Based on observation, interview, and record review, the facility failed to ensure all residents received care per standards of practice when staff failed to address one resident's (Resident #45) change in condition timely. The resident's baseline was alert and oriented and cognitively intact. He/she experienced a change which resulted in the resident being unable to respond to questions, unable to feed him/herself, unable to lift his his/her own feet, and unable to express his/her own desires/wishes. The staff failed to send the resident out emergently, failed to follow-up with the physician when the physician did not return an office message, and failed to reach out to the medical director regarding the change of condition on the day the changes were observed. The resident was sent out the following day after contact with the Nurse Practitioner and was admitted to the hospital for high potassium and elevated labs. The facility census was 59. Review of the facility's policy titled, Notification of Changes Policy, revised 05/14/24, showed the following: -The purpose of the policy was to ensure the facility promptly informed the resident, consulted the resident's physician; and notified, consistent with his or her authority, the resident's representative when there was a change requiring notification; -The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there was a change requiring such notification; -Circumstances requiring notification include significant change in the resident's physical, mental, or psychosocial condition such as deterioration in health, mental or psychosocial status, which may include life-threatening condition or clinical complications; -For competent individuals, the facility must still contact the resident's physician and notify resident's representative, if known; -When a resident is mentally competent, such a designated family member should be notified of significant changes in the resident's health status because the resident may not be able to notify them personally, especially in the case of sudden illness or accident; -When a resident was incapable of making a decision, the representative would make any decisions that have to be made. Review of the facility's policy titled, Notifying Clinicians Policy, revised 06/26/24, showed the following: -Policy purpose was to ensure the clinicians are properly notified of a resident's change in condition and overall, health and/or mental status; -The clinician shall be notified of changes in conditions, emergent situations, routine diagnostics, and concerns of the resident's overall health status. Examples included altered mental status, poor intake, changes in behaviors, and anything regarding a change in the residents baseline or condition; -All resident health status updates, changes in condition, and deviation from baseline must be reported to the physician; -The nurse will initiate verbal communication with the clinician (i.e. physician, nurse practitioner (NP), etc.) when a condition or incident arises with resident which would warrant an immediate implementation of a change in plan of care to include physician advisement or initiation of physician orders to avoid a delay in treatment that may cause worsening in condition; -If staff are unable to reach the physician, staff shall notify nursing administration and they will assist in contacting a physician if/when needed. Staff to ensure that there is documentation of time, phone number dialed, and to whom staff spoke with when they reached out to the physician's office. Staff to document if staff reached anyone, or the number of attempts made, and if messages were left; -The licensed nurse will notify the resident's physician or the on-call physician for all changes in conditions, incidents and accidents, and emergency responses after hours to ensure the physician is kept informed and to give guidance; -In the event the licensed nurse cannot reach the physician for guidance, the licensed nurse must call the medical director for guidance; -In the event the licensed nurse cannot reach the physician or the medical director, the licensed nurse must call the director of nursing (DON) for further guidance; -If the licensed nurse cannot get a hold of the physician in an event where a resident needs to be sent to the hospital via 911, the nurse will send the resident to the hospital and continue attempts to notify the physician of the situation. 1. Review of Resident #45's face sheet (resident's information at a quick glance) showed the following: -admission date of 02/19/25; -Diagnoses included urinary tract infection (UTI), chronic kidney disease (damaged kidneys that can no longer filter blood the way they should), and type two diabetes (a chronic condition that affects the way the body processes blood sugar). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 01/30/25, showed the following: -The resident was cognitively intact; -The resident used a walker for mobility; -The resident had an indwelling catheter (a tube that is inserted into the bladder allowing urine to drain freely). Review of the resident's care plan, revised 03/13/24, showed the following: -The resident was independent with activities of daily living (ADL - dressing, grooming, bathing, eating, and toileting) and walked with a rolling walker; -Monitor for and document regarding signs and symptoms of UTI including deepening of urine color, altered mental status, change in behavior, and change in eating patterns. Review of the resident's February 2025 Physician Order Summary Report showed the following: -An order, dated 9/23/24, for weekly comprehensive metabolic panel (CMP - a routine blood test that measures various substances in the body to assess overall health and detect potential medical conditions) and complete blood count (CBC - a common blood test that measures various components of the blood to assess overall health and detect potential medical conditions) with differential, one time every Monday; -An order, dated 02/08/25, to send resident to local emergency department for evaluation and treatment if indicated. During an interview on 02/23/25, at 5:31 P.M., the resident said the following: -He/she was on antibiotics for pneumonia and a UTI; -He/she had spent seven days in the hospital; -He/she wore oxygen as needed prior to the recent hospital admission; -He/she had been wearing oxygen continuously since returning from hospital stay. Review of resident's progress note dated 02/23/25, at 11:45 P.M., showed Registered Nurse (RN) E documented the resident was disoriented. The disorientation was new. The resident was coherent, speech was clear, and the resident was able to make him/herself understood. Staff did not document physician notification of the change in condition. Observation on 02/24/25, at 12:05 P.M., of the resident showed the following: -The resident was sitting in his/her recliner, holding the lunch tray of food near his/her left shoulder with one hand; -A plastic cup containing a red liquid had spilled on the tray, ran onto the resident, and ran to the floor below the recliner; -A coffee mug with a lid that contained a liquid sat on the foot stool of the recliner; -The resident's right leg was hanging off the foot stool. The resident's left leg was on foot stool; -The resident tried to sit up in the recliner, but was unable to do so; -The resident was not alert or oriented and kept dozing off; -The resident's nasal cannula was resting on the resident's