**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident #13 was admitted to the facility in September 2023 with diagnoses including dementia, fracture of the second cervical vertebra (a broken bone in the neck), and mild cognitive impairment. Review of Resident #13's MDS assessment, dated 9/10/24, indicated that the Resident was severely cognitively impaired as evidenced by a BIMS score of 6 out of 15. Review of Resident #13's medical record indicated that a guardian was appointed by the Court on 8/13/24. Review of the facility's fall incident report completed for Resident #13 on 10/30/24 indicated that the Resident sustained an unwitnessed fall and was transported to the hospital for evaluation. The report failed to indicate that the Resident's guardian was notified of the fall or subsequent transfer. Review of a progress note written for Resident #13, dated 10/20/24 7:00 P.M., indicated that the Resident was found on the floor in the dining room and complained of right hip pain, right-sided head pain, and back pain. The progress note indicated the provider was notified and an order was obtained to send the Resident to the emergency department for evaluation. The progress note failed to indicate that the Resident's guardian was notified of the fall or subsequent transfer. Review of an eINTERACT Change in Condition Evaluation completed for Resident #13 on 10/31/24 indicated the Resident returned from the hospital with no new orders and the physician was aware. The Evaluation indicates that the name of family/healthcare agent notified was self. The Evaluation failed to indicate that the Resident's guardian was notified. During an interview on 12/5/24 at 1:09 P.M., the DON reviewed the Resident's record and said that there is no documentation that facility staff notified Resident #13's guardian of the fall and transfer to the hospital. The DON said that the Resident's guardian should have been notified of the fall and transfer. During a telephonic interview on 12/5/24 at 2:52 P.M., Resident Representative #1 said that he was not notified of the Resident's fall and transfer to hospital. Refer to F684 2. Resident #58 was admitted to the facility in September 2024 with diagnoses including obesity and pleural effusion (fluid builds up in the pleural space, the thin cavity between the lungs and the chest wall). Review of Resident #58's Minimum Data Set (MDS) assessment, dated 9/26/24, indicated he/she was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Review of Resident #58's Registered Dietitian's notes indicated but was not limited to: - 11/21/24: Resident #58 continues to trigger for significant weight loss over 180 days. Resident #58 down approximately 13 pounds. - 10/22/24: Reweight obtained 10/18 of 354.8 pounds which verifies weight loss. - 10/18/24: Weight on 10/14 reordered in electronic medical 358.6 pounds. Weight on 10/9 410.9 pounds. This reflects a weight loss of 43 pounds in 5 days. Further review of Resident #58's medical record failed to indicate his/her Physician or Physician Extender had been notified of his/her weight loss. During an interview on 12/9/24 at 9:50 A.M., Resident #58 said he/she had lost about 99 pounds since his/her hospitalization and facility admission. Resident #58 said he/she was happy with weight loss. During an interview on 12/5/24 at 10:36 A.M., Nurse #11 said if it was identified that a resident had a weight loss the nurse would notify the Dietitian and if the Dietitian made a recommendation the nurse would notify the Physician. Nurse #11 said if the Physician had been notified then it would be documented in the medical record in a nurse's note. During an interview on 12/5/24 at 10:40 A.M., Unit Manager (UM) #2 said the Dietitian was notified for all significant weight loss. UM #2 said the Dietitian would make recommendations, if appropriate, and then the doctor would be called to approve the recommendation. UM #2 said the Physician would often be verbally notified of changes in resident conditions. UM #2 said the nurses do not document Physician notification anywhere. UM #2 said there is not a system in place to notify the Physician of a significant weight loss and there should be a process for Physician notification, but there isn't one in place. During an interview on 12/5/24 at 11:06 A.M., the Dietitian said she did not notify the physician if a resident had a significant weight loss. The Dietitian said her expectation was for the nurses to notify the physician of a significant weight loss. During an interview on 12/5/24 at 11:30 A.M., Physician #1 said he was not aware of Resident #58's significant weight loss. Physician #1 said regardless of if a resident is on prescribed weight loss regimen or had an unplanned weight loss he should be notified of all weight loss. During an interview on 12/9/24 at 3:40 P.M., the Director of Nursing (DON) said the Physician should have been notified of Resident #58's weight loss and the notification should have been documented in his/her medical record but was not. 3. Resident #70 was admitted to the facility in August 2024 with diagnoses including heart failure and obesity. Review of Resident #70's MDS assessment, dated 10/21/24, indicated he/she had a mild cognitive deficit as evidenced by a