**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #13 was admitted to the facility in June 2024 with diagnoses including diabetes and heart failure. Review of the most recent Minimum Data Set (MDS) assessment, dated 9/11/24, indicated Resident #13 was cognitively intact as evidenced by a Brief Interview for Mental Status exam score of 15 out of 15. The MDS further indicated Resident #13 was always incontinent of bowel and bladder. Review of the most recent comprehensive MDS assessment, dated 6/13/24, indicated Resident #13 triggered for incontinence and the care area assessment indicated a need to develop an incontinence care plan. Review of Resident #13's medical record failed to indicate a care plan had been developed for incontinence care. Review of Resident #13's Documentation Survey Report, dated 10/24/24 to 10/30/24, indicated Resident #13 was incontinent six out of the seven days. On 10/29/24 at 9:21 A.M., the surveyor observed Resident #13 in bed and the room smelled strongly of stool. Resident #13 said he/she was incontinent, and that staff were aware. Resident #13 said he/she had told staff many times over the last few months that he/she would like to have incontinence care before meals, but staff said they were unable to. Resident #13 said that the staff change him/her after breakfast. On 10/30/24 at 7:45 A.M., the surveyor observed Resident #13 in bed and the room smelled strongly of stool. Resident #13 expressed being very upset because he/she had no choice but to sit in feces for the breakfast meal. Resident #13 said he/she had told staff but was told they could not provide incontinence care because it was during mealtime. Resident #13 said he/she had not had any incontinence care this shift and asked the surveyor to ask staff for assistance with incontinence care stating please, I don't want to eat breakfast in my own feces again. During an interview on 10/30/24 at 9:45 A.M., the surveyor observed Resident #13 tell Nurse #3 that she was tired of not having incontinence care provided before meals and during the night and that she had asked for many times before. Resident #13 asked Nurse #3 to change the rule that residents were not allowed to have incontinence care during meals. Nurse #3 said she didn't think staff was allowed to provide incontinence care during meals, but that she would make sure staff assisted Resident #13 with incontinence care before meals. On 10/31/24 at 7:51 A.M., the surveyor observed Resident #13 in bed with breakfast tray. Resident #13 said that she was incontinent of urine and waiting for incontinence care to be provided. Resident #13 said that he/she had asked for the care before the breakfast tray arrived, but that it had not occurred. During an interview on 10/31/24 at 9:15 A.M., Certified Nurse Assistant (CNA) #5 said Resident #13 requires assistance with incontinence care and toileting needs and never refuses care. CNA #5 said that although Resident #13 did not have any specific incontinence care interventions that she was aware of, that it was the facility expectation to provide incontinence care promptly when necessary. During an interview on 10/31/24 at 12:24 P.M., the Director of Nursing (DON) said the MDS Nurse was responsible for developing incontinence care plans that triggered on an MDS, but that nurses on the floor can also create and update care plans when needed. The DON said she was surprised there was no incontinence care plan or interventions in Resident #13's medical record as the Resident had been incessant about incontinence care not being provided. The DON said because of the Resident's past concerns with incontinence care she had told staff Resident #13 should have incontinence care before each meal, and that this is an intervention that should be on an incontinence care plan. During an interview on 11/1/24 at 8:42 A.M., the MDS Nurse said Resident #13's comprehensive MDS triggered for incontinence and that an incontinence care plan should have been developed but never was. Based on observation, record review, and interview, the facility failed to develop a comprehensive person centered care plan and implement the plan of care for two Residents (#55 and #13) out of a total sample of 27 residents. Specifically: 1. for Resident #55, the facility failed to develop a Suicidal Ideation (SI) care plan, after vocalization of suicidal ideation, which resulted in the Resident attempted to commit suicide at the facility and; 2. for Resident #13, the facility failed to develop and implement a plan of care for incontinence. Findings include: The facility policy titled Comprehensive Care Plan, undated, indicated the following: - Policy Statement: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. - Areas of concern that are triggered during the resident assessment are evaluated using specific assessment tools (including Care Area Assessments) before interventions are added to the care plan. - The resident's comprehensive care plan is developed within seven (7) days of completion of the resident's comprehensive assessment (MDS) and no more than twenty-one (21) days after admission. 