**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, observation, and interview, the facility failed for one Resident (#88), out of a total sample of 19 residents, to provide care and implement pressure prevention interventions resulting in the development of facility acquired pressure ulcers (injuries to the skin and underlying tissue resulting from prolonged pressure exerted over areas of the body) on both the left and right buttocks and right heel of Resident #88. Findings include: Review of the facility's policy titled Skin Integrity Management, dated as revised on 3/16/22, indicated but was not limited to the following: - Based on assessment the facility will ensure that residents receive the necessary treatment and services consistent with professional standards of practice to prevent the occurrence of pressure ulcers - Refer to pressure ulcer prevention protocol Review of the facility's policy titled Pressure Ulcer Prevention Protocol, dated as revised December 2015, indicated but was not limited to the following: - Prevention interventions for residents at risk, as defined by risk assessment, [NAME] plus score of 15 or less - Turning and positioning program to include all residents in the facility will be turned in bed every two hours - Reposition residents in bed and chair every two hours - Use devices that float heels. For short term use with cooperative residents place pillows under the calves to raise the heels off the bed. Place heel suspension boot or use heels-up device for long term use. This should be done even if an alternating air mattress is in use. - Monitor and assist with hygiene - For incontinence individualized toileting or change schedule based on assessment - Encourage the use of toilets, commodes, bedpans and urinals to promote dry skin - Apply skin protectant after cleansing incontinence (the loss of bowel and bladder control) Resident #88 was re-admitted to the facility in September 2023 following a brief hospital stay with diagnoses including COVID-19, urinary tract infection, and hypertension (high blood pressure). The Brief Interview for Mental Status (BIMS) score was 7 out of 15 on the re-admission nursing assessment indicating severe cognitive impairment. The Resident's healthcare proxy was not activated, indicating the Resident was competent to make his/her own decisions. During an interview on 10/10/23 at 9:55 A.M., the Nurse Practitioner (NP) said she has not activated the Resident's healthcare proxy and Resident #88 is making their own decisions at this time. Review of the admission Nursing Assessment for Resident #88, following his/her brief hospitalization in September 2023, indicated but was not limited to the following: - Resident was incontinent of bowel and bladder and used disposable incontinence products - The skin was free of pressure ulcers and there were no identified open areas or areas of discoloration on the buttocks - The right heel had a red blanchable (indicates normal blood flow to the area) area that was 4 centimeters (cm) in length (L) by (x) 4cm in width (W) size and was not an area of pressure - The left heel had a red blanchable area that was 4cm L x 4cm W and was not an area of pressure - Resident #88 required assist for transfers, dressing, toileting and hygiene/bathing - Mobility limitations included the need for substantial/maximal assist to move from lying to sitting position in the bed and was dependent on others for transfers out of the bed or to stand - [NAME] plus score of 6 - with an indication to refer to pressure ulcer prevention protocol for care plan suggestions, and an indication that a score of 10 or less was high risk - Speech was clear and Resident readily answered questions and was oriented to person and place Review of the Minimum Data Set (MDS) assessment for Resident #88, dated 9/21/23, indicated but was not limited to the following: - Section GG (functional abilities): Roll left and right while lying on the back in bed and moving from a lying to sitting position in the bed: Moderate assistance required Sitting to lying, sitting to standing, chair to bed & bed to chair transfers: Maximal assistance required - Section H (bladder and bowel): No trial or toileting program to manage incontinence; always incontinent of bowel and bladder - Section M (skin conditions): Resident is at risk for developing pressure ulcers and does not have any pressure ulcers or injuries Skin treatments: pressure reducing surface for bed, turning and repositioning program, applications of ointments/medications other than to feet During an observation with interview on 10/5/23 at 11:03 A.M., Family Member #1 and Family Member #2 were at the bedside of Resident #88. The Resident was out of bed and sitting in a Broda chair (positioning wheelchair) with a gel cushion pad and mechanical lift sling underneath them. Both