Based on interview and record review it was determined the facility failed to ensure a resident received pressure ulcer treatments for 1 of 1 sampled resident (#4) reviewed for pressure ulcers. This failure resulted in Resident 4's pressure ulcer worsening. Findings include: Resident 4 admitted to the facility in 2017 with diagnoses including hypertension and diabetes. The undated facility Event Summary Report indicated the following: -Resident 4 had a dressing in place dated 12/27/23 to her/his right ankle. -On 12/27/23 Staff 8 (LPN) measured Resident 4's wound on the right ankle and measurements were given to the Staff 12 (Former DNS) as requested. There was a dressing in place on the right ankle and Staff 8 measured the wounds and replaced the old bandage with a new one. -On 12/27/23 the wound measured 1.8 cm x 1.2 cm. -On 1/3/24 at approximately 1:30 PM Staff 11 (RNCM) and Staff 10 (LPN Resident Care Manager) completed wound rounds with the outside wound care provider. -On 1/3/24 the dressing was removed and revealed a Stage 3 pressure ulcer that measured 2 cm x 2.5 cm x 0.3 cm revealing a deterioration of the wound. On 6/12/24 at 10:53 AM Staff 11 stated on 1/3/24 she completed wound rounds with Staff 10 and the outside wound care provider. Staff 11 stated Staff 8 measured the wound on 12/27/23 and provided the measurements to Staff 12. Staff 11 stated she did not recall the observation of the dressing and wound from 1/3/24. On 6/12/24 at 11:14 AM Staff 10 stated on 1/3/24 she completed wound rounds with Staff 11 and the outside wound care provider and Resident 4 had a dressing on her/his right ankle initialed by Staff 8 and dated 12/27/23. Staff 11 stated the dressing was saturated when it was removed, and the information was reported to Staff 12. Staff 10 further stated Staff 8 measured the wound on 12/27/23 and reported the measurements to Staff 12. On 6/12/24 at 11:22 AM Staff 8 stated she worked on 12/27/23 and Resident 4 had a dressing on her/his ankle. Staff 8 stated she removed the dressing and took measurements of the wound and provided the measurements to Staff 12. Staff 8 stated she did not remember if she put a new dressing on the wound after measuring it. On 6/14/24 at 11:17 AM Staff 12 stated she was working as the DNS on 12/27/23 and Staff 8 provided Resident 4's right ankle wound measurement. Staff 12 stated she emailed the measurements to a resident care manager, there was no follow up notification to the physician and no orders were put in place for the pressure ulcer. Staff 12 acknowledged she did not follow up on the wound and wound care was not implemented. Staff 12 stated on 1/3/24 the facility staff and wound care provider identified there were no treatments in place for the wound from 12/27/23 through 1/3/24. Staff 12 stated in-services were provided regarding pressure ulcer assessments and wound care on 1/3/24. On 6/14/24 at 11:33 AM Staff 2 acknowledged Resident 4's pressure ulcer to the right ankle measured 1.8 cm x 1.2 cm on 12/27/23, treatments were not put in place and physician orders were not obtained until 1/3/24. Staff 2 acknowledged the wound worsened and on 1/3/24 the wound measured 2 cm x 2.5 cm x 0.3 cm. Staff 2 stated an in-service was provided on 1/3/24. On 6/14/24 at 10:54 AM the facility provided information to indicate education and an in-service was provided to nursing staff related to the identified incident. The deficient practice was determined to be past non-compliance, corrected on 1/3/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure Staff 9 (RN), Staff 10 (LPN), Staff 17 (LPN), Staff 19 (RN) Staff 29 (LPN) and Staff 30 (RN) adhered to professional standards related to provision and documentation of treatments for 2 of 7 sampled residents (#s 23 and 225) reviewed for pressure ulcers and skin conditions. This failure resulted in Resident 23 experiencing a worsening pressure ulcer and placed other residents at risk for worsening skin conditions. Findings include: Oregon Administrative Rule [PHONE NUMBER] Conduct Derogatory to the Standards of Nursing Defined includes: Conduct that adversely affects the health, safety, and welfare of the public, fails to conform to legal nursing standards, or fails to conform to accepted standards of the nursing profession, is conduct derogatory to the standards of nursing. Such conduct includes, but is not limited to: (1) Conduct related to general fitness to practice nursing: (b) Demonstrated incidents of dishonesty, misrepresentation, or fraud. (3) Conduct related to the client's safety and integrity: (c) Failing to develop, implement or modify the plan of care; (4) Conduct related to communication: (a) Failure to accurately document nursing interventions and nursing practice implementation; (c) Entering inaccurate, incomplete, falsified or altered documentation into a health record or agency records. This includes but is not limited to: (A) Documenting nursing practice implementation that did not