**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, and staff, Nurse Practitioner and Medical Director interviews, the facility failed to consult with the physician about a new pressure ulcer that developed on 08/22/25 on Resident #8's right heel. The pressure ulcer was observed 08/22/25 with no notification to the physician until 09/09/25 when the pressure ulcer to Resident #8's right heel was assessed and documented as an unstageable wound to the right heel with black eschar (dry, black, or brown crust that forms on the surface of wounds) with foul odor and measuring 3.5 centimeters (cm) by 3.5 cm. The facility also failed to consult the physician when Resident #2's diabetic foot ulcer was identified on 09/10/25. In addition, the facility also failed to consult the physician when Resident #16's stage II pressure ulcer was identified on 08/31/25 and when Resident #29 experienced significant weight loss. This deficient practice affected 4 of 4 residents reviewed for notification (Resident #2, #8, 16 and #29). The findings included: 1. Resident #8 was admitted to the facility on [DATE] with diagnoses that included history of cerebral vascular accident and diabetes mellitus. Resident #8's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident's cognition was severely impaired, required substantial to maximal assistance with most of her activities of daily living and she did not have pressure ulcers on admission. An interview was conducted with Nurse Aide (NA) #1 on 09/18/25 at 2:35 PM. The NA explained that on 08/22/25 she was preparing to give Resident #8 her shower when she tried to remove her right sock, but it was stuck to her heel and would not come off until she wet the sock first. The NA continued to explain that she noted a red raw area approximately the size of a quarter on her right heel with bloody dried hard drainage on the sock. The NA got Nurse #1 to come to the shower room where she observed Resident #8's right heel and put a dressing over the heel as well as obtained a heel protector to put on after she finished the shower. An interview was conducted with Nurse #1 on 09/18/25 at 4:10 PM and 09/18/25 at 5:30 PM. The Nurse explained that she remembered NA #1 asking her to come to the shower room on 08/22/25 where NA #1 showed her Resident #8's right heel. The wound was pink, and she could not remember if there was drainage. The Nurse continued to explain that she did not measure the pressure ulcer or notify the physician, but she did apply a dry foam dressing to the heel and put a note on the board in the medication room for the Wound Nurse to follow up on the next day. On 09/18/25 at 8:45 AM an interview was conducted with NA #5 who explained that on the night of 09/04/25 she noted an area of drainage on Resident #8's bed sheet while she was providing care to the Resident and when she tried to remove the Resident's right sock, the sock was stuck to her heel. The NA stated she got Nurse #7, and the Nurse cleansed Resident #8's right heel and applied a dressing on her heel. During an interview with Nurse #7 on 09/18/25 at 8:50 AM the Nurse explained that on the night of 09/04/25 NA #5 reported that she could not get Resident #8's sock off her right heel because it was stuck to her heel. The Nurse stated she had to soak the Resident's right heel with wound cleanser in order to remove the sock. The Nurse continued to explain that Resident #8's right heel had a blood-filled blister that was not open, and the area looked like the skin was layered. The Nurse reported that she did not measure the pressure ulcer or notify the physician, but she did apply a foam dressing to the Resident's right heel and applied heel protectors to Resident #8' feet. Nurse #7 also reported that she put a note in the wound communication book for follow up by the Wound Nurse. An interview was conducted with Wound Nurse on 09/16/25 at 2:39 PM, 09/18/25 at 11:45 AM and 09/19/25 at 7:30 AM. The Wound Nurse explained that she first became aware of Resident #8's right heel pressure ulcer on 09/09/25. The pressure ulcer was unstageable with black eschar, malodorous and measured 3.5 x 3.5 centimeters. The Wound Nurse continued to explain that the pressure ulcer had a treatment set up but when she noted that it was black with hard eschar and the drainage was malodorous, she decided to notify the Medical Director and asked for crushed metronidazole (antibiotic) which was what she normally did with a malodorous ulcer. The Medical Director also ordered an X-ray to rule out osteomyelitis which was negative. The Nurse stated she also obtained an order for a wound consult and Resident #8 was seen by the Wound Care Nurse Practitioner on 09/11/25. Nurse #4 reported that she did not see the note on the board in the medication room left by Nurse #1 on 08/22/25. She stated that 08/22/25 was a Friday and she did not work on Fridays and neither did she work on the weekends. Resident #8's medical record from 07/17/25 through 09/09/25 revealed there was no documentation in the medical record of the Medical Director being notified of pressure ulcer development. During interviews with the Medical Director on 09/18/25 at 10:25 AM and 09/19/25 at 3:08 PM. The Medical Director explained that he was first made aware of Resident #8's right heel pressure ulcer when the Wound Nurse #4 called and reported it on 09/09/25. He reported that he ordered crushed metronidazole to be applied to the wound daily for the malodor and to follow up with a wound consultation. The Medical Director also stated that based on the description by Wound Nurse he ordered an X-ray to rule out osteomyelitis which was negative. The Medical Director was not informed of the pressure ulcer first being discovered on 08/22/25 and no orders were obtained to follow up with treatment and the Medical Director stated that it was unfortunate because if the orders had been initiated then the pressure ulcer may not have gotten to the point it had. On 09/19/25 at 6:00 PM an interview was conducted with the Director of Nursing (DON) with the Administrator present. The DON explained that there were standing orders for wound care and when the pressure ulcer was first noted on Resident #8 the standing order should have been set up with specific treatment, and the Medical Director should have been notified in case there were further orders to be followed. 2. Resident #2 was admitted on [DATE] with diagnoses of vascular dementia and hemiparesis and hemiplegia of left side following a stroke. A progress note written by Wound Nurse dated 9/10/25 at 2:05 PM wrote she found an open area on Resident #2's left heel. The note read the open area was unstageable and measured 2 centimeters (cm) x 1.5(cm). The Wound Nurse wrote the area around the open area was red with blanchable redness. The wound did not contain an odor, and the area was cleaned, and a dressing was applied. On 9/18/25 at 1:15 PM the Wound Nurse was interviewed. The Wound Nurse stated she first saw the heel wound on 9/10/25 and documented the wound in a progress note. The left heel wound measured 2 (cm) x 1.5 (cm) and did not contain an odor or drainage. The Wound Nurse said she treated the left heel wound with standing wound orders and notified the Wound Nurse Practitioner the following day. Additionally, she thought she had communicated the wound to the Nurse Practitioner (NP) when she found it 9/10/25. On 9/11/25 the Wound Nurse Practitioner evaluated the left heel dorsal wound. The Wound Nurse Practitioner treatment note read that given the dorsal location of this wound, it was consistent with a diabetic etiology. The wound was deep and full of necrotic slough (dead tissue) and suspected the wound had been present for some time. The treatment note also included the estimated depth to bone was less than 2 millimeters. Additionally, the Wound Nurse Practitioner wrote that a medically necessary sharp debridement was indicated and performed for the removal of excessive necrotic tissue and for the promotion of wound healing. The note continued with treatment orders to cleanse left heel wound with a full-strength antiseptic solution and then apply full strength (0.5%) antiseptic solution moistened gauze to the full depth of the wound bed. Finally, the wound was to be covered with a silicone bordered super absorbent dressing. The treatment was to be completed daily and PRN (as needed). An additional order was for a wound culture and sensitivity and x-ray of left heel for evaluation of evidence for presence of osteomyelitis (infection in a bone) and underlying pathology. The Wound Nurse Practitioner also wrote for labs of complete blood count, C reactive protein, and erythrocyte sedimentation rate. The Wound Nurse Practitioner also wrote that the resident was to always wear a podus boot (foot brace to prevent bedsores) for offloading. On 9/15/25 the Wound Nurse Practitioner treated the resident's left heel. A review of the treatment note found the measurements for the left heel diabetic ulcer were 2 cm x 1.5 cm x 1.5 cm. The wound contained 80% necrotic tissue with yellow seropurulent (discharge of serum and pus) drainage. The treatment note included the left heel wound had not improved from the previous treatment day, but the adherent slough that was present last week (9/11/25) was mostly liquefied and ran out of the wound when the dressing was removed. The Wound Nurse Practitioner assessed with certainty if the drainage included purulent drainage mixed with liquified yellow green slough. Furthermore, the Wound Nurse Practitioner's note wrote that a medically necessary sharp debridement was indicated for the removal of excessive necrotic tissue and for the promotion of wound healing. The wound was anesthetized, and debridement was performed. Resident #2's NP was interviewed on 9/17/25 at 11:00 AM. He stated Resident #2 had been placed on comfort measures due to an overall decline and Resident #2 had poor nutritional status and would refuse nutritional supplements. The NP stated he was aware that Resident #2 had wounds on her back and sacrum area but did not know she had a wound on her left heel. He stated he was not notified that Resident #2 had a wound on her left heel. The NP stated he was not notified of any lab results ordered by the Wound Nurse Practitioner on 9/11/25 and was not aware of her treatment orders. The NP stated it was important to be notified of new wounds and any interventions for Resident #2 so treatment could be started and to see what other interventions Resident #2 had in place. He stated Resident #2's left heel wound would be unavoidable due to her overall decline. The NP stated he should have been notified of Resident #2's left heel wound when it was found on 9/10/25. Additionally, the NP stated normally the Wound Nurse Practitioner would have been notified with results of any labs or diagnostics first because she had ordered them, and the results would be placed in his folder to review or would have been called in to him. The Medical Director was interviewed on 9/18/25 at 11:25 AM. The Medical Director stated he was notified by the nursing staff through the nursing communication book or by a phone call when a resident had a new wound. The Medical Director stated he was not notified that Resident #2 had a wound on her left heel. On 9/19/25 at 4:04 PM the DON stated the Medical Director and NP should have been notified for Resident #2's diabetic foot wound on 9/10/25 when found by the Wound Nurse. 