**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure adequate supervision and assistance to prevent accidents for two residents. Staff failed to follow safe practices, respond to request for additional assistance and be aware of the resident's surroundings for one resident (Resident #1) when moving the resident in the bed. The resident fell off the raised bed, onto the floor, sustaining three spinal compression fractures (break in a vertebra (spinal bone) that then collapses), a tooth avulsion (complete displacement of a tooth from its socket due to trauma) and a contusion (bruise) of the face. Staff also failed to complete a safe gait belt (assistive device used to help prevent falls during transfers) transfer for one resident (Resident #2). The sample size was three. The census was 53. Review of the facility's Safety and Supervision of Residents policy, dated July 2017, showed: -Policy Statement: The facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities; -Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; -Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards, and try to prevent avoidable accidents; -The individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents; -The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents; -The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices; -Implementing interventions to reduce accident risks and hazards shall include the following: -Communicating specific interventions to all relevant staff; -Assigning responsibility for carrying out interventions; -Providing training, as necessary; -Ensuring that interventions are implemented; -Documenting interventions. -Monitoring the effectiveness of interventions shall include the following: -Ensuring that interventions are implemented correctly and consistently; -Evaluating the effectiveness of interventions; -Modifying or replacing interventions as needed; -Evaluating the effectiveness of new or revised interventions; -The facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and then adjusts interventions accordingly; -Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. Review of the facility's Gait Belt Use Guideline, dated February 2023, showed: -Purpose: A gait belt is a safety device made of cloth that buckles securely around a resident's waist. The device provides a secure grasping surface to aid during transfer and ambulation. Commonly used for residents who are at risk for falls and those who require assistance during transfer; -If the resident has one-sided weakness, position the destination surface (wheelchair, commode, or chair) on the resident's unaffected side; -Position yourself close to the resident to face each other; -Grasp both sides of the gait belt using an underhand grip; -While firmly gripping the gait belt, keep your back straight, bend your knees slightly, position your feet in a wide stance to maintain proper body mechanics and begin rocking back and forth to overcome forces resisting transfer. Instruct the resident on a count of three to push off of the surface to encourage independence; -Allow the resident to stand for a moment to ensure balance; -Instruct the resident to pivot and to bear as much weight as possible on the unaffected side. Support the affected side because the resident will tend to lean to this side; -Pivot on your back foot, guiding the resident to the destination surface. Maintain contact between the destination surface and the resident's legs to ensure proper positioning prior to the resident sitting; -Flex your knees and hips while assisting the patient onto the destination surface. Using good body mechanics prevents back injury by supporting weight with large muscle groups; -After reaching the destination surface, keep a firm grip on the gait belt and gently lower the patient onto the surface. Tell the patient to reach and grasp the arm resets using them to bear some weight if possible; -If the resident loses weight bearing ability during ambulation or transfer, maintain your grip on the gait belt, pull the resident as close to your body as possible and gently slide them to the floor using the large muscles in your upper leg; -Alert the nurse immediately. 1. Review of Resident #1's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/27/24, showed: -Cognitively intact; -Impairment on both sides of upper and lower body; -Dependent for toileting and bed mobility; -Always incontinent of bowel and bladder; -Diagnoses included debility (physical weakness), dementia, diabetes mellitus, atrial fibrillation (a-fib, irregular heart rhythm), depression and psychotic disorder; -Used a pressure reducing device for bed. Review of the resident's physical therapy Discharge summary, dated [DATE], showed: -Dependent for all mobility; -Dependent for all bed mobility, including rolling left to right; -There was no documentation showing if bed mobility required a one or two person assist. Review of the Primary Care Provider's (PCP) progress note, dated 8/13/24, showed: -Chief complaint was skilled therapy evaluation; -The resident was overweight; -The resident reported limited range of motion, muscle stiffness and stiffness localized to one or more joints; -The resident reported confusion, gait abnormality, difficulty with balance and poor coordination; -The resident's motor strength of his/her arms was normal; -The resident had lower body weakness, lack of coordination and impaired balance; -There was no documentation showing the resident's bed mobility status and/or an order for therapy to evaluate the resident. Review of the resident's progress notes, showed: -8/19/24 at 9:30 P.M., the nurse was alerted to come to the resident's room. Upon arrival the nurse saw the resident was on the floor, on the side of his/her bed lying close to the wall on his/her stomach. The resident's arms were straight at his/her sides and his/her legs were stretched out straight. The resident was rolled over to his/her back by multiple staff members. The resident had a small amount of blood on his/her lips and on the side of his/her face, and a hematoma (collection of blood that pools under the skin) on the right side of his/her forehead. The PCP, resident's responsible party (RRP), Nursing Supervisor and Director of Nursing (DON) were notified. The resident was ordered to go out to the emergency room for evaluation. Review of the hospital discharge documents, dated 8/19/24, showed: -The resident was seen for a fall and head injury; -Diagnoses included fall, compression fracture of T7 vertebra, compression fracture of T10 vertebra, compression fracture of T12 vertebra, tooth avulsion and contusion of face. Review of Certified Nurse Assistant (CNA) D's written statement, dated 8/19/23, showed: -He/She was providing perineal care (peri-care, washing the front and back of the hips, genitals, anal area and buttocks) for the resident; -He/She rolled the resident to the left side of the bed, reached for wipes with one hand and held the resident in place with his/her other hand; -The resident rolled closer to the edge of the bed and CNA D was not able to catch the resident or bring the resident back towards him/her; -The resident rolled out of the bed, face down on the floor; -He/She called out for help and the nurse came to assess the resident; -The resident was sent out to the hospital. Review of CNA D's written statement, dated 8/21/24, showed: -He/She was cleaning the resident and the resident was actively incontinent of bowel, so the CNA went to get more wipes; -The bed started moving and the resident fell over so fast the CNA was unable to catch him/her; -He/She did not remember the resident calling out he/she was falling; -It all happened so fast; -He/She did not get assistance because the resident had always been a one person assist. Review of the resident's progress notes, dated 8/20/24 at 4:10 A.M., showed the resident returned from the hospital to the facility. The resident had new diagnosis of fall, compression fractures of thoracic vertebrae (located on the spine at mid-back) at T7, T10 and T12, a tooth avulsion and a contusion of the face. Review of the resident's care plan, dated 8/23/24, showed: -Problem: Activities of Daily Living (ADLs) self-care performance deficit related to activity intolerance, fatigue and impaired balance; -Interventions included the resident requires max assist of two staff for repositioning and turning in the bed frequently and as necessary -There was no documentation showing bed mobility transfer status prior to the updated care plan on 8/23/24. Review of the resident's [NAME] (summary of resident's information, such as medications, care instructions, and follow ups), dated 8/27/24, showed no documentation regarding one or two person assist for bed mobility. Observation of the resident on 8/27/24 at 8:15 A.M., showed: -The resident lay on a low air loss mattress (LALM), breathing in short, shallow breaths, with his/her eyes closed and grimacing in pain; -The resident had a raised lump located above his/her bruised right eye and a brown dried substance trailed out of the right side of his/her mouth; -The resident's left arm had a dark, raised bruise located above the elbow and a dark bruise located on his/her lower forearm. During an interview on 8/27/24 at 8:16 A.M., the resident said: -He/She was in a lot of pain; -His/Her right eye was painful and felt heavy; -His/Her back and left shoulder really hurt; -He/She sometimes felt like he/she wanted it all to end; -Sometimes two people moved him/her in the bed, sometimes it was only one; -He/She remembered telling CNA D to get help to move him/her in the bed because he/she did not feel safe with the CNA doing it by him/herself; -CNA D did not listen to the resident's request and replied he/she could do it by him/herself; -The resident asked CNA D again to get a second person to help move him/her in the bed, as it would make the resident feel more comfortable, safer; -CNA D proceeded to roll the resident over towards the wall and then all hell broke loose; -The resident could not remember if the CNA was holding him/her; -The resident called out that the bed was moving and he/she was sliding; -CNA D replied Hold on, hold on but there was nothing for the resident to hold on to; -The resident fell partly off the bed to the floor hitting his/her left shoulder and head on the floor; -The resident thinks his/her lower body was still on the bed and must have slid off after his/her upper body hit the floor; -The resident couldn't remember anything else but excruciating pain; -Staff did not always listen to the resident when he/she asked for a second staff member to help with transfers. Sometimes staff got a second person to help but most of the time they did not. During an interview on 8/27/24 at 10:32 A.M., Licensed Practical Nurse (LPN) C said: -He/She was just coming on assignment on 8/19/24 when he/she was called to the room to assist the resident off the floor; -The bed was up pretty high, as CNA D was rather tall, and the resident was lying face down on the floor between the bed and the wall; -He/She helped roll the resident over and saw the resident had a bruise in the middle of his/her forehead, a little blood on his/her lips and the resident's face looked pale and swollen; -He/She was not sure what the resident's bed mobility transfer status was before the incident on 8/19/24; -He/She expected CNA D to get a second person to help move the resident in his/her bed for safety as the resident was weak and on a LALM which was slick and increased the risk of the resident falling off the bed. During an interview on 8/28/24 at 12:39 P.M. and at 1:48 P.M., the Director of Therapy said: -When a