**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to protect three Residents (#20, #23, #26), from neglect, out of a total sample of 26 residents. Specifically, 1. For Resident #20, the facility neglected to a.) implement wound treatments as recommended by the Consultant Wound Physician resulting in the deterioration of a closed unstageable pressure injury to a Stage 4 pressure injury and b.) failed to follow up on a progress note indicating right hip redness dated 8/28/24, and implement the use of an air mattress. 2. For Resident #23, the facility neglected to implement treatment recommendations by the Wound Consultant Physician for wound care. 3. For Resident #26, the facility neglected to implement the treatments as recommended by the Consultant Wound Physician resulting in treatment being implemented without active physician's orders resulting in undocumented wound treatment being implemented and not implementing the Consultant Wound Physician's treatment orders on a newly identified pressure ulcer to the right hip and trauma area to the right, second toe. It was determined the Immediate Jeopardy began on 7/16/24 and was identified on 9/6/24. The Department of Public Health sent a Notice of Determination of Immediate Jeopardy to the Facility Administrator on 9/6/24, including the Immediate Jeopardy Templates. Findings include: Neglect, as defined at §483.5, means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The American Nurses Association (ANA), Scope of Nursing Practice, Third Edition, indicated Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, facilitation of healing, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, groups, communities, and populations. Review of the facility's policy Pressure Ulcer/Injury Risk Assessment undated, indicated the following: - The purpose of this procedure is to provide guidelines for the structured assessment and identification of residents at risk of developing pressure ulcers/injuries. The risk assessment should be conducted as soon as possible after admission, but no later than eight hours after admission is completed. Repeat the risk assessment weekly for the first four weeks, if there is a significant change in condition, or as often as is required based on the resident's condition. - Conduct a comprehensive skin assessment with every risk assessment. Once inspection of skin is completed document the findings on a facility-approved skin assessment tool. If a new skin alteration is noted, initiate a (pressure or non-pressure) form related to the type of alteration in skin. Develop the resident-centered care plan and interventions based on the risk factors identified in the assessments. The effects of the interventions must be evaluated. 1. Resident #20 was admitted to the facility in June 2024 with diagnoses including Alzheimer's disease, anemia, vitamin D deficiency, overactive bladder and cognitive communication deficit. Review of the Minimum Data Set (MDS) assessment, dated 6/23/24, indicated that Resident #20 had severely impaired cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15, and required assistance with activities of daily living. Further review of the MDS indicated that Resident #20 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 #20's Braden Scale for Predicting Pressure Injury Risk, dated 6/17/24, indicated a score of 15 indicating the resident is at risk for pressure injury development. On 9/3/24 at 8:58 A.M. and 9/4/24 at 8:05 A.M., the surveyor observed Resident #20 laying in bed with one prevalon boot (Prevalon Heel Protectors help reduce the risk of bedsores by keeping the heel floated, relieving pressure), placed on the right heel. His/her left heel was directly on the mattress and not elevated. There was no air mattress applied to the bed. Review of the facility document titled Skin Only Evaluation (Assessment tool used to evaluate resident's skin for any abnormalities, including the presence of any open areas or lesions) dated 7/3/24, indicated that Resident #20's skin was intact, no issues noted. Further review of the medical record indicated physician orders were implemented on 7/16/24 which included obtain pedal pulse every shift for wound ulcer and booties while in bed every shift for wound. The medical record failed to indicate any further documentation that a wound was identified on Resident #20, including the assessment, location, size of wound. Review of the facility document titled Skin Only Evaluation dated 7/17/24, indicated that Resident #20 had open lesions of the foot with a Right heel area measuring 2 cm(centimeters) x 2.5cm, with documented granulation, exudate, purulent, thin, thick, opaque, tan/yellow drainage, erythema. Tissue documented as painful and warm. The skin note indicated Right heel area with open wound injury 2cm x 2.5cm. Stage 3. New order: Wash with NS (normal saline). Apply Xeroform every day then cover with dry dressing and wrap as ordered. Booties at Hs (hour of sleep). Review of the medical record indicated Resident #20 was seen by the Consultant Wound Physician, on 7/18/24, and indicated one right heel unstageable DTI (Deep Tissue Injury), closed, surface area 30 cm, length 5 cm, width 6 cm, no depth, intact with purple/maroon discoloration. Treatment plan: Alginate calcium cover with ABD pad and kerlix daily. Off-load wound, float heels in bed. Review of the medical record failed to indicate the facility notified the attending providers of the recommendations from the wound consultant and failed implement the above wound treatment recommendations of the newly identified pressure injury on the right heel until 7/24/24; six days after the wound consultant first saw the Resident. Review of Nurse Practitioner #1's (NP) progress note dated 7/24/24, (nine days after the right heel pressure injury was first identified and six days after the Resident was first seen by the Consultant Wound Physician) indicated the following: Suspected deep tissue injury to right heel. Acute on chronic Right heel due to elevated wbc (white blood cells) with wound odor swelling. I will order Keflex 500mg by mouth for wound infection X 10 days, Probiotic 250 mg capsule twice daily X 15 days. Repeat lab 7/30 for CBC, CMP. continue in house wound team follow up. Review of the medical record indicated orders for Celphalexin 500 mg every 12 hours for infected right heel wound were not implemented until 8/2/24; 10 days after NP #1's note. Review of Resident #20's Skin Only Evaluation, dated 7/24/24, (the same date of NP's assessment and progress note indicating right heel infection) indicated no signs and symptoms of infection. The assessment further indicated wound exudate: purulent thin, thick, opaque, tan/yellow drainage. Peri wound condition: Erythema Dressing saturation moderate 26-75%. Tissue: Painful, warm. Skin note indicated Right heel area with open wound injury 2cm x 2.5cm. Stage 3. New order: Wash with NS. Apply Xeroform every day then cover with dry dressing and wrap as ordered. Booties at Hs. The skin only evaluation dated 7/24/24 indicated a new order for Xeroform dressing every day for the right heel pressure injury, however, this order had already been implemented on 7/17/24 and was inconsistent with the Wound Consultant recommendations for the use of Alginate Calcium on 7/18/24. Review of the Consultant Wound Physician note dated 7/25/24 indicated: undefined, exacerbated, wound is unstageable with necrosis (the death of tissues of the body due to lack of blood flow or oxygen) thick adherent devitalized necrotic tissue 100%. The progress of this wound and context surrounding the progress were considered in greater detail today. Patient not following repositioning or offloading recommendations and counseling provided. Reviewed off-loading surfaces and discussed surfaces care plan. Treatment plan: Apply hydrogel with silver and xeroform gauze cover with ABD pad and kerlix daily. Off-load wound, float heels in bed. Review of the medical record failed to indicate nursing implemented the above wound treatment recommendations until 7/27/24; two days after the recommendation was made. Review of the physician order, dated 7/27/24 through 9/3/24, indicated: right heel full thickness wash with NS, pat dry, apply xeroform gauze then hydrogel with silver change daily then ABD pad wrap with kerlix change daily. Off load wound, float heel in bed one time a day for wound care. Review of the NP's's note dated 7/29/24, indicated the following: Right heel cellulitis. Patient was recently evaluated for new right heel DTI infection and elevated WBC Keflex was added to medication list. Today follow up visit reviewed inhouse wound team visit summary agreed with plan. Review of the Resident #20's Skin Only Evaluation, dated 7/31/24, indicated: skin was warm/dry and indicated a Stage 4 wound to the right heel with copious drainage, no foul odor. The skin only evaluation failed to indicate any measurements or any further assessment of the wound. The medication administration record contained two active physician orders in place for the same right heel wound from 7/31/24 through 9/2/24 as follows: -right heel full thickness unstageable wash with normal saline padded dried apply xerofoam gauze then hydrogel with silver change daily then abd pad wrap with kerlix change daily offload wound float heel in bed one time a day for wound care. Dated (7/27/24-9/3/24). -site unstageable due to necrosis of the right heel full thickness wash with normal saline apply xerofam gauze hydrogel one daily Abd bad [SIC] wrap with kling [NAME] [SIC] daily one time a day for tage [SIC] 4 wound in right heel. Dated (7/31/24-9/3/24). Further review of the MAR (Medication Administration Record) indicated the nursing staff documented both orders as administered to Resident #20's right heel for 34 days. (One order containing hydrogel with silver and one order containing hydrogel only- both being signed off on the same day). Review of the medical record indicated Resident #20 was seen by the Consultant Wound Physician on 8/1/24, and 8/8/24, and indicated Stage 4 pressure wound of the right heel full thickness. Treatment recommendation is: Apply hydrogel with silver and xeroform gauze cover with ABD pad and kerlix daily. Review of NP's note dated 8/5/24, indicated the following: Nursing report poor appetite with poor wound healing. Pt (patient) recently completed antibiotic for right heel cellulitis with good effect. Today follow up visit reviewed inhouse wound team visit summary agreed with plan. Notify provider with acute suspected deep tissue injury. Acute on chronic site unstageable due to necrosis of the right heel full thickness. This documentation was inconsistent as the Resident now has a Stage 4 right heel wound as documented by the Consultant Wound Physician on 8/1/24 and 8/8/24. Review of the medical record indicated Resident #20 was seen by the Consultant Wound Physician on 8/14/24, 8/22/24, and 8/29/24, which indicated granulation, stage 4 pressure injury. Treatment recommendation indicated: Start Alginate calcium once daily cover with ABD pad and kerlix. Off load wound, float heels in bed. Review of the medical records indicated that the Wound Consultant's recommendations for the use of alginate calcium was not implemented until 9/4/24; a total