**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake number MI00151442 and MI00151852 Based on observation, interview, and record review the facility failed to provide for three out of three residents (Resident #105, #106, #111) care and services to prevent and promote healing of pressure ulcers resulting in worsening wounds, osteomyelitis, and hospitalization. Findings Included: Review of the facility Matrix, dated 4/8/25, the facility census was 69 and they had nine current residents with pressure ulcers and three had facility acquired pressure wounds. Review of two complaints received by the State Agency alleged the facility failed to prevent worsening of pressure ulcers for R105 and R106, who was known high risk for skin breakdown. Resident #106(R106) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R106 was a [AGE] year-old male admitted to the facility on [DATE], with re-admission 3/13/25 related to wound infection with other diagnoses that included traumatic brain dysfunction, cerebral vascular accident, acute respiratory failure with anoxic brain damage with tracheostomy, contracture of left knee and right knee, The MDS reflected R106 was dependent on staff for all care. Continued review of the MDS reflected R106 had one new stage 4 pressure ulcer(PU) (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed) not present on admission. During a telephone interview on 4/9/25 at 9:43 a.m., R106 Responsible Party (RP) K reported R106 was currently in the hospital for several infected worsening facility acquired pressure wounds since 4/1/25. R106 RP K facility staff were not turning and repositioning R106 enough and on several occasions appeared to be unkept and ungroomed. Review of R106 Physician Progress Note, dated 10/25/24, reflected, Patient is a 38M[male], medical history of TBI[traumatic brain injury],trach and PEG [percutaneous endoscopic gastrostomy] placement, nonverbal, AOx0[alert and oriented times 0] at baseline, who resides at [named long term care facility]. His brain injury occurred in April 2022 when he was struck by a vehicle on his bicycle. He was admitted to [named hospital] for medical management. He required PEG tube and tracheostomy. Ultimately, he was admitted to [named long term care facility] on 8/1/2024. He has required multiple ED[emergency department] visits for PEG tube replacement after being dislodged. Additionally, his most recent hospitalization was due to aspiration PNA [pneumonia]. However, he was recently able to be decannulated and is now doing well on room air .consulted for rehab needs and evaluation of contracture's and bruxism [grinding of teeth] . Review of R106 Provide Note, dated 10/28/24, reflected, Primary Chief Complaint: Skin: Pressure Wound .History Present Illness : 38M with hx[history] TBI, chronic resp.[respiratory] failure, nonverbal, total care, developed a new Stage 2 pressure wound on his coccyx .This is an acute new problem . Review of R106 Pertinent Charting Skin Note, dated 2/2/25, reflected, Location of skin area being documented: Coccyx, bilateral ischial tuberosities Coccyx, wound is white around the edges but improving with the wound bed. Cleaned and dressing applied. Right Ischial tuberosity has a fluid filled blister that is intact. Skin prep applied, let dry, then applied non-adherent pad then comfort foam border. Left: hip is open . Review of R106 Pertinent Charting Skin Note, dated 2/14/25, reflected, Location of skin area being documented: Coccyx, bilateral hips Coccyx wounds still declining, with the rim of wound white, skin prepped the outside of wound before applying dressing. Right hip doing well, still flush with skin, dressing applied. Left hip declining, slightly deeper than last observed by myself with significant amount of drainage . Review of R106 Pertinent Charting Skin Note, dated 2/17/25, reflected, Location of skin area being documented: Coccyx, Left hip, right hip left outer foot. Coccyx wound no change, but still not doing well, left hip is worse, wound is draining more and has an odor to it. Right hip is almost completely healed. This area looks great. Left outer foot has a blister on it .risk management started Review of R106 Wound Notes, dated 10/29/24 through 3/4/25, reflected the following: 10/29/24-Coccyx NEW Facility Acquired(FA) Stage 4 pressure ulcer(PU)--1.07 x 0.6 x 0.1 cm Start date 10/28/24. 2/4/25--Coccyx FA stage 4 PU-3.6 x 2.3 x 0.3 cm -Left Trochanter(hip) New Facility Acquired-6.7 x 3.3 x 0.2 cm--NEW -Right Trochanter New Facility Acquired blister-4.8 x 3.3 x 0.1 cm-NEW 2/18/25-Coccyx FA stage 4 PU-4.2 x 3.3 x 0.4 cm-slough -Right Trochanter FA PU-RESOLVED -Left Trochanter FA blister-3.9 x 5 x 0.2 cm-slough, dark non-granulation -Left lateral foot NEW hematoma-2.4 x 1.3 x 0 cm--NEW 3/4/25--Coccyx FA unstageable PU-4.7 x 3.0 x 0.4 cm--slough -Left Trochanter FA unstageable pressure-6.2 x 2.2-slough -Left lateral foot FA deep tissue injury-2.4 x 1.5 x 0 cm Review of R106 Provider Notes, dated 3/13/25, reflected, Primary Chief Complaint: readmission .Patient was sent to ED on 3/6 sepsis and sacral wound infection. Patient had a sacral decubital and it was debrided, and patient grew out Escherichia coli ESBL and Pseudomonas aeruginosa and staff. Patient was treated with Zyvox. And patient is requiring meropenem 500 mg every 6 hours and levofloxacin 750 every 24 hours for 6 weeks. Patient is being readmitted to the facility . Review of R106 Nursing Evaluation Summary Note, dated 3/13/25 at 9:21 p.m., reflected, Resident arrive via stretcher from [named] hospital after a hospital stay r/t[related to] infection . Review of R106 Physician History and Physical Note, dated 3/14/25, reflected, He is being seen for readmission to the facility after hospitalization at [named]. He was admitted for suspected sepsis with hypotension and tachycardia. Source was felt to be due to a sacral ulcer. He was taken for debridement