resident rolls to one side on a LALM, the mattress would deflate underneath the body pressure which would increase the risk of falling off the bed, especially if there was not another person on the side of the resident to support them; -It was not safe practice to roll a resident on a LALM unassisted; -He expected two nursing staff to assist the resident with bed mobility before the incident on 8/19/24; -He was not sure if that was ever told to nursing staff; -The therapy documentation only specifies maximum assist or moderate assist which did not specify if one or two staff members were required. During an interview on 8/30/24 at 11:45 P.M., the Administrator said: -She did not know what the resident's transfer status for bed mobility was prior to the accident that occurred on 8/19/24; -Therapy verbally told her the resident was a one person transfer for bed mobility and the nursing staff agreed; -She expected the resident's transfer status for bed mobility to show if it was one or two person assist and be documented in the resident's care plan, [NAME] and therapy screen so all staff knew how to safely transfer the resident; -CNA D did not make the correct decision to move the resident by him/herself. It was not a safe or good decision, and regardless if the CNA thought he/she could move the resident independently, the resident asked for a second person; -She expected CNA D to stop his/her care, put the resident in a safe position on the bed and to go get a second person to assist for safety. Review of the facility's final summary, dated 8/23/24, showed: -The employee failed to obtain assistance even after the resident requested and failed to ensure bed wheels were in locked position; -The resident did fall out of the bed; -The incident occurred but it was an accident; -The employee failed to follow safe practices, respond to request for additional assistance and be aware of the resident's surroundings. 2. Review of Resident's #2's hospice (specialized care for those with anticipated life expectancy of six months or less) documents, showed: -admitted to hospice on 2/8/24; -Long-term Care/Hospice Coordination of Care Form, dated 2/8/24, showed medical equipment required by the patient included a Broda chair (a specialized reclining chair propelled by staff). Review of the resident's physician orders, showed an order, dated 3/22/24, for Occupational Therapy (OT, treatment to improve ability to perform daily tasks) evaluation and treatment as indicated for transfer status and positioning. Review of the resident's electronic medical record (EMR), showed there was no documentation showing OT evaluated the resident following the 3/22/24 order. Review of the resident's quarterly MDS, dated [DATE], showed: -Severe cognitive deficit; -Impairment on one side of upper body; -Required maximal assistance for bed mobility and transfers; -Diagnoses included kidney failure and dementia; -Received hospice services. Review of the resident's care plan, dated 6/3/24, showed: -Problem: activities of daily living (ADL) self-care performance deficit related to cognitive impairment, gait and balance impairment, generalized weakness and decreased mobility; -Interventions included monitor resident/document/report any changes, reasons for self-care deficit, declines in function; Pad sit to stand lift (mechanical lift used to transfer resident from one seated surface to another) with soft pad to prevent skin issues. Review of the Morse Fall scale (fall risk assessment tool), dated 7/29/24, showed the resident had a high risk of falling. Review of the resident's hospice documents, showed: -A nursing recertification assessment, dated 7/30/24, showed the resident required two assist for all transfers; -A nursing visit, dated 8/8/24, showed the resident required maximal assistance with transfers and care; -There was no documentation of a therapy evaluation found. Review of the resident's [NAME], dated 8/27/24, showed the resident was able to transfer with a gait belt and one staff assist. Observation on 8/27/24 at 8:23 A.M., showed the resident lay in his/her bed while CNA A dressed the resident in clean clothes. The resident did not respond to any directions, did not speak, open his/her eyes or move his/her body independently during CNA A's care. Observation on 8/27/24 at 8:55 A.M., showed: -CNA A and CNA B provided care to the resident while he/she lay in his/her bed; -CNA A placed his/her hands under the resident's shoulders and pulled the resident up from a lying position to a seated position, then swung the resident's legs from on top of the bed, to the side of the bed; -CNA A held the resident upright with his/her left arm encircling around the resident's back while trying to put the gait belt in place around the resident's waist with his/her right hand; -CNA B helped secure the resident's gait belt around his/her waist while CNA A held onto the resident's left shoulder to keep the resident upright; -The resident did not support his/her own body in an upright position and did not respond to directions or open his/her eyes while the CNAs put the gait belt in place; -The gait belt was very loose, hanging off the resident's waist to his/her lap; -CNA A positioned him/herself on the resident's left side, looped his/her right arm under the resident's left underarm and reached behind the resident to grab on to the resident's gait belt and the back of the resident's pants with his/her left hand; -CNA B positioned him/herself on the resident's right side, looped his/her left arm under the resident's right underarm and reached behind the resident to grab on to the back of the resident's pants with his/her right hand; -Both CNAs lifted the resident up from his/her seated position on the bed and, without the resident's feet touching flat on the floor, put the resident into his/her Broda chair; -The resident did not support his/her own weight when standing, did not pivot, speak or open his/her eyes during the transfer. During an interview on 8/27/24 at 11:18 A.M. and at 12:27 P.M., CNA A said: -He/She knew a resident's transfer status from the EMR under task charting for ADLs; -The resident was a two person gait belt transfer; -Gait belts were placed around a resident's waist with a two finger gap between the gait belt and the resident's body to avoid the resident slipping out of the gait belt during transfer; -When two staff members transfer a resident with a gait belt, one staff member should be on each side of the resident, hook one arm under the resident's underarms while using their opposite hands to grasp the side of the resident's gait belt to assist the resident to a standing position; -Residents are expected to support their own weight during a gait belt transfer; -Pulling a resident up by their shoulders, a loose gait belt and/or the back of the resident's pants increases the risk of a resident falling to the ground, injury to their body or trauma to their skin; -He/she did not know why he/she did not use safe gait belt technique for the resident. During an interview on 8/27/24 at 12:48 P.M., CNA B said: -Gait belts were used to transfer a resident safely; -Gait belts were placed around the resident's chest with a gap large enough to put a hand between the gait belt and the resident's body; -Nursing staff were expected to hook their hands under the gait belt at the back of the resident and in the front of the resident when pulling them up to a standing position; -Pulling a resident up by their shoulders, a loose gait belt and/or the back of the resident's pants increases the risk of a resident falling to the ground, injury to their body or trauma to their skin; -He/she did not know why he/she did not use safe gait belt technique for the resident; -He/She found out transfer status from the nurse at the beginning of his/her assignment and did not know where else to find the information; -He/She was asked by CNA A to assist in the resident's transfer; -He/She did not know if the resident was safe to transfer with a gait belt with two staff member assist. During an interview on 8/27/24 at 12:56 P.M., LPN C said: -He/She expected nursing staff to follow the gait belt policy to ensure resident's safety; -Pulling a resident up by the back of their pants or holding them up by their shoulders puts the resident at risk of injury and did not respect a resident's dignity; -The resident was a two person assist with gait belt according to the resident's chart. During an interview on 8/27/24 at 1:31 P.M., the Administrator said: -She expected nursing staff to place a gait belt at the resident's chest, with a two finger gap, put one hand under the gait belt at the back of the resident and one hand under the gait belt at the side of the resident to assist the resident to a standing position; -Residents were at risk of falling if a gait belt was too loose or not used appropriately; -Residents were at risk of injury to their joints and/or trauma to their skin if nursing staff pulled residents up by their limbs or the back of their pants; -Residents were expected to stand, supporting their own weight, and pivot to transfer from one surface to another with a gait belt; -She expected nursing staff to alert the nurse if a resident was not able to support their own weight and then use a mechanical lift to transfer the resident for safety; -She expected nursing staff to know resident's transfer status and to inquire of their supervisors or the therapy department if there were any questions. During an interview on 8/28/24 at 12:39 P.M. and at 1:48 P.M., the Director of Therapy said: -He expected nursing staff to place a gait belt between a resident's waist and chest and the best practice was placement under the belly button; secured with a couple of fingers' gap between the belt and the resident's body; -He expected during a two person gait belt assist for staff members to stand one on each side of the resident, hook their arms under the resident's arm and then grab the back of the gait belt to assist the resident to a standing position; -Residents needed to be able support their own weight and pivot during a gait belt transfer; -It was not appropriate for nursing staff to lift and move a resident from one surface to another. It increased the risk of injury to the resident, increased fall risk and increased risk of injury to staff; -The nursing staff increased the risk of the resident falling off the bed when the resident had no trunk control, and was not able to support him/herself in an upright seated position; -He expected nursing staff to report any declines or changes in mobility to their nurses in charge, the supervisors or the therapy department; -When the resident went on hospice, his department was told to defer to the hospice team and their evaluations of the resident's ADL capabilities; -He believed the last time the resident was evaluated by his department was in April or March and the resident was appropriate for a gait belt transfer. He could not recall if the resident was appropriate for a one or two person gait belt transfer at that time. 3. During an interview on 8/27/24 at 10:10 A.M., LPN C said: -Nursing staff was informed of residents' transfer status by the therapy department, either verbally or by putting transfer status in the residents' EMR; -Nurses relay residents' transfer status at the beginning of the shift and CNAs could also access residents' transfer status by looking at the [NAME]; -Two staff members were sometimes needed for bed mobility or transfers if the resident was immobile, especially if the CNA was not able to move/support the resident's weight on their own; -He/She expected therapy to designate if a resident