**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation is or complaint # 2573833Based on observations, interviews, and record reviews, the facility failed to follow a transfer status and fall protocol for one resident (R303) of three residents reviewed for falls, resulting in R303 obtaining a serious injury.Findings include:A record review revealed that on 7/8/25 R303 fell from bed while being changed and sustained a head injury and required a higher level of care. According to the incident report R303 was being changed by one certified Nursing assistant (CNA) and rolled out of bed and hit their head. R302 care planned as a two person assist for actives of daily living (ADLs). On 8/5/25 at 10:40 AM, R303 was interviewed, and asked did they remembered how they fell from the bed. R303, report that they rolled out of bed and remembered hitting their head but that was it, R303 could not recall the staff that was around. A record review revealed that R303 was re-admitted to the facility on [DATE] with the medical diagnosis of Traumatic Subarachnoid Hemorrhage without loss of consciousness, contusion of eyeball and orbital tissues, left eye and fall. A further review of the record showed that R303 was a two person assist with ADLs.On 8/5/25 at 12:22 PM, the administrator was interviewed and asked about the fall for R303, and reported that it happened and the CNA who was involved was terminated for that reason, the CNA had been educated on proper transfer status of residents. The administrator was then asked about the facilities fall protocol, the Administrator reported that staff is supposed to follow the policy and complete all required documentation. The administrator was then asked for the incident and accident reports for R303 and R302, and agreed that required documentation was missing from the report. A review of the Employees file who was terminated revealed that the CNA had dropped three different residents and all were improper transfers. No additional information was provided by the exit of survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to prevent a facility acquired pressure ulcer for one (R59) out of four residents reviewed for pressure ulcers, resulting in the development of an unstageable pressure ulcer (full thickness skin and tissue loss with obscured wound bed) to the left heel and sepsis infection from tight fitting shoes. Findings include: On 12/2/24 at approximately 8:55 AM, R59 was observed lying in bed. The resident was alert but confused and not able to answer questions asked. The resident was not wearing shoes and had yellow skid socks on. A review of R59's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Dementia, type II diabetes and atrial fibrillation. A review of the resident Minimum Data Set (MDS) noted the resident had a Brief Interview for Mental Status (BIMS) score of 1/15 (severely cognitively impaired). Continued review of the MDS (7/5/24) noted the resident had no physical and/or verbal behaviors directed towards others. Continued review of R59's clinical record revealed, in part, the following: Care Plan: Focus: Risk for Pressure Ulcer Formation related to generalized debility and weakness as evidenced by decreased mobility in bed and wheelchair .Resident need staff assistance with incontinence care, turning and repositioning, Braden score <17 .10/4/23-no pressure ulcers noted .7/8/24 - no pressure ulcer noted .9/3/24: LEFT HEEL UNSTAGEABLE PRESSURE ULCER .Date initiated: 10/2/22 .Interventions: Encourage resident to float heels and/or wear heel boots (10/2/22) . Skin and Wound Evaluation (date 8/19/24- lock date: 8/29/24): .Describe: Type: Pressure .Stage: Unstageable (obscured full-thickness skin and tissue loss) .Location: Left medial calf .acquired: In house Acquired .Wound measurements .length 2.6 cm .width 1.0 cm .Notes on pain: Patient complained of pain during dressing change .Goal of care: Slow to heal .Education: Patient educated on the importance of not wearing shoes while in bed, or that they are too tight, as the wound was caused by her shoe . 8/17/24: Note Test: assisted cna (certified nursing assistant) with changing the patient and notice a swollen ankle and bleeding heel. Pt (patient) refused to let me examine further but did say she would allow an x-ray. The patient states it hurts, I can't stand, and the pain started yesterday. 8/19/24: Physician Team: R59 .has history of significant Alzheimer's dementia, atrial fibrillation .and diabetes mellitus .is seen today for left ankle pain and bleeding .she apparently keeps her shoes on while in bed and that is rubbing against her left Achilles area and left heel she started having a wound with intermittent bleeding and swelling of the left heel .she has refused to allow staff to dress her left heel and ankle .Impression and plan: Left ankle wound likely from her shoes that she refuses to remove while lying in bed, we will have patient seen by wound care services, she appears that she has secondary cellulitis she will be started on Augmentin (antibiotic) every 8 hours for 5 days, apply TAO (triple antibiotic ointment) and wrap with Kerlix and removed shoe when she is in bed keep he <sic>is floated while in bed 8/19/24: Nursing Skin/Wound Note: Late Entry: Wound care consulted for left ankle wound. Wound care able to remove shoes from residents' feet. Observed by wound care left ankle and top of foot is swollen, left Achilles has an area of eschar tender to touch. Area has some moisture damage from edema. Resident being treated for cellulitis. Will apply adaptic <sic> with dry dressing. Wound care to follow. No shoes. Supplied grip socks for resident to wear. Will encourage elevation of heels while in bed . 8/31/24: Wound Rounds: Patient (R59) .is being seen for the management of a wound that she has acquired on the left heel close to the Achilles. It is trauma induced, as she was wearing tight shoe and refusing to take it off .has history of advanced Alzheimer's type dementia The examination was focused on left foot . During the record review that included facility staff notes, care plans, Task/[NAME] interventions there were no documents as to the resident either wearing shoes in bed prior to 8/19/24, refusing to take off their shoes, or attempts to remove the resident's shoes while in bed. On 12/4/24 at approximately 9:30 AM, an interview was conducted with Wound Nurse Coordinator P and Nurse Q who reported they were working with Nurse P. Both were asked as to the protocol for preventing and treating wounds. Wound Nurse P reported that they do not work with residents until they receive a report of a concern with skin. When asked about R59, Nurse P reported that they received information about R59 on 8/19/24 and noted it was the first time they had seen the resident. When asked about the facility acquired wound on R59's heel, they noted that they believed the root cause was due to R59 refusing to remove their shoes that were too tight. However, they indicated again that they had never seen the resident for wound care prior to 8/19/24. On 12/4/24 at approximately 9:41AM, an interview was conducted with both the Director of Nursing (DON) and Former DON/Administrator in Training (AIT)A. Both were asked about R59's facility acquired unstageable wound to the left heel. AIT A reported that it was determined the wound stemmed from the resident's shoe and their refusal to have staff remove them while lying in bed. AIT A was asked to provide any documentation that attempts were made to remove the resident's shoe(s) and their refusal to have it removed. In addition, AIT A was asked to provide any interventions initiated regarding shoe removal. On 12/4/24 at approximately 10:01 AM, R59 was observed attempting to get out of their bed. The resident had yellow gripper socks on, was alert, non-combative, but confused as to where they were and where they wanted to go. Their call light was out of reach. CNA S was asked to come assist the resident who appeared confused. CNA S reported they had worked at the facility for over 10 years and was familiar with the resident. When asked if they were aware that R59 refused to have her shoes removed during care. CNA S noted that they did not recall that the resident refused. On 12/4/24 at approximately 11:16 AM, an interview was conducted with Medical Director (MD) U. MD U was asked about R59's facility acquired unstageable wound to the left heel and noted that he saw the resident right after the wound was found and noted that they remember removing the resident's shoe to view the wound. MD U was not certain as to interventions that were tried prior to discovering the wound. Prior to the end of the Survey, the facility provided documentation regarding R59's wound however, the documentation provided did not contain any evidence that attempts were made to remove the resident's shoes while in bed and/or documentation that the resident refused prior to 8/19/24. There was also no documentation as to whether the resident feet were floated and/or heel boots were provided as noted in the resident's care plan.