5.) Resident #3 was admitted to the facility September 2023 with diagnoses including a stroke, acute inflammatory demyelinating polyneuropathy (AIDP) (weakness and sensory loss in limbs), and anemia. Review of the Minimum Data Set (MDS) assessment, dated 7/4/24, indicated Resident #3 had a Brief Interview for Mental Status (BIMS) score of 13 out of a possible 15 which indicated she is not cognitively impaired and requires total assist with all activities of daily living. Review of nursing skin evaluation, dated 7/6/24, indicated Resident #3 had no skin issues. Review of consultant wound physician notes, dated 7/9/24, indicated initial evaluation of Resident #3's right lateral ankle wound, documented duration of wound as greater than 50 days. The consultant wound physician classified the wound as non-pressure caused by trauma/injury and made dressing treatment recommendations for xeroform gauze daily, covered by abdominal pad, kerlix gauze roll and tape. Review of Medication Administration Record (MAR), Treatment Administration Record (TAR), and physician orders failed to include that nursing implemented this recommendation. Review of physician progress note, dated 7/13/24, indicated Resident #3 had a right foot pressure sore. Review of consultant wound physician notes, dated 7/15/24, indicated the physician had performed a surgical excisional debridement procedure at bedside to remove necrotic tissue and establish the margins of viable tissue. The consultant wound physician continued to recommend xeroform gauze daily, covered by abdominal pad, kerlix gauze roll and tape to Resident #3's right ankle wound. Review of Medication Administration Record (MAR), Treatment Administration Record (TAR), and physician orders failed to include that nursing implemented this recommendation. Review of the consultant orthopedic physician, dated 7/16/24, indicated recommendations to right ankle ulcer for Resident #3: -Daily dressing changes per wound care. -PRAFO offloading (always keeps pressure off wound) bootie. -maintain non-weight bearing to right side -continue range of motion/exercise/physical therapy to right ankle daily. Review of physician progress note, dated 7/16/24, indicated Resident #3 had a right foot pressure sore. Review of Nurse Practitioner #1's note, dated 7/16/24, said that Resident #3 was seen by foot ankle specialist and recommendations included daily dressing changes per wound care for Resident #3's right ankle wound. Review of physician's order, dated 7/17/24, indicated right outer ankle area wound, normal saline wash, pat dry, apply xeroform cover with border dressing daily. Discontinue when healed on day shift each day. Further review indicated this was implemented eight days after the recommendation was made by the consultant wound physician. However, upon further review, this order was not scheduled into the electronic health record (EHR). Review of TAR dated July 2024, indicated Nurse #8 had added scheduled order for right ankle wound treatment starting on 7/30/24. Further review of this TAR indicated only Nurse #8 had signed as completing the treatment to Resident #3's right ankle wound on 7/30/24, 22 days after the initial wound physician's recommendation. On 7/30/24 at 8:10 A.M. the surveyor and Nurse #8 reviewed Resident #3's wound care order to right outer ankle and observed the following: -there was an order for right ankle wound care ordered 7/17/14. -there failed to be an order scheduled on TAR for right ankle wound care. Nurse #8 said she knew she had an order and what the treatment was because the consultant wound physician had given her a verbal order and she forgot to verify with physician and transcribe the order. During an interview on 7/29/24 at 2:20 P.M., the Unit Supervisor said he completed wound rounds with the Wound Physician on 7/9/24. The Unit Supervisor said he was supposed to print the Wound Physicians recommendations and present them to the Nurse Practitioner (NP), but he never had time, so he never notified the provider of the change in wound condition and need to alter wound treatment. The Unit Supervisor said a lot of recommendations are probably missed because I don't have time to follow up. During an interview on 8/1/24 at 7:47 A.M., the Director of Nursing (DON) said the Unit Supervisor is responsible for notifying the NP of the change in wound condition and the need to alter wound treatment. 4) Resident #103 was admitted to the facility in March 2024 with diagnoses that include diabetes, pressure ulcer of the right buttock (stage IV) and bacteremia. Review of Resident #103's most recent Minimum Data Set (MDS) Assessment, dated 6/21/24, indicated a Brief Interview for Mental Status (BIMS) score of 12 out of a possible 15, indicating that the Resident had moderate cognitive impairment. The MDS further indicated that the Resident had one stage IV pressure ulcer that was present on admission to the facility and was at risk for the development of pressure ulcers. Review of Resident #103's most recent Norton Assessment (a tool designed to help clinicians evaluate a resident's risk of developing pressure injuries), dated 6/15/24, indicated a score of 9, placing Resident #103 at high risk for the development of pressure injuries. During an observation and interview on 7/23/24 at 8:28 A.M., Resident #103 was observed laying on his/her back in bed. Resident #103 said that he/she has a pressure injury that they had when they were admitted to the facility on their sacrum. Resident #103 said that sometimes the dressing covering the pressure injury comes off and it takes a while for nursing staff to replace it. Review of Resident #103's active physician's orders indicated an order for santyl external ointment (a medication that is used to break up and remove dead skin tissue from skin ulcers) 250 unit/ gram. Apply to sacrum area topically every shift. Wash wound with normal saline, pat dry then apply Santyl to calcium alginate, dated 3/28/24. Review of the wound consultant note, dated 6/18/24, included recommendations to discontinue the use of santyl ointment in the wound bed. Review of the most recent wound consultant note, dated 7/30/24, included recommendations for a calcium alginate dressing covered with a foam silicone dressing to be changed once daily. Review of Resident #103's active pressure ulcer care plan, dated 4/1/24, indicated to follow up with [consultant wound physician] as needed and follow [physician] orders for treatment. Review of Resident #103's July 2024 Treatment Administration Record indicated that santyl was applied to the wound bed twenty-two days in July. Review of Resident #103's progress notes failed to indicate that the physician or nurse practitioner were made aware of the recommendations to discontinue santyl ointment, and the treatment continued as an active order through 7/26/24. During an interview on 7/25/24 at 10:04 A.M., Nurse Practitioner #1 said that the consultant wound physician writes notes that are uploaded into the resident's medical record. Nurse Practitioner #1 said that nursing staff round with the consultant wound physician and if changes are made to the treatment recommendations, she would expect nursing to communicate that with her. Nurse Practitioner #1 said that she was not made aware of the recommendations to discontinue the use of santyl ointment to the wound for Resident #103. Nurse Practitioner #1 further said that she accepts and puts into place all consultant wound physician recommendations that are made when she is made aware of them. During an interview on 7/26/24 at 8:19 A.M., Nurse #2 said that the consultant wound physician does not communicate to the direct care staff any changes that are made, and it is up to the Unit Supervisor to check the notes and implement the changes with the Nurse Practitioner. Nurse #2 and surveyor reviewed the consultant wound physician note from 6/18/24 and Nurse #2 said that those recommendations should have been communicated to the Nurse Practitioner, but they were not. During an interview on 7/26/24 at 11:18 A.M., the Director of Nurses (DON) said that nurses should be reviewing the consultant wound physician notes that are uploaded into the resident's medical record. The DON said that typically the Unit Supervisor rounds with the consultant wound physician and would know if any recommendations are made to change current treatments. The DON said this should be communicated to the Nurse Practitioner and recommendations should be followed. The DON said neither the Nurse Practitioner or Physician were not notified of the recommendations to discontinue the use of santyl on 6/18/24. 3.) Resident #88 was admitted to the facility in August 2023 with diagnoses including diabetes and hypertension. Review of the most recent Minimum Data Set (MDS) assessment, dated 5/30/24, indicated that Resident #88 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out of 15. The MDS also indicated the presence of surgical wound requiring surgical wound care. Review of the Wound Physician's progress note, dated 7/15/24, indicated the following dressing treatment plan for Resident #88's right third amputated toe surgical wound: - Add Skin Prep, once daily, for 30 days. - Discontinue Alginate Calcium. - Discontinue Tape (Retention), Gauze Sponge Sterile. Review of the Wound Physician's progress note, dated 7/23/24, indicated the following dressing treatment plan for Resident #88's right third amputated toe surgical wound: - Continue Skin Prep, once daily, for 22 days. Review of Resident #88's active physician's order, initiated 3/20/24, indicated: -Wash wound with soapy water, pat dry. Place Silver alginate to wounds of Right 3rd toe, left 3rd toe and left plantar foot. Cover with dry gauze, secure with keflex wrap and Ace from toe to knee. 50% overlap 50% stretch. Review of Resident #88's Treatment Administration Record (TAR) indicated the following order was documented as implemented on 7/25/24, 7/26/24, 7/27/24 and 7/28/24. -Wash wound with soapy water, pat dry. Place Silver alginate to wounds of Right 3rd toe, left 3rd toe and left plantar foot. Cover with dry gauze, secure with keflex wrap and Ace from toe to knee. 50% overlap 50% stretch. Review of Resident #88's plan of care related to actual alteration in skin integrity, revised 7/1/24, indicated: -Consult and treatment by Certified Wound MD or Certified Wound Nurse PRN. On 7/23/24 at 9:04 A.M., the surveyor observed Resident #88 in bed. Resident #88 said he/she had multiple hospitalizations and foot surgeries because of infections in his/her foot wounds. Resident #88 said he/she is concerned about future infections and how long the wounds are taking to heal. Resident #88 shows the surveyor his/her bilateral feet, which both have undated dressings in place. During an interview on 7/29/24 at 2:20 P.M., the Unit Supervisor said he completed wound rounds with the Wound Physician on 7/15/24 and 7/23/24. The Unit Supervisor said he was supposed to print the Wound Physicians recommendations and present them to the Nurse Practitioner, but he never had time, so he never notified the provider of the change in wound condition and need to alter wound treatment. The Unit Supervisor said a lot of recommendations are probably missed because I don't have time to follow up. During an interview on 7/29/24 at 2:27 P.M., Nurse #14 said she frequently provides wound care for Resident #88. Nurse #14 said she puts calcium alginate and a dressing on his/her right third amputated toe surgical wound because that is what the physician order is for. During an interview on 8/1/24 at 7:47 A.M., the Director of Nursing (DON) said the Unit Supervisor is responsible to notify the Nurse Practitioner of the change in wound condition and need to alter wound treatment. The DON said the Nurse Practitioner always approves the Wound Physician's recommendations and after approved the physician's orders should be transcribed exactly as the Wound Physician writes them. Based on observations, interviews and record review, the facility failed to notify the physician of a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) and/or a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) for five Residents (# 85, #24, #88, #103 and #3) out of a total sample of 39 residents. Specifically: 1) For Resident #85, the facility failed to notify the physician of a new necrotic skin condition or of the Wound Physician's recommendations for wound care treatment leading to the skin condition progressing to an wound leading to osteomyelitis (a bone infection) and sepsis (a life-threatening response to infection) requiring hospitalization and need for a fecal-diverting colostomy (a surgical procedure that creates an opening in the abdomen, called a stoma, that allows digested food to pass out of the body through an external pouch system). 2.) For Resident #24, who had four stage 4 pressure ulcers and one unstageable pressure ulcer, the facility failed to notify the provider of the consultant wound physician's recommendations and subsequently nursing did not obtain new physician's orders for wound care based on these recommendations. 3) For Resident #88, the facility failed to notify the provider of the change in wound condition and need to alter wound treatment. 4) For Resident #103, the facility failed notify the physician of new recommendations from the consultant wound practitioner for treatment of a stage IV pressure ulcer. 5) For Resident #3, the facility failed to notify physician of the change in wound condition and need to initiate wound treatment. Findings include: Review of the facility policy titled Pressure Wound Prevention, revised January 2023, indicated, but was not limited to, the following: Monitoring 1. Evaluate, report and document potential changes in the skin. 1) Resident #85 was admitted to the facility in March 2023 with diagnoses including Alzheimer's Disease, cerebral infarction, diabetes, hemiplegia (muscle weakness or paralysis on one side of the body that can affect arms, legs, and facial muscles), and dysphagia (difficulty swallowing). Review of the Minimum Data Set (MDS) assessment, dated 2/27/24, indicated that Resident #85 scored a 5 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident had severe cognitive impairment. Further review of the MDS indicated that Resident #85 did not have any pressure ulcers but was at risk for developing pressure ulcers. Review of Resident #85's Potential Skin care plan, initiated 3/8/23, indicated the Resident had potential for alteration in skin integrity, with the following interventions: - Complete skin condition checks weekly. - Dietary interventions/evaluation. - Follow MD (Medical Doctor/physician) orders for skin care and treatments (utilize best practice guidelines). Review of Resident #85's Norton Scale for predicting risk for pressure ulcer, dated 2/27/24, indicated the Resident scored an eight, placing the Resident in the high risk category. Review of Resident #85's Skin Only Evaluation, dated 3/6/24, indicated Resident #85 had no skin issues. Review of Resident #85's Skin Only Evaluation, dated 3/11/24, indicated Resident #85 had a new necrotic (the death of body tissue or an organ due to a lack of blood supply) wound on the left buttock, medial area, and that the wound did not have an odor. Review of Resident #85's initial Wound Evaluation and Management Summary, dated 3/12/24, indicated the Wound Physician evaluated the Resident for a rash. The Wound Physician diagnosed Resident #85 with diaper dermatitis and recommended lotrisone cream (an anti-fungal cream) to be applied twice daily to the affected area and prn (as needed). Review of Resident #85's Treatment Administration Records failed to indicate that the lotrisone cream was implemented. During an interview on 7/29/24 at 10:03 A.M., Nurse #17 said that when changes in skin are identified they should be reported to the NP (Nurse Practitioner)/MD (medical doctor). Nurse #17 said that the Wound Physician will give recommendations to the staff member accompanying her during wound rounds every Tuesday. Nurse #17 said that a Certified Nursing Assistant had initially reported the wound to her, and that the Resident had a wound on the middle of the coccyx and a wound on the left buttocks; Nurse #17 said she had not reported the wound to the physician because the wound did not need the physicians' attention because of how small it was. Nurse #17 said she did not apply lotrisone, and that the aides have been using house barrier cream which was not a new treatment for the newly identified wound in March. During a follow-up interview on 7/30/24 at 8:19 A.M., Nurse #17 said that communication with the physician would be included in a progress note, and in the communication book. Review of the communication book and Resident #85's progress notes failed to indicate that the physician was notified of the new necrotic skin condition identified on 3/11/24. Review of the Nurse practitioner (NP) progress note, dated 3/13/24, failed to indicate that the NP was aware of, evaluated, or initiated treatments for Resident #85's necrotic wound. Review of Resident #85's wound evaluation and management summary, dated 3/19/24, indicated the Wound Physician evaluated the Resident's rash. The Wound Physician recommended lotrisone cream for the diaper dermatitis. During an interview on 7/30/24 at 11:13 A.M., the Wound Physician said that when she is consulted, she does not do a full skin check due to time constraints. The Wound Physician said she was initially consulted for Resident #85 to evaluate a rash on the frontal groin area, and nothing else; as the rash was on the front she may not have evaluated the backside and she was not aware of a necrotic wound when she evaluated the rash. The Wound Physician said this may have been a result of bad communication. Review of Resident #85's Treatment Administration Records (TAR) failed to indicate that the lotrisone cream was implemented. Review of Resident #85's medical record failed to indicate a nursing skin evaluation was completed the week of 3/18/24. Review of Resident #85's physician orders indicated the following discontinued orders: - Triad Hydrophilic Wound Dress External Paste (Wound Dressings) Apply to Sacrum topically one time a day for Wound, initiated 3/23/24, 12 days after nursing had initially identified the Resident's necrotic wound, and discontinued on 5/24/24. - Left butt wound wash with normal saline cover with silicone bordered form dressing every day shift left butt wound, initiated 3/22/24, 12 days after nursing had initially identified the Resident's necrotic wound, and discontinued on 5/24/24. - Wound Consult for left butt wound, initiated 3/25/24, 15 days after nursing had initially identified the Resident's necrotic wound, and discontinued on 4/25/24. Review Resident #85's progress note, written by NP #2, dated 3/26/24, indicated the following: I was asked to see this pt (patient) because of worsening wounds. Nursing reports they had started as superficial, but now were open and deeper. He/she had not been followed by the wound care team. Consult initiated and wound team saw this resident the AM of 3/26. They will now follow his/her wounds which are pressure related. Further review of Resident #85's progress note, written by Nurse Practitioner (NP) #2, dated 3/26/24, indicated that the consult for the Resident's wound was initiated 15 days after nursing had initially identified the necrotic area. Further review of the progress note indicated that the wound team requested multi-interventions in addition to wound care. During an interview on 7/30/24 at 11:42 A.M., NP #2 said she would expect to be notified of a new skin condition. NP #2 said that her review of systems includes communication with the nurses, and that she does not do a full-skin check as part of her regular evaluation; the NP said that she would only look at skin if a concern is brought to her attention. NP #2 said a staff member will follow the Wound Physician to communicate the recommendations to her, and that she would expect the recommendations to be implemented. NP #2 said that the risk of not implementing the Wound Physician recommendations would be that the wound could get worse, and that the wound could get infected and develop osteomyelitis. NP #2 said she was first notified of the wound on 3/26/24, when nursing reported to her that the wound had developed an odor, and that when she had evaluated the Resident on 3/13/24 she had not been aware of the wound. During an interview on 7/31/24 at 9:16 A.M., Physician #2 said he would expect nursing to notify himself or an NP of a change in skin condition. Physician #2 said a facility nurse should be following the Wound Physician for recommendations, and that the risk of Wound Physician recommendations not being followed would be that the wound would probably get worse if the Resident was not receiving treatment. Review of Resident #85's Wound Evaluation and Management Summary, dated 3/26/24, indicated Resident #85 had an unstageable (due to necrosis) pressure injury on his/her left ischium measuring 2.5 x 2.4 cm (centimeters), and an unstageable (due to necrosis) pressure injury on his/her sacrum measuring 3.9 x 3.7 cm. Further review of the wound evaluation indicated that the duration of both wounds was greater than six days, and that the Wound Physician recommended a house supplement (a calorically and nutritionally fortified drink typically utilized to address weight loss and/or meet assist in meeting nutrient, such as protein, needs) alginate calcium (a gel that promotes wound healing), and santyl (an ointment used to promote the healing of skin ulcers by removing damaged tissue). Review of the nursing progress note, dated 3/27/24, indicated Resident #85 was being