**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of clinical record, review of facility policies, interview with staff and resident, it was determined the facility failed provide tracheostomy care consistent with professional standards of practice for two of two residents. This failure resulted in an Immediate Jeopardy situation for Resident R32 and R34 who had a tracheostomy obstruction, experienced respiratory and emotional distress and potential death. (Resident R34) Findings include: Review of the facility policy Tracheostomy Care Protocol Licensed Staff last reviewed [DATE], indicates respiratory care must be provided per professional standards, physician orders are required for all aspects of tracheostomy (trach) care, including suctioning and oxygen use. Care plans must be resident-specific, updated upon condition change, and interdisciplinary. A baseline care plan must be developed within 48 hours of admission for all resident with a tracheostomy. Step by step tracheostomy care education for licensed staff includes but not inclusive to: A. Preparing for trach care: Review residents care plan and orders. B. Explaining the procedure C. Suctioning (if needed prior to cleaning) D. Inner Cannula care E. Stoma and skin care F. Dressing and ties G. Oxygen and humidification management H. Monitoring I. Emergency Preparedness J. Infection prevention K. Resident -centered considerations Tracheostomy monitoring and infection prevention: II. Signs and symptoms of tracheostomy infection III. How to obtain a trach culture IV. Documentation and reporting Review of the admission record indicated R32 was admitted to the facility on [DATE], with the diagnosis of respiratory failure (lungs have trouble loading your blood with oxygen), heart failure (heart doesn't pump the way it should), and tracheostomy (surgical hole in the windpipe that helps with breathing) status. Review of Resident R32's Minimum Data Set (MDS- assessment of resident's care needs) dated [DATE], section C0200 BIMS (Brief interview for mental status) revealed that Resident R32 scored 13 which indicated that Resident R32 was cognitively intact. Review of section O (Special treatments and procedures) 0110, C1 (oxygen therapy) and E1 (tracheostomy care) confirmed that Resident R32 received oxygen and tracheostomy care. Section D1 (suctioning) revealed suctioning completed. Review of Resident R32's care plan initiated [DATE], with revision on [DATE], indicated Respiratory: Resident has a tracheostomy related to impaired breathing mechanics; diagnosis of chronic obstructive pulmonary disease (COPD) and is dependent with oxygen since 2017. Resident is self-sufficient with trach care, including cleaning and changing inner cannula and suctioning as needed. Review of Resident R32's physician orders dated [DATE], indicated check stoma weekly as needed for diagnosis of tracheostomy status check stoma site for skin breakdown/maintenance, order was discontinued on [DATE], at 2:02 p.m. Review of Resident R32's physician orders dated [DATE], indicated tracheostomy care check stoma every evening shift for diagnosis of tracheostomy status check stoma site for skin breakdown, order was discontinued on [DATE], at 2:02 p.m. Review of Resident R32's physician order dated [DATE], indicated tracheostomy care - ensure clean ties daily every evening shift. clean ties daily, order was discontinued on [DATE], at 2:02 p.m. Review of Resident R32's physician orders dated [DATE], indicated tracheostomy care - ensure clean ties daily as needed for diagnosis of tracheostomy status clean ties for trach, orders were discontinued on [DATE], at 2:02 p.m. Review of Resident R32's physician orders dated [DATE], indicated change inner cannula daily Shiley XLT 6.0 every day shift for diagnosis of tracheostomy status, order was discontinued on [DATE], at 2:02 p.m. Review of Resident R32's physician orders dated [DATE], indicated oxygen 6 liters to maintain oxygen (02) sat greater than 92% via trach mask. every shift for oxygen dependency, order was discontinued on [DATE], at 2:02 p.m. Review of Resident R32's nursing progress notes dated [DATE], 2:29 p.m. indicated resident was discovered on floor face down in moderate amt pooled blood. Wound to head actively bleeding. No loss of consciousness noted. Resident remained alert and oriented to baseline throughout assessment. Complained of back, left leg and head pain. Unable to obtain VS due to position on floor. EMS called for emergency transport to hospital per Resident request. Physician notified. Review of Resident