BIMS score of 10 out of 15. Further review of Resident #70's MDS assessment indicated he/she had a five percent weight loss and he/she was not on a prescribed weight loss regimen. Review of Resident #70's Registered Dietitian's notes indicated but was not limited to: -12/3/24: Resident #70 continues to trigger for significant weight loss. Review of Resident #70's care plan titled Resident #70 is at nutritional risk, last revised 10/21/24, indicated but was not limited to: - Intervention: Weight a/o (as ordered) and alert the dietitian and physician to any significant loss or gain, revision date 8/8/24 During an interview on 12/5/24 at 10:32 A.M., Physician #1 said he was not aware of Resident #70's significant weight loss. Physician #1 said regardless of if a resident is on prescribed weight loss regimen or had an unplanned weight loss he should be notified of all weight loss. During an interview on 12/5/24 at 10:36 A.M., Nurse #11 said if it was identified that a resident had a weight loss the nurse would notify the Dietitian and if the Dietitian made a recommendation the nurse would notify the Physician. Nurse #11 said if the Physician was notified then it would be documented in the medical record in a nurse's note. During an interview on 12/5/24 at 10:40 A.M., UM #2 said the Dietitian was notified for all significant weight loss. UM #2 said the Dietitian would make recommendations, if appropriate, and then the doctor would be called to approve the recommendation. UM #2 said the Physician would often be verbally notified of changes in resident conditions. UM #2 said the nurses do not document Physician notification anywhere. UM #2 said there is not a system in place to notify the Physician of a significant weight loss and there should be to a process for Physician notification, but there isn't one in place. During an interview on 12/5/24 at 11:06 A.M., the Dietitian said she did not notify the physician if a resident had a significant weight loss. The dietitian said her expectation was for the nurses to notify the physician of a significant weight loss. During an interview on 12/9/24 at 3:40 P.M., the DON said the Physician should have been notified of Resident #70's weight loss and the notification should have been documented in his/her medical record but was not. Based on observation, interview, and record review, the facility failed to notify the Physician and/or responsible party of recommendations or changes in condition for four Residents (#65, #13, #58, and #70), out of a total sample of 18 residents. Specifically, the facility failed: 1. For Resident #65, to notify the Physician of treatment recommendations and orders to initiate a 40-day Vancomycin (antibiotic) taper due to a diagnosis of Enterocolitis due to Clostridium Difficile (C. diff - an infection of the large intestine often resulting in diarrhea or loose stools) for 19 days after a hospitalization resulting in a decline in the Resident's stage IV pressure injury (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) on the sacrum; 2. For Resident #58, to notify the Physician of his/her significant weight loss; 3. For Resident #70, to notify the Physician of his/her significant weight loss; and 4. For Resident #13, to notify his/her Guardian of a fall that required transfer to the hospital. Findings include: Review of the facility's policy titled Change in a Resident's Condition, Acute Care Transfer and Notification, dated 2024, indicated but was not limited to: - Should a change in condition be suspected or noted, the nurse(s) shall be promptly alerted, shall promptly assess the resident, notify his or her Attending Physician of changes in the resident's medical/mental condition and/or status asking for orders/guidance and/or initiate life sustaining supportive measures accordingly to one's presenting condition in accordance with one's advance directives, and notify the resident's representative appropriately. - The Nurse Supervisor/Charge Nurse shall be notified of a change in a resident's condition, presentation, disposition or routine that may serve as an early warning sign of clinical events by staff or other concerned parties. Those may include but are not limited to: (g) a need or request to alter the resident's medical treatment, (k) Instructions to notify the Physician of changes in the resident's condition. 1. Resident #65 was admitted to the facility in June 2024 with diagnoses including C. diff, pressure ulcer of sacral region, and chronic kidney disease. Review of the Minimum Data Set (MDS) assessment, dated 9/26/24, indicated Resident #65 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 4 out of 15. Further review of the MDS assessment indicated he/she was being treated for a stage IV pressure ulcer and had a medical diagnosis of C. diff. Review of Resident #65's nursing progress note, dated 7/29/24, indicated Resident #65 was seen by physician who recommended a transfer to the hospital due to a change in medical status. Review of the Hospital Discharge summary, dated [DATE], indicated but was not limited to the following: - Resident had diarrhea on the overnight of 7/29/24. - Resident tested positive for C. diff on 7/30/24. - The Resident was seen by Infectious Disease (ID) during the