**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Intake: MI00150656This citation has two separate deficiencies. Based on interview and record review, the facility failed to provide all necessary care and services for one resident (R128) of one resident reviewed for quality of life, resulting in R128 not maintaining his highest practicable well-being, being hospitalized three times and endangering his life. Findings include: Review of R128's Electronic Medical Record (EMR) revealed admission to the facility on 3/4/25 with diagnoses including multiple right rib fractures and alcohol dependence with withdrawal. R128 was his own responsible party for medical and financial decisions. Review of R128's Discharge Summary from [Hospital Name] dated 3/4/25 read, in part, .Patient is a pleasant 78 y.o. (year old) male who tripped over a tv cord the morning of admission [DATE]) and had right sided chest wall pain. He was diagnosed with multiple right sided rib fractures, however refused hospital admission .He then went home and slipped and fell on the ice of his driveway and returned having never made it inside his house. This time he did strike his had [sic] and had questionable LOC (loss of consciousness). On second presentation to the ED (emergency department), he was only complaining of right sided chest wall pain. He was found to have fractures to R (right) ribs 7, 8, 9. He was admitted to the ICU (intensive care unit) given the severity of his rib fractures to monitor his vital signs and oxygenation .He demonstrated some signs of alcohol withdrawal, mainly tremors. This was treated satisfactorily with oral Librium (medication used to treat anxiety or alcohol withdrawal) .He is being discharged to [Facility Name] in stable condition .He will be sent on a 3-day taper of oral Librium to prevent DT's (delirium tremens) while at the facility .Medications: chlordiazepoxide (Librium) 75 mg (milligrams) to be given evening of 3/4/25, 50 mg BID (twice a day) to be given on 3/5/25, 25 mg BID to be given on 3/6/25 . Review of R128's Physician Note dated 3/5/25 read, in part, .Overall the patient remained stable although he did develop concerns of minor alcohol withdrawal in which he was discharged to [Facility Name] for subacute rehab with oral Librium taper. Upon arrival to [Facility Name] the patient was stable with mild tremor. Librium was not stocked in the back up medications and the patient did not come with any from the hospital therefore I did place him on Ativan 1 mg x (times) 1 with .5 mg Q4hrs as needed .He has mild tremor and anxiety .Assessment: Alcohol withdrawal syndrome without complication - with chronic alcohol abuse and acute alcohol withdrawals. Mild with tremor and agitation. Vitals stable. Continue Ativan taper as ordered with PRN Ativan x 7 days. Continue thiamine and folic acid as ordered. Monitor closely, vitals every shift x 3 days .Review of R128's Medication Administration Record (MAR) for March 2025 revealed two Physician Orders for Librium which read as follows, Librium 25 mg 1 capsule by mouth two times a day for ETOH for 1 day (3/5/25) and Librium 25 mg 2 capsule by mouth two times a day for ETOH for 1 day (3/4/25). During review it was confirmed that R128 did not receive either order of his Librium medication.Review of R128's Progress Notes read, in part, 3/4/25 08:22 This writer received a phone call from primary nurse at 0020. Primary nurse stated that resident became extremely agitated for no apparent reason and was trying to rip the TV off of the wall. PRN Ativan was given. Resident is a heavy ETOH user, prior to hospitalization and admission and is suspected to be going through withdrawals. NP (Nurse Practitioner) was notified this morning. She would like resident to have Ativan this morning 1 mg if Librium did not come in. 3/5/25 12:04 Med with (R128) to get food preferences. (R128) was very out of it had trouble answering my questions .3/5/25 17:53 Pt (patient) medicated throughout shift for agitation and pain . 3/7/25 08:11 .Sending out to hospital due to ETOH and elevated blood pressure, complaining of chest pain and stating that he is having a heart attack . 3/7/25 15:25 Resident stated that he feels like he is dying, and can't breath. Resident appears to have tremors, increased anxiety and agitation, denies auditory or visual hallucinations. PRN Ativan given .3/7/25 16:38 Resident extremely agitated stated he was calling the police, there was people trying to take over his home, stated he would walk home in his pajamas if he had to. Appears to be having delusions and agitation related to alcohol withdrawal. NP contacted. Gave one time order for Ativan .5mg and lisinopril 20mg. Asked that vitals be rechecked in 1 hour and texted to her. Primary nurse notified. 3/7/25 20:56 This writer was notified that the resident was yelling at staff exit, having episodes of delirium. Upon assessment the residents blood pressure was elevated, immediate action was taken blood sugar obtained. Resident was oriented only to person, slurred speech, right sided facial drooping, ataxia NIH performed with positive results. NP notified with an order to send out . 3/7/25 22:17 Resident was walking on his own, very unsteadily, and he tried to go out the back door. He was pushing on the handle making the alarm go off. He also tried to set off the fire alarm .He was given .5mg Ativan, on 4 different occasions .he said Don't touch me, I'm going to get my gun .he called 911 and told the operator that he was being held against his will .he was going to kill everyone, one by one .police officers came .3/7/25 23:13 .Per nurse patient is detoxing from alcohol, has been having high blood pressure despite several Ativan doses. He tried eloping several times, threatened to kill people. Nurse states that the new nurse that is coming on shift does not feel comfortable in taking care of this patient and thus is requesting the patient go back to the hospital .3/8/25 14:21 Resident returned from [Hospital Name] .3/8/25 18:08 Resident was observed to be having aggressive behaviors. Attempted to his glass door with oxygen tank. Threatening staff. Resident was extremely agitated and having delusional thoughts. He called 911 and told the police he was being held against his will .Review of R128's Physician Note dated 3/7/25 read, in part, .This patient is being seen today in follow up ER visit that occurred last night. The patient developed increased anxiety and hypertension and was sent to [Hospital Name] .the patient was given additional dose of linisonpril 20mg, oxycodone 5mg, and Librium 50mg and discharged back .Assessment: Alcohol withdrawal syndrome without complication .extended Ativan taper as ordered with continued PRN Ativan .Addendum: Staff requested repeat evaluation on the afternoon of 3/7/25 as the patient was requestioning to go to the ER. Upon exam, the patient notes he needs to go to the hospital because he is dying. He notes he is having anxiety and shortness of breath .Approx (approximately) 1 hour later the staff did call me again stating the patient called 911 himself stating he wanted the police to take him to the hospital .At 2000 the staff called and stated the patient was having acute right facial droop, hypertension, slurred speech, weakness with ataxia. At this point EMS was called and the patient was transferred to the hospital .Assessment: Alcohol withdrawal