family members said they had concerns with the care of Resident #88 and said they did not feel he/she was being repositioned or gotten out of bed consistently, or being changed and cleansed following episodes of incontinence, and as a result developed new open areas on his/her skin. They said they had reported their concerns to the facility. Review of the medical record indicated Resident #88 developed two facility acquired Stage 2 pressure ulcers one on his/her left buttocks and another on the right buttocks first identified on 9/27/23 and a right heel deep tissue pressure injury first identified on 10/3/23. Review of the Certified Nurse Assistant (CNA) Care [NAME] (summary of resident's care and preferences), undated, indicated but was not limited to the following: - Bowel and bladder incontinent - Toileting, hygiene and bathing - Dependent for care with one assist - Bed mobility - Dependent for care with two assist - Transfers - Dependent for care with two assist and Hoyer (mechanical lift device) - Quarter size bilateral side rails, air mattress to bed setting two - Skin interventions: house protocol; bed cradle when in bed; off-load heels when in bed and encourage to keep off-loaded; gel cushion to Broda chair Review of the CNA Activities of Daily Living (ADL) documentation and positioning for Resident #88 indicated but was not limited to the following: September 2023: Resident bed mobility, transfers, toileting, hygiene and bathing documentation was incomplete (blank) on the following days: - 9/19/23, 9/23/23, 9/29/23, and 9/30/23. Review of September 2023 CNA positioning sheet for Resident #88: From 9/10/23 - 9/30/23 indicated 23 of the 63 shifts for positioning opportunities were either blank or documented as the Resident positioning being not applicable. Review of October 2023 CNA ADL sheets (reviewed on 10/10/23) indicated: Resident bed mobility, transfers, toileting, hygiene and bathing: documentation was incomplete (blank) on the following days: - 10/1/23: night shift, 10/3/23, 10/4/23, 10/5/23, 10/6/23, 10/7/23, 10/8/23, 10/9/23. Review of October 2023 CNA functional ability documentation (reviewed on 10/10/23) titled Roll right / roll left (this indicates positioning per the Director of Nurses) from 10/1/23 - 10/9/223 indicated 7 of the 27 shifts for positioning opportunities were either blank or documented as the Resident positioning was not attempted/not applicable. Review of the CNA documentation indicated the facility failed to ensure a consistent repositioning and turning schedule was in place as well as consistent incontinence care was being provided or any off-loading of the Resident's heels. Review of the current care plans for Resident #88 indicated but was not limited to the following: (9/5/23) Breakdown: Resident is at risk for skin breakdown related to five or more medications, diagnosis of hypertension (HTN), mobility and physical condition. Goal: Resident will be free of skin breakdown x 90 days through next review date Interventions (all dated 9/5/23): encourage activity and mobility; weekly skin check by licensed nurses; encourage repositioning every one to two hours or reposition resident every two hours in bed and every one hour in the chair; ensure resident/family participation by providing education on prevention and treatment while a resident at the facility as well as after discharge (9/28/23) Stage 2: pressure ulcers on the left (Lt) and right (Rt) buttocks related to decreased mobility; (10/3/23 revised) right heel deep tissue injury (DTI) Goals: Stage 2 pressure areas will show signs and symptoms of healing as evidenced by decrease in size and depth (9/28/23); Stage 2 pressure areas will be free of infection (9/28/23) DTI on Rt heel will resolve with current treatment by next review (10/3/23) Interventions: Minimize or eliminate contributing factors by low air loss mattress (9/28/23); pressure redistribution cushion to chair when out of bed (9/28/23); refer to at risk skin care plan (9/28/23) treatment to areas per physician orders (9/28/23) follow skin and wound care protocols (9/28/23) weekly documentation of wound site, treatment response and progression (9/28/23) incontinence plan - refer to incontinence care plan (9/28/23) treatment to Rt heel as ordered (10/3/23) bed cradle applied to bed (10/3/23) off-load heels and encourage resident to keep off-loaded (10/3/23) Further review of the care plans failed to identify a care plan for incontinence care and management or refusal/resistance to care. Throughout the survey the surveyor made the following observations of Resident #88: - 10/5/23 at 9:18 A.M., Resident in bed lying on their back on an air mattress, his/her heels were flat against the mattress and not off-loaded with pillows or any special devices. - 10/10/23 at 9:44 A.M., Resident in bed lying on his/her back on an air mattress, his/her