transferred to emergency room for evaluation as the resident was very week [sic]. And oxygen of at 58% at room air. Review of Resident #85's Treatment Administration Record (TAR) failed to indicate that alginate calcium, or santyl were implemented prior to the Resident's hospitalization on 3/27/24. Review of Resident #85's physician orders and diet manager change history failed to indicate that a house supplement was implemented. Review of the hospital discharge paperwork, dated 4/22/24, indicated that Resident #85 presented to the hospital on 3/27/24 with encephalopathy (a broad term for any brain disease that alters brain function), found to be in sepsis with an infected sacral ulcer as the presumed source. Further review of the hospital paperwork indicated that the Resident underwent wound debridement (a procedure that removes unhealthy or dead tissue from a wound to promote healing and prevent infection) on 3/29/24, 3/31/24, 4/5/24, and 4/21/24, and that fecal diversion was indicated to allow for the wound to heal due to the wound's proximity to the anus; on 4/5/24 the Resident underwent a diverting loop sigmoid colostomy creation. The hospital paperwork indicated there was clinical and imaging evidence of osteomyelitis with the sacrum/coccyx bones exposed in the wound. Review of the nursing progress note, dated 4/22/24, indicated that Resident #85 had returned from the hospital with a sacral ulcer with underlying osteomyelitis status post multiple debridement's and the creation of a diverting loop colostomy. Further review of the progress note indicated that the Wound Physician would evaluate the Resident on 4/23/24 to provide guideline on wound vac (a treatment that uses suction to help wounds heal) use [sic]. Review of the Minimum Data Set (MDS) assessment, dated 4/28/24, indicated that Resident #85 scored a 10 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident had moderate cognitive impairment. Further review of the MDS indicated that Resident #85 had a new Stage IV and a new Stage III pressure ulcer and was at risk for developing pressure ulcers. According to the Mayo Clinic, complications and outcomes of Stage IV pressure ulcers include: - Osteomyelitis, which is characterized by a mixture of inflammatory cells, fibrosis, bone necrosis, and new bone formation. It is associated with nonhealing wounds, surgical flap complications, and an increased length of hospitalization. It may develop within the first 2 weeks of pressure ulcer formation and despite treatment may require amputation in lower extremity cases. - Joint infections (septic arthritis) can damage cartilage and tissue. - Bone infections (osteomyelitis) can reduce the function of joints and limbs. - Long-term, nonhealing wounds can develop into a type of squamous cell carcinoma. - Sepsis (blood infection). Review of the Wound Evaluation and Management Summary, dated 4/23/24, indicated that Resident #85 had a stage IV sacral pressure wound (Stage IV pressure wounds are defined as deep wounds that may impact muscle, tendons, ligaments, and bone) measuring 17 x 17 x 4.5 cm. Further review of the Wound Evaluation and Management Summary indicated the Wound Physician recommended a house supplement, foley catheter (a medical device that helps drain urine from the bladder) and negative pressure wound therapy (wound vac) to be applied three times per week for 30 days at 125 mmHg (millimeter of mercury, a manometric unit of pressure) continuously. Review of Resident #85's TAR indicated that the wound vac was scheduled to be changed twice a week, initiated on 4/22/24. Review of Resident #85's physician orders and diet manager change history failed to indicate that a house supplement was implemented. Review of the Wound Evaluation and Management Summary, dated 4/30/24, indicated that Resident #85 had a stage IV sacral pressure wound measuring 17 x 16.8 x 4.5 cm. Further review of the Wound Evaluation and Management Summary indicated the Wound Physician recommended a house supplement and negative pressure wound therapy to be applied three times per week for 23 days at 125 mmHg continuously. Review of Resident #85's TAR indicated that the wound vac was scheduled to be changed twice a week, initiated on 4/22/24. Review of Resident #85's physician orders and diet manager change history failed to indicate that a house supplement was implemented. Review of Resident #85's progress notes indicated the Resident was transferred to the emergency room on 5/2/24. Review of the hospital discharge paperwork, dated 5/9/24, indicated Resident #85 presented to the hospital with lethargy, anorexia (abnormal loss of appetite for food), hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions), and worsening wound drainage. Further review of the hospital paperwork indicated the Resident required intravenous antibiotics for sepsis during hospitalization, and was discharged back to the facility with the recommendation to change the wound vac three times per week. Review of the Wound Evaluation and Management Summary, dated 5/14/24, indicated that Resident #85 had a stage IV sacral pressure wound measuring 16.8 x 16.5 x 4.5 cm and a stage IV pressure wound on the left ischium measuring 2 x 1 x .4 cm. Further review of the Wound Evaluation and Management Summary indicated the Wound Physician recommended a house supplement and negative pressure wound therapy to be applied three times per week for nine days at 125 mmHg continuously. Review of Resident #85's TAR indicated that the wound vac was scheduled to be changed twice a week, initiated 4/22/24. Review of Resident #85's physician orders and diet manager change history failed to indicate that a house supplement was implemented. Review of the Wound Evaluation and Management Summary, dated 5/21/24, indicated that Resident #85 had a stage IV pressure wound measuring 16.8 x 16.7 x 4.8 cm, and that the wound progress was exacerbated due to infection; the Wound Physician recommended a house supplement and sodium hypochlorite solution (dakins) twice daily for 30 days. Further review of the Wound Evaluation and Management summary indicated the Resident had a stage 4 pressure injury of the left ischium measuring 1 x 1 x 0.2 cm, and that the Wound Physician recommended alginate calcium once daily for 23 days. Review of Resident #85's physician orders and diet manager change history failed to indicate that a house supplement was implemented. Review of Resident #85's Nurse Practitioner progress note, dated 5/22/24, indicated that the Resident had been seen on 5/21/24 by the Wound Physician who found bone chips in the Resident's wound. Further review of the progress note indicated that the Resident was transferred to the hospital on 5/21/24 for sacral wound for IV antibiotics or hospice. Review of the hospital discharge paperwork, dated 5/24/24, indicated Resident #85 had presented to the hospital after the facility had noticed bone chips in his/her wound. Review of the Wound Evaluation and Management Summary, dated 5/28/24, indicated that Resident #85 had a stage IV pressure wound measuring 17 x 16.8 x 4.8 cm, and that the wound continues to deteriorate; the Wound Physician recommended sodium hypochlorite solution (dakins) twice daily for 23 days. Further review of the Wound Evaluation and Management summary indicated the Resident had a stage 4 pressure injury of the left ischium measuring 1 x 0.9 x 0.2 cm, and that the Wound Physician recommended alginate calcium once daily for 23 days. Review of Resident #85's physician orders and diet manager change history failed to indicate that a house supplement was implemented. Review of the Wound Evaluation and Management Summary, dated 6/4/24, indicated that Resident #85 had a stage IV pressure wound measuring 17 x 17 x 4.8 cm, and that the wound was exacerbated by acute osteomyelitis; the Wound Physician recommended a house supplement and sodium hypochlorite solution (dakins) twice daily for 16 days. Review of Resident #85's physician orders and diet manager change history failed to indicate that a house supplement was implemented. Review of Resident #85's progress note, dated 7/10/24, indicated the Resident was sent to the hospital as the resident was shaking and pale. Review of the hospital discharge paperwork, dated 7/20/24, indicated Resident #85 presented to the hospital on 7/10/24 with severe sepsis secondary to sacral wound infection requiring admission to the ICU (intensive care unit) for pressor support. Further review of the hospital discharge paperwork indicated the Resident's wound was debrided on 7/11/24, the Resident required IV antibiotics for sepsis, a urinary foley catheter was placed on 7/11, 80 days after the Wound Physician initially recommended the placement of the foley catheter, and a wound vac was placed on 7/13 with instructions to be changed on Monday, Wednesday, and Friday. Review of the most recent Wound Evaluation and Management Summary, dated 7/23/24, indicated that Resident #85 had a stage IV pressure wound measuring 16 x 15.5 x 4.8 cm, and that the wound was not at goal; the Wound Physician recommended a house supplement and to change the wound vac three times per week. Review of Resident #85's physician orders indicated the following discontinued orders: - Change (wound vac) dressing every 3 days and PRN (as needed), initiated on 4/22/24 and discontinued on 5/24/24. Review of Resident #85's physician orders and diet manager change history failed to indicate that a house suppleme[TRUNCATED]

4.) Resident #3 was admitted to the facility September 2023 with diagnoses including a stroke, acute inflammatory demyelinating polyneuropathy (AIDP) (weakness and sensory loss in limbs), and anemia. Review of the Minimum Data Set (MDS) assessment, dated 7/4/24, indicated Resident #3 had a Brief Interview for Mental Status (BIMS) score of 13 out of a possible 15 which indicated she is not cognitively impaired and requires total assist with all activities of daily living. Review of nursing skin evaluation, dated 7/6/24, indicated Resident #3 had no skin issues. Review of consultant wound physician notes, dated 7/9/24, indicated initial evaluation of Resident #3's right lateral ankle wound, documented duration of wound as greater than 50 days. The consultant wound physician classified the wound as non-pressure caused by trauma/injury and made dressing treatment recommendations for xeroform gauze daily, covered by abdominal pad, kerlix gauze roll and tape. Review of Medication Administration Record (MAR), Treatment Administration Record (TAR), and physician orders failed to include that nursing implemented this recommendation. Review of physician progress note, dated 7/13/24, indicated Resident #3 had a right foot pressure sore. Review of consultant wound physician notes, dated 7/15/24, indicated the physician had performed a surgical excisional debridement procedure at bedside to remove necrotic tissue and establish the margins of viable tissue. The consultant wound physician continued to recommend xeroform gauze daily, covered by abdominal pad, kerlix gauze roll and tape to Resident #3's right ankle wound. Review of Medication Administration Record (MAR), Treatment Administration Record (TAR), and physician orders failed to include that nursing implemented this recommendation. Review of the consultant orthopedic physician, dated 7/16/24, indicated recommendations to right ankle ulcer for Resident #3: -Daily dressing changes per wound care. -PRAFO offloading (always keeps pressure off wound) bootie. -maintain non-weight bearing to right side -continue range of motion/exercise/physical therapy to right ankle daily. Review of physician progress note, dated 7/16/24, indicated Resident #3 had a right foot pressure sore. Review of Nurse Practitioner #1's note, dated 7/16/24, said that Resident #3 was seen by foot ankle specialist and recommendations included daily dressing changes per wound care for Resident #3's right ankle wound. Review of physician's order, dated 7/17/24, indicated right outer ankle area wound, normal saline wash, pat dry, apply xeroform cover with border dressing daily. Discontinue when healed on day shift each day. Further review indicated this was implemented eight days after the recommendation was made by the consultant wound physician. However, upon further review, this order was not scheduled into the electronic health record (EHR). Review of nursing skin evaluation, dated 7/19/24, indicated Resident #3 had pressure ulcer/injury with granulation tissue to wound bed, purulent wound exudate, maceration to peri wound and minimal wound drainage. Review of consultant wound physician notes, dated 7/23/24, indicated Resident #3 could not tolerate debridement due to pain. The consultant wound physician continued to recommend normal saline wash, pat dry, apply xeroform cover with border dressing daily to Resident #3's right ankle wound. Review of nursing skin evaluation, dated 7/26/24, indicated Resident #3 had pressure ulcer/injury with granulation tissue to wound bed, purulent wound exudate, maceration to peri wound and minimal wound drainage. Review of physician's order, dated 7/30/24, indicated right outer ankle wound, normal saline, pat dry. Apply xeroform (dressing to cover wounds) cover with abdominal pad and wrap with kerlix, and tape for retention daily. Review of TAR dated July 2024, indicated Nurse #8 had added scheduled order for right ankle wound treatment starting on 7/30/24. Further review of this TAR indicated only Nurse #8 had signed as completing the treatment to Resident #3's right ankle wound on 7/30/24, 22 days after the initial wound physician's recommendation. On 7/30/24 at 8:10 A.M. the surveyor and Nurse #8 reviewed Resident #3's wound care order to right outer ankle and observed the following: -there was an order for right ankle wound care ordered 7/17/14. -there failed to be an order scheduled on TAR for right ankle wound care. Nurse #8 said she knew she had an order and what the treatment was because the consultant wound physician had given her a verbal order and she forgot to verify with physician and transcribe the order. During an interview on 7/30/24 at 11:30 A.M., the Wound Physician said Resident #3 said that the wound occurred during a transfer and physician feels that it is not related to pressure as her heels are always offloaded (free from an pressure) and wound appears more related to sheering consistent with rubbing against something during a transfer. During an interview on 7/31/24 at 12:27 P.M., Director of Nursing (DON) said recommendations from wound doctor should be approved by physician and implemented. The DON said not providing wound care as ordered can be considered neglect. 4. Resident #103 was admitted to the facility in March 2024 with diagnoses that include diabetes, pressure ulcer of the right buttock (stage IV) and bacteremia. Review of Resident #103's most recent Minimum Data Set (MDS) Assessment, dated 6/21/24, indicated a Brief Interview for Mental Status (BIMS) score of 12 out of a possible 15, indicating that the resident had moderate cognitive impairment. The MDS further indicated that the Resident had one stage IV pressure ulcer that was present on admission to the facility and was at risk for the development of pressure ulcers. Review of Resident #103's most recent Norton Assessment (a tool designed to help clinicians evaluate a patient's risk of developing pressure injuries), dated 6/15/24, indicated a score of 9, placing Resident #103 at high risk for the development of pressure injuries. During an observation and interview on 7/23/24 at 8:28 A.M., Resident #103 was observed laying on his/her back in bed. Resident #103 said that he/she has a pressure injury that they had when they were admitted to the facility on their sacrum. Resident #103 said that sometimes the dressing covering the pressure injury comes off and it takes a while for nursing staff to replace it. Review of Resident #103's active physician's orders indicated an order for santyl external ointment (a medication that is used to break up and remove dead skin tissue from skin ulcers) 250 unit/ gram. Apply to sacrum area topically every shift. Wash wound with normal saline, pat dry then apply Santyl to calcium alginate, dated 3/28/24. Review of the wound consultant note, dated 6/18/24, included recommendations to discontinue the use of santyl ointment in the wound bed. Review of the most recent wound consultant note, dated 7/30/24 included recommendations for a calcium alginate dressing covered with a foam silicone dressing to be changed once daily. Review of Resident #103's active pressure ulcer care plan, dated 4/1/24, indicated to follow up with [consultant wound physician] as needed and follow [physician] orders for treatment. Review of Resident #103's July 2024 Treatment Administration Record indicated that santyl was applied to the wound bed twenty-two days in July. Review of Resident #103's progress notes failed to indicate that the physician or nurse practitioner were made aware of the recommendations to discontinue santyl ointment, and the treatment continued as an active order through 7/26/24. During an interview on 7/25/24 at 10:04 A.M., Nurse Practitioner #1 said that the consultant wound physician writes notes that are uploaded into the resident's medical record. Nurse Practitioner #1 said that nursing staff round with the consultant wound physician and if changes are made to the treatment recommendations, she would expect nursing to communicate that with her. Nurse Practitioner #1 said that she was not made aware of the recommendations to discontinue the use of Santyl Ointment to the wound for Resident #103. Nurse Practitioner #1 further said that she accepts and puts into place all consultant wound physician recommendations that are made when she is made aware of them. During an interview on 7/26/24 at 8:19 A.M., Nurse #2 said that the consultant wound physician does not communicate to the direct care staff any changes that are made, and it is up to the Unit Supervisor to check the notes and implement the changes with the Nurse Practitioner. Nurse #2 said that she does not review the wound consultant notes. Nurse #2 and surveyor reviewed the consultant wound physician note from 6/18/24 and Nurse #2 said that those recommendations should have been communicated to the Nurse Practitioner, but they were not. During an interview on 7/26/24 at 11:18 A.M., the Director of Nurses (DON) said that nurses should be reviewing the consultant wound physician notes that are uploaded into the resident's medical record. The DON said that typically the Unit Supervisor rounds with the consultant wound physician and would know if any recommendations are made to change current treatments. The DON said this should be communicated to the Nurse Practitioner and recommendations should be followed. During an interview on 7/30/24 at 11:28 A.M., the Consulting Wound Physician said that she would expect her recommendations to be followed as written. 3.) Resident #88 was admitted to the facility in August 2023 with diagnoses including diabetes and hypertension. Review of the most recent Minimum Data Set (MDS) assessment, dated 5/30/24, indicated that Resident #88 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out of 15. The MDS also indicated the presence of surgical wound requiring surgical wound care. Review of the Wound Physician's progress note, dated 7/15/24, indicated the following dressing treatment plan for Resident #88's right third amputated toe surgical wound: - Add Skin Prep, once daily, for 30 days. - Discontinue Alginate Calcium. - Discontinue Tape (Retention), Gauze Sponge Sterile. Review of the Wound Physician's progress note, dated 7/23/24, indicated the following dressing treatment plan for Resident #88's right third amputated toe surgical wound: - Continue Skin Prep, once daily, for 22 days. Review of Resident #88's active physician's order, initiated 3/20/24, indicated: -Wash wound with soapy water, pat dry. Place Silver alginate to wounds of Right 3rd toe, left 3rd toe and left plantar foot. Cover with dry gauze, secure with keflex wrap and Ace from toe to knee. 50% over lap 50% stretch. Review of Resident #88's Treatment Administration Record (TAR), dated 7/25/24, 7/26/24, 7/27/24, and 7/28/24, indicated the following order was being documented: -Wash wound with soapy water, pat dry. Place Silver alginate to wounds of Right 3rd toe, left 3rd toe and left plantar foot. Cover with dry gauze, secure with keflex wrap and Ace from toe to knee. 50% over lap 50% stretch. Review of Resident #88's plan of care related to actual alteration in skin integrity, revised 7/1/24, indicated: -Consult and treatment by Certified Wound MD or Certified Wound Nurse PRN. Review of Resident #88's physician's orders fail to indicate that Wound Physician's treatment plan to add skin prep, discontinue Alginate Calcium, and discontinue tape (retention) and gauze sponge sterile was ever implemented. On 7/23/24 at 9:04 A.M., the surveyor observed Resident #88 in bed. Resident #88 said he/she had multiple hospitalizations and foot surgeries because of infections in his foot wounds. Resident #88 said he/she is concerned about future infections and how long the wounds are taking to heal. Resident #88 shows the surveyor his/her bilateral feet, which both have undated dressings in place. During an interview on 7/29/24 at 2:20 P.M., the Unit Supervisor said he completed wound rounds with the Wound Physician on 7/15/24 and 7/23/24. The Unit Supervisor said he was supposed to print the Wound Physicians recommendations and present them to the Nurse Practitioner, but he never had time so he never notified the provider of the change in wound condition and need to alter wound treatment, resulting in the treatment order never being implemented. The Unit Supervisor said a lot of recommendations are probably missed because he doesn't have time to follow up. During an interview on 7/29/24 at 2:27 P.M., Nurse #14 said she frequently provides wound care for Resident #88. Nurse #14 said she puts calcium alginate and a dressing on his/her right third amputated toe surgical wound because that is what the physician order is for. During an interview on 7/31/24 at 11:46 A.M., the Director of Nursing said she would consider it neglectful to not provide services or treatments that are needed. During an interview on 8/1/24 at 7:47 A.M., the Director of Nursing (DON) said the Unit Supervisor is responsible to notify the Nurse Practitioner of the change in wound condition and need to alter wound treatment. The DON said the Nurse Practitioner always approves the Wound Physician's recommendations and after approved the physician's orders should be transcribed exactly as the Wound Physician writes them. The DON said that since the Wound Physician's recommendations were never communicated to the Nurse Practitioner, the treatment was never implemented. Based on observations, interviews and record review, the facility failed to protect five residents, out of a total sample of 39 residents, from neglect. Specifically: 1a) For Resident #85, the facility failed to implement treatments and physician orders recommended by the consulting wound physician resulting in a new necrotic skin condition progressing to an unstageable wound leading to osteomyelitis (a bone infection) and sepsis (a life-threatening response to infection) requiring hospitalization and need for a fecal-diverting colostomy (a surgical procedure that creates an opening in the abdomen, called a stoma, that allows digested food to pass out of the body through an external pouch system). 