left in June 2023. During an interview on 12/4/23 at 1:00 P.M., the DON said she was unable to provide evidence of weekly wound rounds because none have been done on any unit. During an interview on 12/05/23 at 9:28 A.M., NP #1 said the previous Wound Nurse sent him regular updates regarding wounds in the facility and once she left the updates stopped. See F686 and F726

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Resident #65 was admitted to the facility in March 2023, and had diagnoses which included dementia, cellulitis, cerebral ischemia, and dysphagia. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #65 scored a 7 out of 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. Review of Resident #65's nursing skin check note dated 3/10/23, indicated he/she was admitted with a left lower extremity abrasion, pressure area to coccyx, and Prevalon heel protectors (a device used to reduce the risk of pressure injuries by keeping the heel floated, relieving pressure), applied to bilateral lower extremities. His/her skin was warm and dry. Review of Resident #65's nurse practitioner note dated 3/20/23, indicated the presence of pressure area to the Right buttock but failed to indicate the wound was evaluated or measured. There was no documentation of the left lower extremity abrasion and had no documented evaluations including measurements or observations of the Residents skin. Review of Resident #65's admission documentation failed to indicate measurements or further description of the pressure area to coccyx or left lower extremity. Review of physician's orders dated 3/6/23 indicated the following: BUTTOCKS WOUND: Cleanse wound with soap and water. Apply skin prep to peri wound, apply TRIAD nickel thickness to open wound. every day and evening shift. L HEEL PRESSURE INJURY: Cleanse with normal saline and apply skin prep to wound. Leave open to air. Every evening shift. Moisture Barrier - Apply every shift and as needed to peri-area and buttocks every shift. L HEEL PRESSURE INJURY: Cleanse with normal saline and apply skin prep to wound. Leave open to air. Every evening shift. Moisture Barrier - Apply every shift and as needed to peri-area and buttocks every shift. Off-load heels with Prevalon boots or pillows while in bed. Every shift. Review of Resident #65's Norton Pressure Ulcer Scale dated 3/5/23, indicated he/she was at high-risk for developing pressure ulcers. Review of Resident #65's plan of care dated 3/6/23, indicated he/she was at risk for skin breakdown, and/or bruising related to advanced age, decreased activity, frail fragile skin, incontinence, limited mobility, nutritional concerns, poor safety awareness, and frequent falls. Care plan intervention included the following: - Provide wound treatment as ordered. - Weekly skin check by a licensed nurse. - Weekly wound assessment to include measurements and description of wound status. - Monitor for signs and symptoms of infection and report to physician. - Monitor for skin redness/irritation and report as indicated. -Pat (do not rub) skin when drying. -Provide preventative skin care i.e., lotions, barrier creams as ordered. -Use arm protectors as ordered. -Apply barrier cream with each cleansing. - Observe skin for signs/symptoms of skin breakdown i.e., redness, cracking, blistering, decrease sensation, and skin that does not blanche easily. - Evaluate for any localized skin problems, i.e., dryness, redness, pustules, inflammation. - Observe skin condition daily with ADL care and report abnormalities. - Utilize device to assist resident with turning/positioning to reduce friction/shear. - Observe verbal and nonverbal signs of pain related to wound or wound treatment and medication as ordered. - Pressure redistribution surface to bed as per guideline. Review of Resident #65's nursing note dated 9/12/23, indicated the following: Scattered and various stages of heeling to bilateral hands, and forearms, [NAME] red discoloration to BLE, multiple intact scabbed areas to bilateral shins, pressure right buttocks superficial stage 2. Review of Resident #65's nursing notes failed to indicate weekly wound assessments to include measurements and description of wound status were completed. Review of Resident #65's provider exam notes failed to indicate wound evaluations and assessments to include measurements and description of wound status were completed. Review of physician's orders dated indicated the following: 9/23/23- Optifoam Gentle Heel, to heels bilaterally every three days (apply Sure prep and let dry before applying dressing). One time a day every 3 days for DTI left heel, redness right heel. 9/24/23- Diflorasone Diacette External Ointment 0.05. Apply to affected skin topically as needed for rash, itching two times a day. 9/25/23- R buttock Stage 2: NSW, pat dry. Apply triad to wound bed. Cover with foam dressing if needed every 8hours as needed if soiled or dislodged. 