**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake #1230868.Based on observation, interview and record review, the facility failed to 1) Ensure that nursing staff gave appropriate care for failure, 2) Ensure that nursing staff completed a respiratory assessment during a respiratory crisis, and 3) Ensure that nursing staff followed facility nursing care plan for 1 resident (Resident #105) of 3 residents reviewed for nursing care, resulting in pulmonary edema, HH (excessively high) CO2 (Carbon Dioxide-lab) blood level, hypoxia, pneumonia, acute respiratory distress, hospitalization, respiratory failure with the high likelihood of death. Findings Include:Resident #105:Review of the Face Sheet, nurses and physician progress notes dated 7/2/25 through 7/5/25, nursing assessments dated 7/25, physician orders dated 5/25 through 7/25, and care plans dated 5/25, revealed Resident #105 was [AGE] years old, admitted to the facility on [DATE] and re-admitted on [DATE], alert and oriented and able to make healthcare decisions, and dependent on staff for Activities of daily living/ADL. The resident's diagnosis included, chronic respiratory failure with hypercapnia (high much carbon dioxide in blood, respiratory), disorder of the muscle, diabetes, alkalosis (blood pH to alkaline), absence of right leg above knee, and high blood pressure.Review of the facility altered respiratory care plan dated 3/25/25, stated Evaluate lung sounds and vital signs as needed; monitor for s/sx (signs and symptoms) of respiratory distress and report to MD PRN: Increased respirations, decreased pulse oximetry, increased heart rate, restlessness, diaphoresis, headaches, lethargy, confusion, hemoptysis, cough, pleuritic pain, accessory muscle usage, skin color changes to blue/gray.Review of the Nursing notes dated 7/5/25 at 3 minutes after 12 midnight, stated Resident was transferred to Hospital, oxygen level was dropping. Director of Nursing/DON notified. (Physician Q ) and (Family member) notified. No nurse assessment, vital signs, Spo2 (oxygen levels), mental acuity assessment, skin color, lung sounds, pain, nor breathing pattern was found in the nursing note dated 7/5/25, prior to the resident being transferred to the hospital.During a phone interview done on 7/17/25 at 9:43 a.m., the only Family Member listed (Family Member R) stated, They (the facility) did not call me, no the facility did not call me (Family Member R checked his phone for the call on 7/5/25 and was unable to locate one). The hospital called me and told me I needed to make a decision on her (a code status). The hospital was upset because they did not clean her up before they sent her. Family Member R denied the facility contacted him at the time of transfer to the hospital on 7/5/25.Review of the ambulance run sheet dated 7/5/25 at 11:48 p.m., revealed Resident #105's spo2 (oxygen blood level) was 67% (Spo2 blood oxygen level, normal 90 to 100%). PD (police Department) brought (ambulance staff) to the patient who was found in her room responsive to pain (unresponsive). Facility staff did not enter the patient's (room) upon (ambulance) arrival, and it was reported by PD and rescue that the patient was suffering from unknown breathing problems and unknown for how long. Rescue reported the was at 67% (Spo2) on her nasal cannula upon arrival. The patient was then placed on a non-rebreather (oxygen mask for respiratory distress) at 15 liters. The patient was alert and orientated x0 (unresponsive); the patient's hypotension and hypoxia were addressed. Barries to care: unconscious. The Fire Department and Police were already at the facility when the ambulance arrived. The nurse did not give them any information, vital signs nor Spo2 level or any information about the residents upon arrival. Patient is unresponsive on arrival to the emergency department; patient is being bagged by (ambulance) personnel.Review of the hospital ED Course dated 7/5/25, stated immediately decision was made to intubate the patient (artificial airway for breathing assistance) due to significant respiratory distress, difficulty moving air and concern for impending respiratory failure.Review of the hospital admit date d 7/5/25, stated intubation (artificial airway) due to respiratory distress and impending respiratory failure; We will proceed with a medically necessary hospitalization due to medical complexity for management of sepsis (infection) of unknown origin, respiratory distress, IV diuresis (pulling fluid off lungs). The resident was transferred from the emergency department to the Intensive Care Unit/ICU. Diagnosis: Hyperkalemia, Hypercapnic respiratory failure, Acute on Chronic Congestive Heart Failure, Leukocytosis (infection), Sepsis (acute infection from pneumonia).Review of the hospital Infectious Disease report dated 7/5/25, stated patient started on broad-spectrum antibiotics for healthcare associated pneumonia.Review of the hospital chest x-ray dated 7/5/25, stated Impression: There is a pulmonary edema that could be congestive heart failure and unchanged.Review of the hospital Lab dated 7/5/25, revealed the resident's CO2 was 42 (normal range=22 to 32). Review of the hospital Discharge Diagnosis dated 7/10/25, stated Recurrent acute on hypercapnic and hypoxic respiratory failure (low oxygen level), acute pulmonary edema (fluid on lungs), narcotic induced constipation, contraction alkalosis (abnormal respiratory gases), acute encephalopathy, hypoventilation syndrome.Observation and interview of Resident #105 was done on 7/15/25 at 10:45 a.m. The resident was in her bed, somewhat confused and was unable to recall 7/5/25, I don't remember what went on, I got sick, I don't remember what happened. The resident said she woke up at the hospital, and did not know what had happened.During an interview done on 7/15/25 at 12:36 p.m., Nurse, LPN D said she was working the night shift (7:00 p.m. to 7 a.m.) shift on 7/5/25. When resident #105 was found non-responsive and in a respiratory crisis, she said she did not do a lung or respiratory assessment, did not do a full set of vital signs, and did not do an oxygen saturation blood level (Spo2), did not do any alert or pain assessments, nor a blood glucose level on her. Nurse D had no reason why she did not do any assessment at all on the resident. Nurse D stated I put her oxygen to 8 to 9 (8L to 9L) when she ask's. Review of the physician oxygen order (dated 7/1/25) revealed O2 was to be at 5L. Nurse D said she kept the resident on her Nasel Cannula/NC (for oxygen therapy) and did not put her on a rebreather mask (for respiratory distress, crisis), she had no answer why she did not use a mask for increased oxygen delivery. Oxygen masks were kept on the units crash cart for easy access during an emergency. When this surveyor asked her if she had looked at the resident's respiratory care plan at all, she said no. When asked what she could have done better in this situation, Nurse D said she could of done an assessment. Nurse D stated, It was during COVID, so we did not get to go out (she had no clinical nursing experience due to COVID). Nurse D was assigned to a unit as Charge Nurse starting in January 2025, having been on her own for a total of 7 months; no competency evaluation documentation was found in the HR record. During an interview done on 7/15/25 at 10:59 a.m., Nurse Manager, LPN A stated It was on a weekend, oxygen sat dropped, Nurse on was (Nurse, LPN D), who is a new nurse was the nurse. Nurse Manager A did not recall anything else about the resident's transfer to the hospital on 7/5/25; no flow-up was done by the manager regarding significant respiratory change in condition of Resident #105.During an interview done on 7/16/25 at 1:39 p.m., the DON stated, I think the facility respiratory Therapist/RT is to educate new nurses in the future; we assumed she was safe because she had a license. I did talk to her (Nurse D) on the 5th, I talked to about her (Resident #105) CO2 level was critically high from that day, and her vitals (lack of vital signs), there should of been a change of condition done by her (Nurse D), I did it. Neither ADON or DON followed up with any education for Nurse D until the investigation was initiated by this surveyor on 7/15/25.During an interview done on7/16/25 at approximately 11:25 a.m., Respiratory Therapist/RT L said she had not been informed of the incident regarding Resident #105 until 7/15/25, when an education was requested of her to be done with Nurse D by the DON.Review of the facility documentation of education done with Nurse D on 7/15/25, at 3:30 p.m.; Signs/Symptoms RRT (related to) Respiratory Distress revealed Nurse D was educated by RT.During an interview done on 7/16/25 at 1:40 p.m., the Assistant Director of Nursing/ADON, LPN B stated (Nurse D) is definitely, a brand-new nurse, she needs more education, and she doesn't know assessment education and performance, she may not have known how to put the two together. It's the facilities responsibility to educate prior to assigning to the floor.Review of Nurse D's facility HR file revealed a Licensed Nurse Documentation Skills Checklist, all items were dated 2/20/25. No documentation of emergency care, or respiratory distress education was found on the checklist.During an interview done on 7/15/25 at 11:22 a.m., Human resource/HR M stated I did the first day of orientation with her (Nurse D), I reviewed all of HR file for nurses. No reference check was done because she was a new nurse, so she wouldn't have reference checks (for nursing). She got extra time because she was a new nurse. Yes, we are supposed to get reference checks. Review of the change of condition dated 7/7/25, revealed the DON had done the change of condition documentation 2 days after the transfer to the hospital on 7/5/25. Review of the Documentation in the Medical Record policy dated 1/8/25, stated A record of resident's assessments should be included in resident documentation.Review of the nursing education done by the DON on 7/15/25 revealed the following education was given to nursing staff:- Signs of Hypoxia/Respiratory DistressShortness of [NAME]/accessory muscle usageLow oxygen saturation-less than 92% for most residents (COPD residents less than 88%)Tachypnea (respiratory Rate greater then 20)Tachycardia (Heart Rate greater than 100)Cyanosis (blue/dusky coloring in the face/lips/fingers)AnxietyNon-Responsive/unable to get resident to wake up-What to do in Case of EmergencyIf residents have a low sat (oxygen saturation level), and is already on oxygen, increase the oxygen flow on the concentratorIf the concentrator is at max flow, and the resident's sat is not coming up-place resident on a non-rebreather connected to a tank (oxygen tank-E-tank) set at 15L (15 liters). Note: Non-rebreathers have to be ran at a minimum of 12L and are not to be used with our concentratorsIf the resident is requiring a non-rebreather-contact DON for further steps (i.e. transport to the hospital.