( 10/2/22).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R59 On 12/2/24 at approximately 8:55 AM, R59 was observed lying in bed. The resident was alert but confused and not able to answer questions asked. On 12/4/24 at approximately 10:01 AM, R59 was observed attempting to get out of their bed. The resident had yellow gripper socks on, was alert, non-combative, but confused as to where they were and where they wanted to go. Their call light was out of reach. CAN S was asked to come assist the resident who appeared confused and was trying to get out of bed on their own. A review of R59's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Dementia, type II diabetes and atrial fibrillation. A review of the resident Minimum Data Set (MDS) noted the resident had a Brief Interview for Mental Status (BIMS) score of 1/15 (severely cognitively impaired). Continued review of R59's clinical record revealed, in part, the following: 5/28/24: Note Text: Resident observed on floor sitting on buttocks holding on to wheelchair . 10/8/24: Note: Resident found sitting on floor . 10/26/24: Note: Pt (Patient) usually stands up on her own to transfer, when attempting to transfer patient fell on the floor . 12/1/24: Note: resident in wheelchair asking for help with her bed, writer told the resident ok, head back to your room and I will assist you. When going to assist the resident, observed resident in room [ROOM NUMBER]P (not the resident's assigned room) trying to transfer herself to the bed when the resident lost balance and fell on her buttock . 12/2/24: IDT (interdisciplinary team): IDT team reviewed fall .Care plan was updated to reflect Staff was educated on the importance of taking the resident back to her room and assisting her into the bed . Review of R59's care plan revealed, in part, Focus: Resident is at Risk for Falls and Potential for Injury r/t (due to): Gait/balance problems; confusion with Dementia .use of psychoactive and/or narcotic medications(s) .date initiated 10/2/22 .Interventions/Task .fall intervention per facility protocol (10/2/22) .Staff is to do frequent rounding on resident (5/31/24) .staff was educated on the importance of taking the resident back to her room and assisting her into bed (12/2/24) . On 12/4/24 at approximately 2:00 PM an interview was conducted with AIT A. AIT A was queried as to the interventions put into place to prevent falls for R59 who had a history of falls and was noted as having severe dementia. AIT A reported that they were aware of the resident's inability to follow directions provided and reported that the last fall on 12/2/24 the Nurse was provided education as to assisting resident into their room for assistance into bed. A review of the facility policy titled, Fall Management Workflow (12.13.24) revealed, in part: .To provide a workflow for licensed nurses in conjunction with the Fall Management Guidelines Policy to assist with fall risk .The fall risk evaluation should be completed: upon admission .Quarterly .After a resident falls- to ensure there are no new or changed risk factors for the resident that need to be addressed .with a significant change of condition . R129 On 12/2/24 at 12:00 PM and 2:00 PM, R129 was observed seated in their wheelchair in the common area near the 100 unit. Dycem (a non-slip, rubber-like material used to stabilize surfaces and improve grip) could not be observed in the seat of the wheelchair. On 12/3/24 at approximately 10:00 AM, R129 was observed sleeping in their bed. Their wheelchair was at the bedside and there was no Dycem on top of the wheelchair cushion. The top of the wheelchair cushion was observed to be slightly shiny and had a slippery texture. On 12/3/24 Nurse 'AA' and Certified Nurse Aide (CAN) 'X' were asked if R129 could stand with assist and said they could. They were asked if they could assist them to stand so an observation of the wheelchair cushion could be made. Nurse 'AA' and CAN 'X' assisted R129 to stand and no Dycem to the top of the wheelchair cushion was observed. They did say Dycem was under the cushion to prevent the cushion from sliding out of the wheelchair. They were asked what was in place to prevent R129 from sliding off the top of the slippery cushion and they said Dycem should probably be on the top of the cushion as well. A review of R129's clinical record revealed they admitted to the facility on [DATE] with diagnoses that included: dementia and repeated falls. R129's most recent Minimum Data Set assessment revealed they had severe cognitive impairment. A review of R129's progress notes revealed they sustained a fall on 11/12/24. A note dated 11/12/24 at 6:35 PM read, .writer waked by room and observed staff in room with resident sitting at the edge of the bed. writer <sic> asked staff what happened. staff <sic> member informed resident was found sitting on the ground . No incident report or investigation into the fall was provided by the facility. Continued review of R129's progress notes revealed a note dated 11/13/24 that indicated R129 had an unwitnessed fall in the bathroom. An incident/accident report was provided, and indicated R129 was ambulatory without assistance Predisposing factors to the fall listed on the report included: poor lighting, confusion, incontinence, impaired memory, weakness, improper footwear, and ambulating without assistance. A new care plan intervention after the fall on 11/13/24 was to apply dycem to R129's wheelchair. A progress note dated 11/22/24 was reviewed and read, Pt. (patient) was leaning too far forward and slid out of wheelchair onto his buttocks . A follow-up progress note dated 11/23/24 read, IDT (interdisciplinary team) team reviewed. Care plan updated to reflect the use of dycem in the wheelchair to prevent sliding . It was noted this was not a new intervention as it had been added on 11/13/24. It was unclear from the investigation whether R129 had dycem in the wheelchair at the time of the fall on 11/22/24 as suggested by the care plan intervention on 11/13/24. On 12/4/24 at 8:45 AM, an interview was conducted with the former Director of Nursing (DON) who was currently an Administrator in Training (AIT) in the presence of the new DON. They explained that when a fall occurs, staff should implement new and appropriate interventions. A review of a facility provided policy titled, Fall Management Workflow dated 12/2023 was conducted and read, .Post-Fall Evaluation: .Attempt to determine the root cause of the event and initiate modifications to the resident's care plan as indicated. Complete an incident report in risk management . This citation pertains to Intake Number(s): MI00148148 and MI00147901 Based on observation, interview, and record review, the facility failed to transfer a resident in a safe manner, provide adequate supervision, and implement effective interventions to prevent falls for three (R7, R129, R59) of four residents reviewed for accidents, resulting in R7 falling and sustaining a right oblique humerus fracture (broken at an angle) and right fifth digit (finger) fracture which caused a decline with additional assistance needed (substantial to dependent). Findings include: R7 On 12/2/24 at 9:50 AM, R7 was observed seated in a wheelchair in their room. At that time, an interview was conducted with R7 regarding the care in the facility. R7 reported they fell multiple times due to not being able to stand like they used to. R7 reported the worst fall was several months ago and occurred when a Certified Nursing Assistant (CNA) did not assist them to get back into the bed after using the bathroom. R7 reported when they asked the CNA to help get back in bed, the CNA told R7, You can do it yourself. It's only 2 or 3 steps. According to R7, their legs gave out and they fell to the floor and broke the big bone in my arm and some fingers. R7 stated, My arm still bothers me sometimes. A review of R7's progress notes revealed the following: On 2/26/24, it was documented in a Physician Team - Progress Note that R7 had cough, congestion, body aches, hypoxia (low oxygen levels) with fatigue. On 2/27/24 at 10:42 PM, it was documented in a Nursing-Progress Note that the on-call doctor ordered a complete x-ray for the right arm. It was documented Writer and care team placed resident back in wheelchair then placed in bed and R7 had small bruising on right arm. On 2/28/24 at 7:36 AM, it was documented in a Nursing-Progress Note that it was one day status post a witnessed fall and R7 complained of pain to the right arm. It was documented an x-ray was pending. On 