syndrome without complication . Review of R128's Physician Note dated 3/10/25 read, in part, The patient is being seen today in follow up from 2 ER visits over the weekend. The patient has been having acute alcohol withdrawal in which he developed agitation and delirium .the patient was treated for increased alcohol withdrawal and discharged back .upon arriving back records reveal the patient became agitated and was threatening to shoot staff with a gun and was aggressive therefore staff requested the patient go back to the ER. The patient was kept in the ER overnight in which he was noted to have persistent delirium and started on Risperidone .25mg twice daily and his symptoms did improve. The patient was brought back to [Facility Name] on 3/8/25 .Review of R128's ED summaries read, in part, Admit 3/7/25 01:16 He is brought to the ED by EMS (Emergency Medical System) from [Facility Name] .It is a bit unclear why the patient is here in the ED this evening .vital signs on arrival are significant for elevated blood pressure .We did call the [Facility Name]. Nursing staff spoke with their nurses .I did review his discharge summary from trauma surgery several days ago. It was noted that he was discharged with 3 days of Librium to finish his taper. Nursing staff at [Facility Name] did confirm that he has not been taking this, therefore maybe this is contributing to his elevated blood pressures .I have also ordered him a dose of Librium . Admit 3/8/25 00:04 Returns to the emergency department, his current skilled nursing facility where he was residing for rehabilitation purposes reports that they are unable to care for him, there is no clear report as to what exactly is occurring that is precluding them from caring for him, they alleged that it may be because of alcohol withdrawal .He has been seen in the emergency department 3 times in the past 24 hours .An interview was conducted with RN U on 5/22/25 at 11:39 a.m. RN U recalled R128 and said, It was kind of wild and crazy those few days, I remember him (R128) going through active detoxing. His behaviors were crazy. RN U confirmed he was not provided any additional resources or education for detoxing residents. An interview was conducted with Former Director of Nursing (DON) V on 5/22/25 at 12:06 p.m. DON V stated that R128 was suffering from severe withdrawals and having delusions and behaviors. DON V confirmed R128 never received Librium as the facility could not fill that order from the hospital and instead was given Ativan. DON V confirmed R128's behaviors continued, and the facility felt they could no longer care for the resident no longer felt comfortable doing so and discharged him 3 separate times to the emergency department. DON V stated the staff were not provided any additional education for residents who are suffering from withdrawal symptoms. An interview was conducted with Certified Nurse Aide (CNA) Q on 5/22/25 at approximately 10:30 a.m. CNA Q recalled R128 and said, I remember him having a lot of behaviors, he was taking oxygen tanks and throwing them at the exit doors, he called police, he was very scary and threatening us. I heard that he was having alcohol withdrawal. CNA Q recalled not having proper training on how to properly care for residents who are having withdrawal symptoms. Review of R128's Care Plans read, in part, Date Initiated: 3/6/25 Recent history of substance abuse; Goal: Resident will be in safe environment during stay at facility; Interventions: Complete review using medical record and resident/family interview, Education to resident on potential injury related to ordered medications and interaction with substances abuse, Establish resident goals, Notify MD (Medical Director) if resident appears impaired (prior to administering medications), Social Services referral of emotional support, Use calm and empathetic approach for communication . An interview was conducted with Regional Clinical Registered Nurse (RN) L on 5/22/25 at 11:29 a.m. who confirmed the facility does not have an alcohol withdrawal or assessment. Based on observation, interview, and record review, the facility failed to provide standards of care for hypoglycemia and diabetes management for one Resident (#5) of 18 residents reviewed for quality of care. Findings include:Resident #5 (R5)The medical record for R5 revealed an admission date to the facility on 1/15/22 with a primary diagnosis of diabetes mellitus. R5 had a BIMS assessment score of 15 out of 15 indicating intact cognition. On 5/20/25 at 11:12 AM, an observation was made of R5 in their room sitting on the side of their bed without any pants on. R5 was asked how they were doing and if they had any recent falls and replied, Yes, I had low blood sugar and I bumped my leg on my walker (four-wheeled walker). R5 was observed with a bandage on their left leg. R5 stated that orange juice does not work well if their sugar is low, and milk works best for them. Review of R5's medication administration record (MAR), dated 5/2025, revealed an order for lispro solostar 100 unit/ml (milliliter) pen-injector. Inject as per sliding scale: if 0 - 199 = 0; 200 - 250 = 2; 251 - 300 = 3; 301 - 350 = 4; 351 - 500 = 5;501 - 999 = 6 Call physician if BS [blood sugar] if (sic) greater than 500.Review of fasting blood glucose sugar levels (FSBS), dated 4/27/25 through 5/19/25, revealed the following:- 4/27/2025 7:23 AM, 44.0 mg/dL (milligrams/deciliter) - no progress note.- 4/27/2025 7:38 AM, 64.0 mg/dL - no progress note.- 4/28/2025 8:06 AM, 38.0 mg/dL - no progress note - no follow-up FSBS.- 4/30/2025 7:24 AM, 56.0 mg/dL - no progress note - no follow-up FSBS.- 5/5/2025 11:34 AM, 47.0 mg/dL - no progress note.- 5/5/2025 11:47 AM, 54.0 mg/dL - no progress note - no follow-up FSBS.- 5/9/2025 11:57 AM, 69.0 mg/dL - no progress note - no follow-up FSBS.- 5/17/2025 12:22 AM, 42.0 mg/dL - no progress note - no follow-up FSBS.- 5/18/2025 11:58 AM, 55.0 mg/dL - no progress note - no follow-up FSBS.- 5/19/2025 11:47 AM, 58.0 mg/dL - no progress note.- 5/19/2025 11:59 AM, 58.0 mg/dL - no progress note - no follow-up FSBS.Review of R5's progress notes, dated 4/27/25 through 5/19/25, lacked any notification to the physician of a low blood glucose level and no follow-up on the intervention or status of R5. On 5/21/25 at 12:15 PM, an interview was conducted with the Director of Nursing (DON) regarding their expectation for nursing encountering a resident with blood glucose levels below 70 mg/dL. The DON replied, I would expect to see a progress note communication on the physician notification, the interventions, and the repeat FSBS until the blood sugar was within normal limits. Review of policy titled, Diabetes Management, dated 6/29/17, read in part, Purpose: To develop a practice in which our facility consistently provides care for the resident with diabetes. Guidelines .Nursing Evaluation / Symptoms: Blood glucose monitoring .Results <70 or >400 indicate hypo or hyperglycemia require immediate follow up. Determine with the physician / extender if the individual has specific parameters to monitor .Nursing intervention .Evaluate signs and symptoms of diabetes complications .Notify the physician of any findings .