3. Resident #29 was admitted to the facility on [DATE]. Her diagnoses included dementia, hypothyroidism, nutritional deficiency, protein-calorie malnutrition. Resident #29's electronic record documented the following weights -7/29/25- 132.1 pounds (lbs.) -8/26/25- 114.4 lbs. A progress note dated 8/31/25 by the Registered Dietitian (RD) #1 indicated Resident #29 was reviewed. The note indicated she had a significant weigh loss of 13.6 % in a month. The note indicated Resident #29 received a regular diet with mechanical soft texture and her intakes ranged from 0-50% of most meals. The note indicated she was receiving Med Pass (nutritional supplement) 60 milliliters (ml) twice daily and a mighty shake (nutritional supplement) three times daily. The note indicated the RD recommended obtaining a reweight for weigh loss verification and increasing her Med Pass to 90 ml twice daily to promote weight stability. RD #1 was not available for interview. A reweigh weight was not located in Resident #29's electronic medical record. An interview was conducted with the Director of Nursing (DON) on 9/18/20 at 10:20 AM. She said if a resident had significant weight loss it was the Assistant Director of Nursing (ADON) who was responsible for ensuring the provider was notified and said it should be documented somewhere. The DON stated when someone had significant weight loss the physician should be notified. Review of Resident #29's medical record revealed there was no documentation the physician was notified of the weight loss. An interview was conducted with the ADON on 9/18/25 at 11:01 AM. The ADON reported she was responsible for keeping up with the facility weights and ensuring they were completed. The ADON stated she had not notified the physician of Resident #29's significant weight loss. She said the Physician should be notified if a resident had significant weight loss so they could check the resident medically to see if there was a reason for the weight loss. The ADON stated Resident #29's reweight not being reported or entered until 9/18/25 by Unit Clerk #1 was a little late. The ADON said she noticed Resident #29's weight loss at the end of August but was waiting on the reweight before she notified the Physician. The ADON said she should have followed up on Resident #29's reweight but had gotten busy. The ADON thought she was the person who would be responsible for notifying the Physician of significant weight loss. She stated she had just got busy and forgot because she was working on the floor. An interview was conducted on 9/19/25 at 10:45 AM with RD #2. RD #2 reported that the Physician should also be notified if a resident had significant weight loss. RD #2 said she was not aware of who notified the physician at the facility. RD #2 stated she was not told by anyone at the facility the RD was the person who notified the Physician. RD #2 reported it was important to notify the Physician of significant weight loss so the Physician could review the resident from a medical standpoint. An interview was conducted with the Medical Director on 9/18/25 at 9:53 AM. He stated he was aware Resident #29 had some prior weight loss in the past but had not been notified in the last month about her having significant weight loss. He said if a resident had significant weight loss it would trigger for him to review and see them. The Medical Director said if he had been notified of Resident #29's significant weight loss he may have done labs and checked a TSH level because Resident #29 took Synthroid (thyroid medication). The Medical Director said the facility should have followed the RD recommendations and obtained a reweight to confirm her weight loss and ensured the weight was reported. The Medical Director said he would have asked for a reweight to be obtained too. The Medical Director explained there was no reason not to notify him immediately when the facility became aware someone had significant weight loss. He further explained if he was off, the facility could notify him through the provider's communication book, and the information would be there for him to review when he returned. The Medical Director stated he had not seen a note about Resident #29 having weight loss in the provider communication book. The Medical Director said he would expect to be notified within a week. An interview was conducted with the Administrator on 9/18/25 at 5:11 PM. The Administrator stated the ADON had notified her about Resident #29's weights today. The Administrator stated the Physician should be notified if a resident had significant weight loss. She said previously the RD notified the Physician if a resident had significant weight loss. She reported that it was still the process. The Administrator explained RD #1 went on medical leave at the end of August and said she thought that was why there was a breakdown in communication. 4. Resident #16 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, hemiplegia (paralysis or weakness on one side of the body) and hemiparesis (decreased control and strength on one side of the body) following cerebral infarction affecting right dominant side, muscle wasting and atrophy, muscle weakness. An interview was conducted on 9/15/25 at 9:23 AM with Resident #16. He reported he had a pressure ulcer to the back of his right thigh. A nursing note dated 8/31/25 by Nurse #8 read: “Nurse notified by resident of bleeding spot on the back of his thigh. Possible stage 2 pressure injury noted to right outer back thigh. Wound bed pink, scant red drainage noted on resident's reusable chuck on his manual wheelchair. No signs of infection. Nurse cleansed wound with wound cleanser, covered wound bed with silver alginate and covered with adhesive dressing. Resident will be added to acute book for this issue and nurse will enter wound care orders until wound care nurse can assess.” An order dated 8/31/25 was entered by Nurse #8 and read: Cleanse wound with wound cleanser, cover wound bed with silver alginate (highly absorbent wound dressing embedded with silver particles to fight infection), place dry adhesive dressing over wound, two times a day for pressure injury for 7 days. The order ended on 9/7/25. There were no additional wound care orders after 9/7/25. An interview was conducted with Nurse #8 on 9/17/25 at 2:57 PM. She recalled finding the stage 2 pressure ulcer to the back of Resident #16's right thigh on 8/31/25. Nurse #8 stated she had not notified the Physician when she found Resident #16's wound to obtain treatment orders, she said that was not the process. Nurse #8 explained what she understood was the facility's process when a wound was found. She said the nurse entered a treatment order for the wound, made a nursing note, and entered a note in the nursing “acute book” so everyone would know about the wound and document on the wound for 72 hours. An interview was conducted with the ADON on 9/17/25 at 11:00 AM. The ADON reported she reviewed Resident #16's orders and stated Resident #16 had a treatment order for the stage 2 pressure ulcer entered on 8/31/25. She said when a wound was found the nurse was supposed to notify the provider by placing a note in the provider's communication book or by calling them. The ADON reviewed the provider's communication books and stated there was not a note left to notify the provider about Resident #16's wound. An interview was conducted on 9/17/25 at 12:11 PM with the Nurse Practitioner (NP). He said he was not aware Resident #16 had a wound and that he had not been asked to look at the area. He said Nurse #8 should have notified a provider when the wound was found to obtain wound care orders. He stated if he had been notified, he would have ordered Resident #16 to be seen by the Wound Care Provider. An interview was conducted with the Medical Director on 9/18/25 at 9:46 AM. The Medical Director stated he was not aware that Resident #16 had developed a wound. He stated the nurse should have notified him or the NP of Resident #16's wound and to get wound care orders when the wound was identified. An interview was conducted with the Director of Nursing (DON) and Administrator on 9/19/25 at 6:00 PM. The Administrator reported that Nurse #8 should have notified the provider when she found Resident #16's wound. The Administrator stated she did not know why Nurse #8 did not notify the Physician about the wound.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews with staff, Wound Nurse Practitioner, Nurse Practitioner (NP), and Medical Diractor the facility failed to provide skin assessments, failed to identify a new wound on the heel at the onset, and failed to ensure necessary medical treatment when positive culture and sensitivity results were available Resident #2. This delayed the treatment for an infected wound. This was for 1 of 2 residents (Resident #2) reviewed for quality of care. Findings included:The findings included:Resident #2 was admitted on [DATE] with diagnoses of vascular dementia and hemiparesis (one-sided muscle weakness) and hemiplegia (one-sided paralysis or weakness of the face, arm and leg) of left side following a stroke. A review of Resident #2's quarterly Minimum Data Set (MDS) dated [DATE] coded her with severe cognitive impairment. Resident #2 was coded for one (1) stage one pressure ulcer, needing maximal assist with rolling, and total dependence on transfers. Resident #2 was care planned for do not resuscitate with comfort measures(1/24/25). Interventions included to notify the residents family and MD if resident condition worsened (7/4/24). A care plan for skin related to hemiplegia and wound on bottom (4/24/25). Interventions included excoriation on buttocks treated with zinc (3/27/25), air overlay discontinued per resident request (3/27/25), assist and turn frequently (7/9/24), cleanse peri area in AM and PM following each episode of incontinence episode (7/9/24), follow in- house wound care(7/9/24), cushion to chair and panacea mattress(pressure reducing mattress) to bed (1/2/25), monitor nutrition (7/9/24), and monitor skin for any redden or open areas. Notify nurse immediately (7/9/24). A review of Resident #2's medical record found there were no weekly skin assessments documented for Resident #2. On 9/5/25 the Medical Director saw Resident #2 and his progress note was reviewed. The Medical Director wrote there was a 5-centimeter (cm) erythematous plaque (raised, flat skin area that is red in color) on Resident #2's upper left back and a similar wound on her sacrum. The Medical Director wrote the chronicity and characteristics of the wounds suggested a potential for infection and poor healing. The plan from the Medical Director was to consult wound care specialist for further evaluation and treatment recommendations and ordered alginate (dressing used to keep wound moist for healing) dressing for wound management on both wounds. A review of Resident #2's September 2025 physician orders included an order dated 9/8/25 to float heels every shift. On 9/18/25 at 4:10 PM a Nurse Aide (NA) #3 who was on the shower team was interviewed. She stated Resident #2 had received a shower on 9/9/25, and she completed a skin assessment for Resident #2. NA #3 said Resident #2 did not have an open wound on her left heel, but only a red area on it. NA #3 stated she communicated the red area to Resident #2's assigned nurse on the second shift. Resident #2's assigned second shift nurse on 9/9/25, Nurse #6, was interviewed on 9/18/25 at 5:12 PM. Nurse # 6 stated she did not recall NA #3 telling her about a red area on Resident #2's left heel on 9/9/25. Nurse #6 stated she became aware of the left heel wound on 9/10/25 from the Wound Nurse. A progress note written by Wound Nurse dated 9/10/25 at 2:05 PM wrote she found an open area on Resident #2's left heel. The note read the open area was unstageable and measured 2 (cm) x 1.5 (cm). The Wound Nurse wrote the area around the open area was red with blanchable redness. The wound did not contain an odor, and the area was cleaned and a dressing was applied. On 9/18/25 at 1:15 PM the Wound Nurse was interviewed. The Wound Nurse stated she first saw Resident #2's heel wound on 9/10/25 and documented the wound in a progress note. The left heel wound measured 2(cm) x 1.5 (cm) and did not contain an odor or drainage. The Wound Nurse said she treated the left heel wound with standing wound orders and notified the Wound Nurse Practitioner the following day, as she was scheduled to be in the facility. Additionally, she thought she had communicated the wound to the medical provider when she found it 9/10/25.On 9/11/25 the Wound Nurse Practitioner evaluated the left heel dorsal wound. The Wound Nurse Practitioner treatment note read that given the dorsal location of this wound, it was consistent with a diabetic etiology. The wound was deep and full of necrotic slough (dead tissue) and suspected the wound had been present for some time. The treatment note also included the estimated depth to bone was less than 2 millimeters. Additionally, the Wound Nurse Practitioner wrote that a medically necessary sharp debridement was indicated and performed for the removal of excessive necrotic tissue and for the promotion of wound healing. The note continued with treatment orders to cleanse left heel wound with a full-strength antiseptic solution and then apply full strength (0.5%) antiseptic solution moistened gauze to the full depth of the wound bed. Finally, the wound was to be covered with a silicone bordered super absorbent dressing. The treatment was to be completed daily and PRN (as needed). An additional order was for a wound culture and sensitivity and x-ray of left heel for evaluation of evidence for presence of osteomyelitis (infection in a bone) and underlying pathology. The Wound Nurse Practitioner also wrote for labs of complete blood count, C reactive protein, and erythrocyte sedimentation rate. The Wound Nurse Practitioner also wrote that the resident was to always wear a podus boot (foot brace to prevent bedsores) for offloading.The Wound Nurse Practitioner was interviewed via phone on 9/18/25 at 1:30 PM and stated Resident #2 was evaluated by her on 9/11/25 for the first time. Resident #2 was evaluated for 3 wounds with one being the left heel diabetic wound. The Wound Nurse Practitioner stated the left heel wound had yellow necrotic slough and it was difficult to measure the depth but suspected it was to the bone. The provider said she could not state how long the left heel wound had been present. She stated Resident #2 had comorbidities including poor nutrition, and it would be plausible for her heel wound to develop quickly from a small area to the way it presented when evaluated. Furthermore, the Wound Nurse Practitioner stated she had ordered a culture and sensitivity for the left heel wound, along with other labs and an x-ray to determine if osteomyelitis