R32's nursing progress notes dated [DATE], 2:29 p.m. indicated resident was transferred to hospital. Review of Resident R32's nursing progress note dated [DATE] 6:18 p.m. resident admitted to hospital with diagnosis of encephalopathy. Review of Resident R32's nursing progress note dated [DATE], at 8:00 p.m. indicated Resident R32 returned from hospital. Alert and oriented X4 with no confusion. Admits to pain of 6. Pupils equal, round, reactive to light accommodation (Perrla). Diagnosis of urinary tract infection (UTI) now with 16F foley (tube inserted into the bladder) draining clear yellow urine without difficulties. Vital within in normal limits (wnl) of resident baseline. Trach intact with 6XLT Shiley. No noted fever. Pills whole, regular diet with thin liquids. bed in lowest position. Resident is able to make her needs known. call light within reach. will continue to monitor. Review of Resident R32's re-admission assessment dated [DATE], form V10.8 indicated tracheostomy present. Review of Resident R32's current physician orders on [DATE], failed to include current orders for tracheostomy care. Review of Resident R32's [DATE] medication administration record (MAR) indicated trach care discontinued on [DATE]. Review of Resident R32's [DATE] MAR indicated tracheostomy Care - Ensure clean ties daily was discontinued on [DATE]. Review of Resident R32's [DATE] MAR indicated Oxygen 6 liters to maintain 02 sat greater than 92% via trach mask. every shift for Oxygen Dependency was discontinued on [DATE]. Review of Resident R34's clinical record revealed that Resident R34 was admitted to the facility on [DATE], with diagnoses of tracheostomy (tube inserted through the neck to assist breathing) status, repeated falls, and hip fracture. Review of Resident R34's physician's order dated [DATE], indicated to administer 10 liters (L) of oxygen via trach mask every shift for oxygen dependency. Review of Resident R34's progress note dated [DATE], revealed the resident has a tracheostomy and was on three liters of oxygen. The facility failed to administer oxygen as ordered or notify physician of the change in oxygen demand. Review of Resident R34's progress note dated [DATE], indicated trach care was provided and Registered Nurse (RN), Employee E12 was unable to insert inner cannula. The resident was taken to the hospital for evaluation. Review of Resident R34's progress note dated [DATE], revealed Licensed Practical Nurse (LPN), Employee E13 went into the resident's room to answer her call light and the resident was found holding her trach in her hand and was unable to put it back in. The supervisor was notified and 911 was called. Review of Resident R34's Minimum Data Set (MDS- assessment of resident's care needs) dated [DATE], section C0200 BIMS (Brief interview for mental status) revealed that Resident R34 scored 13 which indicated that Resident R34 was cognitively intact. Review of section O (Special treatments and procedures) 0110, C1 (oxygen therapy) and E1 (tracheostomy care) confirmed that Resident R34 received oxygen and tracheostomy care. Section D1 (suctioning) revealed suctioning was not a treatment that was performed. Review of Section GG (Functional Abilities) reveled that Resident R34 required supervision or touching assistance in bed mobility and required substantial/maximal assistance with transfers. Review of Resident R34's baseline care plan dated [DATE], failed to include a care plan for suctioning, tracheostomy care, and isolations precautions. The facility failed to implement a baseline care plan within 48 hours of admission. Review of Resident R34's progress note dated [DATE], revealed the resident required significant assistance for ADL (activity of daily living) tasks. It was indicated nursing was working on trach care, the son was going to bring in cleaning supplies as resident completed this on her own before. Review of Certified Registered Nurse Practitioner, Employee E15 progress note dated [DATE], revealed the resident was assessed and the resident had a history of laryngeal cancer and had a permanent trach. It was indicated to have respiratory therapy as ordered. Review of Resident R34's progress note dated [DATE], revealed the RN Supervisor notified Assistant Director of Nursing, Employee E8 that Resident R34 was having respiratory difficulties intra cannula from trach was dislodged. The resident was transferred to the hospital. Review of Resident R34's progress note dated [DATE], indicated the resident's inner cannula was removed and staff were unable to reinsert. The resident