occur; (B) Documenting the provision of services that were not provided; 1. Resident 23 admitted to the facility in 2017 with diagnoses including multiple sclerosis (a neurodegenerative disease) and paraplegia (paralysis of half the body). A current order initiated 6/14/19, indicated Resident 23 had a Stage 3 (full thickness skin damage) pressure ulcer to the right lateral calf and staff were to complete the following treatment: -Cleanse the area, pat dry, apply medihoney treatment, skin prep the surrounding tissue, cover with border or foam gauze and secure with tape daily and PRN until resolved. On 7/2/19 the Skin Grid indicated Resident 23's Stage 2 right lateral calf pressure ulcer measured 3.4 cm x 1.0 cm x 0.1 cm. Review of the 7/2019 TAR from 7/1/19 through 7/11/19, indicated treatments were completed as ordered on all dates including: -7/9/19, signed off by Staff 10 (LPN) -7/10/19, signed off by Staff 17 (LPN) On 7/11/19 at 1:47 PM Resident 23 was observed during wound care. Resident 23's dressing contained serosanguineous (blood and fluid) drainage and the dressing was dated as last changed on 7/8/19. Staff 2 (DNS) was present during wound care and confirmed the date of the dressing. The right lateral calf wound was observed to be a Stage 3 pressure ulcer and the wound bed measured 2.5 cm x 0.5 cm x 0.3 cm (an increase of 0.2 cm in depth since the previous assessment). On 7/12/19 at 8:30 AM Staff 17 wrote a statement acknowledging she signed the treatment as completed on the TAR on 7/10/19 but was unable to perform the ordered dressing change for Resident 23 because the resident was asleep and she did not want to wake her/him up. On 7/12/19 at 10:09 AM Staff 10 stated wound care was to be done daily for Resident 23. She acknowledged she signed the treatment as complete on the TAR for 7/9/19 before the treatment was done. She stated she did not complete the treatment due to becoming occupied with other resident care and forgot to go back and do the treatment. On 7/11/19 at 2:11 PM and 7/12/19 at 11:50 AM Staff 2 confirmed the dressing was dated 7/8/19 during the dressing change on 7/11/19 and confirmed two wound treatments were signed on the TAR by nursing staff but were not completed. She acknowledged the wound bed was assessed 7/2/19 and measured 0.1 cm in depth and then the wound was assessed on 7/11/19 and measured 0.3 in depth, indicating the wound worsened. Refer to F686. 2. Resident 225 admitted to the facility on [DATE] with diagnoses including leg fracture. On 7/8/19 at 2:19 PM Resident 225 was observed to have an ACE bandage wrapped around her/his lower left leg, with only the resident's toes exposed. The resident was observed to have several surgically implanted pins, which extended out from the resident's skin and attached to an external stabilizing cage on her/his lower left leg. The tops of the pins were visible, but the bottom of the pins, where the pins entered the skin, were not visible due to the bandage. None of the Resident 225's skin on the left lower leg was visible between her/his knee and toes due to the bandage. On 7/9/19 at 11:33 AM the same bandage was observed covering the resident's left lower leg. Resident 225 stated the bandage was present since her/his surgery prior to admission to the facility. Resident 225 stated staff did not monitor her/his skin and the incisions under the bandage. A review of the resident's 11/2019 TAR indicated the pin sites were to be monitored for signs of infection on each shift and the TAR noted the treatment was completed on each shift from 7/6/19 through 7/10/19. Staff 9 (RN), Staff 17 (LPN), Staff 19 (RN), Staff 29 (LPN) and Staff 30 (RN) all documented the treatment was completed. On 7/10/19 at 2:05 PM Staff 19 (RN) stated he monitored Resident 225's leg for infection the past few days but had not yet assessed the resident's skin that day. Staff 19 stated Resident 225's left lower leg was to be assessed on each shift. Staff 19 stated he was on his way to look at Resident 225's leg. The surveyor accompanied Staff 19 to Resident 225's room to observe the resident's leg. On 7/10/19 at 2:15 PM Staff 19 was observed to provide treatment to the resident's leg incision and pin sites. Asked again how often the resident's leg was to be monitored and treated Staff 19 stated wound care to the incision and pin sites was to be completed once per day. As the bandages were removed the resident expressed that the current time was the first time she/he saw the wounds since surgery. No signs of infection or skin deterioration were observed. It was noted that the same bandage previously observed on 7/8/19 and 7/9/19 was surrounding the resident's leg. On 7/10/19 at 2:28 PM Staff 2 (DNS) stated it was not possible for staff to assess the resident's pin sites for signs of infection without removing the bandage. On 7/10/19 at 2:31 PM Staff 17 acknowledged she documented monitoring of Resident 225's pin sites for infection. Staff 17 acknowledged she did