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to readily identify, promote healing, and prevent the development of pressure injuries for two Residents (#26 & R42) out of three residents reviewed for pressure ulcer care. This deficient practice resulted in R26 developing a stage 3 pressure ulcer that worsened into a stage 4 pressure ulcer, and R42 developing infection and the deterioration of pressure wounds. Findings include:Resident #42 (R42)The medical record for R42 revealed an admission date to the facility on 5/25/23 with a primary diagnosis of pneumonia. R42 had a Brief Interview for Mental Status (BIMS) assessment score of 15 out of 15 indicating intact cognition. On 5/20/25 at 12:04 PM, an observation was made of R42 in their room and lying in bed with a pillow under their left side and both heels touching the bed. R42 was asked when the last time staff had turned and repositioned them and replied, Since last night. R42 was asked if they had a pressure ulcer and replied, Yeah, on my buttocks. R42 did not have a personal protective equipment (PPE) cart outside of their room door and no used PPE was observed in the trash cans in their room. R42 was asked how often they normally get turned and repositioned and replied, Usually every three to four hours. R42 was noted not to be wearing puffy boots while in bed. Review of R42's Quarterly Minimum Data Set (MDS), dated [DATE], read in part, .Section E: Behaviors .Rejection of care: Behavior not exhibited .Section G: Functional abilities and goals .Substantial/maximum assistance for toileting, upper body dressing, personal hygiene, and rolling left to right .Section M: Skin conditions .Resident has a stage 1 or greater, a scar over bony prominence, or a non-removable dressing/device (checked) .Risk of pressure ulcer development check yes .Unhealed pressure ulcers checked yes .Number of stage 2 pressure ulcers - two. Number of these stage 2 pressure ulcers that were present upon admission/reentry - two . Number of stage 3 pressure ulcers - one. Number of these stage 3 pressure ulcers that were present upon admission/reentry - one . Number of stage unstageable pressure ulcers - three. Number of these stage unstageable pressure ulcers that were present upon admission/reentry - zero . Number of venous and arterial ulcers - two .Review of R42's Braden assessment for determination of developing pressure ulcer risk, dated 4/15/25 at 3:10 PM, revealed that R42 was at, very high risk. Review of R42's active wound summary list, dated 5/21/25, revealed the following:1.) Wound site: buttocks/hip left, date identified 1/17/25, type: pressure, classification: ulceration, clinical stage: unstageable, and measured 0.70 length (L) cm (centimeters) x 0.50 width (W) cm x 0.00 depth (D) cm,2.) Wound site: left flank lower wound, date identified 12/16/24, type: pressure, classification: ulceration, clinical stage: unstageable, and measured 2.40 L cm x 3.00 W cm x 0.10 D cm,3.) Wound site: left flank upper wound, date identified 3/25/25, type: pressure, classification: ulceration, clinical stage: stage 3, and measured 2.70 L cm x 4.20 W cm x 0.20 D cm,4.) Wound site: left buttocks 2 medial, date identified 1/17/25, type: pressure, classification: ulceration, clinical stage: unstageable, and measured 2.00 L cm x 1.30 W cm x 0.30 D cm,5.) Wound site: left heel, date identified 5/20/25, type: pressure, classification: ulceration, clinical stage: unstageable, and measured 3.50 L cm x 4.60 W cm x 0.00 D cm,6.) Wound site: right buttock, date identified 2/27/25, type: pressure, classification: erythema, clinical stage: healed stage 2, and measured 2.00 L cm x 1.50 W cm x 0.00 D cm,7.) Wound site: sacrum, date identified 9/13/24, type: pressure, classification: ulceration, clinical stage: stage 3, and measured 8.00 L cm x 2.50 W cm x 0.70 D cm.Review of R42's task for behavioral monitoring for refusals of care, dated 4/21/25 through 5/20/25, revealed no refusals of care and no behaviors observed. Review of R42's care plan, dated 5/2/25, read in part, .Focus: The resident is on antibiotic therapy r/t (related to) cellulitis to buttocks. Goal: The resident will be free of any discomfort or adverse side effects of antibiotic therapy .Interventions: Administer antibiotic medications as ordered by physician .Focus: The resident has pressure ulcer (to) coccyx, sacrum, buttocks, (and) left scapula region. Goal: The resident's skin risk for further alteration in skin integrity will be minimized by staff allocated interventions. Interventions .Assess/record/monitor wound healing (q week) [every week] Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed and healing process .The resident needs to turn/reposition at least every 2 hours, more often as needed or requested .Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate .On 5/22/25 at 11:55, an observation was made of R42's wound dressing changes in their room with the Director of Nursing (DON), the Regional Clinical Registered Nurse (RN) L, and Licensed Practical Nurse (LPN) K to measure, assess, and complete wound dressing changes on R42's buttocks area. Findings include:1.) Pressure ulcer, stage 3 to left buttocks (next to intergluteal cleft), facility acquired and measured 8.00L cm x 3.00W cm x 0.20D cm,2.) Pressure ulcer, stage 3 to left buttocks (lateral side), facility acquired and measured 0.75L cm x 1.00W cm x 0.10D cm,3.) Pressure ulcer, stage 3 to left lower buttocks facility acquired and measured 2.00L cm x 1.00W cm x 0.50D cm with tunneling,4.) Pressure ulcer, unstageable to left heel, facility acquired and measured 3.50L cm x 4.60W cm x 0.00D cm.On 5/22/25 at 12:30 PM an interview was conducted with the DON who was asked if the documentation for the wound summary should reflect the actual presentation of the wound weekly after being assessed and replied, Yes, I don't know why it doesn't. We need to do a better job with documentation of wound assessments and measurements. (R42's) Pressure ulcers should not have developed or worsened. Resident #26 (R26)Review of R26's electronic medical record (EMR) revealed admission to the facility on 6/10/24 with diagnoses including dementia and aphasia (difficulty expressing thoughts). Review of Section C (Cognitive Patterns) of R26's most recent Minimum Data Set (MDS) Assessment, dated 3/21/25, revealed R26's cognitive skills for daily decision making were, severely impaired. On 5/20/25 at 1:35 PM, a phone interview was conducted with R26's son and Durable Power of Attorney (DPOA) R regarding his overall satisfaction with care received at the facility. DPOA R stated deterioration of a wound on R26's right buttock contributed to her overall decline and eventual enrollment with hospice services. Review of progress note dated 2/28/25 written by Nurse Practitioner (NP) S read, in part: Chief complaint/Nature of Presenting Problem: Progressing pressure ulcer, hospice discussion . History of Present Illness: [R26] is being seen today due to [a] progressing pressure ulcer. The staff notes [R26's] pressure ulcer is a stage 4 [extending through all layers of skin, exposing muscle, tendons, or bones], and [R26] overall continues to decline over time . hospice was recommended . Review of a R26's Wound Summary documentation read, in part: Site: right ischial tuberosity . Type: Pressure . Source: Facility Acquired . Date identified: 1/6/25 . Clinical stage: stage 3 . Review of R26's skin assessments revealed the most recent documented assessment prior to identification of the stage 3 pressure wound on 1/6/25 occurred on 12/18/25, an 18 day