-Remember:Hypoxia (low oxygen saturation) will lead to a code if left untreated.We treat all hypoxic residents with the same steps above, including the ones diagnosed with COPD.Review of the facility Nurse (RN/LPN) Position summary (un-dated) stated The charge nurse provides direct care; evaluates resident's medical, physical and mental status and accurately records the resident's care and response to their comprehensive care plan. Performance Requirements: Knowledge, skills, and abilities to perform the essential functions of the job; consistent application of current knowledge, use of good judgement, common sense, ability to establish and carry out priorities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to prevent a Stage III coccyx pressure ulcer from developing for 1 resident (Resident #76), and failed to implement meaningful and planned interventions for 1 resident (Resident #332), of 2 residents reviewed for pressure ulcers, resulting in a Stage III infected pressure ulcer, IV antibiotic usage, and hospitalization with the potential for delayed healing of pressure ulcers. Findings Include: Review of hospital records dated 1/22/25, stated The patient had Covid and pneumonia in December (2024) and was admitted from 12/7/24 to 12/26/24 and has been in rehabilitation (living at the facility) until today. The patient was getting settled his noon nursing facility (the resident was transferred from the facility to a Assisted Living facility/ALF on 1/22/25), they (ALF) noticed of the wound and thought it looked significant and recommended that he come to the emergency department. Do (the ER physician) have concerns that patient may be developing cellulitis (inflammation/infection of skin) around his sacral (coccyx area) wound. Do believe he needs to be admitted for IV antibiotics and to see wound care. Spoke with (hospital physician) hospitalist and discussed the medical management of the patient's case. They agreed to admit the patient for infected decubitus (coccyx area) ulcer stage III. Patient is still symptomatic with decubitus sacral ulcer with surrounding cellulitis and has not achieved medical stability for safe discharge from the hospital. I am concerned that, if discharged today (on 1/22/25, day of discharge from the facility), the current condition would worsen and an adverse event like cysts and deaf (death) may occur. Large stage 2-3 sacral ulcer with severe tenderness to palpation. 600 mg Zyvox IVPB (antibiotic given per IV) and 1 g Maxipime IVPB (antibiotic given per IV) were ordered for the patient's infected sacral ulcer. Diagnosis: Infected decubitus ulcer, stage III, dehydration. Review of hospital records dated 1/28/25, stated I (Infectious Disease physician) was consulted from Infectious Disease perspective regarding the patient having a infected sacrococcygeal decubitus ulcer. Patient has redness, tenderness, induration around the margins of the ulcer. Patient also has leukocytosis (high white blood cells in blood, indicating saver infection). Resident #76: Review of the Face Sheet, Nursing admission assessment dated [DATE], nursing notes dated 12/26/24 through 1/22/25, physician orders dated 12/27/24 through 1/22/25, revealed Resident #76 was 80 years-old, alert and able to make his needs known, admitted to the facility on [DATE], and required staff assistance with all Activities of Daily Living/ADL's. The resident's diagnosis included, cervical disc disorder, acute respiratory failure, muscle weakness, dysphagia (swallowing deficit), cancer of the prostate, cognitive communication deficit, atrial fibrillation, and history of falls. Review of the facility admission skin total body eval dated 12/27/24, revealed numerous bruises and scratches, however no documentation of any pressure ulcers was found. No coccyx stage III pressure ulcer was documented by staff. Observation of the resident's coccyx pressure ulcer dressing change was done on 1/21/25 at 11:00 a.m., Nurse, LPN N did the dressing. When Nurse N went to take the dressing off his coccyx area, there was no dressing. Nursing Assistant/CNA O stated I took it off earlier, it had BM on it. The CNA did not inform the nurse when she removed the coccyx dressing. The resident had a large stage III pressure ulcer on his coccyx area; he complained of pain and discomfort during the application of a dressing. Review of the resident's shower sheets done on 1/22/25, revealed only 1 shower sheet available that was filled out for the resident from his admission to discharge. Nurse Manager, RN H and the Director of Nursing looked for additional shower sheets, however no other sheets were available. Review of the resident's only shower sheet dated 1/14/25, revealed no documentation of any pressure ulcers and stated, No skin concerns. Review of the physician order dated 1/6/25, stated House zinc paste every 12 hours for reddened coccyx. Review of the facility at risk for alteration in skin integrity care plan dated 12/30/24, revealed staff were to observe skin condition with ADL care daily; report abnormalities. Review of the facility actual skin impairment care plan dated 1/14/24, and nursing notes dated 1/14/24, revealed the resident had developed macerated skin on the coccyx area, and staff were to do weekly treatment documentation (including measuring). Review of the physician order dated 1/20/25, stated Cleanse area on coccyx with normal saline, apply calcium alginate to wound bed, cover with abd (dressing) secure with tape, z guard to surrounding areas of maceration. Review of the physician order dated 1/20/25, stated Order to discharge to ALF on 1/21/25, with skilled home care services including PT/OT, nurse and home health aide. During an interview done on 1/21/25 at approximately 11:40 a.m., Family Member #2 stated every time I come here, he is soiled and wet, he has gone down since he has been here. Family Member #2 revealed the resident did not have any pressure ulcers when he was admitted to the facility. A second observation of the resident was done on 1/21/25 at 11:00 a.m. when he was at the nursing desk waiting to be discharged ; he was complaining about pain in his feet, so Nurse, RN P took him in a private room and evaluated his feet. Nurse P found 2 more pressure ulcers (on both feet) that were not documented prior to 1/21/25 (the day the resident was discharged ). Review of the nursing note dated 1/21/25 at 11:00 a.m., stated At approximately 11 am this nurse (Nurse, RN P) was called into room to assess a resident (Resident #76). Upon assessment a area was found on the back of his left heel. This area was approximately 4 x 4 x 0.0, there was no open areas and had approximately .02 area of redness surrounding area (this was a unstageable pressure ulcer per Nurse P verbalization to surveyor, it was a harden black cap (eschar) on top of a pressure ulcer), no odor, no drainage. This nurse also assessed an area on the right foot between the first and second toe and the second and third toe that had a small open area approximately 1 x 1 x .01 small open area in the middle (a small pressure ulcer). Review of the facility Communication with physician form dated 1/21/25 at 13:46 (1:46 p.m.), stated Area of unstageable eschar (harden black cap over pressure ulcer) was found on the left heel. A small open area between the first and second toe and between the second and third toe. During an interview done on 1/21/25 at 11:15 a.m., Nurse P stated I would of checked (the resident for pressure ulcers and wound abnormalities) more frequently then weekly. Resident #332: On 1/22/25 at 9:19 AM, an observation occurred of Resident # 332 in their room. The Resident was sitting in bed with a meal tray on the overbed table in front of them. The Resident's heels were positioned directly against the bed. When spoke to, Resident #332 made eye contact but did not engage when asked questions. On 1/22/25 at 10:32 AM, Resident #332 was observed sitting in a Broda chair (reclining, high back wheeled chair with solid, padded leg and footrests). Resident #332 was visibly upset and crying and their lower extremities and heels were positioned directly against the solid leg/footrest of the chair. A Hoyer (mechanical lift) sling was under the Resident in their Broda chair. Record review revealed Resident #332 was a [AGE] year-old individual who was admitted to the facility on [DATE] with diagnoses which included cerebral infarction (stroke) with right sided hemiplegia and hemiparesis (one sided paralysis), Multiple Sclerosis (MS), aphasia (impaired ability to understand language and express speech), and Deep Tissue Injury (DTI) pressure ulcers (wound caused by pressure with unknown depth) on their left ankle and both heels. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and required maximum to total assistance with transferring, mobility, toileting, bathing, and dressing. The MDS further detailed the Resident had three unstageable DTI pressure ulcers. Review of Resident #332's Electronic Medical Record revealed a Care Plan entitled, At risk for alteration in skin integrity related to: currently has 3 DTI's admitted with, incontinence, and immobility (Initiated: 12/31/24). The care plan included the interventions: - Elevate heels as able (Initiated: 12/31/24) - Encourage and assist as needed to turn and reposition; use assistive devices as needed (Initiated: 12/31/24) - Use pillows/positioning devices as needed (Initiated: 12/31/24) A second care plan entitled, Resident has Deep Tissue Injuries to right heel, right ankle, left heel (Initiated: 12/31/24) was also present in Resident #332's EMR. This care plan included the interventions: - Administer treatment per physician orders (Initiated: 1/3/25) - Heel Protectors (FYI) (Initiated: 12/31/24) On 1/23/25 at 7:30 AM, Resident #332 was observed sitting near the nurses' station with a blanket over their head. The Resident did not respond when spoke to. Their lower extremities and heels were positioned directly against the leg/footrest of the Broda Chair. A Hoyer (mechanical lift) sling was under the Resident in their Broda chair. At 9:41 AM on 1/23/25, Resident #332 was observed sitting in the same place near the nurses' station and in the same position in their Broda chair. Certified Nursing Assistant (CNA) CC took Resident #332 to their room to complete incontinence care with CNA BB and an