on 3/8/25 with cultures showing ESBL E. coli and Pseudomonas. ID was consulted and recommended 6 weeks of meropenem and Levaquin .PICC[peripherally inserted central catheter] was placed on 3/13. Today, he was noted by nursing to have been grinding his teeth more, diaphoretic, and appearing more uncomfortable . Review of R106 Pertinent Charting-Infections/Signs Symptoms Note, dated 3/16/25, reflected, .Resident has had a difficult night tonight. Has been moaning and groaning, have given PR muscle relaxer and his scheduled medications and they do not appear to help. When dressing was completed, he did appear to settle down and is at this time quiet. Review of R106 Provider Wound Note, dated 3/18/25, reflected, Chief Complaint / Nature of Presenting Problem: Sacral and left hip pressure wounds History Of Present Illness:39yr old male requested by facility for evaluation of wounds and follow up related to coccyx, left lateral foot, and left hip pressure wounds .Coccyx stage 4 pressure Measurements- 5.1 x 3.7 x 1.5cm Tissue type- Pink non-granulation/slough .Infection- delayed healing/non-viable tissue .Wound Plan Of Care- Medihoney/lightly fluffed saline gauze/foam BID and prn .Wound Additional Orders- Caregiver staff to provide frequent turning and repositioning .Left lateral foot deep tissue injury Measurements- 3 x 1.7 x 0cm Tissue type- discolored epithelial .Left trochanter unstageable pressure Measurements- 6.6 x 7 x Unable to determine true depth Tissue type- pink non-granulation/slough .Wound Plan Of Care- Medihoney/lightly fluffed saline gauze/foam BID and prn . Review of R106 Provider Wound Note, dated 3/25/25, reflected, Coccyx stage 4 pressure Measurements- 5 x 3.8 x 1.2cm .Tissue type- Pink non-granulation/slough Peri Wound- fragile Drainage- Light serosanguineous Pain- none Infection- delayed healing/non-viable tissue Overall Wound Condition- stable Wound Plan Of Care- Medihoney/lightly fluffed saline gauze/foam BID and prn .Left lateral foot deep tissue injury Measurements- 2.8 x 1.7 x 0cm Tissue type- discolored epithelial Peri Wound- fragile .Left trochanter unstageable pressure Measurements- 7.7 x 7.6 x Unable to determine true depth Tissue type- pink non-granulation/slough Peri Wound- fragile Drainage- Light serosanguineous Pain- none Infection- non-viable tissue . Review of R106 Wound Provider Note, dated 4/1/25, reflected, Chief Complaint / Nature of Presenting Problem: Sacral and left hip pressure wounds History Of Present Illness: 39yr old male requested by facility for evaluation of wounds and follow up related to coccyx, left lateral foot, and left hip pressure wounds. Caregiver staff notes recent fevers and odor from buttocks wounds .Coccyx unstageable pressure Measurements- 5.8 x 5.2 x unable to determine true depth Tissue type- slough/dark avascular tissue Peri Wound- fragile Drainage- Light serosanguineous Pain- none Infection- delayed healing/non-viable tissue Overall Wound Condition- deterioration .Left lateral foot deep tissue injury Measurements- 2.8 x 2 x 0cmTissue type- discolored epithelial .Overall Wound Condition- stalled Wound Plan Of Care- skin prep and OTA daily .Left trochanter unstageable pressure Measurements- 7.8 x 7 x Unable to determine true depth Tissue type- pink non-granulation/slough Peri Wound- fragile Drainage- Light serosanguineous Pain- none Infection- non-viable tissue .Right trochanter blister Measurements- 1.5 x 2.5 x 0.1cm Tissue type- dermal Peri Wound- fragile .Overall Wound Condition- new .Right Upper arm blister lateral Measurements- 1.3 x 0.9 x 0cm Tissue type- fluid filled epithelial Peri Wound- fragile .Overall Wound Condition- new .Right Upper arm blister medial Measurements- 1.8 x 0.5 x 0cm Tissue type- fluid filled epithelial Peri Wound- fragile .Overall Wound Condition- new .Reclassified sacral wound as unstageable d/t increase in slough and appearance of avascular tissue. Concern as wound continues to deteriorate despite use of IV meropenem and levaquin. Pt now experiencing blisters in recurrent areas such as his right trochanter. Pt likely requires advanced imaging and diagnostics to assist in identifying underlying reason for sacral wound deterioration. Notified physician and she agreed pt should be transferred to [named] ER for further evaluation . Review of R106 Skin Care Plan, dated 8/1/24, reflected interventions that included, Assist resident with turning and repositioning per facility protocol and PRN. Resident utilizes pillows and wedges to assist with offloading boney prominence .Preventative treatment(s) per orders . Provide incontinence care as needed .Provide incontinence care as needed . Review of R106 Treatment Administration Record, dated 2/1/25 through 3/31/25, reflected R106 had 20 missed wound treatments, as evidenced by no documentation as completed, for facility acquired pressure wounds. Continued review of the TAR reflected Provider order for twice daily wound care to R106 Coccyx wound was completed daily (seven missed treatments). Review of R106 facility, Documentation Survey Report v2(Task Report), dated 2/1/25 through 3/31/25, reflected R106 had task, Assist/Remind to Turn and Reposition per Care Plan and PRN. The Report reflected R106 had 42 eight-hour shifts that R106 was not turned and repositioned, as evidenced by no documentation as completed. Resident #111(R111) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R111 was a [AGE] year-old female admitted to the facility on [DATE], with re-admission 4/5/25 related to wound infection with other diagnoses that included non-traumatic brain dysfunction, heart failure, and seizure disorder. The MDS reflected R111 was dependent on staff for all care. Continued review of the MDS reflected R111 had one unstageable pressure wound related to slough in wound bed and one unstageable pressure wound related to suspected deep tissue injury both on admission. During an observation on 