of 22 days since his/her recommendations. Additionally, staff continued to document the administration of the two additional orders for the use of hydrogel with and without silver. During an interview on 9/4/24 at 9:01 A.M. Nurse #5 said Resident #20 has a right heel wound and that measurements are done weekly by the Wound Consultant. Nurse #5 said there is no unit manager or Director of Nurses (DON) currently and he does not have access to the wound recommendations and visit notes. Nurse #5 said the DON is the only one who had access to the wound recommendations and treatments visit notes. During an interview on 9/4/24 at 9:28 A.M Project Manager #1 said the DON is the only person with access to the Consultant Wound Physician visit and recommendation visit notes and that she has been out of the building since 8/22/24. Project Manager #1 said he would need to call the company to get access to the visit notes. During an interview on 9/5/24 at 8:12 A.M., the Consultant Wound Physician said he expects recommendations to be followed, and that Resident #20 should not have duplicate treatment orders for the same wound because hydrogel and hydrogel with silver are two different treatment orders. The Consultant Wound Physician said Hydrogel with silver helps to stop the growth of microorganisms and regular hydrogel does not contain the antimicrobial barrier. The Consultant Wound Physician said Resident #20 requires and air-mattress and prevalon booties to both heels because he/she is at risk for pressure areas and requires turning and repositioning. The Consultant Wound Physician said he has recommended these preventative measures to the nursing staff and clinical management and expects them to be implemented and said Residents who are high risk for pressure ulcers require off-loading interventions. During an interview on 9/5/24 at 12:25 P.M., the Medical Director (MD) said he expects the wound treatment recommendations and orders to be implemented and followed. MD #1 said he expects a tracking system to be in place and reviewed by clinical management to update the plan of care and to track wound progression. MD #1 said he expects senior management to be diligent and implement measures for clinical oversight for all residents. MD #1 said clinical oversight is needed and must have access to the wound treatment recommendations and status of wounds. During an interview on 9/5/24 at 11:56 A.M., the Administrator said he has no knowledge of wounds, infections, or any recommendations not being followed and that he was not aware that Resident #20 had an infected wound that progressed to a Stage 4. The Administrator said the DON should have known orders were not followed and treatment recommendations not implemented correctly and said he would not be notified of wounds unless its relevant and that wounds and infections are discussed only if there are concerns during the quarterly QAPI meeting. The Administrator said nursing staff should have access to the wound recommendations and that orders should be updated. 1b. Resident #20 developed a right hip wound as indicated on a skin check dated 9/11/24. The facility failed to implement the use of an air mattress and failed to follow up on a progress note indicating right hip redness dated 8/28/24. Review of the facility policy titled Bed Safety-Air Mattress-Side Rails undated, indicated but was not limited to the following: - It is the policy of the facility to provide air mattress, with a physician's order, to residents who are bedridden, have limited mobility, are at high risk for pressure sores on the buttocks/hips or who are recovering from a wound. Nursing will follow these procedures: - Obtain a physicians order for an air mattress. - Apply air mattress to residence bed. - Follow manufacturers instructions for use in care of the mattress. - The mattress should be pumped in accordance with their residence weight. - Document all skin assessments. - Maintenance will audit quarterly or as needed to determine proper usage of the air mattress. Review of medical record indicated Resident #20 was being followed weekly by the Wound Consultant Physician as of 7/18/24, for the development of a DTI to the right heel. Further review of the medical record indicated the Wound Consult Physician made recommendations to off load wound, float heels while in bed and the use of pressure relieving boots and an air mattress. Review of the Care Plan's for Resident #20 included but was not limited to the following: - I need heels kept off bed by and prevent direct contact between bony prominences keep heels off load. - Evaluate wound for: Size, Depth, Margins: peri-wound skin, sinuses, undermining, exudates, edema, granulation, infection, necrosis, eschar, gangrene. Document progress in wound healing on an ongoing basis. Notify physician as indicated. 7/25/24 prevalon boot at all times keep elevated at all times keep feet off load feet off load keep elevated and off load. (Dated: 7/26/24). - Booties while in bed (Dated 7/16/24) - ADL Self- Care Performance Deficit, included the following interventions dated 7/10/24, and revised on 8/31/24: - Bed Mobility: I required, 2 staff participation to reposition and turn in bed. I required an Air Mattress d/t (due to) stage 4 ulcer on my heel, and I am at risk for further skin breakdown. - Skin Inspection: I required, SKIN inspection daily. Observe for redness, open areas, scratches, cuts, bruises and report changes to the nurse. - Wound Management due to DTI care plan, initiated on 8/2/24 and last revised 8/31/24: - Provide wound care per treatment order. I require an air mattress. (Dated 8/2/24). On 9/3/24 at 8:58 A.M., 9/4/24 at 8:05 A.M., 9/4/24 at 1:03 P.M., 9/6/24 at 8:05 A.M., and 9/9/24 at 8:00 A.M., the surveyor observed Resident #20 lying in bed on his/her left side with one prevalon boot placed on the right heel. The left heel was directly on the mattress and was not elevated. There was no air mattress applied to the bed. The observations made by the surveyor during the survey revealed that Resident #20's care planned interventions related to the use of prevalon boots to bilateral feet, offloading and the use of an air mattress were not implemented. Review of the physician's orders for Resident #20 indicated the following: - May use prevalon boot every shift for use for skin protection (7/26/24). - May have booties all the time every shift (9/5/24). Further review of the medical record failed to indicate an order was in place for the use of an air mattress. Review of NP's note dated 8/28/24, indicated the following: Nursing requested right hip redness, and in house wound visit with rec (recommendation). Pt (patient) recently completed antibiotic for right heel cellulitis with good effect. Today follow up visit reviewed in house wound team visit summary agreed with plan. Cellulitis right heel suspected DTI. Further review if the medical record failed to indicate Nurse #4 documented the right hip redness to Resident #20 hip, despite being reported to NP. Review of Resident #20's Skin Only Evaluation, dated 9/11/24, (15 days after right hip redness was first documented in NP #1's note) indicated the following: - Pressure Ulcer/ Injury Right Hip, Stage 2 (Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible). -Pressure Ulcer / injury Right Heel, Stage 4 Full thickness tissue loss. Area on right heel, moderate serosanguineous drainage on old dressing, no foul odor, wound measuring 3.8cm x 2.6cmx no depth; wound bed remains red with healthy tissues surrounding the area; skin pink. Wound washed with NS, applied Calcium Alginate, cover with ABD and wrap with Kerlix as ordered. Further review of the medical record indicated Resident #20 was seen by the Consultant Wound Physician on 9/12/24, and indicated the following: - Wound 1 Stage 4 Pressure Right Heel - Wound 2 Unstageable (due to necrosis) of Right Hip Full Thickness - Wound 3 Unstageable DTI of the Right, First Toe Undetermined Thickness - Wound 4 Unstageable DTI of the Right Ankle Undetermined Thickness The nursing skin assessments completed on 9/11/24 and 9/12/24 indicated Resident #20 developed three additional areas on right 1st toe, right ankle and right hip. Resident #20 had a total of 4 wounds identified, 3 identified as new wounds. During an interview on 9/5/24, at 8:09 A.M., Certified Nurse's Aide (CNA) #7 said that he was not aware that Resident #20 should have his/her legs elevated and that Resident #20 does not have an air-mattress. During an interview on 9/5/24 at 8:11 A.M., Nurse #5 said Residents with skin issues will have an air mattress and heel botties in place to prevent skin breakdown and the plan of care will be updated so staff know what the resident needs for care. During an interview on 9/4/24 at 9:44 A.M., NP said she was notified by staff that Resident #20 had right hip redness and that she did not visualize the resident's skin. NP said she was not aware that Resident #20 did not have an air mattress in place and said Residents at high risk for pressure ulcers should have an air mattress and heel booties in place and she expects staff to notify her of any new skin issues or if wounds are getting worse and that she expects preventative measures to be implemented and followed to prevent the wounds from deteriorating. The NP said she would expect the orders and care plan interventions be followed and said resident #20 requires and air mattress and prevalon booties to both feet. During an interview on 9/5/24 at 8:02 A.M., Nurse #4 said if a new skin area is observed there should be a skin check indicating the new area and the NP or MD will be notified. Nurse #4 said she notified NP #1 that Resident #20 had redness to his/her right hip and that he/she was seen by the wound physician but was not aware of any new orders or follow up because the DON has been out. During an interview on 9/5/24 at 8:09 A.M., the Consultant Wound Physician said Resident #20 requires an air mattress and prevalon boots to both heels because he/she is high risk for wounds and has wounds that need preventative measures. The Consultant Wound Physician said wound recommendations have not been implemented on admission and said he expects recommendations and preventative measures to be followed. The Consultant Wound Physician said Resident #20 is high risk for more pressure areas and prevalon booties, air-mattress and elevation of the legs at all times are needed and should have been implanted because he/she is dependent on staff and can't turn and reposition without staff assistance. During an interview and observation on 9/16/24 at 7:47 A.M., the surveyor along with Nurse #8, The MDS Nurse, and Nurse #6 observed Resident #20 during a wound dressing change. Nurse #8 said Resident #20 has wounds to his/her right hip, right heel, and right toe. Nurse #6 said the resident does not have any other skin areas and that a skin check was completed, and these new areas were identified. The surveyor asked Nurse #8 and the Nurse #6 to turn and reposition the Resident to look observe the Residents skin. The Resident was repositioned and the surveyor asked Nurse #8 to open the brief covering the left hip, observed was intact pink/maroon skin with a localized area of non-blanchable erythema. The Nurse #6 said the area is a pressure area on his/her left hip bone in the same location as the pressure area to the right hip bone. Upon further skin inspection, Resident #20 was observed to have an open skin area to the left ankle, with pink and red drainage. Nurse #6 said the area to the left ankle is a Stage 2 wound that should have a dressing in place due to drainage. During an interview on 9/16/24 at 8:05 A.M., the Nurse #6 said the open wound is a Stage 2 and the area on the left hip bone is pressure that needs to be reported and documented. Nurse #6 said staff should have reported and documented any new areas observed when providing care and during any skin checks or dressing changes. 