**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident was free from physical restraints imposed for the purpose of convenience in 1 of 1 resident (Resident #11) reviewed for restraints, resulting in the restriction of mobility, episodes of anxiety and frustration, a potential for decline in physical functioning, and an increased risk of injury. Findings include: Review of Physical restraint in older people: an opinion from the Early Career Network of the International Psychogeriatric Association, October 2023, www.researchgate.net , revealed: .The fundamental rationale for employing physical restraints is ostensibly to ensure the safety of the patient .common justi?cations for resorting to physical restraints include: . To reduce the risk of falls or accidents in ambulant patients with safety concerns .These well-intended motives, however, are not supported by the evidence. On the contrary, many studies show that restraints do not prevent falls and can instead increase the likelihood of injury from falls ([NAME], et al., 2011). Review of Restraint Definition and Examples, [NAME] D [NAME], OTR/L, 2015, phsyicaltherapy.com revealed: .examples of restraints: .A reclining geri-chair (a specialized reclining chair which cannot be propelled by the user, and restricts movement in a resident that is able to propel in a manual wheelchair) would be considered an example of a restraint .An upright geri-chair with a lap tray .that prevents the resident from rising from the seat .they are not able to stand up. Review of an admission Record revealed Resident #11 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: alzheimer's disease (disease causing progressive deterioration of cognitive skills), anxiety disorder (excessive worry and fear that are persistent, intense, and often out of proportion to the situation), major depressive disorder (persistent depressed mood or loss of interest in activities causing significant impairment in daily life) and edema (buildup of fluid in the body's tissue, most commonly in the legs and feet). Review of a Minimum Data Set (MDS) assessment for Resident #11 with a reference date of 1/7/25, revealed a Brief Interview for Mental Status (BIMS) score of 99 which indicated Resident #11 was unable to complete the evaluation. Section E revealed Resident #11 did not exhibit behavioral symptoms of verbal/vocal screaming or making disruptive sounds during the 14-day assessment period. Section GG revealed Resident #11 could ambulate 10' with supervision or light touching assistance and could propel a standard wheelchair up to 150' with moderate assistance. Section M revealed Resident #11 was at risk for developing pressure ulcers. Section P revealed no physical restraints were used on Resident #11. Review of a Care Plan for Resident # 11 with a reference date of 1/30/25, revealed a focus/goal/interventions of: (Resident #11) is at risk for complications due to they (sic) require use of a Gerichair (sic) w/tray (with tray) to enable her up related to multiple falls. Goal: (Resident #11) will be free from complications related to the use of Gerichair w/tray through next review. interventions: Apply Gerichair w/tray when up and release tray after meals or when in bed .Release and reposition q2 hours, with supervised meals, supervised activities and with toileting. During an observation on 4/15/25 at 9:21 am, Resident #11 sat in a geri-chair in the common area of the memory care unit. The arms of the geri-chair pushed against a table and the brakes locked. Resident #11 sat upright, supported her torso with her trunk muscles with her back unsupported. Resident #11 rocked her trunk back and forth as a staff member passed by and said to her (Resident #11's name) what's wrong? We're going to do a history activity in twenty minutes. Resident #11's feet hung unsupported above the floor with her feet extended, causing her toes to point toward the floor. Resident #11's feet appeared swollen. During an observation on 4/15/25 at 9:58 am, Resident #11 sat unsupported at the edge of her bed with the geri-chair parked against the wall across from the foot of her bed. A lap tray for the geri-chair was propped against the wall. No staff were in her room and the call light was activated. In an interview on 4/15/25 at 12:15pm, Certified Nursing Assistant (CNA) U reported the nursing and hospice staff decided to use a geri-chair with a table across it for Resident #11 after the resident had multiple falls. When asked if the resident seemed upset about using the geri-chair with the lap tray, CNA U reported Resident #11 hates it. CNA U reported Resident #11 was not able to get out of the chair with the lap tray in place and frequently made statements such as get me out of here while in the chair. CNA U reported Resident #11 was less frustrated if the geri-chair did not have the tray on it but was pushed up against a table, although the resident still could not stand when she was in this position. In an interview on 4/15/25 at 1:49pm, Social Services Director (SSD) T reported Resident #11 started using the geri-chair after she had been hospitalized and returned too weak to maintain good trunk control. SSD T reported Resident #11's strength had improved, and she could now sit unsupported. When queried regarding the use of the lap tray across the chair, SSD T confirmed the lap tray was affixed across Resident #11's lap at times and to her knowledge, was used so Resident #11 could pursue tabletop leisure interests. SSD T reported the geri-chair and tray were not used to reduce Resident #11's fall risk and she was not aware of any negative response the resident had to it. In an interview on 4/16/25 at 9:27am Activity Aide (AA) E reported Resident #11 had become more anxious and agitated in recent months. When further queried, AA E reported in the past Resident #11 was very proud of her independence and felt the resident was experiencing more distress now due to her loss of independence and the inability to move around as much. In an interview on 4/16/25 at 9:32am, CNA HH reported Resident #11 was screaming out, calling staff names and hitting at them more frequently than she had a few months ago. CNA HH described Resident #11 as irritated with the lap tray when it was on her chair. In an interview on 4/16/25 at 9:51am, CNA U reported Resident #11 frequently pounded on the lap tray of the geri-chair and stated, get me out of this thing. CNA U reported Resident #11 had regained the strength she lost during a recent hospitalization, could walk short distances again and had been found with one leg over the lap tray of the geri-chair as she tried to get out of it unassisted. CNA U reported the use of the geri-chair and lap tray had been detrimental to Resident #11's mood and described it as agitating to the resident. CNA U reported Resident #11 had difficulty expressing her thoughts but the resident commonly, clapped her hands and said yay! when CNA U removed the lap tray in preparation to transfer the resident out of the geri-chair. During an observation on 4/16/25 at 10:16am, Resident #11 sat in a geri-chair with a hard plastic lap tray affixed across her lap in the common area of the memory care unit. 2 staff members sat next to Resident #11. In an interview on 4/16/25 at 10:20am, Resident #11 was asked about the geri-chair and although she did not verbally respond, she grabbed the lap tray of the chair and rattled it side to side several times. During an observation on 4/16/25 at 10:46am, Director of Nursing (DON) B walked past Resident #11 as she sat in the common area of the memory care unit, in the geri-chair with the lap tray affixed across her lap, as she engaged in a supervised activity. DON B waved to Resident #11. In an interview on 4/16/25 at 10:51am, Registered Nurse/Hospice Care Coordinator (RNCC) GG reported Resident #11 was provided with the geri-chair in February 2025 after a