2/28/24 at 1:13 PM, it was documented in a Physician Team-Progress Note that R7 was seen for follow-up after a witnessed fall the previous night while being assisted from a transfer into bed from the wheelchair. It was documented R7's legs became weak and they landed on the floor. R7 had pain in her right arm, an x-ray was ordered, and they were unable to move their arm due to pain. On 2/28/24 at 7:27 PM, it was documented in a Nursing-Progress Note that R7 was transferred to the hospital due to an oblique fracture involving the humeral neck. On 3/2/24, it was documented in a Nursing-admission Note that R7 was readmitted into the facility from the hospital with acute pain/fx (fracture) to right arm from recent fall. On 3/4/24, it was documented in a Physician Team - H&P (History and Physical) that R7 returned from the hospital with a right proximal humerus fracture. R7's arm was placed in a sling and due to pain in their right hand, an x-ray was done at the hospital which revealed a nondisplaced fracture of the base of the proximal base of the right fifth digit and was placed in a special brace and non-weightbearing in the right upper extremity. On 12/3/24 at 10:28 AM, the Administrator and Director of Nursing were asked to provide all incident reports with any associated investigation documentation since February 2024 for R7. A review of an incident report for R7 dated 2/27/24 at 9:25 PM revealed R7 had a witnessed fall on that date. It was documented by the nurse that upon entrance to R7's room, R7 was on the floor sitting on her bottom with (CNA) standing right behide <sic> resident .Resident states that her legs became weak and could no longer complete the stand pivot to bed. It was documented an x-ray to the right arm was ordered. In the section labeled statements, no name was included. R7's pain level was noted as seven out of 10 with 10 being the highest level of pain. There were no additional documents that indicated the incident was investigated to determine the root cause of the fall. A review of R7's clinical record revealed R7 was admitted into the facility on 3/31/16 and readmitted on [DATE] with diagnoses that included: hemiplegia and hemiparesis right dominant side and osteoarthritis. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R7 had moderately impaired cognition and required substantial/maximum assistance for bed mobility, transfers, including toilet transfers, and partial/moderate assistance to walk 10 feet. R7 did not have any falls within the assessment period. R7 was assessed to have occasional mild pain. A review of a significant change MDS dated [DATE] (after R7's fall resulting in a fracture) revealed R7 had severely impaired cognition and was dependent on staff for bed mobility and transfers and was unable to walk. Further review of R7's incident reports revealed on 6/11/24 at 7:50 AM, R7 fell during a staff assisted transfer from the bed to the wheelchair. It was documented R7 was unable to continue standing and was assisted to the floor by staff. The staff member involved was not included in the information provided. In the notes section, the following was documented, IDT (Interdisciplinary Team) reviewed fall .Care Plan was updated to reflect educating staff on the use of gait belt when transferring resident . On 12/4/24 at 9:01 AM, an interview was conducted with the former Director of Nursing (DON), Administrator in Training (AIT) 'A'. When queried about what was done to investigate the root cause of R7's fall that occurred during the CNA assisted transfers on 2/27/28 and 6/11/24, AIT 'A' reported education was provided to the CNAs and he will provide it. At that time, the name of the CNAs involved were requested and AIT 'A' reported he would get that information. A review of R7's care plans revealed the following: A care plan initiated on 5/31/23 revealed R7 had ADL and mobility deficits R/T (related to) ongoing health events, minimal right sided weakness. An intervention initiated on 11/14/23, indicated R7 required 2 person assist for bed mobility and toileting. It was documented that R7 required 2 person assist for transfers at the time of the falls on 2/27/24 and 6/11/24. According to the care plan, as of 5/31/24, R7 required 2 person assist with a sit to stand lift. On 12/4/24 at 12:05 PM, an interview was conducted with CNA DD'. CNA 'DD' was able to recall the incident with R7 on 2/27/24. When queried about what happened, CNA 'DD' reported she was getting her in the bed using a gait belt after taking her to the toilet and R7 was unable to stand and pivot and her legs gave out and CNA 'DD' was unable to hold her up and she fell and sustained an injury. At the time of the fall, CNA 'DD' was the only CNA providing assistance. When queried about any education that was provided to CNA 'DD' after the incident, CNA 'DD' reported she talked to the DON (AIT 'A') and R7 was changed to use a sit to stand lift. The facility provided a document titled, Employee Counseling & Corrective Action Record dated 6/19/24 for CNA 'EE'. The document noted CNA 'EE' did not follow the resident's (R7's) plan of care for transfers (two person assist). No further information was provided for the incident with R7 that occurred on 2/27/24. On 12/4/24 at 1:31 PM, a follow up interview was conducted with the DON and AIT 'A'. AIT 'A' reported additional information was unable to be located and acknowledged R7 was not assisted by two people on 2/27/24 and 6/11/24 according to their plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This cite pertains to intake MI00138070. R806 Review of an intake submitted to the State Agency (SA) documented concerns of surgical site dressing changes not being completed. Record review revealed that R806 was admitted to the facility on [DATE] with the diagnoses of Spinal Stenosis lumbar region, Low back pain and encounter for surgical aftercare following surgery on the nervous system. Record review revealed that R806 Brief interview mental status(BIMs) was a 13 and the minimum data set(MDS) showed that they needed moderate assistance with activities of daily living(ADLs). Record review revealed that R806 on 6/21/23 has a spinal stenosis lumbar incision with several sutures. Record review revealed that on 6/25/23 a treatment and care plan was put in place for the surgical site. Record review revealed on 6/27/23 there was a progress note R806 was started on oral antibiotics (for infection) for the surgical site. On 9/20/2023 at 11am Nurse D was interviewed for if there was a care plan or treatment ordered for R806 and if treatment orders go in upon admission. Nurse D noted there was a treatment order in place four days after arriving to facility. Nurse D was asked if there would be orders to monitor a surgical site upon admission. Nurse D replied, Yes there should. On 9/21/2023 at 12 pm, the DON was interviewed and asked if incision sites need treatments ordered upon admission. The DON explained that there would be an incision monitoring order unless it was an occluded surgical dressing, and the treatment should be documented as completed per day. Record review revealed that on 6/27/23, R806 was sent out to hospital for lower back pain and dark green drainage from her back and uncontrolled pain to the lower back area. There was no addition information given by the exit of survey. This citation pertains to intake(s): MI00137355 & MI00138070. Based on interviews and record reviews the facility failed to consistently assess, monitor, and implement a plan of care of a surgical site (R806) and failed to identify a head abrasion and follow up on the origin of the head abrasion (R809) for two of three residents reviewed for non-pressure wounds. Findings include: R809 Review of an intake submitted to the State Agency (SA) documented concerns of bruising to the resident head that was not reported to the family. An onsite investigation was conducted of the complainant's concerns. Review of the medical record revealed R809 was admitted to the facility on [DATE] with diagnoses that included: dementia, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, aphasia, and type 2 diabetes mellitus. A Minimum Data Set (MDS) assessment dated [DATE], documented Severely impaired cognitive skills for daily decision making and required staff assistance for all Activities of Daily Living (ADLs). Review of the medical record revealed no documentation of the identification of any head bruising or trauma to R809. On 9/19/23 at 12:04 PM, the facility's Administrator and Director of Nursing (DON) was asked to provide all grievances and Incident and Accident reports completed for R809. Review of a grievance form provided, dated 4/28/23 documented the following in part . reported from the floor nurse that family was in room stating there was a bruise noted to