**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to implement Activity of Daily Living (ADL) care plans for Residents #1, #17, and #30 and failed to implement a pressure ulcer care plan for Resident # 6 for (4) four of 16 resident care plans reviewed. Findings Include: Review of the facility policy titled, “Plan of Care,” last revised 06/27/24, revealed, Policy: It is the policy of “Proper Name” to properly provide patient care planning… Procedure: 2.) “An interdisciplinary collaborative manner as appropriate to the needs of the patient should be utilized to develop and implement the care plan . Resident #1 Record review of the Care Plan for Resident #1 revealed under, Problem/Need: I require assistance w/ (with) ADLs (activities of daily living) r/t (related to) weakness, debility, and dementia. Also revealed under, Approaches: Personal Hygiene- Limited-Extensive x (times) 1 (one). During an observation and interview on 7/21/2025 at 11:18 AM, Resident #1 was sitting in his wheelchair in his room. He was unshaven, with black and gray facial hair approximately 1/4 (one-fourth) inch in length. The resident stated he wanted to be shaved but preferred to keep his mustache. On 7/22/2025 at 10:36 AM, an interview with Certified Nurse Aide (CNA) #5 confirmed Resident #1 needed shaving. An interview with the Minimum Data Set (MDS) Nurse on 7/24/25 at 9:15 AM revealed the purpose of the care plan was to give staff instruction and paint a picture of the residents care to be provided. She confirmed Resident #1's care plan was not followed for shaving. Record review of the “Demographics” revealed the facility admitted Resident #1 on 4/14/25 with a medical diagnosis of Unspecified Dementia. Record review of Resident #1’s “Flowsheet History” dated 7/18/25 revealed a Brief Interview for Mental Status (BIMS) summary score of 3, indicating the resident was severely cognitively impaired. Resident #6 Review of the “Care Plan” for Resident #6 revealed under, “Approaches: Observe for s/sx (signs/symptoms) of new skin breakdown during daily care document and report as indicated . An interview with the Director of Nursing (DON) on 7/24/25 at 9:20 AM revealed Resident #6 transferred to the hospital on 3/1/25 and returned on 3/9/25. Record review of Resident #6’s hospital stay “Integumentary Flowsheet History” revealed documentation on 3/7/25 of deep tissue injury (DTI) left heel. Record review of the “Nursing Note” for Resident #6, dated 3/9/25 revealed, “Resident returned from proper name of hospital around 10 AM.” There was no documentation regarding any skin concerns. Record review of Resident #6’s body audits conducted on 3/9/25, 3/10/25, 3/13/25, 3/14/25, 3/15/25 revealed scattered bruising, no abrasion, no blister, no excoriation. There was no documentation regarding the left heel. Record review of Resident #6’s body audit conducted on 3/16/25 revealed, “Unstageable pressure injury to left posterior heel, dark purple, dry, hard, closed, without pain. Measures 4.5 x 2.2 x 0.” Record review of Resident #6’s “Integumentary Flowsheet History” dated 7/15/25 revealed, “Redness to buttocks.” Record review of Resident #6’s “Wound History” dated 7/17/25 revealed, “Sacrum stage III pressure wound, red, slightly moist measuring 1.8 cm (centimeters) x 0.5 cm (centimeters) x 0.1 cm (centimeters) full thickness tissue loss with slough. On 7/23/25 at 11:12 AM, an interview with the DON confirmed Resident #6 developed a pressure injury to her left heel while in the hospital, and the wound was not identified in the facility until eight days later. Additionally, she revealed that after the resident’s body audit conducted on 7/15/25 identified redness to her buttocks, there was no documentation to show the skin concern was addressed. She confirmed the plan of care was not followed. On 7/24/25 at 8:30 AM, an interview with Registered Nurse (RN) #2 reconfirmed that on 7/15/25, she assessed the resident’s skin and noted redness to the buttocks. She revealed that she applied pink cream and a bandage to the area but did not document it or initiate wound care orders. An interview with the MDS Nurse on 7/24/25 at 9:00 AM confirmed Resident #6's skin care plan was not followed. Record review of the “Demographics” revealed the facility admitted Resident #6 on 2/13/25 with diagnoses including Dementia with Anxiety. Record review of the “Flowsheet Data” dated 5/16/25 revealed a BIMS summary score of 6, indicating Resident #6 was severely cognitively impaired. Resident# 17 During an observation on 7/22/25 at 10:30 AM, with Registered Charge Nurse #1, it was confirmed that Resident #17’s nails were long and jagged and needed to be trimmed. She stated it was her responsibility to trim the nails but confirmed she had not gotten around to it. Record review of the ADL care plan for Resident #17, last revised 7/11/25, revealed the problem: “I require assistance with ADLs … Approaches: Nail care as indicated. … Personal hygiene – limited to extensive assistance . During an interview with the MDS nurse, on 7/22/25 at 11:30 AM, she confirmed that if staff had not trimmed Resident #17’s nails, they did not implement the resident’s ADL care plan. She revealed the purpose of the comprehensive care plan is to give staff a description of the type of care the residents require. Review of the “Demographic Report” for Resident #17 revealed the facility admitted the resident on 1/15/22 with a diagnosis of Hemiplegia affecting the left side as a late effect of Cerebrovascular Accident. Record review of Resident #17's BIMS, dated 7/11/25, revealed a score of 15, indicating the resident was cognitively intact. Resident #30 Record review of the Care Plan with a problem onset of 6/21/23 revealed, Problem/Need: ADL's I require assistance with my ADLs r/t Parkinson's .Approaches: Assistn with shaving as desired . On 7/21/2025 at 12:23 PM during an observation and interview with Resident #30 revealed that he had facial hair measuring one-half to one inch on his cheeks, chin, upper lip, and neck. During the interview, Resident #30 stated, I cannot shave myself and I would like to be shaved. During an interview with the MDS Coordinator at 12:41 PM on 7/22/25, confirmed that while Resident #30 was capable of taking showers independently with supervision, he has not been shaved in quite some time. She further confirmed there was no documentation indicating that Resident #30 had refused to be shaved. During an interview on 7/24/2025 at 9:37 AM, the MDS Coordinator confirmed that the ADL Care Plan, which includes assistance with shaving as desired, was not implemented. She verbalized that the purpose of this care plan was to serve as a guide for all staff involved in providing ADL care, ensuring consistency and quality across all shifts and personnel. A record review of Resident #30's Demographics revealed that the resident was admitted to the facility on [DATE], with diagnoses that included Parkinson’s Disease. A record review of Resident #30's Flowsheet History revealed a BIMS Summary Score of 13 with an Assessment Reference Date (ARD) of 5/30/25, which indicated that the resident was cognitively intact.