was a one or two person assist when a resident was dependent with any ADLs; -He/She expected CNAs to ask for help during any type of care, including moving residents in bed or during transfers, in order to keep residents safe. During an interview on 8/30/24 at 11:39 A.M., the Administrator said: -She expected nursing staff to have knowledge of and to follow facility policies; -The therapy department evaluated new admissions and readmits, and after a new event. They screen to determine if further therapy was needed and made the determination how the resident would transfer; -Therapy educated clinical staff on residents' transfer status; -She expected nurses to report transfer status of residents to other staff and update the care plan if needed; -She expected MDS staff to include residents' transfer status in their care plan and on their [NAME]; -She expected therapy to notify nursing staff of specific directions for transfers, bed mobility and to signify if a one person or two person assist was necessary for safety. MO00240878

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to thoroughly and accurately assess, document, and notify the physician of a change in condition sustained by two of 14 sampled residents (Residents #44 and #36) and one closed record (Resident #306). Resident #44 had a diagnosis of congestive heart failure and history of fluid retention. The facility failed to monitor and report the resident's weight gain and respiratory changes. Resident #44 was transported to the hospital and administered intravenous Lasix (diuretic). Resident #306 experienced symptoms of confusion and inability to use a motorized wheelchair. The facility received orders for lab work on 6/6/24 and critical lab results were sent to the facility on 6/7/24. Resident #306 continued to experience a change in condition that included inability to use utensils and increased confusion. Between 6/7 and 6/9/24, nursing staff failed to notify the physician of the critical labs and the resident's worsening status until 6/10/24. The resident was transported to the hospital with diagnoses of acute kidney failure and urinary tract infection. The facility also failed to order a urinalysis for Resident #36, who went to the hospital one week later with a diagnosis of kidney infection. The census was 53. Review of the facility's Change in Resident's Condition or Status policy, revised August 2008, showed: -The Director of Nursing (DON) or designee will notify the resident's Attending Physician or On-Call Physician when there has been: -An accident, incident, unusual occurrences, abuse situation, or allegation of abuse involving the resident (ex: choking episodes and etc.); -A discovery of any injury - with cause known or unknown; -A reaction to medication/medication error; -A significant change in the resident's physical/emotional/mental condition; -A need to alter the resident's medical treatment significantly; -Refusal of treatment or medications as clinically appropriate; -A need to transfer the resident to a hospital/treatment center; -A discharge without proper medical authority (Against Medical Advice); and/or -Instructions to notify the physician of changes in the resident's condition; -A significant change of condition is a decline or improvement in the resident's status that: -Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not selflimiting); -Impacts more than one area of the resident's health status; -Requires interdisciplinary review and/or revision to the care plan; -The final decision regarding what constitutes a significant change in status is based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument; -DON or designee will notify the resident/ legal representative when: -The resident is involved in any accident, incident or unusual occurrence with or without injury including injuries of an unknown source; -Abuse situations, or allegations of abuse; -There is a significant change in the resident's physical. mental. or psychosocial status; -There is a need to change the resident's room assignment; -A decision has been made to discharge the resident from the facility; -It is necessary to transfer the resident to a hospital/treatment center; -Notification will be made as soon as possible (within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status.). In medical emergencies notification should be made as soon as possible after occurrence of the event; -The DON or designee will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status; -If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted as required by current Omnibus Budget Reconciliation Act (OBRA) regulations governing resident assessments and as outlined in the Minimum Data Set (MDS) 2.0 RAI Instruction Manual; -A representative of business office/ social service will verify the address and telephone number of the resident's family or legal representative on a quarterly basis. Any noted changes will be reported to the Director of Nursing Services to ensure that such information is changed in the resident's medical record; -A representative of the business office will notify the resident, his/her family, or legal representative when there is a change in resident's billing status. 1. Review of Resident #306's medical record, showed: -admitted on [DATE]; -Diagnoses of hypertension (HTN, high blood pressure), chronic kidney disease, constipation, gastroenteritis and colitis (a digestive disease that causes inflammation of the colon's mucosal lining). Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/10/24, showed: -No cognitive impairment; -Diagnoses included hypertension, renal failure, depression, anemia, and asthma; -Always incontinent of bowel and bladder; -Independent with eating at admission; -Uses motorized wheelchair. Review of the resident's care plan, dated 2/2/24, showed: -Focus: Has an Activity of Daily Living (ADL) self-care performance deficit related to weakness and limited mobility. He/She is non-ambulatory and uses a motorized wheelchair for mobility; -Goal: The resident will improve current level of function in transfers; -Interventions: Monitor/document/report PRN (as needed) any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. Review of the resident's progress notes, showed: -On 6/6/24 at 2:50 P.M., Resident exhibiting increased confusion and inability to bear weight. Resident displays difficulty navigating in his/her motorized wheelchair due to gross bilateral lower extremity (BLE), edema and weakness. Informed DON, Physical therapy (PT) assessed and provided regular wheelchair. Resident's transfer status changed to Hoyer lift (mechanical lift) at this time. Call placed to physician's office to report and request order for lab work. Call placed to power of attorney (POA), message left; -On 6/6/24 at 3:44 P.M., Call back from physician's office. Order obtained for complete blood count (CBC, determines general health status and screens for and monitors for a variety of disorders) and basic metabolic panel (BMP, measures several important aspects of your blood). Call placed to lab and informed of need for draw. Phlebotomist will be out on next business day. Requisition completed. Call placed to responsible party (RP), message left; -On 6/7/24 at 11:21 A.M., late entry: lab here for blood draw. Results pending. Review of the resident's vital signs, showed no documentation of the resident's temperature on 6/6 through 6/9/24. No documentation of the resident's respirations on 6/6 through 6/9/24. Review of the resident's critical lab results, showed: -Collection date: 6/7/24 at 10:40 A.M.; -Received date: 6/7/24 at 4:00 P.M.; -Glucose showed 48, critical low (reference range/cut off 82-115); -BUN showed 59, critical high (reference range/cut off 8-23); -Bicarbonate (CO2) showed 13, critical low (reference range/cut off 22-29); -Originally reported on 6/7/24 at 5:25 P.M. Review of the resident's progress notes, showed: -On 6/8/24 at 7:28 P.M., resident requires assists with feeding. He/She not able to use utensils. Resident has increased confusion, able to answer simple yes or no answers. RP informed of changes. Continue on antibiotic therapy for cellulitis (a bacterial infection that affects the deeper layers of the skin and the tissue underneath). Encourage fluids; -No documentation of acknowledgement of critical lab results or notification of change in condition to physician between 6/7 through 6/9/24; -No documentation of an assessment or monitoring the resident's change in condition on 6/9/24; -On 6/10/24 at 7:00 A.M., patient remains on close observation for antibiotic related to cellulitis. Zero complaints of pain or discomfort. Patient was resting in bed all night with eyes closed. Patient appeared to be asleep but easily awaken with call light in reach; -On 6/10/24 at 4:06 P.M., resident exhibits listlessness (a state of having little to no interest in anything, or a lack of energy), malaise (a general feeling of discomfort, uneasiness, or lack of well-being), and disorientation. Final lab results received. Many high and low values as well as critical results. Labs faxed and called to physician's office. Call back received from Physician L. Telephone orders received to send to emergency room for evaluation and treatment for abnormal labs. Call placed to daughter and informed. DON made aware. Call placed to local 911 for transport. Ambulance service had no available units; -On 6/10/24 at 5:02 P.M., Emergency Medical Service (EMS) in facility. Assumed care of resident. Report given. Exited facility in route to emergency room. Report called to nurse. Review of the resident's vital signs, showed: -On 6/10/24 at 4:44 P.M., the resident's temperature was 97.3 degrees Fahrenheit (F). -On 6/10/24 at 4:44 P.M., the resident's respirations were 20 breaths per minute. -No documentation of the resident's blood sugar on 6/6 through 6/10/24; -No documentation of the resident's oxygen saturation on 6/6/ through 6/10/24. Review of the resident's Physician Order Sheets (POS), showed an order, dated 6/10/24, to send to the hospital for evaluation and treatment for abnormal lab values. During an interview on 8/15/24 at 11:48 A.M., the Administrator said they were looking into the resident's labs from 6/6/24, to see when it was reported. They had notes during their clinical meeting about the resident's change in condition. They ordered the labs and they were the ones who sent the resident out as well. They noticed the change in condition. During an interview on 8/15/24 at 1:17 P.M., Licensed Practical Nurse (LPN) M said the results were faxed from the lab and he/she had access to look at the labs as well. The lab company would call the facility and fax any critical labs. If there was a critical lab, he/she would call the physician immediately and give the results. Physician L wanted the resident sent out. LPN M received a verbal order to send the resident out and he/she faxed the lab results. During an interview on 8/15/24 at 1:26 P.M., Receptionist O from the lab company said there was a phone call to the facility attempted on 6/7/24 between 5:30 P.M. and 5:45 P.M. with no answer. The facility has three fax numbers on file, and the lab faxed the lab results to all three fax numbers between 5:26 P.M. and 5:27 P.M. The lab results were uploaded to the online portal as soon as the results were completed. It was instant. There was also an email on file and the lab results were also emailed. He/She read the email address that belonged to RN B. The only confirmation he/she was able to see was the system showed a status of completed. During an interview on 8/16/24 at 8:40 A.M., the DON said if there were critical labs, the lab would