the patient's forehead . Investigation: upon entering the room family stated there was a bruise on the patients head yesterday when they were here . family stated they had a picture but would not show this nurse. Assessment of head/scalp performed, and no sign of bruising noted . No further concerns noted . Message left with daughter . There were no Incident and Accident reports provided for R809. Review of the progress notes revealed R809 was transferred to the hospital on 5/2/23 for concerns with a sacral coccyx wound. Review of the hospital ER (Emergency Room) Provider note dated 5/2/23 at 3:51 PM, documented the following assessment in part . Physical Exam . Head: Normocephalic . Abrasion to top of head, redness on middle forehead . On 9/20/23 at 8:43 AM, the DON was interviewed and asked about the family to have verbalized their concern regarding bruising identified on their loved one's head, a grievance completed documenting no findings, compared to an initial ER physical examination that was conducted when the resident was transferred from the facility to the ER, in which the ER physician identifies an abrasion and redness to R809's head. The DON stated they vaguely remember the incident, however stated there was nothing found on the resident when they completed their assessment. When asked how R809 obtained an abrasion with redness to their head with nothing documented in the medical record and no Incident and Accident reports revealing any falls and/or accidents, the DON was unsure of how it could have occurred. No further explanation or documentation was provided by the end of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake(s): MI00136632 and MI00137232. Based on observation, interview and record review, the facility failed to ensure consistent and comprehensive skin assessments and implement interventions for two (R811 and R820) of two residents reviewed for pressure ulcers(PU), resulting in R820 developing an unstageable (the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) PU and R811 developing multiple PU's. Findings include: On 9/20/23 around 11:30AM, R820 was observed in his room lying in the bed. R820 was asked if he had any wounds or sores. R820 believed so and that they (the facility) put a dressing on it. Review of the clinical record revealed that R820 was admitted into the facility on [DATE] with diagnoses that included weakness, multiple fractures of ribs right side and traumatic pneumothorax. Record review of the most recent Minimum Data Set(MDS) revealed that R820 needed supervision and assistance with activities of daily living(ADL's) and had an intact cognition. The MDS assessment indicated that R820 did not have any PUs upon admission. Review of R820's nursing admission entrance assessment dated [DATE] revealed there were no open areas but did document redness on the coccyx area. Reviewed R820's comprehensive care plan revealed no interventions to prevent skin break down. Review of R820's physicians orders revealed no orders for preventative measures to protect skin integrity. Review of R820's clinical record revealed no skin assessments after the inital assessment upon admission. On 9/20/23 at 11AM, Nurse D, who serves as the facilities wound care nurse, was interviewed in regard to R820's skin and the skin management program of the facility. NurseD explained that there is one unstageable wound located on the coccyx of R820 and that the floor nurses are responsible for the initial skin assessment and if issues with skin are noted, a wound consult will be put in as an order. Nurse D was asked if R820 came into the facility with any skin issues. Nurse D explained that the admitting nurse put redden area in the progress notes of R820. Nurse D was asked if redden areas receive interventions or treatments? Nurse D stated, They should put in an order for barrier creams and frequent repositioning. Nurse D was asked if the facility conducts assessments of the skin and replied Yes, they are done weekly. On 9/20/23 around 12PM Nurse L was interviewed who acted as the interim Unit manager for the unit. Nurse L was asked after admission to the facility, what is the process for assuring that skin assessments are completed correctly. Nurse L explained that they to check to make sure everything is signed and locked, but do not physically go and assess the residents for accuracy. On 9/20/2023 at 4:30 PM the Director of Nursing(DON) and Administer was interviewed and asked a how are skin assessments completed with new admissions, how do the nurses know to do skin assessments, and what orders would be put in for reddened areas? The DON replied, Skin assessments are to be done upon admission and then weekly. The DON explained the nurse who admitted a resident will look at the skin and if there is a problem, [Nurse D] will be consulted. The DON further explained that weekly skin assessments are auto populated (by the computer system) and if its (the skin assessment) is not in (the computer) then it (the assessment of the skin) could be on shower sheet. The DON stated, We instruct certified nursing assistants to notify a nurse no matter how big, little or old an area may be. I would hope to see and order for peri guard (a barrier cream) if a person has a redden area. There was no addition information provided by the exit of survey. R811 Review of the medical records revealed R811 was readmitted to the facility on [DATE] with diagnoses that included: dementia, chronic kidney disease (stage 3), and glaucoma. A MDS assessment dated [DATE], documented a BIMS score of 3 (which indicated severely impaired cognition) and required staff assistance for all ADLs. Review of an admission Braden assessment dated [DATE], documented a score of 19. The facility's Braden categorization documented in part . At Risk 15-18, Moderate Risk 13-14, High Risk 10-12, very high risk 9 or below . Review of a Nursing - admission Note dated 2/25/23 at 7:18 PM, documented in part . Rec'vd (received) pt (patient) via ambulance stretcher . Alert and oriented x1-2 with confusion noted . Skin assessment complete with no open areas noted, skin clean dry and intact. Bil (bilateral) feet dryness noted with brille (sic) yellowish toenails observed . Review of a skin assessment completed on 2/27/23 documented no skin abnormalities identified and on 2/28/23 documented . scattered superficial scratches to bilateral upper extremities, toenails are discolored, brittle and uneven. Patient has dry flaky skin to bilateral feet . no other skin abnormalities were identified. Review of a Physician note dated 3/21/23 at 5:24 AM, documented in part . Continue wound care as ordered . Review of the March 2023 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed the following: . Skin Evaluation weekly . Check skin for open areas . PLEASE OPEN SKIN EVALUATION UNDER ASSESSMENTS TAB: two times a day every Mon (Monday), Thu (Thursday) . Start Date: 2/27/23. . Medihoney Wound/Burn Dressing External Paste (Wound Dressings) Apply to left buttocks topically one time a day for wound care cleanse wound, pat dry, apply medihoney and border gauze . Start Date 3/30/23. Review of the medical record revealed no documented weekly skin evaluations completed (from admission until discharge) under the assessment tab as ordered. Further review revealed no wound treatment in place on 3/21/23 as documented by the practitioner. Review of a Health Status Note dated 3/29/23 at 11:37 AM, documented in part . resident has two open areas on his left buttocks. Area cleaned and treatment applied. Wound consult done . Review of a care plan titled Risk for Pressure Injury Formation related to: generalized debility and weakness as evidence by: decreased mobility in bed and wheelchair, incontinence of bowel and bladder. Resident need staff assistance with incontinence care, turning and repositioning . Date initiated 2/27/23, documented the following interventions . Braden scale to be completed per facility protocol . Cushion to wheelchair daily . Encourage intake of 75-100% of diet and fluids daily. RD (Registered Dietician) to assess dietary needs quarterly and with significant changes . These three interventions were not adequate in preventing pressure wounds for R811, who had decreased mobility, utilized a wheelchair, was incontinent of urine and bowel and required staff assistance for all ADLs. Review of a care plan titled The resident has potential/actual impairment to skin integrity of the (SPECIFY location) r/t impaired bed mobility and fragile skin (Date Initiated 3/7/23) documented the following interventions . Keep skin clean and dry. Use lotion on dry skin. Do not apply on (Specify: site of injury) . Monitor for side effects of the antibiotics and over-the-counter pain medications; gastric distress, rash, or allergic reactions which could exacerbate skin injury . Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx (signs/symptoms) of infection, maceration etc to MD (Medical Doctor), Obtain blood work such as CBC (complete blood count) with Diff, Blood Cultures and C&S (cultures and sensitivity) of any open wounds as ordered by Physician . Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations . This care plan failed to implement resident specific, adequate and effective interventions in attempts to prevent wounds. Review of a Skin & Wound evaluation dated 3/30/23 at 3:28 PM, documented in part . skin tear . Left Buttock . In-House Acquired . How long has the wound been present . 1 week . Area 6.2 cm2 (centimeters squared) . Length 3.8 cm (centimeters) . Width 2.3 cm . Depth Not Applicable . Exudate . Light . Serosanguineous . Patient has full skin loss secondary to shear tear on the sacral region . On the left buttock area, patient again has a full skin tear with complete skin loss . Further review of the care plan titled Risk for Pressure Injury Formation related to: generalized debility and weakness as evidence by: decreased mobility in bed and wheelchair, incontinence of bowel and bladder. Resident need staff assistance with incontinence care, turning and repositioning . (initiated 2/27/23), documented the addition of the following interventions on 4/3/23: . Low Air Loss mattress on bed . Monitor skin daily during care for redness, excoriation, or breakdown . Review of a Wound Rounds Note' dated 4/4/23 at 11:01 AM, documented in part . seen for follow up management of his wound . On the coccyx there is an unstageable wound measuring 1.49cm x 0.87 2.46cm x 0.87, wound base has slough . On the sacrum there is an unstageable wound measuring 3.29 cm x 2.33cm . On the right heel there is a deep tissue injury measuring 3.22 cm x 2.53cm . Review of a Skin & Wound evaluation dated 4/4/23 at 11:12 AM, documented in part . Pressure . Deep Tissue Injury: Persistent non-blanchable deep red, maroon or purple discoloration . Right heel . In-House Acquired . New . Area 6.1 cm2 . Length 3.2 cm . Width 2.5 cm . Depth Not Applicable . Review of a Skin & Wound evaluation dated 4/4/23 at 11:19 AM, documented in part . Skin Tear . Sacrum . Area 5.7 cm2 . Length 3.3 cm . Width 2.2 cm . Depth Not Applicable . Exudate . Light . Serosanguineous . On the left buttock area, patient again has a full skin tear with complete skin loss . Review of a Skin & Wound evaluation dated 4/4/23 at 11:25 AM, documented in part . Blister . Coccyx . In-House Acquired . New . Area 0.9 cm2 . Length 1.5 cm . Width 0.8 cm . Depth Not Applicable . Ruptured serum filled blister . Exudate . Light . Serous . patient has full skin loss secondary to shear tear on the sacral region; it has irregular borders; periwound is intact . Review of the physician orders documented the following order, . Wound Care Order Site: right/left heel 1) Cleanse wound with NS (normal saline) 2) Pat Dry with Gauze 3) Apply skin prep, let dry 4) Cover with ABD (abdominal dressing), 5) Wrap in kerlix 6) Tape - (date and initial the tape) every day shift for wound care . This order had a start date of 4/5/23. Review of the medical record revealed no documentation of the identification of a wound on the resident's left heel. Review of a Wound Rounds Note dated 4/11/23 at 11:13 AM, documented in part . seen for follow up management of his wound. He has an unstageable wound on the sacrum . On the coccyx there is an unstageable wound . On the right heel there is a deep tissue injury . Further review of the medical record revealed R811 was discharged from the facility three days later on 4/14/23. The resident admitted to the facility two months prior with no wounds and discharged home with three documented wounds (two unstageable wounds and one deep tissue injury). On 9/20/23 at 4:00 PM, Wound Care Nurse (WCN) D was interviewed and asked about the skin management protocol in the facility, WCN D replied all resident's have a weekly skin assessment completed and documented in their record. WCN D was asked to provide the weekly skin assessments completed for R811. WCN D was then asked about the 19 (indicating a low risk for skin breakdown) braden score and questioned the accuracy of the Braden assessment, WCN D stated they would look into it and follow back up. WCN D was then asked about the lack of adequate resident specific interventions implemented to prevent wound development to R811's skin and WCN D replied they would look into it and follow back up. WCN D was also asked to provide the documentation regarding the identification of the left heel wound and WCN D again replied they would look into it and follow back up. On 9/21/23 at 9:57 AM, WCN D returned and stated there was an unavoidable pressure ulcer document put in the system for R811. WCN D was asked how they could say R811's was unavoidable if the facility failed to implement the bare minimum of preventative interventions and accurate assessments for this resident, and WCN D did not have a response. WCN D was then asked for the documentation regarding the resident's left heel wound and WCN D stated they could not provide any documentation. WCN D stated they believed the Braden score was inaccurate because R811 had an overall decline in the two months that they were admitted into the facility, WCN D was then asked why the facility did not implement additional interventions to reflect the decline for R811 and to help prevent the development of wounds and WCN D did not have a response. WCN D stated they were unable to provide documentation of weekly skin assessments completed for R811. No further explanation or documentation was provided by the end of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R122 On 9/26/22 at 4:34 PM, and 9/28/22 at 8:26 AM, a review of R122's closed clinical record was conducted and revealed they admitted to the facility on [DATE] and discharged to the hospital on 4/14/22 per the family's request over concerns with their pressure ulcers. R122's diagnoses included: protein calorie malnutrition, heart failure, stroke, and chronic pain. R122's Minimum Data Set assessment dated [DATE] indicated R122 had moderately impaired cognition, was non-ambulatory, and required extensive to total assistance from one staff member for activities of daily living. It was further noted the MDS assessment documented R122 admitted to the facility with one unstageable pressure ulcer and one deep tissue injury. A review of an admission SKIN OBSERVATION TOOL dated 3/22/22 and locked on 3/29/22 was conducted and read, .Site .Right buttock .Description .DTI (deep tissue injury, purple or maroon localized area of discolored intact skin due to damage of underlying soft tissue from pressure and/or shear') noted area measures 5cm (centimeters) x 5cm, wound bed noted as purple in color, surrounding skin fragile . Site . Sacrum .Description .Unstageable pressure ulcer (Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough and or eschar in the wound bed) noted, area measures 5cm x 5cm, 80% adherent slough noted to wound bed .Notes: Treatment in place to areas mentioned . A review of R122's physician's orders and treatment administration records (TAR) was conducted and revealed no orders had been placed for treatment to R122's right buttock DTI or the unstageable pressure ulcer to their sacrum, and no documentation was included on the TAR to indicate any treatments to R122's pressure ulcers had been performed upon their admission. R122's admission COMPREHENSIVE MEDICAL EVALUATION entered into the record by Dr. 'D' on 3/23/22 was reviewed and read, .PHYSICAL EXAMINATION: . SKIN: Warm and dry . It was noted there was no mention of R122 admitting to the facility with any pressure ulcers. A review of a wound consultation entered into the record by Dr. 'T' on 3/29/22 was reviewed and read, .I was consulted for the management of the wounds. She does have 2 areas. She has an unstageable ulcer on the sacrum and she has a deep tissue injury on the right buttock . INTEGUMENTARY: On examination of the sacral area, the patient has an unstageable measuring 4 cm x 1 cm .On the right buttock, the patient has a deep tissue injury measuring 5 cm x 5 cm . ASSESSMENT AND PLAN: 1. Unstageable sacral ulcer. The patient needs to be turned frequently. We are going to clean it with normal saline and use Triad (wound care treatment). 2. Regarding the right buttock DTI, again, we are going to clean with normal saline and use Triad. The patient needs to be turned frequently . R122's care plan was reviewed and indicated that care planning for R122's pressure ulcers was initiated 3/31/22, despite the documentation that indicated they admitted with pressure ulcers on 3/21/22. It was further noted R122's care planning, did not address interventions such as turning/repositioning or a low air loss mattress as recommended by Dr. 