4/9/25 at 3:15 p.m., Registered Nurse (RN) C entered R111 room with dressing supplies to complete wound care treatment. R111 was laying in bed and was nonverbal. CNA staff assisted with positioning. RN C removed old dressing dated 4/8/25 that was saturated over sacral area. R111 had large sacral wound the size of small football with about 50 % slough in base of wound. RN C cleaned would bed with normal saline and gauze, ointment, then place dry gauze pads loosely under border foam dressing. RN C reported R111 admitted with sacral wound and was recently re-admitted to hospital related to osteomyelitis (bone infection). Review of R111 Physician order, dated 4/5/25, reflected, Monitor sacral wound, if saturated/ missing replace every day and night shift for WOUND CARE related to PRESSURE ULCER OF SACRAL REGION Review of R111 Provider Note, dated 2/27/25, reflected, [AGE] year old seen today for new admission. She is currently resting in bed. She was admitted to the hospital secondary to cardiac arrest .Her neurological status did not improve and neurology was consulted, EEG[brain activity scan] showed no seizure and did show diffuse encephalopathy. MRI[soft tissue scan] brain showed anoxic brain injury pattern. She had trach and peg placed on 2/11. She was also treated for Klebsiella UTI and moraxella and MSSA[type of bacteria] pneumonia and she did complete course of antibiotics. She then continued to have fevers and ID[infectious disease] rec to continue with Cefazolin for 14 days as repeat respiratory culture showed MSSA. She has picc line in place . Review of R111 Nursing Evaluation Summary, dated 2/27/25, reflected, Skin assessment completed and open areas to coccyx and right gluteal fold noted as well as DTI[deep tissue injury] to right heel, no other skin issues noted. Review of R111 Wound Notes, dated 2/27/25 through -----, reflected the following: 2/27/25-Coccyx-3.69 x 1.48 cm 3/4/25--Coccyx unstageable PU-3.6 x 3.7 unable to determine depth related to slough. -Right ischium stage 2 pressure-0.6 x 0.5 x 0.1 cm -Right heel deep tissue injury-1.4 x 1 x 0 cm 3/18/25-Coccyx unstageable PU-9.7 x 7.2 x unable to determine related to slough/dark non- granulation. Note, Caregiver staff to provide frequent turning and repositioning to offload wounds. -Right heel deep tissue injury-1.1 x 1.2 x 0cm 3/25/25-Coccyx unstageable PU-11.9 x 8.9 x unable to determine depth related to slough, deterioration. -Right heel-1.1 x 1 x 0 Continue review of wound note, dated 3/25/25, reflected, Ordered 2 V xray of sacral wound d/t continued acute deterioration AEB[as evidenced by] increase in size, significant odor, and delayed healing. Ordered metrogel applied to wound followed by dakins gauze. Later during documentation reviewed xray results showing suspicion for osteomyelitis. Discussed results with physician and authorized transfer to [NAME] ER for advanced imagining, culturing, abx [antibiotic]selection, and debridement of wound. DON notified. Called facility and notified nursing of findings and requested pt be sent to [NAME] ER along with xray results . Review of R111 Provider Progress Note, dated 4/7/25, reflected, Chief Complaint / Nature of Presenting Problem: Re admission, osteomyelitis History Of Present Illness:[AGE] year old seen today for re admission she was in the hospital secondary to osteomyelitis. There is no discharge summary at this time. Reviewed progress notes in [named EMR] and she was admitted to the hospital with concern for worsening decubitus ulcer, she had CT scan that showed coccygeal soft tissue ulceration . worrisome for osteomyelitis. She was placed on IV antibiotics and ID was consulted. Review of R111 Hospital Infectious Disease Consult, dated 4/2/25, revealed diagnosis that included osteomyelitis of scrum and coccyx, stage 4 pressure ulcer and sepsis. Review of R111 Treatment Administration Record, dated 3/1/25 through 3/25/25, reflected R111 had 4 missed wound treatments, as evidenced by no documentation as completed, for worsening coccyx pressure wound. Review of R111 facility, Documentation Survey Report v2(Task Report), dated 3/1/25 through 3/25/25, reflected R111 had task, Assist/Remind to Turn and Reposition per Care Plan and PRN. The Report reflected R111 had 23 eight-hour shifts that R111 was not turned and repositioned, as evidenced by no documentation as completed. Resident #105(R105) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R105 was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included cerebral vascular accident with current comatose state, acute respiratory failure with anoxic brain damage with tracheostomy, Pulmonary embolism, diabetes mellitus, hypertension, and one stage 2 pressure ulcers present on admission and one unstageable pressure ulcer not present on admission. The MDS reflected R105 was dependent on staff for all care. Continued review of the MDS, dated [DATE], reflected R105 had one new unstageable pressure wound not present on admission [DATE]). During a telephone interview on 4/9/25 at 9:32 a.m., R105 family I reported R105 admitted to facility 10/30/24 with an open area on coccyx area and on left side. R105 family I reported R105 coccyx area was almost healed, and staff stopped repositioning R105 and wound gradually worsened and R105 developed new skin breakdown on right side at the facility. R105 family I reported R105 was re-admitted several times to the hospital for repeat wound infections, last time on 3/26/25 and stated, tired of it, she had been through enough. R105 family reported spoke with management several times with concerns that R105 was not being turned and repositioned every two hours and they hung a turning log on wall over R105 bed that staff were instructed to document every time R105 was turned. R105 family member reported log was incomplete and still in R105 room. During an observation and record review on 3/9/25 at 9:40 a.m., R105 name was