Based on interview and record review, the facility failed to provide oversight and prevent injury for one resident (Resident #1), who was dependent on staff for transfers and bed mobility and had a history of falls from bed on 8/25/24 and 10/1/24, in a review of 12 sampled residents. On 10/7/24, staff failed to ensure interventions to prevent falls from the bed were in place when staff left the resident's bedside while in the resident's room. The resident rolled out of bed and hit his/her head. The resident sustained an intraventricular hemorrhage (bleeding inside the brain) and left hip fracture, which resulted in his/her death. The facility census was 56. The administrator was notified of the Immediate Jeopardy (IJ) on 10/16/24 at 5:10 P.M., which began on 10/7/24. The IJ was removed on 10/7/24 as confirmed by surveyor onsite verification. Review of the facility policy, Safety and Supervision of Residents, revised July 2017, showed the following: -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; -Individualized, resident-centered approach to safety addresses safety and accident hazards 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: -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; -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; -The type and frequency of resident supervision may vary among residents and over time for the same resident. Review of the facility Managing Falls and Fall Risk policy, revised March 2018, showed based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. 1. Review of Resident #1's undated Face Sheet showed the resident's diagnoses included dementia (a chronic condition that causes a decline in mental functioning, such as thinking, remembering and reasoning, to the point that it interferes with daily life), and cerebral infarction (stroke; disrupted blood flow to the brain). Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/21/24, showed the following: -Severely impaired cognitive skills; -Dependent on staff for transfers and bed mobility; -Required substantial/maximal assistance for rolling left and right in bed. Review of the resident's Care Plan, dated 8/1/24, showed the following: -The resident was at risk for falling due to limited mobility; -Ensure the resident was positioned in the center of the bed and positioned with a pillow to the side of the resident. -Two staff were to assist the resident with transfers. Review of the resident's Progress Notes, dated 8/25/24 at 12:30 A.M., showed a certified nurse assistant (CNA) found the resident on the floor. The resident slid off a low bed onto the floor mat. The resident landed on his/her right side. The resident had red bruising on his/her right hip, right upper thigh, on his/her right side, right elbow and left thigh. The resident had a 1 centimeter (cm) abrasion on his/her right shoulder surrounded by red bruising. Review of the resident's Care Plan showed no documentation staff evaluated the current interventions or implemented new interviews to prevent falls after the resident fell out of bed on 8/25/24. Review of the resident's Physician Order Sheet (POS), dated October 2024, showed an order for 81 milligrams (mg) of aspirin once daily in the morning. Review of the resident's Progress Notes, dated 10/1/24 at 6:25 A.M., showed staff found the resident on the fall mat. It appeared the resident was rolled up in his/her bed covers and that he/she rolled out of bed. No injuries noted. Review of the resident's Care Plan, updated 10/1/24, showed the resident rolled out of bed. Re-educate staff on positioning the resident with pillows to the side of the resident. Review of the resident's Progress Notes, dated 10/7/24 at 8:00 A.M., showed Licensed Practical Nurse (LPN) C documented the following: -Staff called him/her to the resident's room due to the resident rolling off the side of the bed while staff were getting the resident ready to get up, cleaned, changed, and dressed for the day; -When LPN C entered the resident's room, the resident laid on the floor next to his/her bed which was a little lower than waist high. The fall mat had been picked up off the floor. There were a few drops of blood on the floor under the resident's head; -The CNA said he/she was in the room getting the resident ready when the resident rolled over and off the side of the bed; -The resident had a raised area to the left side of his/her head that was purple in color with a small abrasion to one side and a laceration to the other side. The resident had a large amount of blood in his/her hair. The abrasion measured 1 centimeter (cm) by 0.4 cm and the laceration measured 1.5 cm by 0.2 cm. The laceration was actively bleeding; -The fall was witnessed, the fall mat was not in place, and the bed was not in the low position; -Notified administration and the resident's emergency contact and expressed the resident should be seen in the emergency room (ER) due to raised area with laceration to left side of head. Notified the resident's physician of the fall and injuries and received orders to send the resident to local hospital emergency room (ER) for evaluation and treatment; -All current fall interventions were not in place at the time of the fall. Review of the resident's care plan, updated 10/7/24, showed staff witnessed the resident roll off the side of his/her bed. Staff were educated on