1. For Resident #55, the facility failed to develop a comprehensive person centered care plan for a Resident who admitted with a recent history of verbalizing Suicidal Ideation (SI). Resident #55 had another incidence of verbalizing SI and the facility failed to develop a plan of care related to SI, which resulted in an attempted suicide in December 2023. The facility policy titled Suicide Threats, dated 12/6/21, indicated the following: PURPOSE: To ensure residents that make suicide threats have timely intervention to ensure safety. POLICY: Resident suicide threats shall be taken seriously and addressed appropriately. PROCEDURE: - If the resident remains in the facility, the resident will remain on 1:1 observation. Staff will monitor the resident's mood and behavior and update care plans accordingly, until a physician has determined and documented that a risk of suicide does not appear to be present. Review of the facility assessment, reviewed 7/25/24, indicated the facility is able to manage the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care for someone with cognitive impairment, care for individuals with depression, trauma/PTSD, other psychiatric diagnoses, and intellectual or developmental disabilities. The facility is able to care for and implement nonpharmacological interventions. On average, the facility manages about 40-65 residents with behavioral health needs at a time. Resident #55 was admitted to the facility in February 2023 and had diagnoses that include depression and dementia. Review of the Nurse Practitioner's admission note indicated that Resident #55 had a question of some passive suicidal ideation, reporting that he/she feels useless and cannot do much. Review of the admission Minimum Data Set (MDS) assessment, dated 2/23/23, indicated Resident #55 scored a 13 out of a possible 15 on the Brief Interview for Mental Status exam, indicating intact cognition. Review of the Mood Interview indicated Resident #55 self-reported a PHQ9 score of 5, which indicates mild depression (score of 0-4=minimal depression, 5-9=mild depression). Review of the Resident's hospital discharge paperwork, given to the facility upon admission, indicated: -Resident's daughter states that her father/mother has been dosing [sic] some passive suicidal ideations, without any plans. I had asked patient about this as well, he/she does not have any active plans. He/she states that he/she feels 'useless and that he/she cannot do much'. He/she states that when it is time to go just let him/her go. He/she does not have any active plans, especially in the hospital. He/she states that he/she has been seeing things that other people may not see. DC instructions included: Patient does not have active SI and will not act upon thoughts. Therefore, I don't think he needs a 1:1 or safety tray at this time. Again, it may be reasonable to obtain psych consult for med recommendations for some of patient's hallucinations. At the time of admission to the facility, a psychosocial well-being care plan was developed for Resident #55 and indicated the following: Focus: Resident #55 has a potential for psychosocial well-being problem r/t Inability to meet role expectations, Recent admission and current COVID status (initiated 2/15/23). Interventions: -Consult with: Pastoral care, Social services, Psych services, Other: (initiated 2/15/23) -Increase communication between resident/family/caregivers about care and living environment: Explain all procedures and Treatments, Medications, Results of labs/tests, Condition, All changes, Rules, Options. (initiated 2/15/23) -Initiate referrals as needed or increase social relationships: Invite and encourage Resident #55 to participate in activities. (initiated 2/15/23) -Monitor/document residents feelings relative to (isolation, unhappiness, loss). (initiated 2/15/23) -Provide opportunities for I and family to participate in care. (initiated 2/15/23) -Provide support to Resident #55 in setting realistic goals. (initiated 2/15/23) -When conflict arises, remove residents to a calm safe environment and allow to vent/share feelings. (initiated 2/15/23) Review of Resident #55's other comprehensive care plans failed to indicate a care plan was developed for the Resident's history of suicidal ideation (SI), interventions related to the safety of Resident #55, or nonpharmacological interventions to manage thoughts of suicidal ideation. Review of the progress note, dated 8/5/23, indicated: Resident sent out at 7 PM for suicidal ideations w/ active plan. Reported to this writer that today was going to be his/her last day here i'm going out one way or another. Resident reported that he/she wants to end his/her life today and has a plan to do