'T'. A review of R122's TARs for March 2022 and April 2022 was conducted and revealed Unit Manager, Registered Nurse 'B' signed off their performance of skin assessments on 3/30/22 and 4/6/22, but did not open an assessment and document any skin impairments per the order that read, .PLEASE OPEN SKIN ASSESSMENT UNDER ASSESSMENTS TAB .Check skin for open areas, bruises, abrasions, DTI . A second review of R122's physician's orders and TARs was conducted and revealed the first orders placed for any treatments and the first documentation on the TAR to indicate R122 received any treatments to their DTI and unstageable pressure ulcer were entered on 4/8/22, 18 days after their admission to the facility and 9 days after Dr. 'T's wound care consult. A nursing progress noted dated 4/14/22 was reviewed and read, .Resident and family have spoke extensively with MD (doctor) and DON (Director of Nursing) regarding transfer to hospital for evaluation of sacral ulcer and intermittent slurred speech .Family request that resident be transferred to hospital and resident states that it is here <sic> wish to go to the hospital . On 9/28/22 at 1:28 PM, a review of R122's hospital records for their admission on [DATE] was conducted and revealed a document from the transportation company that indicated R122 transferred to the hospital for, .Chief Complaint: Pain caused by ulcers . Further review of the hospital records revealed a consultation for Surgical Wound Care dated 4/15/22 that read, .Reason for Consultation/Indication: Wound Care .Focal examination .Wound Location: Sacrum: Full thickness skin loss, unable to determine depth of injury necrotic (black) tissue obscuring base. Measurement: 5 by 4.5 by 2.4 cm .Wound Base: Moist black necrotic tissue .Drainage: Old dry dressing .Odor: strong foul odor .Wound Location: Left ischium (lower back part of hip bone) .Unable to determine depth of injury related to non-blanching region .Measurement: 4 by 2.5 cm .Wound Base: dry black .Wound location: Right ischium .Full thickness skin loss with depth to subcutaneous tissue .Measurement: 1.8 by 2.4 by 0.3 cm .Wound Base: Moist pink with yellow slough .Assessment: .Open unstageable sacral pressure injury. Open unstageable pressure injury of Left ischium. Open stage 3 (Full thickness skin loss involving damage of subcutaneous tissue) pressure injury of right ischium . R24 On 9/27/22 at 3:55 PM a review of R24's clinical record was conducted and revealed they admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included: dementia, diabetes, heart failure and peripheral vascular disease. R24's MDS assessment dated [DATE] revealed R24 had severely impaired cognition and required assistance from one staff member for activities of daily living. A review of a Skin & Wound Evaluation with an In Progress status dated 9/13/22 was reviewed and revealed R24 had developed a facility acquired deep tissue injury to their left heel. A review of a Wound Rounds Note entered into the record on 9/13/22 by Dr. 'T' was conducted and read, .patient has a deep tissue injury to her left heel On the left heel, the area is erythematous. She does have a deep tissue injury which does measure 0.3 x 0.4 cm. ASSESSMENT AND PLAN: 1. Left heel deep tissue injury .6. Patient would get dry dressing to the left heel. She will need heel protective shoe . A review of R24's physician's orders and treatment administration record (TAR) for September 2022 was conducted and revealed there were no orders for treatment to the left heel or documentation on the TAR to sign off the treatment to the heel was completed. On 9/28/22 at 12:42 PM, an interview was conducted with Wound Care Coordinator, Nurse 'R' regarding R24's left heel deep tissue injury and said they did not know why Dr. 'T's order for R24's left heel had never been entered. R50 On 9/26/22 at 10:25 AM, R50 was observed lying on her back, sleeping. A low air loss mattress was observed on R50's bed. R50 woke up and stated she was sleepy and did not wish to talk. On 9/26/22 at approximately 11:30 AM and 1:15 PM, R50 was observed lying on her back. Review of R50's clinical record revealed R50 was admitted into the facility on 5/6/20 and readmitted on [DATE] with diagnoses that included urinary tract infection, sepsis, severe protein malnutrition, chronic kidney disease, and vascular dementia. R50 was transferred to another facility on 7/2/22 due to testing positive for COVID-19 and returned to the current facility on 7/13/22. Review of a MDS assessment dated [DATE] revealed R50 had severely impaired cognition, no behaviors including rejection of care, and required extensive physical assistance from two staff members for bed mobility and transfers. The MDS documented R50 had one Stage 4 pressure ulcer present upon admission. Review of a Nursing-Progress Note dated 7/13/22 revealed, .wound consult entered for buttocks . Review of a Physician Team - Progress Note dated 7/14/22 revealed, .Chronic Sacral Decubitus ulcer stage IV .Foley catheter as recommended by wound care physician for reopened sacral wound, healed again since catheter reinsertion . Review of a Nursing - Skin/Wound Note dated 7/14/22, written by Wound Care Coordinator, Nurse 'R', revealed, .The following skin alterations were noted during assessment .Coccyx Pressure injury, area measures 1.1 cm x 0.8 cm x 0.2 cm . Review of a Wound Rounds Note dated 7/19/22 revealed, .previously treated for a sacral wound which completely healed. she was recently diagnosed with COVID, was transferred to (another facility), has returned back to the facility, her previous sacral ulcer has reopened, likely secondary to moisture associated, has been incontinent of urine (It should be noted that R50 had an indwelling urinary catheter prior to the transfer to the other facility and at the time of that assessment) .On the sacral area, previous stage 4 ulcer has reopened, measuring 1.5 cm x 1.5 cm x 0.3 cm, no discharge, no odor .ASSESSMENT AND PLAN: 1. Moisture associated skin damage in the sacral regions to the previous stage 4 sacral ulcer .We will use alginate (an absorbent wound dressing) to the area . Review of a Wound Rounds Note dated 7/26/22 revealed, .On the sacral area, previous stage 4 ulcer has reopened, measuring 1.8 cm x 1.0 cm x 0.3 cm, scant bloody drainage .We will use alginate to the area . Review of a Wound Rounds Note dated 8/4/22 revealed, .seen for follow up wound management .sacral area, previous stage 4 ulcer has reopened, MEASURING 1.5 (cm) X 0.6 CM X 0.5CM .We will use alginate to the area .Patient needs to be turned frequently . Review of a Wound Rounds Note dated 8/8/22 revealed, .seen for follow up wound management. She has a sacral ulcer .She has been getting Alginate to her wound .Sacral area, previous stage 4 ulcer has reopened, MEASURING 1.3 (cm) x 0.9 CM x 1.0 CM, there is some slough to the wound, scant drainage .We will discontinue Alginate and use Medihoney (an antibacterial wound dressing) to the area . Review of R50's Physicians Orders revealed the following order that started on 7/14/22, Wound Care Order Site: coccyx (sacrum) 1). Cleanse wound with wound cleanser 2) Pat Dry with Gauze 3) Apply Triad paste (wound dressing) 4) Cover with ABD (abdominal pad) 5) Tape - (date and initial the tape) as needed for wound care AND every day shift for wound care. This order was discontinued on 7/21/22. On 7/21/22, R50's wound care treatment order was changed to .Apply Calcium Alginate to area .as needed for wound care AND every day shift for wound care . This order was active until it was discontinued on 9/19/22. (It should be noted that as of the Wound Rounds note dated 7/19/22, calcium alginate was the documented treatment for R50's pressure ulcer to the coccyx. The treatment was not ordered until two days after R50 was evaluated by the wound provider. Further review of R50's Physicians Orders revealed an order for Medihoney .Apply to coccyx topically every day shift for wound care was started on 8/10/22, two days after the wound provider evaluated R50's pressure ulcer and documented it had worsened (increased width and depth and appearance of slough) and the order for Calcium Alginate was also active and not discontinued. Review of a Wound Rounds Note dated 8/16/22 revealed, follow up wound management. She has a chronic sacral ulcer .On the sacral area, has a stage 4 ulcer measuring 1.0 cm x 0.5 cm, periwound is red, has positive drainage, greenish, mild oder <sic> .will get wound culture, clean with normal saline (NS), and use metrogel (an antibiotic wound dressing) to the wound, will follow up the cultures . Review of R50's Physicians Orders revealed an order dated 8/16/22 for Metrogel Gel 1% (percent) (metroNIDAZOLE) Apply to coccyx