**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intakes 1275497 and 1275498. Based on observation, interview, and record review, the facility failed to: 1) operationalize policies and procedures, 2) provide services as documented, 3) notify physician of wounds with oversight, 3) timely interventions of wounds, and 4) implement care plan interventions of wounds for 3 residents (R5, R6, and R9) of 4 residents reviewed for pressure ulcers, resulting in the development and worsening of pressure ulcers. Findings include: Review of a policy titled Pressure Injury Prevention and Care, last reviewed 1/2025 revealed: 1. Nurses will complete the Skin Body Assessment Observation upon admission/readmission, then weekly and as needed. 2. Nurses will complete Braden Scale for residents on admission/readmission, weekly for 4 weeks, quarterly, at time of new pressure injury identification, and as needed. 5. Interventions will be implemented, and care planned to prevent pressure injury development or to promote pressure injury resolution. 6. Pressure injuries will be assessed and documented upon admission, readmission, upon discovery, and weekly thereafter. Assessment may include the size, location, category/stage, odor (if any), drainage (if any), peri-wound condition, wound edges, undermining, tunneling, exudate, pain, and current treatment order. 7. Physicians and responsible parties will be notified of pressure injury upon identification and with change in status of pressure injury. 8. Physician/provider will be notified if pressure injury shows signs of deterioration, infection, or no improvement for further evaluation and recommendations regarding treatment and interventions. Resident #5 (R5) Review of a Face Sheet revealed R5 originally admitted to the facility on [DATE]. No diagnoses of pressure ulcers. Review of the Progress Notes for R5 revealed she died in the facility on [DATE]. Review of a Facility Reported Incident (FRI) dated [DATE] regarding an allegation of R5 not receiving a pressure ulcer dressing change in 5 days. The facility reported Registered Nurse (RN) G provided a dressing change on [DATE] for R5 and initialed and dated the dressing that day. RN G also provided care on [DATE] and noticed the same dressing with her initials was in place and dated [DATE]. The facility reported the pressure ulcer dressing changes were ordered to be done every day and acknowledged two different nurses documented the dressing changes were done [DATE] and [DATE] but did not actually provide the services. The Nursing Home Administrator (NHA) reported they identified like residents, reviewed dressing change orders and skin assessments to ensure dressing changes aligned with treatment documentation and did not find any concerns or discrepancies. The NHA concluded she could not substantiate the allegation. Review of the Electronic Medical Records (EMR) for R5 revealed some notes were in the nursing progress notes, some notes were in the Wound Summary, some notes were in the observations tab, and some were under the skin assessments. However, they did not correlate with one another. Review of an order dated [DATE] and discontinued on [DATE] for R5 revealed: Cleanse wound site with wound cleanser, apply triad wound dressing, cover with foam dressing, twice a day. This was documented as done on [DATE] between 7:00 AM and 11:00 PM, then the order changed. The exact wound is not identified. Review of the Nursing Progress notes for R5 revealed she went to the hospital on [DATE] at 8:00 PM and returned to the facility on [DATE] at 10:04 AM. Hospice admission was in progress upon her return. Review of a Nursing Progress Note for R5 dated [DATE] revealed: wound care provided to buttock (exact location not identified), wound bed 100% granulated tissue. Peri wound intact with discoloration from noted scar tissue. resident denies pain with wound cares. consulted with provider [Name] regarding ordered wound cares. new orders received. wound measuring 1.7cm x 3cm x 0.1 cm. DON (Director of Nursing) informed of findings. An order for R5 dated [DATE] and discontinued on [DATE] to be done at bedtime revealed: left upper buttock stage 2 pressure injury: 1. cleanse with normal saline 2. apply skin prep to intact peri wound. 3. allow skin prep to dry fully to air. 4. apply small amount of medihoney to wound bed. 5. place foam dressing over wound bed as secondary dressing 6. nursing to change daily and PRN (as needed). This is documented as done on 5/1 by RN G, 5/4 by LPN H, 5/5 by LPN F, and 5/6 by RN G. (Out to the hospital on 5/2 and 5/3). It was documented the dressing changes were done on [DATE] and on [DATE]; but not done per the facility's investigation. Review of an order dated [DATE] and discontinued on [DATE] for R5, once every 3 days, revealed: Left upper buttock: 1. Cleanse with soap and water. 2. Apply skin prep to area. 3. Cover with foam dressing. 