3. Resident #26 was admitted to the facility in July 2024 with diagnoses including pressure ulcer of left buttock stage 2, pressure ulcer of right upper back, non-pressure chronic ulcer of skin of other sites and dementia. Review of Resident #26's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Status score of 4 out of a possible 15 indicating severe cognitive impairment. Further review of Resident #26's MDS under section M indicated that the Resident is at risk for developing pressure ulcers and has one or more unhealed pressure ulcers/injuries. Review of Resident #26's physician's orders indicated the following: - Dated 8/1/24: weekly skin assessment on Thursday 7-3 shift one time a day every Thu (Thursday). - Dated 7/30/24: May be seen by the wound doctor. - Dated 7/31/24: wash left wound heel with normal saline apply Santyl Ointment cover with 4x4 then wrap with kling as of 7/19/24. Review of Resident #26's assessment titled Admit/Readmit Screener, dated 7/18/24 under Section C. Skin Integrity indicated the following: - Site: left mid-back, Type: Pressure, Length: 3, Width: 3, Stage: II - Site: Coccyx, Type: Pressure, Length: 4, Width: 5, Stage: IV - Site: Left Heel, Type: Scar, Length: 4, Width: 4, Stage: IV - Site: Right Heel, Type: Scar, Length: 3, Width: 3, Stage: Unstageable - Site: Ischial Chronic Wound, Type: Pressure, Length: 1, Width: 1, Depth: 2,3, Stage: IV - Details/Comments: Tunneling 7.2 cm (centimeters) nsw aquacel AGrope packing 3x week cover with boder [sic] gauze. Bilateral heel escar apply skin prep daily cover with boarder from dgs (dressings). Review of Resident #26's document titled Braden Scale for Predicting Pressure Ulcer Risk, dated 7/18/24 indicated that the Resident was at a Moderate Risk for developing pressure ulcers. Review of Resident #26's Wound Evaluation & Management Summary developed by the Consultant Wound Physician during his weekly visits with Resident #26 indicated the following: - Dated 8/1/24: -Stage 3 Pressure Wound of the Left Heel, Dressing Treatment Plan - Primary Dressing(s): Xeroform gauze apply once daily for 30 days; Hydrogel gel w/silver apply once daily for 30 days. Secondary Dressing(s): ABD pad apply once daily for 30 days; Gauze roll (kerlix) 4.5 apply once daily for 30 days - Wound of left foot, fourth toe, Dressing Treatment Plan - Primary Dressing(s): Xeroform gauze apply once daily for 30 days; Hydrogel gel w/silver apply once daily for 30 days. Secondary Dressing(s): Gauze Island w/ bdr (border) apply once daily for 30 days - Dated 8/8/24: -Stage 3 Pressure Wound of the Left Heel, Dressing Treatment Plan - Primary Dressing(s): Xeroform gauze apply once daily for 23 days; Hydrogel gel w/silver apply once daily for 23 days. Secondary Dressing(s): ABD pad apply once daily for 23 days; Gauze roll (kerlix) 4.5 apply once daily for 23 days - Wound of left foot, fourth toe, Dressing Treatment Plan - Primary Dressing(s): Xeroform gauze apply once daily for 23 days; Hydrogel gel w/silver apply once daily for 23 days. Secondary Dressing(s): Gauze Island w/ bdr apply once daily for 23 days. - Non-Pressure Wound of left buttock, Primary Dressing(s): Alginate Calcium apply once daily for 23 days. Secondary Dressing(s): Gauze Island w/ bdr apply once daily for 23 days. - Non-pressure wound of the right, second toe, Dressing Treatment Plan - Primary Dressing(s): Skin prep once daily for 30 days. - Non-pressure wound of the right shin, etiology: Dressing Treatment Plan - Primary Dressing(s): Xeroform gauze apply once daily for 30 days; Hydrogel gel w/silver apply once daily for 30 days. Secondary Dressing(s): Gauze Island w/ bdr apply once daily for 30 days - Dated 8/14/24: -Stage 3 Pressure Wound of the Left Heel, Dressing Treatment Plan - Primary Dressing(s): Xeroform gauze apply once daily for 17 days; Hydrogel gel w/silver apply once daily for 17 days. Secondary Dressing(s): ABD pad apply once daily for 17 days; Gauze roll (kerlix) 4.5 apply once daily for 17 days - Wound of left foot, fourth toe, Dressing Treatment Plan - Primary Dressing(s): Xeroform gauze apply once daily for 17 days; Hydrogel gel w/silver apply once daily for 17 days. Secondary Dressing(s): Gauze Island w/ bdr apply once daily for 17 days. - Non-Pressure Wound of left buttock, Primary Dressing(s): Alginate Calcium apply once daily for 17 days. Secondary Dressing(s): Gauze Island w/ bdr apply once daily for 17 days. - Non-Pressure Wound of the Right, Second Toe, Dressing Treatment Plan - Primary Dressing(s): Xeroform gauze apply once daily for 17 days; Hydrogel gel w/silver once daily for 17 days. Secondary Dressing(s): Gauze island w/bdr apply once daily for 17 days. - Non-pressure wound of the right shin, Dressing Treatment Plan - Primary Dressing(s): Xeroform gauze apply once daily for 24 days; Hydrogel gel w/silver apply once daily for 24 days. Secondary Dressing(s): Gauze Island w/ bdr apply once daily for 24 days - Dated 8/22/24: -Stage 3 Pressure Wound of the Left Heel, Dressing Treatment Plan - Primary Dressing(s): Xeroform gauze apply once daily for 9 days; Hydrogel gel w/silver apply once daily for 9 days. Secondary Dressing(s): ABD pad apply once daily for 9 days; Gauze roll (kerlix) 4.5 apply once daily for 9 days - Wound of left foot, fourth toe, Dressing Treatment Plan - Primary Dressing(s): Xeroform gauze apply once daily for 9 days; Hydrogel gel w/silver apply once daily for 9 days. Secondary Dressing(s): Gauze Island w/ bdr apply once daily for 9 days. - Non-Pressure Wound of left buttock, Dressing Treatment Plan - Primary Dressing(s): Alginate Calcium apply once daily for 9 days. Secondary Dressing(s): Gauze Island w/ bdr apply once daily for 9 days. - Non-Pressure Wound of the Right, Second Toe, Dressing Treatment Plan - Primary Dressing(s): Xeroform gauze apply once daily for 9 days; Hydrogel gel w/silver once daily for 9 days. Secondary Dressing(s): Gauze island w/bdr apply once daily for 9 days. - Dated: 8/29/24: -Stage 3 Pressure Wound of the Left Heel, Dressing Treatment Plan - Primary Dressing(s): Xeroform gauze apply once daily for 30 days; Hydrogel gel w/silver apply once daily for 30 days. Secondary Dressing(s): ABD pad apply once daily for 30 days; Gauze roll (kerlix) 4.5 apply once daily for 30 days. - Wound of left foot, fourth toe, Dressing Treatment Plan - Primary Dressing(s): Xeroform gauze apply once daily for 30 days; Hydrogel gel w/silver apply once daily for 30 days. Secondary Dressing(s): Gauze Island w/ bdr apply once daily for 30 days. - Non-Pressure Wound of left buttock, Dressing Treatment Plan - Primary Dressing(s): Alginate Calcium apply once daily for 30 days. Secondary Dressing(s): Gauze Island w/ bdr apply once daily for 30 days. &nbs[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide care and treatment to prevent the development and worsening of pressure injury's (wounds that occur when the skin and tissue are damaged by prolonged pressure, usually on bony areas like the coccyx, hips, heels, or elbows) for three Residents (#20, #23, and #26) out of a total sample of 26 residents. Specifically, 1a. For Resident #20 the facility failed to implement treatments and physician orders recommended by the Consultant Wound Physician resulting in the wound requiring antibiotic therapy resulting in the deterioration of an unstageable pressure wound progressing to a Stage 4 pressure injury. 1b. For Resident #20 the facility failed to implement the use of an air mattress and failed to follow up on a progress note indicating right hip redness dated 8/28/24 resulting in the development of a right hip wound as indicated on a skin check dated 9/11/24. 2. For Resident #23, the facility failed to implement treatment recommendations by the Wound Consultant Physician for wound care. 3. For Resident #26, the facility failed to implement treatment recommendations by the Wound Consultant Physician for wound care. Findings include: According to the National Pressure Injury Advisory Panel, a Stage 4 Pressure Injury is defined as a full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in injury. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and /or tunneling often occur. Depth varies by anatomical location. Review of the facility's policy Pressure Injury/Injury Risk Assessment, undated, indicated the following: - The purpose of this procedure is to provide guidelines for the structured assessment and identification of residents at risk of developing pressure injurys/injuries. The risk assessment should be conducted as soon as possible after admission, but no later than eight hours after admission is completed. Repeat the risk assessment weekly for the first four weeks, if there is a significant change in condition, or as often as is required based on the resident's condition. - Conduct a comprehensive skin assessment with every risk assessment. Once inspection of skin is completed document the findings on a facility-approved skin assessment tool. If a new skin alteration is noted, initiate a (pressure or non-pressure) form related to the type of alteration in skin. Develop the resident-centered care plan and interventions based on the risk factors identified in the assessments. The effects of the interventions must be evaluated. - The care plan must be modified as the resident's condition changes, or if current interventions are deemed inadequate. - Contact the Medical Director for updated orders. Contact the Wound Doctor for a scheduled visit. Documentation in medical record addressing (MD) notification if new skin alteration noted with change of plan of care, if indicated. Notify attending (MD) if new skin alteration noted. Review of the facility policy, titled Decubitus Prevention, revised 2/4/21, indicated but was not limited to the following: It is the policy of the facility to prevent the formation of pressure sores and other skin breakdowns. - All residents shall be assessed upon admission, quarterly and periodically for the risk of skin breakdown by a licensed staff member. This assessment shall be done using the Norton Scale and by careful review of history, health conditions, environment, medications, nutrition, as well as visualization of the resident's body. The Norton Score will indicate a resident's risk for skin breakdown. To avoid breakdowns a preventative program shall be instituted by the Unit Manager which will include a repositioning schedule, a consult with the Dietician, notification of the attending physician, and use of pressure relieving devices. Skin care treatments will be documented by the licensed nurse and the appropriate areas of the residence chart. All residents at risk for skin breakdown will be care planned quarterly and as needed skin barrier will be used on all residents. 