all current fall interventions for the resident. During interviews on 10/15/24 at 3:26 P.M., 10/16/24 at 10:25 A.M., and on 10/16/24 at 5:41 P.M., CNA A said the following: -He/She and CNA B had raised the resident's bed to perform peri care and to prepare to transfer the resident out of bed for breakfast. The resident was on his/her left side facing the wall in the middle of the bed (the left side of the resident's bed was against the wall). The mechanical lift sling was under the resident; -He/She and CNA B realized they forgot to bring the mechanical lift into the room. CNA B left the room to retrieve the lift; -He/She stayed in the resident's room and lowered the bed somewhat, but not all the way back down to a low position. The resident was not moving and appeared to be sleeping. He/She had never seen the resident move around much. The resident did not have any pillows behind him/her because they were prepared to get the resident out of bed. He/She removed the fall mat from in front of the bed and moved it to the side and began to straighten up the room by folding clothes and blankets on the resident's recliner (the recliner sat approximately five feet from right side of the bed). He/She turned his/her back away from the resident for less than five minutes and the resident rolled out of the right side of the bed; -He/She was aware the resident fell out of bed on 10/1/24. The facility had implemented putting pillows around the resident after that fall. He/She did not put the pillows around the resident on 10/7/24 because he/she was getting the resident up and was not leaving the resident in bed. During interview on 10/15/24 at 12:57 P.M., CNA B said the following: -When he/she first entered to the resident's room to assist CNA A, the resident's bed was in the low position, the fall mat was on the floor next to the right side of the bed and there were pillows around the resident. He/She and CNA A raised the bed to perform peri care and placed the mechanical lift sling under the resident. The resident was not moving around in the bed; -He/She left the room to get the mechanical lift. Before he/she left the room, the resident was in the center of the bed facing the wall. The resident did not have any pillows around him/her. The resident was not moving around at all on his/her own; -The mechanical lift was down the hall and he/she was probably gone approximately two minutes to get the lift. He/She did not know exactly what happened while he/she was out of the room; -When he/she returned to the room with the mechanical lift, the fall mat was not on the floor and the resident lay on the floor; -The resident had rolled out of bed in the past and moved/rolled around in the bed when he/she was in pain. During an interview on 10/16/24 at 10:00 A.M., Licensed Practical Nurse (LPN) C said the following: -When he/she arrived to the room after the resident's fall, the bed position was between knee and thigh height. The resident lay directly on the floor to the right side of the bed facing the bed on his/her left side. The fall mat was not on the floor next to the bed. Blood was visible on the floor and the resident had a goose egg and laceration on the left side of his/her head. The resident was sent to the hospital emergency room for evaluation; -The resident had the ability to move when he/she wanted to move, but for the most part, the resident didn't move around much. The resident was supposed to have pillows behind his/her back when in bed. The fall interventions (i.e. fall mat in place, pillows behind the resident and a low bed) should have been in place to keep the resident safe. Staff should have stood at the bedside with the resident until it was time to conduct the mechanical lift transfer. During interviews on 10/16/24 at 11:38 A.M. and on 10/16/24 at 3:01 P.M., the Director of Nursing (DON), said the following: -Staff reported the resident fell after CNA B left the room to get the mechanical lift. CNA A turned towards the recliner (away from the resident) to get clothing and the resident fell out of bed. LPN C reported the bed height at the time of the fall was below waist high and the resident lay on his/her left side in bed facing the wall prior to the fall; -When the resident was in bed at night, the bed should be low to the floor. The resident did not follow commands and cried out sometimes and could be fidgety. The resident moved around some when he/she was in pain, possibly due to the pressure ulcer on his/her bottom; -She would have been okay with CNA A staying in the room (in close proximity) with the resident and doing other things, like tidying up the room, moving clothes around, etc. without out putting the care-planned interventions in place because the resident wasn't moving around and was turned towards the wall; -The identified fall interventions were to be in place when the resident was in the bed. At the time of the fall, staff were trying to get the resident up and out of bed. During interview on 10/16/24 at 5:05 P.M., the Administrator said the following: -Staff reported one staff left the room to get the mechanical lift. The other staff had turned away from the resident's bed to pick up some clothing from the recliner and the resident fell out of bed; -Nine times out of ten, the resident had no movement, but there were times when the resident