cheek near his/her right eye; -The resident used his/her right hand to lift his/her right leg onto foot stool. After doing this, the resident's left leg fell off stool; -The resident's lunch tray now sat on the resident's left thigh; -The resident had his/her eyes closed and used his/her fingers to pick up coleslaw off the plate; -The resident attempted to put the coleslaw in his/her mouth. It fell out of his/her hand and on to his/her shirt; -The resident then picked up the black napkin, which was wet from the red liquid that had spilt, off the lunch tray. The resident put the napkin up to his/her mouth and attempted to take a bite. Observation on 02/24/25, at 12:29 P.M., of the resident's room showed the following: -The resident's roommate (Resident #6) entered the room, looked at the resident, and then entered the restroom; -Resident #6 pushed the call light after entering the restroom; -Certified Nursing Assistant (CNA) P entered the residents' room to address the call light; -Resident #6 told CNA P that he/she pushed the call light for Resident #45; -CNA P took the resident's tray and told the resident he/she would be back to help clean up the resident; -The resident had his/her eyes closed and was not responsive to CNA P; -Certified Medication Tech (CMT) D entered the resident's room at 12:31 P.M. The resident opened his/her mouth when prompted by the CMT and the CMT poured the pills out of the cup into the resident's mouth. The resident then took a drink of water, which the CMT held; -The resident had his/her eyes closed and was not otherwise responsive to CMT D; -No staff attempted to adjust the resident's nasal cannula during this time; -CNA P returned to the resident's room and cleaned up the floor. CNA M entered the room to assist CNA P with cleaning the resident. Observation on 02/24/25, at 3:17 P.M., of the resident showed the following: -The resident sat in a wheelchair, with his/her feet on the floor with no foot pedals on the wheelchair; -CNA M pulled the resident in his/her wheelchair behind CNA M with the resident dragging his/her feet; -The resident had his/her eyes closed and appeared lethargic; -The resident was returning from a shower. Observation on 02/24/25, at 3:34 P.M., of the resident showed the following: -The resident was slurring his/her words when trying to answer questions; -The resident appeared unable to keep his/her eyes open and unable to make eye contact. Review of resident's progress note dated 02/24/25, at 4:13 P.M., showed the DON documented the following as a late entry: -The resident had been noted to have increased weakness off and on all day; -The resident was alert and oriented times 3 and able to carry on a conversation with staff; -The resident had decreased urinary output noted and urine was amber in color; -Therapy reported to the DON the resident had been refusing therapy since returning from the hospital; -The resident had not been eating as much when meals were taken to his/her room. Staff were to take the resident to the dining room for meals to ensure the resident was assisted with meals; -The facility physician notified and nursing staff will continue to monitor resident every shift. -The DON did not document when or how the physician was notified and if the physician gave direction regarding care. -The DON did not document a full assessment of the resident's condition. Observation on 02/24/25, at 5:01 P.M., of the resident showed the following: -The resident sat in his/her recliner with the foot stool of the recliner partially up; -The resident's legs were hanging off to the sides of the foot stool; -The resident's dinner tray was sitting on his/her lap; -The resident's eyes were closed and when asked what was on the resident's dinner tray he/she did not answer. Observation on 02/24/25, at 5:10 P.M., of the resident showed the following: -The resident had his/her eyes closed; -The resident's tray slid down the resident's right leg and was partially sitting on the resident's left leg; -The resident's dinner tray then fell to the floor, spilling the food on the floor; -The resident had not eaten any food off the dinner tray; -CNA L and CMT D came into the resident's room, picked up the tray, and then transferred the resident to the wheelchair; -The resident was taken to the dining room and CMT D assisted the resident with eating. -When prompted by staff the resident ate with assistance. Observation on 02/25/25, at 8:43 A.M., of the resident showed the following: -The resident was sitting in his/her recliner with eyes closed; -The resident was wearing the same clothes from the previous day after his/her shower; -The resident was slurring his/her speech. Review of the resident's lab results for his/her weekly CMP and CBC lab showed the following: -Collection date of 02/24/25 at 5:37 A.M.: -Reported date of 02/25/25 at 8:01 A.M.; -The resident's potassium was high at 6.3 (normal range is between 3.5 and 5.3 millimoles per liter (mmol/L). During an interview on 02/25/25, at 9:17 A.M., Licensed Practical Nurse (LPN) A said the following: -LPN A was unable to get the resident awake enough to answer questions; -When the resident returned from the hospital the previous week he/she was alert and oriented; -The resident was alert, oriented, able to carry on a conversation, and able to feed him/herself over the weekend; -The residents oxygen (O2) saturation was not going above 78 percent (normal O2 saturation is 95% -100%); -The resident had weekly labs drawn on 02/24/25, at 5:37 A.M., and the results showed the resident's potassium was high at 6.3 mmol/L; -The DON had not been available at that time for the LPN to give report to; -The resident would refuse to go to the hospital until his/her condition had declined tremendously; -LPN A felt the resident was unable to make decisions due to his/her current condition and needed to be sent out to the hospital; -LPN A was told he/she was not to call the physician regarding residents; -LPN A was to call the DON regarding a resident's change of condition. The DON would contact the physician and then tell the LPN what to do next. During an interview on 02/25/25, at 9:32 A.M., CNA L said he/she assisted the resident with eating breakfast. The resident required prompting to eat. The resident was not alert. During interviews on 02/25/25, at 10:45 A.M., and 02/28/25, at 9:55 A.M., the resident's family member said the following: -The last couple of weeks the resident had gone between alert/oriented and lethargic/disoriented; -The resident refused to go to the local hospital at times, because of a prior experience; -The family member was working and unable to transport the resident to a different hospital; -The family member would have preferred the resident to be sent out to the hospital yesterday 02/24/25; -If the staff were unable to contact the physician, he/she would expect them to keep trying until contact was made; -The family member would expect staff to do what was in the best interest of the resident if the resident was unable to make his/her own decision. Review of the resident's care plan, revised 03/13/24, showed staff did not care plan regarding the resident's hospital preference, or a refusal to go to a local hospital. Review of resident's progress note dated 02/25/25, at 11:43 A.M., showed LPN A documented the following: -The resident was not at his/her baseline when this nurse performed the resident's blood sugar check this morning; -The resident would wake up when this