9/25/23- R buttock Stage 2: NSW, pat dry. Apply triad to wound bed. Cover with foam dressing if needed every evening shift for Stage 2 care. Review of Resident #65's nursing skin check note dated 9/26/23, indicated Stage 2 pressure on right buttocks. Review of Resident #65's nursing note dated 9/26/23, indicated the presence of a new unstageable wound to mid back measuring 7 centimeters (cm) x7 cm, mostly white/yellow slough. Review of Resident #65's skin check dated 9/26/23, indicated a skin check was performed and a new skin injury/wound was identified as a pressure area located on the right buttock described as a DTI, measuring 4x1, and a new Stage I heel DTI. Nursing note indicated the following skin injuries/wounds were previously identified and were evaluated as follows: *Scattered bruises * Discoloration- Bilateral Lower extremity (BLE) dark red/purple. * Abrasion -Description: Left shin *Rash - penis and testicles- bright angry red. *MASD-Moisture Associated Skin Damage to buttocks. * Pressure Area- Stage 1, coccyx, Stage 2 L buttock, Stage 2 R buttock. Review of physician's orders dated 9/27/23 indicated the following: MID BACK WOUND: wash with wound cleanser, pat dry. Apply Silver Alginate to wound bed and cover with DPD daily and as needed. Review of Resident #65's provider exam notes failed to indicate wound evaluations and assessments to include measurements and description of wound status were completed. Review of the facilities risk meeting notes indicated the following: 8/10/23- Abrasion LLE [left lower extremity] new after fall. 8/17/23- Left shin abrasion healing. 9/29/23- DTI [deep tissue injury] Butt. [SIC] 9/14/23- Wound at butt, no signs of infection. [SIC] 10/12- L [left] heel DTI. 10/5/23 L heel DTI somewhat improved. Review of Resident #65's physician orders dated 11/4/23, indicated: - MID BACK WOUND: wash with wound cleanser, pat dry. Apply Silver Alginate to wound bed and cover with DPD daily and as needed. - MID BACK WOUND: wash with wound cleanser, pat dry. Apply Silver Alginate to wound bed and cover with DPD daily and as needed. Every day shift. - MONITOR dressing to mid back. Notify if any changes around dressing. Every shift. - Skin Prep heels every evening shift. - Triad cream to open area to Scrotum daily until healed. One time a day for open area scrotum. - Diflorasone Diacetate External Ointment 0.05 % (Diflorasone Diacetate) Apply to affected skin topically as needed for rash, itching two times a day. Review of Resident #65's skin check dated 11/14/23, indicated mid back wound with slough surrounding area, red, DTI left heel, both buttocks red non-blanchable intact. Review of Resident #65's nursing notes failed to indicate weekly wound assessments to include measurements and description of wound status were completed. Review of Resident #65's provider exam notes failed to indicate wound evaluations and assessments to include measurements and description of wound status were completed. Review of Resident #65's medical record failed to indicate staff implemented physician's order for weekly wound evaluations and measurements. On 11/16/23 at 10:38 A.M., the surveyor observed Resident #65 lying supine in bed. Resident #65 said his/her bottom and back were painful and that staff will sometimes place pillows behind his/her back or legs for comfort. Resident #65 did not have any pillows placed behind his/her back, under his coccyx area, legs and heels were flat on the bed and Resident #65 was not wearing Prevalon boots. During an interview with Certified Nursing Assistant (CNA) #7 on 11/16/23 at 10:01 A.M., she said Resident #65 needs pillows under his/her feet and back because of wounds and to offload pressure. CNA #7 said Resident #65 does not wear Geri sleeves (Protects residents' arms and legs against damage caused by friction and shearing to his upper extremities and uses pillows). During an interview with Nurse #10 