moved around; -Most of the time, staff couldn't hardly get the resident to wake up; -She was unsure what she would have expected staff to have done differently. Staff stayed in the room with the resident and the resident usually didn't move around; -The resident was supposed to have a low bed, fall mat in place and pillows in place when in the bed, but the interventions were not in place when the fall occurred because staff were getting the resident out of bed. Review of the resident's hospital radiology (a medical specialty that uses imaging techniques to diagnose and treat diseases and injuries) results showed the following: -On 10/7/24 at 10:36 A.M., a CT scan (a computed tomography scan is a non-invasive medical imaging procedure that uses X-rays to create detailed, cross-sectional images of the inside of the body) of the abdomen and pelvis showed a minimally displaced left intertrochanteric fracture (a break in the upper part of the thigh bone, or femur, between the greater and lesser trochanters); -On 10/7/24 at 12:21 P.M., a CT scan of the head showed an acute intraventricular hemorrhage (bleeding inside or around the spaces in the brain). Review of the resident's progress notes, dated 10/14/24 at 6:45 P.M., showed the hospital notified the facility the resident passed away this evening. During interview on 10/16/24 at 1:39 P.M., hospital Physician D, one of the physicians who cared for the resident while in the hospital, said the resident's fall from his/her bed was a major factor in his/her death. Review of the resident's death certificate, dated 10/21/24, showed the following: -The resident passed away on 10/14/24; -Causes of Death: 1. Acute hemorrhage within basilar cisterna (fluid-filled spaces in the brain), 2. Intraventricular hemorrhage within the left lateral ventricle; -Other Significant Conditions Contributing to Death: Left hip fracture; -Describe How Injury Occurred: Resident fell out of bed; -Certified by the Medical Examiner/Coroner. NOTE: At the time of the survey, the violation was determined to be at the immediate jeopardy level J. Based on interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO-243218 MO-243314

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide necessary treatment and services to one resident (Resident #5) in a review of 11 residents, who developed a Stage II pressure ulcer on 9/7/22. The facility did not adequately assess the resident's pressure ulcers, consistently identify the sites of the pressure ulcers, or notify the physician when the ulcer changed resulting in the resident developing a necrotic unstageable ulcer. The resident became unresponsive on 10/26/22 and was sent to the hospital where he/she was diagnosed with necrotic deep tissue injury. The facility census was 46. The Director of Nursing was notified on 11/9/22 at 4:08 P.M. of the Immediate Jeopardy (IJ), which began on 10/26/22. The IJ was removed on 11/10/22, as confirmed by surveyor onsite verification. Review of the facility's Pressure Ulcers/Skin Breakdown - Clinical Protocol policy, revised October 2010, included the following: -The nursing staff will complete the Braden Scale (a tool used for identification of residents at risk for forming pressure ulcers. The scale consists of six subscales and the total scores range from six to 23. A lower Braden score indicates higher levels of risk for pressure ulcer development) on admit and at routine intervals; -The physician will help the staff define the type of an ulceration; -The physician will help identify factors contributing or predisposing residents to skin breakdown; -The physician will help clarify relevant medical issues; for example, whether there is a soft tissue infection or just wound colonization (the presence of multiplying micro-organisms on the surface of a wound, but with no immune response from the host), whether the wound has necrotic (dead or dying) tissue, the impact of comorbid conditions on wound healing, etc.; -The physician will authorize pertinent orders related to wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings and application of topical agents; -The physician will help identify medical interventions related to wound management; -The physician will help staff characterize the likelihood of wound healing, based on a review of pertinent factors as needed; -During resident visits, the physician will evaluate and document the progress of wound healing- especially for those with complicated, extensive, or non-healing wounds; -The physician will help staff review and modify the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions. Review of the facility's Pressure Ulcer Treatment policy, revised October 2010, included the following: -The purpose of the procedure is to provide guidelines for the care of existing pressure ulcer and the prevention of additional pressure ulcers; -The pressure ulcer treatment program should focus on the following strategies: a. assessing the resident and the pressure ulcer(s); b. managing tissue loads; c. pressure ulcer care; d. managing bacterial colonization and infection; e. operative repair of the pressure ulcer(s); f. education and quality improvement; -When eschar (a collection of dry, dead tissue within a wound) is present, a pressure ulcer cannot be accurately staged until the eschar is removed; -Suspected Deep Tissue Injury: purple or maroon localized are of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear; -Stage I Pressure Ulcer: Intact skin with non-blanchable redness of localized are usually over a bony prominence; -Stage II Pressure Ulcer: Partial thickness loss of skin presenting as a shallow open ulcer with a red/pink wound bed, without slough (non-viable yellow, tan, gray, green or brown tissue) and may also present as an intact or open/ruptured blood filled blister; -Stage III Pressure Ulcer: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling; -Stage IV Pressure Ulcer: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed, often include undermining and tunneling; -Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed; -Pressure ulcer treatment requires a comprehensive approach, including: debridement, managing infections, managing systemic issues, and maximizing the potential for healing and pain control; -Stage II Pressure Ulcer Intervention/Care Strategies: -Clean, shallow, minimal drainage: a. protect; b. manage drainage; c. promote moist wound healing; d. treatment: Cleanse with normal saline or other skin cleanser in accordance with physician orders and facility protocol, apply barrier cream, hydrogel (a gel which enables painless debridement of necrotic and infected tissue), cover with non-adhesive light gauze or transparent dressing, alternate dressing, change per physician order and manufacturer's directions, manage pain; -Medium drainage: follow above procedure and consider alginate (dressings that can absorb wound fluid in the dry form and form gels that can provide a dry wound with a physiologically moist environment and minimize bacterial infections) or foam; -Follow-up: If wound does not improve in two to three weeks, notify physician. Consider a skin consult with a wound specialist; -The following information should be recorded in the resident's medical record: the type of treatment and resident response, the date and time the wound care was given; the position in which the resident was placed, any change in the resident's condition, all assessment data (color, size, pain, drainage) when inspecting the wound; resident tolerance of the procedure, any problems or complaints made by the resident related to the procedure, resident refusal of the treatment and the reason why, the signature and title of the person recording the data. Review of the Long Term Care Facility Resident Assessment Instrument User's Manual, Version 3.0, Chapter 3, Section M, defines the different stages of pressure ulcers (as follows: -Stage I: an observable, pressure related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in skin temperature, tissue consistency, sensation, and/or a defined area of persistent redness; -Stage II: Partial thickness loss of dermis (the inner layer that makes up skin) presenting as a shallow open ulcer with a red-pink wound bed, without slough (non-viable yellow, tan, gray, green or brown tissue). May also present as an intact or open/ruptured blister; -Stage III: full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining (destruction of tissue or ulceration extending under the skin edges) or tunneling (a passage way of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound); -Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color) may be present on some parts of the wound bed. Often includes undermining and tunneling; -Unstageable pressure ulcers (known but unstageable due to coverage the wound bed by slough (necrotic/avascular tissue in the process of separating from the viable portion of the body, usually light colored, soft, moist and stringy) and or eschar (thick leathery, frequently black or brown in color, necrotic tissue). Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined; -Deep tissue injury: Purple or maroon area of discolored intact skin due to damage of underlying soft tissue damage. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue; -Slough: necrotic/avascular tissue in the process of separating from the viable portions of the body and is usually light colored, soft, moist, and stringy; -Eschar: thick, leathery, frequently black or brown in color, necrotic (dead) or devitalized tissue that has lost its usual physical properties and biological activity. Eschar may be loose or firmly adhered to the wound. 1. Review of Resident #5's face sheet showed the following: -The resident was admitted to the facility on [DATE]; -The resident had diagnoses that included anemia (low levels of healthy red blood cells) and chronic myeloproliferative disease (a group of slow-growing blood cancers in which the bone marrow makes too many abnormal red blood cells, white blood cells, or platelets, which accumulate in the blood). Review of the resident's physician order sheet (POS), dated 7/26/22, showed an order for weekly skin assessments. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 8/4/22, showed the following: -The resident's cognition was intact; -The resident did not reject cares; -The resident was frequently incontinent of bladder and bowel and was dependent on staff for all hygiene/toileting cares; -The resident required substantial to maximum assistance to roll left and right; -The resident was at risk for pressure ulcers; -The resident did not have any unhealed pressure ulcers; -The resident had pressure reducing devices for his/her chair and bed; -The resident triggered for the care areas that included urinary incontinence and pressure ulcers. Review of the resident's Braden Scale (a scoring system used to identify residents at risk for developing pressure ulcer), dated 8/26/22, showed the resident scored an 18 which put the resident at risk for pressure ulcers. Record review of the resident's progress notes, dated 9/7/22, showed the following: -New open area noted to coccyx (tail bone) measuring 0.5 centimeters (cm) by 0.5 cm; -Treatment initiated: cleanse area with wound cleanser, apply hydrogel (a gel which enables painless debridement of necrotic and infected tissue) and collagen powder (a powder used to help new blood vessel and tissue formation in a wound) and cover with foam dressing daily and as needed (PRN) until resolved; -Will continue to monitor; -No documentation to show color or if there was drainage to open area. Review of the resident's Skin Integrity Events - Pressure Wound Documentation, dated 9/7/22, showed the following: -Registered Nurse (RN) B completed the pressure wound documentation; -The resident had a Stage II pressure ulcer; -The resident had immobility; -The physician was notified by fax on 9/7/22 at 9:06 A.M. of wound and treatment initiated. Review of the resident's POS showed an order, dated 9/7/22, to cleanse area to coccyx with wound cleanser, apply hydrogel and collagen powder and cover with a foam dressing daily until resolved. Review of the resident's care plan, dated 9/7/22, showed the following: -The resident had a pressure ulcer to his/her coccyx related to immobility; -The resident's ulcer will heal without complications; -Apply treatment as ordered; -Conduct a systematic skin inspection weekly, report any sign of further skin breakdown; -Keep clean and dry as possible. Minimize skin exposure to moisture; -Keep linens clean, dry and wrinkle free; -Provide incontinence care after each incontinent episode; -Use cushion for pressure reduction when resident is in chair; -Resident requires assist of one to two staff with activities of daily living (ADL's) and transfers; -Assist of one staff member with ADLs and two staff members at times with repositioning as needed. Review of the resident's progress notes, dated 9/8/22, showed the following: -Resident continued with an open area to coccyx; -Area cleansed, hydrogel and collagen powder applied and covered with a foam dressing; -Will continue to monitor; -No documentation to show measurements, color or if there was drainage to open area. Review of a picture, taken by Licensed Practical Nurse (LPN) H on 9/8/22, of the resident's coccyx showed two open areas with a black area in the center of one open area and a dark red/black area to the side of one open area with the surrounding skin of both areas red in color. Record review showed no documentation in the resident's progress notes to show any changes in the resident's pressure ulcer or that the physician was notified the resident's coccyx showed two open areas with a black area in the center of one open area and a dark red/black area to the side of one open area with the surrounding skin of both areas red in color. Review of the resident's weekly skin assessment, dated 9/9/22 at 6:50 P.M., showed the following: -LPN D completed the skin assessment; -The resident's heels, bottom, hips, back and shoulders were normal; -There were no red areas; -The resident did not have any open ulcers (documentation on 9/8/22 showed the resident had an open area on the coccyx and a photo showed the resident had two open areas. No measurements taken of open areas). Review of the resident's progress notes, dated 9/10/22 as a late entry for 9/9/22 at 6:50 P.M., showed the following: -Weekly skin assessment complete; -No areas of concern noted; -Will continue to monitor and assess as needed. Review of the resident's progress notes, dated 9/14/22, showed the following: -RN B noted the resident with three open areas to the coccyx measuring 0.7cm x 0.6cm, 1.0cm x 0.8cm and 0.4cm x 0.5cm; -Areas cleansed and dressing applied; -Pictures obtained of all areas; -No documentation to show color or if there was drainage to the open areas. Review of a picture, taken by LPN D on 9/14/22, showed three open pressure ulcers on the resident's coccyx. The largest of the pressure ulcers showed light tan slough. The second largest open area was red around the edges and a yellow/tan in the center. The smallest open area was red throughout. Review showed no documentation the physician was notified when the resident developed a third pressure ulcer on his/her coccyx. Review of the resident's weekly skin assessment, dated 9/17/22 at 12:40 A.M., showed the following: -LPN H completed the skin assessment; -The resident had an open area on his/her bottom (picture review only showed the resident had open areas on his/her coccyx); -The resident had an open ulcer on his/her coccyx that measured 1.0 cm x 0.5cm; -No changes from previous skin assessment (previous assessment showed three open areas to the resident's coccyx); -The physician was not notified of any changes; -No documentation to show the resident had two more open areas to his/her coccyx; -No documentation to show measurements, color or if there was drainage to open area. Review of the resident's progress notes, dated 9/19/22 at 12:37 