nurse called his/her name, but then would go back to sleep; -When the resident did speak, he/she had slurred speech along with jerking movements in arms and legs; -Resident had labs drawn on 02/24/25 and the results came in the morning of 2/25/25. Labs showed that resident's potassium was 6.3 (mmol/L); -This nurse notified the DON who then notified the NP who gave the order to send the resident out by emergency medical services (EMS) to the hospital; -The resident's vital signs prior to being sent to the hospital were blood pressure 119/64 millimeters of Mercury (mm/hg) / 64 mmHg (normal range is less than 120/80 mmHg), pulse was 56 (normal pulse rate is between 60 and 100 beats per minute (bpm), temperature was 97.6 degrees Fahrenheit (F), oxygen was 86% with nasal cannula on 2 liters and blood sugar 159 milligrams per deciliter (mg/dL) (normal range is blood sugar level less than 140 mg/dL); -The resident left the facility at 10:30 A.M.; -The MDS Coordinator contacted the hospital at approximately 11:15 A.M., for an update and was informed the resident had been life flighted to a different hospital. Review of the resident's emergency department (ED) visit documentation, dated 2/25/25, showed the following: -Resident reported to the ED with history of altered mental status and decreased responsiveness; -Resident was taken by ground crew to local ED and then flown to present ED; -Initial report was the patient's heart rate was in the 20 bpm range, however EMS reported heart rate of 50 bpm on their monitor while in their care. Review of the resident's attending Physician Attestation, dated 2/25/25, showed the following: -Resident presented to ER via helicopter from a nursing home for evaluation of report of altered mental status/lethargy and bradycardia (a heart rate that is slower than normal, typically below 60 beats per minute) reported as being as low as 20 bpm and 30 bpm, although the helicopter crew reported the patient bradycardic in the 50 bpm range; -Resident was reported to have had an elevated potassium; -Resident initially oriented to person, but neither city nor state, month or year. Review of the resident's Medical Decision Making notes from the hospital, dated 02/25/25, showed the following: -The resident was seen and evaluated in the ED for altered mental status; -Resident was able to follow one step commands, but not consistently enough for full neuro exam; -Diagnoses included of hyperkalemia (high potassium level); -The resident's BUN (blood urea nitrogen) level was elevated at 40 milligram per deciliter (mg/dL). (Normal level is between 6 and 20 mg/dl. An elevated BUN can indicate kidney problems or dehydration); -Creatinine (a waste product produced by muscle metabolism) level was 4.17 mg/dL. (Normal range for is .06 to 1.1 mg/dl. An elevated level can indicate kidney problems.); -ALT (alanine aminotransferase) and AST (aspartate aminotransferase) levels were elevated (which can indicate liver cell damage); -Creatinine kinase (an enzyme found primarily in muscle and brain tissues) level was elevated at 746 units per liter (u/l). (Normal range is 30-150 u/l. An elevated level can indicate may indicate muscle injury or disease); -Troponin (a protein complex found in the heart and skeletal muscles) was elevated. (An elevated level can indicate heart damage.); -Blood gases (measurements of the levels of oxygen (O2) and carbon dioxide (CO2) in the blood, as well as the pH (acidity) of the blood) showed respiratory acidosis (a condition where the blood becomes too acidic due to an accumulation of carbon dioxide (CO2)) with a pH of 7.29 (normal pH range is 7.35-7.45); -Elevated CO2 (carbon dioxide) level; -Low O2 (oxygen saturation) at 74% (normal range between 95% to 100%). During an interview on 02/26/25, at 11:08 A.M., CNA O said the resident was fine over the weekend. The resident ate in his/her room and had staff put food trays on his/her lap. During an interview on 02/26/25, at 6:42 P.M., CNA N said the following: -CNA N would notify the charge nurse regarding a resident's change of condition; -The resident was alert and oriented over the weekend and said he/she was feeling much better; -The resident was able to feed herself and carry on a conversation. During an interview on 02/28/25, at 10:01 A.M., CNA P said the following: -On 02/24/25, he/she had gone to check on the resident and found his/her lunch tray on the floor; -CNA P reported to the DON the resident had a change in condition; -CNA P was told the DON would assess the resident; -The resident was not him/herself on 02/24/25. The resident was usually up walking and alert and oriented. During an interview on 02/25/25, at 2:10 P.M., CNA M said the following: -When CNA M noticed a change of condition in a resident he/she reported to the charge nurse or the DON; -The resident's baseline was alert, oriented, talking, and able to walk with walker; -CNA M reported to the DON the resident's change of condition after lunch on 02/24/25; -The DON told CNA M to give the resident a shower to see if that would wake him/her up; -The resident was not alert during the shower and kept falling forward in the shower chair; -The DON helped CNA M give the resident the shower and was aware of the resident's condition; -The resident was slurring his/her speech and was unable to answer questions. During an interview on 02/25/25, at 2:24 P.M., CNA L said the following: -The resident was very independent, able to walk, alert and oriented and able to answer questions; -The resident came back from the hospital last week and was able to answer questions and feed him/herself; -The resident had been lethargic and unable to answer questions yesterday (02/24/25) and today (02/25/25); -On 02/24/25, CNA L took the resident his/her dinner and sat it on his/her lap; -After CNA L delivered the resident's dinner tray on 02/24/25. He/she was told to keep an eye on the resident by the DON; -CNA L returned to the resident's room on 02/24/25 and the resident's dinner tray was on the floor; -On 02/24/25, CNA L helped transfer the resident to his/her wheelchair. The resident was lethargic and slurring his/her speech; -After the resident was transferred to his/her wheelchair on 02/24/25, the resident was taken to the dining room and staff had to assist the resident with eating; -CNA L reported to the DON staff had to assist the resident with eating. During an interview on 02/25/25, at 3:50 P.M., LPN C said the following: -The aides reported changes of condition to the LPN and the LPN would assess the resident. If the resident was not baseline, the LPN would have the registered nurse (RN) assess the resident then contact the DON; -The DON would contact the physician and the resident's next of kin; -The resident's baseline included the resident walking around, going outside, sitting on the porch, talking, and being very coherent; -On 02/24/25, the resident's stomach was swollen and he/she had slurred speech; -The resident did not get insulin on 02/24/25 because the resident's blood sugar was too low for insulin administration. The resident had not eaten breakfast; -On 02/24/25, the resident dumped his/her lunch and dinner tray and ate very little with staff assistance; -LPN C reported to the DON his/her concern for the resident as his/her condition worsened in the afternoon; -On 02/25/25, LPN A asked LPN C to assess the resident. The resident's speech was worse, his/her stomach was more swollen, and his/her cheeks were swollen; -LPN C