not remove the bandage in order to assess the pin sites for infection. Staff 17 stated she looked at the skin adjacent to the bandage and determined there was no infection present. On 7/10/19 at 2:59 PM Staff 19 acknowledged he documented monitoring of Resident 225's pin sites for infection. Staff 19 acknowledged he did not remove the bandage in order to assess the pin sites for infection. Staff 19 stated he looked at the skin adjacent to the bandage and determined there was no infection present. Staff 19 acknowledged the bandage he removed from Resident 225 on that day was in place since the resident's admission to the facility. During an interview on 7/10/19 at 3:08 PM with Staff 2 and Staff 4 (Corporate RN) both staff acknowledged Staff 9, Staff 17, Staff 19, Staff 29 and Staff 30 all documented the resident's leg was monitored for infection, however the resident's leg was not monitored as the same dressing was in place since the resident's admission to the facility. Refer to F684.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 268 was admitted to the facility on [DATE] with diagnoses including morbid obesity and lymphedema. The 7/6/19 admission nursing assessment indicated Resident 268 was dependent on staff for bed mobility and she/he had unblanchable redness to the coccyx. The 7/6/19 In Room Care Plan indicated Resident 268 required extensive 1-2 person assistance for bed mobility and skin care interventions including keep linen clean, dry and turn and reposition every two hours. Multiple observations of Resident 268 on 7/10/19 and 7/12/19 found the resident in bed on her/his back. On 7/10/19 at 11:20 AM Staff 14 (LPN Resident Care Manager) stated Resident 268 was difficult to turn and turning caused the resident pain. She also stated she assisted the resident with incontinent care on 7/8/19 and did not observe any pressure wounds. The coccyx area was red but blanchable. Staff 14 stated Resident 268 was high risk for skin integrity issues due to immobility. On 7/12/19 at 12:28 PM Staff 23 (CNA) stated Resident 268 had a lot of pain when turning and it was difficult to turn the resident when performing incontinent care. Staff 23 stated she was unable to turn Resident 268 for repositioning and acknowledged the resident remained on her/his back most of the time. She also stated if Resident 268 could not turn there was not much that could be done about it. On 7/12/19 at 10:30 AM Staff 14 stated the physician was not notified of Resident 268's inability to turn due to pain prior to 7/10/19 and no alternate interventions were care planned or implemented to reduce risk for pressure ulcer formation. On 7/12/19 at 1:00 PM Staff 2 (DNS) stated she was unable to meet with Resident 268 since admission to assess her/his needs and plan interventions because it was a busy week. Based on observation, interview, and record review it was determined the facility failed to implement interventions to prevent and treat pressure ulcers for 2 of 4 sampled residents (#s 23 and 268) reviewed for pressure ulcers. This resulted in Resident 23 experiencing a worsened pressure ulcer and placed residents at risk for the development of pressure ulcers. Findings include: 1. Resident 23 admitted to the facility in 2017 with diagnoses including multiple sclerosis (a neurodegenerative disease) and paraplegia (paralysis of half the body). a. A 1/4/19 admission nursing assessment indicated Resident 23 readmitted to the facility from the hospital and had a fluid filled blister on the back of her/his right heel. The 1/2019 TAR indicated weekly skin checks were to be completed on Tuesdays. On 1/8/19 there was no indication of new skin changes for Resident 23. A 1/10/19 Skin Incident Investigation indicated a CNA reported a new skin issue on Resident 23's right posterior lower leg. The wound was noted to have non-blanchable redness discoloration and measured 6 cm x 2 cm. Resident 23 preferred to lay in bed with legs elevated on pillows and was unable to move her/his legs independently. The investigation indicated Resident 23 was rehospitalized on [DATE] so the investigation was unable to be completed. A 1/10/19 physician order indicated staff were to monitor the resident's non-blanchable redness to the lower right posterior leg twice daily for signs of worsening. A 1/14/19 Hospital Wound, Ostomy and Skin Department Progress Note indicated Resident 23 had a 3 cm x 1 cm non-blanchable red area to the right posterior leg, source unknown. A 1/14/19 admission nursing assessment indicated Resident 23 readmitted to the facility with an abrasion to the right lower leg. No measurements were indicated. No indication of non-blanchable redness was noted. The 1/2019 TAR indicated no treatment was completed for Resident 23's right leg wound until 1/20/19, seven days after the resident readmitted . A 1/20/19 Skin Incident Investigation indicated new skin impairment on Resident 23's right lower calf. The wound measured 5 cm x 1 cm. The investigation