A.M., showed the following: -Staff gave the resident a as needed (PRN) pain pill due to the resident having facial grimacing and not being able to get comfortable; -The resident said his/her bottom hurt; -The resident had a wound to the coccyx that he/she was reminded of and also reminded to lay on his/her side to keep the pressure off the wound; -Will continue to monitor and reassess as needed. Review of the resident's progress notes showed no documentation the physician was notified of the resident's pain to his/her bottom. Review of the resident's progress notes, dated 9/21/22 at 9:14 A.M., showed the following: -The resident continued with four open areas to his/her coccyx measuring 0.3cm x 0.2cm, 0.1cm x 0.1cm, 0.8cm x 0.5cm, and 0.9cm x 0.4cm (staff documented one open area on 9/17/22); -The wound bed was pink and no drainage noted from any of the areas; -Surrounding skin pink and intact; -Areas cleaned and treatment completed as ordered; -Will continue to monitor. Review showed no documentation the physician was notified the resident had developed additional pressure ulcers on his/her coccyx (staff documented the resident had four pressure ulcers on his/her coccyx). Review of the resident's weekly skin assessment, dated 9/23/22 at 7:16 P.M., showed the following: -LPN C completed the skin assessment; -The resident had an open area on his/her bottom (picture review only showed the resident had open areas on his/her coccyx); -The resident had four open ulcers on his/her coccyx that measured 1cm x 0.5cm, 0.5cm x 0.3cm, 0.1cm x 0.1cm and 0.1cm x 0.2cm with picture documentation provided; -No changes were noted from the previous skin assessment (documentation of measurements of open areas was not consistent with the previous skin assessment). Review of a picture, taken by LPN C on 9/23/22, showed four small pressure ulcers on the resident's coccyx. All pressure ulcers had a light pink outline with a darker pink wound bed. Review showed no documentation the physician was notified the resident had developed additional pressure ulcers on his/her coccyx (staff documented the resident had four pressure ulcers on his/her coccyx). Review of the resident' progress notes, dated 9/24/22 at 12:10 A.M., showed the following: -A weekly skin assessment was completed; -The resident had four open areas to his/her bottom measuring 1cm x 0.5cm, 0.5cm x 0.3cm, 0.1cm x 0.1cm, and 0.1cm x 0.2cm; -Picture documentation provided of all areas; -Treatment reapplied to bottom at this time; -Will continue to monitor and assess as needed; -No documentation to show color, if there was drainage to open area or if the wounds were improving or declining. Review of the resident's Braden Scale, dated 9/26/22 at 6:32 A.M., showed the following: -Resident was at moderate risk for pressure ulcers; -Sensory Perception; responds to verbal commands and no sensory deficit limiting ability to feel or voice discomfort/pain; -Moisture; skin is often but not always moist. Linen must be changed at least once a shift; -Activity; ability to walk severely limited or nonexistent. Can't bear own weight and/or must be assisted into chair or wheelchair; -Mobility; makes frequent, though slight, changes in body or extremity position independently; -Nutrition; never eats a complete meal. Rarely eats more than one-third of food offered, eats two servings or less of protein per day and takes fluids poorly. Doesn't take liquid dietary supplement; -Friction and Shear; required moderate to maximum assist in moving. Complete lifting without sliding against sheets is impossible and frequently slides down in bed or chair, requiring frequent repositioning with maximum assist. Spasticity, contractures, or agitation leads to almost constant friction; -Interventions included: pressure reducing device for bed, turning and repositioning program, pressure ulcer care, application of nonsurgical dressings (with or without topical medications) other than to feet, application of ointment/medication other than to feet; -The resident scored a 13 and put him/her at moderate risk for pressure ulcers. Review of the resident's progress notes, dated 9/26/22 at 8:23 A.M., showed the following: -Monthly Braden Scale completed with a score of 13 making the resident a moderate risk; -Resident continued with pressure ulcer daily dressing changes; -No new referrals necessary; -Continue with current plan of care. Review of the resident's weekly skin assessment, dated 10/1/22 at 5:52 A.M., showed the following: -LPN H completed the skin assessment; -The resident's bottom was macerated (the softening and breaking down of skin resulting from prolonged exposure to moisture) and open; -The resident had an open ulcer on his/her coccyx measuring 1.0cm x 0.5cm; -No changes noted from the previous skin assessment; -The physician was not notified of any changes; -No documentation to show there were any previously assessed pressure ulcers or to show they had healed. No documentation of color or if there was drainage to the open areas. Review of the resident's progress notes, dated 10/6/22 at 4:32 P.M., showed the physician was in the facility and made rounds. Review showed no documentation staff notified the physician of the resident's pressure ulcer status during the physician's rounds. Review showed the physician did not address the resident's wounds. Review