on 11/16/23 at 10:21 A.M., she said Resident #65 has a wound to his/her thoracic spine, and a deep tissue injury on his/her heel, and moisture area to the coccyx that is treated daily. Nurse #10 said the facility had a dedicated wound nurse, but they resigned over the summer and weekly wound rounds are no longer conducted. Nurse #10 said she would expect heels to be offloaded, should not be flat on bed, pillows are to be placed for offloading pressure and Resident #65 should be wearing Geri sleeves and using Prevalon boots to both feet. Nurse # 10 said she would expect the orders and care plan interventions to be updated and followed to prevent skin issues. During an interview on 11/16/23 at 11:18 A.M., the Director of Nurses (DON) said only weekly skin checks are conducted at this time as they no longer have an in-house wound nurse. The DON said the wound nurse resigned in June of 2023. The DON said skin issues are reported in Risk Management System (RMS) and care plans are updated if indicated and wounds are discussed in weekly Risk meeting. The DON said measurements, pressure stage, color, and drainage information should be documented on the skin and wound evaluation assessment that is separate from the weekly skin check. The DON said she expects physician orders and care plans to be implemented and followed. The DON said Resident #65 did not have weekly skin or wound evaluations, or assessments completed and there is no documentation that the skin and wound evaluations or assessments were completed for Resident #65. The DON said all residents with skin issues, including wounds, should have documented weekly evaluation and assessments completed by nurses and medical providers. 4. Resident #67 was admitted to the facility in February 2023 with diagnosis including cancer. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #67 scored a 10 out of 15 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. Further review of the MDS indicated the Resident is on hospice services. Review of the wound nurse progress note dated 6/27/23, indicated Resident #67 had a Stage V (sic.) coccyx wound and recommended packing the wound with Aquacel Ag rope (an antimicrobial wound dressing which controls the development and growth of biofilms to better manage infection and absorb exudate). Review of the medical record including the Nurse Practitioner notes and nursing notes failed to indicate the wound nurse recommendation was reviewed. Review of the risk meeting notes dated 6/28/23, indicated Resident #67's Stage 4 coccyx wound treatment was changed secondary to slough (dead tissue). Review of the physician's orders and treatment administration records failed to indicate Resident #67's wound nurse recommendation was implemented, and that the current wound dressing treatment to Resident #67's coccyx had not been changed since 5/31/23 when it was initiated. Review of the most recent hospice visit note report dated 10/16/23, indicated Resident #67 still had a Stage 4 pressure ulcer on his/her coccyx with an onset date of 5/30/23. During an interview on 11/20/23 at 8:00 A.M., Nurse Practitioner (NP) #1 said he does not recall if he was made aware of the wound nurse's recommendation on 6/27/23 to change the wound dressing/treatment. During an interview on 11/20/23 at 10:53 A.M., NP #2 said she receives written or verbal recommendations, and does not recall if she was made aware of the wound nurse recommendation made on 6/27/23. During an interview on 11/20/23 at 10:43 A.M., the Medical Director said she would expect nursing to communicate any wound nurse recommendations to the NPs by either phone call or written recommendation, and that if the recommendations were reviewed by the NPs this would be documented by nursing. The Medical Director said she was unaware of the dressing/wound treatment change recommendation made by the wound nurse. During an interview on 11/20/23 at 10:21 A.M., the Director of Nursing (DON) said she would expect the NP to review and either approve or disapprove by their signature when a written recommendation is made. The DON said she would expect nursing to document that a recommendation was acknowledged by the NP in a progress note when a verbal recommendation is made. The DON said the wound nurse should have either verbalized her recommendation to the NP and documented that the NP acknowledged the recommendation or submitted a written