**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to MI00148054: Based on interview and record review the facility failed to properly transcribe and administer medications per physicians orders for 1 Resident (#3) of 4 residents reviewed for quality of care, resulting in the lack of assessment, monitoring, and documentation and resulted in hospitalization and subsequent delay in treatment/resolution of the infection with the potential for worsening of condition. Findings include: Resident #3 (R3) Review of an admission Record revealed R3 was originally admitted to the facility on [DATE] with diagnoses including, osteomyelitis (bone infection), left ankle and foot. Review of a Minimum Data Set (MDS) assessment for R3 with an assessment reference date (ARD) of 11/5/24 revealed a Brief Interview for Mental Status (BIMS) score of 4/15 indicating R3 was severely cognitively impaired. In an interview on 12/4/24 at 10:00 AM., R3 reported he was recently admitted to the facility for Rehabilitation and Intravenous (IV) antibiotics for his PICC (Peripherally Inserted Central Catheter-Type of IV) line, and wound care for his left foot. R3 reported the facility nursing staff did not administer his IV-Antibiotics for approximately 5 days that were prescribe for his (foot/wound/bone infection) infection. R3 Reported he had been at the facility a few days and went out on a Leave of Absence (LOA) for overnight with his guardian (whom is also a family member) to spend the night. R3 reported the next day, while at his guardians he was feeling ill. R3 reported his guardian was worried about the way his left foot, and leg looked, she (guardian) took him to the (local hospital name) hospital. R3 reported he was treated for a few things, including the worsened infection in his left foot. R3 reported they (facility nursing staff) didn't give antibiotics in his IV, and they didn't clean his wound properly. R3 reported during his stay for a few days in the hospital the doctors there said, I was going to lose my foot if the infection doesn't get treated immediately. R3 reported the hospital doctor ordered antibiotics IV, to be given once returning to the facility. R3 reported he was very scared and concerned about his left foot. Review of R3's Hospital Discharge Paperwork dated 10/31/24, including a Physicians Order-dated 10/30/24 (from the hospital to the facility upon R3s admission to the facility) revealed: Physicians Order-10/30/24 cefTRIAXone Sodium Intravenous Solution Reconstituted 2 GM (grams) PICC line Use 2 gram intravenously every 24 hours for 6 weeks intended use for osteomyelitis left foot .further reviewed in the Hospital Discharge Paperwork discharge instructions on medications to remain on and follow up included: cefTRIAXone Sodium Intravenous Solution Reconstituted 2 GM Use 2 gram intravenously and Normal saline flush 10 ml (milliliters) to (IV/PICC) bid (twice daily) . Review of R3's facility Nursing Progress note revealed: 11/1/24 14:43 p.m., Resident (R3) has wound on left great toe. PICC line present in right arm Review of R3's Care Plan revealed: Date Initiated: 11/01/2024 .Focus: Resident (R3) requires enhanced barrier precautions related to surgical wound, and PICC line. Revision on: 11/14/2024 . Review of R3's November 2024's facility Medication Administration Record (MAR) revealed: Normal saline flush 10 ml to (IV/PICC) bid (twice daily) every morning and at bedtime .discontinue order when line is removed -Start Date 11/04/2024 . further review of the MAR revealed R3 received no NS flushes twice daily 11/1/24-11-4/24 Review of R3's November 2024's facility Medication Administration Record (MAR) revealed: Treatment: Surgical, left 1st metatarsal (Toe). Wash with wound cleanser, pat dry. Apply Xeroform (wound dressing material) to wound bed and cover with silicone bordered foam dressing. in the afternoon every other day for Skin impairment -Start Date 11/02/2024 1100 . Further review of R3's 11/2024 MAR revealed no nursing documentation that the wound care as ordered to treat was completed from 11/2/23-11/5/24. Review of R3's facility Nursing Progress note revealed: 11/5/24 15:31 p.m., called pt. (patients)- next of kin (guardian) and was notified that the antibiotic was being ran (administered) . (guardian) was thankful for the call In an interview/record review on 12/4/24 at 10:55 AM., Registered Nurse' (RN) M reported R3 had went home on a overnight when he first arrived at the facility, about 4-5 days after he admitted . RN M reported R3 had a PICC line and was at the facility for rehabilitation for PICC/IV antibiotics and wound care originally. RN M reported R3 went out early November with his guardian. RN M reported they became concerned about is wound and he was ill, so she took him the hospital. RN M reported R3's guardian reported that R3's wound and leg looked swollen and red. RN M reported according to the MAR and nurses' notes (which were reviewed together with this surveyor) RN M reported something got missed, the flush for the PICC line, and original antibiotic order for 10/30/24 should have been transcribed before actual admission or within a few hours of admitting . RN M reported it appears for R3 November 2024 MAR and nursing notes, the orders were not followed. RN M reported after R3 was back from the hospital she recalls R3 was upset and scared about his left leg and foot might be amputated. RN M reported had the original physician's orders been followed and transcribed properly R3 should have been getting his PICC line flushed twice daily with NS, and this antibiotic administered from date of admission which was 11/1/24. In an interview on 12/4/24 at 3:30 PM.,the Director Of Nursing (DON) reported R3's initial hospital discharge paperwork came through on 10/31/24 from the hospital where R3 was discharged from, on admission to the facility. The DON reported R3's PICC/IV line Antibiotic and NS flushes for the PICC was missed during transcription of the physicians' orders. The DON reported the nursing staff missed' or did not catch the physicians' orders because the paperwork was a lot different than the hospital discharge paperwork other local hospitals around the area usually send. The DON reported R3 did in fact go a few days without his IV-Antibiotics and PICC line flush. The DON reported R3 went out with family for a night and it was noticed his foot and leg were swollen and red, so the guardian took him to the hospital. The DON reported R3 should not have missed his medications, and the nursing staff did not follow policy and procedures to ensure proper transcription of medications are administered, and/or ordered if not in stock. Review of R3's facility Incident Reported dated 11/11/24 revealed: Description-(R3) was admitted to the facility on [DATE]. The resident (R3) was found to have missed the start of his IV antibiotic (abx) medication on 11/11/24, it wasn't started until 11/5/24 . Resident admitted to the facility on [DATE]. Staff did not see the order for the IV abx . Staff were interviewed . thru that weekend (nurses who worked R3's admission weekend) 11/2 and 11/3. He (R3) was noted to have a PICC in place, but this was not researched by staff at the time Antibiotic order was noted to be in the admission paperwork as a separate order. Staff consensus was that they never saw an order for it. Monday AM it was initiated - (multiple nurses on the incident reported) stated it was the first time they knew anything about the IV abx, although they saw the PICC line) It is noted that the guardian was updated when the abx was running. Management was not aware of the delay until 11/11/24. Review of Nursing References Materials for medication transcription and physicians ordered revealed: Nurses must obey the orders of the physician in charge of a patient, unless an order would lead a reasonable person to anticipate injury if it were carried out, according to [NAME] in Law Every Nurse Should Know, 5th Edition, page 98 The Professional Standard of Quality for documentation of the residents health care in a medical record is the information must be true and complete. Under no