heels were not elevated off the mattress with any pillows or an off-loading device. - 10/10/23 at 10:11 A.M., Resident lying in bed on his/her back on an air mattress, bilateral heels are flat against the mattress and no pillows or off-loading devices are observed in the area of the foot of the bed. - 10/10/23 at 10:27 A.M., Resident lying in bed on his/her back on an air mattress, bilateral heels are flat against the mattress and no pillows or off-loading devices are observed by the foot of the bed or in the vicinity. - 10/10/23 at 11:31 A.M., Resident lying in bed on his/her back on an air mattress, his/her heels were not elevated off the mattress with pillows or any off-loading devices. - 10/10/23 at 12:08 P.M., Resident in bed on his/her back with head of bed elevated to approximately 90 degrees, eating lunch, his/her heels are not elevated off the mattress with pillows or any off-loading devices. - 10/11/23 at 8:48 A.M., Resident is out of bed in Broda chair on a gel cushion with socks and shoes in place. During an interview on 10/10/23 at 9:44 A.M., Resident #88 said he/she feels that there are times the staff do not come in to help him/her and he/she has to wait a long time to be changed when he/she is wet or dirty. The Resident said he/she does not usually have a pillow under their legs, feet or heels but once in a while one is put there when he/she complains their legs hurt. The Resident said they lie on their back most of the time and no one tries to position him/her on their side unless they are washing or changing them. The Resident was observed to be on their back, without any off-loading devices or pillows under their legs to elevate their heels off the bed, and their heels were directly touching the mattress. The Resident was agreeable to the surveyor observing his/her buttocks wounds but did not wish for the surveyor to view his/her heels as they did not wish to remove their socks. Review of the initial skin record for Resident #88's Lt buttock wound, dated 9/28/23, indicated but was not limited to the following: - Left buttock stage 2 (partial thickness skin loss wound with exposed underlying tissue) pressure ulcer, not present on admission, first identified on 9/27/23 - wound assessment: 2cm L x 1cm W x 0.1cm depth (D) with a scant (minimal) serous (thin clear to yellow fluid) drainage, and the surrounding skin normal in color Review of the weekly assessment for Resident #88 Lt buttock wound, dated 10/6/23, indicated but was not limited to the following: - Lt buttock wound had not resolved - wound assessment: 2.5cm L x 7cm W x 0.1cm D with no drainage and bright red surrounding skin - wound progress was documented as unchanged Review of the initial skin record for Resident #88's Rt buttock wound, dated 9/28/23, indicated but was not limited to the following: - Right buttock stage 2 pressure ulcer, not present on admission, first identified on 9/27/23 - wound assessment: 0.8cm L x 0.8cm W x 0.1cm D with a small amount of serous drainage, and the surrounding skin normal in color Review of the weekly assessment for Resident #88's Rt buttock wound, dated 10/6/23, indicated but was not limited to the following: - Rt buttock wound had not resolved - wound assessment: 0.7cm L x 0.7cm W x 0.7 with a small amount of serous drainage and pink surrounding skin - wound progress was documented as improved Review of the initial skin record for Resident #88's Rt heel, dated 10/6/23, indicated but was not limited to the following: - Rt heel DTI (a local area of purple or dark maroon intact skin or blood-filled blister due to damage of underlying soft tissue from pressure or sheering) pressure wound, not present on admission, first identified on 10/3/23 - wound assessment: 1.2 cm L x 1cm W - no depth and no drainage with pink surrounding skin During an interview on 10/10/23 at 10:23 A.M., Nurse #1 said she completed the 10/6/23 weekly assessment on Resident #88's Lt and Rt buttock wounds. She reviewed the information and said she should have documented the wound as deteriorated, as the Lt buttock pressure ulcer had grown in size from 1cm W to 7cm W and the Rt buttock pressure wound had an increased depth from 0.1cm to 0.7cm. She said prior to the development of both the Lt and Rt stage 2 pressure ulcers to the Resident's buttocks the intervention in place was turning and repositioning, but the areas had developed despite the CNAs repositioning the Resident. She said since the wounds were discovered the staff were applying Triad cream (a thick white cream used to coat and protect open areas of skin from incontinence) to the buttocks wounds as a treatment. She said for the Resident's heels the nurses were applying skin prep and the CNAs were supposed to be off-loading the Resident's heels with pillows, but the information on off-loading the heels does not get documented