noted the wound was present on admission per the 1/14/19 nursing assessment. A 1/20/19 physician order indicated staff were to cleanse the wound to the right calf, skin prep around the wound and cover it with a dressing daily. A 1/21/19 Skin Grid indicated Resident 23 had a Stage 2 pressure ulcer (partial-thickness skin loss) on the right lateral lower leg which measured 5.5 cm x 1.2 cm. The resident's current care plan, last updated 5/6/19, indicated on 1/14/19 Resident 23 had a pressure ulcer on the right lateral calf and was at risk for slow healing secondary to impaired mobility, disease process and a preference to support/elevate leg with pillows, which could increase the risk of pressure. On 7/11/19 at 2:11 PM and at 4:02 PM Staff 2 (DNS) confirmed the Stage 2 pressure ulcer was identified on 1/14/19 but treatment was not initiated until 1/20/19. She further acknowledged the 1/14/19 hospital record assessed the wound as 3 cm x 1 cm and the Skin Incident Investigation dated 1/20/19 assessed the wound as 5 cm x 1 cm, indicating the wound had increased in size. Staff 2 stated the heel blister, the non-blanchable redness and the skin abrasion were all the same wound; a pressure ulcer on the resident's right calf. b. Resident 23's current care plan, last revised 5/6/19, indicated Resident 23 was at risk for developing further skin breakdown and had a pressure ulcer on the right lateral calf and was at risk for slow healing secondary to impaired mobility, disease process and preference to support/elevate leg with pillows, which could increase the risk of pressure A 5/5/19 physician order indicated Resident 23 had a Stage 3 (full thickness skin loss) Pressure Ulcer to her/his right lateral calf and staff were to cleanse the area, pat dry, apply santyl to the wound, skin prep to surrounding tissue, cover with border or foam gauze and secure with tape. The 5/7/19 Skin Grid indicated Resident 23 had a Stage 2 (partial thickness skin loss) Pressure Ulcer to the right lower lateral calf and the wound bed measured 2.0 cm x 1.0 cm x 0.2 cm. A 5/28/19 admission nursing assessment indicated Resident 23 readmitted from the hospital with a right lower extremity sore measuring 3.8 cm x 1.9 cm x 0.2 cm. Treatment was initiated. The 6/4/19 Skin Grid indicated Resident 23 had a Stage 2 right lateral lower leg pressure ulcer measuring 3.2 cm x 1.0 cm x 0.2 cm. A current order initiated 6/14/19, indicated Resident 23 had a Stage 3 pressure ulcer to the right lateral calf and staff were to complete the following treatment: -Cleanse the area, pat dry, apply medihoney treatment, skin prep the surrounding tissue, cover with border or foam gauze and secure with tape daily and PRN until resolved. A 6/14/19 late entry wound note, completed 7/11/19 by Staff 2 (DNS), indicated Resident 23 readmitted to the facility from the hospital on 5/28/19 with a Stage 3 right lateral calf pressure ulcer. The note further indicated on 6/14/19 Staff 2 reassessed the resident's right lateral calf wound and the wound bed measured 3.4 x 1 cm x 0.1 cm with 50% yellow adherent slough (dead tissue). On 7/2/19 the Skin Grid indicated Resident 23's Stage 2 right lateral calf pressure ulcer measured 3.4 cm x 1.0 cm x 0.1 cm. Review of the 7/2019 TAR from 7/1/19 through 7/11/19, indicated treatments were completed as ordered on all dates including: -7/9/19, signed off by Staff 10 (LPN) -7/10/19, signed off by Staff 17 (LPN) On 7/11/19 at 1:47 PM Resident 23 was observed during wound care. Resident 23's dressing contained serosanguineous (blood and fluid) drainage and the dressing was dated as last changed on 7/8/19. Staff 2 was present during wound care and confirmed the date of the dressing. The right lateral calf wound was observed to be a Stage 3 pressure ulcer and the wound bed measured 2.5 cm x 0.5 cm x 0.3 cm (an increase of 0.2 cm in depth since the previous assessment). On 7/12/19 at 8:30 AM Staff 17 wrote a statement acknowledging she signed the treatment as completed on the TAR on 7/10/19 but was unable to perform the ordered dressing change for Resident 23 because the resident was asleep and she did not want to wake her/him up. On 7/12/19 at 10:09 AM Staff 10 stated wound care was to be done daily for Resident 23. She acknowledged she signed the treatment as complete on the TAR for 7/9/19 before the treatment was done. She stated she did not complete the treatment due to becoming occupied with other resident care and forgot to go back and do the treatment. On 7/11/19 at 2:11 PM and 7/12/19 at 11:50 AM Staff 2 acknowledged the discrepancies with the wound staging and condition. She confirmed the dressing was dated 7/8/19 during the dressing change on 7/11/19 and confirmed two wound treatments were signed on the TAR by nursing staff but were not completed. She acknowledged the wound bed was assessed 7/2/19 and measured 0.1 cm in depth and then the wound was assessed on 7/11/19 and measured 0.3 in depth, indicating the wound worsened.