4. Change every 3 days or prn (as needed) if soiled/dislodged. This is documented as done on [DATE].Review of a Nursing Progress Note for R5 dated [DATE] revealed: Coccyx wound resolved. Will continue to use foam dressing for protection. Change every 3 days or prn if soiled/dislodged. This progress note did not correlate with the wound care orders indicating there was still a wound. Review of a Wound Management report for R5 revealed the following: -Date identified: [DATE] -Unspecified Ulcer- Coccyx: 3.2 centimeters (cm) x 4.5 cm. On [DATE] it measured 11.5 x 13 (measurement standards not identified) with heavy seropurulent (yellow or tan, cloudy and thick) drainage with a foul odor. On [DATE] it measured 12 x 15 (measurement standards not identified.) Described as having a foul odor with necrotic tissue. -Date identified: [DATE]- Unspecified Ulcer- Right big toe pressure area: 0.7 x 1.4 cm. -Date identified: [DATE]- scab, right 2nd toe: 0.2 cm x 0.2 cm. On [DATE] it measured 0.2 x 0.2 and non-blanchable. -Date identified: [DATE]- Right hip- unstageable, deep tissue: 7 x 2.3 (measurement standards not identified). -Date identified: [DATE]- Pressure ulcer, right heel: 3.5 x 2.5 (measurement standards not identified). -Date identified: [DATE]- Right inner ankle: 2.5 x 2 (measurement standards not identified). -No wound assessment for the left upper buttock documented. Review of a Nursing Progress Noted for R5 dated [DATE] revealed: Placed new overlay mattress on resident's bed. Wound care done to coccyx, slight sheer noted on skin, no bleeding or drainage noted . Surrounding skin intact. Review of a Nursing Progress Note for R5 dated [DATE] revealed: RN (Registered Nurse) performed skin assessment. Stage 2 noted to coccyx region. Tx (treatment) in place and measurements recorded in event. SDTI (suspected deep tissue injury) to right great toe, measurements recorded in event. Second right toe reddened and blanchable. Tx (treatment) in place for both toes. Review of a Nursing Progress note dated [DATE] for R5 revealed: wound care provided per order no indication for infection noted at this time. wound on coccyx worsening. added to provider rounding book for review. DON notified of worsening wound. hospice also informed of wound decline. No documentation the physician assessed and addressed her wounds.An order dated [DATE] and discontinued on [DATE] for R5 revealed: Stage 2 coccyx pressure injury: cleanse with N/S (normal saline), pay (sic) dry. Apply sacral comfort foam to area, once a day every other day. This was documented as done on [DATE], [DATE] and [DATE]. (No dressing changes provided/documented from [DATE] to [DATE]). An order dated [DATE] and discontinued on [DATE] for R5 revealed: Stage 2 coccyx pressure injury: Cleanse with N/S, pay (sic) dry. Apply sacral comfort foam to area, once a day on Mon, Fri. This was documented as done on [DATE], [DATE], and [DATE]. An order dated [DATE] and discontinued on [DATE] for R5 revealed: Stage 2 coccyx pressure injury: Cleanse with N/S, pay (sic) dry, apply xeroform to wound bed, cover with sacral comfort foam to area, once a day on Mon, Fri. This is documented as done on [DATE], refused [DATE] with no reapproach or another attempt at another time documented, and 6/13. Review of a Nursing Progress note dated [DATE] with a late entry of [DATE] for R5 revealed: wound cares provided per provider order. wound significantly larger. Resident is currently actively EOL (sic) Hospice RN assisted with wound care wound identified as Kennedy ulcer per hospice rn. Daughter present for wound cares informed of decompensation and etiology of Kennedy ulcers. provider [name] also informed no new orders received at this time. No physician oversight or diagnoses of a new [NAME] Pressure Ulcer documented. Review of a Pressure Ulcer/Injury Care Plan for R5 initiated [DATE] revealed R5 was at risk for skin pressure and moisture associated skin damage. New Sacral stage 2 pressure ulcer and unstageable to Right great toe. (5-20-25) An intervention on [DATE] revealed: Nursing to provide wound care per physician's order. Report and (sic) decline or signs and symptoms of infection. On [DATE], a specialty mattress and a pressure reduction cushion for her wheelchair were implemented. On [DATE] (the year before) an intervention of SACRAL pressure ulcer developed (5-20-25). Assess for stage, presence/absence of granulation tissue and epithelization, and condition of surrounding skin with every treatment/dressing change. Measure weekly. Review of the Nursing Progress notes dated [DATE] revealed R5 passed away. In an interview on [DATE] at 4:00 PM, the DON reported the FRI with R5 happened before she started working at the facility but was aware that the nurse missed the admission skin assessment after R5 readmitted back to the facility from the hospital. When questioned about the Wound Audit from the FRI report with no dates of the audit, the DON reported it looked like the person who documented several residents on this form did a onetime audit of residents and identified residents who had wounds with no dressing orders in