was a factor on 9/11/25. On 9/11/25 at 2:37 PM the Wound Nurse wrote Resident #2 had 3 wounds. An opened area to the upper left section of her back on a bony prominent area that was covered with alginate for three days. Resident #2 also has a wound on her sacral area and on her left heel that were both covered.On 9/11/25 at 12:47 PM a Unit Clerk progress note read the ordered labs for Resident #2's CBC (complete blood count), CRP (C reactive protein), and ESR (erythrocyte sedimentation rate), were drawn and awaiting lab pick up.On 9/11/25 at 12:48 PM the Unit Clerk wrote a progress note. The note read that the orders for Resident #2's wound culture of left heel were collected by the Wound Nurse Practitioner and awaiting pick up.Lab results reviewed found a wound culture and sensitivity lab result for Resident #2. The lab result included the ordered date of 9/11/25 and the verified final date of 9/14/25. The wound culture and sensitivity results found moderate proteus mirabilis (bacteria) and scant staphylococcus aureus (bacteria). Results for an x-ray of Resident #2's left heel ordered on 9/11/25 and completed on 9/11/25 found no osteomyelitis. On 9/15/25 the Wound Nurse Practitioner provided treatment to the residents' left heel. A review of the treatment note found the measurements for the left heel diabetic ulcer were 2 centimeters (cm) x 1.5 cm x 1.5 cm. The wound contained 80% necrotic tissue with yellow seropurulent (discharge of serum and pus) drainage. The treatment note included the left heel wound had not improved from the previous treatment day, but the adherent slough that was present last week (9/11/25) was mostly liquefied and ran out of the wound when the dressing was removed. The Wound Nurse Practitioner wrote she was unable to assess with certainty if the drainage included purulent drainage mixed with liquified yellow green slough. Additionally, the Wound Nurse Practitioner wrote the Wound Nurse reported the wound culture obtained last Thursday (9/11/25) was negative. The Wound Nurse Practitioner noted a subsequent culture was obtained today because she had a high suspicion that the previous culture result was inaccurate. The treatment note indicated to cleanse the wound with full strength wound cleanser with antimicrobial and debridement actions solution and pat dry. Then skin prep (skin protectant) the wound edges and apply full strength wound cleanser with antimicrobial and debridement actions moistened gauze to the entire depth of the wound bed and cover with a silicone bordered super absorbent dressing. The frequency of the treatment order was to change daily and PRN (as needed). In addition, the Wound Nurse Practitioner documented that a medically necessary sharp debridement was indicated for the removal of excessive necrotic tissue and for the promotion of wound healing. The wound was anesthetized, and debridement was performed. On 9/15/25 at 12:09 PM the Wound Nurse wrote a progress note for order to repeat the wound culture and sensitivity (left heel wound).The Nurse Practitioner (NP) was interviewed on 9/17/25 at 11:00 AM. He stated Resident #2 had been placed on comfort measures due to an overall decline, but the resident did not elect to go with a hospice program. The NP stated Resident #2 had poor nutritional status and would refuse nutritional supplements. The NP stated he was aware that Resident #2 had wounds on her back and sacrum area but did not know she had a wound on her left heel. He stated he was not notified Resident #2 had a wound on her left heel. The NP stated he was not notified of any lab results ordered by the Wound Provider on 9/11/25 and was not aware of her treatment orders. He stated Resident #2's left heel wound would be unavoidable due to her overall decline. The NP stated he should have been notified of Resident #2's left heel wound when it was found on 9/10/25. Additionally, the Medical Provider stated normally the Wound Nurse Practitioner would have been notified with results of any labs or diagnostics first because she had ordered them, and the results would be placed in his folder to review or would had been called in to him. A follow-up interview was conducted with the NP on 9/17/25 at 2:30 PM. He stated Resident #2's culture and sensitivity lab had been reviewed by him today. The NP stated the culture and sensitivity for the wound was positive for moderate proteus mirabilis and scant staphylococcus aureus on the results dated 9/14/25. He then added orders were written for 2 antibiotics (Bactrim 400/80 milligrams by mouth twice daily for 14 days, Ceflin 250 milligrams by mouth one time daily for 14 days) for the infected heel wound, based on the culture and sensitivity results.Resident #2 had physician orders written on 9/17/25 for Ceflin (antibiotic) 250 milligrams by mouth once daily for 14 days for wound infection and Bactrim (antibiotic) 400/ 80milligrams by mouth twice daily for 14 days for wound infection.The Medical Director was interviewed on 9/18/25 at 11:25 AM. The Medical Director stated he was notified by the nursing staff through the nursing communication book or by a phone call when a resident had a new wound. The Medical Director stated he was not notified that Resident #2 had a wound on her left heel. He said on 9/5/25 he had seen Resident #2 for an upper back wound and a sacrum wound and was not aware Resident #2 had a heel wound. He said Resident #2 was followed by the NP and was unaware if they were notified of the heel wound. The Medical Director further stated the culture and sensitivity lab was verified on 9/14/25 and the facility should have notified the Wound Nurse Practitioner or the NP on 9/15/25 of the results. The Medical Director said Resident #2's labs had indicated an infection of the left heel, but not a high infection and Resident #2 had missed one (1) day of antibiotic treatment with the Wound Nurse Practitioner not receiving the wound culture and sensitivity results. On 9/18/25 at 1:15 PM the Wound Nurse stated Resident #2 did not have scheduled or routine skin assessments to be completed by herself or a nurse. She stated when a resident received a shower, the shower team would also do a skin check and report any skin issues to the residents assigned nurse. The Wound Nurse stated that when lab results were completed and sent to the facility, the labs were faxed to the provider that had ordered them. She would then wait on the provider to write orders and send back to the facility. The Wound Nurse said she had not sent any lab results to the Wound Nurse Practitioner or the NP.9/18/25 at 1:30 PM the Wound Nurse Practitioner said on 9/15/25, she treated Resident #2 and was told by the Wound Nurse that the culture and sensitivity had come back negative. The Wound Nurse Practitioner stated she had not seen the results of the culture and sensitivity, labs or x-ray. The Wound Nurse Practitioner went on to state she had suspected an infection of the left heel wound and was surprised the results were negative. She ordered another culture and sensitivity to be sent to the lab. The Wound Nurse Practitioner said she was only able to see lab results if they were uploaded to the resident's electronic chart or handed to her in person. The surveyor informed the Wound Nurse Practitioner the wound culture and sensitivity was completed on 9/14/25 and sent to the facility and the NP had seen the results on 9/17/25 and had ordered antibiotics for the infected heel wound. The Wound Nurse Practitioner responded, Resident #2 had missed at least one (1) day of antibiotic treatment because she had been provided with incorrect information for the culture and was not provided with the results on 9/15/25. The Wound Nurse Practitioner said the wound culture and labs should have been made available for her to review. Additionally, the Wound Nurse Practitioner stated the Dakin's solution ordered for treatment on 9/11/25 did provide some broad-spectrum antibiotic treatment to the wound and the one (1) day of missed antibiotic treatment would not have made a great difference in the healing of the wound. The Wound Nurse stated on 9/18/25 at 1:15 PM she did not know why she communicated to the Wound Nurse Practitioner that the left heel wound culture was negative on 9/15/25. The Wound Nurse said she had not seen the results of the culture and sensitivity that was ordered on 9/11/25. The Director of Nursing (DON) was interviewed on 9/18/25 at 12:45 PM. She stated labs or culture results were not given to the providers until all the results had been completed and returned to the facility from the lab. The DON stated Resident #2's lab results were not completed fully until 9/16/25 and the resident's medical provider's would not see the results until that day. DON said the culture and sensitivity results had been completed by the lab on 9/14/25 but was not sure at what time on 9/14/25 the results were faxed to the facility. Additionally, the DON stated the Wound Nurse Practitioner should have been shown the results of the culture and sensitivity results at her visit on 9/15/25, because it was a positive result for infection. The DON stated she was not aware the Wound Nurse had told the Wound Nurse Practitioner the results of the wound culture were negative on 9/15/25. On 9/19/25 at 4:04 PM a follow-up interview with the DON stated she did not know why the Wound Nurse had told the Wound Nurse Practitioner the heel wound culture results were negative. The DON stated the results of the left heel wound culture and sensitivity should have been communicated to the Wound Nurse Practitioner on 9/15/25 and to Resident #2's NP for review.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, interviews with the Wound Care Nurse Practitioner, Medical Director and staff, the facility failed to obtain treatment orders for two (2) pressures ulcers (Resident #8 and Resident #16) when first identified resulting in numerous days that the pressure ulcers went without treatment and worsening to unstageable for Resident #8 and a stage 2 for Resident #16. Resident #8's pressure ulcer was first identified on 08/22/25 as a red open area but an assessment or treatment was not documented. The pressure ulcer was later identified on 09/04/25 and treatment was initiated but no assessment was documented. The pressure ulcer was assessed and documented on 09/09/25 as unstageable wound to the right heel with black eschar (dry, black, or brown crust that forms on the surface of wounds) with foul odor and measuring 3.5 centimeters (cm) by 3.5 cm. The facility failed to routinely assess Resident #16 for being at risk of pressure ulcer, failed to implement measures to prevent Resident #16 from developing a pressure ulcer and then failed to provide ongoing assessment and treatment for Resident #16's pressure ulcer. Resident #16 was identified on 8/31/25 to have a stage 2 pressure wound to the back of his right thigh, there were no wound measurements completed until 9/3/25. After 9/3/25 there was no assessment or measurement documented for the wound. Resident #16 had an initial treatment order entered on 8/31/25 for his stage 2 pressure ulcer that was for 7 days and stopped on 9/7/25. After 9/7/25 there were no additional treatment orders for the wound. The facility failed to complete accurate head to toe skin assessments to identify new or existing pressure ulcers that include the location, type of wound, length, width, depth, and stage of pressure ulcers. This deficient practice occurred for 2 of 3 residents reviewed for pressure ulcers (Resident #8 and Resident #16). The findings included: 1. Resident #8 was admitted to the facility on [DATE] with diagnoses that included history of cerebral vascular accident (CVA) and diabetes mellitus. Review of Resident #8's admission Nursing assessment dated [DATE] written by Nurse #5 revealed there were no pressure ulcers identified on the assessment. An interview was conducted with Nurse #5 on 09/19/25 at 5:10 PM. The Nurse confirmed that he conducted the admission nursing assessment on Resident #8 on 07/17/25 and explained that he did not recall any issues with pressure ulcers on her heels or anywhere on her body. Review of Resident #8's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident's cognition was severely impaired, required substantial to maximal assistance with most of her activities of daily living and she did not have pressure ulcers on admission. Review of Resident #8's care plan dated 07/31/25 revealed Resident #8 had the potential for impaired skin integrity related to decreased mobility, incontinence and poor appetite. The goal that Resident #8 would maintain skin integrity as evidence by no development of pressure ulcers or peri area excoriation through the next review. The goal would be attained by utilizing interventions such as assisting and turning frequently, monitoring her skin for any open areas and notifying the nurse immediately and providing treatments as ordered. Review of Resident #8's medical record for skin assessment documentation from admission on [DATE] to present 09/19/25 revealed there were no skin assessments documented. Review of Resident #8's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for