anywhere. She said the nurses are currently treating the heels with skin prep and that is documented on the treatment administration record (TAR). On 10/10/23 at 10:27 A.M., the surveyor entered the Resident's room with Nurse #1 and Nurse #2 to view the Resident's bilateral buttocks wounds. The Resident was rolled to his/her right side by the two staff members. The buttocks appeared to have dark red/purple discoloration on both the right and left upper buttocks, but the open areas could not be visualized well related to a thick layer of white cream over the area. The staff replaced the Resident's brief and straightened the draw sheet underneath the Resident and left the Resident lying on his/her back. The Resident was not observed to have any pillows under his/her legs, heels, or feet during this time and no off-loading device was in place for the heels. The two staff nurses were not observed to correct the situation or off-load the Resident's heels prior to leaving the room and did not ask the Resident if they declined having pillows placed under his/her legs to off-load the heels. Review of the TAR and treatment orders for Resident #88 from 9/15/23 through 10/10/23 indicated but was not limited to the following: - Air mattress every shift; Resident on low air loss mattress set at 2, check settings every shift (initiated: 9/28/23) - Site: bilateral heels, red and blanchable day and evening shift apply skin prep to heels (discontinued: 10/6/23) - Right heel DTI treatment day and evening apply skin prep to heels (initiated: 10/6/23) - Apply triad cream to coccyx with incontinence care every shift (initiated: 9/28/23) During an interview on 10/10/23 at 11:48 A.M., CNA #1 said she is familiar with Resident #88's care. She said the Resident is incontinent and requires full assistance with care. She said the Resident is now on an air mattress and has some skin issues and is to be repositioned every two hours. She said she does not know why the Resident's heels are not off-loaded on pillows today but she did not provide his/her care today. She said the Resident or his/her family will notify the staff if they need anything and the Resident does not have any behaviors but does prefer to stay in bed most days. During an interview on 10/10/23 at 12:17 P.M., CNA #2 said he is familiar with the Resident's care and provided care to the Resident today (10/10/23). He said the Resident can be uncomfortable at times and that is when he/she is repositioned. He said the Resident did not want to get out of bed today so he would reapproach the Resident after lunch. He said the Resident should have pillows under his/her feet for off-loading but he did not do that today. He said he has not repositioned the Resident yet today, but he will do that and use pillows to do so after the Resident has his/her lunch. He said the Resident is incontinent and wears a brief and he checks to see if incontinence care is necessary about two or three times a shift or if the Resident or family requests it. He said they are using a thick cream on the Resident's buttocks because there are some skin areas. During an interview on 10/10/23 at 2:56 P.M., Family Member #4 said she was visiting the Resident on 10/2/23 and was unhappy with the lack of care the Resident received on this day. She said the Resident was not approached by any staff during her visit that lasted over six hours and no repositioning, incontinence care or checks were completed on the Resident. She said she placed a complaint on that day because she was aware that the Resident had already developed skin issues at the facility and felt the lack of care she witnessed was likely a contributing factor. During an interview on 10/11/23 at 8:52 A.M., CNA #2 reviewed the CNA documentation for Resident #88 for September and October with the surveyor and said the Resident should have been repositioned every two hours. CNA #2 said that documentation would be made on paper for the month of September and could not explain the missing documentation on the positioning sheet or why it would be marked does not apply since the Resident requires assistance with bed mobility. During an interview on 10/11/23 at 8:58 A.M., CNA #1 said in September of 2023 they documented repositioning on paper every two hours but starting on 10/1/23 they started a new system that simply asks them if they provided repositioning. She said all residents should be repositioned and checked for incontinence about every two hours. She said the CNAs are supposed to document all care provided to their assigned residents every day to prove it was completed. She could not explain why Resident #88 had so many episodes of missing documentation. She said there is nowhere in the CNA documentation that the CNAs can document that they off-loaded the Resident's heels or that they applied any creams; that would