place or skin assessments. The DON was not aware of any ongoing audits for dressing changes and wounds at this time but does have a nurse who has been doing weekly wound rounds on residents and documenting them in the medical records. On [DATE] at 10:30 AM, a request was made to the DON for documentation that indicated R5's care was overseen by a physician. No documentation was provided by the end of this survey. In an interview on [DATE] at 8:09 AM, the DON reported physicians should be notified of any changes in conditions for residents. If it's not documented, then it's not done. The DON verified she could not find documentation from the practitioners that R5's care was overseen by a practitioner. The DON stated she expected care plan interventions to be updated and implemented. In an interview on [DATE] at 10:13 AM, the NHA was questioned about the FRI regarding R5 and the audit they did when they identified several other residents who had wounds that were not identified with treatments in place prior to this incident. The NHA confirmed they did a one-time audit of wounds since the FRI and have not done any monitoring for ongoing compliance to ensure dressing changes were being done as ordered and new wounds were being identified and treated timely. The NHA reported skin assessments and wound care has been a concern for a while and identified it as an area that needs improvement. The FRI documentation reflected R5's dressing changes were not done on 5/4, 5/5, 5/6 and on 5/7 it was acknowledged that the nurse identified the dressing for R5 still had her initials on it from [DATE]. The NHA reported that the nurse changed the dressing on [DATE] on the 3rd shift which technically was done on 5/7. The MAR shows R5 had a dressing change documented on [DATE] by another nurse. In an interview on [DATE] at 11:36 AM, Registered Nurse (RN) D and Licensed Practical Nurse (LPN) E reported wound management notes are sometimes in progress notes and was told as long as they get the notes in the EMR, it didn't matter where it was charted. Resident #6 (R6) Review of a Face Sheet revealed R6 admitted to the facility on [DATE]. During an observation on [DATE] at 1:15 PM, R6 was observed in bed sleeping on her back. The facility matrix revealed she had an unstageable pressure ulcer. Review of the Wound Summary for R6 revealed the following: 1. Date identified: [DATE], Right heel, unstageable ulcer, right medial heel: 1 cm x 0.5 cm x eschar scant serious drainage treatment in place. On [DATE], it measured 1.8cm x 1.5 cm. 2. Date identified: [DATE], Coccyx, right medial coccyx (no initial measurements). On [DATE] it measured 0.3 cm x 0.3 cm. 3. Date identified: [DATE], Right big toe, tipoff right great toe: 0.5 cm x 0.5 cm x eschar. On [DATE], it measured 0.5 cm x 0.5 cm. 4. Date identified [DATE]: Coccyx, stage II pressure ulcer: 1.75 cm x 0.5 cm x 0.2 cm. On [DATE], it measured 2.4 cm x 1.5 cm. 5. During an observation on [DATE] at 3:12 PM, R6 was observed sleeping in her bed on her back in the same position as the last observation. 6. During an observation on [DATE] at 4:24 PM, R6 was observed sleeping in her bed on her back in the same position as the last observation. Review of a Nursing Progress noted dated [DATE] for R6 revealed: coccyx DTI (deep tissue injury) wound care provided, no drainage noted. wound bed 100% granulation healing appropriately. no concerns for infection at this time. recommend continuation of current plan of treatment. Review of the Practitioner Progress notes for R6 between [DATE] to [DATE] revealed no Practitioner oversight or acknowledgement of R6's wounds. Review of the Hospice IDG (Interdisciplinary Group) Meeting notes for R6 for the certification period of [DATE] to [DATE] revealed orders with an effective date of [DATE] for the resident's coccyx wound and another order with an effective date of [DATE] for the right heel. Both orders do not reflect the orders at the facility and no other documentation to indicate hospice is aware of the orders for wound care at the facility or that the facility contacted hospice for different/new orders. Hospice orders are as follows: 1. Coccyx- wash with soap and water, pat dry, apply barrier cream, apply mepliex (sic) (border foam dressing) dressing, change q3 (every 3) days and prn (as needed) if soiled or remove, effective [DATE]. (This does not indicate there are two coccyx wounds as the facility has identified). 2. Right big toe- clean with soap and water and pat dry, apply skin prep and leave open to air, complete daily, effective [DATE]. 