1b) For Resident #85, the facility failed to ensure that an air mattress was set at the appropriate setting to promote wound healing in the presence of a stage IV pressure wound (defined as deep wounds that may impact muscle, tendons, ligaments, and bone). 2a) For Resident #24, the facility failed to implement the physician's order for air mattress settings, in the presence of four stage four pressure ulcers and one unstageable pressure ulcer. 2b) For Resident #24, the facility failed to implement dietician recommendations for wound healing. 2c) For Resident #24, the facility failed to implement wound physician's recommendations for wound care. 3) For Resident #88, the facility failed to implement treatment recommendations from the wound consultant physician for a right third amputated toe surgical wound. 4) For Resident #3, the facility failed to implement wound physician's recommendations for wound care. 5) For Resident #103, the facility failed to implement treatment recommendations by the consultant wound practitioner for a stage IV pressure ulcer. Findings include: The Centers for Medicare and Medicaid Services defines neglect as the failure to provide goods and services necessary to avoid physical harm or mental anguish. Review of the facility policy titled Pressure Wound Prevention, revised January 2023, indicated, but was not limited to, the following: - Inspect the skin on a daily basis when performing or assisting with personal care or ADLS (activities of daily living). - Evaluate, report and document potential changes in the skin. - Review the interventions and strategies for effectiveness on an ongoing basis. Review of the facility policy titled Ulcer/skin Breakdown Clinical Protocol, created January 2023, indicated, but was not limited to, the following: - The nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; - The interdisciplinary team should collectively complete Route Cause Analysis for any newly identified in-house acquired pressure injury. - The wound care specialist/medical provider will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents. 1a) Resident #85 was admitted to the facility in March 2023 with diagnoses including Alzheimer's Disease, cerebral infarction, diabetes, hemiplegia (muscle weakness or paralysis on one side of the body that can affect arms, legs, and facial muscles), and dysphagia (difficulty swallowing). Review of the Minimum Data Set (MDS) assessment, dated 2/27/24, indicated that Resident #85 scored a 5 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident had severe cognitive impairment. Further review of the MDS indicated that Resident #85 did not have any pressure ulcers but was at risk for developing pressure ulcers. Review of Resident #85's Potential Skin care plan, initiated 3/8/23, indicated the Resident had potential for alteration in skin integrity, with the following interventions: - Complete skin condition checks weekly - Dietary interventions/evaluation - Follow MD (Medical Doctor/physician) orders for skin care and treatments (utilize best practice guidelines) Review of Resident #85's Norton Scale for predicting risk for pressure ulcer, dated 2/27/24, indicated the Resident scored an eight, placing the Resident in the high risk category. Review of Resident #85's Skin Only Evaluation, dated 3/6/24, indicated Resident #85 had no skin issues. Review of Resident #85's Skin Only Evaluation, dated 3/11/24, indicated Resident #85 had a new necrotic (the death of body tissue or an organ due to a lack of blood supply) wound on the left buttock, medial area, and that the wound did not have an odor. Review of Resident #85's initial Wound Evaluation and Management Summary, dated 3/12/24, indicated the Wound Physician evaluated the Resident for a rash. The Wound Physician diagnosed Resident #85 with diaper dermatitis and recommended Lotrisone cream (an anti-fungal cream) to be applied twice daily to the affected area and prn (as needed). Review of Resident #85's Treatment Administration Records failed to indicate that the lotrisone cream was implemented. During an interview on 7/29/24 at 10:03 A.M., Nurse #17 said that when changes in skin are identified they should be reported to the NP (Nurse Practitioner)/MD. Nurse #17 said that the Wound Physician will give recommendations to the staff member accompanying her during wound rounds every Tuesday. Nurse #17 said that a Certified Nursing Assistant had initially reported the wound to her, and that the Resident had a wound on the middle of the coccyx and a wound on the left buttocks. Nurse #17 said she had not reported the wound to the physician because the wound did not need the physicians' attention because of how small it was. Nurse #17 said she did not apply lotrisone, and that the aides have been using house barrier cream which was not a new treatment for the newly identified wound in March. During a follow-up interview on 7/30/24 at 8:19 A.M., Nurse #17 said that communication with the physician would be included in a progress note, and in the communication book. Review of the communication book and Resident #85's progress notes failed to indicate that the physician was notified of the new necrotic skin condition identified on 3/11/24. Review of the Nurse practitioner (NP) progress note, dated 3/13/24, failed to indicate that the NP was aware of, evaluated, or initiated treatments for Resident #85's necrotic wound. Review of Resident #85's wound evaluation and management summary, dated 3/19/24, indicated the Wound Physician evaluated the Resident's rash. The Wound Physician recommended lotrisone cream for the diaper dermatitis. Review of Resident #85's Treatment Administration Records (TAR) failed to indicate that the lotrisone cream was implemented. Review of Resident #85's medical record failed to indicate a nursing skin evaluation was completed the week of 3/18/24. Review of Resident #85's physician orders indicated the following discontinued orders: - Triad Hydrophilic Wound Dress External Paste (Wound Dressings) Apply to Sacrum topically one time a day for Wound, initiated 3/23/24, 12 days after nursing had initially identified the Resident's necrotic wound, and discontinued on 5/24/24. - Left butt wound wash with normal saline cover with silicone bordered form dressing every day shift left butt wound, initiated 3/22/24, 12 days after nursing had initially identified the Resident's necrotic wound, and discontinued on 5/24/24. - Wound Consult for left butt wound, initiated 3/25/24, 15 days after nursing had initially identified the Resident's necrotic wound, and discontinued on 4/25/24. Review Resident #85's progress note, written by NP #2, dated 3/26/24, indicated the following: I was asked to see this pt (patient) because of worsening wounds. Nursing reports they had started as superficial, but now were open and deeper. He/she had not been followed by the wound care team. Consult initiated and wound team saw this resident the AM of 3/26. They will now follow his/her wounds which are pressure related. Further review of Resident #85's progress note, written by Nurse Practitioner (NP) #2, dated 3/26/24, indicated that the consult for the Resident's wound was initiated 15 days after nursing had initially identified the necrotic area. Further review of the progress note indicated that the wound team requested multi-interventions in addition to wound care. During an interview on 7/30/24 at 11:42 A.M., NP #2 said she would expect to be notified of a new skin condition. NP #2 said that her review of systems includes communication with the nurses, and that she does not do a full-skin check as part of her regular evaluation; the NP said that she would only look at skin if a concern is brought to her attention. NP #2 said a staff member will follow the Wound Physician to communicate the recommendations to her, and that she would expect the recommendations to be implemented. NP #2 said that the risk of not implementing the Wound Physician recommendations would be that the wound could get worse, and that the wound could get infected and develop osteomyelitis. NP #2 said she was first notified of the wound on 3/26/24, when nursing reported to her that the wound had developed an odor, and that when she had evaluated the Resident on 3/13/24 she had not been aware of the wound. During an interview on 7/31/24 at 9:16 A.M., Physician #2 said he would expect nursing to notify himself or an NP of a change in skin condition. Physician #2 said a facility nurse should be following the Wound Physician for recommendations, and that the risk of Wound Physician recommendations not being followed would be that the wound would probably get worse if the Resident was not receiving treatment. Review of Resident #85's Wound Evaluation and Management Summary, dated 3/26/24, indicated Resident #85 had an unstageable (due to necrosis) pressure injury on his/her left ischium measuring 2.5 x 2.4 cm (centimeters), and an unstageable (due to necrosis) pressure injury on his/her sacrum measuring 3.9 x 3.7 cm. Further review of the wound evaluation indicated that the duration of both wounds was greater than six days, and that the Wound Physician recommended a house supplement (a calorically and nutritionally fortified drink typically utilized to address weight loss and/or meet assist in meeting nutrient, such as protein, needs) alginate calcium (a gel that promotes wound healing), and santyl (an ointment used to promote the healing of skin ulcers by removing damaged tissue). Review of the nursing progress note, dated 3/27/24, indicated Resident #85 was being transferred to emergency room for evaluation as the resident was very week [sic]. And oxygen of at 58% at room air. Review of Resident #85's TAR failed to indicate that alginate calcium, or santyl were implemented prior to the Resident's hospitalization on 3/27/24. Review of Resident #85's physician orders and diet manager change history failed to indicate that a house supplement was implemented. Review of the hospital discharge paperwork, dated 4/22/24, indicated that Resident #85 presented to the hospital on 3/27/24 with encephalopathy (a broad term for any brain disease that alters brain function), found to be in sepsis with an infected sacral ulcer as the presumed source. Further review of the hospital paperwork indicated that the Resident underwent wound debridement (a procedure that removes unhealthy or dead tissue from a wound to promote healing and prevent infection) on 3/29/24, 3/31/24, 4/5/24, and 4/21/24, and that fecal diversion was indicated to allow for the wound to heal due to the wound's proximity to the anus; on 4/5/24 the Resident underwent a diverting loop sigmoid colostomy creation. The hospital paperwork indicated there was clinical and imaging evidence of osteomyelitis with the sacrum/coccyx bones exposed in the wound. Review of the nursing progress note, dated 4/22/24, indicated that Resident #85 had returned from the hospital with a sacral ulcer with underlying osteomyelitis status post multiple debridement's and the creation of a diverting loop colostomy. Further review of the progress note indicated that the Wound Physician would evaluate the Resident on 4/23/24 to provide guideline on wound vac (a treatment that uses suction to help wounds heal) use [sic]. Review of the Minimum Data Set (MDS) assessment, dated 4/28/24, indicated that Resident #85 scored a 10 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident had moderate cognitive impairment. Further review of the MDS indicated that Resident #85 had a new Stage IV and a new Stage III pressure ulcer and was at risk for developing pressure ulcers. According to the Mayo Clinic, complications and outcomes of Stage IV pressure ulcers include: - Osteomyelitis, which is characterized by a mixture of inflammatory cells, fibrosis, bone necrosis, and new bone formation. It is associated with nonhealing wounds, surgical flap complications, and an increased length of hospitalization. It may develop within the first 2 weeks of pressure ulcer formation and despite treatment may require amputation in lower extremity cases. - Joint infections (septic arthritis) can damage cartilage and tissue. - Bone infections (osteomyelitis) can reduce the function of joints and limbs. - Long-term, nonhealing wounds can develop into a type of squamous cell carcinoma. - Sepsis (blood infection). Review of the Wound Evaluation and Management Summary, dated 4/23/24, indicated that Resident #85 had a stage IV sacral pressure wound (Stage IV pressure wounds are defined as deep wounds that may impact muscle, tendons, ligaments, and bone) measuring 17 x 17 x 4.5 cm. Further review of the Wound Evaluation and Management Summary indicated the Wound Physician recommended a house supplement, foley catheter (a medical device that helps drain urine from the bladder) and negative pressure wound therapy (wound vac) to be applied three times per week for 30 days at 125 mmHg (millimeter of mercury, a manometric unit of pressure) continuously. Review of Resident #85's TAR indicated that the wound vac was scheduled to be changed twice a week, initiated on 4/22/24. Review of Resident #85's physician orders and diet manager change history failed to indicate that a house supplement was implemented. Review of the Wound Evaluation and Management Summary, dated 4/30/24, indicated that Resident #85 had a stage IV sacral pressure wound measuring 17 x 16.8 x 4.5 cm. Further review of the Wound Evaluation and Management Summary indicated the Wound Physician recommended a house supplement and negative pressure wound therapy to be applied three times per week for 23 days at 125 mmHg continuously. Review of Resident #85's TAR indicated that the wound vac was scheduled to be changed twice a week, initiated on 4/22/24. Review of Resident #85's physician orders and diet manager change history failed to indicate that a house supplement was implemented. Review of Resident #85's progress notes indicated the Resident was transferred to the emergency room on 5/2/24. Review of the hospital discharge paperwork, dated 5/9/24, indicated Resident #85 presented to the hospital with lethargy, anorexia (abnormal loss of appetite for food), hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions), and worsening wound drainage. Further review of the hospital paperwork indicated the Resident required intravenous antibiotics for sepsis during hospitalization, and was discharged back to the facility with the recommendation to change the wound vac three times per week. Review of the Wound Evaluation and Management Summary, dated 5/14/24, indicated that Resident #85 had a stage IV sacral pressure wound measuring 16.8 x 16.5 x 4.5 cm and a stage IV pressure wound on the left ischium measuring 2 x 1 x .4 cm. Further review of the Wound Evaluation and Management Summary indicated the Wound Physician recommended a house supplement and negative pressure wound therapy to be applied three times per week for nine days at 125 mmHg continuously. Review of Resident #85's TAR indicated that the wound vac was scheduled to be changed twice a week, initiated 4/22/24. Review of Resident #85's physician orders and diet manager change history failed to indicate that a house supplement was implemented. Review of the Wound Evaluation and Management Summary, dated 5/21/24, indicated that Resident #85 had a stage IV pressure wound measuring 16.8 x 16.7 x 4.8 cm, and that the wound progress was exacerbated due to infection; the Wound Physician recommended a house supplement and sodium hypochlorite solution (dakins) twice daily for 30 days. Further review of the Wound Evaluation and Management summary indicated the Resident had a stage 4 pressure injury of the left ischium measuring 1 x 1 x 0.2 cm, and that the Wound Physician recommended alginate calcium once daily for 23 days. Review of Resident #85's physician orders and diet manager change history failed to indicate that a house supplement was implemented. Review of Resident #85's Nurse Practitioner progress note, dated 5/22/24, indicated that the Resident had been seen on 5/21/24 by the Wound Physician who found bone chips in the Resident's wound. Further review of the progress note indicated that the Resident was transferred to the hospital on 5/21/24 for sacral wound for IV antibiotics or hospice. Review of the hospital discharge paperwork, dated 5/24/24, indicated Resident #85 had presented to the hospital after the facility had noticed bone chips in his/her wound. Review of the Wound Evaluation and Management Summary, dated 5/28/24, indicated that Resident #85 had a stage IV pressure wound measuring 17 x 16.8 x 4.8 cm, and that the wound continues to deteriorate; the Wound Physician recommended sodium hypochlorite solution (dakins) twice daily for 23 days. Further review of the Wound Evaluation and Management summary indicated the Resident had a stage 4 pressure injury of the left ischium measuring 1 x 0.9 x 0.2 cm, and that the Wound Physician recommended alginate calcium once daily for 23 days. Review of Resident #85's physician orders and diet manager change history [TRUNCATED]