likely be in the nurses' paperwork. During an interview on 10/11/23 at 9:14 A.M., Nurse #2 reviewed the medical record of Resident #88. He said when the Resident returned from the hospital the risk for skin breakdown care plan should have been updated since the skin risk Norton Score had changed and the Resident had moved from what he would consider moderate risk to high risk. He said upon reviewing the care plan that there were no interventions in place to prevent the breakdown of the Resident's buttocks or heels except for repositioning. He reviewed the Resident ADL documentation and repositioning sheets for both September and October of 2023 and said that if the documentation was not complete you would have to go by if it's not documented, it's not done. He said having the Residents' repositioning be coded as not applicable or does not apply does not make any sense since the Resident requires assistance with all ADLs and repositioning. He said it does not appear that there was any documentation available to support the premise that prevention for pressure ulcers was in place for this Resident prior to the areas developing on his/her left and right buttocks and right heel. He said the Resident did not have a care plan for incontinence to show any interventions on managing incontinence or any evidence of a care plan that indicated the Resident would be resistive to care. Review of the facility incident report and investigation packet for Resident #88's Lt and Rt buttocks stage 2 pressure ulcers, indicated but was not limited to the following: - Areas were identified on 9/27/23 - [NAME] plus skin risk assessment score = 12, indicating moderate risk (completed on 9/28/23) - Clinical risk factors: immobility; no lab values available for review or evidence Resident has refused preventative measures during the past month - Facility interventions: preventative skin care, consistent turning and repositioning, pressure reduction support surfaces, weekly skin checks, incontinence management program; preventative measures on care plan, preventative measures on CNA care plan - Summary: all preventative measures were not in place, but investigation reveals the area is unavoidable related to: Resident recovering from COVID-19 and very fatigued with limited mobility. Further review of the investigation packet indicated: Page two of the investigation and witness statements were blank and incomplete. During an interview on 10/11/23 at 10:05 A.M., the Director of Nurses (DON) said that the Resident's care plan for skin breakdown prevention should have been updated when he/she returned from their hospitalization and their Norton risk score had changed, making them high risk. She said repositioning should have been appropriate for the Resident but upon reviewing the repositioning sheets said the documentation was not completed as it should have been and it appeared the Resident was not repositioned as he/she should have been to prevent the development of pressure areas. On review of the provided incident report for the pressure areas on the Resident's left and right buttock, she could not explain why the investigation concluded all preventative measures were not in place but the areas were unavoidable. She said she did not complete the investigation and would check with the Nurse consultant. An incident report for the right heel DTI was requested by the survey team. During an interview on 10/11/23 at 10:14 A.M., the Nurse Consultant said she felt the facility was doing a good job and must have checked off that all prevention was not in place in error, as she believed all preventative measures were in place. She reviewed the repositioning documentation and lack of evidence that repositioning occurred for Resident #88 on numerous days prior to the development of the areas and following. She said she did not review the documentation when she completed the investigation and asked the staff if the Resident was being repositioned and they confirmed that he/she was. During an interview on 10/12/23 at 8:07 A.M., the NP said although Resident #88 is not in good health that with prevention in place the pressure areas on Resident #88's right and left buttocks and right heel should not have developed. She said although there are times the Resident declines to get out of bed, the Resident shouldn't have developed pressure areas if he/she was consistently repositioned or had consistent preventative measures in place. During an interview on 10/12/23 at 9:31 A.M., the DON said the incident report and investigation for the Rt heel DTI for Resident #88 had not yet been completed and was not available. She said there was minimal documentation she could find to show any prevention was in place for the Resident prior to the pressure areas developing on 9/27/23 to the buttocks and 10/3/23 to the right heel. She said there is no documentation that the Resident's heels were being off-loaded or that repositioning was occurring consistently. She said it appears the facility did not consistently implement pressure prevention measures consistently for Resident #88 and the protocols were not in place as they should have been resulting in the Resident developing pressure areas that he/she should not have developed.