reported his/her concerns to the DON again. The DON assessed the resident and convinced the resident to go to the hospital; -The resident was his/her own person; -LPN C said the resident's mental status was altered and he/she felt the resident was not able to make his/her own decisions and should have been sent out to the hospital sooner. Review of resident's progress note dated 02/25/25, at 1:05 P.M., showed the DON documented the following: -This nurse was alerted by LPN A the resident was not at baseline; -The day prior, the resident noted to have increased weakness and sleeping more than usual; -When awake the resident was able to have a conversation and was alert and oriented times three; -The resident was still on antibiotics for a UTI and pneumonia from a previous hospital stay; -The resident was his/her own responsible person; -The DON asked the resident after his/her shower on 02/24/25 if he/she wanted to go to the hospital and the resident said he/she did not want to go to the hospital. The DON did not document why or how the resident relayed this information; -The DON assessed the resident this morning and resident was not able to recall what facility he/she was at or the DON's name; -The resident was asked again about going to the hospital and the resident agreed; -The NP was contacted and orders were given to send the resident to the hospital via EMS. During interviews on 02/26/25, at 1:23 P.M., 02/28/25, at 10:06 A.M., and 02/28/25, at 10:54 A.M., the DON said the following: -Facility staff would notify the DON regarding residents who had a change of condition; -The DON would then contact the physician regarding the resident's change in condition; -The protocol for contacting the physician was to call the number provided by the physician; -The resident's baseline included the resident walking with assistance of a walker, being alert and oriented, and talking; -The resident refused to be sent out to the local hospital at times due to a bad past experience; -The resident's family member would take the resident to a hospital in a neighboring town when possible; -On 02/24/25, the DON checked on the resident during lunch time. The DON did not talk to the resident and was not sure if the resident ate his/her lunch; -The DON and CNA M gave the resident a shower. The resident was extremely weak and the color of his/her urine was dark; -The resident's condition improved after the shower, but only for a brief period; -The resident became lethargic again; -The resident dropped his/her dinner tray on the floor. The DON had staff move the resident to the dining room and assist the resident with eating; -On 02/25/25, LPN A reported to the DON the resident had a change of condition. The resident was not oriented to self or place; -No staff expressed concerns to the DON on 02/24/25 regarding the resident's condition and being sent out; -The DON had called the facility's physician's office the afternoon of 02/24/25 to report the resident's change in condition and left a message regarding the resident's change in condition. The DON did not hear back from the physician nor attempt to try to contact the physician or nurse practitioner again that day; -On 02/25/25, the DON made contact with the NP regarding the resident's change of condition; -The DON was advised by the NP to send the resident out to the local hospital; -The resident had an altered mental status; -The DON did not know if there was a policy regarding contacting the physician and what to do if no return call were received from the physician; -If a resident were their own person and had an change in mental status she would contact the resident's family; -If the DON could not get a hold of the physician, after multiple tries, she would send the resident out, call the physician again and let them know the resident was sent to the hospital; -The DON or the charge nurse was responsible for calling the physician when a resident had a change in condition; -All charge nurses have access to the physician's phone numbers. During a phone and text conversation on 02/28/25, at 9:12 A.M., the resident's primary care physician said the following: -The NP said staff did not contact her on Monday (02/24/25), but did contact her on Tuesday (02/25/25) regarding the resident's change in condition; -He did not find any documentation of the facility contacting the provider office on Monday (02/24/25); -He expected the facility staff to contact the provider if the resident slurred his/her words and had a change from his/her baseline. He would had ordered the resident to be sent out for an evaluation. During an interview on 02/28/25, at 9:53 A.M., the Medical Director said the following: -His role for the facility included being available to take calls 24 hours per day; -Staff call him with any questions for medical or psychological issues; -Changes in condition include a change in a resident's temperature, heart rate, mental status, change in functionality, and respiratory rate; -Staff should contact the physician as early as they can if a resident has a change in condition; -Physicians are available after hours and staff have direct contact with the primary care physician; -He is on call 24 hours, seven days a week for all his facilities and staff should call the primary care physician if they cannot get in touch with him; -Staff should had called the primary care physician or the NP for the resident and should have kept calling; -Staff should had kept calling if the resident's condition was different from before. During an interview on 02/28/25, at 10:13 A.M., the Administrator said the following: -When a resident had a change of condition, he expected staff to notify the charge nurse, the charge nurse to assess the resident, and the charge nurse to contact the physician; -If the charge nurse cannot reach the physician, they were to contact the DON and the Administrator; -The charge nurse was to continue to try to reach the physician; -The charge nurse should contact the resident's family regarding the change of condition; -The staff should do what is in the best interest of the resident, if the resident is unable to make their own decisions. MO00249509

Based on observation, interview, and record review, the facility failed to provide care of pressure ulcers per standards of practice, when staff failed to have processes in place to ensure consistent, accurate, and thorough wound assessments were completed upon discovery and weekly; to complete weekly wound tracking; to complete accurate and timely entries of wound treatments; and to complete wound treatments as ordered for one resident (Resident #22) who had a facility acquired wound that required wound care specialist treatment and was considered for foot amputation. The facility census was 59. Review of the facility's policy titled Wound Treatment Management Policy, reviewed 05/18/24, showed the following: -Policy purpose was to promote wound healing of various types of wounds. It was the policy of the facility to provide evidence-based treatments in accordance with current standards of practice and physician orders; -Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change; -In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse; -Treatments will be documented on the Treatment Administration Record (TAR) or in the electronic health record; -The effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modifications included lack of progression towards healing, changes in the characteristics of the wound, and changes in the resident's goals and preferences, such as at end-of-life or in accordance with his/her rights. Review of the facility's policy titled Skin Assessment, last reviewed 06/26/24, showed the following: -It was the policy of the facility to perform a full body skin assessment as part of the systematic approach to pressure injury prevention and management. The policy included the procedural guidelines for performing the full body skin assessment; -A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission and weekly thereafter. The assessment may also be performed after a change in condition or after any newly identified pressure injury; -Documentation of skin assessment included date and time of the assessment, staff name and position title, observations (skin conditions, how the resident tolerated the procedure, type of wound, wound description (measurements, color, type of tissue in wound bed, drainage, odor, pain)), if the resident refused assessment and why, and other information as indicated or appropriate. 