observation of care was completed. When queried how long Resident #332 had been sitting up in their Broda chair, both CNA BB and CNA CC stated, Been up since before we got here. When asked what time they started work, the staff revealed they start at 6:00 AM. When queried if they had repositioned the Resident in their Broda chair since they started work at 6:00 AM, both staff verbalized this was the first time they had provided care to the Resident today. Resident #332 was noted to have dressings in place to both their heels/ankles. During care an open wound was observed on the Resident 's left coccyx. The center of the wound was red, and the surrounding tissue was white in color. The removed brief had bright red blood where it had been positioned against the wound. When queried, CNA CC and CNA BB stated the area had healed and had reopened. A second open wound was observed towards the back of the Resident's left mid upper thigh. This wound bed was red in color with the first layers of skin gone, elongated, irregularly shaped, and larger than a quarter in size. When queried regarding the wound on the Resident's thigh, both CNA's verbalized the area was new. The location of the open wound on the Resident's left thigh correlated with the location of the Hoyer sling was positioned for transfer. When queried if the wound was located where the sling had been positioned, both CNA CC and CNA BB confirmed it was. CNA CC stated the Resident may need a bigger sling because it's digging in. At 10:00 AM, the Resident's assigned Nurse was unable to be located, and Unit Manager Registered Nurse (RN) B was asked to come to the room. RN B entered the room to observe the wounds. RN B verbalized the open area on the Resident's coccyx was caused by moisture and indicated they would obtain cream to apply to the area. When queried regarding the area on the Resident's left upper/mid-thigh, RN B confirmed the area was new. When asked if the wound was caused by the Hoyer sling, RN B did not provide a direct response but indicated it was possible. RN B exited the room at this time and returned with the Director of Nursing (DON). The DON revealed they were going to apply a dressing to the new wound on the Resident's left upper/mid-thigh. Review of documentation in Resident #332's EMR revealed the following: - 12/31/24 at 4:00 PM: admission Evaluation . Clinical Evaluation Integumentary (Skin) . abnormality . Right buttock: 3.5 x 2.5 cm (centimeter) pink/white area . Left Heel: 5 x 4 cm eschar to inner heel, 4 x 4 (cm) dark area lateral outer heel . Right heel: 5 x 6 cm blister filled area to inner heel . Other: Dark skin on left outer ankle . - 1/1/25 at 9:03 AM: Physician Team - Progress Note . Sacral decub (Pressure Ulcer) at level 3 (full thickness tissue loss). Right heel blister . Sacral decub is stable. Right heel is stable. Both medial and lateral malleolus, eschar of the right heel . Skin and Wound: Intact . - 1/10/25 at 11:46 AM: Physician Team - Progress Note . Left heel skin damage . Skin and Wound: Intact . Upon request for all Resident #332's pressure ulcer wound documentation, the facility provided documentation related to the Rear Left Malleolus (ankle), Lateral (side) DTI and Rear Right Malleolus DTI. No documentation was provided for the sacrum pressure ulcer identified in the Physician note on 1/1/25 and/or any other pressure injuries. On 1/23/24 at 11:44 AM, Resident #332 was observed sitting alone by the wall in the [NAME] Hall, near the nurses' station, in their Broda Chair. The Resident's lower extremities and heels were positioned directly against the leg/footrest of the Broda chair. An interview was completed with the DON on 1/23/25 at 12:24 PM. When queried regarding the new wound identified on Resident #332's left upper/mid-thigh, the DON stated, I put a border gauze on it. A review of the Resident's EMR at this time revealed the open area had been documented as MASD (Moisture Associated Skin Damage). When queried how the area was MASD when it was not an area covered by a brief and not in an area prone to moisture, the DON replied, I have to chose something to put it (wound) in (the EMR) and we will change it after the wound nurse evaluates it. When queried if the wound was caused by rubbing from the Hoyer sling, the DON stated, I am doing an investigation. The DON was asked if the open wound was in the area where the Hoyer sling would rub/apply pressure and did not provide a response. When queried how often Resident #332 should be turned and repositioned in their Broda chair, the DON did not provide a direct response. When queried regarding observations and staff interviews revealing the Resident had not been repositioned for approximately four hours, no explanation was provided. Review of Resident #332's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for January 2025 revealed the following: - Skin prep to blister on right heel every 12 hours for Blister (Start Date: 1/1/25 at 9:00 AM). The TAR was blank, indicating the treatment was not completed on 1/9/25 at 9:00 AM and 1/12/25 on 9:00 AM. - Skin prep to Dark spot Lateral heel and Dark spot on lateral heel every 12 hours for Wound care (Start Date: 1/1/25 at 9:00 AM) The TAR was blank, indicating the treatment was not completed on 1/9/25 at 9:00 AM and 1/12/25 on 9:00 AM. - Betadine to Eschar to left inner heel, wrap with ABD pad every day shift for Wound care (Start Date: 1/1/25 at 6:00 AM). The TAR was blank, indicating the treatment was not completed on 1/9/25, 1/12/25, 1/13/25, and 1/15/25. - Boarder dressing to right buttock, ever 2 days and as needed every day shift every 2 day(s) for Wound care (Start Date: 1/1/25). The TAR was blank, indicating the treatment was not completed on 1/3/25, 1/9/25, 1/13/25, 1/13/25, and 1/15/25. - Left heel DTI apply skin prep daily every day shift for DTI (Start Date: 1/3/25). The TAR was blank, indicating the treatment was not completed on 1/9/25 and 1/12/25. -Left outer ankle-DTI-apply skin prep daily every day shift for DTI (Start Date: 1/3/25). The TAR was blank, indicating the treatment was not completed on 1/9/25 and 1/12/25. - NO: Zinc hose paste to sacral area daily and prn (as needed) for MASD every day shift for MASD (Start Date: 1/3/25). The TAR was blank, indicating the treatment was not completed on 1/9/25 and 1/12/25. - Right Hell (sic) -apply skin prep daily DTI every day shift for DTI (Start Date: 1/3/25). The TAR was blank, indicating the treatment was not completed on 1/9/25 and 1/12/25. On 1/23/25 at 1:34 PM, an interview was completed with RN B. When queried if staff should document resident refused in the EMR if a Resident refuses care and/or treatment, RN B indicated they should. When queried regarding observations of Resident #332's heels/lower extremities being positioned directly against the leg/footrests of their Broda chair, RN B did not provide a response. When asked why the Resident did not have heel boots in place as per their care plan, RN B stated, I will discuss with (the DON). Review of the facility Skin and Wound procedure dated 3/20/24, revealed staff were to do weekly skin checks. Review of the facility Skin and Wound Guidelines Policy dated 3/20/24, stated Body audits are completed: BY licensed nurse routinely and documented in the resident's electronic medical record. By the nursing assistant during scheduled baths/showers (twice weekly showers), and if indicated during routine daily care. The nursing assistant will inform the licensed nurse of any new areas of skin breakdown for evaluation and documentation. Pressure Ulcer: Localized damage to the skin and underlying soft tissue, usually over a bony prominence or related to a medical or other device. Can be present as intact skin or an open ulcer and may be painful.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to prevent and document the occurrence of a skin abrasion and Deep Tissue Injury (DTI) for one resident (Resident #1) and the development of pressure ulcers for one resident (Resident #2), resulting in Resident #1 to be found with an abrasion to the left lateral hip and right heel deep tissue injury and Resident #2 developing a pressure ulcer to the left heel as a deep tissue injury and increased to a Stage III pressure ulcer and, also, the left foot 5th toe pressure ulcer to develop and increase in size to a Stage II pressure ulcer, resulting in skin breakdown, pain, the likelihood for infection and diminished overall health and wellbeing. Findings include: Record review of the facility 'Skin and Wound Guidelines' dated 3/20/2024 revealed to describe the process steps required for identification of residents at risk for development of pressure injuries, identify prevention techniques and interventions to assist with the management of pressure injuries and skin alterations. Stages of pressure injury: Stage II Partial thickness skin loss with exposed dermis .Stage III Full thickness skin loss . Deep Tissue Injury (DTI) persistent non-blanchable deep red, maroon, or purple discoloration .Skin alterations and pressure injuries are evaluated and documented by the licensed nurse. Body audits are completed routinely and documented in the resident's electronic medical record. The nursing assistant will inform the licensed nurse of any new areas of skin breakdown for evaluation and documentation. definition: Pressure Injury- Localized damage to the skin and underlying soft tissue, usually over a bony prominence or related to a medical or other device. Can present as intact skin or as open ulcer and may be painful. Injury occurs because of intense and or prolonged pressure or pressure in combination with shear and is classified by stage. Resident #1: Observation on 9/17/202 at 11:10 AM of Resident #1 who resided in room [ROOM NUMBER]-2, revealed no there was no roommate residing in room. Resident #1 was asleep with the head of bed elevated, and the resident slumped to the bottom of the bed. There was a breakfast tray set in front of resident still, thick fall mat noted at bedside, other side of bed against the wall. Upper half side rails noted to be in use bilateral. the TV was on. The Oxygen concentrator was set at 2 liters with nasal cannula looped over the concentrator and running. The oxygen concentrator was located across the room behind room divider curtain, not on resident, out of reach of resident. Resident #1's left leg was amputee, right leg/heel noted to be resting on the gray plastic mattress extender pieces at foot of the bed, there was no prafo boot noted to be visible in the room, Right post heel noted to have discoloration spot and dry flaky skin noted. Resident #1 did not arouse to her