hospitalization. RNCC GG reported Resident #11 needed the geri-chair for trunk support and to maintain proper positioning while eating but she did not recommend the use of the tray table. RNCC GG reported it was her expectation that the facility would communicate to her if Resident #11 regained her strength and could sit unsupported or if the resident began to express any distress related to using the geri-chair. RNCC GG reported it was important that the facility share this type of information because the resident would need to be reassessed to see if another type of wheelchair would better meet her needs. RNCC GG stated we want her to be more mobile and more independent if she can be because that will maintain her best quality of life. RNCC GG reported she was not aware the facility was using the lap-tray on Resident #11's geri-chair, that doing so would be considered a restraint and could be detrimental to the resident's overall psychosocial well-being. RNCC GG stated She (Resident #11) is already behavior prone, and we should not do anything that makes her more anxious. When further queried, RNCC GG reported that Resident #11 being found with her leg over the lap-tray indicated she felt anxious and trapped and increased her risk of falling. In an interview on 4/16/25 at 11:19am, RN Unit Manager (UM) X reported she did not know why a geri-chair and lap-tray had been implemented for Resident #11. UM X reported the lap tray should be removed anytime the resident voices that she wants it off, and that Resident #11 cannot remove the tray herself. UM X reported she had heard Resident #11 multiple times as she banged on the lap-tray and said repeatedly that she wanted to lay down. UM X reported the staff usually assisted Resident #11 to bed at that time. UM X reported she was not aware Resident #11 had been found with one of her legs over the lap-tray as she tried to climb out of the geri-chair, which put her at greater risk for injury, and that staff were expected to report this type of information to her. In an interview on 4/16/25 at 12:05pm, DON B reported the facility implemented the use of a geri-chair with a lap tray for Resident #11 in effort to reduce the number of falls the resident had. DON B reported Resident #11 had become very restless, at times wanted to lay down or get up every 15 minutes and the staff did not have time to assist her with doing that, so the geri-chair was implemented. DON B reported the intent for use of the geri-chair and lap-tray was to keep Resident #11 comfortable but out of her room and in one place. DON B reported the only other way to keep Resident #11 safe would have been to assign 1 staff member to her and that was not feasible. When asked about Resident #11's current ability to sit unsupported, DON B reported he believed her core isn't strong and he was unsure if the resident was able to stand up. DON B reported Resident #11's most recent Physical Restraint Reduction assessment was 1/29/25. When asked if staff members had reported Resident #11 having any behaviors related to the geri-chair and the lap tray, DON B did not respond. When further queried about any anxiety the resident had exhibited because of the use of the geri-chair and lap tray, DON B stated she was banging on the tray this morning, saying she wanted to go to bed when I tried to talk to her. DON B reported when Resident #11 banged on the lap tray and asked to go to bed during his interaction with her on this date, he responded by consoling her. In an interview on 4/16/25 at 2:26pm, AA Z reported she had seen Resident #11 trying to get out of the geri-chair at times and that the resident could not remove the lap-tray on her own. Review of a Physical Restraint Reduction Assessment for Resident #11 with a reference date of 1/29/25 revealed 2. Is the resident a candidate for restraint reduction? Yes. 2a. If yes, what actions are going to be taken (include less restrictive measure to be used and start date for when reduction is going to begin) .1/29/25 remove tray table q (every) 2 hours and prn (as the situation demands) and when in supervised activity. Review of a Nursing Progress Notes for Resident #11 revealed: 4/11/25 at 6:59pm, Banging hands on tray and yelling. 4/10/25 at 4:14am, resident .trying to get up out of her chair this shift .we found a chair just like hers because she (sic) getting out of this one . 4/9/25 at 5:35pm, clamp that hold tray onto geri-chair broke off . 3/30/25 at 2:15am, Resident have(sic) been yelling and beating on her table . 3/28/25 at 2:00pm, Res started yelling and banging the board on her chair, hard to be redirected. 3/25/25 at 9:00pm, Resident was very agitated beating on table and yelling out. 3/25/25 at 9:40am, Yelling out nonsensical statements, hitting lap tray with her hand, unable to redirect. 3/25/24 at 1:48am, she have (sic) been hitting on the table and getting out of her recliner chair yelling out to get up we have taken her to the bathroom and laid her down when she asked and she would get up from bed in 5-10min after we put her in because she asked to go to bed, she is up in recliner chair at this time because we caught her getting out of bed . 3/16/25 at 3:35am resident .was yelling to get up and hitting the table she got out of her chair . Review of a Behavior Monitoring Log with a reference date of 1/1-1/31/25 revealed Resident #11 demonstrated behavioral symptoms (frequent crying, repeated movements, yelling, wandering, grabbing, hitting) 38 times during the 31-day period. Review of Physician Orders for Resident #11 with a reference date of 1/29/25 revealed Geri chair with lap tray to enable her to be up with reduction in falls. Review of a Behavior Log for Resident #11 with a reference date range of 3/18/25-4/15/25 revealed the resident displayed behavioral symptoms (frequent crying, repeated movements, yelling, wandering, grabbing, hitting) 97 times during the 30-day period. Review of a facility Restraint Management policy with a reference date of 3/7/23 revealed Policy: Restraints are not used unless the resident has medical symptoms that warrant the use of the restraint. Overview: Physical restraints are not used for the purpose of .convenience .physical restraints include .lap trays the resident cannot easily remove .placing a resident in a chair .that prevents a resident from rising .Guidelines .8. Residents using physical restraints will have a Physical Restraint Reduction Evaluation completed .with any significant change of condition for the use and appropriateness of physical restraints. Attempts to contact Resident #11's legal guardian were unsuccessful at the time of the completion of the survey. Using the reasonable person concept, though Resident #11 could not recall and verbalize the degree of emotional distress she experienced because of being physically restrained, she clearly demonstrated a desire to be free from the chair and lap tray that limited her movement, and experienced increased anxiety from the confinement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #MI00147013 Based on observations, interview, and record review the facility failed to provide prompt medical care after a fall for 1 (Resident #100) of 4 residents reviewed for falls resulting in Resident #100 experiencing significant pain, suffering, and a delay in emergent care after a fall with fracture. Findings include: Resident #100 Review of an admission Record revealed Resident #100, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: age-related osteoporosis (disease that causes the bones to become weak and more likely to break), alzheimer's disease (disease that causes loss of cognitive abilities), fracture of pelvis, and falls. Review of a Minimum Data Set (MDS) assessment for Resident #100, with a reference date of 7/17/24 revealed a Brief Interview for Mental Status (BIMS) score of 99 which indicated Resident #100 was unable to complete