Based on observation, staff interview, record review, and facility policy review, the facility failed to assess and implement timely interventions to address skin integrity concerns, resulting in progression of a pressure injury and delayed wound healing for one (1) of three (3) residents reviewed for pressure ulcers. (Resident #6) Findings include: Review of the facility policy titled “Assessment and Reassessment of Patients” with a revision date of 5/12/25 revealed under, “Policy: It is the policy of (proper name of facility) that patients should be properly assessed and reassessed.” Also revealed under, “Procedure: … 6. Wound assessments and measurements should be performed at start of care, resumption of care, and recommended weekly. Reassessment should be performed any time there is a significant change noted .” Record review of Resident #6’s hospital “Integumentary Flowsheet History” revealed documentation on 3/7/25 of deep tissue injury (DTI) left heel. An interview with the Director of Nursing (DON) on 7/24/25 at 9:20 AM revealed Resident #6 transferred to the hospital on 3/1/25 and returned on 3/9/25. Record review of the “Nursing Note” for Resident #6, dated 3/9/25 revealed, “Resident returned from “proper name” of hospital around 10 AM.” There was no documentation regarding any skin concerns. Record review of Resident #6’s body audits conducted on 3/9/25, 3/10/25, 3/13/25, 3/14/25, 3/15/25 revealed scattered bruising, no abrasion, no blister, no excoriation. There was no documentation on the left heel. Record review of Resident #6’s body audit conducted on 3/16/25 revealed, “Unstageable pressure injury to left posterior heel, dark purple, dry, hard, closed, without pain. Measures 4.5 x 2.2 x 0.” Record review of Resident #6’s wound care “Work List Task Details” revealed an order dated 3/16/25, “Unstageable pressure injury to left, posterior heel. Clean with betadine and leave OTA (open to air) daily at 10:00 AM.” Record review of Resident #6’s “Integumentary Flowsheet History” dated 7/15/25 revealed, “Redness to buttocks.” Record review of Resident #6’s “Wound History” dated 7/17/25 revealed, “Sacrum stage III pressure wound, red, slightly moist measuring 1.8 cm (centimeters) x 0.5 cm (centimeters) x 0.1 cm (centimeters) full thickness tissue loss with slough. Record review of Resident #6’s wound care “Work List Task Details” revealed an order dated 7/17/25, “Cleanse stage III pressure ulcer to sacral area with NS (normal saline) or DWC (dermal wound cleanser), pat dry with 4 x 4 gauze, apply collagen with silver, cover with dry dressing. Change T (Tuesday)/Th (Thursday)/Sat (Saturday) and prn (as needed).” An interview with the Director of Nursing (DON) on 7/23/25 at 11:12 AM confirmed Resident #6 developed a pressure injury on her left heel while in the hospital, and the wound was not identified in the facility until eight days later, at which point it had progressed to an unstageable pressure injury. She revealed it would have been the charge nurse’s responsibility to assess the resident’s skin on readmission and then weekly thereafter. She confirmed there were no interventions implemented when the resident returned to address the skin concern. The DON explained that after the body audit conducted on 7/15/25 identified redness to the resident’s buttocks, no treatment was initiated. She confirmed interventions should have been implemented. She stated, I thought we were better than that. She acknowledged that the lack of assessment and follow-through with treatment could have caused both wounds to progress and worsen. An interview with Registered Nurse (RN) #2 on 7/24/25 at 8:30 AM revealed she was the charge nurse working on 3/9/25 when Resident #6 returned from the hospital. She confirmed she did not perform a body audit on readmission and stated, I don't remember doing one. She explained that on 7/15/25, she assessed the resident’s skin and noted redness to the buttocks. She revealed that she applied pink cream and a bandage to the area but did not document it or initiate wound care orders. She stated, As far as why I didn't, I get busy, and it just fell through the cracks. An observation on 7/24/25 at 9:50 AM with Resident #6 during wound care revealed the left heel (unstageable due to eschar) revealed a round eschar covered wound. The wound bed was black; peri wound intact with no redness or irritation. Edges were well defined. The sacral wound (stage III) was oval shaped, yellow adherent slough covered, edges well defined, peri wound without redness or irritation. Record review of the “Demographics” revealed the facility admitted Resident #6 on 2/13/25 with diagnoses including Dementia with Anxiety. Record review of the “Flowsheet Data” dated 5/16/25 revealed a Brief Interview for Mental Status (BIMS) summary score of 6, indicating Resident #6 was severely cognitively impaired.