call the facility. Critical labs were also faxed and emailed. When she spoke to the lab company, they said they would call and send results to the three fax numbers they had. Nursing was expected to call the physician and fax the lab results to the physician. If they did not get the physician right away, she expected nursing to call back and relay a message. The DON did not have any knowledge of what happened with the lab results for the resident. She expected nursing to contact the physician if a resident had a change in condition. She expected nursing to contact the physician if the resident had a change in condition during the weekend. The resident's oxygen saturation should have been checked and blood sugar as well, regardless if diabetic or not. The DON said the resident's glucose on the lab result would be considered low. The resident's lab results should have been addressed immediately. If staff could not reach the physician, they could call the family and send the resident out to the emergency room for evaluation. During an interview on 8/16/24 at 10:14 A.M., the Social Worker for Physician L said on 6/6/24, the Nurse Practitioner ordered a BMP/comprehensive metabolic panel (CMP, measurement of blood sugar, electrolyte, fluid balance, kidney and liver function). The nurse reported the resident had increased confusion, safety concerns using a manual wheelchair and would be transferred in a Hoyer lift. On 6/10/24, it was reported to the physician there were critical labs. They received labs at 3:15 P.M. Physician L ordered to send the resident to hospital due to critical labs. Staff were expected to call the physician for critical labs. There was no documentation the facility contacted Physician L between 6/7 and 6/9/24, but he/she could not say the facility did not call or if they tried to contact the physician. But they could call the exchange on the weekends. Sometimes there was not a quick turn around with labs, they were seeing a trend. Labs results were not coming in from the lab like they used to. The facility should follow their policy in regards to monitoring and assessment for a change in condition, but the facility had a plan in place and notified the office. They had a safety plan for the resident and the labs were reported to them. If staff continued to have concerns regarding the resident's symptoms, staff could call the exchange on the weekend. During an interview on 8/16/24 at 9:41 A.M., medical assistant for Physician K said the resident had diagnoses of colitis, chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lung), and a skin ulcer on the right heel. The resident was last seen by Physician K on 5/23/24. There was documentation positive for leg swelling, but no chest pain or palpitations. There was no documentation the facility contacted the physician between 6/7 through 6/10/24. The medical assistant read the documentation from the emergency room on 6/10/24. The resident was admitted for acute renal failure and urinary tract infection (UTI). It was documented the resident was discharged back to the facility and eventually went home for hospice care. During an interview on 8/18/24 at 9:36 A.M., LPN T vaguely remembered the weekend of 6/7 through 6/9/24. He/She remembered the resident started to decline. He/She could not recall anything about 6/7/24, but in general, the resident's condition declined more. He/She had more confusion, and already had weakness on one side. He/She did get to a point he/she could not hold utensils. LPN T did not recall receiving any critical labs that weekend or the resident's labs in general. LPN T was not aware of any labs. The resident was definitely slowly declining and had wounds on his/her lower leg. At baseline, the resident was alert, he/she was up, and used a mobilized wheelchair. His/Her left side was weaker than the other side. He/She went to the hospital and was not really the same when he/she came back. He/She had a lot of incontinent episodes of stool and constant bowel movement. LPN T spoke with the resident's POA about the decline. The POA noticed a decline as well and wanted another opinion from Physician K. He/She had started to decline at that point. They had to feed the resident when he/she declined. When he/she had loose stools, the resident stayed in bed. They put the resident in the regular wheelchair. LPN T did not remember notifying anyone at that point during that weekend. They continued to monitor his/her blood pressure and temperature. During an interview on 8/18/24 at 4:32 P.M., LPN U said he/she remembered the resident. In general, he/she remembered working the weekend of 6/7 through 6/9/24. The resident was in the hospital at one point prior to that weekend. The resident was not herself when he/she came back. LPN U remembered that the resident was unsafe in the mobile chair, so they suggested a Hoyer for his/her safety and staff safety. LPN U remembered the resident had labs done, but it was toward the end, right before the resident was sent to the hospital. He/She remembered they were monitoring the resident closely, as they would with a change in condition. They were doing full assessments, mental and physical, and vitals. The resident was alert and oriented and could have a conversation. The nurse did not remember what happened in specifics of assessments on the weekend of 6/7, but they were monitoring the resident every hour. He/She did not have his/her light on, but the rounds were done hourly. He/She could not recall if anyone was notified. If he/she called, it would have been documented. During an interview on 8/16/24 at 12:29 P.M., the Administrator said she expected staff to contact the physician if the resident had a change in condition on 6/8 that showed he/she could not use utensils or required assistance with feeding. Staff should have called the exchange. The change in condition policy was referring to the condition, but a baseline was needed. Staff should get vitals and any assessments that were appropriate for the change that resident was having. Staff should always have baseline vitals so they can compare previous to current. Blood sugar should be checked if they were on dialysis or diabetic, but she would have to see new protocols on that. Oxygen saturation, blood pressure, respirations, and temperature should be obtained. She expected nursing to notify the physician timely for the labs. The Administrator said the resident's critical labs should have been addressed immediately. The only thing that was mentioned to her was the resident had frequent stools. They were discussing the resident having a private room, but it was related to frequent stools. It was the last month before he/she went out. She expected staff to routinely check labs because the resident could become dehydrated due to the loose stools. She expected the resident to be hydrated and receive fluids. They had a plan in place for the frequent stools, as it was discussed in the clinical meeting. The Administrator was not aware of the resident being sent to the hospital prior to 6/10/24. From 6/7 through 6/11/24, the Administrator did not receive any information on the resident. 2. Review of Resident #44's admission MDS dated [DATE], showed: -Severe cognitive impairment; -Required set-up for eating and oral hygiene; -Required supervision for showering and personal hygiene; -Mobility: independent; -Diagnoses included heart failure, high blood pressure, dementia and COPD. Review of the resident's care plan, last revised on 6/5/24 and in use during the survey, showed: -Focus: Resident has congestive heart failure (CHF, a chronic condition that occurs when the heart can't pump blood efficiently enough to meet the body's needs and can cause fluid build up in the body's organs); -Goal: The resident will have clear lung sounds, hear rate and rhythm within normal limits; -Interventions included: -Monitor lab work: Potassium (K+, measures amount of potassium in the blood), Sodium (NA, measures amount of sodium in the blood), blood urea nitrogen (BUN, measures amount of urea nitrogen in the blood), creatinine (measures how well the kidneys are filtering waste form the blood); -Monitor/document PRN any signs/symptoms of CHF: weight gain unrelated to intake, shortness of breath (SOB) upon exertion, dependent edema (swelling that occurs in areas of the body affected by gravity, happens when extra fluid gets trapped in the body's tissues) of legs and feet, perioribital edema (swelling around the eyes due to fluid buildup and inflammation), weakness and/or fatigue. Review of the resident's Physician Orders, showed: -An order, dated 5/3/24, Albuterol Sulfate Inhalation Nebulization Solution (treats sudden episodes of difficulty breathing) (2.5 milligrams (mg)/3 milliliter (mL)), 3 mL inhale orally via nebulizer PRN for SOB/wheezing. Administer one vial four times a day PRN for wheezing/SOB; -An order, dated 5/3/24, apply oxygen (O2) per nasal canula (a device that delivers extra oxygen through a tube into the nose) PRN and check O2 (saturation (sat, amount of oxygen in the blood) every shift PRN for SOB. Notify physician if below 90%; -The order did not specify the flow rate of oxygen; -An order, dated 6/14/24, Advair Diskus Inhalation Aerosol Powder Breath Activated (medication used to prevent SOB and wheezing) 250-50 microgram (mcg)/act, two puff inhale orally, every 12 hours related to other emphysema (COPD); -An order, dated 6/13/24, Albuterol-Budesonide Inhalation Aerosol (used as needed to treat and help prevent asthma (inflammation and narrowing of the small airways in the lungs) symptoms, 90-80 mcg/act, two inhalations inhale orally every four hours as needed for shortness of breath; Dyspnea (feeling like you cannot get enough air, air hunger). Review of the resident's weights, showed: -5/3/24, 127.6 pounds (lbs); -5/16/24, 130.2 lbs; -5/21/24, 128.8 lbs; -5/31/24, 128.5 lbs. Review of the resident's progress notes, showed: -A Nutrition/Dietary note dated 5/31/24 at 11:59 A.M., New Admit Note; Resident able to make needs known. Resident on a low-calorie sweeteners (LCS, sugar substitutes used), no added salt (NAS) diet. Regular texture. Thin consistency. Resident is particular about diet and practices a vegetarian lifestyle. Resident has no concerns of chewing or swallowing. Resident has a moderate appetite--consumes 75-100% of meals. Resident is independent with meals. 