so. Resident declined to tell this writer what the plan is but repeatedly stated Anyway I can I'm getting it done tonight, there's lots of ways to do it. This writer stayed with resident and discussed further, Resident #55 voiced frustration with being in a LTC (long term care) facility and that at his/her age he/she should be able to end his/her life if he/she wants. Resident #55 further voiced being alone pertaining to his/her children and that they lied to get him/her here and now he/she is stuck. Resident #55 was teary eyed when discussing and also voiced concerns about his/her financial status and he/she feels his/her daughter lied to him/her and took over his/her money after agreeing placement here was only going to be temporary. This writer was able to talk with Resident #55 and he/she agreed to a hospital evaluation this evening d/t (due to) his/her current thoughts. He/she remained adamant about ending his/her life t/o (throughout) the conversation and was placed on a 1:1 (one to one supervision) until EMT's arrived for transport. Left in stable condition via stretcher accompanied by 2 EMT's, 2 police officers and local fire department. MD aware. HCP aware. (sic) Review of the hospital progress note, dated 8/5/23, indicated a Behavioral Health Crisis Consult-Initial Assessment: Reason for Consult: Patient made suicidal statement. According to the assessment presented to the hospital on 8/5/23, for Psychiatric evaluation. Behavioral health is consulted after he/she made suicidal statement, per staff from nursing home (Nurse named) patient told her that he/she is going to kill him/herself and did not share any specific plan, but patient denies making this specific statement. The trigger includes that the patient doesn't want to stay at the nursing program and he/she said that he/she wants to stay at his/her home. According to the assessment Resident #55 denied SI and then said that if he/she could get his/her hands on a gun then he/she would kill him/herself. Resident did not meet inpatient criteria and was to send back to the nursing facility with no new orders. Review of the clinical record failed to indicate that, upon readmission to the facility, Resident #55's plan of care was reviewed or updated, despite Resident #55's vocalization of suicidal ideation in the hospital and a section 12. The facility failed to develop a care plan related to suicidal ideation, that included nonpharmacological interventions, and interventions related to resident safety. Review of the Behavioral Health Group note for medication management, dated 8/9/23, indicated: Patient can benefit from: Behavior mgmt; Psychiatric meds. Review of the record failed to indicate any changes were made to the plan of care at that time to include behavioral management interventions. Review of the social service progress note, dated 10/16/23 indicated: On this date, SS met with resident and offered emotional support as resident is grieving the death of his friend. SS provided active listening and validated resident's feelings. SS reminded the resident to reach out with any additional support needed. SS to remain in place for continued support and advocacy. Review of the record fails to indicate any changes were made to the plan of care at that time to address this loss, psychosocial stressors, or potential for SI. Review of the Behavioral Health Group note for medication management, dated 10/18/23, indicated Resident #55 was seen by the Psych NP due to increased anxiety and paranoia with recommendation to increase Buspar from 5mg to 10 mg BID for anxiety/agitation. Treatment Plan (completed today): Treatment Goal / Personal Family Vision: rt will remain stable with mood/behaviors Goals: 1. Problem: anxiety - Short Term Goals: client/staff will report no more than 1-2 episode of anxiety per day - Long Term Goals: client/staff will report no more than 2-3 episode of anxiety per week. Client unable to review treatment plan due to cognitive deficit. Review of the record failed to indicate that the recommended treatment plan was communicated to staff, implemented or tracked. Review of the behavior monitoring sheets since admission failed to indicate that the facility was monitoring for any change in Resident #55's daily mood and depression. Review of the progress note dated 12/18/23 indicated: During dinner this evening patient ambulated out to the second floor balcony, climbed up on a chair and attempted to jump off the balcony. Maintenance manager witnessed patient during this attempt and pulled him/her to safety. Patient became extremely agitated screaming at manager for stopping him/her. Patient returned to his/her room with a sitter . Patient continued making suicidal ideations stating I will try and try until I succeed .FD (fire department) transported patient to hospital .etc. Review of the clinical record indicated Resident #55 was psychiatrically hospitalized [DATE]-[DATE]. Review