posted outside room door and turning log document was hanging on the wall above the head of the bed. The log reflected, Resident needs to be turned q2[every two] hours and PRN [as needed]. Continued review of the log reflected first entry 3/13/25 at 6:40 p.m. with L circled that indicated turn direction with a total of six entries including last, dated 3/16/25, for four days. (If R105 was turned every two hours, should be 12 entries each day on log for a total of 156 entries between 3/13/25 and 3/26/25). Review of R105 Electronic Medical Record (EMR), dated 10/30/24 through 3/26/25, reflected R105 admitted to facility 10/30/24 and transferred to hospital 12/10/24 and return 12/24/24. Continued review of the EMR reflected R105 was transferred to the hospital on 1/28/25 and returned to facility 2/21/25. Continued review of the EMR reflected R105 re-admitted back to the hospital on 3/26/25 and had not returned to the facility. Review of R105 Provider Progress Note, dated 10/31/24, reflected, History Of Present Illness: [AGE] year old seen today for new admission. She is currently resting in bed and her husband is at bedside. She had PEA [pulseless electrical activity] arrest and CT [computed tomography scan] chest which showed PE [pulmonary embolism] with moderate clot burden and multifocal consolidation and groundglass disease. She was seen by IR [interventional radiology] and had thrombectomy. CT showed cerebral ischemia. Per notes brainstem reflexes intact but not definite sign of higher function. She was seen by neurology. She was treated for UTI [urinary tract infection]. Urine culture showed e faecium and respiratory cultures showed pseudomonas. She does have trach in place and peg tube. Her husband tells me before she was hospitalized with her blood clots she was pretty healthy. Review of R105 Pertinent Charting-Skin Progress Note, dated 10/31/24 at 8:31 a.m., reflected, Event Date: 10/30/24 Location of skin area being documented: coccyx and left rear thigh Description: pressure ulcers .Physician notification: Resident admitted to facility with wounds, Provider aware. Review of R105 Social Services Progress Note, dated 11/4/24, reflected, IDT [interdisciplinary team] met with res and husband for initial CC [care conference] .Expressed concerns about preventing pressure wounds. Nursing explained res is on a schedule for repositioning . Review of R105 Provider Wound Notes, dated 11/5/24 through 12/3/24, reflected the following: 11/5/24-Coccyx stage 3 pressure-5.5 x 3.9. 0.2 cm -Left rear thigh stage 2 pressure with no measurements noted. Wound Additional Orders-Caregiver staff to provide frequent turning and repositioning to offload wounds. 11/12/24-Coccyx stage 3 pressure-1.4 x 1.7 x 0.2 cm -Left rear thigh stage 2 pressure-RESOLVED. 11/26/24-Coccyx stage 3 pressure-0.6 x 0.4 x 0 cm 12/3/24-Coccyx stage 3 pressure-1.11 x 0.94 cm Review of Provider Note, dated 12/10/24, reflected, This is an acute new problem Condition is guarded 47yo[year old] female with respiratory failure, anoxic brain damage, HTN[hypertension] who has a BP[blood pressure] of 87/53 with a HR[heart rate] of 118 and now desaturating down to 88% on 2L[liters]. She is grey appearing, tachypneic. Orders : Transfer to Emergency Department . Review of R105 Hospital Discharge documentation, dated 12/24/24, reflected R105 had discharge diagnosis that included, severe sepsis, pyelonephritis, pneunomonitis, and decubitus ulcers. Review of R105 Provider Progress Note, dated 12/30/24, reflected, patient with new pressure ulcers on R[right] & L[left] buttocks. L buttocks [NAME] areas of blistering, no drainage, R buttocks is an area of redness, no open wound .Physical Exam - Notes : SKIN stage 1 pressure ulcer R buttocks, stage 2 pressure ulcer L buttocks .Pressure ulcer of left buttock, stage 1 This is an acute new problem Condition is stable cover with xeroform, change daily wound care consultL89312 - Pressure ulcer of right buttock, stage 2 (Primary) This is an acute new problem Condition is stable cover with xeroform, change daily wound care consult . Review of R105 Wound Notes, dated 12/24/24 through 1/28/25, reflected the following: 12/24/24-Coccyx stage 3 pressure-6.57 x 7.92 cm(no mention of other wounds) 12/30/24-Coccyx stage 3 pressure-9.07 x 5.58 cm (worsened) 12/31/24-Coccyx stage 3 pressure-7.9 x 8 x 0.2 cm -Right gluteus blister-4 x 5.9 x 0.1 cm, non-viable dark epithelial (New Facility acquired) 1/7/25-Coccyx stage 3 pressure-9.1 x 5.7 x 0.3 cm(Worsened) -Right gluteus blister -4.8 x 3.6 x 0.2 cm (Facility acquired) 1/14/25-Coccyx stage 3 pressure-8.6 x 4.5 x 0.3 cm -Right gluteus blister-3.2 x 1.8 x 0.2 cm (Facility acquired) 1/21/25-Coccyx stage 3 pressure-7.9 x 4.6 cm, overall wound condition deterioration. -Right gluteus blister-2.7 x 1.2 cm (Facility acquired) 1/28/25-Coccyx stage 3 pressure-7.4 x 4.1 cm -Right gluteus blister-3.1 x 1.8 cm (Facility acquired) Review of R105 provider note, dated 1/28/25, reflected, .Called husband to request consent for conservative sharps debridement of wounds. Husband requested pt be sent to [named] ER [emergency room] for further evaluation of wounds and debridement in hospital as he is currently unwilling to allow debridement within facility. Facility leadership and nurse notified and pt[patient] transferred to [named] ER . Review of R105 Hospital Discharge summary, dated [DATE], reflected, Patient is a [AGE] year-old female who presented to [named hospital] with worsening sacral ulcer .admitted to medicine for sacral ulceration, abdominal abscess .SURGERY Consulted, S/p Bedside Debridement Sacral ulceration 1/30/2025-RECOMMEND Continue DAILY wound care at Discharge. RECOMMEND Continue frequent repositioning. RECOMMEND CLOSE Follow up SURGERY/Wound Clinic at discharge if Able . Review of R105 Nurse Progress Note, dated 2/23/25, reflected, Resident returned from Hospital with left upper arm midline /IV