5/31: 128.5 lbs. Will continue to follow and intervene as needed. Review of the resident's weights, showed: -6/12/24, 134.8 lbs. Review of the resident's progress notes, showed: -A Weight Change note, dated 6/21/24 at 4:38 P.M., Weight Change Warning: Value: 134.8 lbs. Vital Date: 6/12/24 3:38 P.M., +5.0% change. Registered Dietician (RD) recommends notifying the physician of weight gains with history of fluid retention. Follow as needed; -No documentation staff contacted the resident's physician regarding the increase in weight; -A Nurses note, dated 6/26/24 at 2:21 A.M., Weekly weight obtained, 138.8 lbs standing; -No documentation staff contacted the resident's physician regarding the increase in weight. Review of the resident's weights, showed: -6/26/24, 138.8 lbs; -7/3/24, 138.8 lbs. Review of the resident's progress notes, showed: -A Weight Change note, dated 7/10/24 at 11:54 A.M., Weight Warning: Value: 138.8. Triggered for previous weight gain trends, remains stable with no new recommendations, follow as needed; -No documentation staff contacted the resident's physician regarding the increase in weight; -An Order note, dated 7/22/24 at 2:26 P.M., Nurse Practitioner (NP) in to see patient. New orders received for labs: CMP, CBC, thyroid stimulating hormone (TSH, indicates how the thyroid gland is functioning), hemoglobin A1C (HgBA1c, measures the average amount of blood sugar), lipid panel (measures for cardiovascular disease), Vitamin D and B12; -An Order note, dated 7/22/24 at 2:28 P.M., Lab tech in to draw labs today; -A Nurses note, dated 7/24/24 at 11:38 A.M., Labs faxed to resident's physician's office with the following abnormals noted: mean corpuscular hemoglobin concentration 31.9 low (MCHC, blood test that measures average concentration of hemoglobin red blood cells. Normal range is 32-36), HgBA1c 6.0 high (normal range is below 5.7%), Creatinine 1.35 high (normal range is 0.6-1.1) and eGFR 39 low (a test that measures how well the kidneys filter waste and toxins in the blood, normal range is 90 or higher). Review of the resident's vital signs for August 2024, showed: -On 8/6/24, respiration 18 breaths per minute; -On 8/6/24, O2 saturation of 96% at room air. Review of the resident's weights, showed: -8/7/24, 143.8 lbs; -The resident had an 11.9% weight gain in three months. Observation and interview on 8/12/24 at 11:50 A.M., showed the resident sat on his/her rollator in the hallway. He/She said he/she was resting. The resident said he/she just finished a breathing treatment. A nebulizer mask (a device that allows a person to inhale liquid medicine in the form of a mist that goes directly into their lungs) was observed on the resident's bed. The resident said he/she received treatments when out of breath. An O2 concentrator (a medical device that takes in air from the room and filters out nitrogen to provide higher concentrations of oxygen for breathing) sat next to the resident's bed. The resident said he/she used it at night and whenever he/she was out of breath. He/She said it should be set on two liters (L, flow rate). Observation showed the concentrator was set at 2 L. Observation and interview on 8/13/24 at 8:55 A.M., showed the resident lay in bed on his/her side and wore a nebulizer mask. He/She said he/she felt weak today. The nurse was aware and that's why he/she was doing a breathing treatment. Observation on 8/13/24 at 2:08 P.M., showed the resident lay in bed on his/her side. He/She wore the nasal canula to receive oxygen. The concentrator was set at 2 L. Review of the resident's progress notes, dated 8/13/24 at 2:31 P.M., showed the resident was complaining of weakness and SOB when walking. Vital signs (VS) are 127/82 (blood pressure, normal range is 90/60 - 120/80), 78 (pulse, normal ranges is 60-100 beats per minute), 20 (breathing, normal range is 12-18 breaths per minute), 98.6% (oxygen saturation, normal range is 95% -100% while resting) on room air, lung sounds. Medical doctor (MD) made aware and verbal order given for chest x-ray. X-ray, vendor called and scheduled. Observation on 8/14/24 at 9:18 A.M., showed the resident lay in bed on his/her side. The resident's nasal canula was next to him/her on the bed. Review of the resident's August 2024 Medication Administration Record (MAR), showed staff did not document administering the PRN nebulizer treatments, PRN oxygen or PRN O2 saturation. Review of the resident's vital signs for August 2024, showed: -No other documentation regarding the resident's respiratory status. Review of the resident's progress notes, showed: -On 8/14/24 at 2:32 P.M., a Weight Change note, Weight Warning: Value 143.8 lbs. +7.5% change, +10.0% change. Resident reviewed by RD for weight gain trends., recommend contacting the physician to notify of gains with history fluid retention and cardiac concerns; -On 8/14/24 at 5:39 P.M., a Nurses note, Skilled received orders to send patient to emergency room for evaluation and treatment related to SOB, increased activity intolerance and decreased endurance, productive cough green and brown sputum (phlegm), noted and reported signs and symptoms; -On 8/15/24 at 6:30 A.M., Nurses note, Patient was admitted to hospital with diagnosis of CHF exacerbation. During an interview on 8/15/24 at 9:04 A.M. and 1:05 P.M., Registered Nurse (RN) B said the resident went out to the hospital at 6:06 P.M. on 6/14/24. There was a chest x-ray ordered, but the results hadn't been received. Yesterday the resident had increased SOB when walking and green/brown sputum. The MD saw the resident the day before. The resident did not have a lot of edema, it was more SOB. The resident's condition was getting progressively worse. If a resident felt lethargic or had SOB, RN B would check the resident's O2 saturation. He/She was not sure what the facility's standard was for checking O2, but he/she would check it to make sure it was within range. RN B was not sure how dietician recommendations were processed or who put them in place. RN B saw nutritional notes in the resident's record. If he/she received an order for labs, he/she would make a progress note and put the order in and then fax it to the lab. Once the lab results were received, if they were critical, the doctor should be called. If they were not critical, then they would be faxed. There should be a follow up note on the lab results to say if the doctor gave new orders or not. During an interview on 8/15/24 at 9:51 A.M., the RD said she had concerns about the resident's elevated weight caused by fluid retention. She provided her feedback within 48 hours of reviewing a resident. She did not receive any response from facility staff regarding her June recommendation to notify the doctor of the resident's significant weight increase. RD recommendations were sent to the Administrator and DON, who then contact the physician. Usually nursing would follow through if there's an order. During an interview with the Administrator and DON on 8/16/24 at 9:37 A.M., the Administrator said the nurse should have contacted the doctor regarding the resident's increased weight especially since he/she had CHF. If the resident became more labored with breathing, staff should have monitored him/her more frequently. If the resident used continuous O2, it should have been documented somewhere. Staff should have documented their monitoring and observations of the resident. The resident's vitals should have been documented. There could have been additional monitoring and interventions with the resident's change in condition. 3. Review of Resident #36's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Moderate to total staff assistance needed for hygiene, toileting, mobility and transfers; -Always incontinent of bowel and bladder; -Had a urinary tract infection (UTI) in the last 30 days; -Diagnoses included diabetes, stroke, paralysis, heart failure and Alzheimer's disease. Review of the care plan, in use during the survey, showed: -Focus: Bladder incontinence; -Goal: the resident will remain free of UTI's; -Interventions: encourage fluid throughout the day, keep skin clean and dry, labs/diagnostics as ordered and report to the physician, monitor and document for a UTI such as pain, burning, blood tinged urine, foul smelling urine, fever and change in mental status. Review of the progress notes, dated 7/14/24 at 2: 50 P.M., showed the resident complained of burning upon urination. Upon assessment, hematuria (blood in the urine) noted. Physician notified and new order given to obtain a urinalysis (UA) and culture. Staff may straight catheterize (a procedure that involves inserting a hollow, soft-tipped urinary catheter into the urethra and into the bladder to drain urine) if needed. Review of the POS, showed no documented orders for the urinalysis and culture. Review of the progress notes from 7/14/24 through 7/22/24, showed no documentation regarding the ordered UA testing or resident urinary status. Review of the progress notes, showed: -On 7/23/24 at 10:12 A.M., the resident placed into the bed to obtain the UA sample. Staff attempted twice. No UA sample obtained; -On 7/23/24 at 12:35 P.M., NP notified the resident had a mental status change. Staff attempted twice to obtain UA sample with no results. [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one resident who re-admitted to the facility with an identified Stage II pressure wound (a partial thickness loss of the skin epidermis and dermis that appears as an open wound or blister) to the coccyx (tailbone) did not develop worsening or additional skin wounds. The facility failed to conduct re-admission wound measurements, transcribe hospice wound care orders, and notify the physician of the wound. As a result, the wound the resident had on admission got larger and appeared to have slough (moist dead tissue) that developed which is consistent with a Stage III pressure injury (full tissue loss) (Resident #9). The sample size was 14. The census was 53. Review of the state operations manual, showed the following definitions for staging pressure ulcers: -Stage 2 Pressure Ulcer: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present; -Stage 3 Pressure Ulcer: Full-thickness skin loss Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss. Review of the facility's undated pressure/skin breakdown protocol, showed: -Policy specifications: -Document the significant risk factors for developing pressure sores, such as immobility, weight loss and history of pressure wounds; -The nurse shall assess and document/report the following: -Full assessment of the skin condition including but not limited to the location, stage, partial (extends partially into the muscle) or full (extends through all muscle tissue) thickness, length, width, depth and presence of exudate (drainage) or necrotic (black, dead) tissue; -Pain assessment; -The resident mobility status; -Current treatments, including supportive devices; -All active diagnoses; -Examine the skin of any new admission for any alterations of skin integrity; -The physician will assist staff define the type of ulceration; -Identify the factors contributing or predisposing residents to skin breakdown, such as medical comorbidities and macerated (breakdown caused by frequent wetness) or friable (thin, delicate) skin; -Document any signs/symptoms of infection, skin condition assessment, the impact of other diagnoses on wound healing; -The physician will give orders related to wound treatments, including pressure redistribution surfaces, wound cleansing and debridement (surgical removal of dead tissues) approaches, dressing and application of topical agents; -The physician will help identify medical interventions related to the wound management; -The physician will help staff characterize the likelihood of wound healing; -As needed, the physician will help identify medical and ethical issues influencing wound healing. Review of Resident #9's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 5/4/24, showed: -Moderate cognitive impairment; -Does not resist care; -Physical impairment one side upper extremity; -Staff provided substantial to maximum assistance: toileting, bathing, dressing, repositioning, and bed mobility; -Diagnoses included: heart failure, diabetes, stroke, paralysis, depression and malnutrition; -At risk to develop pressure injury; -Had moisture associate skin damage (MASD, inflammation or skin erosion caused by prolonged exposure to moisture); -No pressure injury; -Used a pressure reducing device on the bed; -Application of ointments other than to feet. Review of the resident's care plan, in use during the survey, showed: -Focus: potential for impaired skin integrity and pressure ulcer development related to bowel and bladder incontinence, and requiring assistance for daily care; -Goal: The resident will have intact skin, and be free of redness; -Interventions: Staff administer treatments as ordered, assist with repositioning, follow facility protocol for