hospitalization. - ID recommended Fidaxomicin (antibiotic) 200 milligrams (mg) twice a day for five days (7/30/24 to 8/4/24), then 200 mg every 48 hours for 20 days. - ID also alternatively recommended a 40-day Vancomycin (antibiotic) taper instead of the Fidaxomicin. - The recommendation for the 40-day Vancomycin taper included: 125 mg by mouth four times a day for 10 days, followed by 125 mg by mouth twice a day for 10 days, followed by 125 mg by mouth once daily for 10 days, followed by 125 mg by mouth once every other day for 10 days. Review of Resident #65's nursing progress note, dated 7/31/24, indicated the Resident returned to the facility from the hospital on this date and a Vancomycin taper was recommended for the treatment of C. diff. The nursing progress note indicated the antibiotic treatment options needed to be reviewed with the in-house Physician. Review of nursing progress notes from 7/31/24 to 8/18/24 failed to indicate the antibiotic recommendations were reviewed and/or implemented with the in-house physician. Review of physician progress notes from 7/31/24 to 8/18/24 failed to indicate the antibiotic recommendations from the Resident's hospital discharge on [DATE] were reviewed or implemented. Review of Resident #65's Physician's Orders failed to indicate an order for the 40-day Vancomycin taper or Fidaxomicin taper were implemented following his/her return from the hospital on 7/31/24. Review of the Certified Nursing Assistant (CNA) Documentation Survey Report for the task of Bowel Continence, dated August 2024, indicated Resident #65 was incontinent of large/medium loose stools on the following dates/shifts: - 8/1/24: Night shift - 8/2/24: Night shift - 8/3/24: All shifts - 8/4/24: Night shift - 8/5/24: All shifts - 8/6/24: Day shift - 8/7/24: Day shift - 8/8/24: Day/Evening shifts - 8/9/24: All shifts - 8/10/24: Day shift - 8/11/24: Night shift - 8/13/24: Evening shift - 8/15/24: Day shift - 8/16/24: Day/Evening shifts Review of the Wound Consultant Documentation, dated 8/9/24, indicated but was not limited to the following: - Resident had been hospitalized since last wound evaluation. - Wound measurements increased, mild odor noted. - Wound status: worsening. Review of the Wound Consultant Documentation, dated 8/16/24 indicated but was not limited to the following: - Wound measurements increased. - Increased odor and drainage. - Wound status: worsening. During an interview on 12/5/24 at 11:58 A.M., Wound Consultant #1 said Resident #65 has been followed for a chronic stage IV sacral pressure ulcer since being admitted to the facility. Wound Consultant #1 said Resident #65 has a history of recurrent C. diff. Wound Consultant #1 said in her experience when Resident #65 has C. diff he/she typically has large, loose stools which would require dressing changes of the chronic stage IV sacral pressure ulcer. Wound Consultant #1 said large amounts of loose stool would negatively impact the wound healing process. During an interview on 12/5/24 at 12:35 P.M., the Physician said loose stools and C. diff would have a negative impact on the Resident's wound status. Review of Resident #65's nursing progress note, dated 8/18/24, indicated that the Resident was transferred to the hospital for abnormal test results. Review of the Hospital Discharge summary, dated [DATE], indicated but was not limited to the following: - Resident had a history of recent C. diff (discharged [DATE]). - Resident presented to the hospital with decubitus ulcer pain and diarrhea. - Resident still has diarrhea, unfortunately the Vancomycin was stopped. - ID suggested a 40-day Vancomycin taper during last hospitalization 7/29/24 to 7/31/24. - Communication with the nursing facility indicated there was a misunderstanding by the facility on placing the Resident on the Vancomycin taper. - Communicated with them that when leaving the hospital this time the Resident should definitely be on a 40-day taper of Vancomycin. - ID recommendation for the 40-day Vancomycin taper included: 125 mg by mouth four times a day for 10 days, followed by 125 mg by mouth twice a day for 10 days, followed by 125 mg by mouth once daily for 10 days, followed by 125 mg by mouth once every other day for 10 days. Review of the medical record indicated Resident #65 was placed on the recommended 40-day Vancomycin taper on 8/19/24, 19 days after it was initially recommended. During an interview on 12/5/24 at 12:35 P.M., the Physician said when a resident returns from the hospital the facility typically will call him or a nurse practitioner (NP) to review the discharge medications and recommendations. The Physician said he almost always accepts the recommendations for medications and treatments from the hospital discharge. The Physician said he reviewed each of his residents' medical records when evaluating him/her in the facility. The Physician said he does not recall being notified of recommendations for a 40-day Vancomycin taper after Resident #65's hospitalization from 7/29/24 to 7/31/24. The Physician said he would have addressed the recommendations and documented them in his progress notes. During an interview on 12/9/24 at 8:26 A.M., Unit Manager (UM) #1 said when a resident returns from the hospital the discharge summary is