ATB therapy(meropenem) for bacterial infection to be continued until 2/28/25. Review of R105 History and Physical, dated 3/1/25, reflected, She is being seen for readmission to facility after hospitalization at [named]. She presented to the ED with worsening sacral ulcer and fever .Surgery was performed on bedside debridement of the sacral ulcer on 1/30/25. She will need ongoing daily wound care and follow up with the [named] wound clinic .Abscess of abdominal cavity . Review of R105 Wound Notes, dated 3/4/25 through---, reflected the following: 3/4/25-Sacrum pressure-7.1 x 6.4 x unable to determine true depth. -Right gluteus blister-2 x 1 x unable to determine true depth. (Facility acquired) 3/11/25-Sacrum pressure-6.7 x 3.8 x unable to determine true depth, Tissue type slough -Right gluteus blister-3 x 1.7, Tissue type slough/crusting (Facility acquired) 3/18/25-Sacrum pressure-7.7 x 3.8 x unable to determine true depth, Tissue type: slough. -Right gluteus unstageable pressure-2.8 x 1.2 x unable to determine true depth, slough. (Worsening and Facility acquired) 3/25/25-Sacram pressure-6.4 x 5.8 x unable to determine true depth, slough -Right gluteus unstageable pressure-0.6 x 0.5, unable to determine true depth, slough. (Worsening and Facility acquired) Review of R105 Skin Care Plan, dated 10/30/24, reflected, Resident has impaired skin integrity as evidenced by: Unstageable pressure wound to sacrum, Unstageable pressure injury to rear right thigh related to immobility, anoxic brain damage, respiratory failure, tube feed status .Revision on: 03/20/2025. Continued review reflected interventions that included, Administer treatment(s) per orders .Assist resident with turning and repositioning as needed . Review of R105 Nurse Progress Note, dated 3/26/25, reflected, Res[resident] was having appt with wound clinic. Doctor sent her to [named] ER d/t[related to] worse than anticipated infection to the wounds . Review of R105 Treatment Administration Record, dated 12/1/24 through 3/26/25, reflected R105 had 21 missed wound treatments, as evidenced by no documentation as completed, for coccyx wound and facility acquired right gluteus pressure wound. Continued review of the TAR reflected documentation indicating to see Progress Notes with no evidence of Progress Notes completed on correlating dates. Review of R105 facility, Documentation Survey Report v2(Task Report), dated 1/1/25 through 3/26/25, reflected R105 had task, Assist/Remind to Turn and Reposition per Care Plan and PRN. The Report reflected R105 had 37 eight-hour shifts that was not turned and repositioned, as evidenced by no documentation as completed. During an interview on 4/10/25 at 2:15 p.m., Unit Manager (UM) G reported wounds were assessed every seven days wound team that included wound nurse and wound provider. UM G reported would expect floor nurses to follow Physician treatment orders and document on Treatment Administration Record (TAR) as completed. UM G reported would expect Certified Nurse Aids (CNA) staff to turn and reposition residents every two hours if indicated on the Care Plans and document in the Task documentation (CNA Point of Care Electronic Medical Record). UM G reported the TAR and the Task documentation should not have wholes (no documentation as completed). UM G reported would follow up. Requested UM G for evidence that R106 facility acquired pressure wound was unavoidable. During a telephone interview on 4/10/25 at 4:20 p.m., Wound Nurse (WN) J reported R105 had small coccyx wound on admission that worsened and was later documented as Sacrum wound. WN G reported R105 developed facility acquired pressure ulcer to right gluteus that started blister and was later reclassified to unstageable because of slough in base of wound. WN G reported R105 Coccyx wound was documented as stage 3 pressure wound on admission related to hospital documentation with prior history and verified was small on admission with 0.2 cm depth. During a second interview on 4/10/25 at 4:40 p.m., UM J reported it was discovered recently Wound Nurse (WN) G was not documenting wound treatments as completed on TAR on Tuesdays. UM J verified R105, R106 and R111 had holes on TAR and reported some were documented in progress notes as treatments in place and not on TAR and was unsure why and verified should be documented on TAR as completed with no holes, which reflect missed treatments. UM G reported facility has had issue with staffing for past few months and recent improvements in past two weeks. UM G reported had worked the floor several times in past 2 months to fill in for call-ins with long shifts. UM G reported had also worked as CNA staff to make sure facility has at least three CNA staff in facility. During a second telephone interview on 4/10/25 at 4:58 p.m., WN G reported R105 was unable to locate evidence R105, R106 or R111 worsening pressure ulcers and facility acquired pressure ulcers were unavoidable and reported appropriate interventions were on the Care Plans and staff were expected to follow Care Plans and physician orders. WN G verified R105, R106 and R111 were all at high risk for skin breakdown. WN G reported last week had noticed that wound rounds were not documented as completed on TAR and verified if nurses complete treatment orders should document on TAR as completed. WN G reported facility had staffing issues past couple months with recent improvements. WN G reported facility had several residents that required every two hour turn and repositioning assistance with times with only three CNA staff in entire facility and reported was not possible turn residents every 2 hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake M100134214 Based on interview and record review, the facility failed to routinely assess and monitor a resident with COVID-19 for one (Resident # 6) of 3 residents reviewed for quality of care, resulting in failure to identify a