lapse between routine skin assessments. Review of R26's most recent Braden Scale for Predicting Pressure Sore Risk, dated 7/1/24, revealed a score of 12, indicating high risk of pressure ulcer formation. Review of R26's EMR revealed the following progress note written on 2/14/25 at 11:04 AM: .wound to ischial tuberosity has worsened in condition and is now a stage 4 . On 5/22/25 at 1:33 PM, a group interview was conducted with the Nursing Home Administrator (NHA), Director of Nursing (DON), and Regional Clinical Registered Nurse (RCRN) L regarding wound prevention and care expectations. The DON stated skin assessments should be completed on a weekly basis and documented in the EMR system. All parties agreed identification of the pressure ulcer on R26's right ischial tuberosity should have occurred prior to development into a stage 3 wound.Review of R26's plan of care revealed a focus initiated which read: [R26] has actual and potential for impairment to skin integrity r/t [related to] limited mobility, incontinence, dementia, hydrocephalus, venous insufficiency. An intervention, initiated on 6/11/24, read: Weekly skin assessment. Review of the facility policy titled, Skin Alteration Documentation, revised 2/11/19, read, in part: .patients without skin issues will have skin observed daily during cares and observations weekly by licensed nurses .

This citation pertains to intake numbers; MI00150212, MI00150215, and MI00150297. Based on interview and record review, the facility failed to ensure 1. New admission orders were double checked, 2. Appropriate assessments and wound care were provided, and 3. Timely notification of a change in condition were completed per professional standards for one Resident (#3) of three residents reviewed for new admissions, resulting in R3 being transferred to the emergency department with post-surgical infection, respiratory distress, low blood pressure, sepsis, and subsequent death. Findings include: Resident #3 (R3) Review of complaint intake number MI00150212 to the State Agency (SA), dated 2/11/25 revealed, R3 was transfer to a local hospital by emergency medical services (EMS) in critical condition after a four-day admission from the facility due to his colostomy not being cared for resulting in stool contaminating surgical incision and drains. R3 now had positive blood cultures for VRE (vancomycin-resistant enterococcus) and was in septic shock. Supporting evidence of neglect by the facility can be substantiated by local hospital documentation. Review of complaint intake number MI00150215 to the SA, dated 2/11/25, revealed, on 2/5/25, R3 was discharged from the hospital in stable condition to the facility to recover. On 2/9/25, R3 was admitted to the local hospital in critical condition. R3's oxygen was extremely low, he had low blood pressure, his binder that was over his incision had feces in it, his incision also had feces in it. R3 was in septic shock, he had positive blood cultures, and he was in critical condition. Hospice had been consulted, there was a concern that R3's care was neglected while he was at the nursing home. Review of complaint intake number MI00150297 to the SA dated 2/13/25 revealed on the early morning of 2/9/25, R3 was transferred to a local hospital by EMS. At the time of R3's transfer, his oxygen was in the 40's. R3's abdominal binder that was covering his incision, drains and colostomy bag was off as well as his colostomy bag. He was covered in stool. R3's gown was soaked in feces and fluids and his surgical wounds were packed with stool. R3's blood pressure was also 66/40. R3 was in septic shock before arriving to the local hospital. R3's PICC (peripherally inserted central catheter) line was dirty and dislodged. R3 was treated like garbage by facility staff and his condition was horrific. Review of R3's emergency department (ED) records, dated 2/9/25, read in part .History of Present Illness .presents to the ED for evaluation of low oxygen saturation. He is brought in by EMS. He was brought from the [facility name] .will open his eyes and answers some questions however he is moaning, seems to be in a good amount of pain. According to EMS, they did not get much of a history from the nursing staff over at the [facility name]. Apparently, they checked on him this morning and he had an oxygen saturation of 43% .He does have audible rhonchorous (coarse, low-pitched, rattling sounds heard in the lungs during breathing) breath sounds heard at bedside. He moans and complains of pain basically diffusely with palpation .Patient came into the ED saturated in fluid and feces. His gown is almost completely soaked in fluid .He has an abdominal binder in place. When this is removed his ostomy bag is off and he has a large amount of brown stool covering his abdomen under the binder. He has palpable edema noted to his abdomen as well. With any manipulation he does have fluid expressed from the drain sites .He has a right upper extremity PICC line. When nursing staff went to clean for and wipe around the PICC .it then almost immediately fell out, certainly did not look like it was in the right spot I will place a central line in the patient's left groin. norepinephrine (medication to support low blood pressure) is running through his peripheral IV in the left upper extremity while central line being inserted .Lactic acid (a lab value that measures the lactic acid in the bloodstream) is elevated at 3.2 (normal level is < 2), procalcitonin (a lab value that is a protein hormone used to detect and monitor bacterial infections) is elevated at 5.62 (normal range is between 0.05-2.0 and > 2.0 indicates severe infection), high-sensitivity troponin (a protein found in heart muscle that leaks into the blood when the heart is damaged) is elevated at 148 (normal level is between 0-14) and BNP (a hormone in the blood that indicates how well the heart is pumping) is 5114 (normal level is < 450 in adults over the age of 75) .I did order him 40 mg of IV Lasix (a diuretic to help eliminate excess body fluid) .He will admit the patient to the ICU (intensive care unit) He is obviously in critical condition .Final Impression/Diagnosis: Acute sepsis (life threatening complication of an infection), acute hypotension, acute hypoxic (an absence of enough oxygen in the tissues to sustain bodily functions) respiratory failure .acute lactic acidosis (a metabolic condition that occurs when the body builds up too much lactic acid in the bloodstream) . Review of R3's ED nursing note, dated 2/9/25, read in part .The patient came in altered. This patient had an ostomy bag that was stuck and not attached anymore under an abdominal binder and covered in feces. This patient had 2 (brand name surgical) drains with one that was coming out and the sutures were coming undone. The patient had drainage from both drain sites and his abdominal staples sites. The patient had not been cleaned up in a while .Patient had a PICC line that he came in with and when ED staff went to check patency, the PICC line dislodged and appears to possibly have broken off .When I called the [facility name], the nurse that card for the patient, [facility nurses name], told me she did not know much about the patient. When I told her the patient had an ostomy, she was surprised to find out he had an ostomy. She stated that the CNAs (certified nurse aides) take care of all of that, including