circumstances should erroneous records be removed from the overall record and new pages submitted. (Fundamentals of Nursing, Concepts, and Practice. Mosby. [NAME], P.A., [NAME], A.G., 1985) The nurse is obligated to follow the physician's orders unless they believe the order is in error or would be detrimental to the resident. (fundamentals of nursing, concepts, process, and practice, mosby, [NAME] a. [NAME], [NAME] g. [NAME], 1985) The nurse is obligated to follow the physician's orders unless they believe the order is in error or would be detrimental to the resident. (Fundamentals of Nursing, Concepts, Process, and, Practice, Mosby, [NAME], P., [NAME], A., 1985) . The six rights of medication administration include: 1) the right medication, 2) the right dose, 3) the right client, 4) the right route, 5) the right time, 6) the right documentation. To identify a client correctly, the nurse checks the medication administration form against the client's identification bracelet. When asking the client's name, the nurse should not merely speak the name and assume that the client's response indicates that he or she is the right person. Instead, the nurse asks the client to state his or her name. (Fundamentals of Nursing, 6th edition, 2005, pgs. 841-842.)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This deficiency pertains to Complaint Intake MI00146981. Based on observation, interview, and record review, the facility failed to provide necessary treatment and services to prevent the development and promote the healing of pressure injuries for three Residents (#29, #22, and #36) of three residents reviewed for wounds. This deficient practice resulted in the deterioration of a left heel pressure injury in one Resident (#29) resulting in gangrene, sepsis, and the need for surgical amputation. Findings include: Resident #29 (R29): Review of R29's electronic medical record (EMR) revealed initial admission to the facility on 8/15/22 with diagnoses including vascular dementia and type two diabetes. Review of R29's most recent Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 6, indicative of severe cognitive impairment. On 10/22/24 at 10:25 AM, R29 was observed sitting at the nurses' station in a wheelchair. R29 was observed with a compression sleeve on her left lower limb which appeared to be amputated at approximately mid-shin down. Review of R29's weekly Skin Assessments revealed a new abnormal skin area located the second digit of the right foot on 10/23/23. Review of progress note dated 10/27/23 at 7:30 AM, read, in part: .called to room by CNA [certified nursing assistant] for report of pressure injury to left heel. Back of heel open with loss of first layer of skin, purple area to center of wound, skin around wound intact, small amount of clear liquid drainage mixed with scant amount of blood . The next documentation of R29's left heel wound was recorded on 3/21/24, labeled as an existing abnormal skin area, nearly 5 months after the initial identification of the skin impairment. Review of R29's initial Wound Evaluation, dated 10/27/24, read: Deep Tissue Injury .left heel . in-house acquired . area 16.61 cm2 [centimeters] . Review of Wound Care Clinic progress notes revealed the following orders: -1/24/24: Keep weight off of affected area/limb at all times . offload heels - wear pillow boot at all times . -3/11/24: Keep weight off of affected area/limb at all times . offload heels - wear pillow boot at all times . -4/24/24: Keep weight off of affected area/limb at all times . offload heels - wear pillow boot at all times . Review of R29's physician orders read, Blue boots to bilateral feet while in bed, initiated 3/19/24. Review of R29's Plan of Care revealed a Focus that read, Resident is at risk for impaired skin integrity . with the following intervention initiated 1/12/24: Apply offloading heel protectors in bed as resident tolerates. On 10/23/24 at 3:56 PM, an interview was conducted with Assistant Director of Nursing (ADON) I who stated R29's pressure reducing interventions included turning and repositioning, a specialty mattress, and an offloading padded boot. When asked the frequency in which the offloading boot should have been applied, ADON I stated, all the time. When asked why the care plan specified the heel protectors should be worn in bed only, ADON I stated the care plan was never revised to reflect updated interventions. ADON I verified the CNAs were not provided with the correct interventions. On 10/23/24 at 12:45 PM, an interview was conducted with CNA U who recollected R29 had a blue boot to protect her heel. When asked how often R29 was required to wear the boot, CNA U could not confirm R29 wore it at all times stating, I tried to make sure it was on during my shift, but we're often short staffed. Stuff like that can get missed Review of R29's Wound Evaluations, revealed the following: -5/21/24: Progress: Deteriorating . Wound shows signs of deterioration at this time including macerated skin to periwound [area surrounding wound], increased erythema [redness], increased purulent drainage at time of assessment . -5/28/24: Progress: Deteriorating . Wound continues to deteriorate. Noted increased purulent drainage, odor to wound after cleaning, macerated tissues to periwound. Provider updated and wound culture obtained. Results back and provider ordered new antibiotic . -7/15/24: Progress: Deteriorating . Wound noted with discoloration to wound bed. Wound itself shows no signs/symptoms of infection at this time. Consulted with wound clinic related to declining wound . -7/30/24: Progress: Deteriorating . Wound shows deterioration this week with increased slough to wound bed. Periwound red but blanchable. No warmth to touch. Resident states occasional pain to area . -8/12/24: Progress: Deteriorating . Wound measurement shows nominal change but visible deterioration this week with brown eschar forming over 70% of the wound bed. PCP [primary care physician] was informed and witnessed. Standing order to send resident to ER [emergency room] for evaluation if wound worsens . Review of R29's EMR revealed the following progress note: 8/19/24 at 10:40 AM: Wound to left heel has progressively worsened showing majority necrotic tissue with small area of bone showing . S/Sx [signs/symptoms] of localized infection present. Resident was sent to hospital for evaluation . Review of R29's plan of care revealed no updated care plan interventions since 1/12/24. Review of R29's ER History and Physical, dated, 8/20/24, read, in part: This patient presents with left foot diabetic gangrene with associated sepsis and is at increased risk of septic shock and death . Review of R29's hospital Discharge summary, dated [DATE], read, in part: .female .was admitted to our hospital on 8/20/24 with left calcaneal [heel] diabetic ulcer . patient given surgery here, it was felt that she will unlikely heal the left wound. Left below-knee amputation was recommended. She was taken to the OR [operating room] on 8/28/24 and underwent left below knee-amputation . On 10/24/24 at 9:01 AM, an interview was conducted with the Nursing Home Administrator (NHA) and Director of Nursing (DON) regarding R29's left heel pressure injury and subsequent amputation. The NHA and DON were unsure why the order for heel protection at all times was never reflected in R29's plan of care nor why updated interventions were not added despite deterioration of the wound. The DON could not explain R29's left heel injury was not documented on a skin assessment until 3/21/24 after initial identification on 10/27/23. The NHA stated, That's a big problem. Review of facility policy titled, Pressure Ulcer/Skin Breakdown - Clinical Protocol, reviewed 3/20/24, read, in part: .Because a resident at risk can develop a pressure ulcer/pressure injury (PU/PI) within hours of the onset of pressure, the at-risk resident needs to be identified and have interventions implemented promptly to attempt to prevent PU/PI . Resident #22 (R22) Review of R22's admission minimum data set (MDS), dated [DATE], revealed R22 did not have any open areas or impairments to