change in resident condition resulting in ongoing deterioration to death. Findings include: Resident #6 (R6) was readmitted to facility [DATE] with diagnoses including acute and chronic respiratory failure, chronic obstructive pulmonary disease, acute ischemic heart disease, sleep apnea, and nicotine dependence. Review of Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] reflected a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 9 (moderate cognitive impairment). Section G of MDS revealed that R6 required one-person limited assist with bed mobility, transfers, and toilet use, and was independent with meals after set-up. Review of a second MDS dated [DATE] reflected that R6 deceased while at the facility. Review of R6's medical record completed with the following findings noted: Physician Progress Note dated [DATE] at 11:23 AM stated, .acute COVID 19 positive .patient has some decreased breath sounds, otherwise appears relatively asymptomatic, denies chest pain or shortness of breath . Nurses' Notes dated [DATE] at 2:16 PM stated, .Resident noted to be complaining of shortness of breath today. Rapid test for COVID completed and came back positive. Provider is aware. Review of all Progress Notes revealed no additional Physician Notes or Nurses' Notes from [DATE] through [DATE]. Orders-Administration Note dated [DATE] at 3:56 PM and 3:57 PM stated, .Resident is resting comfortably and does not want to take meds (medications). Nurses' Notes dated [DATE] at 7:07 PM and completed by Registered Nurse (RN) C stated, .About 1730 (5:30 PM) I found resident was found unresponsive. I tried to wake him to no avail. 1731 (5:31 PM) I immediately went to nurse (RN D's name) and told him (R6's name) was unresponsive and I saw (Physician I's name) and asked (RN D's name) to get him while I went back to the (R6's name). I grabbed a stethoscope to listen for breathing and heart sounds. 1733 (5:33 PM) I am back at the bedside of (R6's name) and he remains unresponsive as I listen for a full minute for breath and/or heart sounds. 1734 (5:34 PM) Overhead I hear the code called by (Social Worker F's name). 1735 (5:35 PM) (Physician I's name) arrives and begins compressions and the respiratory therapist brings a bag mask and begins bagging. (Physician I's name, RN G's name, RN H's name, and I) rotate compressions. A nurse grabs the AED (Automated External Defibrillator) and backboard and the AED is placed on (R6's name) as compressions and breaths continue. 1740 (5:40 PM) EMS (Emergency Medical Service) arrives and takes over. They place a mechanical compression device on the resident and continue breaths. The team continued to work on him for 5 rounds before calling time of death at 1748 (5:48 PM). Physician from (local hospital's name) pronounced (R6's name) death as respiratory failure . Nurses' Notes dated [DATE] at 7:26 PM and completed by RN C stated, .Around 1600 (4:00 PM) I check the resident to take his VS (Vital Signs) as the tech came to me a few minutes before alerting me his BP (Blood Pressure) and SPO2 (Oxygen saturation--a measurement of how much oxygen your blood is carrying as a percentage of the maximum it could carry) was low. I went to take a manual BP, but was unable to get a read. I retook the BP with the machine and got 84/48 and SpO2 was 97% (percent) on 5L (liters). He was fatigued, but responsive .I was worried about his BP and was planning to call the doctor for the next steps. I thought he may need IV (intravenous) fluids as he was not eating or drinking much. Physician Progress Note with a [DATE] 4:56 AM created date and a [DATE] 4:56 AM effective date stated, .Patient seen for acute cardiopulmonary arrest .Called to room urgently as patient had a cardiopulmonary arrest and had a code performed .Is still a full code and became unarousable and pulseless .Code performed for 45 minutes, EMS arrived and participated with them. Patent had chest compressions and bagging, had acute automatic defibrillator placed and was not in a shockable rhythm. Code continued once EMS arrived. Patient ultimately expired . COVID Skilled Note dated [DATE] at 6:15 PM with a [DATE] 3:00 AM lock date indicated [DATE] 10:21 PM Vital Signs as follows: Temperature (Temp): 98.9 degrees Fahrenheit, Blood Pressure (BP): 119/60, Pulse: 59 beats per minute, Respirations (Resp): 16 breaths per minute, O2 sats (oxygen saturation): 92.0% (percent) with oxygen via Nasal Cannula. Note also indicated that R6 had a positive Covid test, was in Covid isolation, and had loss of appetite with assessment including no additional details regarding R6's cardiac and respiratory status. COVID Skilled Note dated [DATE] at 2:15 AM with [DATE] 3:00 AM lock date reflected the same Vital Signs obtained [DATE] at 10:21 PM with Temperature: 98.9 degrees Fahrenheit, Blood Pressure: 119/60, Pulse: 59 beats per minute, Respirations: 16 breaths per minute, O2 sats: 92% with oxygen via Nasal Cannula. Note also indicated that R6 had a positive Covid test, was in Covid isolation, and had loss of appetite with assessment including no additional details regarding R6's cardiac and respiratory status. Order dated [DATE] at 2:13 PM with [DATE] 10:00 PM start date stated, Vital Signs including oxygen saturation each shift. Review of Medication Administration Record dated [DATE] through [DATE] reflected order, Vital Signs including oxygen saturation each shift with entries as follows: [DATE] Night BP: 103/34, Temp: 97.6, Pulse 71, Resp: 18, O2 sats: 93% [DATE] Day BP: 103/34, Temp: 97.6, Pulse 71, Resp: 18, O2 sats: 86% [DATE] Evening BP: 89/50, Temp: 98.2, Pulse: 63, Resp: 16, O2 sats: 90% [DATE] Night BP: 96/52, Temp: 98.1, Pulse: 77, Resp: 20, O2 sats: 98% [DATE] Day BP: 104/61, Temp 97.2, Pulse: 86, Resp: 20, O2 sats: 91% [DATE] Evening BP: 104/61, Temp: 97.2, Pulse 86, Resp: 20, O2 sats 94% [DATE] Night BP: 104/61, Temp: 97.2, Pulse 86, Resp: 20, O2 sats 94% [DATE] Day