the wound changes. I let this nurse know our findings and how critical this patient appears. I would like to express my concerns about the care this patient received . Review of R3's hospital history and physical, dated 2/9/25, read in part .He was in shock (a condition that occurs when organs don't get enough blood), hypotensive (low blood pressure), altered mentation, cold to touch, abdominal pain/guarding, hypoxia (low oxygen saturation) - 43% per history, and wet cough .He had a PICC line he was supposed to be getting antibiotics through that was mostly out. Abdominal binder was in place covering his ostomy from last admission and drains - there was extensive stool saturating between skin and binder, stool in wounds, ostomy was off. SNF (skilled nursing facility) may not have known he had an ostomy I was told .Patient said he has eaten very little, maybe none .purulent drainage from midline incision. Mucosa of ostomy initially pale . Review of R3's hospital records, dated 2/9/25 through 2/12/25, revealed the following: a.) Underwent a blood transfusion b.) Received IV blood pressure support medications c.) Had an insertion of a central line in the groin area for cardiac monitoring and IV medication administration d.) Had a nasogastric tube inserted for nutritional purposes e.) Was found to have new wound infection in his abdominal cavity that was stool covered and with VRE (vancomycin resistant enterococcus) bacteremia f.) Had lower abdominal staples removed to allow for drainage g.) Possible PICC line infection h.) Urinary catheter with urinary tract infection i.) Weight gain of 11 pound 7 ounces from 2/6/25 - 2/9/25 j.) Severe protein calorie malnutrition k.) admitted to the ICU l.) Surgical consultation m.) Infectious diseases consultation n.) Went from a full code to Hospice services o.) Death occurred on 2/12/25 Review of R3's face sheet revealed an admission to the facility on 2/5/25, with diagnoses including, hypertension, perforation of intestine (a hole in the intestine), and colostomy (a surgical procedure that creates an opening [stoma] in the abdominal wall to divert stool [fecal material] from the colon [large intestine] directly into a bag or pouch). Review of Minimum Data Set (MDS) assessment, dated 2/9/25, revealed Section GG of the MDS assessment revealed R3 was dependent on staff for all activities of daily living cares including eating, oral hygiene, toileting, upper and lower body dressing, and personal hygiene. R3 was also dependent on staff for all mobility such as rolling from left to right, sit to lying position, and lying to sitting position. Review of R3's progress note dated 2/9/25 at 6:33 AM, read in part, R3 was transferred to [local hospital] at 6:00 AM. Vital signs; blood pressure 77/30, respirations 16, pulse 100, oxygen saturation 46% at 2 liters per minute [via nasal cannula] increased to 5 liters per minute oxygen saturation came up to 93%, unresponsive. Pupils non-reactive. R3 was moaning most of the night shift. R3 was moaning this am [morning] . Review of R3's hospital discharge paperwork, dated 2/3/25, read in part .Cefazolin 6 g (grams) per 24 hours continuous infusion (or 2 g IV [intravenous] q [every] 8 hours . Review of R3's progress note, dated 2/5/25 at 9:35 PM, read in part Resident admitted from (local hospital) . Unable to use any or all devices. Needs assistance with devices .Medication review: A medication reconciliation/review occurred. Findings and actions: Clarified with (local hospital). Review of R3's progress note dated 2/5/25 at 10:26 PM, read in part Received report .Cefazolin last given at 5:00 PM (at local hospital) . Review of R3's new admission phone report form, dated 2/5/25, read in part .Arrived by: EMS (emergency medical services) 1800 ish (approximately 6:00 PM) . Antibiotics: cefazolin - PICC (peripheral inserted central catheter) Q (every) 8 hours last dose 17:00 (5:00 PM) . Review of R3's order recap, dated 2/5/25 through 2/9/25, revealed an order added by Registered Nurse (RN) D on 2/5/25 for cefazolin sodium injection solution reconstitute 2 GM (grams). Use 50 ml (milliliters) intravenously three times a day until 3/7/25 (every 8 hours, last dose at 5:00 PM), and was scheduled to be given at 1:00 AM, 9:00 AM, and 5:00 PM. Order was verified by the same nurse who added the initial order. Review of R3's order recap, dated 2/5/25 through 2/9/25, revealed an order added on 2/6/25 at 10:33 AM for cefazolin sodium injection solution reconstitute 2 GM. Use 2 gram intravenously, every 8 hours, for of cervical hardware infection until 3/7/25, and was scheduled to be given at 6:00 AM, 2:00 PM, and 10:00 PM. Order was added by the Nurse Practitioner (NP) F and verified by Licensed Practical Nurse (LPN) B. Review of R3's medication administration record (MAR), dated February 2025, revealed R3 did not receive a 6:00 AM dose. R3 should have received a dose of antibiotics at 1:00 AM based on the last dose he received prior to being discharge from the local hospital per written orders. R3 did not receive antibiotics for 19 hours, based on the last dose he received at the local hospital. R3 missed two doses of his antibiotics on 2/6/25 at 1:00 AM and at 9:00 AM. On 2/19/25 at 10:15 AM, an interview was conducted with RN D who was asked about the new admission process for entering medication orders. RN D replied, The admitting nurse or the nurse manager adds the orders from the admission paperwork and then a second nurse is to verify that the orders are correct. RN D was asked why the antibiotic order from R3 was not verified with a second nurse. RN D replied, I do not recall, maybe at that time there was not anyone to verify the orders were correct. On 2/19/25 at 3:49 PM, an interview was conducted with LPN B who was asked if she remembered R3. LPN B replied, I remember R3 coming in. R3 had a PICC line, and I think R3 missed his first dose of antibiotics because the order got put in wrong with administration times. On 2/20/25 at 12:15 PM, an interview was conducted with NP F who was asked about R3's antibiotic orders. NP F replied, New admission orders should be verified by another nurse and double checked. It was noted by facility staff that R3 did not receive any antibiotic therapy since admitting to the facility despite having the medication in back-up and a new order was placed. On 2/20/25 at 2:00 PM, an interview was conducted with the Regional Nurse Consultant G who was asked about the admission process. The Regional Nurse Consultant G replied, We recognized a problem and have started a past non-compliance, but it is not completed yet. Nurses are to double check orders with a second nurse to verify the order input is being added correctly. R3 should not have missed any doses of antibiotics. Review of R3's admission phone report document, dated 2/5/25, revealed that R3 had recent abdominal and cervical surgery. R3 had two (name brand surgical) drains in his abdominal cavity, a colostomy in his LUQ (left upper quadrant), an abdominal surgical incision with staple, a PICC line in his RUE (right upper extremity), was receiving IV antibiotics with the last dose indicated, a c-collar (a device to help secure the neck), a urinary catheter, was on oxygen at 3 liters via nasal cannula (soft plastic device to deliver oxygen through the nose), had edema in his upper and lower extremities, was on narcotic (controlled