name. Record review of Resident #1's Minimum Data Set (MDS) dated [DATE] revealed a female resident with cognitive impairment. Brief Interview of Mental status (BIMS) score of 5 out 15, severe cognitive impairment. Medical diagnosis included: Debility, hypertension, peripheral vascular disease, diabetes, dementia, depression, respiratory failure. Review of the bowel/bladder assessment revealed always incontinent. Record review of section M: skin- revealed no pressure ulcers or skin issues. Record review of Resident #1's care plans pages 1- 30 revealed impaired skin related to history of right heel diabetic ulcer. Interventions: right heel allevyn foam dressing at all times for protection started on 8/26/2024. Bridge heels with pillows. Right Profa boot at all times. There was no mention of a left hip/abdomen abrasion, no treatment. Record review of Resident #1's cardiovascular care plan and other diagnosis care plans revealed that there were no interventions for the use of oxygen. Record review of Resident #1's physician orders revealed that on 8/15/2024 oxygen at 2 liters via nasal cannula while napping/sleeping to maintain oxygen saturation above 90% as needed. Observation on 9/17/2024 at 1:10 PM of Resident #1 revealed the resident was asleep with her lunch tray sitting on the bedside over table with lid off. Observed pork roast, carrots, potato cubes, chocolate ice cream. peaches or mandarin oranges in cup. Resident is sleeping with head of bed slightly elevated, noted right foot to be resting on the same spot of the gray plastic bed extensions, same as the last observation of resident. Observed a dark discolored area at back end of right heel, there were no Profa boot in place. The Profa boot was found in the closet. Resident care plan stated that Profa boot to be on. Observed Housekeeper C into room to clean, she swept and mopped the floor, wiped the tabletop and windowsill, Resident #1 did not wake up at all, loud snoring noted, oxygen noted to be left on the concentrator and running, not on or near the resident. Record review of Resident #1's 'Total body skin evaluation' dated 9/12/2024 revealed no skin abnormalities noted on assessment. Observation and interview on 9/17/2024 at 1:30 PM the state surveyor requested Licensed Practical Nurse (LPN)/Unit manager A was brought into Resident #1's room by surveyor. Both the surveyor and LPN A Observed Resident #1 to be slumped over and to be in the same position as surveyor earlier observation, asleep with no oxygen on resident, but concentrator running with nasal cannula looped over the concentrator. Observed Resident #1 to be sleeping with head slumped to side with a whole baby carrot noted in her mouth. The state surveyor revealed that the resident had not been repositioned since the 11:10 AM observation. LPN A made several attempts to move the resident or to wake her up. LPN A left the room to get nurse registered Nurse (RN) B into the room to assist with positioning. Then Registered Nurse (RN)/Infection Control Nurse I came into the room and assisted with resident repositioning. Once repositioned, the state surveyor noted the resident to have a wet brief. The three nurses rolled the resident side to side to change the brief, when there was a noted abrasion to the left hip/abdomen area that was open and had scabbed edges and was not bleeding. The Registered Nurse/Infection control I nurse stated that it was new and that she would get wound care photo of open skin area. Record review of Resident #1's 'Wound & Skin Assessment' dated 9/17/2024 at 1:50 PM revealed an abrasion to left front trochanter (hip) that was in-house acquired, new on 9/17/2024 measuring 3.78 cm length X 0.73 cm width X 0.1 cm depth with granulation noted. Doctor notified. Resident #2: Record review of Resident #2's re-admission assessment dated [DATE] identified the resident to be a mechanical lift for transfers, skin assessment noted no left foot/heel skin issues or injury and to turn/reposition every 2 hours. Record review of Resident #2's physician progress note dated 1/23/2024 at 11:54 AM identified resident required total assistance with bed mobility, transfers, and Activities of Daily Living (ADL). Identified Resident #2 was high risk for developing contractures, pressure ulcers if not receiving adequate therapy . Record review of Resident #2's nursing progress note dated 1/24/2024 at 1:45 PM revealed resident had a medium purple/maroon discoloration to left heel. Heel injury measuring 0.9 cm X 0.5 cm in-house acquired. Record review of Resident #2's wound progress note dated 2/28/2024 revealed deep tissue injury measuring 5.2 cm X 4.0 cm to left heel . Record review of Resident's #2's wound progress note dated 7/9/2024 revealed left dorsum 5th digit (toe) lateral in-house acquired blister measuring 2.4 cm X 2.3 cm (new wound). Record review of Resident's #2's 'wound & skin evaluation' dated 9/10/2024 revealed left heel stage III pressure ulcer measuring 3.5 cm length X 1.9 cm width X 0.4 cm depth. In an Interview and record review on 9/17/2024 at 3:12 PM with Registered Nurse (RN) Infection Control nurse I Wound care- On 8/15/2024 the facility started a new PCC electronic records system for the new owner company. Resident #2's wounds left foot wounds/ulcers- The top of the foot lateral foot started on 7/9/2024 as a blister with dark discoloration area. Not sure how it started. The profa boots are to be worn daily at all times. Back in December Resident #2 went to the hospital for 3 weeks and came back, then on 1/24/2024 the left heel started as a discolored area from pressure.

Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to do a complete assessment, monitor and provide care, per professional standards of practice for one resident (Resident #116) who had a change of condition with heavy breathing and shortness of breath and who was then found unresponsive, resulting in delayed emergency medical care/treatment of changes in condition and death. Findings include: Record review of facility 'Acute Change of Condition' policy dated 9/2017, revealed the facility strived to provide care that enables each resident to achieve and maintain the highest practicable level of living possible for him/her given his/her physical and mental conditions. In order to do so, prompt identification, assessment, and intervention should occur when a resident experiences an acute change in condition that may be reversible or that may have the effects mitigated by prompt medical attention. Assessment and Problem Recognition: Upon admission the licensed nurse performs a baseline history and assessment on the resident. The nursing staff establishes the resident's baseline vital signs by monitoring and recording these each shift for 72 hours following admission noting these in the medical record. (a.) The Certified Nursing Assistant takes the vital signs of the resident once per shift for the first 72 hours after admission and records in the medical record. (2.) When interacting with residents, staff is to note any changes in the resident . (3.) The licensed nurse promptly assesses the resident. If the assessment determines that the resident may be experiencing an acute change in condition, the licensed nurse will contact the physician for further directives . (4.) The licensed nurse describes the symptoms in detail and accurately in the medical record. Record review of the facility 'Acute Change of Condition' policy and 'Guidelines for Reporting to Physician' policy revealed the condition for shortness of breath was not addressed or/nor guidance to report assessment to physician. Resident #116: Resident #116 was admitted to the facility from the hospital setting on [DATE] at 11 AM. Record review of Resident #116's admission assessment dated [DATE] at 11:00 AM revealed respirations of 16 breaths/minute with 92% oxygen saturation on room air. Resident #116 was noted to be oriented to person, place, time and able to understand Record review of Resident #116's electronic medical record revealed late entry physician progress note dated [DATE] at 12:07 PM noted resident was on 2 liters oxygen, medications were reviewed and noted full code status. Another late entry physician note dated [DATE] at 12:08 PM revealed Record review of Resident #116's progress notes revealed on [DATE] at 12:24 PM IDT (Inter-Departmental Team) meeting noted resident admission from hospital and medications reviewed with physician, and baseline care plan initiated. The next progress note was not until [DATE] at 4:00 AM when resident is noted to have heavy breathing and shortness of breath. The resident was repositioned and pulled up in bed with elevated head of bed slightly by Registered Nurse (RN) A. There were no oxygen saturation levels or vital signs taken at that time, no documented lung sounds, or physical assessment noted by RN A with a change of condition. Record review of Resident #116's vital signs: last blood pressure taken on [DATE] at 4:23 PM was 105/51. Last pulse taken on [DATE] at 4:23 PM was 91 beats per minute (bpm). Last respirations taken on [DATE] at 4:23 PM was 18 breaths/minute. Oxygen saturation summary taken on [DATE] at 4:22 PM was 100%, [DATE] at 11:22 PM oxygen saturation level 96%, and [DATE] at 1:29 AM oxygen saturation level 95%. Record review of Registered Nurse (RN) A typed interview dated [DATE] (should have been dated [DATE]) provided by the facility revealed: Resident #116 was use 2 liter (oxygen) and RN A put it (oxygen) up to 4 liters because he assumed she was breathing harder with her shortness of breath. RN A had another resident with a bladder scan and went to look for someone to assist him with the scan. RN A found the nursing assistance. RN A checked on Resident #116 describing shortness of breath, nostrils flaring, with intercostal contractions, breathing hard not the way she was supposed to be breathing. Record review of facility 'Code Status' policy dated [DATE] revealed on admission, the licensed nurse will document the resident's choice of code status on the Advanced Directive form. The Licensed nurse is also responsible for entering the Code Status in the electronic medical record. The resident will be treated as Full Code until the advanced directives are in place. Code status will be documented in the care plan in the electronic medical record . Cardiopulmonary Resuscitation (CPR) will be initiated on all full code residents no matter their condition at the time they are found. In an interview on [DATE] at 8:22 PM with Certified Nurse Assistant (CNA) D revealed that she was working that night with Registered Nurse (RN) A and Licensed Practical Nurse (LPN) B as the nurses. CNA