recommendation instead of writing it in her progress note. The DON said she was unable to find any evidence that the recommendation was reviewed by an NP or MD. The DON also said she is unsure what the 6/28/23 risk note is referencing as there have not been changes made to the coccyx dressing/wound treatment order since 5/31/23. Based on observations, interviews and record review the facility failed to ensure it performed skin checks and wound evaluations, implemented physician orders, updated the physician and plan of care when significant changes occurred, and prevented the deterioration of pressure injuries (wounds that occur when the skin and tissue are damaged by prolonged pressure, usually on bony areas like the hips, heels, or elbows) for five residents (#182, #97, #101, #67, #65) of 11 residents with a pressure ulcer out of a total sample of 44 residents. Specifically: 1. For Resident #182, the facility failed to evaluate a Stage 2 pressure ulcer, complete wound evaluations, notify the physician when the wound deteriorated to a Stage 4 and had signs of infection, or revise the plan of care, which resulted in a significant deterioration to the wound and a 100% increase in wound size. In addition, the facility failed to notify the provider and evaluate a newly developed midspine thoracic wound. 2. For Resident #97, the facility failed to implement physician orders and obtain skin/wound evaluations. 3. For Resident #101, the facility failed to measure a Stage 2 pressure ulcer on admission or obtain physician orders to treat the wound. 4. For Resident #67, the facility failed to review a wound treatment recommendation made by the wound nurse. 5. For Resident #65, the facility failed to perform comprehensive weekly wound assessments, implement interventions to reduce the risk for pressure ulcers and revise the plan of care. Findings include: Review of the facility's policy Skin Integrity and Wound Management dated 2/1/23, indicated: - Complete comprehensive evaluation, and risk evaluation on admission and weekly for the first month. - The plan of care for the patient will be reflective of assessment findings from the comprehensive patient assessment and wound evaluation. Staff will continuously observe and monitor patients for changes and implement revision to the plan of care as needed. - The licensed nurses will document newly identified skin/wound impairments as a change in condition. - Complete wound evaluation with unanticipated decline in wounds. - Document daily monitoring of ulcer including signs of decline in wound status - Notify physician to obtain orders. - Review care plan and revise as needed. 1. Resident #182 was admitted to the facility in November 2023, and had diagnoses which included a Stage 2 pressure ulcer (a break in the top two layers of skin because of pressure), diabetes and congestive heart failure (a heart disease resulting in poor blood circulation). Review of the Minimum Data Set assessment dated [DATE] indicated Resident #182 was admitted to the facility with a Stage 2 pressure ulcer on the coccyx, was at risk for skin breakdown, and had a Brief Interview for Mental Status score of 15 out of a possible 15, indicating intact cognition. Review of the Hospital Discharge summary dated [DATE], indicated Resident #182 was discharged to the facility with a Stage 2 coccyx wound. Review of the nursing note dated 11/2/23, indicated Resident #182 was admitted with a Stage 2 pressure ulcer located on the coccyx with scattered bruising. His/her skin was warm and dry. The skin on the right and left lower extremity was red. Review of the nursing admission assessment dated [DATE], failed to indicate staff measured or further described Resident #182's Stage 2 coccyx wound. Review of the Nutritional assessment dated [DATE], indicated Resident #182 required additional calories and protein for wound healing. The Dietitian recommended Resident #182 have a new order to liberalize his/her diet to regular and add 4-ounce house shakes three times a day. Review of the medical record failed to show the Nurse Practitioner (NP), or other provider, examined Resident #182's wound on 11/3/23 or reviewed the Dietician's recommendations. Review of the nursing note and Treatment Administration Record (TAR) dated 11/3/23, failed to indicate staff measured or further described Resident #182's Stage 2 coccyx wound. Review of the physician order dated 