substance used to treat moderate to severe pain) pain medication, and wore an abdominal binder at all times. Review of R3's care plan, dated 2/7/25, read in part Focus: The resident has an ostomy to (Specify where) r/t (related to). Goal: Resident will have no complications with ostomy through the review date. Interventions: Monitor for signs or symptoms of pain with ostomy or stools and notify physician as needed. Review of R3's physician order, dated 2/5/25, revealed an order for ostomy care to check bag and empty, cleanse skin and pat dry if any leakage every shift. Review of R3's treatment administration record (TAR), dated 2/5/25 through 2/9/25, revealed no documented checking or emptying on 2/5/25 during the night shift. On 2/19/25 at 2:54 PM, an interview was conducted with LPN H who was asked about R3 and the care that was provided on the night of 2/8/25. LPN H stated there was a nurse call-in that night. Nurse-to-nurse reports are not really that great or helpful. LPN H was asked about ostomy care on the night of 2/8/25. LPN H replied, I should have taken more time to do a head-to-toe assessment on him on 2/8/25. The North end is very heavy with as needed narcotic medications and all I had time to do was pass as needed narcotics. I did not look at his ostomy and I don't recall having to do anything with the (brand mane surgical) drains either, because it would have come up on the TAR. I feel terrible that his ostomy opened underneath his binder. I only gave him pain medication and reassessed his pain. On 2/19/25 at 3:18 PM, an interview was conducted with RN I who was asked about the care she provided to R3. He was too heavy acuity. I took care of him on 2/8/25 during day shift until 6:30 PM. He was very sleepy. I attempted to do a dressing change on him, and he refused. I drew labs on him and put them in the refrigerator because I could not take them to the lab, and I am not sure if the driver was out or why they were not taken to the lab or if they were. RN I was asked if she attempted to try again later to complete the dressing changed. RN I replied, No. RN I was asked if she recalled R3's colostomy. RN I replied, He had a midline abdominal incision with staples below his umbilicus that had purulent (discharging pus) drainage. He had a colostomy and an abdominal binder that had some yellow serosanguinous (fluid that contains clear, watery liquid and blood) on the binder. I don't recall what the stoma looked like. RN I clarified that she did not report the purulent drainage to the physician. Review of R3's TAR, dated 2/5/25 through 2/9/25, revealed that R3 had labs drawn by RN I on 2/8/25 at 1:12 PM. On 2/20/25 at 11:30 AM, an interview was conducted with LPN C who was asked about R3 and the care provided on 2/9/25. LPN C replied, I got called in early on 2/9/25 and arrived around 3:00 AM. I got report from LPN 'H' that R3 was moaning, and he gave R3 some pain medication. LPN C was asked if she did any kind of assessment or observed R3's colostomy/stoma. LPN C replied, I probably did not document an assessment on his drains and abdominal area. I did not pull the abdominal binder off or look at it. I had to finish up night shift medications. I went in to see him at 6:00 AM to hook up his IV and his PICC line looked funny, and I had the certified nurse aide (CNA) come into do his vitals. I sent him out at 6:00 AM to the local hospital. That was the first time I took care of him. All I was told was that R3 was in pain and received pain medication and I got no other report on the other residents. R3's oxygen was very low at 46% and (nasal cannula) was only in one nostril. I did not listen to lungs. R3 had quite a bit of edema and I am not sure how we were monitoring that. I normally work the back half. Review of R3's hospital discharge paperwork, dated 2/5/25, revealed discharge instructions for surgical (brand name) drains to remain in place and care instructions that included keeping the skin around the drains dry and covered. There were also instructions for emptying along with how to compress the bulb of the drains for proper function. Instructions also included recording the amount of output in a 24-hour period and to contact the provider if you have less than 30 ml (milliliters) of output. The instructions also stated to monitor daily for signs and symptoms of infection. Laxative instructions were to take one capful of polyethylene glycol 3350 milligrams (mg), mixed in 4-8 ounces of beverage every morning. If in 2 to 3 days your bowel movement is too soft: Reduce polyethylene glycol 3350 mg to ½ capful mixed in 4-8 ounces of beverage every morning. R3's MAR/physician orders had no polyethylene glycol order written. Review of R3's care plan, dated 2/7/25, read in part .I have alteration in skin integrity d/t (due to) placement of (Specify: Drain) post-surgical procedure. Goal: The resident will have no complications with drain sites through the review period. Interventions: Observe and record fluids drained from drain sites . R3 had no other interventions noted for monitoring abdominal surgical incision with staples and staples were not counted to ensure wound did not dehisce (to split open or burst along a natural line or seam). On 2/18/25 at 4:00 PM, an interview was conducted with Family Member (FM) E, who stated, No one voiced any concerns to me. Talked to the staff at the facility while (R3) was there and stated everything was fine. I was assured by staff at the facility that (R3) would be taken care of. (R3) was transferred to the local hospital on 2/9/25 and the facility never called me to let me know (R3) was declining. I was called by the local hospital from the ICU doctor that (R3) had been admitted and was in critical condition. I was planning on going to see him at the facility on 2/10/25. FM E was tearful and hurt during the phone interview and felt very frustrated with the facility staff by the lack of care and communication. FM E stated that she was led to believe R3 was being taken care of and that he was going to be fine. On 2/21/25 at 1:15 PM, an interview was conducted with FM J who was asked about R3 and if they had visited them at the facility while he was there. FM J replied, Yes. I went to see R3 on 2/7/25 on a Friday. R3 was asleep when I arrived, but I called out his name and he opened his eyes. He looked like he was in bad shape. I noticed a banana that had been cut up, appeared to be there for a while and I asked him is he wanted me to go get him something to eat. He said yes, so I checked with the nurse first and they said it was ok. I brought him back a hamburger and a shake. He only took two pea sized bites of the burger and was unable to suck out of the straw. I lifted up R3's gown to see his drains and they were both expanded and not compressed, and I thought that did not look right. His gown was soiled with some blood on it and needed to be changed. R3 was unable to talk to me like he was the last time I saw him the last week in January around the 25th when he carried on a conversation and had a little sense of humor. I noticed that he could not reach his banana or his drink. He need assistance with feeding because he does not have the dexterity to pinch has hands together to grasp a cup. He was having difficulty sitting himself up to reach the cup. All R3's belongings where just lined up along the windowsill and not put