reviewed by the nurse. UM #1 said all discharge medications and recommendations would then be reviewed by the physician or NP either in the facility, if they were present, or by phone. UM #1 reviewed Resident #65's hospital discharge summary from 7/31/24 and said the Vancomycin taper was not listed on the discharge medication list from the hospital. UM #1 said the hospital discharge summary does clearly indicate the recommendation for a Fidaxomicin or Vancomycin taper to be initiated due to the Resident's diagnosis of C. diff. UM #1 said the hospital discharge summary recommendations should have been reviewed with the physician or NP so they could be implemented. UM #1 said no Vancomycin taper was started until Resident #65 returned from the hospital on 8/19/24. During an interview on 12/9/24 at 11:20 A.M., the Director of Nursing (DON) said when a resident returns from the hospital the discharge summary is reviewed by the nurse. The DON said all discharge medications and recommendations would then be reviewed by the physician or NP either in the facility, if they were present, or by phone. The DON said she reviewed Resident #65's medical record and noted the 40-day Vancomycin taper was not implemented when he/she returned from the hospital on 7/31/24 as it should have been. The DON said the hospital discharge summary should have been reviewed and clarified with the Physician. The DON said there should not have been a delay in starting the 40-day Vancomycin taper for Resident #65.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #68 was admitted to the facility in May 2024 with diagnoses including cerebral vascular accident (damage to the brain from interruption of blood supply) and spinal fusion. Review of the MDS assessment, dated 9/3/24, indicated Resident #68 was cognitively intact as evidenced by a score of 15 out of 15 on the BIMS. Additionally, Resident #68 had two unstageable pressure ulcers/injuries which were receiving skin treatments and he/she was dependent on staff for assistance with bed mobility. Review of the comprehensive care plan indicated but was not limited to the following: - Resident has unstageable pressure ulcers to bilateral heels related to immobility - Administer treatments as ordered and monitor for effectiveness - Notify MD/NP and obtain treatment Review of the medical record indicated Resident #68 was followed by a Wound Care Nurse Practitioner at the facility. Review of the Wound Assessment Report, completed by the Consulting Wound NP, dated 11/22/24, indicated but was not limited to the following: -Unstageable Pressure Wound of the Left Heel - Treatment: Cleanse with normal saline (NS), apply Santyl, Calcium alginate, cover with abdominal (ABD) pad and rolled gauze. Change daily and as needed for soiling, saturation, or accidental removal. Review of the Wound Care Specialist's progress note, dated 11/22/24, indicated but was not limited to the following: - Left heel wound no longer with eschar (thick adherent black dead tissue), slough, and granulation to wound bed. Will update treatment plan. - Wound Status: improving without complications. Review of the Wound Assessment Report, completed by the Consulting Wound NP, dated 12/06/24, indicated but was not limited to the following: - Unstageable Pressure Wound of the Left Heel - Treatment: Cleanse with NS, apply Santyl, Calcium alginate, cover with ABD pad and rolled gauze. Change daily and as needed for soiling, saturation, or accidental removal. Review of the Wound Care Specialist's progress note, dated 12/06/24, indicated but was not limited to the following: - Left heel wound continue with treatment plan. - Wound Status: improving without complications. Review of the November and December 2024 Physician's Orders and TARs indicated an order was implemented on 9/13/24 as follows: Left heel: Cleanse with NS and pat dry. Apply Iodosorb (ointment applied to wound bed to remove bacteria and slough). Cover with ABD pad and wrap with kling. Change daily and as needed for dislodgement. Further review of the Physician's Orders failed to include the wound treatment recommendations from 11/22/24. Review of the nursing and physician progress notes failed to indicate the physician declined the recommendation of the wound nurse practitioner. During an interview on 12/9/24 at 11:42 A.M., UM #1 said she rounds with the wound NP weekly on Fridays. She said the wound NP assesses and measures the wounds and provides treatment recommendations. She said she receives the recommendations verbally, and the wound NP follows up with faxing over a Wound Assessment Report and documenting the visit under progress notes in the Resident's medical record. UM#1 said then she implements the orders. She said the medical director defers treatment plans to the wound NP. UM#1 reviewed the Wound Assessment Report, dated 11/22/24, with the active physician order in the medical record and said the treatment was never changed as it should have been. She said she was not in the facility on 11/22/24, and someone else completed rounds with the wound NP, and must have missed the treatment change. UM#1 said the treatment order is incorrect and will notify the physician of the error. During an interview on 12/9/24 at 2:43 P.M., the DON said