of the clinical record failed to indicate that upon readmission to the facility, Resident #55's plan of care was reviewed or updated, despite Resident #55's suicide attempt on 12/18/23. The record indicates that an SI care plan was developed on 1/9/24, 4 days after readmission to the facility. The SI care plan developed on 1/9/24 indicated the following: FOCUS: Resident #55 has a mood problem r/t dx's (diagnoses) of Depression and Anxiety d/o (disorder), as well as recent re-admission. He/she has also had a recent suicide attempt, more specifically on 12/18/23 where he attempted to jump off the facility balcony. INTERVENTIONS: -Start 1/9/24: Administer medications as ordered. Monitor/document for side effects and effectiveness. -Start 1/9/24: Assist I (individual) in developing /Provide I with a program of activities that is meaningful and of interest. Encourage and provide opportunities for exercise, physical activity. -Start 1/9/24: Assist I, family, caregivers to identify strengths, positive coping skills and reinforce these. -Start 1/9/24: Behavioral health consults as needed (psycho-geriatric team, psychiatrist etc.) -Start 1/9/24: Educate I/family/caregivers regarding expectations of treatment, concerns with side effects and potential adverse effects, evaluation, maintenance. -Start 1/9/24: Resident #55 needs encouragement to maintain as much independence and control as possible. Resident #55's strength's are: (he/she is. strong advocate for him/herself, he/she can ask for help, can express feelings etc.) -Start 1/9/24: Monitor/document/report PRN any risk for harm to self: suicidal plan, past attempt at suicide, risky actions (stockpiling pills, saying goodbye to family, giving away possessions or writing a note), intentionally harmed or tried to harm self, refusing to eat or drink, refusing med or therapies, sense of hopelessness or helplessness, impaired judgment or safety awareness. -Start 1/9/24: Monitor/record mood to determine if problems seem to be related to external causes, i.e. medications, treatments, concern over diagnosis. -Start 1/9/24: Monitor/record/report to MD (physician) prn (as needed) acute episode feelings or sadness; loss of pleasure and interest in activities; feelings of worthlessness or guilt; change in appetite/ eating habits; change in sleep patterns; diminished ability to concentrate; change in psychomotor skills -Start 1/9/24: Monitor/record/report to MD prn mood patterns s/sx of depression, anxiety, sad mood as per facility behavior monitoring protocols. -Start 1/9/24: Monitor/record/report to MD prn risk for harming others: increased anger, labile mood or agitation, feels threatened by others or thoughts of harming someone, possession of weapons or objects that could be used as weapons -Start 1/9/24: Observe for signs and symptoms of mania or hypomania racing thoughts or euphoria; increased irritability; frequent mood changes; pressured speech; flight of ideas; marked change in need for sleep; agitation or hyperactivity. Review of a progress note dated 3/17/24: Receptionist informed nurse that she delivered a package to resident and offered to open package for resident. Resident said yes. Package was a plastic and when receptionist offered to throw it away resident stated no, I'm [NAME] to put it over my head.Resident refuse to give the plastic, was adamant but not aggressive. This nurse approached resident and sat on the bed beside resident and gently asked for the bag. Resident laughed and stated I was joking; I want to use it for trash This nurse explained to resident why the bag needed to be taken resident laughed and stated you don't want to go to my funeral? this nurse stated No sir Resident apologized stating the joke was in poor taste and handed the bag over to this nurse. Resident was pleasant, kind, and calm. Night shift staff made aware to keep an eye of resident for any further remarks or behaviors. Review of the record failed to indicate any changes had been made to Resident #55's plan of care, care plan, or that notification to the Physician, NP or family occurred after the Resident verbalized SI. Further review failed to indicate that the facility's policy regarding SI was implemented. Review of the record failed to indicate that the physician was aware or addressed Resident #55's suicidal ideation in March 2024. During an interview on 10/30/24 at 12:19 P.M., with the facility Social Worker (SW) #1 she said that she has worked at the facility for 2 months. She said that if a resident admits to the facility with a history of verbalizing SI, whether remote or recent, she would meet with the resident upon admission and determine the history in order to develop a person centered care plan. SW #1 said that for any resident that voices SI while at the facility, or if they are hospitalized for SI while at the facility, she would review the care plan and update it when this occurs. SW #1 