their skin integrity, was at risk for developing pressure ulcers, and rejection of care. Review of R22's significant change MDS, dated [DATE], revealed R22 had developed one unstageable pressure ulcer and did not have any rejection of care. Review of R22's significant change MDS, dated [DATE], revealed R22 had developed a stage four pressure (severe skin tissue damage) ulcer. Review of R22's quarterly MDS, dated [DATE], revealed R22 had an existing stage four pressure ulcer and lacked any rejection of cares. On 10/21/24 at 1:16 PM, an observation was made of R22 lying in their bed. R22 had a wound vac device on their nightstand with a clear plastic tubing connected to the wound vac device. The plastic tubing was not connected to the other end of the wound dressing and was turned off. R22 was asked how long the wound vac had been turned off and replied, Since last night. On 10/21/24 at 1:30 PM, an interview was conducted with License Practical Nurse (LPN) M and was asked why R22 has wound care solution in their room that belongs to a different resident and replied, That is an excellent question. LPN M was asked why R22's wound vac is off and replied, The night shift nurse turned it off because it was alarming. All nurses have been educated on how to change R22's dressing and use the wound vac. I just don't trust them all to change R22's dressing and I just haven't gotten to it yet today. LPN M was asked what time they arrived at the facility today and replied, Eight o'clock this morning. Typically, we try and change them first thing in the morning. I found some supplies in the other storage room. I will change the dressing next. R22's wound vac dressing change was completed at 2:00 PM on 10/21/24 by LPN M. On 10/23/24 at 12:30 PM, an observation was made of R22 in their room sitting on the side of their bed eating lunch. R22 was asked if his wound vac was working properly today and replied, No, I shut it off because it was alarming. On 10/23/24 at 12:45 PM, an interview was conducted with LPN K and was asked if they were aware that R22's wound vac was turned off and replied, Yes, but I haven't had a chance to change the wound vac dressing. LPN K was asked if LPN M was aware so they could assist with the dressing change and replied, No. LPN M completed the dressing at 2:05 PM on 10/23/24 for R22 that was turned off at 10:00 AM. Review of R22's physician order, dated 8/27/24, read in part, NPWT (negative pressure wound therapy) [A treatment that uses a wound vac to help wounds heal] for coccyx: Change every Mon (Monday), Wed (Wednesday), Fri (Friday) days. Cleanse wound with wound cleanser, pat dry, apply skin sealant (skin prep) to peri wound, fill dead space with black foam, cover with sealant cover film and apply to NPWT tubing . Review of R22's physician order, dated 8/28/24, read in part, PRN (as needed); Coccyx. When Wound Vac fails or is not available. Wash gently with wound cleansing solution, pat dry. Apply calcium alginate to wound bed cover with ABD (abdominal) pad. Secure in place with tape . R22's as needed dressing change for their coccyx wound was not signed out on the treatment administration record (TAR) when the wound vac was turned off that evening. On 10/24/24 at 10:30 AM, an interview was conducted with the Director of Nursing (DON), and was asked what kind of dressing R22 had on when their wound vac had been turned off the night of 10/20/24 and replied, The night nurse did not apply the as needed dressing change. The nurse just took off the wound vac dressing, left the foam in place, covered the coccyx wound with an ABD pad, and secured the dressing with tape. The nurse did not do it correctly. Resident #36 (R36) Review of R36's quarterly MDS, dated [DATE], revealed no impairments to their skin or open areas. Review of R36's quarterly MDS, dated [DATE], revealed one unstageable open area of the skin and at risk for developing open areas or impairments of the skin. Review of R36's quarterly MDS, dated [DATE], revealed on stage three pressure ulcer of the skin, not present on admission, and lack any rejection of cares. On 10/21/24 at 12:35 PM, an interview was conducted with R36 in their room. R36 was lying in bed with the head of the bed up to approximately 80 degrees and was slouched down in an appearing uncomfortable position. R36 was asked if they had any open areas and replied, maybe so. R36 lacked any pillow behind her head during this observation. On 10/22/24 at 11:15 AM, an observation was made of R36 lying in their bed with the head of the bed at approximately a 70 to 80 degrees and was slouched down and hunched over asleep. On 10/24/24 at 8:45 AM, an observation was made of R36 lying in their bed with the head of the bed at approximately a 70 to 80 degrees and was slouched down and hunched over watching TV. R36 was asked if staff reposition them or remind them to reposition and replied, No. R36 was asked if they use a pillow behind their back to help offload and replied, I don't have a pillow behind my back. Should I have one? Review of R36's care plan, dated 8/29/24, read in part, .Focus: Resident has impaired skin integrity as evidence by: Stage 3 pressure ulcer (full thickness tissue loss) to upper spine .Interventions: Encourage resident to offload presure (sic) by repositioning self. Resident prefers to sit with head of bed at 30 - 45 degrees per .preference .Offer turn and Reposition, side to side (limit time on .back .) using pillows/wedge to prop behind back PRN (as needed) Review of R36's wound evaluation, dated 3/24/24, revealed an unstageable pressure ulcer that was six hours old, in house acquired, located on their spine, and measured 2.27 centimeters (cm) in length by 1.18 cm in width. Review of physical therapy consult note, dated 3/25/24, read in part, .Reason for screen: new ulcer to upper spine. Findings: PT (physical therapy) screen only. Pt. (patient) does not want therapy and is at baseline with functional mobility. Pt. does sit on EOB (edge of bed) frequently and rarely lays on .back per nurse . Review of R36's physician progress note, dated 4/4/24, revealed the lack of acknowledgement that R36 had any open areas or skin impairments, and the skin section of the progress note was blank. Review of R36's physician progress note, dated 4/18/24, read in part, .Asked to see patient for wound midback .wound midback approximately 2 cm x 0.5 cm, stage 2, minimal surrounding erythema (redness) .1. Wound care consult . Review of R36's wound clinic consult discharge instructions, dated [DATE], read in part, .Turn every 2 hours. Avoid position directing pressure to Wound site. Limit side lying to 30 degrees tilt. Limit HOB (head of bed) elevation to 30 degrees in bed . Review of R36's wound evaluation, dated 5/30/24, revealed a stage three pressure ulcer, in house acquired, located on their spine, and measured 0.83 cm length by 0.44 cm width by 0.2 cm depth. Review of R36's wound clinic consult note, dated 6/10/24, read in part, .Sharp debridement performed .Recheck in 1 month. Review of R36's wound clinic consult note, dated 8/6/24, read in part, .The wound is again covered with rather adherent slough. Sharp debridement performed .Recheck in 3 weeks. Review of R36's wound clinic consult note, dated 9/4/24, read in part, .She was placed on 10 days of doxycycline (antibiotic) at the nursing home for concern for wound infection. The wound had been improving the first 2 months of treatment, but then started to increase in size .claims .is not lying on it or pressing against it when seated. I would like staff to ensure this is the case .If .is leaning against it when seated, flat memory foam pillow should be used to offload pressure. Wound sharply debrided . return in 2 weeks for a recheck Review of R36's wound clinic consult note, dated 9/18/24, read in part, .measuring larger .continues to report .is not lying on it .Remainder of the wound sharply debrided .Ensure pressure is completely offloaded .Recheck in 1 month . Review of R36's wound evaluation, dated 10/21/24, revealed a stage 3 pressure ulcer to their spine, facility acquired, and measured 1.79 cm length by 