3. Right heel, unstageable- clean with Dakin's (antiseptic solution) cover with hydrofera blue (a foam dressing with antibacterial properties and drainage absorption), cover with bordered dressing, facility nurse to change every other day and prn, effective [DATE]. Review of a Nursing Progress note dated [DATE] for R6 revealed: re-opened stage 2 pressure ulcer on coccyx discovered. irregular boarders. non blanching region measuring 3cm x2.5cm. blister intact and present on left side of coccyx measuring 1.5cm x1cm. reported findings to hospice provider, in house provider . notified. New treatment orders to be put in place. Review of the May, June, and [DATE] MAR for R6 revealed a new order dated [DATE] for a stage 2 pressure ulcer to coccyx region: 1. cleanse with NS or wound cleansing spray and clean 4x4 gauze 2. apply skin prep to intact peri wound and allow to dry 3. apply comfort foam dressing 4x4 over coccyx region. 4. nursing staff to change every other day and PRN. No dressing changes documented between [DATE] and [DATE]. The dressing is documented as not done on [DATE] stating the dressing was intact and the resident was screaming in a lot of pain. Another treatment was not documented as done on [DATE] and [DATE] with no supporting documentation. This does not match hospice orders and does not indicate it addresses both coccyx wounds and their exact locations. Review of the [DATE] MAR for R6 revealed a new order dated [DATE] and discontinued on [DATE] for un-stageable pressure injury right heel once a day on Tuesdays and Saturdays: 1. cleanse with normal saline and clean gauze 2. apply skin prep to adjacent intact skin and allow to dry 3. nursing to change twice weekly and PRN, discontinue order when resolved. No dressing documented as done on [DATE] with a comment stating it was completed by off going nurse.' Review of the [DATE] MAR for R6 revealed a new order dated [DATE] and discontinued on [DATE] for an unstageable pressure injury right heel once a day on Tuesdays and Saturdays: 1. cleanse with normal saline and clean gauze 2. apply skin prep to adjacent intact skin and allow to dry 3. apply comfort foam dressing 4. nursing to change twice weekly and PRN, discontinue order when resolved. Review of a Shower Sheet dated [DATE] for R6 revealed the Hospice Aide documented R6's right heel was wrapped with gauze. Review of a Pressure Ulcer/Injury Care Plan initiated on [DATE] for R6 revealed no new interventions since [DATE]. Review of an Activities of Daily Living (ADL) Care Plan initiated on [DATE] for R6 revealed she requires the assistance of 2 staff for bed mobility. Review of the June [DATE] for R6 revealed an order for a stage 2 pressure ulcer dressing change started on [DATE] to be done every other day. The dressing change was not done on [DATE]. No supporting documentation in the medical record why it was not done. In an interview on [DATE] at 8:09 AM, the DON reported if it's not documented, then it's not done. The DON verified she could not find documentation from the practitioners that R6's care was overseen by a practitioner. The DON expected care plan interventions to be updated and implemented. The DON acknowledged R6's care plan did not indicate she needed a repositioning schedule and reported if a resident is not mobile (like R6), she reported repositioning goes hand in hand with a resident who is not mobile. It is expected that even if it were not on the care plan, she would expect the CNAs to reposition every 2 hours. The DON reported she expects staff to notify hospice as well as the physicians of any changes in condition for R6. When asked about the hospice wound orders from the Hospice IDG notes for R6, the DON reported the facility physicians are to order wound care dressings and is not sure why the hospice information did not match the facility's and reported they should have communicated more effectively. Resident #9 (R9) Review of a Face Sheet revealed R9 originally admitted to the facility on [DATE]. Review of a Wound Summary for R9 revealed as follows:-Identified on [DATE]- right buttock pressure ulcer: measured 1 cm x 0.5 cm x 0.2 cm, on [DATE] (the most recent documentation) it measured 1.6 x 2 cm. No depth documented. -Identified on [DATE]- stage I on mid thoracic back: measured 4 cm x 3.5 cm, on [DATE] it measured 2.5 cm x 3 cm. No depth documented. - Identified on [DATE]- left buttock pressure ulcer. No measurements. Review of a Skin Body Assessment for R9 dated [DATE] revealed there were areas of skin impairment: bilateral buttock wound- treatment in place . lower lumbar pressure- treatment in place. No measurements. Review of a Skin Body Assessment for R9 dated [DATE] revealed: areas on bottom treatments in place. No measurements. Review of the June MAR for R9 revealed orders started on [DATE], once a day on Monday, Wednesday, and Friday, and discontinued on [DATE] for: Left and right side upper buttock wounds: 1. cleanse with normal saline and clean gauze2. 