said that she is the only social worker in the building and that she does not know Resident #55 and that she was not aware that he/she had attempted to commit suicide while residing at the facility. SW #1 said that she would expect to have been told thus so that she could have ensured a plan of care, including nonpharmacological interventions, was in place for Resident #55. During an interview on 10/30/24 at 12:35 P.M., with the Nurse Unit Manager #1 she said that she has been the nurse unit manager for 7 years and knows Resident #55 well. According to Nurse Unit Manager #1, a comprehensive care plan regarding Resident #55's SI should have been developed at admission and she is not sure why it was not. She said that it is the expectation that the team continuously update all SI care plans with any changes in SI status. Nurse Unit Manager #1 said that while she could not recall the SI in August 2023, that at that time an SI care plan should have already been in place and would have been reviewed and updated. During an interview on 10/31/24 at 12:34 P.M., with Resident #55's Physician he said that it is his expectation that the facility would develop and implement a care plan, that includes nonpharmacological interventions, for all residents with a history of SI. The physician said that he was under the impression that Resident #55 was being followed closely by the facility's Social Worker and was surprised to hear that the Social Worker learned only the day prior from the surveyor that Resident #55 had both a history of verbalizing SI and of an actual suicide attempt at the facility. During an interview on 10/31/24 at 1:01 P.M., the Director of Nursing said when a resident is admitted with a history of suicidal ideation, they should be assessed upon admission, and a care plan should be developed that includes nonpharmacological interventions to keep the Resident safe. The DON said that the care plan should be followed and updated any time the resident voices SI or requires intervention related to SI. The DON was surprised to learn that the current facility social worker was unaware that Resident #55 had a history of SI and actual suicide attempt at the facility, and would have expected that to have been important information for her to receive when she was trained 2 months prior.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to provide necessary treatment, services, interventions to promote healing and prevent new ulcers from developing for one Resident (#4), who was assessed to be at risk for pressure ulcer development, out of 27 total sampled residents. Specifically, for Resident #4: a.) the facility failed to implement physician ordered pressure ulcer prevention interventions to offload heels and ensure correct air mattress settings were implemented consistently resulting in new skin breakdown including the re-opening of a previously healed pressure ulcer on the left upper Achilles heel; b.) the facility failed to obtain wound care orders for the newly re-developed pressure ulcer on the left upper Achilles heel; c.) the facility failed to ensure a right heel pressure related deep tissue injury (DTI) was assessed and measured weekly; and d.) the facility failed to ensure the weekly skin assessments were completed and documented. Findings include: Review of the facility policy titled Pressure Ulcer Prevention, revised 12/22/22, indicated: - The facility will implement interventions to minimize and/or eliminate contributing factors for pressure ulcer development on patients/residents at risk. - A weekly body audit will be completed on residents. - Wounds will have weekly assessments and documentation of each area until healed. Review of the facility policy titled Skin Body Audit, revised 3/12/13, indicated: - Purpose: To identify changes in skin integrity through weekly skin audits (head to toe) on all residents. - Licensed nurses will perform skin body audits on a weekly basis. - Any significant abnormal findings are reported to the resident's physician. Resident #4 was admitted to the facility in December 2023 with diagnoses including end stage renal disease and diabetes. Review of the most recent Minimum Data Set (MDS) assessment, dated 9/11/24, indicated Resident #4 was cognitively intact as evidenced by a Brief Interview for Mental Status exam score of 15 out of 15. This MDS indicated Resident #4 required partial/moderate assistance with transferring from bed to chair, moving from a sitting to a standing position, and with lower body dressing. This MDS also indicated the Resident had one deep tissue pressure injury (DTI) and was at risk for developing pressure ulcers. During an interview on 10/31/24 at 12:35 P.M., The MDS Nurse said the DTI on the MDS, dated [DATE], was for Resident #4's right heel. Review of Resident #4's assessment titled Norton Scale for Predicting Risk of Pressure Ulcer, dated 9/20/24, indicated the Resident was