1.65 cm width by 1.0 cm depth. On 10/24/24 at 9:21 AM, an interview was conducted with the Assistant Director of Nursing (ADON) / Registered Nurse (RN) I and was asked how R36's had developed a stage 3 pressure ulcer and replied, I am not sure. We identified there was an increase in pressure wounds around March and so we did a skin sweep and identified residents that had impaired skin or were at risk for breakdown. We added interventions for them at the time. That is when I believe R36's skin impairment was first identified. Interventions for turning and repositioning were added. We got rid of all the heavy absorbant pads because we felt they were adding extra moisture to the skin. The ADON / RN I was asked when the physician is made aware of newly identified open areas to residents' skin and replied, I would get the physician involved if a resident had a reddened skin area that was blanchable after the first few days it had not improved. The ADON / RN I was asked about wound vacs and staff training and replied, All nursing staff are trained on how to use and should be competent to do wound vac dressing changes. Wound vacs are a hit and miss for working. On 10/24/24 at 11:00 AM, an interview was conducted with the Director of Nursing (DON) and was asked if there were any added interventions to R36's care plan now that they were lying on their back more frequently and replied, No. I guess we need to have her evaluate by physical therapy again and see if they have any suggestions that would help with offloading. The DON confirmed R22's wound vac should not have been turned off for more than the amount of time to redress a new wound vac dressing and staff should be assessing proper function of the wound vac with every encounter with R22 and at a minimum of every two hours. Review of policy titled, Pressure Ulcer/Skin Breakdown - Clinical Protocol, dated 3/20/24, read in part, Policy: Based on the comprehensive assessment of a resident, a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Deficient Practice Statement (DPS) has two parts: A and B. DPS A: Based on observation, interview, and record review, the facility failed to provide adequate supervision resulting in a fall with major injury for one Resident (#64) of five residents reviewed for accident hazards and supervision. This deficient practice resulted in serious bodily injury including a head laceration and a cervical (neck) fracture for Resident #64. Findings include: Resident #64 (R64): Review of R64's electronic medical record (EMR) revealed initial admission to the facility on 5/26/23 with diagnoses including osteoporosis, repeated falls, a stroke affecting the right dominant side, and toxic encephalopathy (a brain condition often resulting in changes in cognitive function). Review of R64's most recent Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 8, indicative of moderate cognitive impairment. Review of R64's EMR revealed the following Nurse's Note: 10/20/24 at 2:15 PM: Resident had unwitnessed fall from wheelchair in front of 300 hall nurse desk, had large skin tear to forehead, left eye and left wrist .transferred per EMS [Emergency Medical Services] to emergency room for tx [treatment] and evaluation. On 10/23/24 at 11:50 AM, R64 was observed laying in bed with a large hematoma (bruise) to her left eye and a laceration across her forehead that had been secured with sutures (stiches). On 10/23/24 at 10:29 AM, an interview was conducted with Certified Nursing Assistant (CNA) E who verified she was familiar with R64's level of care. CNA E recalled responding to a fall code on 10/20/24 where she witnessed R64 on the floor with a bleeding laceration on her forehead. When asked R64's level of mobility, CNA E stated R64 for dependent for mobility and could not propel herself in a wheelchair. CNA E stated, Somebody placed her at the nurse's station for better supervision . I think this fall was after lunch, and residents are often placed at the nurse's station after lunch because there is only one care assistant [CNA] on the hall and the other is helping in the dining room. On 10/23/24 at 11:24 AM, a telephone interview was conducted with Registered Nurse (RN) O who verified she responded to the fall code for R64 on 10/20/24. RN O stated in previous days, R64 started trying to get out of bed and had sustained falls from bed, so she was brought to the nurses' station after lunch for increased supervision by the staff who were charting. RN O stated prior to the fall, she responded to a call light in a private resident room with the only CNA on duty on R64's unit. In the process of assisting in the private room, other RN O stated other staff must have left the nurses' station which left R64 unattended. RN O stated, We were spread too thin that day [in regard to staffing levels]. When asked if resident supervision is lacking when staffing level are short, RN O responded, Yes, definitely. On 10/23/24 at 2:18 PM, a phone interview was conducted with RN P who verified she was working on the hall adjacent to the nurses' desk by which R64 was stationed. RN P recollected responding to hearing a loud crash while in a nearby resident room and observing R64 laying on the floor. When asked about contributing factors to R64's fall, RN P stated, There was only one nursing aide on the hall that day Staffing has been challenging. Review of R64's EMR revealed the following entries: 1. Nurses' Notes on 10/22/2024 at 17:09 [5:09 PM]: Resident returned from hospital via EMS on comfort care .Resident with large, sutured laceration of the forehead, Scattered skin tears of the L [left] wrist .Resident mostly non-responsive but did open eyes with painful stimuli. Per MD [medical doctor] at hospital, resident has remained NPO [nothing by mouth] and is unable to swallow pills, food or drinks . 2. Pertinent Charting-Change in Condition note on 10/22/2024 at 20:59 [8:59 PM]: Change identified: decline with mental status and ADL [activities of daily living], unresponsive . 3. Pertinent Charting-Change in Condition note on 10/23/2024 at 9:49 AM [8:59 PM]: Originally identified change: Fall with change in mental status. Resident spent time in hospital following fall with head injury. Resident has returned to facility on comfort are with several skin issues, new C2 [second cervical (neck) vertebrae] fracture, change [in] LOC [level of consciousness] and new comfort care order for EOL [end-of-life] care. On 10/24/24 at 9:01 AM, an interview was conducted with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) who confirmed low staffing levels and subsequent inadequate supervision has been an ongoing issue at the facility. Review of facility policy titled, Accidents and Supervision, revised 12/27/23, read, in part: .Supervision is an intervention and a means of mitigating accident risk. The facility provides adequate supervision to prevent accidents . DPS B: Based on observation, interview, and record review, the facility ensure supervision during smoke for one Resident (#15) of five residents reviewed for accident hazards and supervision. Findings include: Resident #15 (R15) Review of R15's electronic medical record (EMR) revealed initial admission to the facility on 8/12/24 with diagnoses including tobacco use, history of falling, chronic obstructive pulmonary disease (COPD), and vascular dementia. On 10/22/24 at 3:02 PM, R15 was observed sitting on a four-wheeled walker outside the main facility entrance smoking a cigarette unsupervised. On 10/23/44 at 4:45 PM, R15 was again observed sitting on a four-wheeled walker outside the main facility entrance smoking a cigarette unsupervised. On 10/23/24 at approximately 4:50 PM, facility management was made aware of R15's whereabouts and lack of supervision. Assistant Administrator R stated, That's [R15], he's allowed to smoke by himself. When asked about R15's smoking plan of care, Assistant Administrator R was unsure of R15's interventions. Review of R15's Plan of Care revealed the following Goal, initiated 8/12/24: Resident will smoke safely at the designated area(s) at scheduled times through the next review. An intervention, initiated 8/12/24 read, Observe the resident's safety during smoking. Review of facility policy titled, Smoking Policy Smoking Campus-Residents, reviewed 5/31/23, read, in part: It is the policy of this facility to establish and maintain safe resident smoking practices . Any restrictions placed on smoking privileges shall be noted on the care plan so that all personnel may be alert[ed] to smoking restrictions . Any resident with smoking privileges shall not be permitted to smoke without direct supervision of a responsible staff member, family member, visitor or volunteer worker and direct supervision must be provided throughout the entire smoking period . All smoking privileges shall be so noted on the care plan .