2. apply skin prep and allow to dry to intact skin 3. apply medihoney paste to wound bed 4. apply coccyx/ buttock optifoam over region 5. nursing to change three times weekly and PRNThe MAR revealed on [DATE] the dressing change was documented as not done done on 3rd. Resident didn't want done again. The MAR revealed on 6/21 it is documented as not done given night previous. No documentation to indicate this was done. Review of the June MAR for R9 revealed orders that started on [DATE], once a day on Fridays for: Lower lumbar pressure injury: 1. Cleanse with N/S-Pat dry 2. Apply skin prep to area 3. Cover with comfort foam. 4. nursing to change twice weekly and PRN DC (sic) Review of the Pressure Ulcer Care Plan for R9 revealed it was initiated on [DATE] for a pressure ulcer to buttock and lumbar region. This was initiated at least 30 days after the first pressure ulcer was identified. Review of a Nursing Progress note dated [DATE] for R9 revealed: wound cares provided to resident: R (right) buttock/ Coccyx region ulcer measurements 2cm x 2cmx 0.3cm wound bed compromised of 100% slough moderate amount of serosanguinous drainage present no concerns for infection noted. no odor present at this time. Mid thoracic back (middle of back), stage 1 pressure ulcer noted skin intact red non blanching 2.8cm x 3cm no drainage. Review of the EMR for R9 revealed there was no physician oversight of wound/assessment. In an interview on [DATE] at 8:09 AM, the DON reported skin assessments are to be done weekly to include all pertinent assessment information. The DON stated R9's lumbar wound was getting smaller, and his coccyx was a bit bigger. The DON was not certain of the cause of the pressure ulcers and verified R9 required two staff for repositioning. Even though it was not on the task list for the CNAs to reposition R9 every 2 hours, the standard of care was to do that.In an interview on [DATE] at 10:13 AM, the Nursing Home Administrator (NHA) reported the facility had identified areas needed for improvement and skin assessments and wound care was one of them. The NHA stated the facility had recognized it for a while but had not put a plan together yet. The NHA did acknowledge they needed to have physician oversight of resident care especially now that the contracted wound care specialists no longer came to the facility. Review of a policy titled Physician Services last reviewed 1/2025 revealed: The Administrator shall be responsible for assuring or promptly arranging for continuing medical care under the direction of a licensed physician. Arrangement of services from additional Ancillary services will also be arranged based on resident needs, including but not limited to Dentists, Podiatry, Audiology, and Vision Services.Primary Care Physician Procedure:1. A physician approves in writing the resident's admission2. Each resident is under the care of a qualified physician.3. The Physician should:a. See the resident within 30 days of initial admission to the facility.b. The resident must be seen at least once every 30 calendar days for the first 90calendar days after admission and at least every 60 days after that by a physician orphysician delegate as appropriate by State law.c. Review the resident's total care program, including medications and treatments ateach visit.d. Date, write, and sign a progress note for each visit. Review of a Standards of Nursing Practices policy last reviewed 1/2025 revealed: Responsibility with Medications and Physicians Orders1. The licensed nurse that receives an order and notes the order is responsible to carry the order through by placing in achieve Matrix, on the MAR, TAR, ordering the medication from pharmacy, communicating order specifics to appropriate departments, i.e. dietary, therapy, etc. while a resident is determined to be receiving skilled services. Documentation when providing skilled level of care2. Monitoring of the residents' progress when skilled services are provided is essential to evaluate the ongoing benefits as well as need to make changes in the residents' plan of care. It is important to monitor the effectiveness of treatments, medications or rehabilitation services provided. Resident vital signs (temperature, pulse, respirations, blood pressure and pulse oximetry) will be required daily as a minimum nurses' responsibility to document a more detailed assessment when particular issues arise for a resident. Documentation should contribute to the identification and communication of the residents' problems, needs and strengths, providing a tracking of their condition on an on-going basis, recording residents' response to services provided is a matter of good clinical practice and is an expectation of trained and licensed health care professionals.Physical assessment and change of condition:3. Residents with changes in condition will be notified to the Director of Nursing or Clinical Leader to review the residents plan of care to ensure that appropriate care and services are being delivered until the condition is resolved. Residents with change in condition will be communicated during A.M. Clinical Review. Monitoring a change in condition requires the licensed nurse to include an entry in the progress notes. Communications to the physician will require a completion of a SBAR tool in the resident's medical record. The monitoring a resident's condition may have multiple entries in the residents' medical record that include progress notes, observations, and assessment tools.