4. Resident #103 was admitted to the facility in March 2024 with diagnoses that include diabetes, pressure ulcer of the right buttock (stage IV) and bacteremia. Review of Resident #103's most recent Minimum Data Set (MDS) Assessment, dated 6/21/24, indicated a Brief Interview for Mental Status (BIMS) score of 12 out of a possible 15, indicating that the resident had moderate cognitive impairment. The MDS further indicated that the Resident had one stage IV pressure ulcer that was present on admission to the facility and was at risk for the development of pressure ulcers. Review of Resident #103's most recent Norton Assessment (a tool designed to help clinicians evaluate a patient's risk of developing pressure injuries), dated 6/15/24, indicated a score of 9, placing Resident #103 at high risk for the development of pressure injuries. During an observation and interview on 7/23/24 at 8:28 A.M., Resident #103 was observed laying on his/her back in bed. Resident #103 said that he/she has a pressure injury that they had when they were admitted to the facility on their sacrum. Resident #103 said that sometimes the dressing covering the pressure injury comes off and it takes a while for nursing staff to replace it. Review of Resident #103's active physician's orders indicated an order for santyl external ointment (a medication that is used to break up and remove dead skin tissue from skin ulcers) 250 unit/ gram. Apply to sacrum area topically every shift. Wash wound with normal saline, pat dry then apply Santyl to calcium alginate, dated 3/28/24. Review of the wound consultant note, dated 6/18/24, included recommendations to discontinue the use of santyl ointment in the wound bed. Review of the most recent wound consultant note, dated 7/30/24 included recommendations for a calcium alginate dressing covered with a foam silicone dressing to be changed once daily. Review of Resident #103's active pressure ulcer care plan, dated 4/1/24, indicated to follow up with [consultant wound physician] as needed and follow [physician] orders for treatment. Review of Resident #103's July 2024 Treatment Administration Record indicated that santyl was applied to the wound bed twenty-two days in July. Review of Resident #103's progress notes failed to indicate that the physician or nurse practitioner were made aware of the recommendations to discontinue santyl ointment, and the treatment continued as an active order through 7/26/24. During an interview on 7/25/24 at 10:04 A.M., Nurse Practitioner #1 said that the consultant wound physician writes notes that are uploaded into the resident's medical record. Nurse Practitioner #1 said that nursing staff round with the consultant wound physician and if changes are made to the treatment recommendations, she would expect nursing to communicate that with her. Nurse Practitioner #1 said that she was not made aware of the recommendations to discontinue the use of Santyl Ointment to the wound for Resident #103. Nurse Practitioner #1 further said that she accepts and puts into place all consultant wound physician recommendations that are made when she is made aware of them. During an interview on 7/26/24 at 8:19 A.M., Nurse #2 said that the consultant wound physician does not communicate to the direct care staff any changes that are made, and it is up to the Unit Supervisor to check the notes and implement the changes with the Nurse Practitioner. Nurse #2 said that she does not review the wound consultant notes. Nurse #2 and surveyor reviewed the consultant wound physician note from 6/18/24 and Nurse #2 said that those recommendations should have been communicated to the Nurse Practitioner, but they were not. During an interview on 7/26/24 at 11:18 A.M., the Director of Nurses (DON) said that nurses should be reviewing the consultant wound physician notes that are uploaded into the resident's medical record. The DON said that typically the Unit Supervisor rounds with the consultant wound physician and would know if any recommendations are made to change current treatments. The DON said this should be communicated to the Nurse Practitioner and recommendations should be followed. During an interview on 7/30/24 at 11:28 A.M., the Consulting Wound Physician said that she would expect her recommendations to be followed as written. Resident #42 was admitted to the facility in August 2023 with diagnoses including a sacral stage four pressure ulcer. Review of the most recent Minimum Data Set (MDS) assessment, dated 6/7/24, indicated Resident #42 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 8 out of 15. Review of Physician #1's progress note, dated 5/8/24, indicated: - Patient will continue to be treated by Wound MD (medical doctor) while in LTC (long term care). Review of Resident #42's consultant wound evaluation and management summaries, dated 6/25/24, 7/2/24, 7/9/24, 7/15/24, and 7/23/24, indicated: - Continue Alginate Calcium Once Daily, thin coat of santyl on top of calcium alginate and then sprinkle metronidazole on top, place into wound bed. Review of Resident #42's active physician's orders indicated: - Flagyl Oral Tablet 500 MG (Metronidazole), which is an antibiotic medication, Apply to Sacrum area topically two times a day for sacrum. Crush and sprinkle to sacrum wound twice daily with dsg (dressing) change, initiated 1/24/24. - Prescribed treatment: (Alginate calcium) and santyl Location: (Sacrum area), Cleanse area with NS (normal saline) pad [sic] dry and follow order, every day shift, initiated, 1/18/2024. Review of Resident #42's Treatment Administration Record (TAR), dated July 2024, indicated: - Prescribed treatment: (Alginate calcium) and santyl Location: (Sacrum area), Cleanse area with NS (normal saline) pad dry and follow order, was documented as implemented once daily. Review of Resident #42's Medication Administration Record (MAR), dated July 2024, indicated: - Flagyl Oral Tablet 500 mg (Metronidazole), which is an antibiotic medication, Apply to Sacrum area topically two times a day for sacrum. Crush and sprinkle to sacrum wound twice, was documented as implemented twice daily. During an interview on 7/30/24 at 7:36 A.M., the Wound Physician said Resident #42 should only have flagyl applied to his/her wound bed once a day, and the order that states twice a day must have been transcribed in error. During an interview on 7/31/24 at 7:27 A.M., Nurse #2 said she often works day and evening shift taking care of Resident #42. Nurse #2 said Resident #42 has flagyl scheduled twice a day, but only has a dressing scheduled to be changed once a day. Nurse #2 said sometimes if the dressing is soiled, she will change the dressing and apply the second daily flagyl at that time, but often she just throws away the flagyl because there isn't another dressing change ordered. Nurse #2 said Resident #42 does not have an order for an as needed dressing change but should have had an order since all dressing changes require a physician's order. Nurse #2 said she was unaware that the wound recommendation was transcribed incorrectly for Resident #42 and that the flagyl should have applied to the sacral wound once daily instead of twice daily. Nurse #2 said she never clarified this order, but she probably should have. During an interview on 8/1/24 at 7:47 A.M., the Director of Nursing (DON) said wound orders should be done as ordered. The DON said the wound physician's orders should be transcribed as the wound physician recommends. The DON said if a dressing was soiled, a physician's order for an as needed dressing is required. The DON said Nurse #2 should have clarified the flagyl order for Resident #42 since it did not have a corresponding dressing order in place before wasting the medication or applying a new dressing without an order. The DON said Nurse #2 should never have documented flagyl was applied when it was not. Based on observations, interviews, policy review, and record review, the facility failed to provide care and treatment to prevent the development of pressure ulcers (wounds that occur when the skin and tissue are damaged by prolonged pressure, usually on bony areas like the hips, heels, or elbows) for 4 out of a total sample of 39 residents. Specifically: 1a) For Resident #85, the facility failed to implement treatments and physician orders recommended by the consulting wound physician resulting in a new necrotic skin condition progressing to an unstageable wound leading to osteomyelitis (a bone infection) and sepsis (a life-threatening response to infection) requiring hospitalization and need for a fecal-diverting colostomy (a surgical procedure that creates an opening in the abdomen, called a stoma, that allows digested food to pass out of the body through an external pouch system). 1b) For Resident #85, the facility failed to ensure that an air mattress was set at the appropriate setting to promote wound healing in the presence of a stage IV pressure wound (defined as deep wounds that may impact muscle, tendons, ligaments, and bone). 2a) For Resident #24, the facility failed to implement the physician's order for air mattress settings. 2b) For Resident #24, the facility failed to implement dietician recommendations for wound healing. 2c) For Resident #24, the facility failed to implement wound physician's recommendations for wound care. 3) For Resident #42, the facility failed to ensure nursing accurately transcribed the frequency of a physician ordered topical medication for a stage four pressure ulcer. 4) For Resident #103, the facility failed to implement treatment recommendations by the consultant wound practitioner for a stage IV pressure ulcer. Findings include: Review of the facility policy, titled Pressure Wound Prevention, revised January 2023, indicated, but was not limited to, the following: - Inspect the skin on a daily basis when performing or assisting with personal care or ADLS (activities of daily living). - Evaluate, report and document potential changes in the skin. - Review the interventions and strategies for effectiveness on an ongoing basis. Review of the facility policy, titled Ulcer/skin Breakdown Clinical Protocol, created January 2023, indicated, but was not limited to, the following: - The nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; - The interdisciplinary team should collectively complete Route Cause Analysis for any newly identified in-house acquired pressure injury. - The wound care specialist/medical provider will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents. 1a) Resident #85 was admitted to the facility in March 2023 with diagnoses including Alzheimer's Disease, cerebral infarction, diabetes, hemiplegia (muscle weakness or paralysis on one side of the body that can affect arms, legs, and facial muscles), and dysphagia (difficulty swallowing). Review of the Minimum Data Set (MDS) assessment, dated 2/27/24, indicated that Resident #85 scored a 5 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident had severe cognitive impairment. Further review of the MDS indicated that Resident #85 did not have any pressure ulcers but was at risk for developing pressure ulcers. Review of Resident #85's Potential Skin care plan, initiated 3/8/23, indicated the Resident had potential for alteration in skin integrity, with the following interventions: - Complete skin condition checks weekly - Dietary interventions/evaluation - Follow MD (Medical Doctor/physician) orders for skin care and treatments (utilize best practice guidelines) Review of Resident #85's Norton Scale for predicting risk for pressure ulcer, dated 2/27/24, indicated the Resident scored an eight, placing the Resident in the high risk category. Review of Resident #85's Skin Only Evaluation, dated 3/6/24, indicated Resident #85 had no skin issues. Review of Resident #85's Skin Only Evaluation, dated 3/11/24, indicated Resident #85 had a new necrotic (the death of body tissue or an organ due to a lack of blood supply) wound on the left buttock, medial area, and that the wound did not have an odor. Review of Resident #85's initial Wound Evaluation and Management Summary, dated 3/12/24, indicated the Wound Physician evaluated the Resident for a rash. The Wound Physician diagnosed Resident #85 with diaper dermatitis and recommended Lotrisone cream (an anti-fungal cream) to be applied twice daily to the affected area and prn (as needed). Review of Resident #85's Treatment Administration Records failed to indicate that the lotrisone cream was implemented. During an interview on 7/29/24 at 10:03 A.M., Nurse #17 said that when changes in skin are identified they should be reported to the NP (Nurse Practitioner)/MD. Nurse #17 said that the Wound Physician will give recommendations to the staff member accompanying her during wound rounds every Tuesday. Nurse #17 said that a Certified Nursing Assistant had initially reported the wound to her, and that the Resident had a wound on the middle of the coccyx and a wound on the left buttocks; Nurse #17 said she had not reported the wound to the physician because the wound did not need the physicians' attention because of how small it was. Nurse #17 said she did not apply lotrisone, and that the aides have been using house barrier cream which was not a new treatment for the newly identified wound in March. During a follow-up interview on 7/30/24 at 8:19 A.M., Nurse #17 said that communication with the physician would be included in a progress note, and in the communication book. Review of the communication book and Resident #85's progress notes failed to indicate that the physician was notified of the new necrotic skin condition identified on 3/11/24. Review of the Nurse practitioner (NP) progress note, dated 3/13/24, failed to indicate that the NP was aware of, evaluated, or initiated treatments for Resident #85's necrotic wound. Review of Resident #85's wound evaluation and management summary, dated 3/19/24, indicated the Wound Physician evaluated the Resident's rash. The Wound Physician recommended lotrisone cream for the diaper dermatitis. During an interview on 7/30/24 at 11:13 A.M., the Wound Physician said that when she is consulted, she does not do a full skin check due to time constraints. The Wound Physician said she was initially consulted for Resident #85 to evaluate a rash on the frontal groin area, and nothing else; as the rash was on the front she may not have evaluated the backside and she was not aware of a necrotic wound when she evaluated the rash. The Wound Physician said this may have been a result of bad communication. Review of Resident #85's Treatment Administration Records (TAR) failed to indicate that the lotrisone cream was implemented. Review of Resident #85's medical record failed to indicate a nursing skin evaluation was completed the week of 3/18/24. Review of Resident #85's physician orders indicated the following discontinued orders: - Triad Hydrophilic Wound Dress External Paste (Wound Dressings) Apply to Sacrum topically one time a day for Wound, initiated 3/23/24, 12 days after nursing had initially identified the Resident's necrotic wound, and discontinued on 5/24/24. - Left butt wound wash with normal saline cover with silicone bordered form dressing every day shift left butt wound, initiated 3/22/24, 12 days after nursing had initially identified the Resident's necrotic wound, and discontinued on 5/24/24. - Wound Consult for left butt wound, initiated 3/25/24, 15 days after nursing had initially identified the Resident's necrotic wound, and discontinued on 4/25/24. Review Resident #85's progress note, written by NP #2, dated 3/26/24, indicated the following: I was asked to see this pt (patient) because of worsening wounds. Nursing reports they had started as superficial, but now were open and deeper. He/she had not been followed by the wound care team. Consult initiated and wound team saw this resident the AM of 3/26. They will now follow his/her wounds which are pressure related. Further review of Resident #85's progress note, written by Nurse Practitioner (NP), dated 3/26/24, indicated that the consult for the Resident's wound was initiated 15 days after nursing had initially identified the necrotic area. Further review of the progress note indicated that the wound team requested multi-interventions in addition to wound care. During an interview on 7/30/24 at 11:42 A.M., NP #2 said she would expect to be notified of a new skin condition. NP #2 said that her review of systems includes communication with the nurses, and that she does not do a full-skin check as part of her regular evaluation; the NP said that she would only look at skin if a concern is brought to her attention. NP #2 said a staff member will follow the Wound Physician to communicate the recommendations to her, and that she would expect the recommendations to be implemented. NP #2 said that the risk of not implementing the Wound Physician recommendations would be that the wound could get worse, and that the wound could get infected and develop osteomyelitis. NP #2 said she was first notified of the wound on 3/26/24, when nursing reported to her that the wound had developed an odor, and that when she had evaluated the Resident on 3/13/24 she had not been aware of the wound. During an interview on 7/31/24 at 9:16 A.M., Physician #2 said he would expect nursing to notify himself or an NP of a change in skin condition. Physician #2 said a facility nurse should be following the Wound Physician for recommendations, and that the risk of Wound Physician recommendations not being followed would be that the wound would probably get worse if the Resident was not receiving treatment. Review of Resident #85's Wound Evaluation and Management Summary, dated 3/26/24, indicated Resident #85 had an unstageable (due to necrosis) pressure injury on his/her left ischium measuring 2.5 x 2.4 cm (centimeters), and an unstageable (due to necrosis) pressure injury on his/her sacrum measuring 3.9 x 3.7 cm. Further review of the wound evaluation indicated that the duration of both wounds was greater than six days, and that the Wound Physician recommended a house supplement (a calorically and nutritionally fortified drink typically utilized to address weight loss and/or meet assist in meeting nutrient, such as protein, needs) alginate calcium (a gel that promotes wound healing), and santyl (an ointment used to promote the healing of skin ulcers by removing damaged tissue). Review of the nursing progress note, dated 3/27/24, indicated Resident #85 was being transferred to emergency room for evaluation as the resident was very week sic. And oxygen of at 58% at room air. Review of Resident #85's TAR failed to indicate that alginate calcium, or santyl were implemented prior to the Resident's hospitalization on 3/27/24. Review of Resident #85's physician orders and diet manager change history failed to indicate that a house supplement was implemented. Review of the hospital discharge paperwork, dated 4/22/24, indicated that Resident #85 presented to the hospital on 3/27/24 with encephalopathy (a broad term for any brain disease that alters brain function), found to be in sepsis with an infected sacral ulcer as the presumed source. Further review of the hospital paperwork indicated that the Resident underwent wound debridement (a procedure that removes unhealthy or dead tissue from a wound to promote healing and prevent infection) on 3/29/24, 3/31/24, 4/5/24, and 4/21/24, and that fecal diversion was indicated to allow for the wound to heal due to the wound's proximity to the anus; on 4/5/24 the Resident underwent a diverting loop sigmoid colostomy creation. The hospital paperwork indicated there was clinical and imaging evidence of osteomyelitis with the sacrum/coccyx bones exposed in the wound. Review of the nursing progress note, dated 4/22/24, indicated that Resident #85 had returned from the hospital with a sacral ulcer with underlying osteomyelitis status post multiple debridement's and the creation of a diverting loop colostomy. Further review of the progress note indicated that the Wound Physician would evaluate the Resident on 4/23/24 to provide guideline on wound vac (a treatment that uses suction to help wounds heal) use [sic]. Review of the Minimum Data Set (MDS) assessment, dated 4/28/24, indicated that Resident #85 scored a 10 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident had moderate cognitive impairment. Further review of the MDS indicated that Resident #85 had a new Stage IV and a new Stage III pressure ulcer and was at risk for developing pressure ulcers. According to the Mayo Clinic, complications and outcomes of Stage IV pressure ulcers include: - Osteomyelitis, which is characterized by a mixture of inflammatory cells, fibrosis, bone necrosis, and new bone formation. It is associated with nonhealing wounds, surgical flap complications, and an increased length of hospitalization. It may develop within the first 2 weeks of pressure ulcer formation and despite treatment may require amputation in lower extremity cases. - Joint infections (septic arthritis) can damage cartilage and tissue. - Bone infections (osteomyelitis) can reduce the function of joints and limbs. - Long-term, nonhealing wounds can develop into a type of squamous cell carcinoma. - Sepsis (blood infection). Review of the Wound Evaluation and Management Summary, dated 4/23/24, indicated that Resident #85 had a stage IV sacral pressure wound (Stage IV pressure wounds are defined as deep wounds that may impact muscle, tendons, ligaments, and bone) measuring 17 x 17 x 4.5 cm. Further review of the Wound Evaluation and Management Summary indicated the Wound Physician recommended a house supplement, foley catheter (a medical device that helps drain urine from the bladder) as urine will cause wound vac to lose suction and negative pressure wound therapy to be applied three times per week for 30 days at 125 mmHg (millimeter of mercury, a manometric unit of pressure) continuously. Review of Resident #85's TAR indicated that the wound vac was scheduled to be changed twice a week, initiated on 4/22/24. Review of Resident #85's physician orders and diet manager change history failed to indicate that a house supplement was implemented. Review of the Wound Evaluation and Management Summary, dated 4/30/24, indicated that Resident #85 had a stage IV sacral pressure wound measuring 17 x 16.8 x 4.5 cm. Further review of the Wound Evaluation and Management Summary indicated the Wound Physician recommended a house supplement and negative pressure wound therapy to be applied three times per week for 23 days at 125 mmHg continuously. Review of Resident #85's TAR indicated that the wound vac was scheduled to be changed twice a week, initiated on 4/22/24. Review of Resident #85's physician orders and diet manager change history failed to indicate that a house supplement was implemented. Review of Resident #85's progress notes indicated the Resident was transferred to the emergency room on 5/2/24. Review of the hospital discharge paperwork, dated 5/9/24, indicated Resident #85 presented to the hospital with lethargy, anorexia (abnormal loss of appetite for food), hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions), and worsening wound drainage. Further review of the hospital paperwork indicated the Resident required intravenous antibiotics for sepsis during hospitalization, and was discharged back to the facility with the recommendation to change the wound vac three times per week. Review of the Wound Evaluation and Management Summary, dated 5/14/24, indicated that Resident #85 had a stage IV sacral pressure wound measuring 16.8 x 16.5 x 4.5 cm and a stage IV pressure wound on the left ischium measuring 2 x 1 x .4 cm. Further review of the Wound Evaluation and Management Summary indicated the Wound Physician recommended a house supplement and negative pressure wound therapy to be applied three times per week for nine days at 125 mmHg continuously. Review of Resident #85's TAR indicated that the wound vac was scheduled to be changed twice a week, initiated 4/22/24. Review of Resident #85's physician orders and diet manager change history failed to indicate that a house supplement was implemented. Review of the Wound Evaluation and Management Summary, dated 5/21/24, indicated that Resident #85 had a stage IV pressure wound measuring 16.8 x 16.7 x 4.8 cm, and that the wound progress was exacerbated due to infection; the Wound Physician recommended a house supplement and sodium hypochlorite solution (dakins) twice daily for 30 days. Further review of the Wound Evaluation and Management summary indicated the Resident had a stage 4 pressure