1. Review of Resident #22's face sheet (admission data) showed the following: -admission date of 06/01/24; -Diagnoses included schizophrenia (disorder that affects a person's ability to think, feel and behave clearly), chronic kidney disease, and hypertension (high blood pressure). Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 06/06/24 showed the following: -Moderately impaired cognitive skills; -At risk of developing pressure ulcers; -No unhealed pressure ulcers. Review of the resident's progress note dated 07/11/24, at 7:00 P.M., showed a nurse documented the day certified medication aide called the nurse due to the resident being found on the floor. The resident was on his/her left side in a lying position. The resident said he/she ambulated back to his/her room after he/she started feeling dizzy, lost his/her balance, and fell. Staff completed a full assessment to check for physical injuries with no injuries found so far. Staff notified the physician. Review of the resident's physician's progress note, dated 07/16/24, showed the following: -The resident seen for monthly chart review; -The resident had a recent ankle X-ray which showed a nondisplaced avulsion fracture (breaks or splits in the bone) at the tip of the medial malleolus (bony prominence on each side of the ankle); -The resident said he/she had difficulty walking; -There was swelling and tenderness in the medial malleolus of the right ankle; -Diagnosis of closed fracture of malleolus of right ankle; -Orthopedic referral due to nondisplaced avulsion fracture of the tip of the medial malleolus of the right ankle; -Physical and occupational therapy for strengthening conditioning and rehabilitation. (The physician did not document any orders for treatment of the ankle.) Review of the resident's skin/wound note dated 07/19/24, at 10:39 A.M., showed the Director of Nursing (DON) documented the following: -The resident fell a week prior and asked to have his/her foot wrapped to relieve pain/pressure. The charge nurse used an elastic bandage to wrap the resident's right ankle. The wrap was left in place for two days before the resident asked the DON to remove it. Upon removal, mild edema (swelling) noted to the resident's entire right foot. The resident developed cellulitis (bacterial infection of the skin and underlying tissues) within two days to the anterior (front) right ankle. A large blister developed in this area as a result of the cellulitis. The area was red, warm, and the blister was filled with fluid. -The DON notified the facility physician and received order to administer doxycycline (an antibiotic) 100 milligrams (mg) for ten days for cellulitis of the right ankle. -The DON gave the resident a soft boot to wear for protection of his/her foot after she applied a protective dressing of iodine (used to disinfect the skin and clean wounds) and dry gauze to protect the blister until it subsided. -The DON educated the resident and staff regarding the proper use of the soft boot and the importance of the resident maintaining good personal hygiene and using the toilet frequently. -Staff will monitor the resident's foot for improvement or decline in status and report directly to the facility physician. (The DON did not document the size of the area.) Review of the resident's medical record showed staff did not document contact with the physician regarding the resident's request for an elastic bandage and did not document an order for the elastic bandage. Staff did not document monitoring the use of the elastic bandage or the skin under the elastic bandage. Review of the resident's skin only evaluation dated 07/19/24, at 11:06 A.M., showed the DON documented the following: -Skin warm and dry; -Skin color within normal limits (WNL); -Skin turgor (the skin's elasticity) normal; -Location was right ankle; -Other skin issue description as blister; -Episodic pain; -Right heel discoloration, not painful, and other skin issue description of blister. (The DON did not document the size of the of area.) Review of the resident's skin/wound note dated 07/19/24, at 11:16 A.M., showed the DON documented the following: -While she assessed another area on the resident's right foot, she noticed the resident had a small blister to the back of his/her right heel and the entire right heel was no longer blanchable (something that becomes pale or white when pressure is applied). The skin underneath appeared to be dark in color and tender for resident when touched. -The DON notified the facility physician and received orders to apply an iodine soaked gauze dressing and wrap in kerlix (a sterile, cotton bandage to protect wounds) before utilizing a soft boot to the resident's right foot in conjunction with treatment of the blister to the top of the resident's right foot/ankle. -Staff will continue to monitor the resident's foot for further improvement or decline in status and staff will notify the physician of any changes. (The DON did not document the size of the of areas.) Review of the resident's skin only evaluation dated 07/19/24, at 11:34 A.M., showed the DON documented the following: -Skin warm and dry; -Skin color WNL; -Skin turgor normal; -New issue; -Location right ankle with other skin issue description of blister Episodic pain; -Right heel discoloration, not painful and other skin issue description of blister; -New issue of discoloration of right heel that was not painful; -New issue of other skin issue of right heel. Other skin issue description of blister that was not painful. (The DON did not document the size of the of area.) Review of the resident's progress note, dated as effective on 07/19/24 at 1:07 P.M., and noted to be a late entry, showed the following: -The DON documented therapy staff reported the resident had a large blister on the top of his/her right foot/ankle area. The DON assessed the resident and found the blister covered a large area of the anterior aspect of the ankle. The area was where part of the avulsion fracture was located in the X-ray that was completed on the resident the week prior. The resident also had a lot of pain in this area. Underneath the blister, the skin was red and hot and there was a lot of fluid within the blister. -The DON notified the facility physician who gave new orders to drain the blister, cover with an iodine and dry gauze dressing, and start doxycycline 100 mg twice a day and probiotic twice a day