BP: 104/61, Temp: 97.2, Pulse 86, Resp: 20, O2 sats 94% [DATE] Evening BP: 104/61, Temp: 97.2, Pulse 86, Resp: 20, O2 sats 94% [DATE] Night BP: 119/60, Temp: 98.9, Pulse: 59, Resp: 16, O2 sats: 92% [DATE] Day BP: 119/69, Temp: 98.9, Pulse: 59, Resp: 16, O2 sats: 87% Review of all Vital Signs documented within the March MAR, Vital Sign tab within PCC (Point Click Care), and the [DATE] and [DATE] COVID Skilled Notes reflected the same Blood Pressure, Temperature, Pulse, and Respiratory Rate on [DATE] night and [DATE] day shifts; the same Blood Pressure, Temperature, Pulse, and Respiratory Rate across the [DATE] day, [DATE] evening, [DATE] night, [DATE] day, and [DATE] evening shifts; and the same Blood Pressure, Temperature, Pulse, and Respiratory Rate on [DATE] night and [DATE] day shifts. In a telephone interview on [DATE] at 12:14 PM, Certified Nurse Aide (CNA) E stated familiarity with R6 and confirmed that she was R6's assigned CNA on [DATE] from 6:00 AM to 6:00 PM. Per CNA E, R6 was independent with transfers, toilet use, and wheelchair mobility prior to his Covid diagnosis but quickly became weaker, required more assist, started sleeping more, and did not get out of bed. CNA E stated that at the beginning of her 6:00 AM to 6:00 PM shift on [DATE], R6 was alert and talkative but by the middle of the shift, R6 was no longer responding to her. CNA E stated that in the morning of [DATE], she obtained R6's vital signs, did not recall that any of the vital signs were out of his normal and that it was her routine to enter the vital signs into the computer but that if she did not, she would have just given them to the nurse to enter. CNA E stated that she also emptied R6's catheter and set up his breakfast tray and recalled that he ate his ice cream but thought that he may have refused the remainder of the meal. CNA E stated that with 10:00 AM rounds on [DATE] R6 was sleeping, she awakened him to check his brief but that he was still half asleep, grunted but did not arouse any further. Per CNA E, R6 was still sleeping with 2:00 PM rounds, moaned when she tried to awaken him, was no longer responding verbally, hands were cold and that she could not obtain his oxygen level, blood pressure, or pulse with the vital sign machine. CNA E stated that she watched R6's breathing and although could not recall what his respirations were, stated that his respirations were really quick. CNA E stated that she exited the room and alerted RN C of R6's decreased level of responsiveness and inability to obtain vital signs and that RN C acknowledged her stating that she would have to check his vital signs manually. CNA E stated that as she was concerned about R6, she tried to awaken him again around 3:00 PM without success and again alerted RN C. CNA E stated that she was unsure if RN C checked on R6 as she proceeded to continue with rounds on remainder of assigned residents and that she did not see R6 again until she completed postmortem care. In a telephone interview on [DATE] at 3:36 PM, RN C confirmed familiarity with R6 stating that she was his assigned nurse from 6:00 AM to 6:30 PM on both [DATE] and [DATE] and denied receiving any information in report on either date that would have indicated a change in status for R6. RN C stated that on [DATE], R6 did ok throughout the shift and that, from what she could recall, his vital signs had been stable. On [DATE], RN C stated that R6 was more tired than usual and seemed lethargic at start of shift but that when she entered his room at approximately 8:00 AM, he had eaten some ice cream for breakfast and that she reviewed his vital signs and didn't see anything out of the ordinary. When questioned as to why the blood pressure, temperature, pulse, and respirations documented on the MAR for [DATE] day shift reflected the exact values as the shift prior ([DATE] night shift), RN C stated that happened when the use last charted option was selected when documenting vital signs on the MAR but that she had charted the vitals that CNA E had obtained and entered into the chart earlier that morning. When informed that review of R6's medical record contained no documented vital signs from the morning of [DATE], RN C clarified that sometimes the CNA's obtained the vital signs and provided them to the nurse so that the nurse could enter them but could not recall that if on that day the CNA entered the vitals or if she entered them herself after the CNA provided them to her. When questioned about the [DATE] day shift MAR reflecting an O2 sat level of 87%, RN C stated that R6 had been on oxygen but that she could not recall the number of liters and stated that she did not have to adjust the number of liters as recalled that his level was fine on whatever number he was already on. RN C stated that she entered R6's room next between 12:00 PM and 1:00 PM at which time he was noted to be sluggish, slower to verbally respond, and moving slower but that he still took the medication cup from her and took his medication independently. RN C stated that she completed a brief assessment on R6 during that time which included an assessment of his level of consciousness and listened to heart and lung sounds but that information was not documented as everything checked out ok at that time. RN C stated that as R6's vital signs had been fine earlier in the shift (which reflected the documented vital signs from [DATE] at 10:21 PM), she did not consider obtaining follow up vital signs at that time even though R6 was noted to be sluggish and slower to verbally and physically respond then he had been at start of the [DATE] 6:00 AM shift. RN C stated that she next observed R6 at approximately 4:00 PM as he had scheduled medications due at that time. Per RN C, R6 was observed from the doorway of his room and as he was resting comfortably she did not enter his room to check on him further or attempt to administer his scheduled 4:00 