1a. Resident #20 was admitted to the facility in June 2024 with diagnoses including Alzheimer's disease, anemia, vitamin D deficiency, overactive bladder and cognitive communication deficit. Review of Resident #20's Minimum Data Set (MDS) assessment, dated 6/23/24, indicated that Resident #20 had severely impaired cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15, and required assistance with activities of daily living. Further review of the MDS indicated Resident #20 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 #20's Braden Scale for Predicting Pressure Injury Risk, dated 6/17/24, indicated a score of 15 indicating the Resident is at risk for developing pressure injuries. On 9/3/24 at 8:58 A.M., the surveyor observed Resident #20 laying in bed with one prevalon boot (Prevalon Heel Protectors help reduce the risk of bedsores by keeping the heel floated, relieving pressure), placed on his/her right heel. The left heel was observed to be directly on the mattress and was not elevated. There was no air mattress applied to the bed. On 9/4/24 at 8:05 A.M., the surveyor observed Resident #20 laying in bed with one prevalon boot placed on the right heel. The left heel was observed to be directly on the mattress and was not elevated. There was no air mattress applied to the bed. Review of the facility document titled Skin Only Evaluation (Assessment tool used to evaluate resident's skin for any abnormalities, including the presence of any open areas or lesions) dated 7/3/24, indicated Resident #20's skin was intact, no issues noted. Further review of Resident #20's medical record indicated physician orders were put into place on 7/16/24 which included obtain pedal pulse every shift for wound ulcer and booties while in bed every shift for wound. The medical record failed to indicate any further documentation that a wound was identified on Resident #20, including the assessment, location, size of wound. During an interview on 9/5/24 at 8:06 A.M., Nurse #5 said treatment orders are entered if staff identify new skin areas until the resident can be seen by the wound doctor. Nurse #5 said the Nurse Practitioner (NP) or MD (medical doctor) will review the orders in the recommendations book and if the provider wants to change them they will let the nurses know. Nurse #5 said if a new skin area is observed there should be a skin check when it was first found. Review of the facility document titled Skin Only Evaluation dated 7/17/24, indicated that Resident #20 had open lesions of the foot with a right heel area measuring 2 cm (centimeters) x 2.5 cm, with documented granulation, exudate, purulent, thin, thick, opaque, tan/yellow drainage, erythema. Tissue documented as painful and warm. The skin note indicated Right heel area with open wound injury 2 cm x 2.5 cm. Stage 3. New order: Wash with NS (normal saline). Apply Xeroform every day then cover with dry dressing and wrap as ordered. Booties at Hs (hour of sleep). Further review of Resident #20's medical record indicated the above order was implemented to the Stage 3 on the right heel on 7/17/24, however the medical record failed to indicate the provider was notified of the newly identified pressure injury on the right heel. During an interview on 9/5/24 at 8:09 A.M., Nurse #4 said the right heel area was identified on Resident #20 on 7/16/24 and an order was entered, however the skin assessment was not completed until 7/17/24. Nurse #4 said nursing staff put in orders until the Resident is seen by the wound doctor. Review of the medical record indicated Resident #20 was seen by the Consultant Wound Physician, dated 7/18/24, and indicated one right heel unstageable DTI (Deep Tissue Injury), closed, surface area 30 cm, length 5 cm, width 6 cm, no depth, intact with purple/maroon discoloration. Treatment plan: Alginate calcium cover with ABD pad and kerlix daily. Off-load wound, float heels in bed. Review of the medical record failed to indicate the facility notified the attending providers of the recommendations from the wound consultant and failed implement the above wound treatment recommendations of the newly identified pressure injury on the right heel until 7/24/24, 6 days after the wound consultant first saw the Resident. Review of Nurse Practitioner (NP) progress note dated 7/24/24, (9 days after the right heel pressure injury was first identified and 6 days after the Resident was first seen by the wound consultant MD) indicated the following: Suspected deep tissue injury to right heel. Acute on chronic Right heel due to elevated wbc (white blood cells) with wound odor swelling. I will order Keflex (antibiotic) 500 mg by mouth for wound infection X (times) 10 days, Probiotic 250 mg capsule twice daily X 15 days. continue in house wound team follow up. Further review of the medical record indicated on 7/24/24 the Resident started Keflex 500 mg every 12 hours for infected wound in the right heel until 8/2/24. During an interview on 9/5/24 at 8:12 A.M., the Consultant Wound Physician said Resident #20 had an unstageable DTI that required antibiotics for an infection and that wound treatments must be followed to promote healing. The Consultant Wound Physician said Alginate Calcium sterile primary dressing for wounds with moderate to heavy exudate /drainage, while maintaining a moist wound environment), is used to promote healing and he expects orders to be followed. Review of Resident #20's Skin Only Evaluation, dated 7/24/24, (the same date of the NP's assessment and progress note indicating right heel infection) indicated no signs and symptoms of infection. The assessment further indicated wound exudate: purulent thin, thick, opaque, tan/yellow drainage. Peri wound condition: Erythema Dressing saturation moderate 26-75%. Tissue: Painful, warm. Skin note indicated Right heel area with open wound injury 2 cm x 2.5 cm. Stage 3. New order: Wash with NS. Apply Xeroform every day then cover with dry dressing and wrap as ordered. Booties at Hs (hour of sleep). The skin only evaluation dated 7/24/24, indicated a new order for Xeroform dressing every day for the right heel pressure injury however this order had already been implemented on 7/17/24 and was inconsistent with the wound consultant recommendations on 7/18/24. During an interview on 9/4/24 at 9:42 A.M., NP #1 said staff must document skin checks accurately at the time of the assessment and when skin issues are identified, they must document findings and notify providers for any new treatment or medication orders before implementing them. Review of the medical record indicated Resident #20 was seen by the Consultant Wound Physician, dated 7/25/24, and indicated undefined, exacerbated, wound is unstageable with necrosis, thick adherent devitalized necrotic tissues 100%. Expanded evaluation performed: The progress of this wound and the context surrounding the progress were considered in greater detail today. Patient not following repositioning or off-loading recommendations and counseling provided. Reviewed off-loading surfaces and discussed surfaces care plan. Treatment plan: Apply hydrogel with silver and xeroform gauze cover with ABD pad and kerlix daily. Off-load wound, float heels in bed. Review of the medical record failed to indicate nursing implemented the above wound treatment recommendations until 7/27/24, 2 days after the recommendation was made. During an interview on 9/5/24 at 8:10 A.M., the Consultant Wound Physician said Resident #20 requires and air-mattress and prevalon booties to both heels because he/she is at risk for pressure areas and requires turning and repositioning. The Consultant Wound Physician said an air mattress should have been in place when Resident #20 first developed the skin issue to the right heel and, he has recommended these preventative measures to the nursing staff as well as clinical management and expects them to be implemented and said Residents who are high risk for pressure ulcers require off-loading interventions. Review of Resident #20's physician order, dated 7/27/24 through 9/3/24, indicated right heel full thickness wash with NS, pat dry, apply xeroform gauze then hydrogel with silver change daily then ABD pad wrap with kerlix change daily. Off load wound, float heel in bed one time a day for wound care. Review of NP #1's note dated 7/29/24, indicated the following: Right heel cellulitis. Patient was recently evaluated for new right heel DTI infection and elevated WBC Keflex was added to medication list. Today follow up visit reviewed inhouse wound team visit summary agreed with plan. During an interview on 9/4/24 at 9:42 A.M., NP said she does not have access to wound recommendation or visit notes and she relies on the nursing staff to notify her of any new or worsening skin issues. The NP said she may have been told by staff that Resident #20 had cellulitis and that is why she documented it in her note. Review of the Resident #20's Skin Only Evaluation, dated 7/31/24, indicated, skin was warm/dry and indicated a Stage 4 wound to the right heel with copious drainage, no foul odor. The skin only evaluation failed to indicate any measurements or any further assessment of the wound. Further review of the medical record indicated a second wound treatment order was implemented on 7/31/24 to the right heel. Which indicated site unstageable due to necrosis of the right heel full thickness, wash with normal saline, apply Xeroform gauze, hydrogel once daily ABD pad wrap with Kling change daily. The medication administration record contained two active physician orders in place for the same right heel wound from 7/31/24 through 9/2/24 as follows: - right heel full thickness unstageable wash with normal saline padded dried apply xerofoam gauze then hydrogel with silver change daily then abd pad wrap with kerlix change daily offload wound float heel in bed one time a day for wound care. Dated (7/27/24-9/3/24). - site unstageable due to necrosis of the right heel full thickness wash with normal saline apply xerofam gauze hydrogel one daily Abd bad [SIC] wrap with kling [NAME] [SIC] daily one time a day for tage [SIC] 4 wound in right heel. Dated (7/31/24-9/3/24). Further review of Resident #20's MAR (Medication Administration Record) indicated the nursing staff documented both orders as administered to Resident #20's right heel for 34 days. (One order containing hydrogel with silver and one order containing hydrogel only- both being signed off on the same day). During an interview on 9/5/24 at 8:12 A.M., Nurse #4 said she did not realize that there were two treatments and that she does not recall documenting two different orders even though they are singed off and said most residents receive hydrogel for wounds. Review of the medical record indicated Resident #20 was seen by the Consultant Wound Physician on 8/1/24, and 8/8/24, and indicated Stage 4 pressure wound of the right heel full thickness. Treatment recommendation is: Apply hydrogel with silver and xeroform gauze cover with ABD pad and kerlix daily. Review of the medical record indicated Resident #20 continued to have two active physician orders in place for the same right heel wound. During an interview on 9/5/24 at 