July 2025 and August 2025 revealed there were no treatments set up for pressure ulcers on the MARs or TARs. An interview was conducted with Nurse Aide (NA) #1 on 09/18/25 at 2:35 PM. The NA explained that on 08/22/25 she was preparing to give Resident #8 her shower when she tried to remove her right sock, but it was stuck to her heel and would not come off until she wet the sock first. She noted a red raw area approximately the size of a quarter on her right heel and there was bloody hard (dried) drainage on the sock. The NA remarked she showered Resident #8 on 08/15/25 and there were no issues with her heels. The NA got Nurse #1 to come to the shower room where she observed Resident #8's right heel and put a dressing over the heel as well as obtained a heel protector to put on after she finished the shower which the NA completed. An interview was conducted with Nurse #1 on 09/18/25 at 4:10 PM and 09/18/25 at 5:30 PM. The Nurse explained that she remembered NA #1 asking her to come to the shower room on 08/22/25 where NA #1 showed her Resident #8's right heel. The wound was pink, and she could not remember if there was drainage. The Nurse continued to explain that she applied a dry foam dressing to the heel and put a note on the board in the medication room for the Wound Nurse #4 to see the next day. The Nurse stated she did not put a note in the wound communication book because she did not know about the wound communication book. The Nurse continued to explain that she did not assess, measure the pressure ulcer or notify the Medical Director of the pressure ulcer because she thought the Wound Nurse would do it on her follow up. On 09/18/25 at 8:45 AM an interview was conducted with NA #5 who explained that on the night of 09/04/25 she noted an area of drainage on Resident #8's bed sheet while she was providing care to the Resident and when she tried to remove the Resident's right sock, the sock was stuck to her heel. The NA stated she got Nurse #7, and the Nurse cleansed Resident #8's right heel and applied a dressing on her heel. During an interview with Nurse #7 on 09/18/25 at 8:50 AM the Nurse explained that on the night of 09/04/25 NA #5 reported that she could not get Resident #8's sock off her right heel because it was stuck to her heel. The Nurse stated she had to soak the Resident's right heel with wound cleanser in order to remove the sock. The Nurse continued to explain that Resident #8's right heel had a blood-filled blister that was not open, and the area looked like the skin was layered. The Nurse reported that she applied a foam dressing to the Resident's right heel and applied heel protectors to Resident #8' feet and wrote orders to clean open area to right heel with wound cleanser and apply border foam every two days and apply heel protectors while in bed. Nurse #7 also reported that she put a note in the wound communication book for follow up and reported the pressure ulcer to the Assistant Director of Nursing. During a telephone interview with the Assistant Director of Nursing (ADON) on 09/19/25 at 5:43 PM the ADON explained that she could not remember the exact day she found out about Resident #8's pressure ulcer but when she did become aware of it she went to see it and before she got to the Resident's door she could smell the foul odor coming from the Resident's room. The ADON stated that she obtained an order from the MD for an antibiotic, and the Wound Nurse came in the next day (09/09/25) and got an order for crushed metronidazole (antibiotic) to be applied to the pressure ulcer to control the odor. The ADON continued to explain that the nurses do not do routine skin assessments, but the Wound Nurse used to do them quarterly and she would inform the management team about them in the morning meeting if she knew about them. the ADON indicated the nurses depended on the shower team to inform them of the skin issues, and the nurses should follow up on them. An interview was conducted with the Wound Nurse on 09/18/25 at 11:45 AM and 09/19/25 at 7:30 AM. The Wound Nurse explained that she first became aware of Resident #8's right heel pressure ulcer on 09/09/25. The pressure ulcer was unstageable with black eschar, malodorous and measured 3.5 cm x 3.5 cm. The Wound Nurse continued to explain that the pressure ulcer had a treatment set up but when she noted that it was black with hard eschar and the drainage was malodorous, she decided to notify the MD and asked for crushed metronidazole which was what she normally did with a malodorous ulcer. The MD also ordered an X-ray to rule out osteomyelitis which was negative. The Wound Nurse stated she also obtained an order for a wound consult and Resident #8 was seen by the Wound Care Nurse Practitioner on 09/11/25. The Wound Nurse reported that she did not see the note on the board in the medication room left by Nurse #1 on 08/22/25. She stated that 08/22/25 was a Friday and she did not work on Fridays and neither did she work on the weekends. The Wound Nurse stated the next time she would have seen the note would be on 08/25/25 and that was if she worked on the medication cart that was parked in front of the board in the medication room. She indicated the best place to put notes about pressure ulcers was in the wound communication book and she would see them when she worked as the Wound Nurse. Review of Resident #8's MAR and TAR for September 2025 revealed orders for: -09/09/25 ceftriaxone sodium (antibiotic) 1 gram intramuscularly one time a day for 7 days for wound infection. -09/10/25 metronidazole (antibiotic) 500 milligrams (mg) crush tablet and apply to right heel wound bed every day for wound infection. Review of Resident #8's September 2025 MAR and TAR revealed the orders for the heel protector and foam boarder dressing were initialed as completed. Review of a Wound Care Consult dated 09/11/25 provided by the Wound Care Nurse Practitioner revealed Resident #8 had a pressure ulcer to her right heel measuring 3.5 cm x 3.0 cm x 1.0 cm with 30% black necrotic tissue that was unstageable and had no drainage and no odor. An interview conducted with the Wound Care Nurse Practitioner 09/19/25 at 1:30 PM. The Wound Care Nurse Practitioner explained that she had consulted on Resident #8's right heel twice with the first time being on 09/11/25 and she found the wound having black necrotic tissue and no drainage that she could recall. She stated that the pressure ulcer was not at the point of needing debridement (surgical removal of dead tissue), but she anticipated that would need to occur. The Wound Care Nurse Practitioner reported she could not say if the pressure ulcer was avoidable or unavoidable because of company policy but she did disclose that she did not feel the pressure ulcer was chronic. On 09/16/25 at 2:49 PM an observation of Resident #8's right heel pressure ulcer treatment was conducted and performed by the Wound Nurse. The pressure ulcer was approximately the size of a fifty-cent piece with black eschar. A raw area approximately the size of a pea was noted in the eschar. On 09/19/25 at 6:00 PM an interview was conducted with the Director of Nursing (DON) with the Administrator present. The DON explained that there were standing orders for wound care and when the pressure ulcer was first noted on Resident #8 the standing order should have been set up with specific treatment, and the physician should have been notified in case there were further orders to be followed. She stated the pressure ulcer should have been assessed, measured and documented on weekly through wound assessments in order to follow whether the pressure ulcer improved or worsened in case the treatment needed to be changed. The DON indicated skin assessments were done monthly on normal skin and the shower team should notify the nurses if they discovered any skin issues in between. The DON stated she did not know why Nurse #1 did not initiate the standing orders for the pressure ulcer because she had been at the facility for a number of years. The Administrator also stated Nurse #1 should have initiated the standing orders for the pressure ulcer because if she had, it was possible that the pressure ulcer would not have gotten to the point it was and if Resident #8 had gotten the services she needed the pressure ulcer could have been healed by now. During interviews with the Medical Director on 09/18/25 at 10:25 AM and 09/19/25 at 3:08 PM. The Medical Director explained that he was first made aware of Resident #8's right heel pressure ulcer when the Wound Nurse called and reported it on 09/09/25. He reported that he ordered crushed metronidazole to be applied to the wound daily for the malodor and to follow up with a wound consultation. The Medical Director also stated that based on the description by the Wound Nurse he ordered an X-ray to rule out osteomyelitis (infection in the bone) which was negative. The Medical Director was not informed of the pressure ulcer first being discovered on 08/22/25 and no orders were obtained to follow up with treatment and the Medical Director stated that it was unfortunate because if the orders had been initiated then the pressure ulcer may not have gotten to the point it had. The Medical Director remarked that he considered the pressure ulcer to be considered avoidable. 2. Resident #16 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, hemiplegia (paralysis or weakness on one side of the body) and hemiparesis (decreased control and strength on one side of the body) following cerebral infarction affecting right dominant side, muscle wasting and atrophy, muscle weakness. A care plan dated 7/1/24 for skin was in place. The care plan goals were for Resident #16 to maintain skin integrity as evidence by no development of pressure ulcers or peri-excoriation through the next review date. The care plan interventions included: float heels while sleeping, pressure relief cushion to wheelchair or recliner, monitor skin for any reddened open areas, monitor nutrition, use recliner for sleep and to reduce pressure, treatments as/if ordered. A Braden scale assessment (assessment for predicting pressure ulcer risk) dated 2/18/25 indicated Resident #16 was at risk for developing pressure ulcers. An annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #16 was cognitively intact. The MDS documented he had impairment of his upper and lower extremities on one side. The MDS indicated he was independent with his activity of daily living (ADL) tasks and mobility but required partial/ moderate assistance with showers. The MDS documented that he did not have a pressure ulcer but that he was at risk for developing a pressure ulcer. The MDS further documented that he had a pressure relieving device to his chair. An interview was conducted on 9/15/25 at 9:23 AM with Resident #16. He was observed resting in a recliner chair in his room. The recliner chair was observed in the reclined position and Resident #16 was positioned lying on his right side. The recliner chair was covered with a sheet and had a folded pad in the recliner seat. There was no cushion noted in the seat of his recliner. His wheelchair was positioned next to the recliner; a cushion was present in his wheelchair. Resident #16 stated he slept in his recliner chair and that was his preference. He reported he had a pressure ulcer to the back of his right thigh. A review of Resident #16's electronic medical record revealed that weekly skin assessments had not been completed. There were no skin assessments documented. A nursing note dated 8/31/25 by Nurse #8 read: “Nurse notified by resident of bleeding spot on the back of his thigh. Possible stage 2 pressure injury noted to right outer back thigh. Wound bed pink, scant red drainage noted on resident's reusable chuck on his manual wheelchair. No signs of infection. Nurse cleansed wound with wound cleanser, covered wound bed with silver alginate and covered with adhesive dressing. Resident will be added to acute book for this issue and nurse will enter wound care orders until wound care nurse can assess.” An order dated 8/31/25 was entered by Nurse #8 and read: Cleanse wound with wound cleanser, cover wound bed with silver alginate (highly absorbent wound dressing embedded with silver particles to fight infection), place dry adhesive dressing over wound, two times a day for pressure injury for 7 days. The order ended on 9/7/25. There were no additional wound care orders after 9/7/25. Review of the Treatment Administration Record (TAR) dated September 2025 revealed a twice daily treatment order that read, cleanse wound with wound cleanser, cover wound bed with silver alginate, place dry adhesive dressing over wound. for 7 days, started 8/31. The treatment was signed to indicate it was administered as ordered. The order stopped on 9/7/25. There was no additional treatment orders present on the TAR for the stage 2 pressure ulcer after 9/7/25. Review of the Wound Care communication book revealed on 8/31/25 Nurse #8 made a note about Resident #16 that read: “right posterior thigh stage 2 pressure injury”. There was a column labeled Wound Care Nurse initials. The notation was not initialed by