prevention of skin breakdown, monitor skin with routine care and immediately notify the nurse of changes, and weekly skin assessments. Review of the facility wound report, dated 6/7/24 through 8/7/24, showed the resident not listed. Review of the progress notes, showed on 8/9/24 at 9:49 A.M., a nurse note: the resident re-admitted to the facility from. He/She had a Stage II to the sacrum (tailbone) and a dressing in place. He/She is awaiting hospice evaluation. Review of the resident's re-admission Braden scale (assessment tool commonly used in health care to assess and document a client's risk for developing pressure ulcer) risk assessment, dated 8/9/24, showed a score of 9 or very high risk to develop pressure injury Review of the resident's progress notes, showed on 8/9/24 at 10:40 A.M., a nurse documented the resident was assessed and admitted into hospice services. Currently awaiting orders. Review of the resident's hospice admission assessment, dated 8/9/24, showed: -Wound protocol: -Wound #1: Pressure injury, lower back-tailbone; -Skin prep (protective barrier wipe); -Cover with foam border dressing; -Change every day and as needed (PRN). Review of the resident's electronic Physician Order Sheet (ePOS), reviewed on 8/12/24 at 4:17 P.M., showed no orders for wound care or wound treatments. During observation and interview on 8/14/24 at 7:42 A.M., Certified Nurse Aide (CNA) J entered the resident's room and assisted the resident to stand at the bathroom grab bars and removed the resident's pants and brief. CNA J said the resident had an open wound on the left buttock and added the resident recently returned from the hospital. CNA J said the wound had a treatment yesterday morning, and the dressing fell off yesterday afternoon, he/she told the nurse yesterday. He/She started the shift today at 6:30 A.M. and he/she did not see a treatment in place at morning care. Observation of the resident's left upper buttock and the left mid-buttock showed two open, uncovered wounds. The wounds appeared red and approximately nickel sized. CNA J cleaned and dried the wounds. CNA J applied skin barrier ointment to the wounds and buttock area. CNA J reapplied the brief, and pulled up the resident's pants. CNA J assisted the resident into the main dining room and did not notify the nurse of the open areas. Review of the resident's medical record, reviewed on 8/14/24 at 11:53 A.M., showed no documentation of wound care orders, wound assessment, or wound measurements. During an observation and interview on 8/14/24 at 1:09 P.M., Licensed Practical Nurse (LPN) C said he/she re-admitted the resident to the facility on 8/9/24. The resident was admitted to the facility with a small open area close to his/her coccyx area. The resident was admitted to hospice services on 8/9/24. He/She was the nurse on duty and he/she spoke to the hospice nurse after the admission. He/She last worked at the facility on 8/9/24. LPN C said he/she was not notified of any additional wounds by any nurse or aide and added the resident did not have current wound care orders in the medical records. LPN C entered the resident's room [ROOM NUMBER]/14/24 and removed the sheet and exposed the resident's buttocks. LPN C said there were multiple open wounds to the resident's left inner upper and midline buttock. The two wound measurements noted: -Left upper, inner buttock: Stage II pressure ulcer (PU): 2.0 centimeter (cm) x 0.8 cm x 0 cm. Skin gray and slough noted, surrounding tissue red and inflamed; -Left midline buttock: Stage II PU: Measured 0.5 cm x 0.4 cm x 0.0 cm. Surrounding tissue red, inflamed. When LPN C cleaned the area, the resident said Ouch, stop, it hurts. -In addition, there were approximately 6 additional open wounds scattered across the left buttocks, LPN C said the wounds appeared from shearing. LPN C said the resident had more wounds since he/she returned to the facility. The wound near the tailbone, that he/she had assessed upon re-admission, had gotten larger and appeared to have slough. LPN C said he/she did not notify the physician of the wound near the tailbone when the resident re-admitted to the facility. The resident was admitted to hospice services, and LPN C assumed the hospice provider would obtain wound care orders. The hospice provider did not notify LPN C of any wound care orders after admission into hospice. On 8/14/24 at 2:21 P.M., LPN C reviewed the hospice plan of care binder. He/She noted the wound care orders and said the wound care orders did not get entered into the medical records. The aides should have reported the changes in the skin since the resident's re-admission. If aides notice a change in the skin or no treatments, they should notify the nurse immediately so an assessment and treatment can be applied. The resident should have an air mattress, the resident currently had a standard mattress. LPN C would notify the hospice provider of the skin condition and obtain orders. Review of the resident's medical record, reviewed on 8/15/24 at 6:50 A.M., showed no wound measurements from 8/14/24 and no physician or hospice notifications. Observation on 8/15/24 at 7:48 A.M., showed the resident asleep in bed, on his/her back on a standard mattress, with a brief noted in place. During an interview on 8/15/24 at 7:49 A.M., LPN C said he/she had forgotten to document the wound assessment from 8/14/24. He/She called the hospice provider on 8/14/23 and requested wound care orders. The hospice provider had not responded before he/she left work after 7:00 P.M., on 8/14/24. LPN C did not call the physician to obtain wound care orders and continued to wait for the hospice provider to respond with orders as of the time of the interview. LPN C said hospice should obtain orders for the wound care. During an interview on 8/15/24 at 7:55 A.M., the Director of Nursing (DON) said she had been employed at the facility since July 2024. the facility did not have a wound care nurse, and the DON was recently notified by the Administrator that she was responsible for tracking wounds. She expected aides to immediately notify the nurse of any skin changes. The nurse should immediately assess the resident's skin, obtain measurements, and notify the physician for orders. The nurses should notify the DON of any wounds and she would add the resident to the wound report. The facility wound report is two weeks behind, and she used the wound reports for wound identification. The wound report is based off staff reporting skin issues to her. If a resident is admitted with a wound, the admitting nurse should measure and document the wound. The physician should be notified and orders given. If the resident received hospice services, the same procedure should apply. Wounds need an initial measurement at the time of discovery, and then measured weekly after to monitor changes. The resident should get a weekly skin assessment by the charge nurses and this should be documented in the medical record. She was not notified of the resident's original wound on 8/9/24. LPN C notified her of the skin assessment from 8/14/24 on the morning of 8/15/24. LPN C should have documented measurements, started a wound event in the medical record, and contacted the physician. Nurses should not rely on hospice to obtain orders, that is the responsibility of the facility. The resident should have had wound care orders since the time of re-admission since a wound was noted at that time. It is the nurse's responsibility to ensure all hospice orders are documented in the medical record. During an interview on 8/15/24 at 1:35 P.M., the hospice director said the resident admitted on hospice services on 8/9/24. The admitting Registered Nurse (RN) documented a wound to the upper left buttock and documented wound care orders onto the start of care. Wound orders were obtained and verbally given to the facility charge nurse, LPN C. LPN C called the hospice provider on 8/15/24 and requested additional wound care orders and notified the hospice provider of additional wounds. The hospice director instructed LPN C to begin the treatments and the orders would be faxed over once the physician signed them. She expected facility staff to implement hospice orders when given, orders should be started when given to prevent a delay in care and treatment. The hospice nurses provide orders both verbally and written to the facility staff. Hospice staff also write orders in the hospice binder for additional information. During an interview on 8/16/24 at 8:45 A.M., the Administrator said all wounds should be measured, physician orders obtained, wound measurements and the type documented. If the resident received hospice care, the hospice nurse should give an oral report to the facility nurse. Hospice orders should be immediately transcribed into the medical record. If aides notice a change in skin condition, they should report it to the charge nurse or nurse supervisor immediately. MO00239868

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one resident (Resident #3) was free from abuse when staff failed to appropriately intervene and separate Residents #1 and #3 upon observation of the residents engaging in an increasingly agitated argument over Resident #3's walker. Resident #1 grabbed Resident #3's walker and pushed him/her to the ground, resulting in a fractured femur to Resident #3. The sample was four. The census was 51. Review of the facility's Abuse Prevention policy, undated, showed: -This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. This will be done by: -Orienting and training employees on how to deal with stress and difficult situations, and how to recognize and report occurrences of abuse neglect, exploitation, and misappropriation of property; -Establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment; -Immediately protecting residents involved in identified reports of possible abuse, neglect, exploitation, mistreatment, and misappropriation of property; -This facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriation of property and mistreatment by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals; -Orientation and Training of Employees: --During orientation of new employees, the facility will cover at least the following topics: -What constitutes abuse, neglect, exploitation, and misappropriation of resident property; -Dementia management and resident abuse prevention; -How to assess, prevent and manage aggressive, violent and/or catastrophic reactions of residents in a way that protects both residents and staff; -The policy failed to provide written guidance for staff on how to correct and intervene in situations in which abuse is more likely to occur. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/26/24, showed: -Moderate cognitive impairment; -Behaviors not exhibited; -Diagnoses included Alzheimer's disease, dementia, and anxiety. Review of the resident's care plan, revised 5/24/24, showed: -Focus: Behavior: The resident is an elopement risk/wanderer related to history of attempts to leave facility unattended and impaired safety awareness; -Interventions include distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Distract resident by talking about his/her minister days and how God saved him/her. Talk about his/her boxing days and who he/she fought. -Focus: Resident has a behavior problem of verbal aggression; -Goal: Resident will not have a decline due to aggression until next review date; -Interventions included: Anticipate and meet the resident's needs. Caregivers to provide opportunity for positive interaction, attention. If reasonable, discuss the resident's behavior and explain/reinforce why behaviors are inappropriate and/or unacceptable to the resident. Monitor behavior episodes and attempt to determine underlying cause. Praise any indication of the resident's progress/improvement in behavior; -Focus: Resident is/has potential to be verbally aggressive related to dementia, ineffective coping skills, and poor impulse control; -Goal: Resident will have less than three episodes per day of verbal aggression through the review date; -Interventions included: Analyze key times, places, circumstances, triggers, and what de-escalates behavior and document. Assess resident's understanding of the situation and allow time for the resident to express self and feelings toward the situation. Monitor behaviors (specify frequency) and document observed behavior and attempted interventions. When the resident becomes agitated, intervene before agitation escalates, guide away from source of distress, engage calmly in conversation, and if response is aggressive, staff to walk calmly away and approach later. Review of the resident's nurse's note, dated 5/24/24 at 5:09 P.M., showed the resident was witnessed attempting to remove front-wheeled walker (FWW) from another resident. Resident then pushed the other resident before staff was able to intervene. Assessed at the time. Alert and oriented times one (to person). Increased aggression and agitation noted at the time. Non-compliant with redirection at the time, triggers unknown. Resident to be transported to hospital related to safety towards self and others, psychiatric evaluation, and treatment. Review of Resident #3's annual MDS, dated [DATE], showed: -Moderate cognitive impairment; -Use of walker; -Diagnoses included arthritis. Review of the resident's care plan, revised 5/24/24, showed the resident at risk for falls related to gait/balance problems, incontinence, wandering, and history of falls. Review of the resident's nurse's note, dated 5/24/24 at 5:00 P.M., showed the nurse documented he/she was made aware another resident was attempting to claim the resident's FWW. When he/she attempted to remove his/her FWW, the resident was pushed onto the floor before staff was able to intervene. Resident assessed at the time. Resident lying on left side, alert and oriented times one to two (to person and place) at times with periods of pleasant confusion noted. Complained of pain, voiced 10 out of 10 to left hip, left side of head noted. Call placed to emergency services related to transport to hospital. Review of the resident's hospital record, dated 5/28/24, showed the resident diagnosed with closed fracture (fracture with the skin intact) of neck of left femur (thighbone). Surgery performed on 5/26/24. During an interview on 6/4/24 at 11:24 A.M., Resident #3 said his/her hip was broken by Resident #1. The residents were in the dining room and when Resident #3 was standing up, Resident #1 snapped. He/She picked up Resident #3 and threw him/her down on the floor. Resident #3 was not sure why this happened. He/She went to the hospital and had surgery. He/She cannot walk right now and uses a wheelchair. During an interview on 6/4/24 at 1:28 P.M., Resident #1 said he/she did not have any issues with other residents. He/She denied hitting or pushing anyone. During an interview on 6/4/24 at 12:42 P.M., Certified Nurse Aide (CNA) I said Resident #1 has a history of verbal and physical aggression toward other residents and staff. On the day of the incident involving Residents #1 and #3, both residents were sitting on the couch in the sitting area next to the dining room. CNA I was walking other residents to the dining room for dinner and heard Residents #1 and #3 talking about Resident #3's walker. Resident #1 started getting angry, raising his/her voice and getting mad. As CNA I continued to walk residents to the dining room, he/she told Resident #1 the walker was not his/hers and told Resident #3 to move away from Resident #1. While Resident #3 tried to move away, Resident #1 stood up and tried to grab Resident #3's walker. CNA I saw this as he/she was walking with another resident, and again told Resident #1 the walker was not his/hers. Resident #1 hopped up in Resident #3's face and pushed Resident #3 hard, using both hands. Resident #3 fell onto the floor and started crying. The Certified Medication Technician (CMT) was also in the area passing medications at the time of the incident. Neither CNA I nor the CMT physically approached Residents #1 and #3 to intervene during the disagreement before Resident #1 pushed Resident #3. During an interview on 6/4/24 at 1:02 P.M., CMT E said on the day of the incident involving Residents #1 and #3, the residents were sitting on the couch in the sitting area next to the dining room. CMT E was passing medications at the cart in the dining room. He/She heard the residents getting agitated. Resident #1 was very, very agitated. He/She is a former boxer, so when he/she gets agitated, people can't get too close to him/her. The CNA who was walking by tried saying something to Resident #1. Resident #3 stood up and Resident #1 kept saying Resident #3's walker belonged to Resident #1. Resident #3 kept saying no, the walker belonged to him/her. Resident #1 grabbed the walker and Resident #3 pulled it back. CMT E turned his/her head toward the resident standing next to him/her at the medication cart, and when he/she turned back around, Resident #3 was on the ground with his/her head against the coffee table. Neither CMT E nor the CNA physically approached the residents to intervene during the disagreement, before Resident #3 was observed on the ground. Looking back at the incident, CMT E does not believe he/she could or should have done anything differently. Review of the facility's list of active employees and in-service trainings on resident to resident interactions, resident behavior, and cognitive impaired behaviors, provided on 5/30/24 and 6/4/24, showed: -74 staff employed by facility; -30 facility staff not documented as in attendance of in-service trainings; -CMT E not documented as in attendance of in-service trainings. During an interview on 6/4/24 at 4:31 P.M., Licensed Practical Nurse (LPN) C said he/she was working on the day of the incident involving Resident #1 and Resident #3, but he/she was in another resident's room and did not witness the altercation. The CNA informed LPN C of what occurred, and LPN C went to the sitting area and found Resident #3 on the floor, crying and hysterical. Staff said Resident #1 pushed Resident #3 after arguing over a walker. Resident #1 has dementia and can be aggressive toward other residents and staff. It is unknown what triggers him/her. He/She has dementia and likes to help with laundry and housekeeping tasks. Staff need to keep him/her busy with something before he/she gets triggered. Staff should redirect him/her as soon as he/she starts getting agitated. During an interview on 6/6/24 at 2:31 P.M., LPN J said Resident #1 likes to help staff and is easily redirected when given tasks he/she enjoys, like folding towels, sweeping, and wiping tables. Staff were expected to anticipate the resident's needs and observe his/her behavior. If they notice the resident is becoming anxious or agitated, they should intervene and redirect the resident. Staff should not wait for the resident to exhibit a behavior before they approach and redirect the resident. During an interview on 6/4/24 at 2:29 P.M., the Director of Nurses (DON) said Resident #1 is cognitively impaired and requires reality orientation. The DON has not seen the resident demonstrate the aggressive behaviors reported by staff. The resident sundowns (demonstrates increased confusion, restlessness, agitation, or irritability as night approaches) and the DON has observed at around 2:00 P.M., he/she jumps up and says he/she has to go to work. The DON is able to redirect him/her and finds the resident is easily redirectable. The resident likes to help clean things and likes working with his/her hands. He/She likes to sing, dance, and watch television, and he/she has preferred television shows. If staff are observing the resident being aggressive, they need to document their observations in the resident's record so she can try to look for what staff are seeing. She needs to see if the resident really has aggressive behaviors, or if staff are afraid of him/her because he/she was a boxer in the past. The resident feeds off staff's energy. Staff should respond to the resident in a calm manner. Administration has been doing in-service training with staff on resident behaviors and communication with residents who are cognitively impaired. During an interview on 6/4/24 at approximately 2:45 P.M., the Administrator said the facility is still relatively new for Resident #1. Prior to moving to the facility, the resident had a routine. Staff are still learning his/her patterns and behaviors, and trying to see what works and what doesn't when addressing him/her. They identified that the resident likes snacks and likes to help staff clean. He/She seemed more relaxed when sitting in one of the chairs in the sitting area, rather than on the couch. He/She did not respond well to overstimulation or people talking to him/her aggressively. Staff seem like they are afraid of the resident. It could be that his/her behavior was exacerbated by staff's response to him/her. During her investigation, the Administrator found that when Residents #1 and #3 started arguing, there was an opportunity where staff should have physically intervened and immediately separated the residents when they started getting agitated. When a resident becomes agitated or exhibits behaviors, the Administrator expected staff to redirect the resident using the identified interventions. MO00236799

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to prevent one resident (Resident #42) from developing an unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough (dead tissue, separating from living tissue) and/or eschar (dry, dark scab or falling away of dead skin) in the wound bed) by failing to monitor the resident's skin, failing to report new wounds, failing to obtain treatment orders in a timely manner and failing to follow the facility's wound policy. The sample size was 13. The facility census was 49. Review of the facility's Pressure Injury and Skin Condition Assessment Policy, dated 11/28/12 and last updated 1/17/18, showed the following: -Purpose: To establish guidelines for assessing, monitoring and documenting the presence of skin breakdown, pressure injuries and other ulcers and assuring interventions are implemented. Pressure (injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or friction) and other ulcers (diabetic, arterial, venous) will be assessed and measured at least every seven days by a licensed nurse and documented in the resident's record; -A skin condition assessment and pressure ulcer risk assessment (Braden) will be completed at time of admission/readmission. The pressure ulcer risk will be updated quarterly and as necessary; -Residents identified will have a weekly skin assessment by a licensed nurse; -A wound assessment will be initiated and documented in the resident chart when pressure or other ulcers are identified by a licensed nurse; -Each resident will be observed for skin breakdown daily during care and on the Certified Nurses Assistant (CNA's) assignment. Changes shall be promptly reported to the charge nurse who will perform a skin assessment; -If the resident receives a shower, it will be necessary to have the resident stand or be returned to bed to visualize the buttocks and groin; -At the earliest sign of a pressure injury or other skin problem, the resident, legal representative