8:12 A.M., the Consultant Wound Physician said he expects recommendations to be followed, and that Resident #20 should not have duplicate treatment orders for the same wound because hydrogel and hydrogel with silver are two different treatment orders. The Consultant Wound Physician said Hydrogel with silver helps to stop the growth of microorganisms and regular hydrogel does not contain the antimicrobial barrier. During an interview on 9/5/24 at 12:25 P.M., the Medical Director (MD) said he is not always made aware of orders that are entered under his name and that staff have been told not to enter orders unless they speak directly with providers. The MD said he was not aware that Resident #20 had a pressure area that developed an infection and deteriorated to a Stage 4 wound and he was not aware that Resident #20 was receiving two different treatment orders for the same wound and said he expects nursing staff to follow recommendations by the wound physician and discontinue orders that are no longer recommended by the wound physician. Review of NP's note dated 8/5/24, indicated the following: - Nursing report poor appetite with poor wound healing. Pt (patient) recently completed antibiotic for right heel cellulitis with good effect. Today follow up visit reviewed inhouse wound team visit summary agreed with plan. Notify provider with acute suspected deep tissue injury. Acute on chronic site unstageable due to necrosis of the right heel full thickness. This documentation was inconsistent as the Resident now has a Stage 4 right heel wound as documented by the Consultant Wound Physician on 8/1/24 and 8/8/24. During an interview on 9/4/24 at 9:46 A.M., the NP said she does not have access to wound recommendation or visit notes and she relies on the nursing staff to notify her of any new or worsening skin issues. NP said she was not aware that Resident #20 had a wound that deteriorated to a Stage 4 wound on 8/1/24 and is not aware of recommendations unless she is notified by nursing. Review of the medical record indicated Resident #20 was seen by the Consultant Wound Physician on 8/14/24, 8/22/24, and 8/29/24, which indicated granulation, stage 4 pressure injury. Treatment recommendation indicated: Start Alginate calcium once daily cover with ABD pad and kerlix. Off load wound, float heels in bed. Review of the medical record failed to indicate nursing implemented the above wound treatment recommendations until 9/4/24 (a total of 22 days from the wound consultants first recommendation on 8/14/24) and continued to document the administration of the two previous orders for hydro gel with and without silver. During an interview on 9/5/24 at 12:25 P.M., the Medical Director said he expects the wound treatment recommendations and orders to be implemented and followed. The Medical Director said he expects a tracking system to be in place and reviewed by clinical management to update the plan of care and to track wound progression. The Medical Director said he expects senior management to be diligent and implement measures for clinical oversight for all residents. The Medical Director said clinical oversight is needed and must have access to the wound treatment recommendations and status of wounds. During an interview on 9/4/24 at 9:01 A.M. Nurse #5 said Resident #20 has a right heel wound and that measurements are done weekly by the Wound Consultant. Nurse #5 said there is no unit manager or Director of Nurses (DON) currently and he does not have access to the wound recommendations and visit notes. Nurse #5 said the DON is the only one who had access the wound recommendations and treatments visit notes. During an interview on 9/4/24 at 9:28 A.M., Project Manager #1 said the DON is the only person with access to the Consultant Wound Physician visit and recommendation visit notes and that she has been out of the building since 8/22/24. Project Manager #1 said he would need to call the company to get access to the visit notes. During an interview on 9/5/24 at 11:56 A.M., the Administrator said he has no knowledge of wounds, infections, or any recommendations not being followed and that he was not aware that Resident #20 had an infected wound that progressed to a Stage 4. The Administrator said the DON should have known orders were not followed and treatment recommendations not implemented correctly and said he would not be notified of wounds unless its relevant and that wounds and infections are discussed only if there are concerns during the quarterly QAPI meeting. The Administrator said nursing staff should have access to the wound recommendations and that orders should be updated. 1b. Resident #20 developed a right hip wound as indicated on a skin check dated 9/11/24. The facility failed to implement the use of an air mattress and failed to follow up on a progress note indicating right hip redness dated 8/28/24. Review of the facility policy titled Bed Safety-Air Mattress-Side Rails undated, indicated but was not limited to the following: - It is the policy of the facility to provide air mattress, with a physician's order, to residents who are bedridden, have limited mobility, are at high risk for pressure sores on the buttocks/hips or who are recovering from a wound. Nursing will follow these procedures: - Obtain a physicians order for an air mattress. - Apply air mattress to residence bed. - Follow manufacturers instructions for use in care of the mattress. - The mattress should be pumped in accordance with their residence weight. - Document all skin assessments. - Maintenance will audit quarterly or as needed to determine proper usage of the air mattress. Review of medical record indicated Resident #20 was being followed weekly by the Wound Consultant Physician as of 7/18/24, for the development of a DTI to the right heel. Further review of the medical record indicated the Wound Consult Physician made recommendations to off load wound, float heels while in bed and the use of a pressure relieving boots and an air mattress. Review of the Care Plan's for Resident #20 included but was not limited to the following: - Venous/Stasis Ulcer (abnormal vein function) r/t (related to) CHF (Congestive Heart Failure- heart doesn't pump blood as well as it should), included the following interventions, dated 7/16/24: - I need heels kept off bed by and prevent direct contact between bony prominences keep heels off load. - Evaluate wound for: Size, Depth, Margins: peri-wound skin, sinuses, undermining, exudates, edema, granulation, infection, necrosis, eschar, gangrene. Document progress in wound healing on an ongoing basis. Notify physician as indicated. 7/25/24 prevalon boot at all times keep elevated at all times keep feet off load feet off load keep elevated and off load. (Dated: 7/26/24). - Booties while in bed (Dated 7/16/24). - ADL Self- Care Performance Deficit, included the following interventions dated 7/10/24, and revised on 8/31/24: - Bed Mobility: I required, 2 staff participation to reposition and turn in bed. I required an Air Mattress d/t (due to) stage 4 ulcer on my heel, and I am at risk for further skin breakdown. - Skin Inspection: I required, SKIN inspection daily. Observe for redness, open areas, scratches, cuts, bruises and report changes to the nurse. - Wound Management due to DTI care plan, initiated on 8/2/24 and last revised 8/31/24: - Provide wound care per treatment order. I require an air mattress (Dated 8/2/24). On 9/3/24 at 8:58 A.M., the surveyor observed Resident #20 laying in bed on his/her left side with one prevalon boot placed on the right heel. The left heel was directly on the mattress and was not elevated. There was no air mattress applied to the bed. On 9/4/24 at 8:05 A.M., the surveyor observed Resident #20 laying in bed on his/her left side with one prevalon boot placed on the right heel. The left heel was directly on the mattress and was not elevated. There was no air mattress applied to the bed. On 9/4/24 at 1:03 P.M., the surveyor observed Resident #20 laying in bed on his/her left side with one prevalon boot placed on the right heel. The left heel was directly on the mattress and was not elevated. There was no air mattress applied to the bed. On 9/6/24 at 8:05 A.M., the surveyor observed Resident #20 laying in bed on his/her left side with one prevalon boot placed on the right heel. The left heel was directly on the mattress and was not elevated. There was no air mattress applied to the bed. On 9/9/24 at 8:00 A.M., the surveyor observed Resident #20 laying in bed on his/her left side with one prevalon boot placed on the right heel. The left heel was directly on the mattress and was not elevated. There was no air mattress applied to the bed. The observations made during survey failed to indicate Resident #20 had care planned interventions in place including the use of prevalon boots to bilateral feet, keeping bilateral heels elevated and the use of an air mattress. Review of the physician's orders for Resident #20 indicated the following: - May use prevalon boot every shift for use for skin protection (7/26/24). - May have booties all the time every shift (9/5/24). Further review of the medical record failed to indicate an order was in place for the use of an air mattress. Review of NP #1's note dated 8/28/24, indicated the following: Nursing requested right hip redness, and in house wound visit with rec (recommendation). Pt (patient) recently completed antibiotic for right heel cellulitis with good effect. Today follow up visit reviewed in house wound team visit summary agreed with plan. Cellulitis right heel suspected DTI. During an interview on 9/4/24 at 9:44 A.M., NP said she was notified by staff that Resident #20 had right hip redness and that she did not visualize the resident's skin. The NP said she was not aware that Resident #20 did not have an air mattress in place and said Residents at high risk for pressure ulcers should have an air mattress and heel booties in place and she expects staff to notify her of any new skin issues or if wounds are getting worse and that she expects preventative measures to be implemented and followed to prevent the wounds from deteriorating. The NP said she would expect the orders and care plan interventions be followed and said resident #20 requires and air mattress and prevalon booties to both feet. During an interview on 9/5/24 at 8:02 A.M., Nurse #4 said if a new skin area is observed there should be a skin check indicating the new area and the NP or MD will be notified. Nurse #4 said she notified NP that Resident #20 had redness to his/her right hip and that he/she was seen by the wound physician but was not aware of any new orders or follow up because the DON has been out. During an interview on 9/5/24, at 8:07 A.M., Certified Nurse Aide (CNA) #7 said that he was not aware that Resident #20 should have his/her legs elevated and that Resident #20 does not have an air-mattress. During an interview on 9/5/24 at 8:11 A.M., Nurse #5 said Residents with skin issues will have an air mattress and heel botties in place to prevent skin breakdown and the plan of care will be updated so staff know what the resident needs for care. Further review if the medical record failed to indicate Nurse #4 documented the right hip redness to Resident #20 hip, despite being