at high risk for pressure ulcer development as evidenced by a score of 10. Review of Resident #4's assessment titled Weekly Skin Checks, dated 10/18/24, failed to indicate a pressure related wound on his/her left upper Achilles heel. Review of Resident #4's plan of care related to potential for new skin breakdown, revised 9/19/24, indicated: - Resident #4 has the potential for new skin breakdown due to impaired mobility, episodes of incontinence, and diagnosis of type 2 diabetes. - Assist with turning/ redistributing weight per facility protocol. - Complete skin checks weekly per facility protocol. Pay particular attention to the bony prominences. - Notify MD if any skin breakdown occurs. a.) The facility failed to implement physician ordered pressure ulcer prevention interventions to offload heels and ensure correct air mattress settings were implemented consistently, resulting in new skin breakdown including the re-opening of a previously healed pressure ulcer on the left upper Achilles heel, as evidenced by the following: Review of Resident #4's physician's orders indicated: - Offload both heels at all times, every shift, initiated 8/13/24. - Offload right heel with 2-3 pillows under calf or apply offloading boots at all times while in bed, every shift, initiated 8/13/24. - Low air loss mattress - settings at 250 lbs. (pounds) alternating pressure. Check function and setting each shift, initiated 8/13/24. Review of Resident #4's medical record failed to indicate any refusal or rationale for his/her heels not being offloaded or the air mattress being set at 200 lbs. (instead of 250 lbs.) alternating pressure. On 10/29/24 at 9:01 A.M. and 10:34 A.M., 10/30/24 at 7:37 A.M., 9:16 A.M., and 10:01 A.M., and 10/31/24 at 8:09 A.M. and 10:18 A.M., the surveyor observed Resident #4 in bed with his/her heels directly on the mattress without any pillows or offloading boots. Resident #4 was on an air mattress which was set at 200 lbs. alternating pressure (instead of 250 lbs.). During an interview on 10/31/24 at 8:09 A.M., Resident #4 said staff used to help offload his/her heels with pillows and offloading boots, but they haven't in a long time. Resident #4 said he/she isn't sure why staff doesn't help offload his/her heels anymore because he/she has a new left heel wound. Resident #4 said he/she would like to have his/her heels offloaded and would never decline because he/she thinks it would make his/her sore heels feel better. Resident #4 said his/her air mattress is often not comfortable. During an interview on 10/31/24 at 8:23 A.M., CNA (Certified Nurse Assistant) #6 said she was currently assigned to care for Resident #4 and was unaware his/her heels should be offloaded. CNA #6 said the CNAs are made aware of specific interventions through report from nurses and the care card. CNA #6 said the nurse never reported that Resident #4 needed to have heels offloaded and his/her care card had no interventions to offload heels. During an interview on 10/31/24 at 8:28 A.M., CNA #7 said he was previously assigned to care for Resident #4 recently and was unaware his/her heels should be offloaded. CNA #7 said the CNAs are made aware of specific interventions to prevent skin breakdown through report from nurses and the care card. CNA #7 said the nurse never reported that Resident #4 needed to have heels offloaded. CNA #7 reviewed Resident #4's care card with the surveyor and said there were no interventions listed to offload heels. During an interview on 10/31/24 at 8:33 AM, Nurse #2 said she was a consistently assigned day shift nurse for Resident #4 during the last two weeks. Nurse #2 said she was unaware his/her heels should be offloaded. Nurse #2 observed Resident #4's heels with the surveyor and said the right heel is dark red and probably had pressure related damage and there is an unstageable pressure ulcer on his/her left upper Achilles heel that had been there since she started two weeks ago. Nurse #2 said there is no treatment in place for the pressure ulcer on left upper Achilles heel. Nurse #2 said she applies skin prep (a topical medication used to prevent skin breakdown) to the medial aspect of the heel only and never applies to the pressure ulcer on left upper Achilles heel because there is no order for it to be applied to that anatomical location. During an interview on 10/31/24 at 10:48 A.M., Nurse Unit Manager #1 said Resident #4 needed to have his/her heels offloaded to prevent skin breakdown because he/she was at high risk for skin breakdown relating to a history of pressure wounds on both heels. Nurse Unit Manager #1 said Resident #4 has a DTI on the right heel and a history of a healed pressure ulcer on the left upper Achilles heel, which in spring 2024. Nurse Unit Manager #1 also said Resident #4 is on an air mattress to prevent the development of pressure ulcers and nurses should check to ensure the correct air mattress settings are in