stated she can breathe easier with the inner cannula out. RN, Supervisor, Employee E2 indicated the hospital discharge paperwork were reviewed to identify next steps. Review of Resident R34's physician order dated [DATE], indicated the resident was scheduled a tracheostomy evaluation on [DATE], at 10:00 a.m. Review of Resident R34's physician order dated [DATE], indicated to obtain a culture one time only for trach infection site on [DATE]. Review of Resident R34's [DATE] Treatment Administration Record (TAR) failed to indicate Resident R34's culture was obtained as ordered. Review of Resident R34's care plan dated [DATE], revealed the resident had a tracheostomy. The resident's goal was to have no signs and symptoms of infection. Interventions included to ensure trach ties are secure and monitor/document for restlessness, agitation, confusion, increased heart rate, and bradycardia. It was indicated to monitor/document respiratory rate, depth, and quality every shift/as ordered, and to suction as necessary. The care plan failed to include tracheostomy care including, cleaning and the size of the inner cannula. Review of Resident R34's physician order dated [DATE], indicated to administer one tablet of 100 milligram (mg) Doxycycline Hyclate (antibiotic that treat bacterial infections) by mouth, two times a day for infection for 10 days. Review of Certified Registered Nurse Practitioner, Employee E15 progress note dated [DATE], revealed Resident R34 had recent concerns for trach maintenance and care. Review of Resident R34's physician order dated [DATE], indicated to obtain a culture one time only for trach infection site. Review of Resident R34's office visit summary dated [DATE], revealed the resident was referred to see an otolaryngology (ear, nose, and throat, is a medical specialty that focuses on the diagnosis and treatment of conditions affecting the ears, nose, throat, and related structures of the head and neck) provider for a consultation for the resident's tracheostomy status. Resident R34 used a metal [NAME] tracheostomy tube. While a resident at a skilled nursing facility, Resident R34's inner cannula dislodge, and staff were unable to reinsert and the resident was sent to the hospital. Resident R34 was transferred to the hospital and underwent a laparoscopy (a surgical procedure in which a small incision is made through which a viewing tube is inserted) which showed some circumferential mucus making reinsertion challenging. A saline irrigation and suctioning was performed to remove the crusting, and then a new inner cannula was inserted. Resident R34 presented a month later, on [DATE], with the inability to place the inner cannula. The assessment revealed Resident R34's metal [NAME] tracheostomy has progressively gotten obstructed and with a biofilm. Redness was observed around the skin of Resident R34's tracheostomy. Upon examination, Resident R34 had a complete obstruction of the tracheostomy. An inner cannula was unable to placed. The tracheostomy tube was removed and the inside of both the trach and the inner cannula was extensively cleaned. Resident R34's trach was replaced and Resident R34 was observed to be clear and was able to breathe significantly better. Prior to this, Resident R34 had inspiratory stridor (a high-pitched sound that occurs when breathing through a narrow or obstructed airway, indicating difficulty in breathing. It can be a sign of an abnormality in the airway that may require medical attention). The plan was to start antibiotics for low grade tracheostomy infection, diligent trach care, 20 mg famotidine (medication that decreases stomach acid production), one tablet, for reflux symptoms, change 40 mg pantoprazole (use to treat certain stomach and esophagus problems), one tablet, to 30 minutes before dinner, and to follow up in one month. Review of Resident R34's physician order dated [DATE], indicated to administer one table of 875-125 mg Amoxicillin-Pot Clavulanate (a combination antibacterial medication used to treat various types of bacterial infections), one tablet by mouth every 12 hours for a tracheostomy bacterial infection for 10 days. Review of Resident R34's physician orders dated [DATE], indicated to administer 10 mg famotidine, one tablet by mouth, one time a day for reflux. The facility failed to ensure Resident R34 received 20 mg of famotidine as ordered by the provider at the office visit on [DATE]. Review of Resident R34's physician orders revealed multiple orders for pantoprazole. Resident R34 was ordered 40 mg pantoprazole, one