topically as needed for wound care. Clean area with NS, dry, apply gel to area, cover with 4x4 gauze and ABD pad, secure with tape AND apply to coccyx topically every day shift for wound care . At the time of that order, the orders for Calcium Alginate and Medihoney remained active and were not discontinued and therefore there were three different orders for treatment of R50's coccyx pressure ulcer. Review of an Order Note dated 8/17/22, written by Nurse 'R', revealed Obtain culture of coccyx wound to R/O (rule out) infection .Specimen obtained by writer .Specimen placed in .fridge on (unit) for pick-up . Review of laboratory results in R50's electronic medical record (EMR) revealed no results from the wound culture obtained on 8/17/22. Review of a Wound Rounds Note dated 8/23/22 (six days after the wound culture was obtained), revealed, .wound has green discharge .has been feeling tired .stage 4 ulcer measuring 1.6 cm x 0.7 cm x 0.5 cm, periwound is red, has positive drainage, greenish, mild odor .Wound culture pending. Clean with normal saline, and use metro gel to the wound, will follow up with the cultures . Review of R50's Physicians Orders revealed a new order for metroNIDAZOLE Gel 0.75 % apply to coccyx topically every day shift for wound treatment . The orders for Calcium Alginate and Medihoney remained active at that time. Review of a Wound Rounds Note dated 8/30/22 revealed, .Wound cultures not done (it should be noted that it was documented by Nurse 'R' that the specimen was taken on 8/17/22 and there was no documentation that indicated any follow up had been completed) .has been feeling tired .stage 4 ulcer measuring 1.6 cm x 0.7 cm x 0.5 cm, periwound is red, has positive drainage, greenish, mild odor .now looking unstageable, periwound has multiple satellite lesion (secondary lesions in close proximity to the primary lesion), and skin is red .Plan Clean with normal saline, and use Medihoney to wound, use antifungal to the periwound, will treat for suspected candida (fungal) infection with Diflucan x 5 days, 100 mg (milligrams) a day . Review of R50's Physicians Orders revealed Diflucan was not ordered, per the wound provider's recommendations on 8/30/22. Medihoney was ordered since 8/10/22. However, Metrogel was not discontinued and either was Calcium Alginate. All three orders remained active until 9/19/22. Review of R50's Medication and Treatment Administration Records (MAR and TAR) for August 2022 and September 2022 revealed nurses signed off that R50's coccyx pressure ulcer was treated with Calcium Alginate and Medihoney from 8/11/22 through 9/19/22 and Calcium Alginate, Medihoney, and MetroNIDAZOLE from 8/17/22 through 9/19/22. It is unknown which treatment was done to R50's coccyx or how three different wound treatments were administered. Review of a Nursing - Progress Note dated 9/4/22 revealed, Pt (patient) lethargic only responding to painful stimuli . A second progress note dated 9/4/22 revealed the physician ordered R50 to be sent to the hospital via 911. Review of R50's Hospital Records revealed an H&P (History and Physical) dated 9/4/22 that documented, .Upon arrival to ED (emergency department) .foul odor noted from perineal region .lower back wound noted .Assessment .Sepsis likely secondary to #2, #3, #4 (#4 was sacral decubitus ulcer . A Hospital ICU (intensive care unit) Progress Note documented, .INFECTIOUS .Blood culture showing Proteus mirabilis and gram-negative bacilli .wound cultures growing gram-negative bacilli and Enterococcus . Further review of R50's clinical record revealed the following: A Skin & Wound Evaluation dated 7/14/22, completed by Nurse 'R', documented R50 had a Stage 2 (Partial-thickness skin loss with exposed dermis) pressure ulcer to the coccyx that was present on admission that measured 1.1 cm x 0.8 cm with no depth. At that time, it was documented that a hydrophilic fiber wound dressing (Triad Paste) was implemented. (It should be noted that Nurse 'R' completed a progress note that same day with the following measurements: 1.1 cm x 0.8 cm x 0.2 cm which indicated the wound had measured depth and did not fit the description of a Stage II pressure ulcer. A Skin & Wound Evaluation completed on 8/30/22 by Nurse 'R' documented, R50's wound was unstageable and measured 2.3 cm x 0.8 cm and was 100 % filled with slough. It was documented there was no change in treatment. However, the wound provider note (Wound Rounds Note dated 8/30/22 documented the wound culture was not done and the wound treatment was changed to Medihoney to wound, use antifungal to the periwound, will treat for suspected candida (fungal) infection with Diflucan x 5 days, 100 mg (milligrams) a day which was not ordered. Only the Medihoney order that had been in place since 8/10/22. It should be noted that the measurements documented by Nurse 'R' were different than the measurements documented by the wound provider on 8/30/22. On 9/28/22 at 8:44 AM, Nurse 'R' was interviewed. Nurse 'R' explained she was the facility's Wound Care Coordinator and had been in that position since April 2020. Nurse 'R' explained she was a Licensed Practical Nurse and had not had any formal training or certification in wound care. When queried about her role, Nurse 'R' reported she maintained wounds, did weekly rounds with the wound providers, answered consultations, and collaborated with the interdisciplinary team (IDT) and Director of Nursing (DON). Nurse 'R' was asked to explain how the facility monitored resident's skin for any changes. Nurse 'R' explained that weekly skin assessments were completed by the floor nurses when residents were showered and if any changes in skin were identified, the nurse would notify Nurse 'R'. Nurse 'R' reported the weekly skin assessments were documented in the residents' EMR on a Skin - Total Body Evaluation assessment form. Nurse 'R' explained there were other forms used in the past that were titled, Skin & Wound - Total Body Skin Evaluation and SKIN OBSERVATION TOOL but they were also located in the EMR. Nurse 'R' reported that once a nurse contacted her about a change in skin integrity, she assessed the resident, and requested a consultation from the wound provider. Nurse 'R' reported she determined the type of wound and stage of a pressure ulcer by referring to the facility's policy and the wound provider would confirm when they evaluated the resident. Nurse 'R' reported if the resident's wound matches up with our policy then she would enter the treatment documented on the policy. If she was unsure, she would contact the primary provider or wound provider. When queried about who entered the treatment and intervention orders into the EMR, Nurse 'R' reported she entered them into the EMR immediately after she completed her assessment which she tried to complete by the next business day. If she was not there, the floor nurse should contact the physician and go off the policy. At that time, the policy Nurse 'R' was referring to was requested. When queried about how often pressure ulcers were assessed, Nurse 'R' reported they received treatment daily which was done by either the floor nurses or Nurse 'R' and the wounds were assessed by the contracted wound provider weekly. Nurse 'R' explained she rounded with the wound providers, took photographs of the wounds, and documented her assessment based off of the wound providers' evaluations. Nurse 'R' further explained that since she rounded with them, she wrote down any new interventions or treatments recommended by the wound providers, entered the orders into the EMR, and confirmed the orders with the primary providers. Nurse 'R' was asked how residents were monitored to ensure staff were implementing the appropriate interventions and treatments, Nurse 'R' reported unit managers were responsible to monitor and did so by reviewing MARs and TARs and notified Nurse 'R' if they discovered treatments were not being done. Nurse 'R' reported she had not been notified of any issues regarding treatments or interventions not being done and reported there was currently only one unit manager who worked on the [NAME] Unit. At that time, Nurse 'R' was interviewed about R50's pressure ulcer to the coccyx. Nurse 'R' reported R50 previously had a Stage 4 pressure ulcer in that area and it healed, then reopened when she was transferred to another facility to recover from COVID-19. When queried about why R50 had three different treatments to the same area (coccyx) in August and September 2022 prior to being transferred to the hospital, Nurse 'R' reported it was her fault and she should have discontinued the other orders when she entered the new orders. When queried about how it was known which treatment was being administered to R50 or if any treatment was being administered, as the nurses signed off on all of