Based on record review and staff interview, the facility failed to ensure that for two Residents (#16, #45), from a total sample of 31 residents, that staff provided care and treatment in accordance with Professional Standards of Practice, resulting in: Residents #16 and #45 being transferred to the hospital for assessment and treatment of infected wounds with maggots in them. Findings include: The Practice Principles, Wound Care Essentials, copyright 2020, indicates that: * wound assessment-an appraisal of a patient's condition based on clinical signs and symptoms, laboratory data, and medical history-is an integral part of wound management. *wound documentation essentials .documentation is an essential component of wound assessment. Every wound assessment should be documented thoroughly, accurately, and legibly, with an accompanying signature as well as the date and time of the assessment. Wounds should be documented on the patient's admission, weekly, with each dressing change, upon any significant change in the wound, and upon discharge. 1) For Residents #16 and #45, the facility staff failed to ensure that: -the Residents' skin was thoroughly assessed and monitored and the Residents' skin status was documented. -treatments were provided according to the physician's orders, resulting in the hospitalization of both Residents for infected wounds with maggots in them. A. Review of Resident #16's Minimum Data Set assessment, dated 1/6/21, indicated that Resident #16 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15 out of 15, and required assistance of staff for all activities of daily living. During an interview on 4/6/21 at 10:00 A.M., Resident #16 said that at the end of last summer, he/she developed a wound area on his/her foot that was very painful. The Resident said that he/she saw that large maggots were on his/her foot, and told the former Unit Manager. Resident #16 said that when the Unit Manager came to look at his/her foot and saw the maggots, the Unit Manager tried to cover it up so no one else would see it. Resident #16 said that a few maggots fell on the floor. The Resident said that the pain was so bad they sent him/her out to the hospital, and he/she was diagnosed with sepsis ( a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock,and death). Resident #16 said that while in the emergency room, they soaked his/her feet in Betadine (a topical antiseptic that provides infection protection against a variety of germs) to kill the maggots. Review of nursing progress notes indicated that on 6/2/20, the Resident complained of right lower extremity burning pain. The Resident was assessed by the nurse and was found to have +3 pitting edema (after pressing on a swollen area your body has an indentation or dimple that takes 30 seconds to go away), with a small amount of purulent (having a milky look and texture) discharge oozing off the skin. The physician was notified, and the Resident was started on the antibiotic Doxycycline 100 milligrams (mg), twice a day for 10 days. Review of the interdisciplinary care plan for cellulitis (serious bacterial infection of the skin), developed on 6/2/20, indicated that Resident #16 had a bacterial infection involving the dermis (inner layer of the two main layers of the skin) and subcutaneous tissue (layer of tissue that underlies the skin). Interventions included: -notify physician if the temperature was 100 degrees or greater regardless of other symptoms -administer antibiotics as ordered -monitor symptoms such as pain, tenderness, swelling, warmth, redness spreading to surrounding tissues -notify physician of new or worsening symptoms The care plan failed to identify the specific location of Resident #16's infection. Further review of the medical record failed to indicate that weekly skin assessments were being conducted and documented as per the facility's policy and standards of practice. Review of a nursing progress note, dated 7/5/20, indicated that Resident #16 was readmitted to the facility following a brief hospitalization for cellulitis and sepsis on 7/4/20. The note indicated that the Resident's right leg was edematous (fluid filled), inflamed, and aggressively red with an open area on the right lower leg. The medical record failed to indicate that a wound assessment was conducted and documented weekly thereafter. Review of Resident #16's July 2020 nursing progress notes indicated: -7/6/20 Cellulitis on right leg continues