D stated that she already gave a statement to the consultant lady. CNA D stated that the lady (Resident #116) that passed away was in room [ROOM NUMBER]-1. There was a hospice lady (Resident #118) in room [ROOM NUMBER]-1. RN A the nurse got them mixed up. He thought the hospice lady (Resident #118) passed away. It was me and CNA.C working RN A wanted us to help him straight catheter a lady in room [ROOM NUMBER]-1. On the way into room [ROOM NUMBER]-1 before the straight catheter RN A stated to us that the lady in 123-1 had passed away. It was before we started the straight catheter procedure. It took us 5-10 minutes to position and straight catheter the lady. Then CNA C went to room [ROOM NUMBER]-1 and she (Resident #118) was still alive. CNA C went out and told RN A that room [ROOM NUMBER]-1 was still alive. RN A said no it was the other lady, room [ROOM NUMBER]-1, he mixed up the rooms. He looked down the hallway to see what room he was in. He was not very familiar with our residents. CNA D said that she stated didn't that lady just get here to the facility? was she supposed too passed away? I don't know if they tried to do CPR, it was at shift change 5:30 AM close to 6:00 AM. RN A and CNA C went to the room, we were at the desk when we found out she was a full code. When we found out she wasn't supposed to pass, I believe the Director of Nursing (DON) told them she was a full code, and the DON went to the front door to let the EMS in. In an interview on [DATE] at 11:33 AM with Certified Nurse Assistant (CNA) C revealed That was her first time working with Resident #116. CNA C stated that she received report from second shift stated (Resident #116) would call if she needed anything. She did not call, so halfway through the shift (10:00 PM to 6:00 AM) around 1:00 AM, CNA C checked on Resident #116, she was sleeping, had oxygen on, I left her alone. CNA C stated that then Registered Nurse (RN) A was giving pills and he came out into the hall and said that the lady in room [ROOM NUMBER] had passed away. I went to room [ROOM NUMBER] to check the resident. I went into the room [ROOM NUMBER], I said Hello, the resident #118 (hospice resident) woke up and I said that someone had told me you had passed away. Resident #118 said, I'm not dead yet. I went out to RN A the nurse and I said that she's still alive. He said I meant room [ROOM NUMBER]-1. I went to room [ROOM NUMBER]-1, she was definitely dead. She was cold to me. I started postmortem care, cleansed her face, and cleaned her up the shower aide Certified Nurse Assistant R helped me. CNA C stated that she washed Resident #116's face, did a bed bath, put on a clean gown, and put the sheets back over her. CNA C stated that she was presenting Resident #116 for family viewing. CNA C had just covered her back up when RN A came into the room with the Automated External Defibrillator (AED but didn't put it on the resident, and then the EMS came. I left the room when the EMS put her on the floor and started working. I had to go back in later, put her back into the bed and dress her again. None of the four staff members (2- Licensed nurses and 2- Certified Nurse Assistance) working at the time of the event/incident checked Resident #116's code status in the electronic medical record or the hard binder chart located at the nursing station within reach.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to do a complete assessment, monitor and provide care, per professional standards of practice for one resident (Resident #116) who had a change of condition with heavy breathing and shortness of breath and who was then found unresponsive, resulting in delayed emergency medical care/treatment of changes in condition and death. Findings include: Record review of facility 'Acute Change of Condition' policy dated 9/2017, revealed the facility strived to provide care that enables each resident to achieve and maintain the highest practicable level of living possible for him/her given his/her physical and mental conditions. In order to do so, prompt identification, assessment, and intervention should occur when a resident experiences an acute change in condition that may be reversible or that may have the effects mitigated by prompt medical attention. Assessment and Problem Recognition: Upon admission the licensed nurse performs a baseline history and assessment on the resident. The nursing staff establishes the resident's baseline vital signs by monitoring and recording these each shift for 72 hours following admission noting these in the medical record. (a.) The Certified Nursing Assistant takes the vital signs of the resident once per shift for the first 72 hours after admission and records in the medical record. (2.) When interacting with residents, staff is to note any changes in the resident . (3.) The licensed nurse promptly assesses the resident. If the assessment determines that the resident may be experiencing an acute change in condition, the licensed nurse will contact the physician for further directives . (4.) The licensed nurse describes the symptoms in detail and accurately in the medical record. Record review of the facility 'Acute Change of Condition' policy and 'Guidelines for Reporting to Physician' policy revealed the condition for shortness of breath was not addressed or/nor guidance to report assessment to physician. Resident #116: Resident #116 was admitted to the facility from the hospital setting on [DATE] at 11 AM. Record review of Resident #116's admission assessment dated [DATE] at 11:00 AM revealed respirations of 16 breaths/minute with 92% oxygen saturation on room air. Resident #116 was noted to be oriented to person, place, time and able to understand Record review of Resident #116's electronic medical record revealed late entry physician progress note dated [DATE] at 12:07 PM noted resident was on 2 liters oxygen, medications were reviewed and noted full code status. Another late entry physician note dated [DATE] at 12:08 PM revealed Record review of Resident #116's progress notes revealed on [DATE] at 12:24 PM IDT (Inter-Departmental Team) meeting noted resident admission from hospital and medications reviewed with physician, and baseline care plan initiated. The next progress note was not until [DATE] at 4:00 AM when resident is noted to have heavy breathing and shortness of breath. The resident was repositioned and pulled up in bed with elevated head of bed slightly by Registered Nurse (RN) A. There were no oxygen saturation levels or vital signs taken at that time, no documented lung sounds, or physical assessment noted by RN A with a change of condition. Record review of Resident #116's vital signs: last blood pressure taken on [DATE] at 4:23 PM was 105/51. Last pulse taken on [DATE] at 4:23 PM was 91 beats per minute (bpm). Last respirations taken on [DATE] at 4:23 PM was 18 breaths/minute. Oxygen saturation summary taken on [DATE] at 4:22 PM was 100%, [DATE] at 11:22 PM oxygen saturation level 96%, and [DATE] at 1:29 AM oxygen saturation level 95%. Record review of Registered Nurse (RN) A typed interview dated [DATE] (should have been dated [DATE]) provided by the facility revealed: Resident #116 was use 2 liter (oxygen) and RN A put it (oxygen) up to 4 liters because he assumed she was breathing harder with her shortness of breath. RN A had another resident with a bladder scan and went to look for someone to assist him with the scan. RN A found the nursing assistance. RN A checked on Resident #116 describing shortness of breath, nostrils flaring, with intercostal contractions, breathing hard not the way she was supposed to be breathing. Record review of facility 'Code Status' policy dated [DATE] revealed on admission, the licensed nurse will document the resident's choice of code status on the Advanced Directive form. The Licensed nurse is also responsible for entering the Code Status in the electronic medical record. The resident will be treated as Full Code until the advanced directives are in place. Code status will be documented in the care plan in the electronic medical record . Cardiopulmonary Resuscitation (CPR) will be initiated on all full code residents no matter their condition at the time they are found. In an interview on [DATE] at 8:22 PM with Certified Nurse Assistant (CNA) D revealed that she was working that night with Registered Nurse (RN) A and Licensed Practical Nurse (LPN) B as the nurses. CNA D stated that she already gave a statement to the consultant lady. CNA D stated that the lady (Resident #116) that passed away was in room [ROOM NUMBER]-1. There was a hospice lady (Resident #118) in room [ROOM NUMBER]-1. RN A the nurse got them mixed up. He thought the hospice lady (Resident #118) passed away. It was me and CNA.C working RN A wanted us to help him straight catheter a lady in room [ROOM NUMBER]-1. On the way into room [ROOM NUMBER]-1 before the straight catheter RN A stated to us that the lady in 123-1 had passed away. It was before we started the straight catheter procedure. It took us 5-10 minutes to position and straight catheter the lady. Then CNA C went to room [ROOM NUMBER]-1 and she (Resident #118) was still alive. CNA C went out and told RN A that room [ROOM NUMBER]-1 was still alive. RN A said no it was the other lady, room [ROOM NUMBER]-1, he mixed up the rooms. He looked down the hallway to see what room he was in. He was not very familiar with our residents. CNA D said that she stated didn't that lady just get here to the facility? was she supposed too passed away? I don't know if they tried to do CPR, it was at shift change 5:30 AM close to 6:00 AM. RN A and CNA C went to the room, we were at the desk when we found out she was a full code. When we found out she wasn't supposed to pass, I believe the Director of Nursing (DON) told them she was a full code, and the DON went to the front door to let the EMS in. In an interview on [DATE] at 11:33 AM with Certified Nurse Assistant (CNA) C revealed That was her first time working with Resident #116. CNA C stated that she received report from second shift stated (Resident #116) would call if she needed anything. She did not call, so halfway through the shift (10:00 PM to 6:00 AM) around 1:00 AM, CNA C checked on Resident #116, she was sleeping, had oxygen on, I left her alone. CNA C stated that then Registered Nurse (RN) A was giving pills and he came out into the hall and said that the lady in room [ROOM NUMBER] had passed away. I went to room [ROOM NUMBER] to check the resident. I went into the room [ROOM NUMBER], I said Hello, the resident #118 (hospice resident) woke up and I said that someone had told me you had passed away. Resident #118 said, I'm not dead yet. I went out to RN A the nurse and I said that she's still alive. He said I meant room [ROOM NUMBER]-1. I went to room [ROOM NUMBER]-1, she was definitely dead. She was cold to me. I started postmortem care, cleansed her face, and cleaned her up the shower aide Certified Nurse Assistant R helped me. CNA C stated that she washed Resident #116's face, did a bed bath, put on a clean gown, and put the sheets back over her. CNA C stated that she was presenting Resident #116 for family viewing. CNA C had just covered her back up when RN A came into the room with the Automated External Defibrillator (AED but didn't put it on the resident, and then the EMS came. I left the room when the EMS put her on the floor and started working. I had to go back in later, put her back into the bed and dress her again. None of the four staff members (2- Licensed nurses and 2- Certified Nurse Assistance) working at the time of the event/incident checked Resident #116's code status in the electronic medical record or the hard binder chart located at the nursing station within reach.