the treatments as being done, Nurse 'R' reported she had no way of knowing and the orders should have been clarified. When queried about whether the wound culture was done as ordered on 8/17/22, Nurse 'R' reported she obtained the specimen on 8/17/22. At that time, Nurse 'R' was asked to provide the results from the wound culture. The results were not provided prior to the end of the survey. When queried about whether Diflucan was implemented as recommended by the wound provider, Nurse 'R' reported she did not see a physician's order. On 9/28/22 at 2:35 PM, the DON who started in the position at the facility approximately one month prior, was interviewed. When queried about the facility's processes to monitor residents' skin and wounds, the DON reported Nurse 'R' rounded with the wound providers and implemented new orders as recommended by the wound provider. The DON reported the floor nurses and Nurse 'R' administered wound treatments and unit managers were responsible to oversee that the proper interventions and treatments, as well as weekly skin assessments, were being done according to orders. The DON reported there was only one Unit Manager currently who worked on the [NAME] Unit. When queried about whether any issues with pressure ulcers had been identified or brought to her attention, the DON reported it was identified skin assessments were not always completed and the unit managers had the nurses so back and complete them.This citation pertains to intakes: MI00125343, MI00127649, MI00127888, and MI00127953. Based on observation, interview and record review, the facility failed to accurately assess, identify, and implement timely treatments and interventions for four (R24, R49, R50 and R122) of nine residents reviewed for pressure ulcers, resulting in the residents developing new and/or worsening pressure ulcers at the facility. Findings include: Review of multiple complaints reported to the State Agency included allegations that the facility failed to provide adequate and appropriate care to prevent and/or treat pressure ulcers. According to the facility's policy titled, Skin & Wound Policy dated 2/2022, .A full body, or head to toe, skin and oral cavity assessment will be conducted by a licensed or registered nurse upon admission/re-admission and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury .Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change .Treatment decisions will be based on .Etiology of wound .Characteristics of the wound .Location of the wound .Guidelines for dressing selection may be utilized in obtaining physician orders .Due to unique needs and situations of individuals, the guidelines may not be appropriate for use in all circumstances .Treatments will be documented on the Treatment Administration Record .The effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modifications include: a. Lack of progression towards healing. B. Changes in the characteristics of the wound . According to the National Pressure Injury Advisory Panel (NPIAP) Pressure Injury Stages https://www.npiap.com: Stage 2 Pressure Injury: Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink, or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. Stage 3 Pressure Injury: Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location: areas of significant adiposity can develop deep wounds. Undermining or tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Deep Tissue Pressure Injury: Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration, or epidermal separation revealing a dark wound bed or blood-filled blister .Discoloration may appear differently in darkly pigmented skin. According to https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/IRF-Quality-Reporting/Downloads/IRF-QRP-Training-%E2%80%93-PrU-Staging-May-12-2014, .Do not reverse or back stage .If the pressure ulcer has ever been classified at a higher numerical stage than what is observed now, it should continue to be classified at the higher numerical stage . R49: On 9/26/22 at 3:17 PM, R49 was observed seated in a wheelchair next to their bed. There was no low air loss mattress, and the footboard was observed tilted down with one side hanging down towards the floor. R49 was asked about the bed and reported that had been broken for a while. When asked about general care in the facility, the resident reported they had arrived at the facility in August (2022) with pressure sores but the sores have gotten worse. R49 further reported they were concerned because they used to get dressings twice a day in the hospital and now, they were lucky to be done once a day as there were many times their treatments were not done. When asked about whether they were able to reposition independently while in bed, they reported they were not. When asked about whether they had interventions to offload pressure, such as a low air loss mattress, they reported they used to have one, but since they've been back at the facility for about two weeks, they have not. R49 reported they were ok with discussing these concerns with facility staff. Review of the clinical record revealed R49 was admitted into the facility on 8/22/22, discharged to the hospital on 8/30/22 and readmitted on [DATE] with diagnoses that included: pressure ulcer of sacrum stage 4, pressure ulcer of right buttock stage 4, pressure ulcer of left buttock stage 3, sarcoidosis, diabetes mellitus with diabetic polyneuropathy, paraplegia unspecified, chronic kidney disease stage 3, sickle-cell trait, and myoneural disorder. According to the Minimum Data Set (MDS) assessment dated [DATE], R49's cognition was intact, required extensive assistance of one person for bed mobility, extensive assistance of two people for transfers, and had three stage two pressure ulcers that were present on admission. Review of R49's Actual Pressure Ulcer Formation care plan was last initiated and reviewed on 8/23/22. This care plan identified the resident was admitted with stage two pressure ulcers. Current interventions included, Low Air Loss Mattress. Review of the hospital discharge instructions on 9/15/22 included, .Why you were hospitalized .Your primary diagnosis was: Bilateral leg pain .Sarcoid neuropathy .Pressure injury of right buttock, stage 4 .Pressure injury of sacral region, stage 3 .Patient instructions .Wound Care Instructions: twice daily wound tx (treatment) to sacrum and buttocks. Cleanse wound space with wound cleanser. Gently remove exudate from wound space, do not scrub down to wound bed. Apply Triad ointment, cover with dry 4x4 gauze, secure with medipore tape. Prep periwound with skin barrier wipes. There will always be a white residue with Triad, warmed incontinence wipes will remove stubborn paste . Review of R49's physician orders since their readmission on [DATE] revealed the discharge treatment orders for twice daily were not implemented. The orders implemented on 9/15/22 to start on 9/16/22 read: Santyl Ointment 250 UNIT/GM (Collagenase) Apply to sacrum topically one time a day for wound care. Wound Care Order Site: (left blank) 1) Cleanse Wound with NS (Normal Saline) 2) Pat Dry with Gauze 3) Apply any ordered ointments (santyl) 4) Cover with ABS (an abdominal pad which is an extra thick dressing used for moderate to heavily draining wounds) 5) Tape and Date every day shift for wound care. The wound site sections of this order were left blank and was not clarified until 9/27/22 after the concern was identified during the survey. Prior to R49's hospitalization on 8/30/22, a physician order was in place for Monitor Low Air-Loss (LAL) Mattress Functioning and check that the settings are appropriate for the patient. every shift. This order did not get re-implemented upon R49's readmission on [DATE], and the resident remained without a LAL mattress through 9/28/22. Review of R49's progress notes and wound assessments from the resident's attending physician (Physician 'CC'), wound care physician (Physician 'T'), wound nurse practitioner (NP 'U') and the wound nurse (Nurse 'R') revealed multiple conflicting wound assessments. The resident's weekly Skin & Wound Evaluation from Wound Nurse 'R' on 9/16/22, 9/20/22 and 9/27/22 all documented these assessments were still in progress. The sections to identify the wound descriptions were left incomplete (blank) and only included measurements and pictures of the wounds. R49's pressure ulcer measurements included: Right buttock: On 9/16/22, stage 2: 0.3 cm2 (square centimeter) area; L (Length)=0.6 cm; W (Width)=0.6 cm; D (Depth)=0.2 cm. On 9/20/22, stage 2: 1.6 cm2 area; L=1.1 cm; W=2.0 cm; D=not applicable. On 9/27/22, stage 2 pressure: 1.2 cm2 area; L=3.1 cm; W=1.4 cm; D=not applicable. Sacrum: On 9/16/22, stage (none identified): 1.4 cm2 area; L=2.0 cm; W=0.9 cm; D=0.5 cm. On 9/20/22, stage (none identifi[TRUNCATED]