reported to NP. During an interview on 9/5/24 at 8:09 A.M., the Consultant Wound Physician said Resident #20 requires an air mattress and prevalon boots to both heels because he/she is high risk for wounds and has wounds that need preventative measures. The Consultant Wound Physician said wound recommendations have not been implemented on admission and said he expects recommendations and preventative measures to be followed. The Consultant Wound Physician said Resident #20 is high risk for more pressure areas and prevalon booties, air-mattress and elevation of the legs at all times are needed and should have been implanted because he/she is dependent on staff and can't turn and reposition without staff assistance. Review of Resident #20's Skin Only Evaluation, dated 9/11/24, (15 days after right hip redness was first identified) indicated the following: - Pressure Ulcer/ Injury Right Hip, Stage 2 (Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible). - Pressure Ulcer / injury Right Heel, Stage 4 Full thickness tissue loss. - Area on right heel, moderate serosanguineous drainage on old dressing, no foul odor, wound measuring 3.8 cm x 2.6 cm x no depth; wound bed remains red with healthy tissues surrounding the area; skin pink. Wound washed with NS, applied Calcium Alginate, cover with ABD and wrap with Kerlix as ordered. Further review of the medical record indicated Resident #20 was seen by the Consultant Wound Physician on 9/12/24, and indicated the following: *Wound 1 -Stage 4 Pressure Right Heel (Existing Wound) Treatment Plan- Alginate Calcium apply once daily for 27 days. ABD pad apply once daily for 27 days. Gauze roll Kerlix 4.5cm apply once daily for 27 days. *Wound 2 Unstageable (due to necrosis) of Right Hip Full Thickness - New Wound Pressure, unstageable necrosis, 6x4 depth not measurable due to presence of nonviable tissue and necrosis. 100% thick adherent devitalized necrotic tissue. Treatment Plan- Xeroform gauze once daily for 30 days. Hydrogel with silver apply once daily for 30 days. Gauze island with bdr apply once daily for 30 days. Offload wound, reposition per facility protocol, low air loss mattress. *Wound 3 - Unstageable DTI of the Right, First Toe Undetermined Thickness New Wound. Pressure, unstageable DTI with intact skin 1x1.2 depth not measurable. Skin intact with purple/maroon discoloration. Treatment Plan: Skin prep apply twice daily for 30 days. Offload wound, reposition per facility protocol. *Wound 4 Unstageable DTI of the Right Ankle Undetermined Thickness New Wound Pressure, unstageable DTI with intact skin 1x1 depth not measurable. Skin intact with purple/maroon discoloration. Treatment Plan- Skin prep apply twice daily for 30 days. Off load wound reposition per facility protocol. The skin assessments completed on 9/11/24 and 9/12/24 indicated Resident #20 developed three additional areas on right 1st toe, right ankle and right hip. Resident #20 had a total of 4 wounds identified, 3 identified as new wounds within 2 days. During an interview and observation on 9/16/24 at 7:47 A.M., the surveyor along with Nurse #8, The MDS Nurse, and Nurse #6 observed Resident #20 during a wound dressing change. Nurse #8 said Resident #20 has wounds to his/her right hip, right heel, and right toe. Nurse #6 said the Resident does not have any other skin areas and that a skin check was completed, and these new areas were identified. The surveyor asked Nurse #8 and Nurse #6 to turn and reposition the Resident to look observe the Residents skin. The Resident was repositioned and the surveyor asked Nurse #8 to open the brief covering the left hip, observed was intact pink/maroon skin with a localized area of non-blanchable erythema. Nurse #6 said the area is a pressure area on his/her left hip bone in the same location as the pressure area to the right hip bone. Upon further skin inspection, Resident #20 was observed to have an open skin area to the left ankle, with pink and red drainage. Nurse #6 said the area to the left ankle is a Stage 2 wound that should have a dressing in place due to drainage. During an interview on 9/16/24 at 8:05 A.M., Nurse #6 said the open wound on Resident #20 is a Stage 2 and the area on the left hip bone is pressure that needs to be reported and documented. Nurse #6 said staff should have reported and documented any new areas observed when providing care and during any skin checks or dressing changes. 3. Resident #26 was admitted to the facility in July 2024 with diagnoses including pressure ulcer of left buttock stage 2, pressure ulcer of right upper back, non-pressure chronic ulcer of skin of other sites and dementia. Review of Resident #26's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Re[TRUNCATED]

Based on observation, record review, and interviews 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 licensed nursing staff were trained and demonstrated clinical competency related to pressure injury/wound care, including recognizing and reporting wound deterioration, evaluation and measurements for one resident (#20), out of a total sample of 26 residents. For Resident #20 the facility staff failed to implement treatments and physician orders recommended by the consulting wound physician resulting in the wound requiring antibiotic therapy, resulting in the deterioration of an unstageable pressure injury wound progressing to a Stage 4 pressure injury. 2. Ensure that 13 nursing staff employee files reviewed received the appropriate competencies, and skill sets necessary for the care and treatment of residents. 3. Ensure two scheduled and actively working nurses were clinically competent in providing pressure injury/wound care. 4. Ensure licensed nurses completed wound care competency by failing to be observed for the application of knowledge for delivering safe nursing care related to wound care and treatment. Findings include: Review of 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. Review of the facility's document titled Facility Assessment Tool date of assessment or update April 5, 2024, indicated the following: Our Resident Profile indicated the average daily census: 1/1/24 - 3/31/24 as 65.25. Review of the common diagnoses include but are not limited to, Psychiatric/Mood Disorders, Congested Heart Failure, Coronary Artery Disease, Parkinson's Disease, Hemiparesis, Alzheimer's Disease, Visual Loss, Hearing Loss, Fractures, Osteoarthritis, Prostrate Cancer, Breast Cancer, Lung Cancer, Diabetes, Thyroid Disorders, Chronic Obstructive Pulmonary Disease (COPD), Pneumonia, Asthma, Chronic Lung Disease, Renal Insufficiency, Ulcerative Colitis, Gastroenteritis, Bowel Incontinence, Skin Injury, Injuries, Skin Infections, Respiratory Infections. Part 2: Services and Care We Offer Based on our Residents' Needs Pressure injury preventions and care, skin care, wound care (surgical, other skin wounds) Part 3: Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies. Staff training/education and competencies. Staff members are provided inservices (sic) throughout the year and as needed on topics (see attached list of inservice (sic) types). Training and Inservice review at the Facility: included but not limited to - Specialized Care - catheterization insertion/care, colostomy care, diabetic blood glucose testing, oxygen administration, suctioning, pre-op and post op care, trach care/suctioning, ventilator care, tube feedings, wound care/dressings, dialysis care. Throughout the Recertification Survey on 9/3/24 through 9/6/24 and 9/9/24, 9/12/24, 9/16/24 and 9/24/24, the surveyors identified multiple concerns regarding the repeated failure to implement wound care recommendations, notify the physician of wound care recommendations and failure to transcribe the physician's orders related to wound care. As well as failures in respiratory care practices and communicating changes to the medical provider of residents change in conditions. 1. Resident #20 was admitted to the facility in June 2024 with diagnoses including Alzheimer's disease, anemia, vitamin D deficiency, overactive bladder and cognitive communication deficit. Review of Resident #20's Minimum Data Set (MDS) assessment, dated 6/14/24, indicated that the Resident had severely impaired cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15, and required assistance with activities of daily living. Further review of the MDS indicated that Resident #20 was at risk for developing pressure injuries. Review of Resident #20's medical record indicated that Resident #20's new unstageable DTI (Deep Tissue Injury) wound to the right heel, identified on 7/16/24, required antibiotic therapy, resulting in the wound deteriorating and developed into a Stage 4 pressure injury on 8/1/24. Further review of the medical record failed to indicate that nursing staff implemented treatment and physician orders recommended by the Consultant Wound Physician to Resident #20's right heel, or that staff notified the physician that the right heel wound progressed from an unstageable DTI pressure injury to a Stage 4 pressure injury. Further review of Resident #20's medical record indicated the following: Nurse #7 completed a Skin Only Evaluation dated 7/17/24, indicated that Resident #20 had open lesions of the foot with a right heel area measuring 2 cm (centimeters) x 2.5 cm, with documented granulation, exudate, purulent, thin, thick, opaque, tan/yellow drainage, erythema. Tissue documented as painful and warm. Skin note indicated Right heel area with open wound injury 2 cm x 2.5 cm. Stage 3. Further review of the provider notification section of the Skin Only Evaluation form dated 7/17/24, failed to indicate the provider was contacted as the form was blank and contained no notification information. Review of the medical record failed to indicate that the (MD)/(NP) were notified of the right heel open wound. Review of the medical record indicated Resident #20 was seen by the Consultant Wound Physician, dated 7/18/24, and indicated one right heel unstageable DTI (Deep Tissue Injury), closed, surface area 30 cm, length 5 cm, width 6 cm, no depth. Nurse #4 completed a Skin Only Evaluation, dated 7/31/24, which indicated, skin was warm/dry. Skin turgor normal. Does the resident have current skin issues? Documented answer is No. Skin Note indicated, Stage 4 wound right heel with copious drainage, no foul odor. The evaluation did not contain detailed information regarding the wound. Review of the medical record indicated Resident #20 was seen by the Consultant Wound Physician on 8/1/24, and indicated an undefined, Stage 4 wound on the right heel, measurements: surface area 18.4 cm, 4 cm x 4.6 cm. Further review of Resident #20's medical record failed to indicate any wound assessments were documented on the Skin Only Evaluation form on the following dates: 8/7/24, 8/14/24, 8/21/24, and 8/28/24 and indicated: Does the resident have current skin issues? Documented answer is No. During an interview on 9/5/24 at 9:04 A.M. Nurse #5 said Resident #20 has a right heel wound and that measurements and skin checks are done weekly. Nurse #5 said the wound physician comes out weekly and he will send the wound report to the facility. Nurse #5 said he will round with the wound physician and look at wounds, but he does not document the information in a skin