and attending physician will be notified. The initial observation of the ulcer or skin breakdown will also be described in the nursing notes; -Prior to performing the skin assessment, the nurse is to have a sufficient supply of clean disposable gloves, a disposable measuring device and a clean cotton tipped applicator to measure wound tunneling (channels that extend from a wound into and through subcutaneous (SQ, beneath the skin) tissue or muscle, usually extends in just one direction)/undermining (occurs in all directions beneath the wound opening, affecting a larger area of SQ tissue); -Pressure injuries and other ulcers (arterial, venous, diabetic) will be measured at least weekly and recorded in the resident's medical record; -The wound assessment should include the location, size, stage, odor, drainage, description and date and initials of the person performing the assessment; -Measure the length vertically in relation to head to toe and the width horizontally from hip to hip. Measure straight down into the deepest part of the wound for the depth. *If the wound is necrotic and the base of the wound bed is not visible or tunneling, the stage cannot be determined and must be recorded as an non-stageable with an undetermined depth; -When there are weekly changes which require physician and responsible party notification, documentation of findings will be made in the clinical record. These changes include, but are not limited to: a) New onset of purulent drainage; b) New onset of odor; c) Cellulitis (deep inflammation of the tissues just under the skin, caused by infection); d) Increased pain related to the wound; e) Significant increase in the wound size; f) New onset of ulcers; -Update the care plan accordingly; -Record the treatment on the treatment administration record; -The attending physician will be notified within seven to 14 days of the lack of response to the treatment. 1. Review of Resident #42's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/4/19, showed the following: -admitted to the facility on [DATE]; -No cognitive impairment; -Unable to ambulate; -Dependent on staff for bed mobility and transfers; -Extensive assistance required for personal hygiene, dressing and toileting; -Frequently incontinent of bowel and bladder; -No skin issues; -No risk of developing pressure ulcers; -No special treatments or programs; -Height 65 inches and weight 117 pounds; -Diagnoses included high blood pressure and end stage renal disease. Review of the resident's electronic (e) chart, showed additional diagnoses included altered mental status, osteoarthritis (breakdown of cartilage or cushion between joints leading to pain, stiffness, swelling and pain), chronic lung disease, lack of coordination and diabetes. Review of the admission progress note, dated 7/28/19 at 1:14 P.M., showed the following: -Diagnoses included lung cancer with metastasis (spread) to the bone; -Receives dialysis on Tuesday, Thursday and Saturday; Review of the care plan, dated 7/28 and last updated 8/6/19 and in use during the survey, showed the following: -Problem: Potential for impairment to skin integrity related to weakness; -Goal: Resident will not develop further alteration in skin integrity; -Interventions: Avoid scratching and keep hands and body parts from excessive moisture, keep fingernails short, avoid shearing, use a lift sheet for positioning, avoid skin to skin contact, ensure linens are wrinkle free, minimize pressure over bony prominences and use caution during transfers and bed mobility to prevent striking arms, legs and hands against any sharp or hard surface. Review of the Registered Dietician's (RD's) nutrition assessment, dated 8/7/19, showed the resident had a diagnosis of cancer with potential for metastatic disease, weight barely within normal limits and skin intact. Diet appropriate at that time for nutritional needs but would follow if nutritional supplements were needed. Review of the resident's weekly skin observations, showed the following: -8/4 and 8/11/19, showed resident's skin intact-no concerns; -No other weekly skin assessments found. Review of the facility's wound reports, dated 8/2, 8/9, 8/16 and 8/23/19, showed the resident's name not listed. Observation on 8/23/19 at 7:50 A.M., showed the resident in bed on his/her right side. CNA A present at the bedside and had just provided incontinence care. Resident had an open area to his/her coccyx (tailbone) approximately 2 centimeters (cm) long by 0.1 cm wide, open and deep pink in color. CNA A applied moisturizing cream and said to his/her knowledge, the nurse didn't use any other treatment on the area. He/she said the moisturizing ointment was what he/she used because the open area on the resident's coccyx had been there for a couple of days. During an interview and observation on 8/26/19 at 11:24 A.M., Licensed Practical Nurse (LPN) B said she was not aware of any skin breakdown on the resident. LPN B entered the resident's room and removed the resident's brief. LPN B turned the resident to his/her left side, exposed a triangle shaped area, with a black area in the center, on the resident's coccyx . The area measured approximately 1.5 cm by 1.5 cm, enclosed on all three sides by a yellowish colored substance that measured approximately 0.2 cm in width. LPN B initially said the area was not a wound, then said it was actually an unstageable pressure ulcer. He/she then dressed the resident in a clean brief and said he/she would call the physician. LPN B said he/she was not informed by the CNAs of any skin breakdown. During an interview and observation on 8/26/19 at 11:45 P.M. the Director of Nursing (DON) evaluated the resident's skin. She removed the resident's brief and said Where did this come from? She initially said the wound was a Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister) pressure ulcer. After further assessment, the DON said the wound bed was covered with 100% eschar tissue, and the wound was an unstageable pressure ulcer to the coccyx. She measured the pressure ulcer as 4 cm by 4 cm with 2.5 cm depth and said she was not informed by the charge nurse or CNAs of the skin breakdown. She said licensed nurses do weekly skin assessments and document in the chart and on shower days, the CNAs observe the skin and notify the charge nurse of any skin issues. CNAs should have notified the charge nurse when they initially saw the open area, and an order should have been obtained at that time. Moisturizing lotion was not effective, and they should have used an ointment with zinc oxide because that is a barrier ointment. She said the pressure ulcer should have been covered, and the nurse needed to contact the wound team. Review of the physician's order sheet (POS), showed an order, dated 8/26/19, no time noted, to apply a wet to dry dressing to the unstageable wound daily until seen by the wound team. Further review of the care plan, last updated on 8/26/19, showed the following: -Problem: Resident has an ulcer, unstageable to the coccyx related to immobility; -Goal: Pressure ulcer will show signs of healing and remain free from infection through the review date; -Interventions: Follow facility policies/protocols for prevention/treatment of skin breakdown, monitor nutritional status, serve diet as ordered, monitor intake and record, weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth and type of tissue and exudate. Review of the skin assessment, completed by the DON on 8/26/19 and recorded at 11:05 P.M., showed the following: -Unstageable pressure ulcer to the coccyx; -Wound acquired in-house; -Type of wound is pressure and unstageable; -No tunneling or undermining present; -Odor present; -No pain. Observation and interview on 8/27/19 at 9:35 A.M., showed CNA A and LPN C placed a gait belt around the resident's waist and assisted him/her to bed. LPN C cleansed the bedside table with a bleach wipe, lay a barrier on the table, and opened and prepared dressing supplies. He/she removed the dressing from the resident's coccyx and said It has a little odor and then said I don't know how that got so bad so fast. The wound, completely covered in black eschar, showed an open area below the wound and an open area to the left of the wound. LPN B said the large wound was an unstageable pressure ulcer and the other two wounds were Stage II pressure ulcers. He/she measured the unstageable pressure ulcer as 4 cm in length by 3 cm in width. He/she said the wound has some depth, but he/she did not measure the depth. He/she measured the Stage II pressure ulcer below the unstageable pressure ulcer as 2 cm in length and 1 cm in width and the Stage II pressure ulcer to the left measured 1 cm long by 1.5 cm in width. He/she cleansed the unstageable pressure ulcer with normal saline (NS, sterile solution used to clean wounds) then wet gauze with NS and placed it in the wound bed, covered it with a telfa pad (non-adherent and sterile dressing, which is good for direct wound contact for small to medium sized wounds to help absorb light wound fluid) and applied tape. He/she said he/she would have to contact the physician to get a new order for the Stage II pressure ulcers. Review of LPN C's progress note, dated 8/27/19 at 10:28 A.M., showed a dressing change completed. Removal of wet to dry dressing and serous fluid (typically pale yellow and transparent) found on packing to coccyx wound. Scant amount of serosanguineous fluid (yellow with small amounts of blood) found on dressing from stage 2, measuring 2 cm in length by 1 cm in width just below coccyx wound. Stage 2 wound to left medial buttock measuring 1 cm by 0.5. DON, physician and power of attorney (POA) made aware. Physician notified for new treatment order for stage 2 wound. Review of POS on 8/27/19 at 11:00 A.M., showed no new orders. During an interview on 8/27/19 at 1:00 P.M., the DON said she would expect the CNA to let the charge nurse know of any open areas. The nurse should then do a skin assessment and place a note in the progress notes. She said the charge nurse did tell her of the resident's wound, but not before the survey team did. She said the nurse was supposed to do a skin assessment weekly and as needed. A nurse did apparently do a skin assessment on 8/18/19, but scratched it out, and the DON did not know why that was done. She said the nurse informed her that the resident refused a shower on 8/25/19, so she was unable to do a skin assessment, and the DON told her that was not a legitimate reason to not perform a skin assessment. She said had the skin assessments been performed per policy and had the CNA informed the nurse of the initial skin issue, this whole situation may well have been prevented. She said she recently provided in-services to the staff regarding several different areas of care. Skin care and the prevention and treatment of pressure ulcers was included in the training, which was completed on 5/20 and 6/6/19. She said the resident will now be on an air mattress, have a cushion in his/her wheelchair and be turned and repositioned at least every two hours. When asked, the DON said the staff had not provided adequate and effective care to this resident. During an interview on 8/28/19 at 12:29 P.M., the resident's primary physician said first of all, a CNA should never decide what treatment to use, and the nurse should be instruct the CNAs to always report any kind of skin issue. The physician said the resident's condition was very poor and given his/her condition, wounds were almost unavoidable, but they could not be ignored either. If the skin breakdown had been reported to the nurse when first noticed, the wound may not have progressed to the point it had.