11/3/23, indicated Resident #182 was to receive silver sulfadiazine cream 1% to be applied to coccyx topically every day shift for ulcer after normal saline wash and cover with foam dressing. Review of the Medication Administration Record (MAR) indicated this treatment was administered on this date. Review of the Norton Pressure Ulcer Scale dated 11/3/23, indicated Resident #182 scored 11, signifying he/she was at medium-risk for developing pressure ulcers. Review of the baseline care plan dated 11/3/23, indicated Resident #182 was at risk for skin breakdown related to diagnoses of diabetes and age-related frail skin, and was admitted to the facility with a Stage 2 pressure ulcer located on the coccyx. The baseline care plan was incomplete and failed to include any nursing interventions for wound treatment. Review of the nursing note dated 11/4/23, indicated Resident #182 presented with a pressure area to the coccyx. The note indicated the dressing was changed and the Resident was repositioned. Review of the nursing note and TAR failed to indicate staff obtained wound measurements on this date. Review of the NP note dated 11/4/23, indicated a visit to Resident #182, but there was no reference to his/her coccyx wound or an examination of the wound. Review of the physician orders for Resident #182 dated 11/4/23, indicated: * An as-needed order (PRN): Gently cleanse coccyx wound with vashe wash, allow a vashe soaked gauze to remain in place over the wound for 5 minutes and gently pat dry. Apply sure prep peri wound. Apply cut to fit, moistened hydrofera blue to the wound bed. Cover with a foam dressing as needed for soiling/dislodgement. This order was discontinued the same day, on 11/4/23. A revised physician order for a scheduled treatment dated 11/4/23 and with a start date of 11/6/23, replaced the above PRN order: * Gently cleanse coccyx wound with vashe wash, allow a vashe soaked gauze to remain in place over the wound for 5 minutes and gently pat dry. Apply sure prep peri wound. Apply cut to fit, moistened hydrofera blue to the wound bed. Cover with a foam dressing every day shift every other day for wound care. * Daily weights. Review of the nursing note dated 11/5/23, indicated Resident #182's buttocks were red and an open area on the skin. The nurse applied barrier cream to the skin. The nursing and TAR failed to indicate staff obtained wound measurements on this date. Review of the medical record failed to show the Nurse Practitioner (NP), or another provider, examined or measured Resident #182's wound on 11/5/23. Review of the nursing note dated 11/6/23, indicated Resident #182's buttocks were red and an open area on the skin. The nurse applied barrier cream to the skin. The Resident reported buttocks pain of 6 out of 10 and staff administered an as needed acetaminophen 325 milligrams (mg). The nursing notes and TAR failed to indicate staff obtained wound measurements on this date. Review of the NP note dated 11/6/23, indicated a visit: Decubitus. I could not see [his/her] backside today. [Resident] does have a well-known, well-established decubitus going back several months. Today, [Resident] seemed to believe there was a piece of metal in it. Or maybe [he/she] was in a metal box. [Resident] feels very uncomfortable. Both of [his/her] daughters, and [Resident], were in full agreement to try increased analgesics, beyond just Tylenol. We have agreed upon tramadol (an opioid medication to treat moderate to moderately severe pain) 50 mg every 6 hours as needed for now. This can be titrated up as needed. Review of the medical record failed to show the NP, or another provider, examined or measured Resident #182's wound on 11/6/23. Review of the NP note dated 11/7/23, indicated a visit to Resident #182. The note indicated Resident #182 remained somewhat uncomfortable. Decubitus noted. Continue with regular dressing changes. We will titrate up tramadol 50 mg every 6 to 4 hours, as needed (tramadol is an opioid medication used to relieve moderate to moderately severe pain). Review of the medical record failed to show the NP, or another provider, examined or measured Resident #182's wound on 11/7/23. Review of Resident #182's physician order dated 11/7/23, indicated: * Increase tramadol (pain medication) 50 mg as needed to every 4 hours. Review of the Skin Check assessment, dated 11/8/23, indicated: The following skin injury/wound(s) were previously