her expectation is for the facility staff member who rounds with the wound NP to initiate the recommendations the date received. She said the order was incorrect. Based on observations, interviews, and record review, the facility failed to ensure two Residents (#65, #68), out of a total sample of 18 residents, received care and treatment to promote healing of pressure injuries. Specifically, the facility failed: 1. For Resident #65, to implement wound care orders per physician recommendations for a stage IV pressure injury (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) on the sacrum; and 2. For Resident #68, to implement orders for a change in treatment for the care of an unstageable pressure ulcer injury (full thickness tissue loss that is covered by a layer of dead tissue that prevents the stage from being determined) to the left heel. Findings include: Review of the facility's policy titled Prevention of Pressure Injuries, undated, included but was not limited to: - The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. - Review of the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. - Monitoring: (1) Evaluate, report and document potential changes in the skin; (2) Review the interventions and strategies for effectiveness on an ongoing basis. Review of the facility's policy titled Wound Care, undated, included but was not limited to: - The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. - The following information should be recorded in the resident's medical record: (1) the type of wound care given, (2) the date the wound care was given, (3) the name and title of the individual performing the wound care, (4) any change in the resident's condition, (5) all assessment date (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound, (6) any problems or complaints made by the resident related to the procedure, (7) if the resident refused the treatment and the reason(s) why, (8) the signature and title of the person recording the data. - Reporting: (1) notify the supervisor if the resident refuses the wound care, (2) report other information in accordance with facility policy and professional standards of practice. 1. Resident #65 was admitted to the facility in June 2024 with diagnoses of Enterocolitis due to Clostridium Difficile (C. diff - an infection of the large intestine often resulting in loose stools/diarrhea), osteomyelitis, stage IV pressure ulcer of the sacral region, and chronic kidney disease. Review of the Minimum Data Set (MDS) assessment, dated 9/26/24, indicated Resident #65 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 4 out of 15. Further review indicated that Section M: Skin Conditions of the MDS assessment indicated he/she was being treated for a stage IV pressure ulcer. The assessment also indicated Resident #65 was receiving pressure ulcer/injury care including application of non-surgical dressings and ointments. Review of Resident #65's comprehensive care plans indicated the Resident had a stage IV pressure injury to the sacrum with interventions to provide wound care per treatment order, measure ulcer on at (sic) regular interval and monitor for signs of infection. Review of Resident #65's medical record indicated he/she was hospitalized from [DATE] to 7/31/24. Review of the Hospital Discharge Summary indicated the Resident had a chronic sacral wound with osteomyelitis since January 2024. The Hospital Discharge Summary also indicated the Resident was positive for C. diff and required a Fidaxomicin (antibiotic) or Vancomycin (antibiotic) taper for the treatment of C. diff. Review of Resident #65's medical record failed to indicate an order for a Fidaxomicin or Vancomycin taper was obtained on 7/31/24 upon return from his/her hospitalization. Review of Resident #65's nursing Wound - Weekly Observation Tool, dated 7/31/24, indicated but was not limited to the following: - UM (Unit Manager) wound measurements on admission: Stage 4 pressure ulcer sacrum 7.5 centimeters (cm) x 8.0 cm x 0.3 cm, 25% slough (necrotic (dead) tissue that is green, yellow, tan, or brown and may be moist, loose, or stringy) and 75% granulation (pink-red moist tissue that fills an open wound, when it starts to heal), moderate amount serous sanguinous drainage (yellow serous fluid mixed with blood). - Visible Tissue overall impression - unchanged; granulation tissue, slough tissue - Visible Tissue Comments: 7.0 cm x 8.0 cm x 1.0 cm, 50% slough and 50% granulation. - Drainage: Moderate serous - Odor: NO - Treatment: Santyl (a medication used to treat and debride pressure ulcers), Alginate (fibrous, water insoluble dressing that forms a gel that absorbs drainage), Bfoam (bordered foam), once daily and PRN (as needed). - Evaluation: wound progress - improved Review of Resident #65's Physician's Orders indicated but were not limited to the following: - 7/31/24 to 8/9/24: cleanse with wound cleanser; Santyl, Alginate, border foam change daily. Review of the medical record indicated Resident #65 was seen by the Consulting Wound Nurse Practitioner (NP) on 8/9/24. Review of the Consulting Wound NP's progress note from 8/9/24 indicated but was not limited to the following: - Per staff Resident had been hospitalized since last wound evaluation. - Wound measurements