of a picture, taken on 10/8/22, of the resident's coccyx showed two open areas pink edges and white wound beds. Review of the resident's weekly skin assessment, dated 10/8/22 at 5:54 A.M., showed the following: -LPN D completed the skin assessment; -The resident had an open area on his/her coccyx (photo taken same day showed two open areas); -There were no red areas that remained after 30 minutes of pressure reduction; -The resident had no open ulcers (photo taken same day showed two open areas); -Any changes noted from the previous skin assessment was marked not applicable (previous skin assessment showed an open area to the coccyx); -No documentation to show the measurements of the open areas to his/her coccyx. Review of the resident's progress notes, dated 10/8/22 at 5:56 A.M., showed the following: -A weekly skin assessment was completed with no new areas of concern; -The resident continued with an open area to buttocks; -Will continue to monitor and assess as needed; -No documentation in the resident's progress notes that showed any changes in the resident's pressure ulcer, measurements, the color or if there was drainage. Review of the resident's progress notes, dated 10/12/22 at 10:48 A.M., showed the following; -The resident continued with three open pressure areas to his/her coccyx measuring 0.9cm x 0.5cm, 0.1cm x 0.3cm, and 0.1cm x 0.1cm; -Wound beds were dark pink with no drainage observed from the areas; -Surrounding skin was pink and intact; -Area cleaned and treatment completed as ordered; -Pictures obtained for documentation; -Will continue to monitor. Review of a picture, taken on 10/12/22, showed three open areas to the resident's coccyx. The largest open area to the coccyx had a light pink area surrounding the wound with a red circular area with a white and red wound bed. The second largest open area had a light pink area surround the wound with a red wound bed. The smallest open area showed a small red open ulcer. Review showed no documentation the physician was notified of the resident had three open areas on the coccyx. Review of the resident's weekly skin assessment, dated 10/15/22 at 4:05 A.M., showed the following: -LPN H completed the skin assessment; -There were red areas that remain after 30 minutes of pressure reduction to the resident's bilateral buttocks; -The resident had an open ulcer measuring 1.0cm x 0.5cm on his/her bilateral buttocks (picture documentation showed the resident only had open areas to his/her coccyx); -No changes noted from the previous skin assessment (the previous skin assessment showed three open pressure ulcers to his/her coccyx); -No documentation in the resident's progress notes to show any changes in the resident's pressure ulcers, the color, size or if there was drainage. Review of the resident's progress notes, dated 10/19/22 at 10:20 A.M., showed the following: -The resident continued with two open pressure areas to his/her coccyx measuring 2.5cm x 1.5cm and 1.5cm x 1.0cm; -Wound beds observed as red with yellow slough; -Intact black area noted beneath the two open areas measuring 1.0cm x 0.5cm; -Areas cleansed and treatment completed as ordered; -Pictures obtained for documentation. Review of a picture, taken by LPN D on 10/19/22, showed two open areas and one dark purple/black area about half the size of the smaller open area. The largest open area had yellow/white slough with redness along one side and black along the other side. The smaller open area was red across the top and black on the bottom edge of the ulcer. Review showed no documentation the physician was notified of the change in the resident's pressure ulcers to yellow slough and black edges and another dark purple/black intact area. Review of the resident's weekly skin assessment, dated 10/21/22 at 7:30 P.M., showed the following: -LPN D completed the skin assessment; -The resident had a pressure ulcer to his/her coccyx and red/purple bruising to bottom; -Any changes noted from the previous skin assessment was marked not applicable (previous assessment showed the resident had three open areas with slough); -The physician was not notified of any changes. Review of the resident's progress notes, dated 10/21/22 at 7:30 P.M., showed the following: -The nurse was called to the resident's room by staff due to large bruise to the resident's bottom; -Upon assessment the resident was noted to have a large area of bruising starting at the coccyx on the right side and wrapping around to the side; -Resident continues with open area to the coccyx; -Area cleaned and daily dressing applied; -Pictures obtained for documentation; -Will continue to monitor and assess as needed. Review of picture, taken on 10/21/22, showed one open area to the resident's coccyx that had eschar to the bottom portion of the wound, peeling skin around the open wound and bruising that was light red to dark purple around the wound and to the right of the wound. Review showed the bruising started at the coccyx wound and went about 3/4 of the way on the right buttock. Review showed no documentation the resident's physician was notified on the eschar, peeling skin, or bruising at the site of the resident's pressure ulcer. Review of the resident's progress notes, dated 10/26/22 at 7:45 A.M., showed the following: -The resident continued with an open pressure area to his/her coccyx measuring 