away. I felt like I walked into a dump. On 2/21/25 at 2:17 PM, an interview was conducted with FM K who was asked about R3 and if they visited them at the facility while he was there. FM K replied, Yes, I went to see him on 2/6/25 it was a Thursday. I gave him yes or no questions because he had a hard time with his breathing. I noticed his nasal cannula was only in one of his nostrils and he seemed a little confused when I talked to him. I went to get the nurse, and she came in and checked his oxygen saturation. I had my wife on the phone, and she asked me what the oxygen saturation level was, and the nurse told me it was in the 50's. My wife was freaking out! The nurse went to get a second nurse, and they stayed for a while and rechecked his level and it had come back up. The second nurse seemed to just kind of brush it off like it was not a big deal. No one was checking on him prior to me going to get someone. When he was at the hospital either we as family would assist him in eating or the hospital staff would assist, because he was unable to feed himself. Review of R3's tasks and task list, dated 2/5/25 through 2/9/25, revealed no bed baths or showers were provided during R3's stay at the facility. R3's food acceptance for 2/6/25 was recorded as zero during lunch and no breakfast was recorded. R3's food acceptance for 2/7/25 was recorded for dinner only between 1-25 %. R3's food acceptance for 2/8/25 lacked any documentation. R3's task list indicated that staff was to record food acceptance for each meal offered. No documentation that R3 had low or poor intake to the physician was found. Review of R3's physician order, dated 2/5/25, revealed oxygen was to be delivered continuous via nasal cannula or mask at 2 to 6 liters per minute. R3's oxygen order had no directions for how nursing was to titrate to a certain oxygen saturation level or record how many liters R3 required. Review of R3's physician order, dated 2/5/25, revealed an order for IV PICC: Document signs and symptoms of infection one time a day every 7 days for per protocol. Nursing staff did not measure the initial length of R3's PICC line and had no way of assessing proper placement. Review of R3's MAR, dated 2/5/25 through 2/9/25, revealed on 2/6/25 PICC line dressing change was marked as 9 (see progress notes). Review of R3's progress note, dated 2/6/25 at 1:56 PM, read in part .Dressing is clean, dry and intact. Progress note completed by LPN B. There were no other notes in the EMR indicating the PICC line dressing change was completed as ordered. Review of R3's care plan dated 2/7/25, read in part, .Focus: The resident has actual impairment to skin integrity (SPECIFY location) r/t [related to]. Goal: The residents will have no complications r/t documented skin impairment through the review dated (5/7/25). Interventions: Evaluate and treat per physicians' orders (2/6/25). Evaluate resident for S/SX [signs and symptoms] of possible infections (2/6/25). Monitor IV site q/shift [every shift] and complete dressing change as ordered (2/7/25) . R3 had no interventions to monitor length of the PICC line tubing extending from the insertion site to ensure proper placement. Review of policy titled, Infusion Therapy: Clinical and Pharmacy Services Policies and Procedures for Long-Term Care, dated 05/2022, read in part, Policy: Midline and Central Line IV catheters (CVADs [central venous access devices]) will be flushed to maintain patency; to prevent mixing of incompatible medications and solutions; and to ensure entire dose of solution or medication is administered into the venous system. General Guidelines: 1.) Prior to procedure, assess catheter type for flushing protocols .Types of peripheral catheters .d.) Peripherally Inserted Central Catheter (PICC) .(5) Length of catheter is specific to resident. This length needs to be documented in the medical record .(6) Catheter length is measured for baseline comparison .(8) This is a very fragile catheter and can be broken easily .(12) Anchor catheter to skin to prevent accidental removal . Review of R3's electronic medical record, dated 2/5/25 through 2/9/25, revealed no documented initial admission weight, and no weight obtained on 2/7/25. R3 had one weight recorded on 2/6/25 which was the exact same weight documented in his hospital discharge paperwork. Review of policy titled, Weight Monitoring Guideline, dated 7/1/19, read in part, Purpose: The facility measures and records weights to ensure accuracy and provide information for the evaluation of clinical status unless clinically contraindicated with physician justification. To provide guidance on timely consultation and weight parameters .Guidelines: Residents will be weighed; documentation will be recorded in (EMR): Upon admission and re-admission. Hospital weights should be verified and compared to facility admission and/or re-admission weight. Daily for three days . Review of R3's skilled daily nursing assessments, dated 2/6/25 through 2/8/25, revealed no documented skilled nursing assessment on 2/6/25. On 2/7/25 R3's assessment created by LPN H revealed a note identified as a late entry added on 2/8/25 which used the same vital signs from 2/8/25, with lungs clear and no shortness of breath and surgical wound well approximated. On 2/8/25 the nursing assessment created by RN I revealed R3 had left side weakness, edema; 3+ (noticeable deep, last more than 1 minute) arms, hands, legs, and feet. R3's lung sounds were with rhonchi present, had a cough, had increased or purulent sputum, and had abnormal lung sounds. R3 had shortness of breath when lying flat. R3 had a surgical wound that was an abdominal midline incision with staples wound approximated intact with purulent serosanguinous drainage from the site. There was no documentation showing the left sided weakness, purulent drainage, or edema was reported to the physician. On 2/20/25 at 12:15 PM, an interview was conducted with the Nurse Practitioner (NP) F, who was asked if she was notified of R3's decline and transfer to the hospital. NP F replied, No one called me about anything with R3 and I was on-call the weekend he was sent out. I was not notified that R3 had declined, had respiratory distress, or was moaning in pain all night. I ordered labs on 2/7/25 and they were drawn but never sent to the lab. I can't tell you what happened Friday night into Saturday morning. NP F was asked what kinds of assessments the nursing staff should have been completed on R3. NP F replied, The nursing staff should have been assessing vital signs, weights, and monitoring his ostomy, drains, and surgical sites for signs of infection. NP F stated that the only thing she knew was one day R3's (name brand surgical) drain was not draining, and she assisted nursing staff to get it back working and recalled the abdominal binder being saturated. Review of policy titled, Charting and Documentation, dated 7/2017, read in part Policy Statement: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Policy Interpretation and Implementation .2. The following information is to be documented in the resident medical record: a. Objective observations .d. Changes in the resident's condition .7. Documentation of procedures and treatments will include care-specific details, including .c. the assessment data and/or any unusual findings .f. notification of family, physician or other staff . Review of