the Wound Care Nurse. Facility wound care standing orders for a stage 2 pressure ulcer read, cleanse open area with wound cleanser and apply bordered foam dressing, change every 2 days and as needed. A nursing note dated 9/1/25 by Nurse #8 read: “Resident in acute book for stage 2 pressure injury to left posterior thigh. Dressing was removed. Wound bed is pink/beefy, scant dry drainage noted on dressing. No signs of infection present. Wound cleansed with wound cleanser, silver alginate placed on wound bed and wound covered with dry adhesive dressing. Will continue to monitor.” An additional nursing note dated 9/3/25 by Nurse # 8 read: Right posterior thigh pressure injury wound care completed as ordered: dressing removed, moderate amount of drainage present on dressing. Wound bed appears pink, beefy. No signs of infection present. Wound bed cleansed with wound cleanser. Wound measures 2 centimeters (cm) (length) x 1 cm (width). Wound bed covered with silver alginate and secured in place with adhesive dressing. Resident tolerated well.” There was no additional documentation in the medical record about Resident #16's pressure ulcer being assessed after 9/3/25. Resident #16 was not followed by the Wound Care Provider. An interview was conducted with Nurse #8 on 9/17/25 at 2:57 PM. She recalled finding the stage 2 pressure ulcer to the back of Resident #16's right thigh on 8/31/25. Nurse #8 stated Resident #16 told her he had a wound, and that the back of his leg was hurting. She remembered he had some bloody colored drainage on the pad in his chair. Nurse #8 reported she looked at the wound and recalled it was an open area to back of his right thigh. She remembered the wound bed was pink and the area was moist with a small amount of drainage. Nurse #8 stated she assumed the wound had come from the pad on his chair being folded and creating pressure. She said Resident #16 always slept in his recliner chair and had a folded pad in his recliner chair. Nurse #8 stated she did not measure the wound when she found it but had documented in a nursing note what she had seen. She explained she had planned to talk to the Wound Care Nurse (Nurse #4) the next day and that the Wound Care Nurse would assess the wound when she looked at it. Nurse #8 reported she did not talk to the Wound Care Nurse the next day but had left a note about Resident #16's wound in “the wound book” at the nursing station. Nurse #8 could not remember if she entered treatment orders for Resident #16's wound but said she probably did. Nurse #8 explained the facility protocol was for the nurse to enter an order for whatever was being used to treat the wound at that time until the Wound Care Nurse looked at the wound to see if it needed something else or a different treatment. Nurse #8 explained silver alginate was part of the facility's wound care standing order for stage 2 pressure ulcers and it was what she had seen other nurses put on those types of wounds. Nurse #8 further explained, there were not really standing orders for each piece of material that was used to treat a wound and that the standing orders were vague and not specific. Nurse #8 explained what she understood was the facility's process for wound care orders, she said nurses used their prior knowledge of what treatments they had seen work for wounds and from what wound care supplies the facility had on hand for wound dressings and then entered an order for that. She reported then the Wound Care Nurse would assess the wound and if she thought the treatment needed to be changed then she would change it. Nurse #8 stated there was not a weekly skin assessment scheduled or completed by staff. She reported there was not a process or schedule for nurses to perform routine skin assessments. An interview was conducted with the Wound Care Nurse (Nurse #4) on 9/17/25 at 9:48 AM. The Wound Care stated she was supposed to do wounds but was usually not able to do them because she was being pulled to the floor/medication cart to work due to the facility being short staffed. The Wound Care stated over the last month she had been pulled almost every day she worked to work a medication cart on the floor. The Wound Care stated when she was pulled to work a floor assignment the nurse on the hall was responsible for doing wounds and the treatments for their assigned group of residents. She reported there was not a process in place at the facility where nurses did routine resident skin assessments. The Wound Care explained there was not a schedule or assigned skin assessments for residents that were done on a routine basis by the nurses. The Wound Care said other than the NAs looking at skin during showers and care there were no skin assessments and that the NAs were supposed to tell the nurses if they saw something. The Wound Care said she was not aware of Resident #16 having a pressure ulcer because she had been working on the floor/medication cart. She reported that she heard he may have a wound and said the nurse was going to look at it but that she had not looked at the wound. She did not remember who the nurse was. An interview was conducted with Assistant Director of Nursing (ADON) on 9/17/25 at 10:00 AM. She reported she was not aware of Resident #16 having a pressure ulcer or wound and that Wound Nurse was responsible for keeping up with who had wounds. An observation was completed on 9/17/25 at 10:49 AM with the ADON of Resident #16's wound. Resident #16 was observed in his room in his recliner chair. The chair was in the reclined position, and he was lying on his right side. The recliner chair was covered by a sheet, and a folded pad was in the seat the recliner. There was no cushion in the recliner seat. The ADON asked Resident #16 if he had a wound and he stated, “yes it's on the back side of my leg”. Resident #16 rolled onto his left side and pulled down his pants exposing the back of his right upper thigh. There was a dressing in place dated 9/14/25. The ADON removed the dressing and confirmed the dressing in place was xeroform (wound treatment) covered with a border gauze dressing. Resident #16 was observed to have an open area to the back of his right thigh, the wound bed was pink, the wound edges appeared rolled and thick, there was a small amount of yellow/ tan colored drainage. An interview was conducted with the ADON on 9/17/25 at 11:00 AM. The ADON reviewed the wound care communication book at the nursing station and reported Nurse #8 had made a note on 8/31/25 that Resident #16 had a stage 2 pressure ulcer to his right posterior (back) thigh. The ADON stated the note had not been reviewed by the Wound Care Nurse because it had not been initialed. The ADON reported she reviewed Resident #16's orders and stated Resident #16 had a treatment order for the stage 2 pressure ulcer entered on 8/31/25 for 7 days but that it had been discontinued after the 7 days. She did not know why the order was only for 7 days. The ADON explained the process for what was supposed to be done when a wound was found. She said the facility had standing orders for wound care. She stated when a wound was found the nurse was supposed to use the standing orders for wound care according to the type of wound that was identified. She said the nurse who found the wound was supposed to enter the order into the electronic computer system according to the standing orders, place a note about the wound in the wound communication book so the Wound Care Nurse could follow up on the wound, and notify the provider by placing a note in the provider communication book. The ADON reviewed the provider's communication books and stated there was not a note left to notify the provider about Resident #16's wound. The ADON reported the wound care standing orders for a stage 2 pressure ulcer were to clean the wound with wound cleanser, apply a boarder foam dressing, and change the dressing every 2 days and as needed. She said the wound care orders entered on 8/31/25 for Resident #16's stage 2 pressure ulcer did not follow the facility wound care standing orders. The ADON stated she did not know about Resident #16's wound specifically but had heard in the morning meeting that “he had a spot there”. The ADON said she had asked the wound Care Nurse to look at Resident #16 and see what was going on and what was there. She did not remember the day it was mentioned in the morning meeting or that she had asked the wound Nurse to look at Resident #16. The ADON stated wounds should be measured and assessed once a week. She explained if a resident was not being followed by the Wound Care Provider, then the Wound Nurse was responsible for measuring, assessing, and documenting on the wound weekly. The ADON said Resident #16's wound was last measured on 9/3/25 and that it should have been measured and assessed before today (9/17/25). The ADON acknowledged The Wound Care Nurse was pulled to work on the floor most days but said on Thursdays, if no one called out she only worked on the floor from 7:00 am to 11:00 am and then was pulled off the floor from 11:00 am to 3:00 pm to do rounds with the Wound Care Provider and follow up on “other wound care stuff”. The ADON said the NAs looked at resident skin during showers/ care and if they saw something then they were supposed to alert the nurse. The ADON stated NAs could not assess a resident's skin but could see if something was open or if there was a rash. The ADON reported there was no schedule or process for the nurses to do routine skin assessments on residents. The ADON said skin assessments were important to identify new skin issues. The ADON could not say why there was no formal process or documented scheduled skin assessments completed by the nurses, she said they had never really done it like that. The ADON said she thought normally it would be the Wound Care Nurse who was responsible for doing resident Braden assessments. She reported the Wound Nurse would not do the Braden assessments when she was working on the floor and said she was not sure who would do them but thought it might be the MDS nurse. The ADON said she saw today where Resident #16 had not had a Braden assessment completed since February 2025, she reported they were supposed to be completed quarterly, and she was not sure why his had not been done. An order was entered on 9/17/25 at 1:30 PM by the ADON for a foam boarder dressing, apply to back of right upper thigh every day shift every two days for wound and as needed for wound soiling. An interview was conducted on 9/17/25 at 1:40 PM with Nurse #3. Nurse #3 stated she was the floor nurse assigned to Resident #16's wing. She reported that when she measured Resident #16's wound today it measured 1.5 cm x 0.75 cm x 0.25 cm. She said she would not have known Resident #16 had wound unless he had treatment order in place for the wound. She reported wound care orders were entered today for Resident #16's wound according to the wound care standing orders for stage 2 pressure ulcer. An interview was conducted on 9/17/25 at 12:11 PM with the Nurse Practitioner (NP). He said he was not aware Resident #16 had a wound and that he had not been asked to see the area. The NP said the normal protocol was for wounds to be measured and assessed weekly to see if they were improving or healing. He reported skin assessments were important because they could identify skin issues such as infection and wounds early so there could be an intervention. He said it was hard to say if the initial treatment (silver alginate) put into place for Resident #16 was an appropriate wound care order for his stage 2 wound because he had not seen the wound. An interview was conducted with the Medical Director on 9/18/25 at 9:46 AM. The Medical Director said treatment orders should be in place if a resident has a wound and that there should be a standard protocol for wound orders. He stated wound assessments should be completed weekly. He said the wound assessment should include the characteristics of the wound and wound measurements. The Medical Director explained wound assessments were important to determine if a wound was improving and to guide treatment. He thought basic standard of care was that nurses should do skin assessments at least weekly to identify skin issues. The Medical Director said NAs could help look at resident skin during care and report to the nurse if they saw something but that the facility should have a process in place for nurses to assess residents' skin and not rely on NAs only. The Medical Director stated he was not aware that Resident #16 had developed a wound. An interview was conducted with the MDS nurse on 9/19/25 at 5:30 PM. She stated she did not complete the Braden assessments. She was unsure who completed the Braden assessments but said she thought it might be the ADON. An interview was conducted with the Director of Nursing (DON) and Administrator on 9/19/25 at 6:00 PM. The Administrator stated when Resident #16's pressure ulcer was found the nurse should have initiated the standing orders, assessed the wound, and documented the wound assessment in the nursing notes. The Administrator stated the wound assessment should include measuring the wound. She