injury of the left ischium measuring 1 x 1 x 0.2 cm, and that the Wound Physician recommended alginate calcium once daily for 23 days. Review of Resident #85's physician orders and diet manager change history failed to indicate that a house supplement was implemented. Review of Resident #85's Nurse Practitioner progress note, dated 5/22/24, indicated that the Resident had been seen on 5/21/24 by the Wound Physician who found bone chips in the Resident's wound. Further review of the progress note indicated that the Resident was transferred to the hospital on 5/21/24 for sacral wound for IV antibiotics or hospice. Review of the hospital discharge paperwork, dated 5/24/24, indicated Resident #85 had presented to the hospital after the facility had noticed bone chips in his/her wound. Review of the Wound Evaluation and Management Summary, dated 5/28/24, indicated that Resident #85 had a stage IV pressure wound measuring 17 x 16.8 x 4.8 cm, and that the wound continues to deteriorate; the Wound Physician recommended sodium hypochlorite solution (dakins) twice daily for 23 days. Further review of the Wound Evaluation and Management summary indicated the Resident had a stage 4 pressure injury of the left ischium measuring 1 x 0.9 x 0.2 cm, and that the Wound Physician recommended alginate calcium once daily for 23 days. Review of Resident #85's physician orders and diet manager change history failed to indicate that a house supplement was implemented. Review of the Wound Evaluation and Management Summary, dated 6/4/24, indicated that Resident #85 had a stage IV pressure wound measuring 17 x 17 x 4.8 cm, and that the wound was exacerbated by acute osteomyelitis; the Wound Physician recommended a house supplement and sodium hypochlorite solution (dakins) twice daily for 16 days. Review of Resident #85's physician orders and diet manager change history failed to indicate that a house supplement was implemented. Review of Resident #85's progress note, dated 7/10/24, indicated the Resident was sent to the hospital as the resident was shaking and pale. Review of the hospital discharge paperwork, dated 7/20/24, indicated Resident #85 presented to the hospital on 7/10/24 with severe sepsis secondary to sacral wound infection requiring admission to the ICU (intensive care unit) for pressor support. Further review of the hospital discharge paperwork indicated the Resident's wound was debrided on 7/11/24, the Resident required IV antibiotics for sepsis, a urinary foley catheter was placed on 7/11, 80 days after the Wound Physician initially recommended the placement of the foley catheter, and a wound vac was placed on 7/13 with instructions to be changed on Monday, Wednesday, and Friday. Review of the most recent Wound Evaluation and Management Summary, dated 7/23/24, indicated that Resident #85 had a stage IV pressure wound measuring 16 x 15.5 x 4.8 cm, and that the wound was not at goal; the Wound Physician recommended a house supplement and to change the wound vac three times per week. Review of Resident #85's physician orders indicated the following discontinued orders: - Change (wound vac) dressing every 3 days and PRN (as needed), initiated on 4/22/24 and discontinued on 5/24/24. Review of Resident #85's physician orders and diet manager change history failed to indicate that a house supplement was implemented. Review of Resident #85's physician orders indicated the following active orders: - Change Negative pressure wound therapy (wound vac) dressing every 3 days and PRN, initiated 7/20/24. - Change foley catheter as needed, initiated 7/20/24. Review of Resident #85's TAR indicated that foley care was initiated on 7/20/24. Further review of Resident #85's physician orders, hospital discharge orders, diet manager change history, and TAR indicated that the lotrisone cream, and house supplement recommended by the Wound Physician were never initiated, a wound treatment was not ordered until 3/23/24, 12 days after nursing had initially identified the necrotic wound, and that a foley catheter was not placed until 7/11/24, 80 days after the Wound Physician initially recommended the placement of a foley catheter. Review of Resident #85's MAR failed to indicate that the wound vac was ever changed three times a week as recommended by the Wound Physician. Review of the most recent Minimum Data Set (MDS) assessment, dated 7/23/24, indicated that Resident #85 scored a 2 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident had severe cognitive impairment. Further review of the MDS indicated that Resident #85 had an unhealed Stage IV pressure ulcer and was at risk for developing pressure. On 7/30/24 at 8:01 A.M., the surveyor observed the Wound Physician and the Unit Supervisor performing wound care on Resident #85. The wound was larger in diameter than a cantaloupe with a bright red wound bed and some yellow-colored tissue. During an interview on 7/29/24 at 2:52 P.M., the Nurse Supervisor said that if a Resident is noted with a change in skin condition that a skin assessment will be done, that the change would be reported to the physician, and that a treatment order would be placed. The Nurse Supervisor said that he accompanies the Wound Physician during her wound rounds on Tuesdays. The Nurse Supervisor said that it was his responsibility to print the Wound Physician recommendations and to present them to the NP and that the signed recommendations will be placed in the physical chart. The Nurse Supervisor said that he never has the time to follow this process because he is always working on a cart, as a result the Wound Physician's recommendations for treatment changes don't get implemented. Review of Resident #85's medical chart failed to indicate that the Wound Physician's recommendations for lotrisone, a house supplement, foley catheter placement, or a three day a week wound vac change were reviewed by the NP or MD. During an interview on 7/31/24 at 3:05 P.M., NP #1 said she would not disagree with the Wound Physician recommendations and that the recommendations sound reasonable, but cant recall if she was aware of them. During an interview on 7/3024 at 7:36 A.M., the Wound Physician said her expectation was that the nurse rounding with her should print, review and implement her recommendations. The Wound physician said she was not aware that her recommendation for lotrisone was not implemented. The Wound physician said the wound vac should have been changed three times a week, she was not aware that it was ordered for two times a week and that was not the correct order. The Wound Physician said she had recommended a foley catheter but that it wasn't implemented by the facili[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 7.) Resident #35 was admitted to the facility in February 2024 with diagnoses including a stroke affecting his/her left side, diabetes, and post-traumatic stress disorder. Review of Resident #35's most recent Minimum Data Set (MDS) assessment, dated 5/22/24, indicated that Resident #35 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of 15. Review of Resident #35's physician's order, dated 2/15/24, indicated: -Weigh within 24 hours of admission and daily for two days with supervision of nurse. Review of Resident #35's Medication Administration Record (MAR), dated February 2024, indicated the order to weigh within 24 hours of admission and daily for two days with supervision of nurse was documented as obtained, however the there was no weight recorded in the MAR or in the electronic health record. Review of Resident #35's physician's order, dated 2/21/24, indicated: - Weight every week for four weeks. Review of Resident #35's Medication Administration Record (MAR), dated February and March 2024, indicated on 2/21/24, 2/28/24, 3/6/24, and 3/13/24 that physician's order for Weight every week for four weeks was documented as either NA (not applicable) or not documented as complete. There were no weights recorded in the MAR or in the electronic health record corresponding to these dates. Review of Resident #35's plan of care related to nutrition, dated 5/20/24, indicated: - Monitor weight per facility policy as ordered. Review of nurse progress notes, dated between 2/14/24 and 3/26/24, failed to indicate weights were obtained for Resident #35. The progress notes failed to indicate that Resident #35 refused to have his/her weights obtained or that a physician was notified that weights were not obtained. Review of the Certified Nursing Assistant (CNA) assignment sheet, dated 4/1/24, indicated Resident #35 weighed 142 lbs. This weight was not in the electronic health record. Review of the Certified Nursing Assistant (CNA) assignment sheet, dated 5/14/24, indicated Resident #35 weighed 138.9 lbs. This weight was not in the electronic health record. Review of Resident #35's weights and vitals summary in the electronic health record indicated the following weight readings: - 5/3/24 - 162 lbs. (pounds) - 7/22/24 -148.2 lbs. Review of the nurse progress note, dated 7/22/24, does not indicate any plan for reweigh of Resident #35 to confirm the 24-pound weight loss. Review of the physician progress note, dated 7/23/24, indicated Resident #35's weights of 162 pounds on 5/3/24 and 148.2 pounds on 7/22/24. The note did not include any new orders to address the 24-pound weight loss, which is an 8.52% loss in less than three months. Review of the entire clinical record, between 2/14/24 and 7/23/24, failed to indicate that Resident #35 was evaluated or assessed by a Registered Dietitian. During an interview on 7/30/24 at 4:30 P.M., Nurse #8 said the facility weight process is to weigh residents weekly for four weeks upon admission and then monthly unless otherwise recommended by the dietitian. During an interview on 7/31/24 at 4:00 P.M., Nurse #17 said she can't remember why she documented NA (not applicable) on the MAR as a response for the physician order to obtain Resident #35's weight. Nurse #17 said she did not report to anyone or document that weight could not be obtained on her shift, but she should have. During an interview on 7/25/24 at 12:07 P.M., the Dietitian said on admission each resident should be assessed by a dietitian and be visited two times during that assessment period. The Dietitian said it is expected that each resident has a weight obtained on admission, weekly for four weeks, and then monthly. She would also expect nutritional assessments to be completed as needed, such as with weight loss. The Dietitian said she had noticed missing assessments and weights throughout the facility. The Dietitian said Resident #35 had not been assessed by a Dietitian since admission to the facility but should have. During an interview on 7/31/24 at 11:57 A.M., the Director of Nursing (DON) said upon admission each resident should have a weight obtained, and then weekly for four weeks, then monthly or according to dietitian recommendations. The DON said every resident should be assessed by the Dietician shortly after admission. The DON further said that if a nurse is unable to obtain a weight on a resident the physician should be notified, and it should be documented in the medical record. 5.) Resident #42 was admitted to the facility in August 2023 with diagnoses including severe protein-calorie malnutrition and a sacral stage four pressure ulcer. Review of the most recent Minimum Data Set (MDS) assessment, dated 6/7/24, indicated Resident #42 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 8 out of 15. Review of Dietitian progress note, dated 6/23/24, indicated: - Resident noted to have stage 4 on sacrum. Being seen by wound MD (medical doctor). On regular, mechanical soft, thin liquids with no issues chewing or swallowing current diet textures. Eating about 50-75% independent with set up. Resident currently on Prosource 30cc qd (every day) providing 10 gm (grams) elemental protein. Suggest increase to 30cc bid to provide 20gm elemental protein. Addition of Vit C 500mg bid as well as Zinc 220mg x 30days will aide with wound healing. Per wound MD wound is improving. Suggest weekly weights. Last wt (weight) 1/26 164. Review of nurse's progress note, dated 7/8/24, indicated: - Resident reviewed by IDT at Risk meeting: Resident with stage IV to sacrum. RD recommendation to increase protein supplement, add zinc, attempt weekly weights. Review of Resident #42's active physician's orders indicated: - Prosource Oral Liquid (Nutritional Supplements), Give 30 ml (milliliters) by mouth one time a day, initiated 1/25/24. - Weight every week, every day shift every 2 weeks on Fri (Friday) for monitoring weight, initiated 7/8/24. Review of Resident #42's active and discontinued physician's orders failed to indicate Vit C 500 mg (milligrams) bid (twice a day) or Zinc 220 mg were implemented. During an interview on 7/31/24 at 7:27 A.M., Nurse #2 said Resident #42 receives prosource once a day and does not receive vitamin c or zinc. Nurse #2 said Resident #42 is weighed every two weeks. Nurse #2 said she was unaware of dietitian's recommendations for prosource twice a day, zinc, vitamin c, or weekly weights. During an interview on 7/30/24 at 1:33 P.M., the Dietitian said she emailed the recommendations for increasing in prosource to twice a day and adding zinc, vitamin c, and weekly weights to the Assistant Director of Nursing (ADON) and Director of Nursing (DON) to review with the provider on 6/23/24, since her recommendations require a physician's order to implement. The Dietitian said on 7/2/24 she noticed the recommendations were not implemented, so she spoke with the DON, who said that there was a firewall issue, and they were not able to open her email, but that they would follow up. The Dietitian said that on 7/8/24 she noticed that the recommendations were still not implemented during a risk meeting. The Dietitian said the Nurse Practitioner approved the recommendations at that time and were supposed to be initiated. The Dietitian said it was her understanding that the prosource would be increased to twice a day and zinc and vitamin c should have been implemented as well but were not. The Dietitian further said the weekly weight order must have been put into the computer incorrectly, because Resident #42 should be weighed weekly. During an interview on 8/1/24 at 7:47 A.M., the Director of Nursing (DON) said there was a software issue that delayed the notification of the provider of the Dietitians recommendations. The DON said the orders to increase prosource to twice a day and to add zinc, vitamin c, and weekly weights were approved by the Nurse Practitioner at the risk meeting on 7/8/24 and should have been implemented at that time, but were not. The DON said Dietitian recommendations should be done quickly and a week is too long for the provider to not be made aware of recommendations for prosource, zinc, vitamin c, or weekly weights. 6.) Resident #50 was admitted to the facility in November 20233 with diagnoses including diabetes and chronic pain. Review of the most recent Minimum Data Set (MDS) assessment, dated 5/28/24, indicated that Resident #50 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. On 7/23/24 at 9:15 A.M., the surveyor observed Resident #50 with his/her breakfast untouched. Resident #50 said he/she doesn't eat much because the food isn't good and that he/she has lost weight. Review of the Dietitian's progress note, dated 6/23/24, indicated: - Resident being seen by wound MD (medical doctor) for post surgical R (right) 3rd [NAME] [sic], and R medial thigh. Wt (weight) gain secondary to resident being homeless and has food insecurity. Reinforce availability of food in facility. Encourage increased protein at each meal and snack for blood sugar control. Suggest addition of Prosource 30cc (cubic centimeters) bid (twice daily) providing 20gm (grams) elemental protein, Vit C 500mg (milligrams) bid, Zinc 220mg x 30days. Review of nurses note, date 7/8/24, indicated: - New order from Nurse Practitioner (NP): may utilize ProHealth protein supplement if ProSource unavailable. Review of Resident #50's physician's orders, dated 6/23/24 to 7/24/24, failed to indicate an order for Prosource 30cc bid providing 20 gm (gram) elemental protein. Review of Resident #50's active physician's orders, dated 7/8/24 (which is 15 days after the Dietitians recommendation), indicated: - Vitamin C Oral Tablet (Ascorbic Acid), Give 500 mg by mouth two times a day for supplement for 30 days. - Zinc-220 Oral Capsule (Zinc Sulfate), Give 1 tablet by mouth one time a day for supplement for 30 days. During an interview on 7/25/24 at 12:43 A.M., Resident #50 said he/she has never received prosource. During an interview on 7/24/24 at 10:18 A.M., Nurse #14 said Resident #50 does not take prosource. Nurse #14 said she was unaware of the Dietitians recommendation for addition of prosource. During an interview on 7/30/24 at 1:33 P.M., the Dietitian said she emailed the recommendations for the addition of prosource, zinc, and vitamin c to the Assistant Director of Nursing (ADON) and Director of Nursing (DON) to review with the provider on 6/23/24, since her recommendations require a physician's order to implement. The Dietitian said on 7/2/24 she noticed the recommendations were not implemented, so she spoke with the DON, who said that there was a firewall issue, and they were not able to open her email, but that they would follow up. The Dietitian said that on 7/8/24 she noticed that the recommendations were still not implemented during a risk meeting. The Dietitian said the Nurse Practitioner approved the recommendations at that time and were supposed to be initiated. During an interview on 8/1/24 at 7:47 A.M., the Director of Nursing (DON) said there was a software issue that delayed the notification of the provider of the Dietitians recommendations. The DON said the orders to add prosource, zinc, and vitamin c were approved by the Nurse Practitioner at the risk meeting on 7/8/24 and should have been implemented at that time. The DON said Dietitian recommendations should be done quickly and a week is too long for the provider to not be made aware of recommendations for prosource, zinc, and vitamin c. Based on interview, record review, and observation the facility failed to ensure seven residents maintained acceptable parameters of nutritional status out of a total sample of 39 residents. Specifically, the facility failed to: 1) For Resident #85 the facility failed to assess the nutritional status of and implement pertinent interventions for the Resident who developed a necrotic skin area which worsened to two unstageable wounds and experienced significant weight loss. 2) For Resident #68 the facility failed to address a significant weight loss in a timely manner. 3) For Resident #16 the facility failed to obtain weights as ordered, and address a significant weight loss for in a timely manner. 4) For Resident #24 the facility failed to implement a therapeutic diet as ordered by the physician, failed to identify, and address a potential significant weight loss, and failed to implement recommendations by the Dietitian. 5) For Resident #42, the facility failed to implement dietitian recommendations for prosource (a liquid protein supplement), zinc, vitamin c, and weekly weights. 6) For Resident #50, the facility failed to implement dietitian recommendations for prosource (a liquid protein supplement), zinc, vitamin c. 7) For Resident #35, the facility failed to assess the nutritional status in a timely manner, obtain weights as ordered by the physician and assess for a potential weight loss. Findings include: Review of the facility policy, titled Weighing the Resident revised January 2023, indicated, but was not limited to, the following: 1. Each resident/patient will be weighed within 24 hours of admission. 2. Weights will be obtained and recorded: - Upon admission - Weekly for the first four weeks, - Then either monthly or more frequently if clinical condition warrants or as ordered by the physician. 3. Any unplanned weight loss/gain is to be reported to the physician, family/responsible party, dietitian, nursing supervisor and addressed at the weekly at risk meeting. 4. Re-weigh of resident/patient is required with fluctuation of 3 lbs. from previous weight, with licensed nurse observation/validation. Also with: a. 5% loss or gain in one month b. 7.5% loss or gain in three months c. 10% loss or gain in six months Review of the facility policy, titled Pressure Wound Prevention, revised January 2023, indicated, but was not limited to, the following: Poor Nutrition 1. Dietitian will assess nutrition and hydration and make recommendations based on the individual resident's assessment. 2. Monitor nutrition and hydration status. 3. Monitor laboratory values, notify physician when appropriate. 4. Encourage proper dietary and fluid intake. 5. If a normal diet is not possible, talk to physician about supplements. 