check. Nurse #5 said there is no unit manager or Director of Nurses (DON), so he reports issues to the (NP). Nurse #5 said he has not completed any clinical training or competencies here at this facility and said he signed a packet on orientation for new hire documents but has not been trained on wounds or any other clinical competencies. During an interview on 9/5/24 at 8:11 A.M., Nurse #4 said she will document information on the skin assessment but does not include measurements because the wound physician will do that. Nurse #4 said she has not completed any training aside from her new hire paperwork that was not related to wounds and has not completed any competencies. Review of Nurse #7 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, measurements, and hands-on clinical competency evaluations. Nurse #7's education files indicated he/she did not have the necessary skills to properly evaluate Resident #20's unstageable DTI that deteriorated to a Stage 4 pressure injury. Review of Nurse #4'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, measurements, and hands-on clinical competency evaluations. Nurse #4's education files indicated he/she did not have the necessary skills to properly evaluate Resident #20's unstageable DTI that deteriorated to a Stage 4 pressure injury. Review of Nurse #5'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, measurements, and hands-on clinical competency evaluations. Nurse #5's education files indicated he/she did not have the necessary skills to properly evaluate Resident #20's unstageable DTI that deteriorated to a Stage 4 pressure injury. During an interview on 9/9/24 at 9:21 A.M., the Consulting Nurse said staff should report skin conditions and document findings as well as report new or worsening skin areas. The Consultant Nurse said all licensed clinical staff should have documented clinical competencies and know how to complete a skin assessment and document findings. The Consulting Nurse said nursing staff should know how to assess a pressure wound and apply treatment orders appropriately including how to do a sterile dressing change and follow appropriate infection control protocol. 2. Review of 10 personnel files of actively working clinical nursing staff including 4 Licensed Nurses and 6 Certified Nursing Assistants (CNA) on 9/3/24 and 9/4/24 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 additional 3 personnel files of actively scheduled and working licensed nurses failed to indicate any competencies related to the specialized care areas outlined in the Facility Assessment including wound care/dressings. In all, 7 licensed nurses failed to have clinical competencies including care of pressure injuries, skin and wound assessments, and wound care dressing changes. During an interview on 9/6/24 at 9:40 A.M., the Administrator and Assistant Administrator (AA) said all newly hired employees come to the facility for about three hours and review policies and procedures, they do a skills fair annually, but they do not review any clinical topics. The AA said the Director of Nursing (DON) would determine when the staff are competent enough to work. The AA continued to say historically, the facility has used word of mouth and verbal confirmation to track newly hired employees' status of staff shadowing and training. The AA then said the facility has no training curriculum. The Administrator and AA said the facility provides clinical in-services for all staff. The surveyor requested to see the in-services for the last year. Upon review of the in-services, no clinical topics relating to wound/skin care, or oxygen care were provided. During an interview on 9/9/24 at 7:38 A.M., Nurse #6 said she did an orientation with the DON when she was hired a few months ago. Nurse #6 said they reviewed mostly administrative things, sensitivity training, abuse training, HIPPA over anything clinical. Nurse #6 said wound care/skin care was very limited and only verbal educations was done, nothing written. During an interview on 9/9/24 at 9:21 A.M., the Consulting Nurse said all licensed clinical staff should have documented clinical competencies. 3. Review of the facility's document titled Removal Plan indicated at: 7. As part of the training and re-education, the MDS (Minimum Data Set)/Educator Nurse has developed nursing competencies specific to wound care to be provided to all clinical team members to ensure that this practice does not recur. These competencies are for Registered Nurses and Licensed Practical Nurses. Wound Care competencies will be completed by September 13, 2024. The nursing competencies evaluate the nurse on identifying, assessing and treating wounds, wound care testing regarding sterile dressing changes, Decubitus care, knowledge of and review of each nurse's documentation, evaluations of careplan knowledge, lifting and positioning knowledge, transfer technique, incontinent skin relation to skin integrity, medication evaluations and many other skilled nursing techniques. On 9/16/24 at 8:18 A.M., Review of the working schedule of licensed nurses and the completed wound care competency check list for licensed nurses, failed to indicate two nurses currently working a shift that began at 7:00 A.M., had a completed wound care competency checklist. During an interview on 9/16/24 at 8:20 A.M. the Administrator said one nurse (Nurse #8) is being put through the competency now and the other nurse is an agency nurse and did not have the competency done and will have it done now. The Administrator said all nursing staff were to have the competencies completed by 9/13/24. During an interview and observation on 9/16/24 at 7:47 A.M., the surveyor along with Nurse #8, the MDS Nurse, and Nurse #6 observed Resident #20 during a wound dressing change. Nurse #8 was observed removing old treatment dressings from Resident #20's right hip, right heel, and right toe. Nurse #8 did not perform hand hygiene, remove her gloves or maintain infection control standards throughout the observation. The MDS nurse had to verbally remind Nurse #8 to follow proper infection control measures throughout the observation. Nurse #8 said she would follow proper infection control protocol, but she did not have time to perform all the dressing changes and would return later to complete the treatments. Nurse #8 said she should have worn the proper PPE (personal protection equipment) and removed her gloves and performed hand hygiene when removing the old dressings. Nurse #8 said she has not completed any wound training or clinical competencies in the building. During an interview with the MDS nurse on 9/16/24 at 8:18 A.M., she said she did not complete clinical wound competencies with Nurse #8 or with any nurses in the facility. The MDS nurse said she completed verbal education with nursing staff about following wound treatment recommendations, but no clinical competencies have been done. During an interview on 9/16/24 at 8:22 A.M., Nurse #6 said she has not completed any clinical competencies or had any clinical in-services since training she started working in the facility and continued to say that the DON (Director of Nursing) would verbalize how things should be documented but that was it. During a follow up interview on 9/16/24 at 9:38 A.M., with the MDS Nurse and Nurse #6, the MDS nurse said she just started working with the company last week and that she has not received any clinical training or in-services. The MDS nurse said she does not have a clinical competency on file and said the Administrator asked her to educate the nursing staff about wounds. The MDS nurse said she does not have any formal training on wound care. Nurse #6 said she does not have any clinical in-service or clinical competency on file and that she does not have any formal training on wound care. During an interview on 9/16/24 at 9:41A.M., the Administrator said he did not have any outside clinical training or hands-on clinical competencies completed for the MDS nurse or Nurse #6 and said staff providing education need to be competent and have the necessary training and clinical competencies on file. 4. Review of the facility's policy entitled Wound Care, not dated, indicated the following: -All nurses will need to perform a wound care competency by the nurse trainer before starting a shift. All external agency staffing will need to check in with nursing leadership and perform a wound care competency before starting their shift. Review of the document titled Wound Care Competency for 15 out of 15 licensed nurses reviewed indicated the following: - Two licensed nurses had an incomplete page, indicating an incomplete wound care competency. - Fourteen out of fifteen licensed nurse competencies failed to be checked off as 'Cleaning a wound and applying a dry non-sterile dressing skill checklist requirement met/or Cleaning wound and applying a dry non-sterile dressing skill checklist requirement NOT met. During an interview on 9/24/24 at 8:07 A.M., Nurse #6 said she provided one-to-one education using the wound care competency document with each licensed nurse before they started a shift. Nurse #6 said the second part of the wound care competency would include observing the nurse completing wound care, then they would determine if the nurse met or not met wound care competency. During an interview on 9/24/24 at 10:10 A.M., the Director of Nursing (who recently started at the facility) said education was provided and that no clinical observation wound competency was conducted with the licensed nurses, except for two licensed nurses. Twelve of fifteen licensed nurses failed to have wound care competency to include the evaluated by a trained observer.