for 13 days. -The DON entered all the orders in the computer system and faxed the orders to the pharmacy. -The DON encouraged the resident to wear heel protectors and applied an iodine dressing with a foam heel cup to his/her right heel due to the right heel being discolored (dark purple in color) for skin breakdown prevention. Review of the resident's care plan showed staff did not update the care plan with the newly identified areas to the resident's right heel and right ankle, or related treatments and interventions. Review of the resident's July 2024 Physician Order sheet (POS) showed staff did not transcribe the order to implement or monitor the use of a foam heel cup or the order for doxycycline. Review of the resident's July 2024 TAR showed staff did not transcribe an order to implement or monitor the foam heel cup. Review of the resident's July 2024 Medication Administration Record (MAR) showed an order, dated 07/20/24, for doxycycline hyclate oral tablet 100 mg give one tablet by mouth two times (BID) a day for cellulitis of right ankle for ten days. Staff did not administer the evening dose on 07/20/24. Review of the resident's administration note dated 07/20/24, at 8:27 P.M., showed a nurse documented an order for doxycycline hyclate oral tablet 100 mg, give one tablet by mouth BID for cellulitis of right ankle for ten days. Staff noted the medication was not available. Review of the resident's physician's orders showed an order, dated 07/23/24, for blister to the top right foot/cellulitis. Staff to cleanse with sterile water, cover with iodine soaked gauze, wrap with conforming gauze and secure with non skid socks. Staff to change dressing daily until resolved every day shift. (The order was entered four days after the progress note noted the order was received.) Review of the resident's July 2024 TAR showed an order, dated 07/23/24, for blister to top of right foot from cellulitis. Staff to cleanse with sterile water, cover with iodine soaked gauze, wrap with conforming gauze and secure with non skid sock. Change dressing daily until resolved every day shift. Staff did not document treatments completed 07/19/24 (date ordered) to 07/22/24. Review of the resident's Nurse Practitioner's (NP) progress note, dated 07/23/24, showed the following: -The resident was seen for follow up per staff request. The DON stated the resident had a large blister to the right ankle; -Per notes on 07/19/24, when therapy worked with the resident it was noted the resident had a large blister on top of the right foot and ankle area. Upon further assessment staff found it to be covering a large surface area to the anterior aspect of his/her ankle. The resident's skin was noted to be red and hot surrounding it and there was a lot of fluid within the blister. -Staff notified the physician who gave orders to drain the blister, cover with an iodine dressing and start on cefdinir (used treat bacterial infections) 300 mg two times a day for seven days. -Staff encouraged the resident to wear heel protectors and float his/her ankles. -Staff report the blister was drained and he/she was waiting for a follow up with orthopedic. -The resident digs his/her heels into his/her bed, but that has improved since he/she wears the heel protectors. -The resident's foot was wrapped and floated at this time. The redness extended down his/her foot slightly from the ankle; -Staff to continue with cefdinir for the duration of the seven days as prescribed; -Staff to continue wound care as directed. Review of the resident's medical record showed staff did not document an order to drain the resident's blister, or the process of draining the blister. Review of the resident's July 2024 POS and July 2024 MAR showed staff did not transcribe the order for cefdinir and did not document administration of the cefdinir. Review of the resident's skin only evaluation dated 07/24/24, at 4:03 P.M., showed the DON documented the following: -Skin warm and dry; -Skin color WNL; -Skin turgor normal; -No external device(s) present; -New issue; -Location of right foot and other skin issue description of blister from cellulitis; -No pain; -Right heel discoloration, not painful, with other skin issue description of blister. (The DON did not document the size of the areas or a full assessment of the areas.) Review of the resident's progress notes dated 07/26/24, at 4:27 P.M., showed the DON documented the resident was sent to the orthopedic appointment today. The x-rays on the resident's right ankle showed no fracture and no surgery reported to be necessary at this time due to the resident developed such a large scab over the area on the right ankle where he/she had a large blister from cellulitis. The orthopedic provider's only concern was for the pain and allowing the skin to heal. Staff to continue the daily wound care that was in place of iodine and dry gauze with kerlix wrap and continue the antibiotic for suspected infection. Review of the resident's orthopedic physician orders, dated 07/26/24, showed to continue daily wound care, antibiotic, and non weight bearing on the resident's right leg. Review of the resident's July 2024 TAR showed the following: -An order, dated 07/23/24, for blister to top of right foot from cellulitis. Staff to cleanse with sterile water, cover with iodine soaked gauze, wrap with conforming gauze and secure with non skid sock. Change dressing daily until resolved every day shift; -On 07/26/24, staff did not document completion of the treatment on the top of the resident's right foot; -On 07/30/24, staff did not document completion of the treatment on the top of the resident's right foot. Review of the resident's care plan, dated 08/05/24 showed the following: -The resident has actual impairment to his/her right foot. A stage IV (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) wound to the top of the right foot and stage II (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer) wound to the right heel; -Resident to avoid scratching and keep hands and body parts from excessive moisture; -Staff to follow facility protocols for treatment of injury; -Staff to monitor for side effects of the antibiotics and over the counter pain medications; -Staff to monitor and document location, size, and treatment of the skin injury; -Staff to report abnormalities, failure to heal, signs and symptoms of infection to the medical director. (Staff did not care plan regarding use of heel protector.) Review of the resident's physician's orders, dated 08/07/24, showed the following: -An order for the stage II pressure wound to the right heel. Staff to cleanse the area with wound cleanser and cover with iodine soaked gauze, protect with dry dressing, and wrap with conforming gauze. Staff to change dressing daily every day shift. Registered Nurse (RN) to complete care; -An order for stage II wound to top of the right foot. Staff to cleanse with sterile water, cover with iodine soaked gauze, wrap with conforming gauze, and secure with non skid sock change. Staff to change dressing daily until resolved every day shift. RN to complete wound care. Review of the resident's August 2024 TAR showed the following: -An order for the stage II pressure wound to the right heel. Staff to cleanse the area with wound cleanser and cover with iodine soaked gauze, protect with dry dressing, and wrap with conforming gauze. Staff to change dressing daily every day shift. RN to complete care; -An order for stage II wound to top of the