place each shift. Nurse Unit Manager #1 observed Resident #4's heels with the surveyor. Nurse Unit Manager #1 said Resident #4's right heel is a pressure related DTI and the left Achilles is a new unstageable pressure ulcer where a past pressure ulcer had previously healed in spring 2024. Nurse Unit Manager #1 said she was unaware the pressure ulcer had re-developed, and this is exactly why his/her heels needed to be offloaded. During an interview on 10/31/24 at 12:30 P.M., the Director of Nursing (DON) said Resident #4's heels should have been offloaded and the air mattress should have been set to correct settings, and if he/she refused it should be documented. The DON said the nurses are responsible for check air mattress settings each shift and if found not at the physician ordered setting then should be adjusted and/or clarified. b.) The facility failed to obtain wound care orders for a new pressure ulcer, as evidenced by the following: Review of Resident #4's physician's orders indicated: - Wound: left medial heel, apply skin prep to area daily, imitated 8/13/24. Review of Resident #4's current physician's orders failed to indicate any wound orders for the left upper Achilles heel. During an interview on 10/31/24 at 8:33 AM, Nurse #2 said she was a consistently assigned day shift nurse for Resident #4 during the last two weeks. Nurse #2 observed Resident #4's heels with the surveyor and said there is an unstageable pressure ulcer on his/her left upper Achilles heel that has been there since she started two weeks ago. Nurse #2 said there is no treatment in place for the pressure ulcer on left upper Achilles heel. Nurse #2 said she applies skin prep (a topical medication used to prevent skin breakdown) to the medial aspect of the heel only and never applies to the pressure ulcer on left upper Achilles heel because there is no order for it to be applied to that anatomical location. During an interview on 10/31/24 at 10:48 A.M., Nurse Unit Manager #1 said Resident #4 had a history of a healed pressure ulcer on the left upper Achilles heel, which healed in spring 2024. Nurse Unit Manager #1 observed Resident #4's left upper Achilles heel and said there is now an unstageable pressure ulcer that she was unaware of. Nurse Unit Manager #1 said the order for skin prep to the left medial heel does not cover the left upper Achilles heel, and the provider should have been notified to obtain wound orders but had not been. During an interview on 10/31/24 at 12:30 P.M., the Director of Nursing (DON) said the provider should have been notified to obtain wound orders for the pressure ulcer on Resident #4's left upper Achilles heel. c.) The facility failed to ensure a pressure related deep tissue injury (DTI) was assessed and measured weekly, as evidenced by the following: Review of Resident #4's medical record failed to indicate any wound assessments or measurements for his/her right heel DTI in the past three months. During an interview on 10/31/24 at 10:48 A.M., Nurse Unit Manager #1 said Resident #4 had a DTI on his/her right heel. Nurse Unit Manager #1 observed Resident #4's right heel and said it currently is a pressure related DTI. Nurse Unit Manager #1 said the Resident had this DTI since at least August 2024 and it should have been assessed and measured weekly. Nurse Unit Manager #1 said the consultant wound physician should do this but is unsure why the consultant wound physician had not been following this Resident. Nurse Unit Manager #1 reviewed the record and said that since the consultant wound physician was not following Resident #4 then nursing should have been completing weekly wound assessments with measurements but had not been. During an interview on 10/31/24 at 12:30 P.M., the Director of Nursing (DON) said it was the expectation that if the consultant wound physician was not following Resident #4's right heel DTI, then Nurse Unit Manager #1 should have assessed and measured the heel weekly. d.) The facility failed to ensure weekly skin assessments were being completed, as evidenced by the following: Review of Resident #4's physician's orders indicated: - Weekly skin checks, initiated 8/16/24 and discontinued 10/15/24. - Weekly skin checks on Fridays, initiated 10/18/24 and discontinued 10/18/24. - Weekly skin checks on Fridays, initiated on 10/25/24. Review of Resident #4's medical record, dated 8/13/24 to 10/31/24, indicated skin assessments were only documented on 9/27/24, 10/4/24, and 10/18/24. Skin assessments were not completed eight out of the eleven weeks. During an interview on 10/31/24 at 10:48 A.M., Nurse Unit Manager #1 said skin assessments should be completed and documented every week. During an interview on 10/31/24 at 12:30 P.M., the Director of Nursing (DON) said skin assessments should be completed and documented every week. The DON said weekly skin assessments not being completed was an ongoing concern in the facility.