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 pressure injury prevention and care services following the absence of the Director of Nursing (DON) and implement an effective system for pressure injury (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 an infected Stage 4 pressure injury for one Resident (#20) out of a total sample of 26 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 an infected stage 4 pressure injury. Review of the Facility Assessment Tool, dated as reviewed with the QAPI (Quality Assurance Performance Improvement) committee in April 2024, indicated the facility offers pressure injury prevention and care, skin care, wound care (surgical, other skin wounds). Further review of the Facility Assessment Tool indicated, but was not limited to, the following: Licensed Nurses providing direct care - Plan 1 DON (Director of Nurses) RN full-time Days; if has other responsibilities, add X more RN as Asst. DON to equal one FTE (full time employee). RN or LPN Charge Nurse: 1 for each shift. 1-X residents DON may be Charge Nurse. Staff training/education and competencies. - Staff members are provided in-services throughout the year and as needed on topics (see attached list of in-service types). Infection control-handy hygiene, isolation standard universal precautions including use of personal protective equipment, MRSA/VRE/ CDI precautions, environmental cleaning. Resident assessment and examinations- admission assessment, skin assessment, pressure injury assessment, neurological check, lung sounds, nutritional check, observations of response to treatment, pain assessment. Caring for persons with Alzheimer's or other dementia. Specialized care catheterization insertion/care, colostomy care, diabetic blood glucose testing, oxygen administration, suctioning, pre-op care, trach care/suctioning, ventilator care, tube feedings, wound care/dressings, dialysis care. The facility provides an Infection Control Committee and an Infection Preventionist in the Director of Nursing. Areas Facility Assessment Informed: Training, Competencies - Up to date. 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 #20 was admitted to the facility in June 2024 with diagnoses including Alzheimer's disease, anemia, vitamin D deficiency, overactive bladder and cognitive communication deficit. Review of the Minimum Data Set (MDS) assessment, dated 6/14/24, indicated that Resident #20 had severely impaired cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15, and required assistance with activities of daily living. Further review of the MDS indicated that Resident #20 was at risk for developing pressure injury. Review of the medical record indicated that Resident #20's new unstageable DTI (Deep Tissue Injury) wound to the right heel, identified on 7/16/24, required antibiotic therapy resulting in the deterioration and developed into a Stage 4 pressure injury on 8/1/24. The medical record failed to indicate that nursing staff implemented treatment and physician orders recommended by the Consultant Wound Physician to Resident #20's right heel, or that staff notified the physician that the right heel wound progressed from an infected unstageable DTI to a Stage 4 pressure injury. Review of the nursing notes, physician notes and wound evaluations failed to indicate nursing 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 #20's wound. According to the Mayo Clinic, complications and outcomes of Stage 4 pressure injuries 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 injury 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 Resident #20's medical record indicated the following: Nurse #7 completed a Skin Only Evaluation dated 7/17/24, that indicated Resident #20 had open lesions of the foot with a right heel area measuring 2 cm (centimeters) x 2.5 cm, with documented granulation, exudate, purulent, thin, thick, opaque, tan/yellow drainage, erythema. Tissue documented as painful and warm. Skin note indicated Right heel area with open wound injury 2 cm x 2.5 cm. Stage 3. Further review of the provider notification section of the Skin Only Evaluation form failed to indicate the provider was contacted as the form was blank and contained no notification information. Review of the medical record failed to indicate that the (MD)/(NP) were notified of the findings on the 7/17/24 Skin Only Evaluation. Further review of the medical record indicated Resident #20 was seen by the Consultant Wound Physician, dated 7/18/24, indicated one right heel unstageable DTI (Deep Tissue Injury), closed, surface area 30 cm, length 5 cm, width 6 cm, no depth. Nurse #4 completed a Skin Only Evaluation, dated 7/31/24, indicated, skin was warm/dry. Skin turgor normal. Does the resident have current skin issues? Documented answer is No. Skin Note indicated, Stage 4 wound right heel with copious drainage, no foul odor. The evaluation did not contain detailed information regarding the wound. Review of the medical record indicated Resident #20 was seen by the Consultant Wound Physician on 8/1/24, and indicated undefined right heel wound, Stage 4, measurements: surface area 18.4 cm, 4 cm x 4.6 cm. Further review of Resident #20's medical record failed to indicate any wound assessments were documented on the Skin Only Evaluation form on the following dates: 8/7, 8/14, 8/21, and 8/28 and indicated: Does the resident have current skin issues? Documented answer is No. During an interview on 9/5/24 at 8:11 A.M., Nurse #4 said she will document information on the skin assessment but does not include measurements because the wound physician will do that. Nurse #4 said she has not completed any training aside from her new hire paperwork that was not related to wounds and has not completed any competencies. During an interview on 9/5/24 at 8:11 A.M., the Consultant Wound Physician said he expects staff to have demonstrated competencies on file, know how to implement physician recommendations and treatment orders to care for residents in the facility. During an interview on 9/5/24 at 9:04 A.M., Nurse #5 said Resident #20 has a right heel wound and that measurements and skin checks are done weekly. Nurse #5 said the wound physician comes out weekly and he will send the wound report to the facility. Nurse #5 said he will round with the wound physician and look at wounds, but he does not document the information in a skin check. Nurse #5 said there is no unit manager or Director of Nurses (DON), so he reports issues to the (NP). Nurse #5 said he has not completed any clinical training or competencies here at this facility and said he signed a packet on orientation for new hire documents but has not been trained on wounds or any other clinical competencies. Review of Nurse #7, Nurse #4 and Nurse #5 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, measurements, and hands on clinical competency evaluations. The education files indicated Nurse #7, Nurse #4 and Nurse #5 did not have the necessary skills to properly evaluate Resident #20's unstageable DTI that deteriorated to a Stage 4 pressure injury. During an interview on 9/9/24 at 9:21 A.M., the Consulting Nurse said staff should report skin conditions and document findings as well as report new or worsening skin areas. The Consultant Nurse said all licensed clinical staff should have documented clinical competencies and know how to complete a skin assessment and document findings. The Consulting Nurse said nursing staff should know how to assess a pressure wound and apply treatment orders appropriately including how to do a sterile dressing change and follow appropriate infection control protocol. 2. The facility failed to provide continuation of the pressure injury prevention and care services following the absence of the Director of Nursing and implement an effective system for pressure injury (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. During an interview on 9/4/24 at 8:48 A.M., Project Manager #1 said the DON has been out of the building since last month, the facility has been without a unit manager since last September, and they have been without a supervisor. The Project Manager #1 said he helps around the building with various tasks and worked as the Director of Rehab prior to this role. During an interview on 9/4/24 at 8:51 A.M. Nurse #4 said when she got back from vacation around 8/19/24 the Director of Nursing was already out. Nurse #4 said resident care plans were only updated by the DON. Nurse #4 said if a resident experienced a change, she would notify the Nurse Practitioner. When asked who would be notified in the facility during the DON's absence, Nurse #4 said she would inform the Minimum Data Set (MDS) nurse. During an interview on 9/4/24 at 9:43 A.M., NP #1 said the DON would review wound and other treatment recommendations, and staff would call regarding updates to wounds in the facility but in the absence of the DON she does not have access to any wound recommendations and treatment plans unless staff call her with updates and new orders. During an interview on 9/4/24 at 4:16 P.M., the Administrator said in the absence of the DON the charge nurse is responsible for the clinical decision making in the building. The Administrator said the charge nurse on the [NAME] unit is Nurse #7 and the North Unit is Nurse #5. The Administrator said the charge nurse does rounding on the residents, provides medications, supervises the CNAs (Certified Nursing Assistants), updates care plans, reviews recommendations, puts in new orders, responds to pharmacy recommendations, and reviews admissions. During an interview on 9/5/24 at 9:06 A.M., Nurse #5 said staff contact the Nurse Practitioner (NP) since there is no unit manager or charge nurse available to help and said the former MDS Nurse was available on weekends only but has since left. Nurse #5 said he was never told that he was a charge nurse and that he does not have access to the wound recommendations. and does not have a login. Nurse #5 said he is not sure who is looking at the recommendations in the absence of the DON. During an interview on 9/5/24 at 9:50 A.M., the Consultant Nurse said the Administrator called her two days ago and asked if she could be a contact person for the facility and said she was not aware that the DON had been out of the building and that she is not familiar with this facility. During a follow up interview on 9/5/24 at 10:12 A.M., the Administrator said he is not clinical, had no knowledge of wounds, infections or treatment recommendations not being followed and said he would not be notified unless it's relevant and that information is discussed at QAPI meetings. The Administrator said the facility has been without a Director of Nurses since 8/23/24 and she was responsible for oversight of wounds in the building and has access to the wound treatment recommendations and visit summaries. The Administrator said the facility does not have an assistant director of nurses, infection preventionist, unit managers or supervisors at this time. The Administrator said no outside services were consulted or contracted to provide clinical oversite and that staff nurses were expected to follow up with wound recommendations and update the Nurse Practitioner and Medical Director with concerns. The Administrator said the facility hired a new Minimum Data Set (MDS) Nurse that will be a clinical support person and was scheduled to start this week but was unable to be in the building. The Administrator said there is a covering Director of Nurses at another facility that is available, and staff can call with questions. During an interview on 9/5/24 at 12:25 P.M., the Medical Director said he was notified on 9/4/24 that the DON was out on leave and said he went on vacation on 8/22/24. The Medical Director said he expects the facility to assign someone to cover for the DON because we do not have an assistant director, infection preventionist, or a staff development coordinator, and the new MDS Nurse is not here. The Medical Director said the building must have clinical oversite of areas such as infections, reporting wounds, implementing orders and clinical oversight. The Medical Director said every building must have a DON. The Medical Director said senior members are responsible for clinical oversite and he expects the Administrator to delegate and implement measures to ensure no lapse in clinical oversite. The Medical Director said he expects a tracking system in place, and wound recommendations to be reviewed and implemented. During an interview on 9/6/24 at 11:11 A.M., the MDS Nurse said it is her second day here and she was made aware today that she would be point person for clinical questions. The MDS Nurse said she was told the DON was out sick when she was hired two weeks ago but did not know she was the point of contact for clinical questions and said she is not familiar with the building because she is new.