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent the development of a pressure ulcer and provide pressure ulcer care per professional standards of practice for two Residents (R4 and R8) of three residents reviewed for pressure ulcer care. Findings include: This citation is linked to intake MI00143371. A review of the Electronic Medical Record (EMR) revealed R4 developed an in house acquired unstageable pressure ulcer area on 2/18/24 which subsequently worsened to an increased size and developed into a stage IV pressure ulcer. The pressure ulcer continued to deteriorate from 2/18/24 through 3/11/24 with worsening measurements. R4 developed a pressure ulcer wound infection, requiring hospitalization, antibiotics, intravenous pain medication, wound debridement, a wound vac, and colostomy placement. The facility failed to consistently measure wound care assessments, failed to follow physician wound care orders, failed to ensure a wound care clinic consult was done timely, failed to implement wound care interventions timely, failed to prevent wound infection, and failed to appropriately turn/reposition R4 for pressure relief. Review of R4's census, revealed an admission to the facility on 2/7/24 and discharged on 3/13/24. Review of R4's medical diagnoses, dated 2/7/24, revealed the following diagnoses: need for personal assistance, muscle weakness, pneumonia, fusion of spine, spinal stenosis cervical region and cervical disc disorder at C4 - C5 level with myelopathy, rheumatoid arthritis, and hallux valgus (a bony bump that forms on the joint at the base of the big toe). Review of R4's Minimum Data Set (MDS) assessment, dated 2/13/24, revealed functional abilities for toileting hygiene, shower/bath, upper and lower body dressing, putting on/off footwear, and rolling from left to right as a substantial/maximal assistance. R4 was dependent for transfers to chair to bed, toileting, and lying to sitting/sitting to lying. MDS Section E Behaviors, dated 3/13/24, revealed no rejection of care. Review of R4's electronic medical record (EMR), nursing assessment, dated 2/7/24, part I section V skin, revealed the following skin conditions; right heel - boggy (blanchable redness) and left buttocks - rash. No other skin condition or open areas were documented in the nursing assessment. Review of R4's EMR, skin assessment, dated 2/13/24, revealed no new abnormal skin areas and no existing abnormal skin areas. A subsequent wound evaluation for R4, dated 2/19/24, identified an unstageable pressure injury to the sacral coccyx area. The following measurements are for the same sacral/coccyx wound for R4 as follows: Review of R4's wound evaluation, dated 2/19/24, revealed a pressure injury, unstageable, measuring 12.47 cm (centimeters) in length x 12.83 cm wide. The wound was identified as one day old, in-house acquired. The surrounding tissue was described as excoriated (Wound picture showed a small amount of fecal matter in the rectal area and skin tissue appeared slough brown in color in the center. Edges near rectal area were white with small amounts of yellow color and edges around the wound were reddened.) and covered with foam boarded dressing. This was labeled as a new wound, healable, and the practitioner was notified. Review of R4's wound evaluation, dated 2/26/24, revealed a pressure injury, unstageable, measuring 10.37 cm x 10.71 cm (Area pictured appears larger and left side open towards lower torso. Center appeared brown/red in color and bordered edge on the right side had some spotty eschar noted and outer edges yellow slough with reddened edges). The evaluation noted a moderate amount of serosanguineous [blood mixed with light yellow color] drainage and turning and repositioning program was added to the care plan. Review of R4's wound evaluation, dated 3/4/24, revealed a pressure injury, unstageable, measuring 17.16 cm x 18.93 cm (Area pictured appears to now have depth, approximately 50% of the wound bed appeared to have eschar and increased redness to left buttocks surrounding area when compared to the previous pictured area). There was a heavy amount of purulent drainage with odor. Surrounding tissue had erythema and was noted to be fragile, pain was 3/10 [mild/moderate] intermittent, dressing appearance was saturated, and wound progress was deteriorating. Notes: New orders received to apply medihoney [medical grade honey dressing] to wound bed and new orders to send resident to wound clinic for consultation. Review of R4's wound evaluation, dated 3/9/24, revealed a stage 4 pressure ulcer, measuring 15.29 cm x 14.44 cm (Area pictured appears to have increased depth and a mixture of eschar/slough/tissue granulation. Surrounding redness appeared to be extending past the left gluteal cleft, and linens on resident bed in the photo revealed a large amount of drainage which appeared brownish and serosanguinous in color along with smaller amount of fecal matter). A heavy amount of serosanguinous drainage with a strong odor was documented. Surrounding tissue edges were noted to be non-attached, denuded [protected top layer missing] with erythema [redness], excoriated and fragile. Pain was rated 8/10 [severe] continuous. Wound progress was noted as deteriorating. Review of R4's care plan, dated 2/10/24, read in part, .Focus: Resident has impaired skin integrity as evidence by: Unstageable ulcer to coccyx (revised on 2/19/24) .bowel incontinence (revised on 3/5/24). Goal: Resident will show signs of healing and/or improvement .Interventions: Administer treatment(s) per orders .Assist resident with turning and repositioning .Turning schedule clock in room (revised 3/5/24) .Complete wound evaluation to observe the progress of the resident's skin condition .Pressure redistribution mattress to bed - low air loss mattress (date initiated 3/4/24). Provide incontinence care as needed (date initiated 3/4/24) .Wound consult as needed (date initiated 2/19/24) . Review of R4's physician order, dated 2/19/24, revealed the following, Coccyx, Left & Right buttocks - Gently cleanse with soap and water, pat dry. Apply skin prep and cover with boarder foam dressing. In the morning every Monday, Wednesday, Friday for pressure injury. Review of R4's physician order, dated 2/20/24, revealed the following, Coccyx area - Gently cleanse with soap and water, pat dry. Apply skin prep and cover with boarder foam dressing. In the morning for pressure injury. Review of R4's physician order, dated 3/5/24, revealed the following, Coccyx Pressure injury: 1. Wash wound with wound cleaner 2. Apply skin prep to periwound [skin surrounding wound] 3. Calcium alginate AG [silver] to wound bed 4. Cover with boarder foam dressing until medihoney is available every day shift. Review of R4's physician order, dated 3/5/24, revealed the following, Wound Care Clinic Consult .for unstageable wound to coccyx. *Note: Care plan stated the wound care consult was initiated on 2/19/24. Review of R4's physician order, dated 3/12/24, revealed the following, Coccyx Pressure injury: Wash wound with wound cleaner. Apply skin prep to periwound. Apply calcium alginate AG to wound bed. Fluffed AMD [anti-microbial dressing] gauze. Cover with boarder foam dressing until medihoney is available every day shift. Review of R4's progress note, dated 2/8/24 at 9:21 PM, read in part, [Physician M] in to see resident this am: [Physician M] wrotr (sic) as follows: 1.) Chest x-ray re: pneumonia, cough 2.) F/U (follow-up) with neurosurgery - per discharge order sheet 3.) F/U with Wound Care re: L toe ulcer - per discharge order sheet . Review of R4's progress note revealed the following: 2/18/24 at 5:44 AM, Large excoriated area to both butt cheeks and coccyx, complained of pain to site .bleeding redness and swelling noted . 