the assessment. Section E of the MDS revealed Resident #100 did not reject care during the assessment period. Section GG revealed Resident #100 ambulated up to 50' with supervision and no device. Review of a Care Plan for Resident #100, with a reference date of 7/10/23, revealed a focus/goal/interventions of: Focus: (Resident #100) is at risk for fall related injury and falls R/T (related to) hx (history) of multiple falls .Goal: Will be free from injury related falls .Interventions: Encourage resident to be out in common area when seen ambulating .redirect resident with activity when beginning to wander . Review of an Incident Report for Resident #100 with a reference date of 9/16/24 revealed at 8:00pm, the resident had a witnessed fall during which she landed on her bottom. A section titled Injuries Observed at Time of Incident revealed no injuries observed at time of incident. Review of a Change of Condition Evaluation for Resident #100, written by LPN E on 9/17/24 at 12:48am, a section titled Signs and Symptoms Identified revealed: fall, pain, trauma .right leg is turned outward and shorter than left leg significantly . Review of a Pain Scale report for Resident #100 revealed the resident's pain level was assessed as an 8 out of 10 by LPN E on 9/17/24 at 1:08am. Review of Resident #100's medical record revealed no Change of Condition Evaluation, or post fall assessment completed by RN D for the resident's fall on 9/16/24. Review of Resident #100's physician's orders revealed an order for a two view right hip x-ray was entered by LPN E at 12:28am. Review of a Radiology Report for Resident #100 with a reference date and time of 9/17/24 at 1:03am revealed: Findings: there is an acute communicated right femoral intertrochanteric fracture (hip fracture) . In an interview, Emergency Medical Technician (EMT) G reported he cared for Resident #100 as she was transported to the local acute care hospital on 9/17/24 at approximately 1:15am. EMT G reported Resident #100 yelled out in pain with any movement and had an obvious shortening and rotation of her right leg. Review of a History and Physical report for Resident #100 with a reference date of 9/17/24, from a local emergency room, revealed Extremities: Exam of right lower extremity reveals diffuse tenderness (widespread pain) with any hip movement, shortening and external rotation of the leg . Review of a Physician Discharge Summary for Resident #100, from a local acute care hospital, with a reference date of 9/20/24, revealed a summary of hospital stay: .femur fracture with intramedullary nailing (surgical repair) on 9/17/24 . During an observation on 10/2/24 at 3:49pm, Resident #100 sat in the community room in a wheelchair, wore a hospital gown, grimaced and furrowed her brow, as she rubbed her right upper thigh. In an interview on 10/3/24, at 9:18am, Registered Nurse (RN) D reported she was the nurse who responded when Resident #100 fell on 9/16/24 at 8:00pm. RN D reported Resident #100 was lying on her right side in the hallway near her room. When queried about assessing Resident #100 for injuries while she was on the floor, RN D stated At that time I didn't do an assessment. I wanted to get her off the floor. RN D reported she and 2 Certified Nursing Assistants (CNAs) lifted Resident #100 into a wheelchair and then transferred her to bed. RN D reported she assessed Resident #100 as she laid in bed and at that time, noticed Resident #100's right foot had an outward rotation which was an indication of a potential fracture. When further queried, RN D reported she did not pursue getting an order to transport Resident #100 to the hospital because she thought it was protocol to get an x-ray first. RN D reported she could not recall if she informed the provider of Resident #100's outward leg rotation. In an interview on 10/3/24 at 12:37pm, Certified Nursing Assistant (CNA) M she responded when Resident #100 fell on 9/16/24. CNA M described Resident #100 as hysterical, yelling Ow repeatedly as she laid on the floor. CNA M reported she, RN D, and another CNA assisted Resident #100 to standing but the resident could not bear weight on her right leg and was ultimately transferred to a wheelchair. CNA M reported Resident #100 grimaced and pointed to her right leg as she sat in the wheelchair. In an interview on 10/3/24 at 2:57pm, Certified Nursing Assistant (CNA) K reported Resident #100 complained of hip pain immediately after her fall on 9/16/24. CNA K reported prior to the fall, Resident #100 could walk without assistance but after the fall, the resident could not bear weight on her right leg. CNA K reported Resident #100 struggled to verbally express herself due to her dementia, but in the hours after her fall, she appeared painful, refused to allow anyone to touch her, guarded her leg, and repeatedly said I fell, I fell. In an interview on 10/3/24, at 8:50am, Licensed Practical Nurse (LPN) E reported on 9/16/24 a few hours after the fall, RN D asked LPN E to come take a look at Resident #100 and at that time, RN D also asked if she should call a provider to inquire about getting an x-ray for the resident. LPN E reported when she assessed Resident #100, the resident was complaining of pain in her right leg, had a shortening and rotation of her right leg, and could not tolerate passive range of motion to the extremity. LPN E reported a resident who fell should never be moved prior to the completion of a thorough assessment for injury and that a failure to properly assess the resident could result in lack of identification of injuries and the development of complications. LPN E reported Resident #100 should have gone to the hospital immediately after her fall. In an interview on 10/3/24 at 11:15am (RN) C reported a full assessment should be completed immediately after a resident fall, prior to moving the resident. If the resident was painful or has a gross anomaly such as foot rotation or shortening of a leg, the physician should be contacted immediately, and the resident should be sent to the emergency room for further evaluation. In an interview on 10/3/24 at 2:19pm, Director of Nursing (DON) B reported a post fall assessment should be completed by the nurse prior to moving a resident who had fallen. The post fall assessment should include taking vital signs, assessing for pain, performing range of motion, checking pedal pulses, visual inspection for physical injuries. Upon completion of the assessment, the nurse should then report the findings to the primary care provider and take the action of the provider as directed. In an interview on 10/3/24 at 8:34am, Family Member (FM)/Durable Power of Attorney (DPOA) I for Resident #100 reported he received notification of the resident's fall on 9/16/24 at approximately midnight. When queried about his wishes for Resident #100 regarding hospitalization, FM I reported he wanted Resident #100 to be transported to the emergency room for evaluation if she fell and appeared to have an injury. FM I reported he believed it would have been in Resident #100's best interest to go to the hospital at the time of the fall. FM I reported Resident #100 had intense pain prior to the surgical repair of the hip fracture that she suffered during the fall on 9/16/24. In an interview on 9/17/24 at 2:35pm, Medical Director (MD) F reported a resident who had a rotation or shortening of a leg after a fall should be transported to the emergency room immediately because those were signs of a serious injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #MI00137836 Based on observation, interview, and record review the facility failed to prevent the development of and worsening of pressure ulcers in 2 resident (Resident #9 and Resident #13) of 2 residents reviewed for pressure ulcers resulting in the development of (3) facility acquired pressure ulcers and the worsening of existing pressure ulcer. Findings include: Resident #9 Review of an admission Record revealed Resident #9 had pertinent diagnoses which included: type 2 diabetes, and peripheral vascular disease (the narrowing of blood vessels away from the heart in arms and legs), and cerebellar stoke syndrome (when circulation to the cerebellum (part of the brain) is impaired (blocked)). Review of a Minimum Data Set (MDS) assessment for Resident #9, with a reference date of 1/4/24 revealed a Brief Interview for Mental Status (BIMS) score of 8/15 which indicated Resident #9 was moderately cognitively impaired. Review of Progress Notes for Resident #9 dated 8/22/23 at 12:05 PM., revealed .a previous wound that is now reopened. The wound is on the right lateral ankle measuring 1cm x 1.4 cm x 0.3, draining a small amount of pus mixed with serosanguinous drainage (thin watery drainage with a light red or pink hue) . Review of Progress Notes for Resident #9 dated 8/22/23 at 14:46 PM., revealed . new order for Keflex 500mg 3 x daily x 10 days and to clean and dress wound with CaAg (Calcium Alginate) and border gauze daily. Review of Progress Notes for Resident #9 dated 8/22/23 at 15:34 PM., revealed .new chronic recurring right outer ankle pressure wound . does not get out of bed . body habitus causes her outer feet and ankle to always be touching the bed. History of refusal of care . Review of Progress Notes for Resident #9 dated 8/25/23 at 12:54 PM., revealed .continues with ABT (antibiotics) for infection to the outer right ankle wound. Dressing to area changed as ordered . Review of Progress notes for Resident #9 dated 9/26/23 at 15:52 PM., revealed . Resident seen by wound care (Name Omitted) to re-evaluate wound on right lateral ankle. Evidence shown wound is healed. Review of Care Plan for Resident #9 revealed .at risk for skin breakdown/pressure injury r/t (related to) decreased mobility . does not always allow for her feet to be floated in bed .created on 10/11/2017 . revision on 8/23/24 . Review of wound provider Progress Note Details for Resident #9 dated 1/2/24 revealed .Right Lateral Ankle, onset 8/29/23, context Pressure, supportive surface, sponge boots, offloading pillows . Wound #8 Lateral Ankle is a stage 4 Pressure Injury Pressure Ulcer . Initial wound encounter measurements 2.5 cm length x 2 cm width x 0.3 cm depth . Float heals while n bed- specifically float the ankle. The pillow should not be touching the ankle but be above the calf .measurements post skin/subcutaneous tissue level surgical debridement with a total area of debrided of 1 sq cm muscle and subcutaneous were removed along with devitalized tissue: necrotic/eschar. Debridement Measurements: 2.5 cm length x 2 cm width x 0.3 depth . Review of Progress Notes for Resident #9 dated 1/3/24 at 20:04 PM., revealed .no new skin issues reported or noted at this time . Review of Progress Notes for Resident #9 dated 1/9/24 at 9:34 AM., revealed .on 1/3 staff found stage 4 wound on residents right ankle due to resident external hip rotation of right leg causing resident ankle to lie flat on the bed. Residents wound exposing hardware in ankle .right ankle x-ray, apply skin prep to bilateral heels Q (every) shift, elevate while in bed with pillow to offload heels, every shift for preventative, cleanse right lateral ankle with wound cleanser, pat dry, apply hydrofera blue (cutting to the size of the wound only) cover with foam border gauze. Change Tues, Thu, Sat and as needed if soiled . Review of Progress Notes for Resident #9 dated 1/16/24 at 21:31PM., revealed .Resident sent to (Name omitted) acute care hospital at 1635 per (Name Omitted), wound doctor, d/t (due to) infection/exposed hardware to right ankle . Review of Progress Notes for Resident #9 dated 1/27/24 at 6:44 AM., revealed .continue wound tx (treatment) to right lateral ankle as ordered . Review of wound provider Progress Note Details for Resident #9 dated 1/30/24 revealed .Right Lateral Ankle, onset 8/29/23, context Pressure, saw orthopedic surgeon last week, surgery to remove hardware, possible wound vac on 1/31 . Wound #8 Lateral Ankle is a stage 4 Pressure Injury Pressure Ulcer . The wound is deteriorating .Float heals while n bed- specifically float the ankle. The pillow should not be touching the ankle but be above the calf .measurements 3 X 2.5 X 0.6 .refer to ortho for surgical intervention. Review of Progress Notes for Resident #9 dated 1/31/24 at 22:57 PM., revealed . post -op assessment . dsg. (dressing) on right foot in place, wound vacuum is functioning properly with draining fresh red discharge .Order of doxycycline (antibiotic) po (by mouth) continue for 60 days . Review of Case Information for Resident #9 from (Name Omitted) acute care hospital with surgery note dated for 1/31/24 at 9:54 AM., revealed .removal hardware lower body right ankle lateral aspect .preoperative diagnosis right 3 x 3 cm lateral ankle wound . postoperative diagnosis right 3 x 3 lateral ankle wound . name of operation . application of right lateral ankle wound VAC . Review of Progress Notes for Resident #9 dated 1/31/24 at 22:57 PM., revealed . post -op assessment . dsg. (dressing) on right foot in place, wound vacuum is functioning properly with draining fresh red discharge .Order of doxycycline (antibiotic) po (by mouth) continue for 60 days . Review of Orders for Medications as directed and reviewed for Resident #9 dated 2/27/24 as ordered from (Name Omitted) wound clinic revealed .return to wound clinic in one week . Wear sage boots . Review of Progress Notes for Resident #9 dated for 3/12/24 revealed .wound care provided to R ankle sight .some undermining noted . current dressing change orders as prescribed by wound care clinic . In an interview on 3/25/24 at 3:10 PM., Registered Nurse/Unit Manager/Wound Nurse (RN/UM/WN) M reported that Resident #9 was seen weekly at the wound clinic and her dressing was to be changed daily. During an observation on 3/26/24 at 9:20 AM., Resident #9's wound to the lateral right ankle was visualized. Right lower extremity had extreme dentition due to the pressure of the moon boot and edema in the right lower extremity. A foul odor was noted through a surgical mask and the dressing was noted to be saturated with drainage and no date. The foam of the dressing was black in color and the wound was noted to have red in color and dried drainage surrounding the wound. RN/UM/WN M was observed vigorously scrubbing Resident #9's skin surrounding the wound on the right lateral ankle to remove the dried drainage. In an interview on 3/26/24 at 9:40 AM., RN/UM/WN M reported that Resident #9's dressing to her right ankle should have been changed last night and it was not. RN/UM/WN M reported that the dressing had no date, it was saturated and should have been changed. Review of Progress notes for Resident #9 dated for 3/26/24 revealed .wound care provided to R lateral ankle site. Moderate serosanguinous drainage noted to dressing, some odor noted .Continue current dressing orders per wound care clinic, next appointment scheduled for 4/3/24 . In an interview on 3/26/24 at 9:55 AM., Director of Nursing (DON) B reported that Resident #9's wound began as pressure but was reclassified as surgical after surgical intervention. DON B reported that Resident #9 was to be seen by the wound clinic weekly, and had appointments scheduled on 2/19, 2/23, 2/27 and 3/5. Resident #9 was last seen by the wound clinic on 2/27/24. DON B reported that Resident #9 missed appointments at wound clinic due to lack of transportation. Review of Progress note dated 3/26/24 at 10:48 AM., revealed . wound care clinic next appointment scheduled for 4/3/24 . Review of Care plan for Resident #9 revealed Focus - at risk for skin breakdown/pressure injury r/t (related to) decreased mobility . Float heels, R foot pillow boot, as she will allow . initiated 10/2018, revised on 7/2022 .Heel protector boot to right foot . Created and Initiated on 3/25/24 .has actual skin impairment to skin integrity r/t decreased mobility; R lateral ankle wound initiated on 1/16/24 .Goal - Will have no complications r/t wounds on the R Lateral malleolus initiated on 1/16/24 . interventions -Follow facility protocols for treatment of injury initiated on 1/16/24, Observe for s/s (signs and symptoms) of infection . observe location, size and treatment of skin injury . Treatment to skin impairment per orders initiated on 1/16/24 . Review of Care Plan for Resident #9 revealed no noted care plan interventions in place related to post-surgical intervention of the right lateral ankle wound and/or the use of a wound vac, and/or the additional wound care clinic specialist (name omitted) and/or antibiotic use. In an interview on 3/26/24 at 10:55 AM., MDS coordinator (MDSC) R reported that she was the person that updates care plans if they need to be updated. MDSC R reported that care plans should be updated quarterly, with significant changes, and if there is an identified need for the care plan to be updated. MDSC R reported that any wound would require an individual care plan with person centered interventions. MMSC R reported that the director of nursing and wound nurse can also update care plans. In an interview on 3/26/24 at 11:12 AM., DON B reported that care plans can be updated by all nursing staff and IDT team. Resident #13 Review of an admission Record revealed Resident #13 had pertinent diagnoses which included: dementia with other behavioral disturbance, alzheimer's disease with late onset, muscle wasting, and protein calorie malnutrition. Review of a Minimum Data Set (MDS) assessment for Resident #13, with a reference date of 1/8/24 revealed a Brief Interview for Mental Status (BIMS) score of 3/15 which indicated Resident #13 was severely cognitively impaired. Review of Braden Scale for Resident #13 dated for 1/13/24 revealed high risk 12.0 . no subsequent Braden Scale assessments noted in Resident #13's record. Review of Skin and Wound Evaluation for Resident #13 dated for 2/22/24 revealed .pressure wound, unstageable: obscured full-thickness skin and tissue loss . to right elbow .in-house acquired .New . Review of Nurses Notes for Resident #13 dated for 2/22/24 12:22 PM., revealed New pressure ulcer noted to R elbow .Dressing change orders placed as well as orders for elbow protector to be in place at all times as she allows . Review of Progress Note for Resident #13 dated for 2/25/24 5:59 AM., revealed .resident has a stage II pressure ulcer to back of left knee measuring 2 x 2 x 0.1 . Review of Skin and Wound Evaluation for Resident #13 dated for 2/27/24 revealed .pressure wound, unstageable: obscured full-thickness skin and tissue loss . to right elbow .in-house acquired .manual measurements included 1.2 X 0.8 X 0.1 . Review of Resident at Risk for Resident #13 dated for 2/27/24 revealed new wound found to R elbow . Review of wound provider Progress Note Details for Resident #13 dated for 2/27/24 revealed .wound location right elbow, left medial knee .date of onset February 2024, context pressure .wound #14 right elbow is an unstageable pressure injury observed full-thickness skin and tissue loss pressure ulcer .initial wound encounter measurements are 1.2 cm length X 0.8 cm width X 0.1 cm depth . Wound #15 Left, Medial Knee is an unstageable pressure injury obscured full-thickness skin and tissue loss pressure ulcer .initial wound encounter measurements are 2.1 cm length x 2.2 cm width x 0.1 cm depth . Facility pressure ulcer prevention protocol .place pillow between knees while in bed to offload lower limbs off load heels per facility protocol . Review of Physician Order for Resident #13 dated for 2/28/24 revealed Ensure that a pillow is always place between knees when in bed . Elbow protector to R (right) elbow as resident allows . Review of Skin and Wound Evaluation for Resident #13 dated for 2/27/24 revealed .pressure wound, unstageable: obscured full-thickness skin and tissue loss . to left popliteal Fossa, Medial .in-house acquired .new .manual measurements included 2.1 X 2.2 X 0.1 .reinforced turning and repositioning every 2 hours with pillow between knees . Review of wound provider Progress Note Details for Resident #13 dated for 3/11/24 revealed .wound location right elbow, left medial knee .date of onset February 2024, context pressure .wound #14 right elbow is an unstageable pressure injury observed full-thickness skin and tissue loss pressure ulcer .wound encounter measurements are 1 cm length X 0.7 cm width X 0.2 cm depth . Wound #15 Left, Medial Knee is an unstageable pressure injury obscured full-thickness skin and tissue loss pressure ulcer .wound encounter measurements are 2.2 cm length x 2.3 cm width x 0.5 cm depth . Facility pressure ulcer prevention protocol .place pillow between knees while in bed to offload lower limbs off load heels per facility protocol . Review of wound provider Progress Note Details for Resident #13 dated for 3/21/24 revealed .wound location right elbow, left medial knee, right lateral knee .date of onset February 2024 and March 2024, context pressure .wound #14 right elbow is an unstageable pressure injury observed full-thickness skin and tissue loss pressure ulcer . wound encounter measurements are 0.9 cm length X 0.9 cm width X 0.2 cm depth . Wound #15 Left, Medial Knee is an unstageable pressure injury obscured full-thickness skin and tissue loss pressure ulcer . wound encounter measurements are 2 cm length x 2.7 cm width x 0.4 cm depth . Wound #16 Right Lateral Knee is an unstageable pressure injury obscured full-thickness and tissue loss pressure ulcer . initial wound encounter measurements 1.8 cm length X 1.5 cm width X 0.1 cm depth . Facility pressure ulcer prevention protocol .place pillow between knees while in bed to offload lower limbs off load heels per facility protocol . Review of Total Body Skin Assessment for Resident #13 dated 3/25/24 at 1:20 AM., revealed .continues with stage 3 to left posterior knee and stage 2 to right lateral knee and right elbow with treatments in place . During an observation on 3/24/24 at 1:16 PM., Resident #13 was sitting in her wheelchair, in her room, next to her bed. Resident #13's arms are both inside the arms of the wheelchair pressed against the wheelchair arms. Resident #13 did not have heel protectors in place on both feet. During an observation on 3/25/24 at 8:09AM., Resident #13 was sitting in her wheelchair, in her room, next to her bed. Resident #13's right arm is inside her wheelchair arm rest and resting against the chair. Resident #13 did not have heel protectors in place on both feet. During an observation on 3/25/24 at 9:59AM., Resident #13 was sitting in her wheelchair, in the dining room with activities personnel. Resident #13 was noted to have a wedge-shaped pillow in the right side of her wheelchair between her body and the side of the wheelchair. Resident #13 did not have heel protectors in place on both feet. In an interview on 3/25/24 at 3:07 PM., Registered Nurse/Unit Manager/Wound Nurse (RN/UM/WN) M reported that Resident #13 was seen weekly by wound specialist at the facility. During an observation on 3/26/24 at 8:14 AM., Resident #13 was sitting in her wheelchair, in her room, next to her bed. Resident #13 has a wedge-shaped pillow or her right side along with an elbow protector in place on her right elbow. Resident #13's right elbow was wedged next to the arm rest of the wheelchair. During an observation on 3/26/24 at 9:36 AM., Resident #13 was observed sitting in her wheelchair in the dining room with a black in color padded board noted in the left side of her wheelchair. During an interview on 3/26/24 at 3:23 PM., RN/UM/WN M reported that Resident #13 used the black padded board for positioning in her wheelchair. Review of [NAME] for Resident #13 on 3/27/24 revealed .Resident Care . reposition approx. q2 (every 2) hours .bathing resident was dependent .bed mobility . resident was dependent, provide extensive assistance to reposition frequently and as needed .skin, bilateral heel protectors, cure to reposition self as needed. Follow facility policies/protocols for prevention/treatment of impaired skin integrity. observe skin with showers/care .turn/reposition resident as needed and PRN . During an observation on 3/26/24 at 4:05 of Resident #13's wound dressing change it was noted the left knee was visualized to have tendon exposed. In an interview on 3/26/24 at 4:05 Registered Nurse/Unit manager/Wound Nurse (RN/UM/WN) M reported that Resident #13 wound was on the inner aspect of her left knee from her legs being pressed together. During an observation on 3/26/24 at 4:10 PM., Wound Care Medical Doctor (WCMD) RRR verbalized during wound care that Resident #13's tendon was exposed in the wound present on the left lateral knee and scraping for debridement was not recommended. WCMD RRR pointed to an area inside of Resident #13's wound on the lateral left knee as stated, that is the tendon. During an interview on 3/26/24 at 4:45 PM., RN/UM/WN M reported that Resident #13's wounds are pressure related. RN/UM/WN M reported that Resident #13's bony knees pressing against each other is the how the wound on her lateral left knee occurred. RN/UM/WN M stated I know where the breakdown was, the wounds were not being done. I'm just grateful her wounds didn't deteriorate further. Review of wound provider Progress Note Details for Resident #13 dated for 3/27/24 revealed .wound location right elbow, left medial knee, right lateral knee .date of onset February 2024 and March 2024, context pressure .wound #14 right elbow is an unstageable pressure injury observed full-thickness skin and tissue loss pressure ulcer . wound encounter measurements are 1.6 cm length X 1.2 cm width X 0.1 cm depth . Wound is deteriorating . Wound #15 Left, Medial Knee is an unstageable pressure injury obscured full-thickness skin and tissue loss pressure ulcer . wound encounter measurements are 2.5 cm length x 2.7 cm width x 0.8 cm depth .Wound is deteriorating .Wound #16 Right Lateral Knee is an unstageable pressure injury obscured full-thickness and tissue loss pressure ulcer .wound encounter measurements 2.7 cm length X 2.5 cm width X 0.1 cm depth .Wound #17 Left, Lateral knee is partial thickness skin tear .initial wound encounter measurements are 1.9 cm length X 2.3 cm width X 0.1 cm depth . Facility pressure ulcer prevention protocol .place pillow between knees while in bed to offload lower limbs off load heels per facility protocol . In an interview on 3/27/24 at 1:40 PM., Occupational Therapist (OT) SSS reported that Resident #13 was not receiving therapy services but was evaluated at family request. OT SSS reported that when Resident #13 was seen in October of 2023 for wheelchair positioning and to preserve skin integrity. OT SSS reported that Resident #13 had contractures when she admitted to the facility. OT SSS reported that the most recent evaluation of Resident #13 resulted in a high back wheelchair, cushion to the wheelchair seat, lateral support to be used on either left or right side, and a wedge cushion for trunk support while in her wheelchair. Review of Care plan for Resident #13 revealed no noted interventions related to lateral support or a wedge cushion use, nor an actual present wound. In an interview on 4/2/24 at 1:20 PM., Family Member (FM) MMM reported that the staff does not know how to position Resident #13 in her wheelchair. FM MMM reported that every staff member does it differently, FM MMM reported that the staff needs to be educated on the wheelchair positioning needs of Resident #13. During an observation on 1:20 PM., Resident #13 was sitting in her wheelchair in her room with a black padded board on the left side of her body in the wheelchair, a wedge-shaped cushion on the right side of her body, elbow protector noted on right elbow, right elbow wedged between the wedge-shaped cushion and the wheelchair arm rest, a board noted on the foot rests under Resident #13's heels and no heel protectors noted on both feet and both arm rests of the wheelchair are wrapped with ace bandages. During an interview on 4/2/24 at 2:34 PM., Director of Nursing (DON) B reported that care plans were just continued during the review and not updated to reflect the resident specifics. DON B stated I know there is an issue with care plans. In an interview on 4/2/24 at 3:02 PM., RN/UM/WN M reported that anyone with a wound should have a care plan in place. RN/UM/WN M reported that she did not know that there were different care plans for the risk of pressure ulcers and actual pressure ulcers. In an interview on 4/3/24 at 8:41 AM., when asked what does follow facility policies/protocols for the prevention/treatment of impaired skin integrity means, RN/UM/WN M and DON B reported whatever the policy says to do, such as redness apply z-guar (barrier cream) let the DON know, do an incident report, put information into the doctor's book. DON B reported that the policies can be accessed on every desktop. DON B reported that facility policy does not include resident specific interventions. Review of Care Plan for Resident #13 revealed problem . actual impaired skin integrity .interventions: repositioned every hour when in w/c .initiated 3/29/24 .to be turned every 2 hours when in bed .initiated on 3/29/24 . wear elbow protector tor right elbow at all times, document any refusals .initiated 3/28/24 .bed mobility, resident is dependent with one helper, this is including rolling side to side, lying to sitting on side of bed, and sitting to lying, initiated on 1/18/2024 . has an actual impaired skin integrity related to pressure injury. Site: R elbow, L posterior knee, right lateral knee, stage: unstageable . dated initiated 3/15/2024 .interventions conduct skin assessments weekly and measure area (s) and document characteristics .observe for signs of infection .requires occupational therapy r/t decline in W/C positioning .will present with good upright and midline posture with use of W/C positioning equipment with reported of no skin breakdown .selection of positioning equipment and staff education and training .initiated on 3/29/24 . Review of Timeline provided by DON B regarding Resident #13's wound care revealed .prevention of pressure ulcer interventions in place prior to 1/13/24 included heel protectors 4/26/23, pressure reduction cushion to w/c 5/2/23, pressure reduction mattress 3/22/23. Prevention from 1/13/24 to 2/25/24 included, TX (treatment) to right elbow pressure ulcer with wound care referral 2/22/24. Prevention from 2/25/24 to 3/15/24-elbow protectors ordered, 2/28/24, heel protectors ordered 2/28/24, pillow between knees ordered 2/28/24, care plan updated to address wound prevention 3/15/24 . Review of facility policy Skin Management dated 12/15/2022 revealed .the facility should identify and implement interventions to prevent development of clinically unavoidable pressure injuries .resident with wound and/or pressure injury and those at risk for skin compromise are identified, evaluated and provided appropriate treatment to promote prevention and healing .appropriate preventative measures will be implemented on guests/resident identified at risk an the interventions are documented on the car plan .if the guest/resident is at risk for or has a pressure injury the comprehensive care plan may address . preventative devices, preventative skin care, positioning requirements .the licensed nurse will document preventative measures on the care plan/[NAME] .the DON (Director of Nursing)/designee will document any changes in the care plan/[NAME] at the meeting . Review of Fundamentals of Nursing ([NAME] and [NAME]) 8th edition revealed, .Positioning interventions reduce pressure and shearing force to the skin. Elevating the head of the bed to 30 degrees or less decreases the chance of pressure ulcer development from shearing forces .patient's need repositioning on a schedule of at least every 2 hours .Some patients are able to sit in a chair. Make sure to limit the total amount of time they sit to 2 hours or less. [NAME], P. A., [NAME], A. G., Stockert, P. A., & Hall, A. (2014). Fundamentals of Nursing (8th ed). St. Louis: Mosby. p. 1196-1197.