tablet, once a day on [DATE], and 20 mg of pantoprazole, one tablet, once a day on [DATE]. Review of Resident R34's March MAR revealed Resident R34 received both orders of pantoprazole, a total of 60 mg on seven days. The facility failed to ensure Resident R34 received 40 mg pantoprazole before dinner as ordered by the provider at the office visit on [DATE]. Review of Resident R34's progress note dated [DATE], entered by LPN, Employee E13 indicated trach care was performed. The facility failed to have an order for trach care and the size of the inner cannula. During an interview on [DATE], at 10:08 a.m. Resident R34 was observed lying in bed, not wearing 10 liters of oxygen as ordered. The oxygen was observed across the room, turned off, without tubing, and not within reach of the resident. The resident stated I never had to wear oxygen. Resident R34 was tearful and stated staff do not know how to care for the tracheostomy. It was indicated prior to being admitted to the facility, the facility indicated staff can provide care for residents with a tracheostomy. An undated gallon of distilled water was observed open and on the floor. Resident R34 indicated the gallon of distilled water was used for trach care. During an interview on [DATE], at 11:26 a.m. LPN, Employee E1 was asked if they were trained on tracheostomy care. LPN, Employee E1 indicated it was their first day and the facility did not train or educate LPN, Employee E1 on tracheostomy care. LPN, Employee E1 confirmed they were assigned to Resident R34 and indicated they had experience in pediatric trach care. LPN, Employee E1 confirmed Resident R34 was not receiving oxygen as ordered. During an interview on [DATE], at 11:20 a.m. RN Supervisor, Employee E2 confirmed Resident R34's tracheostomy culture was not completed. It was indicated Resident R34 went out to an appointment and was placed on antibiotics. RN, Supervisor, Employee E2 stated Resident R34 was on doxycycline for the tracheostomy infection. It was indicated RN Supervisor, Employee E2 and licensed practical nurses provide care to Resident R34's trach. RN, Supervisor, Employee E2 confirmed Resident R34's office visit from [DATE], for the tracheostomy evaluation was not available and was not located in the resident's clinical record. RN, Supervisor Employee E2 stated Resident R34 was sent out to the hospital a few times due to the inability to reinsert the inner cannula. It was indicated the resident is monitored every shift and it should be documented in the Treatment Administration Record (TAR). During a phone interview on [DATE], at 11:47 a.m. with Resident R34's otolaryngology provider's office, it was confirmed Resident R34 was evaluated on [DATE], and had a follow up appointment scheduled for [DATE]. Review of Resident R34's clinical record on [DATE], at 11:52 a.m. failed to include an order to follow up with the otolaryngology provider on [DATE]. Review of Resident R34's physician orders failed to include orders for the resident's tracheostomy care, including cleaning, size of inner cannula, suctioning, enhanced barriers, and how often to change the neck ties on the resident's tracheostomy. The facility failed to include orders to monitor/document for restlessness, agitation, confusion, increased heart rate, and bradycardia as the resident's care plan indicated. There were no orders to monitor/document respiratory rate, depth, and quality. Review of 4 of 4 employee files (LPN, Employee E1, RN Supervisor, Employee E2, LPN, Employee E9 and LPN, Employee E11) on [DATE], failed to include evidence they were educated and competent on tracheostomy care. During an interview on [DATE], at 1:59 p.m. the Director of Nursing and Nursing Home Administrator confirmed the facility failed to implement interventions for residents with a tracheostomy, ensure residents have orders and care plans for trach care and suctioning, obtain trach cultures as ordered (Resident R34), and ensure staff were competent in tracheostomy care for two of two residents (Resident R32 and R34). Review of the facility assessment on [DATE], at 2:06 p.m. failed to include tracheostomy care. During an interview on [DATE], at 2:08 p.m. the Nursing Home Administrator confirmed tracheostomy care was not listed in the facility assessment. Based on the above findings an Immediate Jeopardy situation was identified to the Nursing Home Administrator and Director of Nursing on [DATE], at 3:47 p.m. for the failure of the facility to provide tracheostomy care to a resident in accordance with professional standards of practice