increased. - Mild odor noted. - Will switch to cleansing wound with ½ strength Dakins. - Duration: Area first evaluated on 3/27/24 - Etiology: Pressure - Stage/Severity: Stage IV - Wound Status: Worsening - Odor Post Cleansing: Mild - Size: 8.0 cm x 9.5 cm x 0.8 cm - Wound Base: 75% granulation, 25% slough - Exudate (Drainage): Moderate amount of yellow - Recommendations: cleanse with 0.25% Dakins (1/2 strength), apply Santyl, Calcium Alginate to base of the wound, secure with bordered foam. Change daily, PRN (as needed) for soiling, saturation or accidental removal. Review of Resident #65's Physician's Orders indicated the following: - 8/9/24 to 8/26/24: Sacral Dakims (sic), alginate, bordered foam; every day shift Further review of the Physician's Orders failed to include the Santyl portion of the treatment as recommended by the Consulting Wound NP on 8/9/24. Furthermore, the Physician's Orders failed to indicate the Dakin's strength or clarify calcium alginate versus an alginate dressing. Review of the August 2024 Treatment Administration Record (TAR) indicated the following treatment was completed daily to the sacrum between 8/9/24 and 8/16/24: - Sacral Dakims (sic), alginate, bordered foam; every day shift Further review of the August 2024 TAR failed to include the Santyl portion of the treatment as recommended by the Consulting Wound NP on 8/9/24. Furthermore, the TAR failed to indicate the Dakin's strength or clarify calcium alginate versus an alginate dressing. Review of the medical record indicated Resident #65 was seen by the Consulting Wound Nurse Practitioner (NP) on 8/16/24. Review of the Consulting Wound NP progress note from 8/16/24 indicated but was not limited to the following: - Per staff Resident went to the hospital yesterday due to abnormal labs and received one unit of packed red blood cells (PRBCs). - Wound measurements increased. - Increased odor and drainage. - Will switch treatment to Dakin moist gauze. - Recommend x-ray and labs to evaluate for osteomyelitis. - Duration: Area first evaluated on 3/27/24 - Etiology: Pressure - Stage/Severity: Stage IV - Wound Status: Worsening - Odor Post Cleansing: Malodorous - Size: 8.0 cm x 10.0 cm x 1.5 cm - Wound Base: 75% granulation, 25% slough - Exposed Tissue: Bone - Exudate (Drainage): Large amount of yellow - Recommendations: irrigate with wound cleanser, apply ½ strength Dakins moist gauze to base of wound, secure with silicone border foam. Change twice daily and PRN for soiling, saturation, or accidental removal. - Further Recommendations: X-ray of wound site and labs. Review of Resident #65's nursing progress notes, dated 8/16/24, indicated the Resident was seen by the Consulting Wound NP. The nursing progress notes further indicated the recommended labs and x-ray were reviewed with the NP and ordered. Review of Resident #65's telehealth NP progress note, dated 8/17/24, indicated a sacral x-ray was concerning for osteomyelitis. Further review of the telehealth NP progress note indicated the Resident was ordered to be transferred to the hospital for further follow-up. Review of Resident #65's Hospital Discharge summary, dated [DATE], indicated but was not limited to the following: - The Resident had a history of chronic osteomyelitis and chronic decubitus ulcer. - The Resident presented to the hospital with decubitus ulcer pain and diarrhea. - The Resident was positive for C. diff and a 40-day Vancomycin taper for treatment was never initiated as recommended on previous hospital discharge (7/31/24). - It was recommended for the Resident to begin the 40-day Vancomycin taper for treatment of C. diff upon discharge from the hospital on 8/19/24. - The Resident has a chronic decubitus ulcer and osteomyelitis. - A Computed Tomography Angiography of the Pulmonary Arteries (CTAP) completed on 8/17/24 demonstrated worsening soft tissue ulceration overlying the distal sacrum and coccyx with open bone exposure. The CTAP also showed increased fragmentation of the coccyx favoring chronic osteomyelitis. - The Resident was seen by Infectious Disease (ID) who suggested no antibiotics for now. - Wound treatment recommendations included: cleanse with normal saline and pat dry; paint periwound skin with 3M Vailon No String Barrier Film to protect and help Mepilex to better adhere to skin; cover with a piece of Exufiber Ag (silver) to absorb drainage, promote moist would healing and offer broad spectrum topical antimicrobial control through the use of sustained release silver; cover with Mepilex Border Sacrum; and change every other day and PRN (as needed). Review of Resident #65's medical record indicated he/she returned from the hospital on 8/19/24. Review of the medical record indicated the wound treatment recommendations as well as the 40-day Vancomycin taper were implemented. During an interview on 12/5/24 at 11:58 A.M., Wound Consultant #1 said Resident #65 has been followed for a chronic stage IV sacral pressure ulcer since being admitted to the facility. Wound Consultant #1 said Resident #65 has a history of recurrent C. diff. Wound Consultant #1 said in her experience when Resident #65 has C. diff he/she typically has large stools which would require dressing changes of the chronic stage IV sacral pressure ulcer. Wound