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #36: A review of Resident #36's medical record revealed an admission into the facility on 6/1/22 with a readmission on [DATE] and was transferred to the hospital on [DATE]. Diagnoses for Resident #36 included sepsis, pressure ulcer of sacral region, osteomyelitis, gastrostomy status, stroke, diabetes, chronic kidney disease, pain, heart disease and need for assistance with personal care. A review of Resident #36's Minimum Data Set assessment, dated 9/3/22, revealed Brief Interview of Mental Status (MDS) score of 11/15 that indicated moderate cognitive impairment and the Resident needed extensive assistance of two person assist with bed mobility, dressing, toilet use and personal hygiene and was total dependence on staff for transfers and eating. Further review of the MDS indicated the Resident had a Stage 4 full thickness tissue loss with exposed bone, tendon or muscle of one pressure ulcer that was present upon admission/reentry. The MDS dated [DATE], OBRA admission assessment revealed the Resident had one Stage 2 pressure ulcer that were present upon admission/reentry. The MDS dated [DATE], Discharge assessment-return anticipated revealed the Resident had one Stage 2 pressure ulcer that was present upon admission/reentry. The MDS dated [DATE], Discharge assessment-return anticipated, revealed the Resident had one Stage 3 pressure ulcer that was present upon admission/reentry. A review of Resident #36's medical record revealed the following: admission Assessment, dated 6/1/22, skin assessment that revealed, . coccyx 11 cm (centimeters) length top 10 cm width, lower 5.75 cm width, area dark red in color. Progress Note, dated 6/8/22, revealed, Resident admitted with a stage 2 pressure area to sacrum. Area measures 10.4 x 7.05 x 0.1 cm. Area is absent of odor and exudate after cleansing. Area is 90% granulation tissue and 10% slough. Resident mobility is limited and has a difficult time turning and reposition self. Interventions for turning and repositioning in place, and resident is on an air mattress for pressure relief. Treatment: cleanse area with normal saline, pat dry, apply calcium ag and cover with alyven foam dressing. Resident and family educated on the importance of compliance with cares and interventions. Resident, doctor, dietary and family aware and agree with treatment. admission Assessment, dated 7/2/22, skin assessment that revealed, .Pressure ulcer on coccyx . The documentation lacked measurements and wound description. Progress Note, dated 7/2/22 at 10:15 AM, revealed, (Resident name) arrived via (transport ambulance) from (hospital name) and is alert and oriented x 3-4 and able to make needs known . Skin assessment done upon arrival. Progress Note, dated 7/6/22 at 12:43 PM, revealed, Resident admitted with a stage 2 pressure area to sacrum. After returning from a recent hospitalization resident's wound has progressed to a stage 3. Area measures 10.38 x 5.82 x 0.1 cm. Area is absent of odor and exudate after cleansing. Area is 50% granulation tissue and 50% slough. Resident mobility is limited and has a difficult time turning and reposition self. Interventions for turning and repositioning in place, and resident is on an air mattress for pressure relief. Treatment: Clean with NS. Apply santyl. Cover with wet to dry dressing and ABD, Resident and family educated on the importance of compliance with cares and interventions. Resident, doctor, dietary and family aware and agree with treatment. Progress Note, dated 7/13/22 at 11:04 AM, . Area measures 10.1 x 6.16 x 0.1 cm. Area is absent of odor and exudate after cleansing. Area is 50% granulation tissue and 50% slough. Area surrounding wound is firm. Doctor ordered ultra sound. Ultra sound completed and did find there to be an abscess in the area. Doctor ordered warm compresses and if the area does not decrease in size doctor will order incision and drainage. Progress Note dated 7/20/22 at 12:42 PM, Skin/Wound Note, .Area measures 10.2 x 6.12 x 0.1 cm . Area is 60% granulation tissue and 40% slough . Treatment: Clean with NS, apply santyl. Cover with wet to dry dressing and ABD. Progress Note dated 7/27/22 at 11:27 AM, Skin/Wound Note, .Area measures 6.51 x 5 x 0.1 cm .Area is 70% granulation tissue and 30% slough . Treatment: Clean with NS, apply santyl. Cover with wet to dry dressing and ABD. Progress Note, dated 8/3/22 at 5:13 PM, Skin/Wound Note, .Area measures 6.25 x 4.85 x 0.1 cm .Area is 70% granulation tissue and 30% slough . Treatment: Clean with NS, apply santyl, pack open area with aquacel Ag and cover with alyven foam dressing. Progress Note dated 8/7/22 at 11:51 AM, Resident was sent to the hospital at 12 PM for slow response, not eating . Resident returned on 8/18/22. Progress Note dated 8/24/22 at 1:14 PM, Skin/Wound Note, .Area is currently unstageable. Area measures 15.18 x 9.27 x utd (unable to determine) cm. Area is 80% granulation and 20% slough . Treatment: Cleanse area with normal saline, pat dry, apply xeroform gauze [to prevent foam from adhering to the wound bed], apply NPWT (negative pressure wound treatment-wound vac). Progress Note, dated 8/31/22 at 5:54 PM, Skin/Wound Note, .Area measures 12.84 x 10.2 x utd cm. Area is 80% granulation and 20% slough . Treatment: Cleanse area with normal saline, pat dry, apply xeroform gauze [to prevent foam from adhering to the wound bed], apply NPWT (negative pressure wound treatment-wound vac) . Progress Note, dated 9/7/22 at 2:35 PM, Skin/Wound Note, .Area measures 12.94 x 13.49 x 7.2 cm. Area is 80% granulation and 20% slough . Treatment: Cleanse area with normal saline, pat dry, apply xeroform gauze [to prevent foam from adhering to the wound bed], apply NPWT. Progress Note, dated 9/14/22 at 4:14 PM, Skin/Wound Note, .Area measures 11.98 x 11.92 x 7 cm. Area is 90% granulation and 10% slough . Treatment: Cleanse area with normal saline, pat dry, apply NPWT. Progress Note, dated 9/21/22, Skin/Wound Note, .Area measures 10.64 x 6.74 x 1 cm. Area is 90% granulation and 10% slough . Treatment: Cleanse area with normal saline, pat dry, apply NPWT. Progress Note, dated 9/28/22, Skin/Wound Note, .Area measures 10.93 x 7.15 x 1 cm. Area is 80% granulation and 20% slough . Treatment: Cleanse area with normal saline, pat dry, apply NPWT. Progress Note, dated 10/5/22, Skin/Wound Note, .Area measures 13.56 x 11.98 x 1 cm. Area is 90% granulation and 10% slough . Treatment: Cleanse area with normal saline, pat dry, apply NPWT. Progress Note, dated 10/12/22, Skin/Wound Note, .Area measures 9.82 x 8.8 x 1 cm. Area is 90% granulation and 10% slough . Treatment: Cleanse area with normal saline, pat dry, apply NPWT. A review of Resident #36's wound clinic notes revealed the following: 7/22/22, The patient referred to wound clinic for R buttock abscess. He actually has a known sacral decubitus ulcer for the past few weeks. He suffered a stroke back in [DATE] and has been in and out of the hospital ever since, and he still has a fair amount of debility from this . He had a PEG placed in May. He was hospitalized in June with mental status change and was found to have bacteremia related to heart valve vegetations. I was consulted during this hospitalization for his sacral ulcer, and at that time, he had an unstageable sacral ulcer that did not require any acute intervention. We started managing this with Santyl dressings once daily. He was discharged to ECF (extended care facility), but unfortunately, he did not have appropriate wound clinic follow-up scheduled as planned/intended. We then received a referral earlier this week for right buttock abscess. Wound Assessment: Wound #1 Sacral is an acute Stage 4 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 6.42 cm length x 5.26 cm width x 4 cm depth, with an area of 33.769 sq cm (square centimeters) and a volume of 135.077 cubic cm. Adipose is exposed . Integumentary: Has stage 4 sacral ulcer with deep tunneling under right buttock with some foul-smelling necrotic tissue and seropurulent drainage tender to deep palpation; superficial portion of wound is clean with beefy red granulation . A debridement was performed.Dressings: Santyl-Apply a thin film of Santyl to wound bed only, then cover with clean dressing. Santyl to wound bed, cover with aquacel ag, and allevyn. Change daily and as needed. Keep dressing dry and intact. Cover and secure with: allevyn. Aquacel Ag- Apply skin protectant or barrier ointment to protect surrounding skin. Apply Aquacel Ag to wound bed, may use Normal Saline to activate if needed. Cover with dry gauze and wrap with Kerlix/Conform roll gauze. Secure with tape. [NAME] dressing as directed: -santyl to wound bed, aquacel ag, cover with allevyn, change daily and as needed . Brief debridement performed . I believe he will benefit from operative debridement, but given his overall medical status, will need to obtain cardiac risk assessment. For now, will continue Santyl dressings and add Aquacel Ag packing to deep portion, change once daily and as needed. Continue offloading. Maximize nutrition. Need to check nutrition labs and A1C. Follow-up in one week. 7/29/22, .He is a diabetic. The last A1C in the system was from [DATE] and was 11.4 . His last albumin was 2.4 on 6/28. I do not see any more recent labs in the system. 