reported that the nurse should notify the provider about the wound and obtain wound care orders from the provider if the wound needed a different treatment from the wound care standing orders. The Administrator stated wounds should be assessed and monitored weekly to see if the wound was improving or worsening and so the treatment plan could be changed if needed. The Administrator stated the weekly assessment should include what the wound looked like, if there was any draining, any signs of infection, and the wound measurements. The Administrator stated she did not know why Nurse #8 did not follow the wound care standing orders or put ongoing treatment orders in for Resident #16's wound. The Administrator and DON reported the shower team NAs looked the residents' skin when they did showers. The DON said the NAs could not assess resident skin but could notify the nurse if they saw something. The Administrator stated NA skin checks during showers should not replace skin assessments completed by a nurse. The Administrator stated if a resident was assessed to be at risk for skin breakdown, then they should have skin assessments completed weekly. The Administrator explained the Braden assessment identified if a resident was at risk. The Administrator stated the Braden assessment should be done quarterly. The DON said the Wound Nurse was responsible for doing the Braden assessments but if she could not get to them the MDS nurse should do them. The DON said the MDS Nurse should have been checking and auditing to ensure the Braden assessments were completed quarterly. The Administrator said she had spoken with the MDS Nurse earlier today and the MDS Nurse had not known she was supposed to be checking that the Braden assessments were done and doing them if they had not been completed. The Administrator stated Resident #16 should have had a Braden assessment completed since February. The DON and Administrator reported they w

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff, Nurse Practitioner (NP), and Medical Director interviews, the facility failed to provide supervision to prevent a fall with injury and failed to implement effective fall interventions for a resident (Resident #11) who had repeated falls. Resident #11 experienced 12 falls from 1/22/25 to 7/24/25. On 7/24/25 Resident #11 sustained a left ankle fracture when she was left unsupervised in the bathroom and fell. Additionally, the facility failed to supervise a cognitively impaired resident (Resident #10) who wandered and exited the facility unsupervised on two separate occasions. This deficient practice occurred for 2 of 3 residents reviewed for supervision to prevent accidents.Findings included: Resident #11 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (paralysis or weakness on one side of the body) and hemiparesis (decreased control and strength on one side of the body) following cerebral infarction affecting right dominant side, muscle weakness, need for assistance with personal care, abnormalities of gait and mobility, transient ischemic attack (TIA) (temporary episode of stroke-like symptoms). A progress note dated 7/6/25 indicated Resident #11 had a change in level of consciousness, elevated blood pressure, and was sent to the emergency room. A hospital Discharge summary dated [DATE] indicated Resident #11 was admitted to the hospital on [DATE]. Her discharge diagnoses included stroke like symptoms and acute renal failure. A progress note dated 7/12/25 indicated Resident #11 was readmitted to the facility from the hospital on 7/12/25. A significant change MDS assessment dated [DATE] indicated Resident #11 had moderate cognitive impairment. The MDS reported she used a wheelchair and was dependent on staff for showers and toileting. She required partial/moderate assistance with dressing and transfers. The MDS documented Resident #11 did not have behaviors or rejection of care. She was not documented on the MDS for falls. A care plan dated 1/25/25 was in place for impaired mobility and ADL deficit related to TIA with right sided weakness, and debility. The care plan interventions included “Resident will do as able, if unable to complete task assist resident to finish them”. A care plan dated 1/15/25 was in place for fall risk related to TIA, right sided weakness, and history of falls. The care plan goal was for Resident #11 to not sustain significant fall related injury as evidence by no injury more serious than a bruise, abrasion, or skin tear. The care plan included the following interventions dated 1/25/25, attempt to maintain environment adequate lightening, free of clutter, free of safety hazards, and free of glare. Encourage to use appropriate assistive devices, wear non-skid soled shoes when out of bed, give reminders to not transfer without assistance if feeling weak or unsteady, observe for adverse effects of medications, administer anticonvulsant as ordered, place frequently used items in reach. An incident report dated 7/24/25 at 12:38 PM was completed by Nurse #2. The incident report stated therapy assisted Resident #11 onto the toilet. Resident attempting to transfer from toilet to wheelchair independently, her legs buckled and she was sitting with her left ankle twisted beneath her. Head to toe assessment completed. The left foot started to swell within 20 minutes. She was able to rotate the ankle but stated it was painful. Three staff assisted Resident #11 into her wheelchair. The incident report indicated the provider was notified and an x-ray was ordered. A nurse note dated 7/24/25 entered at 2:11 PM by Nurse #2 said Resident #11 “was on the floor in front of the toilet. Therapy assisted Resident onto the toilet. Resident attempting to transfer from toilet to wheelchair (w/c) independently, her legs buckled, and she was sitting with her left ankle twisted beneath her. Head to toe assessment completed. The left foot started to swell within 10 mins. She was able to rotate the ankle, she did state it was painful. 3 staff assisted Resident into w/c”. The note indicated that Resident #11's family member was notified of the fall, the MD was informed, and an X-ray had been ordered. An Occupational Therapy treatment note dated 7/24/25 at 1:07 PM by Occupational Therapy Assistant (OTA) #1 was reviewed. Under precautions the note stated “one to one (1:1) supervision required (falls). Fall risk and confusion”. Under the response to treatment section the note read, “At end of therapy toileting ADL session notified NA on duty of patient need for assist to transfer off toilet once done defecating, NA verbally confirmed understanding of patient need for assist. This therapist instructed patient to pull alert cord when ready for assistance and placed cord in patient's hand.” An interview was conducted on 9/18/25 at 2:27 PM with Occupational Therapy Assistant (OTA) #1. She reported she had been working with Resident #11 on 7/24/25. OTA #1 reported she assisted Resident #11 to transfer to the toilet. She stated she needed about 50 % assistance with the transfer. OTA #1 explained that included hand placement on the grab bars, foot placement, weight shifting over, and clothing assistance. OTA #1 stated Resident #11 needed more time on the toilet. She explained she was out of occupational therapy treatment time and needed to leave. OTA #1 reported she put the call light in Resident #11's hand and reiterated to her not to transfer on her own and to use the call light. OTA #1 said she then found the NA on the hallway, she could not remember who the NA was. OTA #1 stated she told the NA Resident #11 was on the toilet, she would need assistance, and she had the call light to call for assistance when she was done. OTA #1 reported the NA was right outside of Resident #11's room door and confirmed understanding. OTA #1 said Resident #11's balance and strength was okay for her to be able to safely sit on the toilet by herself. She stated she thought Resident #11 was physically able to pull the call bell string and said she thought Resident #11 seemed to have the mental ability to use it. OTA #1 explained at the time she was not sure if she was supposed to stay there with Resident #11 if she was over her treatment time and had thought she would get in trouble if she stayed. OTA #1 said she knew Resident #11 had falls that occurred from the bed but did not think she had falls in the bathroom before this fall. An interview was conducted on 9/18/25 at 12:19 PM with the Director of Rehabilitation (Rehab). The Director of Rehab said OTA #1 had notified the NA at the time that she had taken Resident #11 to the bathroom and instructed Resident #11 to use the call bell. She did not remember who the NA was. The Director of Rehab stated Resident #11 had balance deficits, but the NA was outside of the room and said there was intended to be an immediate transference of care and observation for Resident #11. An interview was conducted with NA #9 on 9/18/25 at 3:26 PM. NA #9 said she was the assigned NA for Resident #11 on 7/24/25 when she fell. NA #9 explained she recalled the fall because she had been upset about what had happened. NA #9 reported a therapist had left Resident #11 on the toilet unattended without notifying her or any NA that she was on the toilet. She could not remember the therapist's name. NA #9 said the fall happened between 11:00 AM and 12:00 PM. NA #9 said she had been on a different hallway helping residents get up for lunch. NA #9 remembered Resident #11's roommate was yelling for help. She said when she went to the room, she found Resident #11 on the bathroom floor. She recalled Resident #11 was sitting on the bathroom floor with her leg bent under her and she was sitting on her ankle. She thought it had been her right ankle but was not sure. NA #9 stated she did not move Resident #11 but had asked her if she was in pain and Resident #11 said she had hurt her ankle. NA #9 stated she notified Nurse #14 and she came first to assess Resident #11. NA #9 stated three staff members assisted Resident #11 back into her wheelchair after the fall. She said Resident #11 wanted to stay up in her wheelchair so she could go smoke. NA #9 reported Resident #11 was not okay to be left in the bathroom alone. She reported Resident #11 needed supervision because she was shaky when she stood and did not always ring the call bell. She said Resident #11 did not ring the call bell on 7/24/25, she stated when she went to Resident #11's room the call light had not been on. An interview was conducted on 9/19/25 at 11:13 AM with Nurse #14. She recalled Resident #11's fall on 7/24/25. Nurse #14 stated that it was the fall where the OTA had put her on the toilet and then told her to ring the call when she was done. Nurse #14 said someone came and told her Resident #11 had fallen, she could not remember who had told her. Nurse #14 stated Nurse #2 came to the room and they had assessed Resident #11 together. Nurse #14 said Resident #11 had not acted like she was in pain at all. She recalled Resident #11 was sitting on the bathroom floor and one of her ankles was under her. She said it looked odd how she was positioned on her leg on floor. Nurse #14 said after they assessed her and got her back into her wheelchair they had asked if her ankle was hurting and Resident #11 had said “no”. Nurse #14 stated Resident #11 had not remembered what happened when they asked her. Nurse #14 was unsure if Resident #11 should be left alone in bathroom and said that she did not usually take care of her. Nurse #14 said staff did not usually leave residents in the bathroom alone if they could not be left unsupervised and that was a question that day. She remembered the NA was upset that day because the OTA had left Resident #11 in the bathroom and had not told her. She stated the NA had said she did not know Resident #11 was in the bathroom. Nurse #14 did not remember the NAs name. An interview was conducted on 9/18/25 at 12:01 PM with Nurse #2. She was the assigned nurse for Resident #11 on the 7/24/25 day shift (7:00 am to 3:00 pm). Nurse #2 recalled Resident #11's fall on 7/24/25 she stated therapy had assisted her to the toilet that day, she did not remember the exact time or if she had gone to Resident #11's room first or if Nurse #14 had. She said Resident #11 had not called for assistance, had tried to transfer herself, and fell. Nurse #2 stated cognitively Resident #11 was able to use the call light at the time of the fall. She reported she had asked Resident #11 why she did not ring the call bell for assistance and Resident #11 had told her she “thought she could do it herself”. Nurse #2 said she asked Resident #11 about pain when she assessed her after the fall and she said Resident #11 had said her ankle hurt. Nurse #2 stated Resident #11 had swelling to her left ankle and that was why she had gotten the x-ray ordered. Nurse #2 said she did not remember if the x-ray results came back on her shift or if she had called the physician about the results. Nurse #2 reported after the fall Resident #11 had stayed up in her wheelchair and had not wanted to lay down in bed. She stated Resident #11 had propelled herself in her wheelchair and continued