Consultant #1 said large amounts of loose stool would negatively impact the wound healing process. During an interview on 12/5/24 at 12:35 P.M., the Physician said recommendations for medications and treatments from the Consulting Wound NP are reviewed with himself or his NP. The Physician said Consulting Wound NP recommendations are generally accepted by the providers. The Physician said he does not recall being notified of recommendations for a 40-day Vancomycin taper after Resident #65's hospitalization from 7/29/24 to 7/31/24. The Physician said loose stools and C. diff would have a negative impact on the Resident's wound status. During an interview on 12/9/24 at 8:26 A.M., Unit Manager (UM) #1 said the Consulting Wound NP rounds on Fridays with the other UM and herself. UM #1 said the Consulting Wound NP will typically undress and evaluate the wound. UM #1 said the Weekly - Wound Observation Tool is updated based on the Consulting Wound NP's observations and recommendations. UM #1 said if any treatment recommendations are changed, they are reviewed with the resident's Physician or NP and orders are updated in the electronic medical record. UM #1 reviewed Resident #65's medical record and said Resident #65's wound treatment orders from 8/9/24 to 8/16/24 did not match the recommendations made by the Consulting Wound NP. UM #1 said the order was missing the Consulting Wound NP's recommendation for Santyl. UM #1 said recommendations for a Fidaxomicin or Vancomycin taper for the treatment of C. diff was not implemented upon return from the hospital on 7/31/24. During an interview on 12/9/24 at 11:20 A.M., the Director of Nursing (DON) said she reviewed Resident #65's medical record and noted the 40-day Vancomycin taper was not implemented when he/she returned from the hospital on 7/31/24 as it should have been. The DON said there should not have been a delay in starting the 40-day Vancomycin taper for Resident #65. The DON reviewed the Consulting Wound NP's recommendations and documentation and said the orders from 8/9/24 to 8/16/24 did not include Santyl as recommended by the Consulting Wound NP.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to promote and manage the delivery of safe nursing care in accordance with accepted Standards of Nursing Practice by failing to identify and address a change in condition and provide necessary care and treatment for one Resident (#65), out of a total sample of 18 residents. Specifically, the facility failed to implement treatment recommendations and orders to initiate a 40-day Vancomycin (antibiotic) taper due to a diagnosis of Enterocolitis due to Clostridium Difficile (C. diff - an infection of the large intestine often resulting in diarrhea or loose stools) for 19 days after a hospitalization resulting a decline in the Resident's stage IV pressure injury (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) on the sacrum. Findings include: Resident #65 was admitted to the facility in June 2024 with diagnoses including C. diff, pressure ulcer of sacral region, and chronic kidney disease. Review of the Minimum Data Set (MDS) assessment, dated 9/26/24, indicated Resident #65 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 4 out of 15. Furthermore, the MDS assessment indicated he/she was being treated for a stage IV pressure ulcer and had a medical diagnosis of C. diff. Review of Resident #65's nursing progress note, dated 7/29/24, indicated Resident #65 was seen by the physician who recommended a transfer to the hospital due to a change in medical status. Review of the hospital Discharge summary, dated [DATE], indicated but was not limited to the following: - Resident had diarrhea on the overnight of 7/29/24. - Resident tested positive for C. diff on 7/30/24. - The Resident was seen by Infectious Disease (ID) during the hospitalization. - ID recommended Fidaxomicin (antibiotic) 200 milligrams (mg) twice a day for five days (7/30/24 to 8/4/24), then 200 mg every 48 hours for 20 days. - ID also alternatively recommended a 40-day Vancomycin taper instead of the Fidaxomicin. - The recommendation for the 40-day Vancomycin taper included: 125 mg by mouth four times a day for 10 days, followed by 125 mg by mouth twice a day for 10 days, followed by 125 mg by mouth once daily for 10 days, followed by 125 mg by mouth once every other day for 10 days. Review of Resident #65's nursing progress note, dated 7/31/24, indicated the Resident returned to the facility from the hospital on this date. Further review of the nursing progress note indicated a Vancomycin taper was recommended for the treatment of C. diff. The nursing progress note indicated the antibiotic treatment options needed to be reviewed with the in-house physician. Review of nursing progress notes, from 7/31/24 to 8/18/24, failed to indicate the antibiotic recommendations were reviewed and/or implemented with the in-house physician. Review of Physician progress notes, from 7/31/24 to 8/18/24, failed to indicate the antibiotic recommendations from the Resident's hospital discharge on [DATE] were reviewed or implemented. Review of Resident #65's Physician's Orders failed to indicate an order for the 40-day Vancomycin taper or Fidaxomicin taper were implemented following his/her