to be aggressively red, edematous. -7/12/20 Right leg reddened, small opening with Optifoam in place (there was no physician's order in place for treatment of the open area with Optifoam). -7/14/20 Small amount of serous drainage noted on old dressing. There was no other information in the medical record that addressed Resident #16's skin integrity during July 2020. Review of wound management documentation and At Risk documentation, failed to indicate that Resident #16's open area on his/her right leg was identified, assessed, or was monitored. Review of a nursing progress note, dated 8/1/20, indicated that the nurse was asked to see Resident #16 for a complaint of leg pain. On assessment, both lower extremities were noted to be dark red, +3 swelling, right more so than left. The right leg was draining black and thick exudate (mass of cells and fluid that has seeped out of blood vessels, especially in inflammation). Toes with +4 swelling, weeping clear fluid. Left leg with copious amounts of clear fluid draining. The Nurse Practitioner was updated, and gave an order for Resident #16 to be sent to the emergency room for evaluation. Review of hospital documentation indicated that Resident #16 presented to the hospital emergency room on 8/1/20 with bilateral leg swelling and erythema (superficial reddening of the skin, usually in patches, as a result of injury or irritation causing dilatation of the blood capillaries). The Resident was found to have maggots between his/her toes (right second, third, and fourth toes, and between left fourth and fifth toes). The Resident was admitted and treated with intravenous antibiotics, Zosyn and Vancomycin, and was discharged back to the facility on 8/5/20. During an interview on 4/12/21 at 10:00 A.M., Unit Manager #1 reviewed Resident #16's medical record and was unable to find orders for treatment to the Resident's legs in July 2020 (as documented in nursing progress notes), unable to find skin assessments or weekly documentation of skin issues prior to the Resident's return from the hospital on 8/5/20, and confirmed that the interdisciplinary care plan had not been updated to reflect the open area on the Resident's leg. B. Review of Resident #45's Minimum Data Set (MDS) assessment, dated 2/17/21, indicated that Resident #45 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15, required extensive assistance of two or more staff for activities of daily living, and had functional limitations in range of motion in both lower extremities. Review of nursing progress notes, dated 7/22/20, indicated that Resident #45 complained of right dorsal (area of the foot facing upward while standing) foot burning pain, with +2 edema (after pressing on an area which leaves a pit, it takes fewer than 15 seconds to go away) with a small amount of drainage. The physician was notified, and ordered the antibiotic Keflex 500 milligrams (mg) 4 times daily for 10 days, and the diuretic Lasix 20 mg daily for 3 days for the treatment of cellulitis. Review of the interdisciplinary care plans failed to indicate that the care plan for skin risk had been updated to reflect the Resident's new skin infection, and treatment. Further review of the medical record failed to indicate that weekly skin assessments were being conducted and documented as per the facility's policy, and that the change to the Resident's skin integrity, that was identified on 7/22/20, had been thoroughly assessed and documented. A thorough assessment would include, but not limited to, location of the wound, exudate (drainage)-amount, color, odor- surrounding tissue, shape of wound, sepsis, maceration (occurs when is in contact with moisture too long). Review of July 2020 physician's orders indicated that Resident #45 was to have a Unna-Z stretch zinc paste bandage applied to bilateral lower extremities at 6:00 A.M., every 3 days (initiated 12/2/19). Review of the July 2020 Treatment Administration Records (TAR) and accompanying treatment notes indicated that the treatment was provided on 2 out of 11 occasions as indicated by staff's initials in the box corresponding to the date and time of the treatment: -7/2/20: staff initials -7/5/20: H (treatment held due to sleeping) -7/8/20: staff initials -7/11/20: M (no notation) -7/14/20: M (no notation) -7/17/20: M (no notation) -7/20/20: M (held due to not documented on previous shift) -7/23/20: M (held due to legs left open to air) -7/26/20: M (held due to sleeping) -7/29/20: M (no notation) During an interview on 4/9/21 at 10:33 A.M., the Director of Nursing said that the letter H documented on the TAR indicated that the treatment was held, and that she did not know what the letter M indicated. During an interview on 4/13/21 at 10:55 A.M., Nurse #4 and Unit Manager #1 confirmed that the letter H documented on the TAR indicated that the treatment was