facility policy Notification of Changes Guideline, dated 7/24/19, read in part Purpose: It is the practice of this facility that changes in a resident's condition or treatment are immediately shared with the resident and/or the resident representative, according to their authority, and reported to the attending physician .The resident and/or their representative will be educated about treatment options and supported to make an informed choice about care .All pertinent information will be made available to the provider by the facility staff .Overview of Components of the Guideline: 1.) Requirements for notification of resident, the resident representative and their physician .2.) A significant change in the resident's physical, mental, or psychosocial status. (i) A significant change includes deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications .Procedure: 1.) The nurse will immediately notify the resident, resident's physician and the resident representative (s) for the following (list is not all inclusive). If the resident's physician is not available contact the Medical Director .e. A decision to transfer or discharge the resident from the facility .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #9 (R9) Resident #9 was admitted on [DATE] with diagnoses including heart failure, neurogenic bladder, obstructive uropathy, and chronic obstructive pulmonary disease (COPD). Review of R9's MDS assessment, dated 4/4/2024 revealed R9 was dependent on staff for toileting and personal hygiene and required substantial/maximal assistance for mobility, including rolling left and right. Further review of the MDS assessment revealed R9 was at risk for pressure ulcers. An observation on 7/15/2024 at 10:50 a.m. revealed R9 lying in bed, supine ( lying on back) with the head of the bed elevated at approximately 45 degrees. The control panel for R9's air mattress was not lit up which indicated the mattress was not actively functioning. Further observation revealed CNA U enter R9's room at which time CNA U was queried as to whether R9's air mattress should be turned on. CNA U stated she was unsure and confirmed the mattress was indeed not functioning. CNA U stated she did not know how to operate the control panel for the mattress. This Surveyor observed CNA U tracing the power cord from the air mattress panel to the power outlet at the head of R9's bed and stated the air mattress was not plugged in. CNA U plugged the air mattress cord into the outlet and confirmed the air mattress was then functioning. CNA U could not state how long the mattress was not functioning. Review of R9's care plan revealed the following, in part: The resident has actual impairment to skin integrity MASD (moisture associated skin damage) r/t limited mobility incontinence. Date Initiated: 11/30/2023 . The resident needs pressure relieving/reducing mattress, pillows to protect the skin while in bed. Date Initiated: 7/11/2024. Based on observation, interview, and record review, the facility failed to implement and maintain interventions to prevent the development and progression of pressure ulcers for two Residents (R9, R18) of four residents reviewed for pressure ulcers. This deficient practice resulted in the development of one unstageable pressure ulcer and the potential for development of new/additional pressure ulcers. Findings include: Resident #18 (R18) Review of R18's Electronic Medical Record (EMR) revealed admission to the facility on 5/10/24 with diagnosis including right tibia fracture, right fibula fracture and nutritional deficiency. Review of R18's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12, indicative of moderate cognitive impairment. Further review of the MDS, section M, revealed R18 was marked at risk of developing pressure ulcers and had three unstageable-suspected deep tissue pressure ulcers. Review of R18's Skin and Wound Evaluation dated 7/9/24 read, in part, .Type: Pressure .Stage: Deep Tissue Injury: Persistent non-blanchable deep red, maroon or purple discoloration .Location: Right heel. Acquired: In-house Acquired .Exact Date: 5/22/24 .Staged by: (blank) .Wound Measurements: .8 cm2 (centimeters squared) by 1.3 cm by .9 cm .Wound bed: Eschar 100% .Additional Care: Heel Suspension/Protection device, Mattress with Pump, Turning/Repositioning program . On 7/15/24 at 2:18 p.m., an interview was attempted with R18 who was lying in her bed after eating her lunch meal. R18 could not recall if she had a pressure ulcer. It was observed that R18's had an air mattress with the air pump attached to the footboard of her bed. R18's air pump was not turned on nor was it plugged into the outlet located on the wall during this interview. On 7/16/24 at 8:45 a.m., an interview was attempted with R18 who was lying in her bed eating her breakfast meal. R18 stated that she was not wanting to eat her breakfast at this time. R18's air mattress pump was not turned on nor plugged into the outlet located on the wall during this interview. On 7/16/24 at 9:00 a.m., an interview was conducted with the Director of Nursing (DON). When asked, the DON stated R18's right heel pressure ulcer was facility acquired due to a brace that was placed on R18's right leg after surgery. The DON stated the pressure ulcer was healing at this time, being treated with betadine as it was not open, and R18 was to have an air mattress with pump as an intervention. The DON was notified that the air mattress had not been turned on or plugged in during previous observations. On 7/16/24 at 1:00 p.m. a wound observation was conducted with Registered Nurse/Unit Manager (RN/UM) S and RN T for R18's right heel. RN T placed a barrier down with all supplies needed for R18's wound care and proceeded to wash their hands. RN S and RN T placed clean latex gloves on their hands but did not don any further Personal Protective Equipment (PPE) to treat R18's wound. When asked if further PPE was needed, RN S stated R18's wound is closed and has never opened, so they did not need further PPE. RN T removed R18's blue puffy boot to expose R18's right foot and heel. RN T began to wash R18's foot with a clean wet washcloth and soap when R18 stated, Ouch that hurts! RN T then used a sterile cloth to wipe betadine over R18's right heel where the pressure ulcer was located. During the pressure ulcer care, RN S stated they were not going to do measurements. Near the bottom of the right heel R18 had an observed dark, thick purple scab approximately the size of a quarter, with bright pink tissue surround the scab. A follow-up interview was conducted with the DON who clarified R18 has an unstageable pressure ulcer with eschar on the right heel which was facility acquired. When asked if R18's air mattress pump was always supposed to be on, the DON confirmed that it should be. The DON stated she is unsure why R18's pump had been turned off and unplugged. Review of R18's Wound Assessment Details Report dated 7/16/24 read, in part, Braden Score:15 (At Risk) .Wound: Right heel .Source: Facility Acquired .Date Identified: 7/16/24; Identified by: RN S .Size (cm) 2.75 x 2.00 x unknown .area 5.5 cm2 .Current Plan and Comments: Bilateral puffy boots, Air Mattress, Turn Schedule, Nutritional Supplements, Betadine . Review of R18's Care Plan read, in part, .5/22/24 Right heel deep tissue Pressure injury .interventions: air mattress (date initiated: 5/13/24) .