2/19/24 at 2:48 AM, Unstageable pressure ulcer to coccyx and bilateral butt cheeks, 18 cm x 14 cm, complained of pain to area .center is dark purple and boggy as you extend out skin is open and with small amount of bleeding and serosanguinous drainage noted . 2/22/24 at 4:29 PM, .Wound deep red and black in color. Resident complained of increased pain in this area. 3/1/24 at 1:19 PM, .coccyx wound black with red/pink borders, foul smell .complained of pain when moved . 3/4/24 at 1:57 AM, .Wound to coccyx is getting deeper and larger, black soft very foul smell, complained of pain and burning . 3/5/24 at 1:42 PM, .Wound is worsening .Obtained consult to wound care clinic. 3/6/24 at 4:21 PM, .Resident on low air loss mattress. 3/7/24 at 12:40 PM, .Wound culture per MD (medical doctor). 3/9/24 at 5:11 AM, Resident is having large amount of purulent drainage with undermining to left buttock cheek, area is very warm to touch and has extremely foul smell, is close to rectum and you can hear a gas release sound when cleaning the rectal area . 3/9/24 at 7:16 AM, .site is getting worse daily and that it is draining large amounts of purulent matter, undermining noted, complained of pain 10/10 . 3/13/24 at 2:27 PM (late entry), Resident out to wound care appointment. Per wound care clinic resident was sent to [local hospital name] emergency department for treatment of sacral wound. Per [local hospital name] will require overnight stay. *Note: Wound care consult was 23 days after the intervention noted on the care plan and 8 days after the physician order written. Progress notes dated 2/7/24 through 3/13/24 lacked any documentation of non-compliance, behaviors, and/or refusals of care. Review of R4's admission history and physical, dated 2/7/24, completed by Physician M, read in part, .Physical examination: Wound left foot .addition comments: 1. Chest x-ray regarding: pneumonia/cough, 2. Follow-up with neurosurgery on order sheet, 3. Follow-up with wound care regarding left toe ulcer on order sheet .Signed off on 2/8/24 by nursing (unable to identify initials of Licensed Practical Nurse). *Note: Wound care consult was not completed by facility regarding left toe. Review of R4's physician communication fax, dated 2/20/24, read in part, Resident has acquired an unstageable ulcer to coccyx .looking for contributing factors such as ARF (acute respiratory failure), infection .Would like order for wound clinic consult please. Physician response: OK. Wound care consult. Signed 2/20/24. *Note: Physician agreed to the wound care consult on 2/20/24 and an order was not written for the wound care consult until 3/5/24. Review of R4's physician communication fax, dated 2/20/24, read in part, New unstageable pressure ulcer to coccyx and both butt cheeks 20 cm x 14 cm. Physician response: OK. Signed 2/20/24. Review of R4's physician progress note, dated 3/7/24, read in part, .Skin/wounds: Stage 4 coccyx pre .Assessment and plan: .4. Wound care consult. 5. Consider hyperbaric therapy, diverting colostomy. 6. Wound culture. Signed by Physician M and noted by Registered Nurse (RN) O. Review of R4's treatment administration record (TAR), dated 2/7/24 through 3/13/24, revealed three dressing changes were not documented as completed on 2/23/24, 2/29/24, and 3/4/24. There was an as needed dressing change order added on 3/4/24, however this was never documented as completed. Review of R4's Braden scale for predicting pressure sore risk, dated 2/7/24, revealed a risk for developing pressure sores. Review of R4's skilled nursing assessment, dated 2/13/24, revealed activities of daily living for rolling from left to right - substantial/maximum assistance. Review of R4's skilled nursing assessments, dated 2/13/24, 2/20/24, 2/22/24, 2/26/24, 3/3/24, and 3/4/24, revealed no documented education provided to R4 by nursing. Review of R4's wound culture, dated 3/11/24, revealed facility cultured coccyx wound positive for bacterial growth. Review of R4's task for turning and repositioning, dated 2/20/24 through 3/13/24, revealed the following: (*Times noted are when resident was documented as being turned and repositioned.) 1.) On 2/20/24 - not documented as turned between 2:21 AM and 2:00 PM, and not turned again between 8:00 PM and 3:08 AM (2/21/24), 2.) On 2/21/24 - not documented as turned between 9:05 AM and 12:03 PM, and not documented as turned again until 6:18 PM, 3.) On 2/22/24 - not turned between 3:26 AM and 8:03 PM, 4.) On 2/23/24 - not turned between 3:07 AM and 6:08 PM, and not turned again until 11:05 PM (last turned), 5.) On 2/24/24 - not documented as turned between 3:12 AM, and next turn was not until 2:00 PM, 6.) On 2/27/24 - not turned until 3:00 AM and then the next turn was not until 1:45 PM. *Note - Further review of turning documentation, dated 2/28/24 through 3/13/24 lacked multiple areas of documentation for turning and repositioning every two hours. Review of R4's hospital emergency department (ED) report, dated 3/13/24, revealed the following: Wound culture obtained was positive for bacterial growth, medications provided two different types of intravenous antibiotics, and an opioid hydromorphone 1 milligram for pain management related to pain 10/10. ED physician history and physical reported development of stage 4 pressure ulcer on coccyx with sacral exposure, necrotic tissue, and patient felt fatigued, weak, upset stomach, miserable, and low-grade fever. Also, reported wound care clinic thought he needed wound debridement and had not been on any antibiotics prior to hospital admission on [DATE]. Furthermore, extensive large sacral wound with exposed bone, and very malodorous. Review of R4's hospital physician exam report, dated 3/13/24, revealed the following: Stage 4 sacral pressure ulcer measuring 12 cm x 16 cm with deep tunneling, large amounts of yellow drainage, and bone appearing gray and soft. Will likely need surgical debridement. General surgery consulted and reviewed and agrees with needing debridement and placement of wound vac. Diagnoses of stage 4 pressure ulcer to the sacral region and osteomyelitis. Review of R4's hospital general surgeon report, dated 3/13/24, revealed the following: Postoperative sacral decubitus ulcer wound debridement measuring 15 cm x 15 cm. Wound vac not feasible related to wound close proximity to anal margin. Patient will most likely require diverting ostomy to avoid stooling into the wound. Review of R4's hospital operative report, dated 3/13/24, revealed the following procedure end-sigmoid colostomy. Review of R4's hospital records, dated 3/18/24, revealed the following placement of a wound vac on the sacral region. On 4/3/24 at 8:15 AM, an interview was conducted with Occupational Therapist (OT) L and was asked about R4 having a pressure reduction cushion in his wheelchair and replied, Nursing came to me on 3/7/24 and that is when a pressure reduction cushion was implemented. OT L was then asked how R4 transferred and what type of locomotion he was and replied, He was a lift the entire time he was here and used a wheelchair for locomotion. OT L stated that if he was aware R4 had a pressure ulcer on his coccyx sooner he would have implemented to nursing the need for a pressure reducing cushion but had not been notified until 3/7/24. OT L was asked if he recalled any type of dressing to R4's left foot and replied, Yes, I do believe he had some type of dressing on his foot. On 4/3/24 at 9:06 AM, a phone call was placed to Registered Nurse (RN) E who initially discovered the coccyx wound on R4 and there was no answer. A message was left for RN E to call this Surveyor back with call back number. *Note: no return call was received during the survey. On 4/3/24 at 9:55 AM, a phone call was placed to Licensed