held. They did not know what the letter M indicated, and said that it may indicate missed. Review of two nursing progress notes, dated 8/1/20, indicated that Resident #45 complained of left foot pain, and was assessed by the nurse. The nurse documented that the Resident's left foot was noted to have a grapefruit sized abscess (tender mass filled with pus) on the dorsal aspect of the foot that was draining thick, purulent exudate. The abscess was described as dark red and hot to the touch. The Nurse Practitioner was updated, and ordered the Resident to be sent to the hospital for evaluation. Review of hospital documentation indicated that Resident #45 was evaluated in the emergency room on 8/1/20. emergency room triage notes indicated that the facility called the emergency department to report that Resident #45 had a large wound on the dorsal aspect of the left foot that they think is full of maggots. Upon evaluation, the Resident was found to have extensive infection to the left foot with + 4 edema, evidence of wet gangrene (death of body tissue due to lack of blood flow), and maggots were in the wound. The wound was debrided (removal of damaged tissue and foreign objects) and the maggots were removed from the wound. Resident #45 was admitted to the hospital and treated with intravenous Vancomycin (antibiotic). The Resident was discharged back to the facility on 8/3/20. During an interview on 4/9/21 at 9:31 A.M., Nurse #5 said that on 8/1/20, that she went into Resident #45's room to remove the wrapping on the Resident's feet. She said she immediately noted that the wrappings on the Resident's feet, were saturated so much that the socks and shoes got wet as well. The Resident had an orange sized area on top of the foot that was grayish white in color, raisin like in texture, and had a candida smell (yeast). Nurse #5 said that she did not know how long the wrappings had been on the Resident's foot. Nurse #5 said that she saw maggots in-between the Resident's toes and crawling all over his/her foot. Nurse #5 said that she did not document her observations of the maggots in the medical record. During interviews on 4/9/21 at 10:33 A.M. and 4/14/21 at 1:30 P.M., the Director of Nursing (DON) said that there was no process in place for documentation of skin assessments, weekly skin assessments were not being done and documented, skin rounds were not being done, care plans weren't being developed and updated, there was no follow up with physician's orders, and nursing staff were doing skin treatments without physician's orders. 2. For Resident #69, the facility failed to follow the physician's orders for a) medication administration of Depakote (used to treat manic phase of bipolar disorder) and Review of the Medication Administration Record (MAR) for the month of March 2021 indicated: -the facility staff transcribed to start Depakote 125 mg on 3/27/21 twice daily at 6:00 A.M. and 11:00 P.M. -The MAR indicated that the facility staff failed to administer two doses of Depakote (125 mg) that were due at 11:00 P.M. on 3/27/21 and 6:00 A.M. on 3/28/21 to Resident #69. -Resident #69 did not receive his/her first dose of Depakote until 11:00 P.M. on 3/28/21, when it should have been a standard order effective 3/27/21. Review of the facility's policy titled Medication Ordering and Receiving from Pharmacy, dated 11/1/03, indicated: The dispensing pharmacy is called if an emergency arises requiring immediate pharmacist consultation concerning appropriateness of therapy, drug information, etc. If the required information is unavailable from the dispensing pharmacy, the pharmacy will determine the appropriate method for obtaining it, including speaking with the facility's consultant pharmacist. Medications are not borrowed from other residents. The ordered medication is obtained either from the emergency box or from the provider pharmacy. The emergency supply is maintained in the Pyxis machines or medication room at the nursing station along with a list of supply contents; expiration dates are noted on the packaging of each individual drug. During an interview on 4/13/21 at 11:17 A.M., Nurse #3 said that the Resident was to receive the first dose of Depakote 125 mg at 11:00 P.M. Nurse #3 said, because the order was written after 09:00 A.M. and the Depakote was not available, the nurse changed the time. There was no verbal order to verify that the physician was made aware. Nurse #3 said it was held because it was not available. Nurse #3 said if the medication was not available they would check the Pyxis, and if it not in there, they would call the physician to inform him. Nurse #3 said medication should not be held without communicating with the physician. During an interview on 4/13/21 at 12:30 P.M., the Director of Nursing Services (DNS) said she was not aware of the medication omission error.