Based on observation, staff interviews, record review, and facility policy review, the facility failed to develop a comprehensive care plan for a resident with pressure ulcers for two (2) of 20 sampled residents. Resident # 28 and Resident # 209 Findings Include: Review of the facility policy titled Care Plan Process with a revision date of 8/17 revealed, .The Care Plan must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . Resident #28 A review of the Skin & Wound Evaluation dated 9/19/24 revealed that Resident #28 acquired an unstageable pressure ulcer on the right fourth (4th) ring finger on 9/19/24. The quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 9/16/24 indicated that Resident #28 had a functional limitation in the range of motion (ROM) in the upper extremity on one side. A review of the comprehensive care plan for Resident #28 showed that no pressure reduction interventions were in place to reduce the risk of pressure ulcers associated with the resident's right fourth finger. On 10/29/24 at 8:30 AM, during an interview with the Wound Treatment Nurse she explained that Resident #28 had developed a pressure ulcer on the right fourth ring finger due to pressure from fingers contracted in a fist. She acknowledged that pressure relief measures should have been implemented to prevent pressure ulcers on Resident #28's fingers. During an interview with MDS Nurse #1 and MDS Nurse #2 on 10/29/24 at 8:45 AM, they stated that the purpose of the care plan is to inform staff of the resident's required care. They confirmed that there was no care plan in place to prevent skin breakdown related to the right-hand contracture and agreed that such a plan should have been established. Record review of the admission Record revealed the facility admitted Resident # 28 on 5/31/21 with a diagnosis of Cerebral Infarction. Resident #209 On 10/29/24 at 11:20 AM, an interview with the Wound Treatment Nurse revealed, Resident #209 had a new pressure wound on the right Achillies area. Record review revealed a care plan was not developed for Resident #209's wound care or pressure ulcer on the right Achilles. On 10/29/24 at 3:50 PM, an interview with the Administrator (ADM) confirmed Resident #209's wound care plan was not developed. An interview with the MDS Nurse #1 on 10/30/24 at 10:40 AM revealed the purpose of care plan development was so that anyone who looks at the wound knew the level of care needed. Record review of the admission Record revealed the facility admitted Resident #209 on 10/9/24 with a medical diagnosis of Displaced Fracture of the Lower Epiphysis of Right Femur.

Based on observation, record review, resident and staff interview the facility failed to provide treatment and services to prevent pressure ulcers for two (2) of five (5) residents observed with pressure ulcers. Resident #28 and Resident # 209 Findings Included: Record review of facility policy Pressure Ulcer Prevention and Treatment Intervention Guidelines, revised 10/22, revealed C. Protection from Fiction or Shear .4. Provide padding for casts, braces, splints, oxygen tubing, shoes etc. as needed to prevent friction. 5. Remove orthotics on a regular basis for skin inspection .Therapy Department Interventions .3. Explore possible therapy interventions for .c. Splinting/orthotic modifications . 1. Provide pressure ulcer topical treatments as ordered Resident #28 A review of the Skin & Wound Evaluation dated 9/19/24, revealed that Resident #28 acquired an unstageable pressure ulcer on the right fourth (4th) ring finger on 9/19/24. Record review revealed measurements of 1.4 centimeters (cm) area, 1.4 cm length, 1.3 cm width and depth not applicable (n/a). The quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 9/16/24 Section GG revealed revealed Resident #28 had a functional limitation in the range of motion in the upper extremity on one side. A record review of Order Listing Report for September and October 2024 revealed no orders for pressure relief devices for Resident # 28. During an observation and interview with Licensed Practical Nurse (LPN) #2 on 10/29/24 at 8:00 AM, Resident #28 was observed with a palm shield in place on the right hand. LPN #2 confirmed that Resident #28 had a contracture in the right hand and stated that the palm shield was applied only after the pressure ulcer developed on the right 4th ring finger. She verified that no splinting or other pressure relief interventions were in place before the pressure ulcer developed. In an interview with the Wound Treatment Nurse on 10/29/24 at 8:30 AM, she explained that Resident #28 had developed a pressure ulcer on the right fourth ring finger due to pressure from the fingers being contracted in a fist. She stated that when she identified the pressure ulcer, she contacted therapy to request a pressure relief device. She acknowledged that pressure relief measures should have been in place to prevent pressure ulcers on