identified and were evaluated as follows: Rash(s): Description: fungal rash groin Pressure Area(s): Location(s): coccyx wound. Midspine thoracic wound. The Skin Check assessment included the following care plan interventions: * Weekly skin check by licensed nurse. * Weekly wound assessment to include measurements and description of wound status. * Provide wound treatment as ordered. * Pat do not rub skin when drying. * Obtain dietitian consult as needed/ordered. * Provide supplements as ordered. * Provide patient and/or healthcare decision maker education regarding risk factors and interventions. * Provide preventative skin care lotions barrier creams as ordered. * Apply barrier cream with each dressing. * Assist resident with turning and repositioning every 2 hours. * Encourage resident to consume all fluids of choice. * Observe skin for signs and symptoms of skin breakdown. * Evaluate for any localized skin problems. * Observe skin condition daily during ADL care and report abnormalities. * Observe for verbal and non-verbal signs of pain related to wound/Tx. Review of the nursing note dated 11/8/23, indicated Resident #182 had a Stage 4 pressure ulcer on the coccyx, (Stage 4 ulcers are defined as deep wounds that may impact muscle, tendons, ligaments, and bone, which indicates Resident #182's wound deteriorated since admission). Resident #182 presented with some discomfort and was relieved from repositioning and scheduled pain medication. Resident #182's pain level was rated as mild and located on the coccyx. The following skin injury/wound(s) were previously identified and were evaluated as follows: Rash(s): Description: fungal rash groin, pressure area(s): Location(s): coccyx wound, midspine thoracic wound. Review of the nursing note dated 11/8/23 failed to indicate Resident #182's coccyx pressure ulcer and midspine thoracic wound were measured or described further, or that staff notified the physician that the coccyx wound progressed from a Stage 2 to a Stage 4, or the developement of the midspine thoracic wound. The nursing note did not indicate if staff applied a dressing treatment to either wound. Review of the NP note dated 11/8/23 indicated the NP visited Resident #182. The note indicated decubitus and to continue with regular dressing changes. The NP note dated 11/8/23, failed to indicate the coccyx or midspine thoracic wounds were examined or measured. Review of the nursing and provider notes from 11/9/23 indicated Resident #182's wounds were not examined or measured on this date. Review of the Risk Meeting note dated 11/10/23, indicated Resident #182 had an unstageable coccyx wound, no signs of infection, and a treatment was in place. No further notes were included. Review of the nursing note dated 11/10/23, indicated Resident #182 had a Stage 4 coccyx wound, was alert and oriented to self only. Resident #182 was pleasant and cooperative with care and presented with pressure area to coccyx. Staff repositioned the Resident side to side and he/she presented with moderate pain and relieved from repositioning and scheduled acetaminophen. The note did not reference the midspine thoracic wound. Review of the NP note dated 11/10/23, indicated: Decubitus. Continue with regular dressing changes. Review of the nursing and provider notes from 11/10/23 indicated Resident #182's wounds were not examined or measured on this date. Review of the care plan dated 11/11/23 for skin breakdown indicated goals and interventions were added on this date. The goal was for the coccyx wound to remain free of infection for 90 days. Interventions included: * Weekly skin check by licensed nurse * Weekly wound assessment to include measurements and description of wound status. * Provide wound treatment as ordered. * Pat do not rub skin when drying * Obtain dietitian consult as needed/ordered. * Provide supplements as ordered. * Provide patient and/or healthcare decision maker education regarding risk factors and interventions. * Provide preventative skin care lotions barrier creams as ordered. * Apply barrier cream with each dressing. * Assist resident with turning and repositioning every 2 hours. * Encourage resident to consume all fluids of choice. * Observe skin for signs and symptoms of skin breakdown. * Evaluate for any localized skin problems. * Observe skin condition daily during ADL care and report abnormalities. * Observe for verbal and non-verbal signs of pain related to wound/Tx. The updated care plan interventions dated 11/11/23, did not indicate an actual pressure ulcer to the coccyx, the progression of Resident #182's coccyx wound from Stage 2 to Stage 4, or include interventions to manage the deteriorated wound. The care plan did not reference the midspine thoracic wound. Review of the nursing and provider notes from 11/11/23, indicated Resident #182's wounds were not examined or measured on this date. Review of the nursing note dated 11/12/23 indicated Resident #182 had Stage 4 on his/her coccyx and was in moderate pain. 