Practical Nurse (LPN) G regarding skilled assessment education and R4's wound. A message was left for LPN G to call this Surveyor back with call back number. At 10:30 AM LPN G came in to the facility to see this Surveyor for an interview. LPN G was asked if she recalled R4 having a dressing on his left foot and replied, I do not recall. LPN G was asked what kind of mattress R4 had on admission and replied, Just the usual pressure reducing mattress. LPN G was not sure about a wheelchair cushion and added the wound was not that bad in the beginning. LPN G indicated the wound was red and excoriated then ended up with an area that was necrotic where it opened up and they were applying a foam gauze dressing 10 cm x 10 cm and it was tunneled. The wound nurse does the wounds and works the floor on Thursdays, and she is not here today. *Note: Wound Care Nurse was unavailable for an interview. On 4/3/24 at 1:10 PM, an interview was conducted with Certified Nurse Assistant (CNA) O, and was asked if they recalled R4 and replied, Yes. CNA O was asked what kind of care R4 required and what kind of person he was like and replied, He was a good guy. He needed extensive assistance and used a lift for transfers to his wheelchair. CNA O was asked if he refused care or was difficult and replied, No. Not that I can recall. On 4/3/24 at 2:00 PM, an interview was conducted with the Director of Nursing (DON) and Regional Clinical Nurse (RCN) H. They were asked if the medihoney ever came in prior to R4 being sent to the wound clinic and admitted back to the local hospital. The DON replied, No. It came in about two weeks ago. I think it was 3/18/24. Both nurses were then asked what their expectation was on wound care documentation and if depth should have been measured sooner when R4's wound showed depth and replied, Yes. Depth should have been measure as soon as the wound presented with depth and wound measurements should have been consistent. The DON was asked why R4 was not seen at the wound clinic sooner and had no reply. Both nurses were asked if they knew how R4's coccyx wound got infected and replied, We do not know. The DON was asked how often dressing changes were being completed on R4 and replied, Twice a day and as needed. The DON was asked if the physician wound dressing change orders reflected that and replied, Nope, it was once a day. Should have been changed if it was saturated. I think there is only one extra change documented. There was a prn order added on 3/4/24 but there are no extra dressing changes signed out. Both nurses were asked what the expectation for wound dressing documentation was and replied, The nurses should be documenting each dressing change in the treatment record. Both nurses were asked if there was not a space to document wound dressing changes as needed then how did they know this was being completed twice or more a day and replied, We do not know. The DON stated physician M did not physically see R4's wound until 3/5/24 and the medical director was requesting that the rounding physician physically see the wound once a month and make a progress note. The DON went on to say that she felt the rounding physician was overwhelmed. Resident # 8 (R8) R8 developed an unstageable pressure ulcer to his coccyx area that was facility acquired and resulted in further deterioration of the wound with increased size and depth. R8 also had placement of a urinary catheter to help promote healing of the coccyx wound. Review of R8's census, revealed an admission to the facility on 1/16/24. Review of R8's medical diagnoses, dated 1/16/24, revealed the following diagnoses obesity, chronic obstructive pulmonary disease, cellulitis, and hypertension. Review of R8's MDS, dated [DATE], revealed functional abilities for shower/bath, upper and lower body dressing, and putting on/off footwear as a substantial/maximal assistance. R8 was partial/moderate assistance for toileting, transfers to chair to bed, and lying to sitting/sitting to lying. MDS section E Behaviors, revealed no rejection of care. MDS, dated [DATE], section E behaviors, revealed no rejection of care. The following measurements are for the same coccyx wound for R8 as follows: Wound evaluation, dated 3/4/24, revealed a pressure injury, unstageable, measuring 1.73 cm in length x 0.5 cm in width, seven hours old, in-house acquired, and progress new. Wound evaluation, dated 3/11/24, pressure injury, unstageable, measuring 1.85 cm in length x 0.86 cm in width x 2.1 cm in depth, seven days old, wound bed 80% slough, moderate amount of serosanguineous exudate, and practitioner notified. Wound evaluation, dated 3/18/24, pressure injury, unstageable, measuring 1.16 cm in length x 0.56 cm in width x 2.1 cm in depth, moderate amount of serosanguineous exudate, and practitioner notified. Wound evaluation, dated 3/24/24, pressure injury, unstageable, measuring 0.83 cm in length x 1.25 cm in width x 2.1 cm in depth, moderate amount of serosanguineous exudate, and practitioner notified. Wound evaluation, dated 4/2/24, pressure injury, unstageable, measuring 3.19 cm in length x 2.76 cm in width x 5.0 cm in depth, moderate amount of serosanguineous exudate, faint odor, and wond (sic) shows some deterioration. Measurements are larger this week. Faint odor noted after wound cleansed. Review of R8's care plan, dated 4/2/24, read in part, Focus: Resident has a need for indwelling catheter related to pressure ulcer(s) . Further review of R8's care plan, dated 3/22/24, read in part, Focus: Resident has impaired skin integrity as evidence by: .pressure injury to coccyx .Interventions: Air mattress 93/19/24) .administer treatment(s) per orders (2/22/24) . Review of physician order, dated, 3/5/24, revealed, Treatment: Coccyx Pressure Injury: 1. Wash with wound cleaner 2. Apply skin prep to periwound 3. Apply medihoney to wound bed 4. Cover with boarder foam dressing. Every day shift every 3 day(s) for skin impairment. Review of physician order, dated, 3/7/24, revealed, Treatment: Coccyx Pressure Injury: 1. Wash with wound cleaner 2. Apply skin prep to periwound 3. Apply hydrogel to wound bed 4. Cover with boarder foam dressing. Every day shift every 3 day(s) for skin impairment. Review of physician order, dated, 3/12/24, revealed, Treatment: Coccyx Pressure Injury: 1. Wash with wound cleaner 2. Apply skin prep to periwound 3. Apply hydrogel to wound bed 4. Apply fluffed gauze 5. Cover with boarder foam dressing. One time [11:00 AM] a day every 3 day(s) for pressure injury. Review of physician order, dated, 3/14/24, revealed, Treatment: Coccyx Pressure Injury: 1. Wash with wound cleaner 2. Apply skin prep to periwound 3. Apply hydrogel to wound bed 4. Apply fluffed gauze 5. Cover with boarder foam dressing. Every night shift every 3 day(s) for pressure injury. Review of R8's TAR, dated 3/1/24 through 3/31/24, revealed no documentation of a wound dressing change completed on 3/7/24 and 3/12/24. Review of R8's physician communication fax, dated 3/7/24, read in part, Resident has new pressure ulcer to buttocks .Please make note of wound and the deterioration of condition of wound. Review of R8's physician communication fax, dated 4/2/24, read in part, [R8] had large clot softball sized come out of his wound on his coccyx when his dressing was changed. Review of R8's progress note, dated 3/19/24, read in part, .Coccyx wound remains open. New order for foley placement to aide in wound healing . On 4/3/24 at 3:30 PM, an observation was made of R8's coccyx wound with RCN H and the DON. During the dressing change observation R8's wound was noted to have deteriorated and have a moderate amount of serosanguinous drainage. On 4/3/24 at 3:45 PM, an interview was conducted with the DON and RCN H, regarding the development of R8's coccyx pressure wound and stated that R8 developed the wound in the facility. The DON was asked if she was aware that a large clot was expelled from R8's coccyx wound on 4/2/24 and replied, No. I was not made aware of that. I will look into it. Review of policy titled, Wound Treatment Management, dated 10/26/23, read in part, Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidenced-based treatments in accordance with current standards of practice and physician orders. Policy Explanation and Compliance Guidelines: 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change . Review of policy titled, Pressure Injury Prevention and Management, dated 1/1/22, read in part, Policy: This facility is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries . Policy Explanation and Compliance Guidelines: .3. Assessment of Pressure Injury Risk .c. Assessment of pressure injuries will be performed by a licensed nurse, and documented in the medical record .4. Interventions for Prevention and to Promote Healing .c. Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions .include .i. Redistribute pressure (such as repositioning, protecting and /or offloading heels, etc.); . iii. Provide appropriate, pressure-redistributing, support surfaces .f. Interventions will be documented in the care plan and communicated to all relevant staff . Review of policy titled, Pressure Ulcer/Skin Breakdown-Clinical Protocol, dated 1/1/22, read in part, Policy: Based on the comprehensive assessment of a resident, a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers .and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice to promote healing, prevent infection . Policy Explanation and Compliance Guidelines: .4. The interdisciplinary team (IDT) will assess and document and individual's significant risk factors for developing PU/PI [pressure ulcer/pressure injury] .7. Continued assessment and management .PUSH [pressure ulcer scale for healing] tool completed on PU/PI weekly during the weekly wound measurements .15. The IDT team will review each pressure ulcer weekly for progress and changes .

Based on observation, interview, and record review, the facility failed to implement an effective pain management program for one Resident (R23) out of four reviewed for pain management. This deficient practice resulted in R23 experiencing new, increasing, and unrelieved pain. Findings include: On 8/29/22 at approximately 12:30 p.m., an interview was conducted with R23. R23 stated that she felt staff were very quick to help her with Activities of Daily Living (ADL) cares (specifically toileting and positioning), and that they were in a rush to do things quickly. R23 stated that she was in a lot of pain due to a broken leg, and that staff were aware her leg was broken, but continued to rush through cares. R23 was observed attempting to reposition herself slightly in her bed and was wincing in pain with movements. On 8/31/22 at approximately 9:00 a.m., an interview was conducted with R23 regarding her pain management. R23 stated that she was in increasing pain due to her recent leg fracture. R23 began to describe an incident a few weeks ago when two nurses and a CNA (certified nurse aide) came into her room to obtain a urine sample using a straight catheter. R23 stated she originally told the staff members that she did not have to urinate, but that if they came back in an hour, she would be willing to attempt to give a urine sample at that time. R23 stated that the staff members refused to listen and began to hold her down and lift her legs to put a catheter in her. R23 said that she began to kick and scream, moving her body around because she did not want to have this procedure, when she was moving, her legs began to fall off the bed which at that point, one of the three staff members grabbed her leg and held it down. R23 stated that is when she heard and felt a 'pop' sound and knew something was wrong. A urine sample was not obtained before another staff member overheard from the hall way and stopped the procedure. R23 stated that the pain was so unbearable that she requested an x-ray and later found out that her leg was broken. R23 again was observed wincing in pain and requesting more pain medication for her leg pain. Review of R23's Electronic Medical Record (EMR) revealed admission to the facility on 1/21/22 with diagnoses including fracture of left femur (8/19/22), Urinary Tract Infection (UTI), post-traumatic stress disorder (PTSD), anxiety disorder, and muscle weakness. Her 6/18/22 Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 8/15 indicating mild cognitive impairment, and required extensive two person assist for bed mobility, extensive one-person physical assist for toileting, and total dependent two person assist for transfers. R23 was also marked for receiving prn (as needed) pain medication and stating she had moderate pain per the verbal pain descriptor scale. A physician communication form for R23 dated 8/9/22 read, in part, .reason for notifications .also is requesting to have x-ray of L (left) hip for pain? response: x-ray of L hip related to pain . A physician progress note dated for R23 dated 8/15/22 read, in part, .diagnoses: left hip pain - await x-ray .assessment and plan: .CT L hip. ASAP. Severe pain .oxycodone 10 mg 1 tab q (every) 6 hours prn. Prognosis grave . A review of R23's Behavioral Care Solutions progress note dated 8/5/22 read, in part, .states her moods are 'crap' and blames this on her ongoing pain. She says her sleep and appetite are poor from pain as well. She is irritable, does not want to talk today unless she is getting more pain meds .PCP (primary care provider) to manage chronic pain . A review of R23's Progress Notes read, in part, the following: 8/5/22 3:40 p.m. event date 7/27/22 .open areas noted on right heal and left calf. Pinpoint open areas on coccyx/buttock. Description: Right heal 3cm (centimeters) x 2.5cm x 0.1 mm (millimeter) open area. No active drainage; left calf 2.4cmx1.7cm no active drainage. Multiple pinpoint open areas on buttock/coccyx area . There was no documentation of R23's pain level. 8/15/22 4:13 p.m.: N.O (new orders) per (Physician X) .CT Left Hip ASAP regarding increase pain, increase oxycodone to 10 mg (milligrams) po (by mouth) every 6 hours prn pain, prognosis grave. 8/15/22 5:13 p.m.: c/o pain oxycodone 5 mg po given 8/30/22 10:00 a.m.: refused to go to ultrasound appointment states she is into much pain and wants it rescheduled for later date. A review of R23's care plan revealed a pain care plan, (R23) is at risk for chronic pain related to spontaneous rupture of extensor tendons, unspecified lower leg, osteoarthritis date initiated 7/2/19. This care plan included interventions as followed: Give Tylenol 650 mg prn for breakthrough pain after oxycodone and ice therapy are given. Do not exceed 3000 mg in a 24-hour period date initiated: 4/17/18 .monitor and change fentanyl patch as ordered date initiated 4/26/22 .monitor/record/report to nurse resident complaints of pain or requests for pain treatment date initiated 12/17/18 .observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease movement or range of motion, withdrawal, or resistance to care date initiated 4/11/18 . A review of R23's Medication Administration Record (MAR) for August 2022 the Resident had only prn medications ordered and no Fentanyl patch was recorded as being used by R23 on the MAR. A review of the facility policy titled, Pain Management revised on 1/1/2022 revealed, The facility will ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences .evaluate the resident for pain upon admission, during ongoing scheduled assessments, and with change in condition or status .identifying key characteristics of the pain: duration, frequency, location, onset, pattern, radiation .the resident's goals for pain management and his/her satisfaction with the current level of pain control .The following are general principles for prescribing analgesics in the long term care setting: .In most cases, prescribe at least one scheduled, not as needed (PRN), analgesic medication .reassess and adjust the dose to optimize pain relief while monitoring and trying to minimize or manage side effects .reassess patients with pain regularly based on the facility's established intervals for effectiveness and/or adverse consequences .if re-assessment findings indicate pain is not adequately controlled, revise the pain management regimen and plan of care as indicated .