6. Administer vitamins, mineral and protein supplements in accordance with physician orders and dietitian recommendations. Pressure ulcers can diminish global life quality, contribute to rapid mortality in some patients and pose a significant cost to health-care organizations. Accordingly, their prevention and management are highly important. Nutritional deprivation and insufficient dietary intake are the key risk factors for the development of pressure ulcers and impaired wound healing. Unplanned weight loss is a major risk factor for malnutrition and pressure ulcer development. Suboptimal nutrition interferes with the function of the immune system, collagen synthesis, and tensile strength. Nutritional status plays a central role in the process of wound healing. Malnutrition accompanies a poor outcome and brings about higher morbidity and mortality. Malnutrition should be recognized rapidly and treated accordingly in all patients suffering from pressure ulcers. Malnutrition impedes pressure ulcer healing. Although the ideal nutrient intake to encourage wound healing is unknown, increased needs for energy, protein, zinc, and Vitamins A, C, and E have been documented. High-protein oral nutritional supplements are effective in reducing the incidence of pressure ulcers by 25% in patients at risk. Energy, protein, arginine, and micronutrients (Vitamins A, C, and zinc) are all vital in the wound healing. Proteins are the most important macronutrients since it is indispensable for the repair of tissues. Pressure Ulcer and Nutrition NIH 2018 Resident #85 was admitted to the facility in March 2023 with diagnoses including Alzheimer's Disease, cerebral infarction, diabetes, hemiplegia (muscle weakness or paralysis on one side of the body that can affect arms, legs, and facial muscles), and dysphagia (difficulty swallowing). Review of the Minimum Data Set (MDS) assessment, dated 2/27/24, indicated that Resident #85 scored a 5 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident had severe cognitive impairment. Further review of the MDS indicated that Resident #85 did not have any pressure ulcers but was at risk for developing pressure ulcers. Review of Resident #85's Potential Skin care plan, revised 4/29/24, indicated the Resident had potential for further alteration in skin integrity, with the following interventions: - Dietary intervention/evaluation, initiated 3/8/23 Review of Resident #85's Nutrition care plan, initiated 3/10/23 and revised 7/1/24, indicated the Resident was at risk for weight loss secondary to esophageal dysmotility, pressure wounds, and mechanically altered diet with a goal for the Resident to remain greater than 190 lbs. (pounds). The following interventions were listed: - Diet consult PRN (as needed), initiated 3/10/23 - Monitor weight per facility policy as ordered, initiated 3/10/23 -Diet as ordered Regular diet, Puree texture, initiated 3/10/23 Review of Resident #85's Self-care care plan, initiated 3/6/24 and revised 5/17/24, indicated the Resident required assistance with activities of daily living related to right side hemiplegia, decreased endurance and fatigues easy. Further review of the care plan indicated the Resident was dependent on staff assistance with eating. Review of Resident #85's most recent comprehensive nutrition assessment, dated 11/14/23, indicated the following: - The Resident did not meet criteria for malnutrition. - A goal for the Resident was to maintain his/her weight. - The Resident's skin was intact. - An intervention to monitor and evaluate the Resident's weight, diet, intakes, skin, labs, mood, and food preferences. On 07/31/24 at 03:17 P.M. the surveyor observed Resident #85 in bed. The Resident appeared cachectic (physical wasting with loss of weight and muscle mass due to disease) as evidence by protruding clavicles, scooping/hallowing temporal region, and thin quadriceps with prominent bones in the patellar region. Review of Resident #85's skin check, dated 3/6/24, indicated Resident #85 had no skin issues. Review of Resident #85's skin check, dated 3/11/24, indicated Resident #85 had a new necrotic wound on the left buttock, medial area, and that the wound did not have an odor. Review Resident #85's progress note, written by Nurse Practitioner #2, dated 3/26/24, indicated the following: I was asked to see this pt (patient) because of worsening wounds. Nursing reports they had started as superficial, but now were open and deeper. He had not been followed by the wound care team. Consult initiated and wound team saw this resident the AM (morning) of 3/26. They will now follow his/her wounds which are pressure related. Review of Resident #85's wound evaluation and management summary, dated 3/26/24, indicated Resident #85 had an unstageable (due to necrosis) pressure injury on his/her left ischium measuring 2.5 x 2.4 cm (centimeters), and an unstageable (due to necrosis) pressure injury on his/her sacrum measuring 3.9 x 3.7 cm. Further review of the wound evaluation indicated that the duration of both wounds was greater than six days, and that the Wound Physician recommended a house supplement. Review of the hospital discharge paperwork indicated that Resident #85 presented to the hospital on 3/27/24 with encephalopathy (a broad term for any brain disease that alters brain function), found to be in sepsis with an infected sacral ulcer as the presumed source. Further review of the hospital paperwork indicated that the Resident underwent wound debridement on 3/29, 3/31, 4/5, and 4/21, and that fecal diversion was indicated to allow for the wound to heal due to the wound's proximity to the anus; on 4/5/25 the Resident underwent a diverting loop sigmoid colostomy creation. The hospital paperwork indicated there was clinical and imaging evidence of osteomyelitis (an infection in the bone caused by bacteria) with the sacrum/coccyx exposed in the wound. Review of the Wound Evaluation and Management Summary, dated 4/23/24, indicated that Resident #85 had a stage IV sacral pressure wound (Stage IV pressure wounds are defined as deep wounds that may impact muscle, tendons, ligaments, and bone) measuring 17 x 17 x 4.5 cm. Further review of the Wound Evaluation and Management Summary indicated that malnutrition was a factor complicating wound healing. Further review of Resident #85's medical record failed to indicate any nutritional evaluation or recommendations/orders were implemented for the Resident. Review of Resident #85's weight and vitals summary indicated the following weight readings: 3/7/23 - 199.3 lbs. 6/19/23 - 204 lbs. 11/14/23 - 203.4 lbs. 2/2/24 - 200.4 lbs. 3/7/24 - 200.8 lbs. 4/22/24 - 189 lbs. 5/14/24 - 185.4 lbs. 7/20/24 - 141 lbs. Review of the Certified Nursing Assistant (CNA) assignment sheet, dated 6/3/24, indicated Resident #85 weighed 181.2 lbs. Further review of Resident #85's recorded weights indicated that Resident #85 had lost 11.8 lbs. of body weight during hospitalization between 3/7/24 and 4/22/234, and then continued to lose weight. Review of the recorded weights indicated that Resident #85's weight loss reached clinical significance on 5/14/24, indicating the Resident had lost a total of 7.6% of his/her total body weight within 2 months. The weight recorded in the CNA assignment book confirms a trend of weight loss, and review of the weight records indicated the Resident had lost an additional 40 lbs. of body weight on 7/20/24, indicating an additional, clinical significant loss of 22.2% of his/her total body weight lost in a month, 25.4% of his/her total body weight lost in three months, or 29.2% of his/her total body weight lost in six months. Review of Resident #85's recorded weights failed to indicate that a reweight was obtained for the weight taken on 4/22/24 until 22 days later, for the weight taken on 5/14/24 until 20 days later, for the weight taken on 6/3/34 until 47 days later, and that a reweight was never obtained to confirm the weight reading on 7/20/24. Review of Resident #85's medical record indicated the Resident was hospitalized again on 5/9/24, 5/22/24, and 7/10/24 for wound-related reasons. Review of the hospital discharge paperwork, dated 5/9/24, indicated the Resident met criteria for severe calorie-protein malnutrition, required enteral nutrition via a nasogastric tube (a tube placed through the nose terminating directly in the stomach used to provide nutrition formula) during the hospitalization, and the hospital recommended to continue supplemental nutrition at the long-term care facility. Review of the hospital discharge paperwork, dated 7/10/24, indicated the Resident appeared cachectic and that the Resident had presented with severe sepsis secondary to his/her sacral wound requiring admission to the ICU (intensive care unit). Further review of Resident #85's medical record failed to indicate any nutritional evaluation or recommendations/orders were implemented for the Resident. Review of Resident #85's medical record indicated he/she was evaluated by the Registered Dietitian (RD) on 7/1/24, 112 days after the necrotic skin condition was first identified, and 48 days after Resident #85's weight loss reached clinical significance. Review of the RD's progress note, dated 7/1/24, indicated the Resident had lost weight and recommended Proheal (a liquid protein supplement) 30cc tid (three times a day) (providing 45 gm elemental protein), Vitamin C 500mg bid, Zinc 220mg x 30 days, and weekly weights. Review of the most recent Wound Evaluation and Management Summary, dated 7/23/24, indicated that Resident #85 had a stage IV pressure wound measuring 16 x 15.5 x 4.8 cm, and that the wound was not at goal; the Wound Physician recommended house supplements. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #85 scored a 2 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident had severe cognitive impairment. Further review of the MDS indicated that Resident #85 was at risk for developing pressure ulcers and that the Resident had an unhealed Stage IV pressure ulcer. Review of Resident #85's medical record indicated that the Wound Physician recommended house supplements on 3/12/24, 3/19/24, 3/26/24, 4/23/24, 4/30/24, 5/14/24, 5/21/24, 5/28/24, 6/4/24, 6/11/24, 6/18/24, 6/25/24, 7/2/24, 7/9/24 and 7/23/24. Review of Resident #85's physician orders, dining manager change history report, and care plans failed to indicate that any nutrition interventions were ever initiated for Resident #85, including the house shakes recommended by the Wound Physician or the Proheal, Vitamin C , Zinc, and weekly weights recommended by the RD. Review of the At Risk documentation indicated that meetings were held on 5/8 and 7/8 but failed to indicate nutrition interventions for Resident #85's weight loss or wounds. Review of the Requested Dietician Information documentation, provided by the facility Administrator, indicated the facility did not have a Registered Dietitian from 1/18/24 to 6/4/24. During an interview on 7/25/24 at 10:12 A.M., the Nurse Supervisor said cardiac residents are weighed every day, and every other resident is weighed monthly and as needed. The Nurse Supervisor said that the nurse will review the weights and enter them into the electronic medical record, and that the nurse should immediately obtain a reweight if there had been a change of three lbs. or more. The Nurse Supervisor said that if the reweight confirms a big change that the physician and RD should be notified, who would be expected to review the weights and address weight changes. During an interview on 7/30/24 at 11:13 A.M., the Wound Physician said that it is always good to have a dietitian involved in wound care and that protein is good for wound healing; she said she tries to get a dietitian involved. The Wound Physician said lack of nutrition interventions will slow down wound healing, increase risk for infection and wound deterioration which can lead to hospitalization. The Wound Physician was not aware that a dietitian was not involved with Resident #85's care. During an interview on 7/25/24 at 1:17 P.M., the RD said that Certified Nursing Aides (CNA's) take weights and give them to nurses, and that if there was a change of three pounds or more from the previous weight that she would expect a reweight to occur within 24 hours. The RD said she would expect to be notified of any confirmed weight changes. The RD said all residents should be assessed quarterly and high risk residents would be assessed monthly; the RD said that an assessment would include weight history, supplement usage, dental status, skin status, past medical history, ideal body weight, feeding status, and past nutrition interventions. During a follow-up interview on 7/30/24 at 12:22 P.M., the RD said she would expect to evaluate a Resident who had returned from the hospital. The RD said that Residents with wounds have elevated protein needs, and that all wounds require a nutrition assessment and intervention even before they progress to stage III or IV pressure wounds; the RD said that protein is important for wound healing. The RD said she would expect to be notified of significant weight loss or a new wound immediately and would assess the Resident within seven days. The RD said that Resident #85 has a wound and has experienced weight loss; the RD said the Resident requires extra protein and that he/she would not be able to meet his/her protein needs by meals alone. The RD said that the risk of nutrition interventions not being implemented for Resident #85 would be further skin breakdown, and that a Resident can't heal a wound and lose weight at the same time. The RD said the NP was aware of her recommendations and that she had not disagreed with them. The RD said that her recommendations for proheal, vitamin C, zinc, and weekly weights were to promote wound healing. The RD said that house supplements would require a physician order. The RD said she had not been notified of the weight loss recorded on 7/20/24 and she should have. Review of Resident #85's medical record failed to indicate that a comprehensive nutrition assessment was completed for the Resident during a regularly scheduled quarterly MDS assessment on 2/27/24, during significant change MDS assessments on 3/12/24, 4/28/24, or 5/15/24, or when the Resident returned from the hospital on 4/22/24, 5/9/24, 5/24/24 or 7/20/24. During an interview on 7/30/24 at 2:02 P.M., the Food Service Director (FSD) said there have been no interventions for weight loss or wound healing initiated by the kitchen for Resident #85. During an interview on 8/1/24 at 9:17 A.M., NP #1 said she would not have disagreed with the RD's recommendation to implement proheal, vitamin C, zinc, or weekly weights for Resident #85 and that she does not recall if she was notified of the Resident's most recent weight loss on 7/20/24. NP #1 said she was not aware of any nutrition interventions in place for Resident #85, and that she had not initiated any nutrition interventions. During a follow-up interview on 7/31/24 at 12:18 P.M., the Wound Physician said she had recommended Resident #85 receive house shakes to help meet calorie needs to help with wound healing and that she was not aware that her recommendations were not implemented. During an interview on 7/31/24 at 8:09 A.M., the Director of Nursing (DON) said she would expect a Resident who had experienced weight loss to be assessed by an RD as soon as possible, as weight loss would compromise the Resident's health. The DON also said that a change in skin condition should be reported to the Dietitian, as the wound could get worse if untreated. During an interview on 8/12/24 at 10:05 A.M., the Speech Language Pathologist (SLP) said that she had worked with Resident #85 to reduce the risk of aspiration, to trial textures, consistencies, and to strengthen swallowing function. The SLP said that she had not been consulted to address Resident #85's weight loss, and that the speech therapy was to address safety with swallowing. During an interview on 8/12/24 at 19:17 A.M., RD #2 said that the she would not consider the Minimum Data Set (MDS) assessment a comprehensive nutrition assessment, and that a comprehensive nutrition assessment would include height, weight, intake, weight changes, wounds, and a review of medications, vitamins and minerals. 2) Resident #68 was admitted to the facility in March 2023 with a diagnosis of Dementia. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #68 scored a 4 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident had severe cognitive impairment. Review of Resident #68's Potential Skin care plan, revised 4/29/24, indicated the Resident had potential for further alteration in skin integrity, with the following interventions: - Dietary intervention/evaluation Review of Resident #68's Nutrition care plan, initiated 3/22/23 and revised 7/8/24, indicated the Resident was at risk for weight loss secondary to poor PO (per os/by mouth) intake associated with dementia with a goal for the Resident to remain greater than 106 lbs and the following interventions: - Diet consult PRN (as needed) Review of Resident #68's active physician o[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, staff education and Facility Assessment review, the facility failed to ensure the nursing staff were trained and demonstrated the competencies and skill sets necessary to provide the level and types of care and services needed as outlined in the Facility Assessment. Specifically: 1.) The facility failed to ensure licensed nursing staff were trained and demonstrated competency related to wound care, treatment administration, transcribing orders, pressure ulcer prevention, change in condition, and communication. For Resident #85, the facility failed to implement treatments and physician orders recommended by the consulting wound physician resulting in a new necrotic skin condition progressing to an unstageable wound leading to osteomyelitis (a bone infection) and sepsis (a life-threatening response to infection) requiring hospitalization and need for a fecal-diverting colostomy (a surgical procedure that creates an opening in the abdomen, called a stoma, that allows digested food to pass out of the body through an external pouch system). 2.) The facility failed to ensure that the nursing staff received the appropriate competencies and skill sets necessary for the care and treatment of residents. Specifically, the facility failed to ensure competencies were completed and documented for 5 out of 5 certified nursing assistants (CNAs), and 12 out of 12 licensed nurses whose education records were reviewed. Findings include: According to the Board of Registration in Nursing, 244 CMR 9.00: Standards of Conduct, 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. 1.) Review of the facility policy titled Ulcer/skin Breakdown Clinical Protocol, created January 2023, indicated, but was not limited to, the following: - All caregivers are responsible for preventing, care of, and providing treatment for Skin Ulcerations. Review of the Facility Assessment Tool, dated 5/24/24, included but was not limited to the following: - Commonly admitted diseases, conditions, physical and cognitive disabilities, or combinations of conditions that require complex medical care and management: Integumentary System (the body system consisting of skin, hair, nails and glands): Skin Ulcers, Injuries, surgical wounds. Facility utilizes Wound Physicians: MD (medical doctor)/NP (nurse practitioner), Nursing, Registered Dietician, Regularly scheduled skin Assessments, Wound care supplies, Consultation with specialist as needed for wound management. - Services and Care we Offer based on our Resident's Needs: Skin Integrity: Pressure injury prevention and care, skin care, wound care, (surgical, other skin wounds). - Staff training/education and competencies: Competencies by department. - Licensed Nurses Competencies on hire and PRN (as needed): Skin Prevention/Wound Program, Transcribing order, Change in Condition, Communication - Licensed Nurses Annual Competencies: Treatment Administration - Certified Nurse Assistant (CNA) Annual Competencies: Preventative skin care. During a tour of the facility on 7/23/24 at 8:11 A.M., the surveyor interviewed residents and the following statements regarding staff competencies were reported: - One resident on the [NAME] Unit said, I'm concerned my nurses weren't trained to care for my wounds. - Another resident on the [NAME] Unit said, sometimes my wound dressing isn't changed every day like it should be because the nurses said they don't know how. Throughout the Recertification Survey (7/23/24 through 7/26/24 and 7/29/24 through 8/1/24) 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. For Resident #85, the facility failed to implement treatments and physician orders recommended by the consulting wound physician resulting in a new necrotic skin condition progressing to an unstageable wound leading to osteomyelitis (a bone infection) and sepsis (a life-threatening response to infection) requiring hospitalization and need for a fecal-diverting colostomy (a surgical procedure that creates an opening in the abdomen, called a stoma, that allows digested food to pass out of the body through an external pouch system). Resident #85 was admitted to the facility in March 2023 with diagnoses including Alzheimer's Disease, cerebral infarction, diabetes, hemiplegia (muscle weakness or paralysis on one side of the body that can affect arms, legs, and facial muscles), and dysphagia (difficulty swallowing). Review of the Minimum Data Set (MDS) assessment, dated 2/27/24, indicated that Resident #85 scored a 5 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident had severe cognitive impairment. Further review of the MDS indicated that Resident #85 did not have any pressure ulcers but was at risk for developing pressure ulcers. Review of Resident #85's Skin Only Evaluation, dated 3/11/24, indicated Resident #85 had a new necrotic (the death of body tissue or an organ due to a lack of blood supply) wound on the left buttock, medial area, and that the wound did not have an odor. Review of Resident #85's initial Wound Evaluation and Management Summary, dated 3/12/24, indicated the Wound Physician evaluated the Resident for a rash. The Wound Physician diagnosed Resident #85 with diaper dermatitis and recommended lotrisone cream (an anti-fungal cream) to be applied twice daily to the affected area and prn (as needed). Review of Resident #85's Treatment Administration Records failed to indicate that the lotrisone cream was implemented. During an interview on 7/29/24 at 10:03 A.M., Nurse #17 said that when changes in skin are