4.5cm x 3.0cm; -The entire wound bed was covered with yellow/brown slough; -No drainage noted from the area; -A deep tissue injury surrounded the open area that was dark purple/red in color and measured 10cm x 15cm; -Area cleansed and dressing applied as ordered; -Pictures obtained for documentation. Review of a picture, taken on 10/26/22, showed the deep tissue injury area had two open areas to the outer edge where there was dark purple bruising. Review of the resident's Braden Scale, dated 10/26/22 at 7:46 A.M., showed the following: -Sensory Perception; responds only to painful stimuli. Can't communicate discomfort except by moaning or restlessness (this is a decrease in sensory perception from the 9/26/22 Braden Scale); -Moisture; skin is often but not always moist. Linen must be changed at least once a shift; -Activity; walks outside the room at least twice a day and inside room at least once every two hours during waking hours; -Mobility; makes occasional slight changes in body or extremity position, but unable to make frequent or significant changes independently (this is a decrease in mobility from the 9/26/22 Braden Scale); -Nutrition; never eats a complete meal. Rarely eats more than one-third of food offered, eats two servings or less of protein per day and takes fluids poorly. Doesn't take liquid dietary supplement; -Friction and Shear; required moderate to maximum assist in moving. Complete lifting without sliding against sheets is impossible and frequently slides down in bed or chair, requiring frequent repositioning with maximum assist. Spasticity, contractures, or agitation leads to almost constant friction; -The resident scored a 12 and put him/her at high risk for pressure ulcers. Review of the resident's progress notes, dated 10/26/22 at 8:30 A.M., showed the following: -Resident had a decline in condition with increased congestion noted audibly; -The resident was transferred to his/her wheelchair to go to the outpatient clinic for a blood transfusion (routine procedure for the resident) and was limp and could not hold up his/her head; -The resident was transferred back to his/her bed; -The physician was notified and the resident was transferred to the emergency room. Review of the resident's hospital records, dated 10/26/22, showed the following: -The resident arrived to the emergency room at 8:25 A.M.; -The resident was noted to have a 43 mm x 35 mm necrotic deep tissue injury to his/her coccyx with macerated surrounding tissue that was thin, purple, scattered peeling skin with non-blanchable tissue; -Diagnoses included UTI, dehydration, septicemia (blood poisoning), necrotic wound to coccyx, pneumonia and mental status changes. During an interview on 10/27/22 at 2:25 P.M., 12/5/22 at 4:18 P.M., RN B/DON/Wound Nurse said the following: -She does weekly skin assessments on residents with wounds and/or pressure ulcers; -She has not had any formal wound care training; -She takes pictures, tracks the progress of the wound/pressure ulcer and completes treatments once a week; -Charge nurses do daily treatments for residents; -If a new area is found by the floor nurses they notify her in report; -She felt the treatment to the resident's coccyx was effective; -She didn't think she needed to contact the physician when the wound declined; -The wound changed drastically overnight; -None of the staff notified her the resident's wound had gotten worse; -She did not realize staff were not using the correct anatomical identifiers for resident wounds; -She would expect the staff to correctly identify wounds as to where they are on the resident's body; -It would make it difficult to track wounds if staff didn't identify the sites correctly. During an interview on 11/1/22 at 4:03 P.M., RN A/DON said the following: -She would expect staff to notify the physician for new orders if a wound/pressure ulcer got worse; -She did not do weekly wound assessments and measurements when RN B/DON/Wound Nurse was gone. She did not know it was expected of him/her to do them. During an interview on 11/1/22 at 11:15 A.M., 11/9/22 at 10:23 A.M., 11/16/22 at 2:22 P.M., and 12/05/22 at 3:48 P.M., the administrator said the following: -She would have expected RN B/DON/Wound Nurse to contact the physician on 10/19/22 when the wound had some eschar on the edges of the wound and it had increased in size; -The physician said he was not aware of the resident's wound to his/her coccyx at the time of his visit on 10/6/22; -She would have expected any of the staff to contact the physician if there was change in the resident's wound; -She would expect RN A/DON to do the weekly wound assessments if RN B/DON/Wound Nurse was not in the building; -The facility had not trained their staff on identifying body sites; -She would expect staff to accurately chart body sites to determine where a wound would be identified on a resident's body; -The Wound Nurse tracks wounds, but if there are questions the she would have to look at documentation and picture documentation to determine the correct site of the wound; -The weekly skin assessment has an area that asks if there is an open area on the resident's bottom and another area that asks about open ulcers with a drop down list with coccyx as an option to choose; -She would expect her staff to be as detailed as possible when documenting wounds. During a