to go out to smoke. Nurse #2 said she remembered Resident #11 had other falls before the fall on 7/24/25 and she stated most of Resident #11's were related to her not calling for assistance and trying to transfer herself. An order dated 7/24/25 was entered at 11:00 AM by the DON that read, left ankle X-ray. The order indicated it had been ordered by the Medical Director. An X-Ray report dated 7/24/25 of Resident #11's left ankle read, “acute nondisplaced fracture at distal fibula, proximal to the lateral malleolus.” An additional progress note dated 7/24/25 entered at 5:17 PM by the DON read, “new order per [Medical Director] refer to [local orthopedic office] ortho for left ankle fracture. Daughter made aware of fracture.” An order dated 7/24/25 was entered at 5:30 PM by the DON that read, refer to [local orthopedic office] orthopedic for left ankle fracture. An interview was conducted on 9/18/25 at 3:56 PM with Nurse #9. Nurse #9 was the 3:00 PM to 11:00 PM nurse on 7/24/25 for Resident #11. Nurse #9 reported Resident #11 had been up in her wheelchair when she arrived at work on 7/24/25. Nurse #9 stated the x-ray results had already been called to the Physician from her earlier fall before she arrived at work. Nurse #9 said Resident #11 had a lot of falls and was a high fall risk. She reported she did not know what fall interventions had been put in place for Resident #11. She said staff tried to keep an eye on her when she was in bed and tried to encourage her to use the call bell. An orthopedic progress note dated 7/25/25 indicated Resident #11 had been seen for a closed displaced fracture of the lateral malleolus of left fibula. The note indicated a repeat X-Ray was completed at the office visit with results showing she had a “minimally displaced oblique (angle) lateral (side) malleolus (ankle bone) fracture that extends to the level of the tibial plafond (bottom of the shin bone). She had no widening of the ankle mortise (were the leg bones and ankle bones come together at the joint) or medial (middle) malleolus fracture”. The note indicated the treatment plan included a short leg walking boot. The note reported a “cam boot (short walking boot) was prescribed” and said the boot could be removed for bathing and sleeping and that she may wear the boot as tolerated. Acetaminophen was recommended for pain. The note said to recheck in 6 weeks for repeat ankle x-rays or sooner if symptoms worsen. A combined interview was conducted with the Administrator and Director of Nursing (DON) on 9/19/25 at 6:00 PM. The Administrator and Director of Nursing stated Resident #11 should not have been left unassisted and unsupervised in the bathroom alone. 2. Resident #10 was admitted to the facility on [DATE]. Her active diagnoses included Alzheimer's dementia. The quarterly MDS dated [DATE] indicated Resident #10 had not exhibited any wandering behavior. Resident #10's care plan with the focus revised on 9/13/24 revealed a risk for elopement related to dementia. Interventions included frequent checks on whereabouts and make sure hallway doors were alarmed at all times. a. Review of the facility incident log revealed there was no incident event for Resident #10 dated 2/02/25. Review of Resident #10's nursing progress note dated 2/02/25 at 3:58 PM entered by Nurse #3 read that the resident was noted outside of the building walking past the 200-hall door. Resident redirected and brought back in the building. An interview on 9/17/25 at 12:51 PM with the Nurse Practitioner (NP) revealed he had been notified of Resident #10's elopement and she was assessed to have no injuries. An interview on 9/18/25 at 10:53 AM with Receptionist #2 revealed she had been on duty at the front desk on 2/02/25 when Resident #10 eloped. She believed that Resident #10 exited the building when she opened the front door for a group of visitors to exit. She stated she did not know the resident had gotten out until Nurse #3 came and told her that Resident #10 had gotten outside. She did not know what time this incident occurred. An interview on 9/18/25 at 2:14 PM with the Business Office Manager revealed Receptionist #1 trained Receptionist #2. She stated she was informed that Receptionist #2 accidentally let Resident #10 out when she opened the door for a group of visitors to leave. She stated there was a book at the receptionist's desk with pictures of the residents. An observation on 9/18/25 at 2:30 PM with the Business Office Manager of the resident book at the receptionist's desk revealed the book contained a printed face sheet for all the facility residents. The face sheet contained a picture of each resident with their name. There was no indication of who was an elopement risk in the book. The Business Office Manager stated the elopement risk residents were verbally communicated to the receptionists and she did not know how the weekend receptionist (Receptionist #2) would become aware of elopement seeking residents. An interview on 9/18/25 at 4:09 PM with Nurse #3 revealed she was walking down the 200-hall when she observed through the glass hall exit door that Resident #10 was walking independently outside the facility. She stated she went out the 200-hall door and escorted Resident #10 back into the facility. She stated that Resident #10 was fully dressed and wearing shoes. She assessed the resident who appeared clean, dry and without injury. Nurse #3 stated she talked to the receptionist, and it appeared the receptionist had let Resident #10 out accidentally when she let a group of visitors out. She stated she did not remember notifying any administrative or supervisory staff. Nurse #3 was unaware Resident #10 had gotten outside until she saw her through the door. She was unable to say the last time she had seen the resident. Resident #10 was known to pace the facility and ask staff how to get out of the facility. An interview on 9/19/25 at 8:51 AM with Receptionist #1 revealed she had trained Receptionist #2 who worked weekends at the facility. She stated she had told Receptionist #2 who the elopement risk residents were but did not remember if she had shown her what the resident looked like or if Resident #10 was specifically included in the conversation. An observation and interview on 9/19/25 at 9:01 AM with the Director of Nursing (DON) revealed from the facility front door around the outside of the facility to the 200-hall door was between 105 to 123 steps depending on if you walked in the grass (105 steps) or the parking lot (123 steps). An interview on 9/19/25 at 10:14 AM with the Director of Nursing (DON) revealed she was unable to say when she became aware of Resident #10's elopement on 2/02/25 and did not have any incident or investigation paperwork. An unsuccessful interview was attempted on 9/19/25 at 1:04 PM with the NA #6 who was on duty on 2/02/25. An interview on 9/19/25 at 2:39 PM with the Administrator revealed Resident #10 had gotten out of the building on 2/02/25. She stated she reviewed the security camera footage, and the resident was outside for ‘minutes'. She stated there was a facility investigation, but she was unable to locate the documentation. She stated that Receptionist #2 was educated on the elopement risk residents. Per wunderground.com reported the weather that day at 3:54 PM was 51 degrees with no rain. b. Review of the facility incident log revealed an elopement incident event dated 3/11/25 at 00:00 for Resident #10. The elopement incident report revealed an incident description that read Resident #10 was observed out front of building by receptionist, assisted back inside by receptionist and business office staff. No injuries were observed at the time of the incident. Resident #10's family member was notified on 3/11/25 at 3:47 PM and the physician was notified on 3/11/25 at 3:44 PM. Review of Resident #10's nursing progress note dated 3/11/25 at 3:53 PM entered by Nurse #6 read that resident was observed out front of building by receptionist, assisted back inside by receptionist and business office staff without incident. No fall; no apparent injury. Sister informed and note to MD. An interview on 9/19/25 at 1:14 PM with Nurse #6 revealed she was on duty and assigned to Resident #10 on 3/11/25. She stated she remembered Receptionist #1 bringing Resident #10 to the nurses' station around 3:45 PM and informing her she found the resident outside the front door. Nurse #6 assessed the resident with no injuries noted. She did not recall if she notified Administration or a Supervisor or if they had already been notified. She stated she completed the incident report but had not entered the correct time of the incident which should have been documented as around 3:45 PM. She was unaware the resident had gotten outside and unable to say the last time she had observed the resident on the unit. An interview on 9/19/25 at 9:38 AM with Receptionist #1 revealed she was on duty at the facility front door on 3/11/25. She stated she observed Resident #10 outside the front door on 3/11/25 around 3:45 PM and went outside and escorted her back into the building and to a nurse at the 200-hall nurses' station. She also stated that Resident #10 was fully dressed and wearing shoes with no visible distress. Receptionist #1 stated no one from the business office assisted her with getting Resident #10 back into the facility. An interview on 9/17/25 at 12:51 PM with the Nurse Practitioner (NP) revealed he had been notified of Resident #10's elopement and she was assessed to have no injuries. An interview on 9/19/25 at 1:29 PM with Nursing Assistant #2 revealed she worked with Resident #10 frequently and was assigned to her hall on 3/11/25. She stated on 3/11/25 before her elopement, Resident #10 was behaving as usual which included pacing inside the facility, exit seeking, and checking doors. She was unable to say the last time she had observed Resident #10 on the unit. An interview on 9/19/25 at 10:14 AM with the Director of Nursing (DON) revealed she was unable to say when she became aware of Resident #10's elopement on 3/11/25. She stated that maintenance monitors the hallway door alarms. An interview on 9/19/25 at 11:15 AM with the Maintenance Director revealed he checked the hall doorway alarms monthly and as needed. An interview on 9/19/25 at 2:39 PM with the Administrator revealed Resident #10 had gotten out of the building on 3/11/25 around 3:45 PM. She stated that the facility power had been off and, in the restoration process around 3:45 PM, the hall door became unlocked. She stated that Resident #10 had not eloped since this incident, and she felt the interventions were effective. Per wunderground.com reported the weather that day at 3:54 PM was 71 degrees with no rain.

Based on observations, record reviews and resident and staff interviews, the facility failed to maintain sufficient staff to provide activities of daily living (ADL) care for dependent residents, to obtain treatment orders for residents with pressure ulcers when the pressure ulcers were first identified, to routinely assess a resident for being at risk of a pressure ulcer, to implement measures to prevent a resident from developing a pressure ulcer and then failed to provide an ongoing assessment, treatment, and necessary medical care for a resident's diabetic and pressure ulcer. Additionally, the facility failed to complete accurate head to toe assessments to identify new or existing pressure ulcers. This was for 5 of 9 residents reviewed for sufficient staffing (Resident #2, Resident #8, Resident #11, Resident #6 and Resident #28). The findings included:This tag was cross referred to:F 677 Based on observation, record review, staff, and resident interviews, the facility failed to provide activity of daily living (ADL) care for dependent residents when Resident #28 and Resident #11 did not receive showers. This deficient practice affected 2 of 4 residents reviewed for ADL care (Residents #28 and #11). F 684 Based on record review, observations, staff wound provider, and physician interviews, the facility failed to provide skin assessments, failed to identify a new wound on the heel at the onset, and failed to ensure necessary medical treatment when positive culture and sensitivity results were available Resident #2. This delayed the treatment for an infected wound. This was for 1 of 2 residents reviewed for quality of care. F 686 Based on observations, record reviews, interviews with the Wound Care Nurse Practitioner, Medical Director (MD) and staff, the facility failed to obtain treatment orders for two (2) pressures ulcers (Resident #8 and Resident #16) when first identified resulting in numerous days that the pressure ulcers went without treatment and worsening to unstageable for Resident #8 and a stage 2 for Resident #16. Resident #8's pressure ulcer was first identified on 08/22/25 as a red open area but an assessment or treatment was not documented. The pressure ulcer was later identified on 09/04/25 and treatment was initiated but no assessment was documented. The pressure ulcer was assessed and documented on 09/09/25 as unstageable wound to the right heel with black eschar (dry, black, or brown crust that forms