return from the hospital on 7/31/24. Review of the Certified Nursing Assistant (CNA) Documentation Survey Report for the task of Bowel Continence, dated August 2024, indicated Resident #65 was incontinent of large/medium loose stools on the following dates/shifts: - 8/1/24: Night shift - 8/2/24: Night shift - 8/3/24: All shifts - 8/4/24: Night shift - 8/5/24: All shifts - 8/6/24: Day shift - 8/7/24: Day shift - 8/8/24: Day/Evening shifts - 8/9/24: All shifts - 8/10/24: Day shift - 8/11/24: Night shift - 8/13/24: Evening shift - 8/15/24: Day shift - 8/16/24: Day/Evening shifts Review of the Wound Consultant Documentation, dated 8/9/24, indicated but was not limited to the following: - Resident had been hospitalized since last wound evaluation. - Wound measurements increased, mild odor noted. - Wound status: worsening. Review of the Wound Consultant Documentation, dated 8/16/24, indicated but was not limited to the following: - Wound measurements increased. - Increased odor and drainage. - Wound status: worsening. During an interview on 12/5/24 at 11:58 A.M., Wound Consultant #1 said Resident #65 has been followed for a chronic stage IV sacral pressure ulcer since being admitted to the facility. Wound Consultant #1 said Resident #65 has a history of recurrent C. diff. Wound Consultant #1 said in her experience when Resident #65 has C. diff he/she typically has large, loose stools which would require dressing changes of the chronic stage IV sacral pressure ulcer. Wound Consultant #1 said large amounts of loose stool would negatively impact the wound healing process. During an interview on 12/5/24 at 12:35 P.M., the Physician said loose stools and C. diff would have a negative impact on the Resident's wound status. Review of Resident #65's nursing progress note, dated 8/18/24, indicated the Resident was transferred to the hospital for abnormal test results. Review of the Hospital Discharge summary, dated [DATE], indicated but was not limited to the following: - Resident had a history of recent C. diff (discharged [DATE]). - Resident presented to the hospital with decubitus ulcer, pain and diarrhea. - Resident still had diarrhea, unfortunately the Vancomycin was stopped. - ID suggested a 40-day Vancomycin taper during last hospitalization 7/29/24 to 7/31/24. - Communication with the nursing facility indicated there was a misunderstanding by the facility on placing the Resident on the Vancomycin taper. - Communicated with them that when leaving the hospital this time the Resident should definitely be on a 40-day taper of Vancomycin. - ID recommendation for the 40-day Vancomycin taper included: 125 mg by mouth four times a day for 10 days, followed by 125 mg by mouth twice a day for 10 days, followed by 125 mg by mouth once daily for 10 days, followed by 125 mg by mouth once every other day for 10 days. Review of the medical record indicated Resident #65 was placed on the recommended 40-day Vancomycin taper on 8/19/24, 19 days after it was initially recommended. During an interview on 12/5/24 at 12:35 P.M., the Physician said when a resident returns from the hospital the facility typically will call him or a nurse practitioner (NP) to review the discharge medications and recommendations. The Physician said he almost always accepts the recommendations for medications and treatments from the hospital discharge. The Physician said he does not recall being notified of recommendations for a 40-day Vancomycin taper after Resident #65's hospitalization from 7/29/24 to 7/31/24. The Physician said he would have addressed the recommendations and documented them in his progress notes. During an interview on 12/9/24 at 8:26 A.M., Unit Manager (UM) #1 said when a resident returns from the hospital the discharge summary is reviewed by the nurse. UM #1 said all discharge medications and recommendations would then be reviewed by the physician or NP either in the facility, if they were present, or by phone. UM #1 reviewed Resident #65's hospital discharge summary from 7/31/24 and said the Vancomycin taper was not listed on the discharge medication list from the hospital. UM #1 said the hospital discharge summary does clearly indicate the recommendation for a Fidaxomicin or Vancomycin taper to be initiated due to the Resident's diagnosis of C. diff. UM #1 said the hospital discharge summary recommendations should have been reviewed with the physician or NP so they could be implemented. UM #1 said no Vancomycin taper was started until Resident #65 returned from the hospital on 8/19/24. During an interview on 12/9/24 at 11:20 A.M., the Director of Nursing (DON) said when a resident returns from the hospital the discharge summary is reviewed by the nurse. The DON said all discharge medications and recommendations would then be reviewed by the physician or NP either in the facility, if they were present, or by phone. The DON said she reviewed Resident #65's medical record and noted the 40-day Vancomycin taper was not implemented when he/she returned from the hospital on 7/31/24 as it should have been. The DON said the hospital discharge summary should have been reviewed and clarified with the Physician. The DON said there should not have been a delay in starting the 40-day Vancomycin taper for Resident #65.