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents received care in accordance with treatment orders and professional standards for non-pressure wounds in 2 of 3 residents (Resident #100 and #13) reviewed for quality of care, resulting in the worsening of existing wound for Resident #100 and a delay in treatment of a new wound for Resident #13. Findings Include: Review of a Minimum Data Set (MDS) assessment for Resident #100, with a reference date of 1/12/23 revealed resident originally admitted to the facility on [DATE], and a Brief Interview for Mental Status (BIMS) score of 13, out of a total possible score of 15, which indicated Resident #100 was cognitively intact. Review of the Functional Status revealed that Resident #100 required extensive assistance of 2 staff for toileting and was frequently incontinent of bowel and bladder. Review of Resident #100's Care Plan revealed, .actual impaired skin, integrity and abrasion on left elbow, open area to left hip and buttock related to periods of incontinence .Date Initiated 3/23/22. Revision on 3/19/23 .Interventions: .Treatment as ordered to each area. Date Initiated 3/17/23 . In an interview on 3/28/23 at 10:24 A.M., Licensed Practical Nurse (LPN) D reported that Resident #100 had several wounds; left hip that was being treated with Medi-Honey (topical for wound healing) and a wound covering, left buttock that was being treated with Exuderm (protective wound covering), an area on his left 2nd toe, and an area on his left elbow. LPN D reported that the wound dressings were due to be changed and would be completed later that day by the wound doctor. In an interview on 3/28/23 at 10:31 A.M., Resident #100 reported that he had sores on his bottom and that they burn. Resident #100 was in his room sitting in his wheelchair. In an interview on 3/28/23 at 10:38 A.M., Wound Nurse (WN) C reported that the wound doctor was not able to come in that day, and that WN C would be completing the wound evaluations and dressing changes. WN C reported that Resident #100 had several wounds that were being managed; an Unstageable Pressure Ulcer on his left hip, MASD (moisture associated skin damage) on his left buttock, an infected wound on his left 2nd toe, and a skin tear on his left elbow. In an interview on 3/28/23 at 11:42 A.M., Resident #100 reported that the wounds on his bottom are very aggravating. Resident #100 was in his room sitting in his wheelchair as previously observed. This surveyor informed Resident #100 that staff would be in soon to look at his wounds, and Resident #100 stated, Good .its burning . During an observation and interview on 3/28/23 at 11:52 A.M. Resident #100 was transferred into bed and observed lying in bed on his right side. Resident #100's buttocks were observed with a bandage on the left hip dated 3/25/23 and an open wound on the left middle buttock that did not have a bandage on it. WN C reported that the wound on Resident #100's left middle buttock was supposed to be covered with Exuderm and that WN C was not aware that the dressing was missing. The wound was measured by WN C and revealed, 3.8 cm x 1.2 cm. WN C reported that the wound had gotten bigger and that WN C wound need to get a larger dressing for it. WN C applied a large Exuderm dressing that covered the wound and the surrounding area. WN C reported that the wound was new last week and it was a lot smaller at that time. WN C reported that it was very important to keep moisture away from the wound, and that he would look at the treatment records to make sure that the wound dressings have been completed every 3 days as ordered. In an interview on 3/28/23 at 12:37 P.M., Certified Nursing Assistant (CNA) K reported that she was not aware that Resident #100's wound dressing was missing. CNA K reported that Resident #100 was continent, stayed dry, often tried to toilet himself and did not like to wear an incontinence brief. In an interview on 3/28/23 at 12:39 P.M., LPN D reported that he had not been informed that Resident #100's wound dressing was missing and stated, .if I had, then I would have put one on him . Review of Resident #100's Treatment Administration Record (TAR) revealed the current treatments for buttocks were as follows: 1. Inzo (barrier cream) to buttocks q (every) shift and PRN (as needed) with incontinent episodes. every shift for Redness Start Date 10/11/2022 at 10:00 P.M. 2. Open area to left buttock to be cleansed with NS, pat dry, apply hydrocolloid (for wound healing) dressing 3x week and PRN for soiled, removed, or saturated dressing. every day shift every Tue, Thu, Sat for treatment Start Date 03/23/2023 at 6:00 A.M. Review of Resident #100's Wound Note dated 3/21/23 revealed, .MASD .Left buttock .in-house acquired .new .Length 1.0 cm Width 0.5 cm .healable .Staff educated on importance of incontinence care and turning/repositioning every 2 hours as well as notifying nurse if dressing becomes removed, soiled or saturated. Review of Resident #100's Wound Note dated 3/28/23 revealed, .MASD .Left buttock .in-house acquired .1 week .Length 3.8 cm Width 1.2 cm .healable .Staff educated on importance of incontinence care and offering toileting to resident approximately every 2 hours. Also notifying nurse if dressing becomes removed, soiled or saturated. Resident #100's wound had worsened. Review of Resident #100's Total Body Skin Assessment dated 3/28/23 at 6:13 A.M. (completed by the third shift licensed nurse (LPN H) indicated, no new skin conditions and no additional comments related to existing wounds or wound dressings. An attempt was made to contact LPN H via phone on 3/28/23 at 3:47 P.M.; no return call received. Resident #13 Review of a Minimum Data Set (MDS) assessment for Resident #13 with a reference date of 1/4/23 revealed an original admission date of 7/1/22, and a Brief Interview for Mental Status (BIMS) score of 10, out of a total possible score of 15, which indicated Resident #13 was cognitively impaired. Review of the Functional Status revealed that Resident #13 required extensive assistance of 2 staff for bed mobility and toilet use, and was always incontinent of bowel and bladder. Review of Resident #13's Care Plan revealed, .At risk for skin breakdown and urinary tract infection related to bladder incontinence. Date initiated 7/13/22. Interventions: .Provide incontinence care with each incontinent episode. Apply moisture barrier as indicated. Date Initiated 7/13/22 . In an interview on 3/28/23 at 10:15 A.M., Resident #13 was lying in her bed with the HOB (head of bed) at approximately 45 degrees. Resident #13 reported that her buttocks were always sore, and that the CNA's get some kind of salve from the nurse's station and smear it all over her bottom and stated, .it stops the burning .works pretty good if I sit still . In an interview on 3/28/23 at 10:24 A.M., LPN D reported that Resident #13 has a treatment in place for a fungal infection on her breasts and groin and stated, .I haven't heard anything about her having a breakdown on her bottom .she is not getting any treatments on her bottom . During an observation on 3/28/23 at 12:34 P.M. Resident #13 was sitting in her wheelchair in her room. During an observation and interview on 3/28/23 at 2:23 Resident #13 was sitting in her wheelchair in her room. Resident #13 reported that her butt hurts and she hoped to lay down soon. Resident #13 reported that if the CNA didn't put the salve on her bottom, she would not be able to sleep because the burning is so bad. During