Resident #28's fingers. She confirmed that there were no orders or documentation for the use of the palm shield. In an interview with the Rehabilitation Director on 10/30/24 at 9:00 AM, she verified that Resident #28 did not have a palm shield before developing the pressure ulcer on the right 4th finger and confirmed that she was consulted, and the shield was implemented after the ulcer appeared. Record review of the admission Record revealed the facility admitted Resident # 28 on 5/31/21 with a diagnosis of Cerebral Infarction. Resident #209 An observation and interview with Resident #209 on 10/29/24 at 10:16 AM revealed, she was lying in bed with an immobilizer to the right leg. The resident verbalized she had an unrepaired femur fracture and revealed she had a new sore that developed under the brace since she admitted . She explained that she followed up with her orthopedic doctor last week, and he asked her to use foam under the brace, but the facility did not have any foam. An interview with the Wound Treatment Nurse on 10/29/24 at 11:20 AM revealed Resident #209 had a new pressure wound caused by the immobilizer on the Achilles area. She explained that she was notified by the Therapy Rehab Director on 10/21/24 that the residents' immobilizer was sliding down and had caused a sore. She revealed she had been treating the wound since she was made aware, but the treatment order was not added to the Treatment Administration Record (TAR) until 10/26/24, and she had not staged the wound. The Wound Nurse confirmed Resident #209's skin had not been assessed under the immobilizer every day to determine if the resident had any skin breakdown. Record review of the Wound Evaluation dated 10/22/24 revealed the wound to the right Achilles was not staged and measured 0.94 cm in length and 0.56 cm in width, with no determination on depth. Review of the October 2024 Treatment Administration Record for Resident #209 revealed an order, dated 10/26/24, Clean open area to right heel with NS (normal saline) and pat dry, apply Xeroform and cover with bandage every other day until resolved with a discontinue date of 10/29/24. Also revealed an order, dated 10/29/24, Clean open area to right Achilles with NS (normal saline) and pat dry, apply TAO (triple antibiotic ointment) and cover with bandage every other day until resolved. Record review of the Order Listing Report revealed there was not a physician order for Resident #209's leg immobilizer or to monitor the skin under the brace for skin breakdown. An interview with the Director of Nursing (DON) on 10/29/24 at 12:50 PM confirmed, Resident #209 did not have an order for the right leg immobilizer. She revealed it was not clear to her why the staff would not have called and followed up on how the resident was supposed to wear it. Record review of the Physician Consultation Report dated 10/24/24 revealed under, Findings: . Pressure sores where hinges are present. Also revealed under, Recommendations: When pt is in bed open brace completely to relieve pressure; Apply thin layer of foam to posterior calf and thigh portion of brace. An interview with the Wound Treatment Nurse on 10/29/24 at 2:30 PM confirmed she did not implement the orders recommended by the Orthopedic Physician. She revealed the foam would have been too thick under the brace and stated, I don't think foam would work. She revealed Resident #209 had told her the hospital applied foam under the immobilizer, and it was too tight. An interview with the Administrator (ADM) on 10/29/24 at 2:48 PM, confirmed the skin should be assessed underneath an immobilizer daily to ensure there was no skin breakdown caused by the device. She confirmed Resident #209's wound was avoidable, if the skin under the immobilizer had been assessed. She revealed the physician's recommendations should have been followed. An interview with the Therapy Rehab Director on 10/30/24 at 9:10 AM revealed she usually had to take Resident #209's immobilizer off to reposition it correctly. She revealed she observed the area to the resident's leg and reported it to the nurse on duty on 10/20/24. She stated the nurse thought the brace had rubbed the area on the leg, and she needed something to pad the area for support. The therapist revealed they placed a towel under the brace that day for extra protection, and she told the Wound Treatment Nurse the following day. An interview with the Wound Treatment Nurse on 10/30/24 at 10:25 AM confirmed Resident #209's wound was avoidable if the proper monitoring under the brace had been done. Record review of the admission Record revealed the facility admitted Resident #209 on 10/9/24 with a medical diagnosis of Displaced Fracture of the Lower Epiphysis of Right Femur. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/16/24 revealed under, section C, a Brief Interview for Mental Status (BIMS) summary score of 15, which indicated Resident #209 was cognitively intact.