right foot. Staff to cleanse with sterile water, cover with iodine soaked gauze, wrap with conforming gauze, and secure with non skid sock change. Staff to change dressing daily until resolved every day shift. RN to complete wound care. -On 08/08/24, 08/09/24, 08/10/24, and 08/11/24, staff did not document treatment completed as ordered to the resident's right heel and top of the resident's right foot. Review of the resident's physician's progress note, dated 08/12/24, showed the following: -Monthly rounds; -No reported redness or swelling. His/her right lower extremity was wrapped and in a heel protector; -The resident or nursing staff did not have any complaints or issues; -No rashes or skin breakdown; -Continue all current medications and treatment plan. (The physician did not address the two pressure wounds on the resident's right foot.) Review of the resident's August 2024 TAR showed on 08/14/24 and 08/15/24, staff did not document treatment completed as order to the resident's right heel and top of the resident's right foot. Review of the resident's skin/wound note, dated as effective on 08/16/24 at 3:55 P.M., and noted to be a late entry, showed the following: -The DON completed the resident's wound care. The rest of the large scab covering the resident's anterior right ankle came away from the wound. Underneath the scab was yellow slough (dead tissue usually yellow or cream in color) covering the entire wound bed. A moderate amount of purulent (pertaining to pus) drainage present with no odor at this time. Edges of wound remained intact. -The DON completed wound care to the right heel. The slough covering remained dark in color and yellow around the edges. As the slough peeled away, underneath there was granulation tissue (a sign of healing) present at the top. The edges were intact with a scant amount of bleeding noted. The resident verbalized no pain or discomfort at this time. (The DON did not document measurements of the wounds.) Review of the resident's August 2024 TAR showed on 08/17/24 and 08/18/24, staff did not document treatment completed as ordered on the resident's right heel and top of the resident's right foot. Review of the resident's skin/wound note, dated as effective on 08/19/24 at 10:14 A.M., and noted to be a late entry, showed the following: -The DON completed wound care to the right anterior ankle and right heel. -No change noted to the dark colored slough that continued to peel from the right heel. It also had yellow slough peeling from the edges still. The top of the wound continued to have granulation tissue present. No odor present. Purulent drainage noted in moderate amount. (The DON did not document measurements of the resident's wound on the resident's right foot.) Review of the resident's skin/wound note, dated as effective on 08/19/24 at 5:30 P.M., and noted to be a late entry, showed the following: -DON completed wound care. (Location of wound not specified.) -Edges remain intact. The entire wound bed was covered with yellow-green slough throughout with 25% granulation tissue present with a scant amount of blood noted. Tendon noted to be present in middle of the wound. Odor present and moderate purulent drainage noted. -DON immediately notified the facility physician and waited for new orders. (The DON did not document measurements of the resident's wounds on the resident's right foot) Review of the resident's skin/wound note dated 08/20/24, at 3:00 P.M., showed the DON documented the following: -The DON completed wound care to the resident's anterior right ankle. The wound was previously staged as a stage II and changed to a stage IV due to the tendon now exposed. The slough was debrided and new granulation tissue was visualized. The tendon had become more prevalent in the center and off to the lateral side of the wound. Granulation tissue made up approximately 45% of the wound bed at this time. The center continues to have a dark yellow-green slough. The edges of the wound were intact with moderate bleeding noted during wound care. A moderate amount of purulent drainage and odor remain. -The DON completed wound care to the resident's right heel. The dark colored slough continued to peel off slowly with yellow slough remaining underneath and along the edges. Granulation tissue was present at the top of the wound and along the sides and made up approximately 25% of the wound bed. Edges surrounding the wound remained intact. Scant amount of bleeding noted with moderate amount of drainage and no odor. The DON to measure and take pictures of both wounds on 08/21/24 during scheduled wound care and place within the chart. -The physician ordered doxycycline 100 mg BID for ten days for infection of the right ankle wound and a consult scheduled with the wound care clinic on 08/29/24. (The DON did not document measurements of the resident's wound on the resident's right foot) Review of the resident's September 2024 Physician Order Sheet (POS)showed an order for the following: -An order, dated of 08/20/24, for acidophilus (used as a probiotic to promote the growth of good bacteria in the body) oral tablet for staff to give one tablet by mouth (PO) two times a day for antibiotic use for 13 days; -Staff transcribed the order for doxycycline to the POS. Review of the resident's progress note dated 08/20/24, at 11:16 P.M., showed the DON documented an order received from the physician to start the resident on doxycycycline 100 mg BID for ten days and probiotic tablet PO BID for 13 days for wound infection. The DON entered the orders and faxed to the pharmacy. The nurse practitioner saw the resident during medical rounds. The facility staff made contact with the local wound care clinic and the resident had an appointment set for a consult in their office on 08/29/24. Review of the resident's skin/wound note, dated as effective on 08/21/24, at 9:55 P.M , and noted to be a late entry, showed the following: -The DON completed wound care per instructions to the resident's right anterior ankle. The edges remained intact and an odor remains present at this time with moderate amount of drainage. Yellow slough covered the center of the wound in approximately 50% surrounding the tendons that are visible. Granulation tissue remains visible to 35% of wound with moderate amount of bleeding noted during cleaning of the wound. -The DON completed wound care to the right heel. The edges remain intact with no odor present. A moderate amount of drainage noted. Dark colored and yellow slough continues to peel off slowly at this time covering 40% of the wound. 