on the surface of wounds) with foul odor and measuring 3.5 centimeters (cm) by 3.5 cm. The facility failed to routinely assess Resident #16 for being at risk of pressure ulcer, failed to implement measures to prevent Resident #16 from developing a pressure ulcer and then failed to provide ongoing assessment and treatment for Resident #16's pressure ulcer. Resident #16 was identified on 8/31/25 to have a stage 2 pressure wound to the back of his right thigh, there were no wound measurements completed until 9/3/25. After 9/3/25 there was no assessment or measurement documented for the wound. Resident #16 had an initial treatment order entered on 8/31/25 for his stage 2 pressure ulcer that was for 7 days and stopped on 9/7/25. After 9/7/25 there were no additional treatment orders for the wound. The facility failed to complete accurate head to toe skin assessments to identify new or existing pressure ulcers that include the location, type of wound, length, width, depth, and stage of pressure ulcers. This deficient practice occurred for 2 of 3 residents reviewed for pressure ulcers (Resident #8 and Resident #16).During an interview with the Wound Nurse on 09/16/25 at 2:39 PM the Wound Nurse explained that she was pulled to the hall to work as the hall nurse about every day and she could not stay caught up with her wound care responsibilities. She stated that the facility tried to give her half a day a week to catch up on all the documentation that pertained to the wounds in the facility but that was not enough time to keep caught up on the documentation. She continued to explain that when the Wound Care Nurse Practitioner made rounds at the facility which was usually one day a week and if she happened to be on the hall that day, one of the administrative nurses would cover her hall while she made rounds with the Wound Care Nurse Practitioner. The Wound Nurse reported it was hard to monitor the wounds in the facility because she was often pulled to the hall to work as the nurse, and she was unable to be consistent in providing the wound care. The Wound Nurse stated that it was not unusual for her not to see a wound for two weeks or longer because of having to be pulled to the hall to work. On 9/18/25 at 5:11 PM during an interview, the shower sheets were reviewed with the Administrator, DON and ADON for the month of September. There were 8 days residents were supposed to receive showers from 9/1/25 through 9/12/25 and 4 out of 8 of the days no showers were given.- The DON reviewed the shower sheet dated 9/1/25 and stated not all residents received showers because one of the shower team NAs (NA #1) was pulled to work on the floor.- There was no shower sheet dated 9/2/25, the DON, ADON, and Administrator explained if there was not a shower sheet then there would be no showers given on that day.- The DON and Administrator reviewed the shower sheet dated 9/5/25 and both stated there was only one shower team member giving showers from 7:00 AM to 2:00 PM and then she was pulled to work the floor. They stated not all residents received showers on that day.- The DON, ADON, and Administrator reviewed stated no showers were given on 9/8/25 due to staffing shortages.- The DON, ADON, and Administrator stated no showers were given on 9/9/25 due to staffing shortages.- The DON, ADON, and Administrator reviewed the shower sheet dated 9/11/25 and all stated only 8 showers were given to residents because the shower team was pulled and then had to leave early that day.- The DON and Administrator stated no showers were given on 9/12/25 due to staffing shortages.An interview was conducted with the Administrator and the Director of Nursing (DON) on 09/19/25 at 6:00 PM who explained that the staffing coordinator was on leave and the administrative nurses were helping out with the scheduling. The Administrator explained that facility was experiencing a difficult and challenging time regarding staffing in that they had staff to go out on leave, go back to school and drop the number of hours they could work as well as other reasons to make staffing challenging. The DON stated the administrative nurses as well as the Administrator had to work on the medication cart recently to help with staffing. The Administrator continued to explain that they were backing up and regrouping and the facility had posted on job sites to draw more staff to the facility. The Administrator stated she knew that duties were not getting done like the showers, wound treatments and assessments but she did not realize to the extent that they were not getting done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews with the Medical Director (MD), resident and staff, the facility failed to provide care in a safe manner when a resident fell from her bed during personal care. Resident #4 fell off her bed striking a chair positioned next to the bed and subsequently fell to the floor that resulted in severe acute pain that required STAT (now) morphine and a fractured right femur. The resident was hospitalized for surgical repair of the fractured femur. This was for 1 of 5 residents reviewed for the prevention of accidents (Resident #4). Findings Included: Resident # 4 was admitted to the facility on [DATE] with diagnosis that included functional quadriplegia, dementia, and traumatic brain injury. A review of Resident #4's care plan updated 3/26/24 found she was care planned for being at risk for falls related to functional quadriplegia, hemiplegia, chronic pain, and TBI. Interventions included maintaining the resident's environment free of clutter and safety hazards, maintain bed in low and locked position, M-rails (half rails) to both sides of the bed for mobility and transfers. A review of the annual Minimal Data Set (MDS) dated [DATE] coded Resident #4 with intact cognition intact and dependent on staff for bathing, dressing, and personal hygiene. She required maximum assistance with rolling left and right, required a 2 person lift for transfers, and a wheelchair for mobility. The resident was not coded for rejection of care during the 7-day lookback period. Nursing Aide (NA #2) who was performing Resident #4's bed bath on 7/16/24 was interviewed on 9/4/24 at 2:42 PM. NA #2 stated she was giving Resident #4 a bed bath after breakfast, was the only NA in the room and was close to being finished with the bed bath when the resident fell off the bed. NA #2 stated prior to beginning the bed bath with Resident #4, the resident was having behaviors and tried to hit her when NA #2 told her she needed to have a bed bath. NA #2 said that Resident #4 had received a bed bath the previous 2 days because she was soiled, and she was not happy she needed another one. NA #2 stated she continued with the bed bath because yelling and attempting to hit behavior was normal for Resident #4. NA#2 said Resident #4 was laying on her left side and was holding onto the bed railing with her right hand. Resident #4 had her right leg bent at an angle above her left leg. NA #2 told Resident #4 to not lower her right leg towards the edge of the bed, that she might fall off the bed. NA #2 stated Resident #4 lowered her right leg that caused the resident to fall off the bed, hitting a chair with her body that was sitting beside the bed and then to the floor. Resident #4 was screaming and yelling when she hit the floor, and NA#2 went to the hallway and called out for Nurse #2 to come to the room. A follow-up interview with NA #2 was conducted on 9/5/24 at 1:46 PM. NA #2 stated Resident #4 was laying on her left side, and she left Resident#4 laying on her side when she went to the sink to rinse out a washcloth. NA#2 stated she was on her way back to the bedside and was near the foot of the resident's bed when Resident #4 lowered her right leg and fell from the bed. NA #2 said she tried to stop Resident #4 from falling and was not able to grip her because the resident was still wet. The fall incident report dated 7/16/24 at 9:30 AM and completed by Nurse #2 was reviewed. The incident report read Nurse #2 was called to Resident #4's room by Nurse Aide (NA)#2, who stated Resident #4 was on the floor. Resident #2 was resisting care and rolled out of bed. The immediate action taken by Nurse #2 read in part: she tried to assess Resident #4 for injuries, but was unable and the resident kept screaming help me and my leg hurts. The Director of Nursing (DON) came to calm down the resident. The MD was in the building and saw Resident #4 and ordered her to be sent to the ER for evaluation. Nurse #2 was interviewed on 9/4/24 at 3:24 PM and stated she was working on 7/16/24 as Resident #4's assigned nurse. Nurse #2 stated NA #2 called for her, and said Resident #4 had fallen out of bed. Nurse #2 said Resident #4 could be heard screaming and yelling in the hallway before she arrived at the Resident's room. Resident #4 was laying on her back, almost flat. Nurse #2 said she tried to assess Resident #4 for injuries and Resident #4 would not allow her to touch her. Resident #4 was screaming her leg hurt. NA#2 told her that the resident had fell off the bed and bounced off the chair prior to hitting the floor. Nurse #2 stated she notified the DON and the MD who was in the building. The MD arrived to the room and ordered one does of pain and anxiety medication and 911 was then called to send Resident #4 to the ER for evaluation. A review of physician's order dated 7/16/24 found an order for morphine 10 mg (milligrams) once and Ativan 1 mg once for pain and anxiety. A review of Resident #4's July 2024 medication administration record (MAR) for 7/16/24 found a one time dose of morphine 10 mg and one time dose of Ativan 1 mg was given as ordered. A review of Nurse #2 nursing progress notes dated 7/16/24 read in part: During a bed bath, Resident #4 was resistant to care and pushed herself out of the bed to the floor. The resident was screaming, and Nurse #2 couldn't assess her injuries. The MD was at the facility and said to send Resident #4 out to the hospital, due to a possible breakage to her right hip/leg. The MD ordered a 1-time dose of pain medicine and anxiety medicine to help calm the resident. Resident #4 had been screaming and was resistant to anyone trying to assess her injuries. Emergency medical services (EMS) was notified, and she was sent to the emergency room (ER) for further eval. A MD progress note dated 7/16/24 read in part: During hands on bathing care, Resident #4 resisted and pushed away causing her to fall landing on the floor and she avoided head injury. She was in acute pain, anxious and distressed. Resident #4 was unable to move without assistance and is intolerant to range of motion without extreme pain. A STAT order for Morphine 10 mg and Ativan 1 mg once and triage to the nearest ER for further care. The hospital discharge report dated 7/20/24 was reviewed. The discharge report summary read in part: Resident #4 was admitted on [DATE] and found to have a fractured right intertrochanteric femur and performed surgical repair of the fractured femur. The resident was discharged to the facility with a follow-up appointment with orthopedist in 2 weeks. The resident was discharged with medication orders of ibuprofen 600 mg every 6 hours as needed for pain, oxycodone 5 mg every 6 hours as needed for pain. Resident #4 was interviewed on 9/3/24 at 11:00 AM in her room. She stated she had a fall from her bed and had broken her leg but was not able to provide details of the incident. The MD stated on 9/5/24 at 10:44 AM Nurse #2 went to him and told him Resident #4 had fallen. The MD stated Resident #4 was found on the floor beside her bed laying on her back when he arrived at the room. The resident was screaming in pain and would not allow an injury assessment. The MD said he ordered STAT pain medication and anxiety medication and had Resident #4 sent to the ER. The hospital found Resident #4 had sustained a broken right femur and required surgery. The MD was unaware of the details of Resident #4's fall, but recalled she was resisting care and fell out of her bed. The DON stated on 9/05/24 at 3:21 PM she was called down to Resident #4's room for a fall on 7/16/24. The MD, Nurse #2, and NA#2 were in the room and she observed Resident #4 laying on the floor and screaming in pain. The MD had ordered pain and anxiety medications for her and then ordered Resident #4 to be sent to the ER. The DON said she interviewed NA #2 about the incident and NA #2 said she was providing a bed bath to Resident #4 who was soiled that morning (7/16/24). NA #2 said Resident #4 had received a couple bed baths already that week and Resident #4 was not happy she needed another bed bath. NA #2 reported she had Resident #4 laying on her left side and was almost done with the bed bath. NA #2went to rinse out the washcloth at the sink and left Resident #4 laying on her side near the edge of the bed. Resident #4 shifted her right leg and fell off the bed hitting the chair beside the bed and then onto the floor. NA #2 was near the sink, and unable to prevent Resident #4 from falling. The DON stated NA #2 should not have left Resident #4 on her side, close to the edge of the bed when she left the bedside.