an observation on 3/28/23 at 2:26 P.M. Resident #13 was transferred to bed by CNA G and CNA L, CNA L then left the room and CNA G prepared to provide incontinence care to Resident #13. Resident #13's buttocks were observed red with deep creases from her brief and/or clothing, and there was a large patch of skin on Resident #13's left upper thigh that was bright red, with several open areas and was bleeding. Resident #13 stated, .it burns really bad .feels like its on fire .I keep telling everybody .it even hurts me to sit down in the chair . CNA G reported that they (CNA's) were putting Inzo on it, and that the nurse was aware. This surveyor requested that WN C observe. WN C observed Resident #13's bottom at 2:37 P.M. and reported that he had not previously been made aware of this concern, and proceeded to obtain supplies to treat the area. Review of Resident #13's subsequent Wound Evaluation dated 3/28/23 revealed, MASD .in-house acquired .new 3/28/23 .6.0 cm length 2.9 cm width .bleeding .pink or red .healable . Review of the facilities Plan of Correction related to Treatment/Services to Prevent/Heal Pressure Ulcer revealed .Residents who are incontinent and require assistance with turning and repositioning have the potential to be affected. Skin sweep of all current residents completed on 2-22-23 and skin issues identified were appropriately addressed, Licensed Nurses will be re-educated on Facility Skin Management Program. Nurse Aides will be re-educated on standard of care in regards to incontinence care and turning and repositioning. QA (quality assurance) committee reviewed Skin Management policy and deemed appropriate, In Morning Clinical Meeting, completion of weekly skin assessments are verified and reviewed for compliance. Rounds will be completed randomly by DON/Designee to ensure incontinence care and turning and repositioning is provided. Rounds will be documented 5 times weekly for 2 weeks, 3 times weekly for 2 weeks, then weekly for 3 months. Results will be summarized and presented to monthly QA committee for further recommendations, Compliant by 3-8-23, Licensed Administrator will be responsible for compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide preventative care consistent with professional standards of practice for 1 resident (Resident #10), out of a total sample of 15 residents, resulting in the avoidable development of a facility acquired stage 3 pressure ulcer and the potential for further skin breakdown, infection, and an overall deterioration in health status. Findings include: Review of an admission Record revealed Resident #10 admitted to the facility on [DATE] with pertinent diagnoses which included congestive heart failure, cardiomyopathy, and anxiety. Review of a Minimum Data Set (MDS) assessment for Resident #10, with a reference date of 12/20/2022 revealed Resident #10 was totally dependent on staff for toileting and personal hygiene. Review of a current incontinence Care Plan intervention for Resident #10, initiated 12/15/2022, directed staff that resident uses disposable briefs and requires to be checked for incontinence every two hours and as needed. Review of a current activities of daily living Care Plan intervention for Resident #10, initiated 12/30/2022, directed staff that resident requires total dependence of one staff for personal hygiene and toilet use. Review of wound timeline for Resident #10 provided by the facility revealed that Resident #10 was identified as having MASD (moisture associated skin damage) on her left buttock on 12/15/2022 and treatment was initiated for barrier cream after each episode of incontinence. In an interview on 2/6/2023 at 12:21 PM, Registered Nurse (RN) D reported that she worked on 12/25/2022 with only 2 other nurses and 2 CNAs for the whole building. RN D reported that residents were complaining about missed care and long wait times to be changed. RN D stated, I literally ran my butt off, no break, it was kind of a disaster. In an interview on 2/6/2023 at 1:59 PM, CNA EE reported that she worked as the only aide on south hall on 12/25/2022, stating that it went terrible. CNA EE reported that she worked with Registered Nurse Y, who had COVID and kept leaving the floor because she was coughing and throwing up. CNA EE reported that residents went without being fed, she was not able to check and change residents every two hours, and showers were not completed. In an interview on 2/6/2023 at 2:32 PM, CNA F reported that she worked on day shift on 12/25/2022 as the only CNA on central. CNA F reported that it was not possible to check and change, toilet, or turn residents every 2 hours. CNA F stated, somebody should have came and helped. In a telephone interview on 2/7/2023 at 8:19 AM, Licensed Practical Nurse (LPN) E reported that he worked on 12/24/22 and 12/25/22, stating that it was hectic. LPN E reported that good staffing on central is with 4 CNA's, 3 is doable, 2 is not safe, and 1 is not possible. LPN E stated, with one CNA, we are lucky to get one round done, reporting that residents wouldn't get cleaned at times, wouldn't get showers, check and changes, or turning, and feeding would not be possible. LPN E stated, I can honestly tell you that weekend (Christmas weekend) was really rough, it's other times too, even without COVID, working with 2 CNAs on central. In a telephone interview on 2/8/2023 at 4:59 PM, CNA K reported that he stayed over to help on day shift on 12/24/2022 after working night shift the previous night and was the only CNA working central unit. CNA K reported that 2-hour check and changes, repositioning, and showers could not be done this shift. In a telephone interview on 2/8/2023 at 7:45 AM, Licensed Practical Nurse (LPN) M reported that she stayed over to help on 12/25/2022 and there were only two CNAs in the building. LPN M reported that she did not have any aide down here hall, stating I wasn't able to give good care, just the bare minimum. LPN M reported that she could not do two-hour check and changes or showers. Further review of Resident #10's wound timeline revealed that a wound was identified on her left buttock on 1/5/2023 with orders placed for wound care, and hospice authorized a wound care evaluation. Review of Resident #10's Nurses Note, dated 1/5/2023 at 3:24 PM, revealed that a new wound was identified on Resident #10's left buttock. Review of Resident #10's wound evaluation on 1/10/2023 by Wound Physician RR revealed .The patient is an [AGE] year old female admitted to (facility) on 12/14/22 . Nursing staff noted a wound on the buttock and a consult was placed for Wound Specialist to eval and treat . Wound #1 Left Buttock is a Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed . Initial wound encounter measurements are 3.8cm length by 1.8cm width by 0.1cm depth . In an observation and interview on 2/7/2023 at 3:07 PM, RN CC and Wound Physician RR evaluated and dressed left buttock wound. Wound Physician RR reported that the wound measured 0.8cm by 0.8cm by 0.1cm. Review of facility policy/procedure Skin Management, effective 12/15/2022, revealed .Guests/residents with wounds and/or pressure injury and those at risk for skin compromise are identified, evaluated and provided appropriate treatment to promote prevention and healing. Ongoing monitoring and evaluation are provided to ensure optimal guest/resident outcomes . Review of the Fundamentals of Nursing ([NAME] and [NAME]) revealed, Continual exposure of the skin to body fluids increases a patient's risk for skin breakdown and pressure ulcer formation .exposure to urine, bile, stool, ascitic fluid, and purulent wound exudate carries a moderate risk for skin breakdown, especially in patients who have other risk factors such as chronic illness or poor nutrition. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing - E-Book (Kindle Locations 71867-71870). Elsevier Health Sciences. Kindle Edition.