PM medications. RN C denied having any verbal interaction with R6 at that time. RN C stated that she checked on R6 again at approximately 5:00 PM as was approached by RN D with concerns that R6 did not look right. RN C stated that R6 was unresponsive at that time, no pulse was palpated, and that his body was ice cold. RN C stated that she exited R6's room, informed RN D that R6 was unresponsive, went back to room to check pulse and breathing and try to get him to respond but that she did not hear breath or heart sounds with the stethoscope and that a short time later, Physician I entered room, confirmed R6 was a full code, and started chest compressions. RN C stated that at no time during the [DATE] 6:00 AM to 6:00 PM shift did CNA E notify her that she was unable to awaken R6 or obtain vital signs. Per RN C, both R6's 6:00 AM and 2:00 PM vital signs were fine, to her knowledge, as CNA E never approached her with any concerns. Furthermore, RN C stated that she could not recall trying to obtain a BP, prior to the 5:00 PM check, and that she used the electronic machine at that time denying that she had tried obtaining a manual BP prior. RN C denied physician notification of changes in vital signs including oxygen saturation levels as stated that, to her knowledge, R6's vital signs were stable throughout the shift until approximately 5:00 PM when he was unresponsive. Furthermore, RN C denied that she had notified physician of the lethargy that she had noted at start of shift or R6's poor oral intake as stated that she thought he was a DNR (Do-Not-Resuscitate) as he had recently been diagnosed with cancer and was considering Hospice. In an interview on [DATE] at 7:38 AM, Director of Nursing (DON) B stated that when a resident was diagnosed with Covid, an order would be written for completion of vital signs and stated that vital signs should be completed every shift (three times daily) and that a nursing assessment should be completed within a Covid Skilled Note once daily. Per DON B, although a Covid assessment was completed and documented once daily, the expectation would be for an assessment to be completed and documented within a nurse progress note when a change in resident condition was depicted and for physician notification at that time. Regarding the documentation of identical vital signs from shift to shift, DON B stated that this had not been identified with R6 and would need time to review the chart further. Upon review of R6's vital signs documented within the [DATE] MAR and the vital signs documented within the Vital Sign task, DON B confirmed that the blood pressure, pulse, temperature, and respirations documented for the day shift of [DATE] were the same vital signs documented for the night shift on [DATE]. DON B further stated that she believed R6's vital signs were obtained the morning of [DATE] but must not have been documented and stated that she would dig to see if she could find them somewhere. DON B provided no additional assessment or vital sign documentation for R6 prior to survey exit. In an interview on [DATE] at 8:02 AM, RN D confirmed familiarity with R6, stated that he worked the 6:00 AM to 6:00 PM shift on [DATE], and that he was assigned to the other medication cart on the unit on that date. RN D stated that although he was not assigned to R6 on [DATE], that he just happened to walk down toward R6's room, noted R6's door to be open a little and stated, he looked pale and just didn't look right from the doorway. RN D stated that he informed R6's assigned nurse, RN C, and that she entered R6's room, at that time, and reapproached him fairly quickly, probably within 1 to 1.5 minutes, to notify him that R6 was unresponsive. In a telephone interview on [DATE] at 10:04 AM, Physician I stated that R6 had severe COPD (Chronic Obstructive Pulmonary Disease), CAD (coronary artery disease), and significant depression over many years with suicidal ideation and close Psychiatric follow-up. Per Physician I, R6's biggest physical decline started with abdominal pain which resulted in a work-up and eventual diagnosis of pancreatic cancer and that around the time he was diagnosed with cancer, R6 developed Covid. Physician I stated that, from what he could remember, R6 was fairly asymptomatic from the Covid as his oxygen levels remained stable and he was still getting up. Physician I stated that he did not believe that he was personally notified of R6's oxygen level of 87% in the AM of [DATE] and upon review of the call logs from his on-call service, confirmed that he did not see any calls from that date/time. Physician I further confirmed that he did not receive a specific call from staff regarding R6 throughout the day on [DATE] and that if he would have been notified of concerns with progressive hypoxia, he would have reviewed the chart to assure that the appropriate orders were in place. Physician I stated that if there was no indication in R6's medical record that he was contacted, then he probably wasn't and stated that he did not recall providing an order to increase R6's oxygen level to 5 liters. Review of the facility policy titled Notification of Changes with a [DATE] reviewed/revised date stated, Policy .The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, resident's representative when there is a change requiring notification .For changes of condition the facility may use: SBAR (Situation, Background, Assessment, and Recommendation) process for assessment, documentation and report to the practitioner 2. Care Paths for the INTERACT (Interventions to Reduce Acute Care Transfers) program 3. Sepsis protocols .Circumstances requiring notification include .2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status .3. Circumstances that require a need to alter treatment. This may include: a. New treatment b. Discontinuation of current treatment due to: i. Adverse consequences. ii. Acute condition .