identified they should be reported to the NP (Nurse Practitioner)/MD (medical doctor). Nurse #17 said she had not reported the wound to the physician because the wound did not need the physicians' attention because of how small it was. Nurse #17 said aides had been using house barrier cream to Resident #85 buttocks region, which was not a new treatment for the newly identified wound in March. During an interview on 7/30/24 at 11:13 A.M., The Wound Physician said she was initially consulted on 3/12/24 to evaluate a rash on Resident #85's frontal groin area, and nothing else; as the rash was on the front she may not have evaluated the backside and she was not aware of a necrotic wound when she evaluated the rash. The Wound Physician said this may have been a result of bad communication. Review of Resident #85's entire medical record indicated a wound treatment was not ordered until 3/23/24, 12 days after Nurse #17 had initially identified the necrotic wound. Following this initial failure to notify the physician of the change in condition (the new necrotic skin condition), failure to implement wound care recommendations for a skin condition, failure to notify the physician of the wound care recommendations, and failure to transcribe the physician's orders related to wound care, there continued to be repeated failures, including, but not limited to: - On 3/26/24, the Wound Physician recommended alginate calcium (a gel that promotes wound healing), or santyl (an ointment used to promote the healing of skin ulcers by removing damaged tissue) for Resident #85's unstageable sacral ulcer, which was first identified by nursing on 3/11/24. The physician's orders for alginate calcium and santyl were never implemented before Resident #85 was emergently hospitalized on [DATE]. Review of Resident #85's hospital discharge summary indicated he/she was admitted with a diagnosis of sepsis with the presumed source of the infected sacral ulcer. During this hospitalization, the status of the sacral ulcer, with osteomyelitis, necessitated the creation of a fecal-diverting colostomy. - On 3/26/24, the Wound Physician recommended a house supplement (a calorically and nutritionally fortified drink typically utilized to address weight loss and/or meet assist in meeting nutrient, such as protein, needs). This house supplement was never implemented. - On 4/23/24, the Wound Physician recommended a negative pressure wound therapy (NPWT) to be applied and to be changed three times per week for 30 days at 125 mmHg (millimeter of mercury, a manometric unit of pressure) continuously, the nurses failed to transcribe the order for the correct frequency. As a result, this NPWT was never changed at the correctly ordered frequency. - On 4/23/24, the Wound Physician recommended a foley catheter (a medical device that helps drain urine from the bladder) as urine will cause wound vac to lose suction. A foley catheter was not implemented until 7/11/24, 80 days after the Wound Physician initially recommended the placement of a foley catheter, when Resident #85 was admitted to the hospital for severe sepsis secondary to a sacral wound infection. During an interview on 7/31/24 at 3:58 P.M., Nurse #17 said she was the nurse who first identified Resident #85's new necrotic area. Nurse #17 said she never had any wound competencies completed at the facility since she was hired on 9/29/22. The surveyor reviewed Nurse #17's education file which failed to indicate any evidence of the required competencies for skin prevention/wound program, treatment administration, transcribing order, change in condition, or communication. During an interview on 7/31/24 at 7:39 A.M., Nurse #2 said she never had any wound competencies completed at the facility since she was hired on 3/8/24. Nurse #2 said she never had any competencies completed since she was hired, including topics such as treatment administration, transcribing orders, skin prevention/wound program, change in condition, or communication. On 7/29/24 1:51 P.M., the surveyor observed Nurse #14 provide wound care on a different resident, during which infection control concerns were noted with failing to perform hand hygiene. Nurse #14 said she had never had any wound competencies completed at the facility since she was hired on 9/6/23. Nurse #14 said she never had any competencies completed since she was hired, including topics such as treatment administration, transcribing orders, skin prevention/wound program, change in condition, or communication. During an interview on 7/31/24 at 9:16 A.M., Physician #2 said he expected that nurses providing wound care would have training completed specific for wound care. During an interview on 8/1/24 at 11:31 A.M., CNA #8 said she had never had any skin prevention competencies completed at the facility since she was hired on 6/27/22. The surveyor requested staff education files with all competencies for 5 Certified Nurse Assistants (CNA) and 12 Licensed Nurses on 7/30/24 at 9:07 A.M., 7/30/24 at 12:20 P.M., 7/31/24 at 8:07 A.M., 7/31/24 at 12:32 P.M., and 8/1/24 at 7:47 A.M. Review of 12 Licensed Nurses education files indicated the following competencies completed as applicable on hire, annually, or as needed: - 0 out of 12 Licensed Nurses had competencies completed for skin prevention/wound program - 0 out of 12 Licensed Nurses had competencies completed for transcribing orders. - 0 out of 12 Licensed Nurses had competencies completed for treatment administration - 0 out of 12 Licensed Nurses had competencies completed for colostomy care. - 0 out of 12 Licensed Nurses had competencies completed for change in condition. - 0 out of 12 Licensed Nurses had competencies completed for communication. Review of 5 Certified Nurse Assistant (CNA) education files indicated the following competencies completed as applicable on hire, annually, or as needed: - 0 out of 5 CNA's had competencies completed for preventative skin care. 2.) Throughout the Recertification Survey (7/23/24 through 7/26/24 and 7/29/24 through 8/1/24) the surveyors identified concerns across multiple care areas including but not limited to: - Medication administration - IV (intravenous) administration - Documentation - CPAP (continuous positive airway pressure) - Restraints - Weights - Psychotropic medication consents - Resident Rights - Advanced Directives Review of the Facility Assessment Tool, dated 5/24/24, indicated the following competencies should be completed for licensed nurses on hire and PRN: - CPAP/BIPAP (bilevel positive airway pressure) - Side rails/restraint policy and procedure - Weights - Nutritional Program - Psychotropic medication consents - IV Therapy - programming pump, peripheral, central lines - DNR (do not resuscitate) Order - Consents, DNR, Advanced Directives, Psychotropic medication Review of the Facility Assessment Tool, dated 5/24/24, indicated the following competencies should be completed for licensed nurses annually: - Medication administration - IV administration - Documentation Review of the Facility Assessment Tool, dated 5/24/24, indicated the following competencies should be completed for CNA's on hire and annually: - Preventative Skin Care - Weights - Resident Rights - Restraint and Ambulation The surveyor requested staff education files with all competencies for 5 Certified Nurse Assistants (CNA) and 12 Licensed Nurses on 7/30/24 at 9:07 A.M., 7/30/24 at 12:20 P.M., 7/31/24 at 8:07 A.M., 7/31/24 at 12:32 P.M., and 8/1/24 at 7:47 A.M. Review of 12 Licensed Nurses education files indicated the following competencies completed as applicable on hire, annually, or as needed: - 0 out of 12 Licensed Nurses had competencies completed for CPAP/BIPAP. - 0 out of 12 Licensed Nurses had competencies completed for side rails/restraint policy and procedure. - 0 out of 12 Licensed Nurses had competencies completed for weights. - 0 out of 12 Licensed Nurses had competencies completed for Nutritional Program - 0 out of 12 Licensed Nurses had competencies completed for Psychotropic medication consents - 0 out of 12 Licensed Nurses had competencies completed for IV administration. - 0 out of 12 Licensed Nurses had competencies completed for IV Therapy - programming pump, peripheral, central lines - 0 out of 12 Licensed Nurses had competencies completed for DNR Order - 0 out of 12 Licensed Nurses had competencies completed for Consents, DNR, Advanced Directives, Psychotropic medication. - 0 out of 12 Licensed Nurses had competencies completed for Medication administration. - 0 out of 12 Licensed Nurses had competencies completed for documentation. Review of 5 Certified Nurse Assistant (CNA) education files indicated the following competencies completed as applicable on hire, annually, or as needed: - 0 out of 5 CNA's had competencies completed for weights. - 0 out of 5 CNA's had competencies completed for resident rights. - 0 out of 5 CNA's had competencies completed for restraint and ambulation. During an interview on 7/29/24 1:51 P.M., Nurse #14 said she never had any nursing competencies completed at the facility since she was hired. During an interview on 7/31/24 at 3:58 P.M., Nurse #17 said she never had any nursing competencies completed at the facility since she was hired. During an interview on 7/31/24 at 7:39 A.M., Nurse #2 said she never had any nursing competencies completed at the facility since she was hired. During an interview on 8/1/24 at 11:31 A.M., CNA #8 said she had never had CNA specific competencies completed since she was hired, including restraints or resident rights. During an interview on 8/1/24 at 1:01 P.M., Nurse #19 said she used to be the Staff Development Nurse a few months ago. Nurse #19 said nursing competencies were not being completed for nurses or CNA's. During an interview on 8/1/24 at 7:40 A.M., The Staff Development Nurse said nursing competencies haven't been completed in years. The Staff Development Nurse said she knew these should have been done, but they had not had the time or a consistent person in the position. During an interview on 7/31/24 at 11:10 A.M., the Director of Nursing (DON) and Assistant Director of Nursing (ADON) said nursing competencies such as medication administration, IV administration, and documentation, should have been completed based on the facility assessment for all nurses upon hire, annually and as needed to prove their competency for these skills before providing care to Residents in the facility. The DON and ADON said these competencies should be documented and readily available but were not. The DON and ADON said all nursing competencies were not being completed because they had trouble filling the staff development nurse position. The DON and ADON said they knew these should have been done, but they had not had the time or resources. The DON and ADON further said that the position had been vacant for a long time and then had multiple turnovers recently. Ref to F835

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** refer to F940 Based on observations and interviews the facility failed to ensure it was administered in a manner that enabled the facility to use its resources effectively to attain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically: 1.) The facility failed to provide nursing staff education and training to provide competent, safe, and effective wound care management. As a result the facility failed to notify the physician, implement treatments recommended by the consulting wound physician, assess the nutritional status and implement pertinent nutrition interventions for a Resident (#85) resulting in a new necrotic skin condition progressing to an unstageable wound leading to osteomyelitis (a bone infection), significant weight loss, and sepsis (a life-threatening response to infection) requiring hospitalization and need for a fecal-diverting colostomy (a surgical procedure that creates an opening in the abdomen, called a stoma, that allows digested food to pass out of the body through an external pouch system). 2.) The facility failed to allocate resources to meet the nutritional needs of residents in the absence of a Dietitian. Findings include: 1.) According to the Board of Registration in Nursing, 244 CMR 9.00: Standards of Conduct, a competency is defined as the application of knowledge and the use of affective, cognitive, and psychomotor skills required for the role of a nurse licensed by the Board and for the delivery of safe nursing care in accordance with accepted standards of practice. Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. Review of the Facility Assessment Tool, dated 5/24/24, included but was not limited to the following: - Commonly admitted diseases, conditions, physical and cognitive disabilities, or combinations of conditions that require complex medical care and management: Integumentary System: Skin Ulcers, Injuries, surgical wounds. Facility utilizes Wound Physicians: MD/NP, Nursing, Registered Dietician, regularly scheduled skin Assessments, Wound care supplies, Consultation with specialist as needed for wound management. - Services and Care we offer based on our Resident's Needs: Skin Integrity: Pressure injury prevention and care, skin care, wound care, (surgical, other skin wounds). - Staff training/education and competencies: Competencies by department. - Licensed Nurses Annual Competencies: Treatment Administration, Colostomy Care. - Licensed Nurses Competencies on hire and PRN: Transcribing order, Skin Prevention/Wound Program. - Certified Nurse Assistant (CNA) Annual Competencies: Preventative skin care. Resident #85 was admitted to the facility in March 2023 with diagnoses including Alzheimer's Disease, cerebral infarction, diabetes, hemiplegia (muscle weakness or paralysis on one side of the body that can affect arms, legs, and facial muscles), and dysphagia (difficulty swallowing). Review of the Minimum Data Set (MDS) assessment, dated 2/27/24, indicated that Resident #85 scored a 5 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident had severe cognitive impairment. Further review of the MDS indicated that Resident #85 did not have any pressure ulcers but was at risk for developing pressure ulcers. Review of Resident #85's Skin Only Evaluation, dated 3/11/24, indicated Resident #85 had a new necrotic (the death of body tissue or an organ due to a lack of blood supply) wound on the left buttock, medial area, and that the wound did not have an odor. Review of Resident #85's initial Wound Evaluation and Management Summary, dated 3/12/24, indicated the Wound Physician evaluated the Resident for a rash. The Wound Physician diagnosed Resident #85 with diaper dermatitis and recommended lotrisone cream (an anti-fungal cream) to be applied twice daily to the affected area and prn (as needed). Review of Resident #85's Treatment Administration Records failed to indicate that the lotrisone cream was implemented. During an interview on 7/29/24 at 10:03 A.M., Nurse #17 said that when changes in skin are identified they should be reported to the NP (Nurse Practitioner)/MD (medical doctor). Nurse #17 said that the Wound Physician will give recommendations to the staff member accompanying her during wound rounds every Tuesday. Nurse #17 said that a Certified Nursing Assistant had initially reported the wound to her, and that the Resident had a wound on the left buttock, medical area; Nurse #17 said she had not reported the wound to the physician because the wound did not need the physicians' attention because of how small it was. Nurse #17 said aides had been using house barrier cream to Resident #85 buttocks region, which was not a new treatment for the newly identified wound in March. During an interview on 7/30/24 at 11:13 A.M., The Wound Physician said she was initially consulted on 3/12/24 to evaluate a rash on Resident #85's frontal groin area, and nothing else; as the rash was on the front she may not have evaluated the backside and she was not aware of a necrotic wound when she evaluated the rash. The Wound Physician said this may have been a result of bad communication. Review of the communication book and Resident #85's progress notes failed to indicate that the physician was notified of the new necrotic skin condition identified on 3/11/24. Review of Resident #85's entire medical record indicated a wound treatment was not ordered until 3/23/24, 12 days after Nurse #17 had initially identified the necrotic wound. Following this initial failure to notify the physician of the change in condition (the new necrotic skin condition), failure to implement wound care recommendations for a skin condition, failure to notify the physician of the wound care recommendations, and failure to transcribe the physician's orders related to wound care, there continued to be repeated failures, including, but not limited to: - On 3/26/24, the Wound Physician recommended alginate calcium (a gel that promotes wound healing), and santyl (an ointment used to promote the healing of skin ulcers by removing damaged tissue) for Resident #85's unstageable sacral ulcer. The physician's orders for alginate calcium and santyl were never implemented before Resident #85 was emergently hospitalized on [DATE]. Review Resident #85's hospital paperwork, dated 4/22/24, indicated he/she was admitted with a diagnosis of sepsis with the presumed source the infected sacral ulcer. Resident #85 underwent wound debridement (a procedure that removes unhealthy or dead tissue from a wound to promote healing and prevent infection) on 3/29/24, 3/31/24, 4/5/24, and 4/21/24, and that fecal diversion was indicated to allow for the wound to heal due to the wound's proximity to the anus; and on 4/5/24 the Resident underwent a diverting loop sigmoid colostomy creation. The hospital paperwork indicated there was clinical and imaging evidence of osteomyelitis with the sacrum/coccyx bones exposed in the wound. - On 3/26/24, the Wound Physician recommended a house supplement (a calorically and nutritionally fortified drink typically utilized to address weight loss and/or meet assist in meeting nutrient, such as protein, needs). This house supplement continued to be documented in Wound Physician written recommendations on 4/23/24, 4/30/24, 5/14/24, 5/21/24, 6/4/24, and 7/23/24. This house supplement was never implemented. - On 4/23/24, the Wound Physician recommended negative pressure wound therapy (wound vac) to be applied and to be changed three times per week for 30 days at 125 mmHg (millimeter of mercury, a manometric unit of pressure) continuously, the nurses failed to transcribe the order for the correct frequency. The Wound Physician continued to document written recommendations to have the wound vac changed three times a week on 4/23/24, 4/30/34, and 5/14/24. As a result, the nurses only changed the wound vac two times a week (instead of three times a week) since it was initially applied on 4/23/24. This wound vac was never changed at the correctly ordered frequency. - On 4/23/24, the Wound Physician recommended a foley catheter (a medical device that helps drain urine from the bladder) as urine will cause wound vac to lose suction. A foley catheter was not implemented until 7/11/24, 80 days after the Wound Physician initially recommended the placement of a foley catheter. During an interview on 7/31/24 at 3:58 P.M., Nurse #17 said she was the nurse who first identified Resident #85's new necrotic area. Nurse #17 said she never had any wound competencies completed at the facility since she was hired on 9/29/22. The surveyor reviewed Nurse #17's education file which failed to indicate any evidence of the required competencies for skin prevention/wound program, treatment administration, transcribing orders, change in condition, or communication. During an interview on 7/31/24 at 7:39 A.M., Nurse #2 said she never had any wound competencies completed at the facility since she was hired on 3/8/24. Nurse #2 said she never had any competencies completed since she was hired, including topics such as treatment administration, transcribing orders, skin prevention/wound program, change in condition, or communication. The surveyor requested staff education files with all competencies for 5 Certified Nurse Assistants (CNA) and 12 Licensed Nurses on 7/30/24 at 9:07 A.M., 7/30/24 at 12:20 P.M., 7/31/24 at 8:07 A.M., 7/31/24 at 12:32 P.M., and 8/1/24 at 7:47 A.M. Review of 12 Licensed Nurses education files indicated the following competencies completed as applicable on hire, annually, or as needed: - 0 out of 12 Licensed Nurses had competencies completed for skin prevention/wound program - 0 out of 12 Licensed Nurses had competencies completed for transcribing orders. - 0 out of 12 Licensed Nurses had competencies completed for treatment administration - 0 out of 12 Licensed Nurses had competencies completed for colostomy care. - 0 out of 12 Licensed Nurses had competencies completed for change in condition. - 0 out of 12 Licensed Nurses had competencies completed for communication. Review of 5 Certified Nurse Assistant (CNA) education files indicated the following competencies completed as applicable on hire, annually, or as needed: - 0 out of 5 CNA's had competencies completed for preventative skin care. 2.) Further review of the Facility Assessment Tool indicated the facility required a dietitian for 24 hours a week and that a dietitian was a necessary resource in managing the following complex medical care: - Integumentary System (skin ulcers, injuries, surgical wounds) - Nutritional Disorder (failure to thrive)Neurological system - Neoplasm - Metabolic Disorders - Respiratory System - Genitourinary system - Diseases of Blood - Digestive System - Infectious Diseases - Covid-19 virus Review of the Dietitian job description indicated, but was not limited to, the following: Position summary: -Provides consultation concerning nutritional services to the Administrator of the facility and works in advisory capacity to the Food Service Director in accordance with current generally accepted professional practices. - Provides consultation to allied staff, consultants and physicians regarding diet, nutritional problems, and management, including patient visitation, nutritional assessment, patient nutritional care plans, and diet reviews. - Updates nutritional care plans on a timely basis. - Will review diets and nutritional status on residents' chart and make recommendation to the physician for changes as necessary. - Will visit each nurse's station weekly and check with the charge nurse and/or the dietary communication book for any comments and/or dietary concerns on that particular unit. Resident #85 was admitted to the facility in March 2023 with diagnoses including Alzheimer's Disease, cerebral infarction, diabetes, hemiplegia (muscle weakness or paralysis on one side of the body that can affect arms, legs, and facial muscles), and dysphagia (difficulty swallowing). Review of the Minimum Data Set (MDS) assessment, dated 2/27/24, indicated that Resident #85 scored a 5 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident had severe cognitive impairment. Further review of the MDS indicated that Resident #85 did not have any pressure ulcers but was at risk for developing pressure ulcers. Review of Resident #85's weight and vitals summary indicated the following weight readings: 3/7/23 - 199.3 lbs. 6/19/23 - 204 lbs. 11/14/23 - 203.4 lbs. 2/2/24 - 200.4 lbs. 3/7/24 - 200.8 lbs. 4/22/24 - 189 lbs. 5/14/24 - 185.4 lbs. 7/20/24 - 141 lbs. Review of the Certified Nursing Assistant (CNA) assignment sheet, dated 6/3/24, indicated Resident #85 weighed 181.2 lbs. Further review of Resident #85's recorded weights indicated that Resident #85 had lost 11.8 lbs. of body weight during hospitalization between 3/7/24 and 4/22/234, and then continued to lose weight. Review of the recorded weights indicated that Resident #85's weight loss reached clinical significance on 5/14/24, indicating the Resident had lost a total of 7.6% of his/her total body weight within 2 months. The weight recorded in the CNA assignment book confirms a trend of weight loss, and review of the weight records indicated the Resident had lost an additional 40 lbs. of body weight on 7/20/24, indicating an additional, clinical significant loss of 22.2% of his/her total body weight lost in a month, 25.4% of his/her total body weight lost in three months, or 29.2% of his/her total body weight lost in six months. Review of Resident #85's recorded weights failed to indicate that a reweight was obtained for the weight taken on 4/22/24 until 22 days later, for the weight taken on 5/14/24 until 20 days later, for the weight taken on 6/3/34 until 47 days later, and that a reweight was never obtained to confirm the weight reading on 7/20/24. Review of Resident #85's medical record indicated the Resident was hospitalized again on 5/9/24, 5/22/24, and 7/10/24 for wound-related reasons. Review of the hospital discharge paperwork, dated 5/9/24, indicated the Resident met criteria for severe calorie-protein malnutrition, required enteral nutrition via a nasogastric tube (a tube placed through the nose terminating directly in the stomach used to provide nutrition formula) during the hospitalization, and the hospital recommended to continue supplemental nutrition at the long-term care facility. Review of the hospital discharge paperwork, dated 7/10/24, indicated the Resident appeared cachectic and that the Resident had presented with severe sepsis secondary to his/her sacral wound requiring admission to the ICU (intensive care unit). Further review of Resident #85's medical record failed to indicate any nutritional evaluation or recommendations/orders were implemented for the Resident. Review of Resident #85's medical record indicated he/she was evaluated by the Registered Dietitian (RD) on 7/1/24, 112 days after the necrotic skin condition was first identified, and 48 days after Resident #85's weight loss reached clinical significance. Review of the RD's progress note, dated 7/1/24, indicated the Resident had lost weight and recommended Proheal (a liquid protein supplement) 30cc tid (three times a day) (providing 45 gm elemental protein), Vitamin C 500mg bid, Zinc 220mg x 30 days, and weekly weights. Review of the most recent Wound Evaluation and Management Summary, dated 7/23/24, indicated that Resident #85 had a stage IV pressure wound measuring 16 x 15.5 x 4.8 cm, and that the wound was not at goal; the Wound Physician recommended house supplements. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #85 scored a 2 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident had severe cognitive impairment. Further review of the MDS indicated that Resident #85 was at risk for developing pressure ulcers and that the Resident had an unhealed Stage IV pressure ulcer. On 7/30/24 at 8:01 A.M., the surveyor observed the Wound Physician and the Unit Supervisor performing wound care on Resident #85. The wound was larger in diameter than a cantaloupe with a bright red wound bed and some yellow-colored tissue. Review of Resident #85's medical record indicated that the Wound Physician recommended house supplements on 3/12/24, 3/19/24, 3/26/24, 4/23/24, 4/30/24, 5/14/24, 5/21/24, 5/28/24, 6/4/24, 6/11/24, 6/18/24, 6/25/24, 7/2/24, 7/9/24 and 7/23/24. Review of Resident #85's physician orders, dining manager change history report, and care plans failed to indicate that any nutrition interventions were ever initiated for Resident #85, including the house shakes recommended by the Wound Physician or the Proheal, Vitamin C, Zinc, and weekly weights recommended by the RD. During an interview on 7/25/24 at 1:17 P.M., the Registered Dietitian (RD) said that she had started in her role six weeks ago, and that the first two weeks were spent in orientation. The RD said that the last RD had left around last December, and that during the interim there had been nothing in place to compensate, and no consulting Dietitians. The RD said that the Food Service Director does not have the expertise to replace the Dietitian and had not been conducting nutrition assessments. The RD said that there have been some assessments that have not been done in the absence of a Dietitian, and that she would expect the facility to have employed a Dietitian. The RD said she had initially agreed to work 10 hours a week but would need more hours than that. During an interview on 7/25/24 at 11:32 A.M. the Food Service Director (FSD) said the previous Dietitian had resigned in January and that there were no consulting Dietitians during the interim. The FSD said he had not been completing nutrition assessments or reviewing weights. During an interview on 7/25/24 at 2:41 P.M. the Administrator said that the previous Dietitian had left in January of 2024, and that there had not been a qualified nutrition professional to cover during the interim. The Administrator said that the facility had not employed a Dietitian from 1/18/24 until 6/4/24. During a follow-up interview on 7/31/24 at 7:40 A.M. the Administrator said that Dietitian responsibilities would have been delegated by the Director of Nursing (DON), that the speech therapist would adjust diets, and that the medical director and Nurse Practitioner (NP) would be implementing nutrition interventions. During an interview on 7/31/24 at 2:59 P.M., the DON said that nothing had been delegated to her to compensate for the lack of a Dietitian. During an interview on 8/1/24 at 9:17 A.M., NP #1 said there was a time when the facility did not have a Dietitian, which was an issue. During a follow-up interview at 7/31/24 at 8:04 A.M., the Administrator said that he would rely on clinical staff to make him aware of a critical need for a Dietitian. During a follow-up interview on 8/1/24 at 9:17 A.M. NP #1 said that no additional responsibilities were delegated to her to compensate for the missing Dietitian. During an interview on 8/1/24 at 1:01 P.M., the Occupational Therapist (OT) said that she was not aware of any additional responsibilities delegated to the therapy department to compensate for the lack of a Dietitian. During an interview on 8/1/24 at 10:18 A.M., the Medical Director said that nothing had changed regarding his practice in the absence of a Dietitian, that typically he would defer to the Dietitian to meet the nutritional needs of residents but in the absence of a Dietitian would defer to weights for monitoring. During an interview on 8/12/24 at 10:05 A.M., the Speech Language Pathologist (SLP) said that she was aware that the facility did not have a Dietitian, but that no additional responsibilities were delegated to her to compensate for the lack of a dietitian. During an interview on 8/12/24 at 10:05 A.M., the Regional Director of Operations said that a contract has been in place for clinical consulting since January 1, 2024 but has not been utilized at the facility. She said that it could have been utilized if the Director of Nursing or Administrator brought concerns within the center forward to regional directors- they would have had the ability to bring a consultant in but no concerns were brought forward until this survey. She said she would have expected the facility administration and clinical leadership to recognize and bring forward concerns. Review of the consulting agreement, with an effective date of January 1, 2024 and an end date of December 31, 2026, indicated an agreement between the governing body and a consultant. Further review of the agreement indicated that the consultant duties included consulting services related to the clinical, operations, and regulatory matters related to the operation of the Facilities, as requested by the governing body.

Based on interview, record review and the Facility Assessment, the facility failed to ensure the Governing Body provided oversight and accountability for effective operational management and quality of care related to the clinical status of residents. Specifically: 1.) The governing body failed to ensure the facility provided consistent and effective nursing staff education and training to provide competent quality of care and effective wound care management, as per the Facility Assessment. 2.) The governing body failed to allocate resources and obtain a Dietitian for the facility, as per the Facility Assessment. Findings include: Review of the facility policy titled, Governing Body, dated as initiated 11/2017, indicated to ensure that the facility has an active (engaged and involved) governing body that is responsible for establishing and implementing policies regarding the management of the facility. Governing Body Members include: Regional VP (vice president) of Operations, Administrator, Assistant Administrator (if applicable), Director of Nursing, Assistant Director of Nursing (if applicable), Quality Assurance Nurse (if applicable). Administrator and/or designee will communicate day to day operation information to the Regional VP of Operations. Day to Day operation information may include survey results, abuse & neglect allegations, complaint surveys. Review of the facility policy titled, QAPI Plan, dated as reviewed 2/18/22, included but was not limited to the following: - (The Company) shall ensure that the Governing Body, Administration, Medical Director, Director of Nursing, clinical and non-clinical staff demonstrate a consistent endeavor to deliver safe, effective, optimal resident care and services in an environment of minimal risk. - This facility shall develop, implement, and maintain an effective, comprehensive, data-driven Performance Improvement Program that focuses on indicators of the outcomes of care and quality of life. - As resident care is a coordinated and collaborative effort, the approach to improving performance shall involve multiple departments and disciplines in establishing the plans, processes and mechanisms that comprise the performance improvement activities at this facility. Organization: - To achieve fulfillment of the objectives, goals and scope of the organizational Performance Improvement Plan, the organizational structure of the program shall be designed to facilitate an effective system of monitoring, assessment and evaluation of the care and services provided throughout the facility. - The Governing Body shall be responsible for the quality of resident care provided. - The Governing Body shall require quality assurance and performance improvement mandatory training that outlines and informs staff of the elements and goals of the facility's Performance Improvement Program. - The Governing Body shall set clear expectations around safety, quality, rights, choice, and respect. - The Governing Body shall require the Medical Director to implement and report on the activities and the mechanisms for monitoring, assessing, and evaluating resident safety practices and the quality of resident care, for identifying and resolving problems and for identifying opportunities to improve resident care and services or performance throughout the facility. This process addresses those departments/disciplines that have direct or indirect effect on resident care, including management, administrative functions, and contracted services. 1.) During an interview on 7/31/24 at 11:10 A.M., the Director of Nursing (DON) and Assistant Director of Nursing (ADON) said all nursing competencies were not being completed because they had trouble filling the Staff Development Nurse position. The DON and ADON said they knew these should have been done, but they had not had the time or resources. The DON and ADON further said that the position had been vacant for a long time and then had multiple turnovers recently. Review of the Facility Assessment Tool, dated 5/24/24, included but was not limited to the following: - Facility utilizes wound physicians: MD (medical doctor)/NP (nurse practitioner), nursing, registered dietician, regularly scheduled skin assessments, wound care supplies, consultation with specialist as needed for wound management. - Services and Care we Offer based on our Resident's Needs: Skin Integrity: Pressure injury prevention and care, skin care, wound care, (surgical, other skin wounds). - Staff training/education and competencies: - Licensed Nurses Competencies on hire and PRN (as needed): Skin Prevention/Wound Program, Transcribing order, Change in Condition, Communication, Treatment Administration, weights, and nutritional program. - Certified Nurse Assistant (CNA) Annual Competencies: Preventative skin care. During the survey the survey team identified 5 Residents (#85, #24, #88, #103, and #3) with concerns including the failure to implement wound care recommendations, notify the physician of wound care recommendations, and the failure to transcribe the physician's orders related to wound care. Review of 12 Licensed Nurse education files indicated the following competencies completed as applicable on hire, annually, or as needed: - 0 out of 12, Licensed Nurses had competencies completed for skin prevention/wound, competencies completed for transcribing orders, competencies completed for treatment administration, competencies completed for change in condition, competencies completed for communication, competencies for weights and the nutritional program. Review of 5 Certified Nurse Assistant (CNA) education files indicated the following competencies completed as applicable on hire, annually, or as needed: - 0 out of 5 CNAs had competencies completed for preventative skin care and weights. During an interview on 8/1/24 at 1:01 P.M., Nurse #19 said she used to be the Staff Development Nurse a few months ago. Nurse #19 said nursing competencies were not being completed for Nurses or CNA's. During an interview on 8/1/24 at 7:40 A.M., The Staff Development Nurse said she just started the position a week prior to the start of survey, and she said she had worked in the facility as the MDS Nurse prior. The Staff Development Nurse said nursing competencies haven't been completed in years. The Staff Development Nurse said she knew these should have been done, but they had not had the time or a consistent person in the position. Review of the Staff Development role indicated between January, 2024 to present, the facility had 6 different individuals covering the responsibilities. During an interview on 8/12/24 at 10:05 A.M., the Regional Director of Operations (Governing Body, representative), said that a contract has been in place for clinical consulting since January 1, 2024, but has not been utilized at the facility. During an interview on 8/20/24 at 12:19 P.M., the Director of Nursing (DON) said that she started in January of 2024 and that she had clinical support who called and hired her, and she said she never saw that person in the facility. The DON continued to say there was a new Regional Clinical Director who started back a few months ago but she has not been to the facility. The DON said that she has been without a stable Staff Development Nurse to complete competencies with facility staff and she could have used help. During an interview on 8/21/24 at 1:22 P.M., the Regional Clinical Director said that she provided clinical oversight to the Director of Nursing, and she was in the facility on 5/16/24, 5/20/24, 6/5/24, 6/12/24, 6/24/24, 6/26/24, and 7/3/24. The Regional Clinical Director said she would attend Medicare meetings and review reportable events. The Regional Clinical Director said she was aware of the facilities need for a Staff Development Nurse. Review of the consulting agreement, with an effective date of January 1, 2024, and an end date of December 31, 2026, indicated an agreement between the governing body and a consultant. Further review of the agreement indicated that the consultant duties included consulting services related to the clinical, operations, and regulatory matters related to the operation of the Facilities, as requested by the governing body. Review of the job description titled, Regional Director of Clinical Services, undated, included but not limited to the following: the Regional Director of Clinical Services (RDCS) will be responsible for assessment and evaluation of clinical services in an assigned geographic service region of the corporation. The RDCS will provide routine consultation services to the facilities in the assigned region. Consultation services include, but not limited to, the areas of resident care, state and federals surveys, regulator compliance, staffing and, MDS reimbursement or case management issues, and clinical services. The RDCS is responsible for driving clinical outcomes, mentoring staff, implementing corporate clinical services policies and procedures and ensuring compliance with state and federal laws, rules and regulations. The RDCS will occasionally be assigned to function as the interim Director of Nursing (DON) in a local facility in times of transition or on an as needed basis short term basis by the VP of Clinical Operations. Review of the job description failed to indicate scope and frequency of visits. 2.) Review of the Facility assessment, updated 5/24/24, indicated the facility required a dietitian for 24 hours a week. Further review of the facility assessment indicated that a dietitian was a necessary resource in managing the following complex medical including: - Integumentary System (skin ulcers, injuries, surgical wounds) - Nutritional Disorder (failure to thrive) Neurological system During the recertification survey there were seven Residents (#85, #68, #16, #24, #42, #50, and #35) identified by the survey team that the facility failed to ensure these Residents maintained acceptable parameters of nutritional status. During an interview on 7/25/24 at 2:41 P.M. the Administrator said that the previous Dietitian had left in January of 2024, and that there had not been a qualified nutrition professional to cover during the interim. The Administrator said that the facility had not employed a Dietitian from 1/18/24 until 6/4/24. During a follow-up interview on 7/31/24 at 8:04 A.M., the Director of Operations (Governing Body, representative) and the Administrator (Governing Body, representative) were present. The Administrator said that he would rely on clinical staff to make him aware of a critical need for a Dietitian, and that cycling Dietitians from other buildings would have to be something directed by the governing body. The Director of Operations said she had started in April and was aware that the facility did not have a Dietitian. The Director of Operations said that if there was ever a need, and things were dire, that they could cycle a Dietitian from another building owned by the company, but that she didn't feel there was a need. During an interview on 8/21/24 at 11:50 A.M., the Director of Operations said that there was a Director of Operations in the facility on the following dates 1/25/24, 2/12/24, 2/28/24. The Director of Operations said she was in the facility on 4/20/24, 5/17/24, 5/30/24, 6/20/24, 6/26/24, and on 7/8/24. Review of the job description titled, Director of Operations, undated, included but not limited to the following: the Regional Director of Operations is responsible for ensuring that the assigned region ensures a high level of quality care based on established nursing standards and resident rights while supporting and assisting with the implementation of facility policy and state regulations. Also includes formulating policies, monitoring budgets, overseeing programs and assessing patient satisfaction. They set and meet financial goals and strive to satisfy all federal and state laws and mandates.