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). Review of the nursing and provider notes from 11/12/23, failed to indicate staff or providers examined or measured Resident #182's wounds on this date. Review of the NP note dated 11/13/23, indicated a sacral decubitus wound measuring about 3 inches x 1- 1 ½ inches [7.62 centimeters (cm) x 2.54/3.81 cm equaling approximately 29 square cm]. The bed of the wound is dark necrotic tissue [necrosis is the death of body tissue, often due to illness, infection, or lack of blood flow to the tissue], with a thin ring of yellow slough, and pink granulation. The necrotic center is not entirely dried out, but obviously very thin and, with palpation, is lying directly over the bone. There is no subcutaneous tissue between the necrotic base and [his/her] bone. Still, technically, this is unstageable. There was no significant surrounding erythema or induration consistent with soft tissue infection. The NP note dated 11/13/23 was the first documented NP examination and first measurement of Resident #182's wound since admission on [DATE]. Review of the NP and nursing notes dated 11/2/23 through 11/13/23, failed to indicate a discussion with the Resident or family members about treatment options for the coccyx wound, including the services of a wound specialist or surgeon, despite the wound's significant deterioration. Review of the NP note dated 11/14/23, indicated very advanced decubitus, very likely stage 4, but technically unstageable. The note indicated there was a likelihood of underlying sacral osteomyelitis and the focus of treatment is transitioning to comfort. The note indicated nursing staff will continue with dressing changes. The note indicated the NP did not believe the coccyx wound was healable. Review of the nursing note dated 11/14/23 indicated Resident #182 had an unstageable deep tissue injury (DTI) to coccyx with slough in center and macerated wound edges. The note indicated the Resident had a thoracic spine pressure area, skin was intact, and staff changed the protective dressing. The note did not indicate staff obtained wound measurements and did not reference the midspine thoracic wound. Review of the physician orders, provider notes and nursing notes indicated that during Resident #182's admission period the facility did not notify a provider that he/she had a midspine thoracic wound, or request an order for a protective dressing, or evaluate and measure this wound. Review of the nursing and provider notes from 11/14/23, failed to indicate staff or providers examined or measured #182's wounds on this date. Review of the NP note dated 11/15/23 indicated Resident #182 exhibited increased pain. Review of the NP note dated 11/16/23 indicated Resident #182 had extremely limited capacity for significant functional recovery, had not been out of bed since admission, and the focus of treatment was shifting to care and comfort. The NP note indicated his/her prognosis is very poor. The plan is for discharge home with hospice, as early as 11/20/2023. Review of the nursing and provider notes from 11/14/23, 11/15/23, 11/16/23 and 11/17/23 failed to indicate staff or providers examined or measured #182's wounds. Review of the nursing note dated 11/18/23, indicated Resident #182 presented with a wound to the coccyx 9 cm x 6.4 cm in total [approximately 58 square cm] 5/4 cm X 4 cm center necrotic area. Necrotic area surrounded by 0.2 cm yellow ring followed by red ring. Moderate purulent drainage noted on dressing. Odor noted. Dressing applied and pressure offloaded. Staff turned the Resident side to side throughout shift. The 11/18/23 nursing note was the first instance of nursing staff documenting measurements of Resident #182's coccyx wound since admission to the facility on [DATE]. The NP's coccyx wound me[TRUNCATED]