7/29/2022 update: Doing the same. Labs were not done last week. Still with pain and copious drainage . (Labs were completed at the facility on 7/27/22 per reviewed lab results but not communicated to the wound clinic.) .Wound Assessment: Initial wound encounter measurements are 6.69 cm length x 5.15 cm width x 3.5 cm depth with an area of 24.29 sq cm, Adipose is exposed. Tunneling has been noted at 1:00 with a maximum distance of 7.5 cm . Topical Treatments: Enzymatic Debriding Agent: Santyl- Continue Santyl to wound bed, special attention to necrotic tissue to upper right quadrant. Apply Nickel Thick. Dressings Santyl- apply a thin film of Santyl to wound bed only, then cover with clean dressing. - Apply Nickel Thick to wound bed. Keep dressing dry and intact. Cover and secure with: -allevyn. Aquacel Ag-Apply skin protectant or barrier ointment to protect surrounding skin. Apply Aquacel Ag to wound bed, may use Normal Saline to activate if needed. Cover with dry gauze and wrap with Kerlix/Conform roll gauze. Secure with tape. Change dressing as directed: Aquacel Ag rope to tunnel at 1 o'clock to depth of 7.5 . Bedside debridement performed, as much as he could tolerate. Will continue Santyl/Aquacel Ag to deep area of wound, change daily and as needed for soilage. Will schedule for operative debridement of sacral wound. Need to obtain pre-op cardiac risk to make sure it is safe to give him anesthesia. Will schedule for surgery ASAP. Follow-up in one week. The facility orders for wound treatments did not include the Aquacel Ag rope to tunnel at 1 O'clock to the depth of 7.5 nor the nickel thick Santyl to the wound bed. 8/5/22, .8/5/2022 update: Continues to have copious foul-smelling drainage . Wound Assessment: Wound #1 sacral is an acute Stage 4 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 6.16 cm length x 3.6 cm width x 3.5 cm depth, with an area of 22.4224 sq cm. Adipose is exposed. Tunneling has been noted at :00 with a maximum distance of 5.5 cm . There is a copious amount of purulent drainage noted which has no odor . Integumentary [Hair, Skin]: Sacral wound with foul-smelling purulent drainage and moderate amount of necrotic fibrinous material within wound, very tender . Topical Treatments: Enzymatic Debriding Agent: Santyl- Continue Santyl to wound bed, special attention to necrotic tissue to upper right quadrant. Apply Nickel Thick. Dressings Santyl- apply a thin film of Santyl to wound bed only, then cover with clean dressing. - Apply Nickel Thick to wound bed. Keep dressing dry and intact. Cover and secure with: -allevyn. Aquacel Ag-Apply skin protectant or barrier ointment to protect surrounding skin. Apply Aquacel Ag to wound bed, may use Normal Saline to activate if needed. Cover with dry gauze and wrap with Kerlix/Conform roll gauze. Secure with tape. Change dressing as directed: Aquacel Ag rope to tunnel at 1 o'clock to depth of 7.5 . Physician Review: Discussed the Plan of Care @ bedside with- 8/5/22: lido and debridement. A lot of drainage purulent drainage noted . Culture taken and sent to lab. More discussion regarding surgery for surgical debridement with wife. They are just waiting for more cardiac testing to be done . The Resident was sent to the hospital on 8/7/22 and returned to the facility on 8/18/22. Resident had incision and drainage of the abscess on 8/11/22. 8/26/22 appointment was canceled due to physician illness. 8/30/22, .Pt (patient) is here for follow up . Wound Assessment: Wound #1 sacral is an acute Stage 4 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 17 cm length x 13 cm width x 7.2 cm depth, with an area of 221 sq cm and a volume of 1591.2 cubic cm. Adipose is exposed . General Notes: 8/30/22 drainage volume in canister 250 cc. canister not changed. Battery dead on wound vac .Dressings: Keep dressing dry and intact. Cover and secure with: Negative Pressure Wound Therapy: -125 continuous suction, Vac changes to occur every three days. Recommend white foam to be placed to greatest depth of 7.1 cm followed by black foam on top . Aquacel Ag rope packed gently to greatest depth of 7.1 cm with tail exposed for removal. Aquacel ag applied to remaining wound bed . Physician Review: . 8/30/22 4% Lido and debridement. Wound bed looks good. Crush flagyl and gentamicin ointment to wound bed. Aquacel ag rope to deepest point 7.1 cm and aquacel ag to wound bed. Wound vac applied but battery dead. Only sent black foam with patient. Recommend white foam to deepest depth of 7.1 cm followed by black foam. Dressing changes every 3 days . 9/7/22, .Patient here for wound care office large decubitus sacral ulcer. Recently he had debridement in the OR with (Physician name) . Wound Assessment: Wound #1 sacral is an acute Stage 4 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 12.94 cm length x 13.49 cm width x 7.2 cm depth, with an area of 174.5606 sq cm and a volume of 1256.836 cubic cm. Adipose is exposed . Topical Treatments: Antibiotic/Antimicrobial Ointment/Cream-Crushed Flagyl to wound bed with each vac change. Gentamicin ointment to wound bed with each vac change. Enzymatic Debriding Agent: Santyl - Santyl to dark necrotic tissue in wound bed. [left side of wound bed]. Dressings: Santyl- Apply a thin film of Santyl to wound bed only, then cover with clean dressing.- santyl to black/brown necrotic tissue to left side of wound bed. Keep dressing dry and intact. Cover and secure with:-aquacel ag and wound vac. Negative Pressure Wound Therapy:- -125 continuous suction. Vac changes to occur every three days. Recommend white foam to be placed to greatest depth of 4.0 cm followed by black foam on top. Aquacel Ag-Apply skin protectant or barrier ointment to protect surrounding skin. Apply Aquacel Ag to wound bed, may use Normal Saline to activate if needed . Aquacel Ag rope packed gently to greatest depth of 4.0 cm with tail exposed for removal. Aquacel ag applied to remaining wound bed. Change with each vac change . Physician Review: .9/7/22: Lido and debridement. Pt has a large area of blackish brown necrotic/fibrotic tissue that doctor (name) was unable to do with a curette and he stated that the tissue would need to be surgically debrided. He did not feel comfortable debriding any of that here in the clinic because it is very attached and he felt it goes rather deep and this would cause possibly a lot of bleeding and pain. He did debride all of the nice beefy red tissue for biofilm and slough that was present. He added santyl to the tx to the area that has that necrotic tissue along with what was ordered prior. Wound vac dressing was put back on but the box they sent us did not match the dressing they sent with us. Called over to (facility name) to let them know and they understood . There were no wound clinic notes provided by the facility and no progress notes that indicated the Resident was sent back to the wound clinic until 9/30/22. 9/30/22, . 9/30/2022 update; Still has rectal tube in place. Currently at (facility name) . Had operative debridement on 8/11/22. Bone biopsy positive for osteomyelitis. Wound, bone, and tissue cultures positive for Proteus, but ID (Infections Disease) only wanted to treat with IV (intravenous) abx (antibiotic) for 7 days .Wound Assessment: Wound #1 sacral is an acute Stage 4 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 9.68 cm length x 15.02 cm width x 7.2 cm depth, with an area of 113.26 sq cm and a volume of 1256.836 cubic cm. Adipose is exposed . Integumentary [Hair, Skin]: Sacral wound with mostly pink granulation tissue but moderate fibrinous exudate some exposed bone with friable bone tissue . Physician Review: . 9/30/22: Lido and debridement. Doctor took a lot of loose slough out of wound with pick up and scissors. Wound is clean and healthy. Pt still has a rectal tube. (Doctor's name) does not feel that a long term rectal tube is good for the pt and discussed with the wife about taking pt to surgery for a colostomy bag. Pt and wife agree . 10/14/22, . Wound Assessment: Wound #1 sacral is an acute Stage 4 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 10.8 cm length x 12.99 cm width x 7.2 cm depth, with an area of 140.292 sq cm and a volume of 1010.102 cubic cm. Adipose is exposed . Integumentary [Hair, Skin]: Sacral wound with pink granulation tissue, moderate fibrinous exudate and debris in wound two small areas of exposed bone, moderately tender, mostly healthy pink granulation tissue . Physician Review: .10/14/22: lido and very aggressive debridement done. Pt's wound is getting cleaner. There is an area on the right side of the wound at about 3 o'clock that has a depth of 7.5. Wound vac applied as ordered. Pt has a new colostomy . A review of Resident #36's orders for the dressing to the coccyx wound include the following: Dated 6/1/22, Cleanse coccyx with NS (normal saline), pat dry, apply Calcium alginate to wound bed, cover with allevyn, daily and PRN. Dated 7/2/22, start date on 7/3/22, Coccyx: Clean with NS. Apply santyl. Cover with wet to dry dressing and ABD. Dated 7/23/22 to start, Coccyx wound treatment: apply 2% lidocaine topical to coccyx wound bed prior to dressing then cleanse wound with NS and apply Santyl then cover with Aquacel Silver and Allevyn, daily and as needed. Dated 8/18/22, start date 8/19/22, Wound treatment negative pressure wound therapy. Apply wound vac. Change every Monday, Wednesday and Friday and PRN. The wound clinic recommendations were for the wound vac to be changed every three days. Dated 8/31/22, start date 9/2/22, Wound Treatment negative pressure wound therapy. [NAME] foam to be placed at greatest depths. Apply aquacel ag to wound bed and pack aquacel ag gently at greatest depth, leaving a tail. Apply wound vac, Change every Monday, Wednesday and Friday and PRN. Dated 9/1/22, start date on 9/2/22, Wound Treatment negative pressure wound therapy. [NAME] foam to be placed at greatest depths. Apply Flagyl and Gentamicin to wound bed with each vac change. Apply aquacel ag to wound bed and pack aquacel ag gently to greatest depth, leaving a tail. Apply wound vac. Change every Monday, Wednesday and Friday and PRN. Review of Resident #36 medical record revealed the Resident was re-admitted on [DATE], transferred to the hospital on 6/22/22, returned on 7/2/22, transferred to the hospital on 8/7/22, returned to the facility on 8/18/22, transferred to the hospital on [DATE] and returned on 10/8/22 and transferred to the hospital on [DATE]. Review of Resident #36's hospital records with admission on [DATE] revealed, .came to the ED from nursing facility where the patient was feeling more drowsy and patient was not at his baseline. When the patient brought to the ED (emergency department) he looks severely dehydrated and his labs showed severe dehydration with elevated sodium lactate was elevated so based on his assessment of dehydration patient was immediately started on fluids. On assessment patient was responsive with only yes or