25% of granulation tissue noted to be visible at this time. (The DON did not document measurements of the resident's wound on the resident's right foot) Review of the resident's physician's orders, dated 08/21/24, showed the following: -An order for stage II pressure wound to the right heel. Staff to cleanse with sterile water, cover wound bed with silver wound dressing and dry gauze, wrap with conforming gauze and secure with non skid socks. Staff to change dressing daily until resolved every day shift. RN to complete wound care; -An order for stage IV wound to top of the right foot. Staff to cleanse with sterile water, cover wound bed with silver wound dressing and dry gauze, wrap with conforming gauze and secure with non skid sock change dressing daily until resolved every day shift. RN to complete wound care. Review of the resident's August 2024 MAR showed the following: -An order, dated 08/21/24, for doxycycline hyclate (antibiotic) oral tablet 100 mg give one tablet PO BID a day for infected wound to right ankle for 10 days; -An order, dated of 08/21/24, for acidophilus (probiotic) oral tablet for staff to give one tablet PO two times a day for antibiotic use for 13 days; -On 08/23/24, staff did not document administration of the antibiotic or probiotic. -Staff did not document administration of the doxycycline on 08/23/24 for the AM and PM doses. Review of the resident's August 2024 TAR showed the following: -An order, dated of 08/21/24, for staff to cleanse with sterile water, cover wound bed with silver wound dressing and dry gauze, wrap with conforming gauze and secure with non skid socks. change dressing daily until resolved every day shift for stage two pressure wound to right heel. RN to complete wound care; -An order, dated 08/21/24, for staff to cleanse with sterile water, cover wound bed with silver wound dressing and dry gauze, wrap with conforming gauze and secure with non skid sock change dressing daily until resolved every day shift for stage IV wound to top of right foot. RN to complete wound care. Review of the resident's skin/wound notes, dated as effective on the dates below and noted as late entries, showed the DON completed wound care to the right anterior ankle. The edges remained intact and an odor remains present at this time with a moderate amount of drainage. Yellow slough covered the center of the wound in approximately 50% of surrounding the tendons that are visible. Granulation tissue remained visible to 35% of wound with moderate amount of bleeding noted during cleaning of the wound. The DON completed wound care to the right heel. The edges remain intact and no odor present and moderate amount of drainage noted. Dark colored and yellow slough continues to peel off slowly at this time covering 40% of the wound 25% of granulation tissue noted to be visible at this time. (The DON did not document measurements of the resident's wound on the resident's right foot) -Effective 08/22/24, at 11:12 A.M.; -Effective 08/23/24, at 10:03 A.M.; -Effective 08/24/24, at 12:15 P.M. Review of the resident's skin/wound note, dated as effective on 08/25/24, at 9:33 A.M., and noted to be a late entry, showed the following: -The DON completed wound care to the right anterior ankle. Edges remain intact and an odor remains present at this time with moderate amount of drainage. Yellow slough covers the center of the wound in approximately 55% surrounding the tendons that are visible. Granulation tissue remains visible to 35% of wound with moderate amount of bleeding noted during cleaning of the wound. -The DON completed wound care to the right heel. Edges remain intact and no odor present and moderate amount of drainage noted. Dark colored and yellow slough continues to peel off slowly at this time covering 60% of the wound 40% of granulation tissue noted to be visible at this time. (The DON did not document measurements of the resident's wound on the resident's right foot) Review of the resident's skin/wound notes, dated as effective on the dates below and noted as late entries, showed the DON completed wound care to the right anterior ankle. The edges remained intact and an odor remains present at this time with a moderate amount of drainage. Yellow slough covered the center of the wound in approximately 50% of surrounding the tendons that are visible. Granulation tissue remained visible to 35% of wound with moderate amount of bleeding noted during cleaning of the wound. The DON completed wound care to the right heel. The edges remain intact and no odor present and moderate amount of drainage noted. Dark colored and yellow slough continues to peel off slowly at this time covering 40% of the wound 25% of granulation tissue noted to be visible at this time. (The DON did not document measurements of the resident's wound on the resident's right foot): -Effective 08/26/24, at 4:30 P.M.; -Effective 08/27/24, at 1:46 P.M. Review of the resident's physician's progress note, dated 08/27/24, showed the following: -The resident visits the wound clinic in the next few days. The nursing staff state he/she urinates on his/her wound on his/her right foot. Apparently he/she had a stage IV wound on top of his/her foot and a stage II wound on the bottom of his/her foot. Nursing staff state that it has a putrid odor. He/she had a significant wound that was presently dressed on the right foot with a putrid smell coming from the area; -Order for rocephin one gram IM (intramuscularly) daily for five days; -Resident to see the wound care specialist in the next one to two days; -Continue all other current medications and treatment plan. Review of the resident's skin/wound note, dated as effective on 08/28/24, at 2:33 P.M., and noted to be a late entry, showed the following: -The DON completed wound care to the right anterior ankle. Edges remain intact and an odor remains present at this time with moderate amount of drainage continued to be present. Dark yellow slough covers the center of the wound in approximately 50% surrounding the tendons that are visible. Granulation tissue remains visible to 35% of wound with moderate amount of bleeding noted during cleaning of the wound. -The DON completed wound care to the right heel. Edges remain intact and no odor present and moderate amount of drainage noted. Dark colored and yellow slough continues to peel off slowly at this time covering 40% of the wound 25% of granulation tissue noted to be visible at this time. (The DON did not document measurements of the wounds on the right foot.) Review of the resident's skin/wound note, dated as effective on 08/29/24, at 8:51 P.M., and noted to be a late entry, showed the following: -The DON cleaned the resident's wounds to both the right anterior ankle and right heel as per treatment order. She applied a simple dry protective dressing Xeroform (non-adherent primary dressing that maintains a moist wound environment) to both areas before the resident left to to to his/her appointment with the wound care clinic. -DON received a phone call from the wound doctor while the resident was at the appointment with concerns regarding the resident's right anterior ankle wound and the tendons showing. The wound doctor stated he/she felt the resident's foot may need to be amputated at this point with how quickly the wound declined and the resident's cardiologic issues. The wound doctor requested pictures of the start to present of the fast progression of the wound and the DON provided the pictures to him/her. Review of the resident's wound clinic doctor's consultation dated 08/29/24, at 10:42 A.M., showed the following: -The resident had a fall with a right ankle sprain a couple days after his/her admission to the facility with a little avulsion fracture of his/her medial malleolus. The resident had an elastic wrap on it for a couple days. The resident had blistering and was treated for cellulitis; -Facility staff told him/her a scab appeared and when the scab came off, all the skin came off with it and the resident had exposed tendon on the anterior ankle and eschar (non viable tissue due to reduced blood supply) on the right heel with exposure of the distal or most inferior Achilles (the thick, fibrous cord that connects the calf muscles to the heel bone) tendon and the calcaneus (heel bone); -Staff placed Xeroform gauze on the wound at this time; -There is a large ulcer on the right anterior ankle 8.2