no and mostly nods his head on initial presentation but after rehydration patient mentation slightly improved his drowsiness got better . Review of Resident #36's wound culture, with results reported on 9/5/22 revealed heavy growth Escherichia coli carbapenem-resistant (Carbapenem resistant enterobacteriacea-CRE), light growth Citrobacter koseri and light Growth Enterococcus faecalis. According to the Centers for Disease Control and Prevention (CDC), https://www.cdc.gov>organisms, CRE are a major concern for patients in healthcare settings because they are resistant to carbapenem antibiotics, which are considered the last line of defense to treat multidrug-resistant bacterial infections. Often, high levels of antibiotic resistance in CRE leave only treatment options that are more toxic and less effective. Further review from the CDC include, CRE are usually spread person to person through contact with infected or colonized people, particularly contact with wounds or stool. This contact can occur via the hands of healthcare workers, or through medical equipment and devices that have not been correctly cleaned, last reviewed 11/13/2019. On 10/17/22 at 10:12 AM, an observation was made on the initial tour of the facility of Resident #36 lying in bed on his back. The Resident was on transmission-based precautions for a wound infection. The Resident was alert and tracked this surveyor with his eyes. When asked questions, the Resident was able to answer simple questions when given extra time to answer, one- or two-word answers, with a barely audible voice. The Resident did not converse in conversation. The Resident indicated he had a wound on his buttock area and wound odor was noted when near the bedside where a wound vac was positioned. An observation was made in the Resident's bathroom of the vent in the ceiling with built up dust and debris. On 10/17/22 at 1:43 PM, an observation was made of Resident #36, lying in bed on his back, sleeping. The Resident appeared to be in the same position as earlier, but it was noted that the wound vac canister had been replaced and the there were no longer an odor in the room. On 10/18/22 at 10:05 AM, an observation was made of Resident #36 lying in bed on his back, sleeping. On 10/20/22 at 10:14 AM, an interview was conducted with Nurse Manager (NM), Nurse S and Wound Care Nurse F regarding Resident #36's wound history of a Stage II documented on 7/6/22, deterioration to a Stage IV with infections in the wound. The NM indicated Resident #36 had been transferred to the hospital on 6/22/22 and returned on 7/2/22, and the Resident presented with the pressure ulcer to his coccyx/sacral area on his readmission into the facility. A review of the admission assessment revealed a documented pressure ulcer to the coccyx area but did not give a description or measurements of the pressure ulcer and documentation of the wound description was not documented until 7/6/22 when the Wound Care Nurse had assessed the wound. The NM indicated that the measurements might be on the paper copy of the skin assessment. After looking for the paper copy, the NM was unable to find the documentation. When asked if wound assessment with measurements were to be done on admission, the NM stated, Yes, if should be in the admission assessment. When asked about the Resident not having an appointment consistently on a weekly basis, the NM and the Wound Care Nurse F indicated the Doctor had been sick and the appointment was canceled and another time, the ambulance transport service was late on picking the Resident up for the appointment due to priority calls and the Resident was not seen when he had arrived at the wound clinic, so the appointment calls got pushed back. When asked about the wound clinic notes that indicated the Resident did not have appropriate wound clinic follow-up scheduled as planned/intended after the Residents hospitalization, the NM indicated that the hospital discharge instructions did not indicate follow-up with the wound clinic. The Resident observed lying on his back in bed in the same position on 10/17 and 10/18 was reviewed with the Nurse Manager and Wound Care Nurse. The Wound Care Nurse indicated that the Resident had interventions in place for turning every two hours and stated, we can turn him, but he won't let us turn him on his side, due to pain in the shoulder. When asked about pain medication, the Wound Care Nurse indicated he was on around the clock pain medication and stated, he won't stay on one side or the other. A review of the care plan revealed the Resident had interventions in place for an air mattress and for repositioning but had not been revised with other interventions in place with refusals for positioning. On 10/20/22 at 2:10 PM, an interview was conducted with the Infection Control Preventionist, Nurse G regarding the infections in the Resident coccyx wound. When asked about the wound infections, including CRE, the Nurse indicated that the culture taken on 8/29/22 was reported to the facility on 9/5/22 that grew multiple organisms that included CRE and stated, every time he goes out to the hospital, he comes back with something else. When asked about isolation precautions, the Nurse indicated that contact precautions were started as soon as he had the positive CRE. Review of facility policy titled, Pressure Ulcers/Skin Breakdown-Clinical Protocol, reviewed/revised 4/27/18, revealed, .Assessment and Recognition: 2. In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure ulcer including location, stage, length, width and depth, presence of exudates or necrotic tissue . 3. The staff will examine the skin of a new admission for ulcerations or alterations in skin . Review of facility policy titled, Prevention of Pressure Ulcers/Injuries, reviewed/revised 5/2/18, revealed, . Mobility/Repositioning: 3. At least every two hours, reposition resident who are reclining and dependent of staff for repositioning. 4. Reposition more frequently as needed, based on the condition of the skin and the resident's comfort, keeping the head of bed 30 degrees or less, unless contraindicated . Monitoring: 1. Evaluate, report and document potential changes in the skin. 2. Review the interventions and strategies for effectiveness on an ongoing basis . Based on observation, interview and record review, the facility failed to ensure assessment and follow wound clinic recommendations for treatment of a pressure ulcer for one resident (Resident #36) and failed to prevent facility-acquired pressure ulcer areas for one resident (Resident #8), resulting in the worsening of a pressure ulcer to Stage IV for Resident #36, and Resident #8 developing a facility-acquired Stage II new pressure area discovered during a dressing change observation while residing in the facility. Findings include: Record review of facility 'Pressure Ulcer/Injury Risk Assessment' policy dated 5/2/2018 revealed the purpose of the procedure was to provide guidelines for the structured assessment and identification of residents at risk of developing pressure ulcers/injuries. Steps in procedure: (4.) (c.) If a new skin alteration is noted, initiate (pressure or non-pressure) documentation in the facility medical record program related to the type of alteration in skin. Record review of the 'Clinical Nursing Skills & Techniques' book, [NAME], [NAME] and [NAME], 9th edition, copyright 2014, Chapter 39- Pressure injury prevention and care, pages 990-997, revealed the following: Pressure injuries occur from unrelieved prolonged soft tissue compression, which interferes with blood flow to the tissues. If this compression continues for prolonged period of time, the tissue dies from lack of blood flow, or tissue ischemia. Ischemia develops when pressure inside the vessels, causing the vessels to collapse and decreasing tissue perfusion. Staging of Pressure Injuries: Stage 1- Pressure injury: non-blanchable erythema or intact skin. Stage 2- Pressure Injury: Partial-thickness skin loss with exposed dermis. Stage 3- Pressure Injury: Full thickness skin loss. Stage 4- Pressure Injury: Full-thickness skin and tissue loss. Resident #8: In an interview on 10/17/22 at 12:19 PM with Resident #8 about her sacral wound pressure ulcer revealed that she was not sure where it came from, she had been in and out of the hospital, not sure where came from. Observation on 10/18/2022 at 8:45 AM Resident #8 is laying on her back with no supporting device in place, record review of care plan, she refuses repositioning or devices. Record review of all care plans pages 1-26 revealed that there was no mention of the wound vac to the sacral pressure ulcer wound. In an interview on 10/18/2022 at 1:30 PM with Registered Nurse (RN) F Wound Care Certified (WCC) revealed that Resident #8 has a wound to the sacral area. Record review of wound care assessments revealed that on 7/28/2021 the sacral pressure ulcer started as a stage II facility acquired, and the size decreased. Then on 11/3/2021 the sacral pressure ulcer increased in size when Resident #8 went to an appointment and in the facility van, she felt like it ripped. On 3/8/22 Resident #8 sacral pressure ulcer increased in size to 3.6 X 1.5 X .01 Centimeters (cm), then on 3/15/22 the wound increased again. On 6/1/22 the sacral pressure ulcer size grew 5.51 X 2.38 CM, we started wound clinic at hospital. On 6/30/22 Resident #8 became COVID positive and stayed here in the facility. The facility placed Resident #8 into the COVID unit, and it became larger in size again. RN/WCC F stated that the facility started a wound vac at the facility. RN/WCC F stated that the rectal tube was for constant loose stools and the Foley catheter was urine. RN/WCC F stated that there is a left upper arm PICC line that we did use for IV antibiotics. The rectal tube is re-evaluated every 30 days by the Nurse Practitioner who also does the wound clinic. RN/WCC F stated that the rectal tube and urinary catheter is emptied per shift. The wound vac dressing is changed Mondays, Wednesday, Fridays around 9:30 AM. Observation and interview on 10/19/22 9:35 AM with Registered Nurse (RN/WCC) F and Certified Nurse Assistant (CNA)H of Resident #8's sacral pressure ulcer dressing wound vac change. Observation of Resident #8's back side revealed a rectal tube observed in place with a Foley catheter also in place. Observed Resident #8 with left leg above the knee amputee, stump well healed. catheter strap in place. RN/WCC F performed hand hygiene, prepped the dressing field on over bed table, barrier put down. and wound vac kit prepped. Resident #8 rolled to right side with assistance of CAN H. RN/WCC F removed the old dr[TRUNCATED]