for two of two residents (Resident R32 and R34). This failure resulted in Resident R34 having a complete tracheostomy obstruction and experiencing respiratory and emotional distress. An Immediate Jeopardy template was provided to the Nursing Home Administrator. On [DATE], at 5:41 p.m. the facility submitted a plan of correction. The plan was reviewed and it was rejected. The facility failed to contain a root cause analysis, who was responsible for the POC, how long the facility was to monitor. On [DATE], at 7:19 p.m. the facility's plan of correction was received and accepted which included the following interventions: The facility developed the following approved action plan: A root cause analysis was completed that determined the cause to be inconstant coverage of information in the clinical meetings due to not following a specific checklist that can be followed by other clinical team members when the DON is not able to be at the daily meeting. A specific checklist will be implemented on [DATE]. 1. Identified Residents -Resident 32 is not in the facility. She will be assessed and reevaluated upon return by the Director of Nursing or designee. R34 baseline care plan was completed on [DATE] by the DON. Order for enhanced barrier precautions obtained by the DON on [DATE]. Order for O2 discontinued for nonuse by the DON on [DATE]. Trach care orders obtained and updated by the DON on [DATE]. Care plan was updated by the MDS Nurse to reflect current status on [DATE]. 2. Like Residents -House review completed by DON and designee on [DATE]. 3. System Correction and Education's -The Director of Nursing and Regional Clinical Director reviewed the trach care policy on [DATE]. No updates were needed. -The licensed staff will be educated on the Trach Care Policy by the DON or designees on [DATE]. -Nursing will sign education signature sheet prior to their next worked shift, if they completed the Carefeed training. Training for all licensed nurses will be completed on [DATE]. -The facility assessment was updated to include trach care was update by the Administrator on [DATE]. 4. Monitor and Audit -An Ad Hoc QAPI meeting was held by Administer on [DATE]. -All new admissions and readmissions will be audited daily in the Clinical Meeting by the DON or designees utilizing a clinical checklist to include trach care, barrier precautions and care plans weekly for 4 weeks beginning on [DATE]. On [DATE], at 7:22 p.m. the NHA and DON were notified the facility was still in immediate jeopardy and in order to lift, the facility must provide evidence the plan of correction was implemented. The DON and NHA were notified staff must be interviewed to verify competency. On [DATE], 12:23 p.m. the NHA was asked if information related to the facility's plan of correction was available for review. It was indicated the facility was pulling stuff together. On [DATE], at 2:18 p.m. the Director of Clinical Operations, Employee E24 provided the education that the facility trained all their licensed staff for tracheostomy care. During an interview on [DATE], at 3:03 p.m. the Director of Clinical Operations, Employee E24, NHA, and DON were asked what professional standards of practice or guidance did the facility utilize to educate the facility's licensed nursing staff. It was indicated staff were educated using the policy and competency tool. The policy and competency tool failed to include what to do with the emergency tracheostomy kit, what emergency supplies must be available at the bedside, suctioning, enhanced barriers, physician orders and care plans. The DON stated it is not the facility's policy to have a smaller trach size available for emergencies. The DON stated an Ambu bag is located on the facility's crash cart located in the common area on each nursing unit. The DON indicated training for emergency care for a resident with a tracheostomy is no different than cleaning or changing the inner cannula when placing one in an emergency. All nurses are CPR certified and CPR training covers how to use an Ambu bag. During an interview on [DATE], at 3:30 p.m. the Nursing Home Administrator was asked to provide the education that was sent on care feed. On [DATE], at 3:36 p.m. the education that was provided on care feed was provided by the Director of Clinical Operations, Employee E24. On [DATE], at 3:52 p.m. a review of the documents provided by the facility for the plan of correction failed to include evidence staff were educated on what to do with the emergency tracheostomy kit, what emergency supplies must be available at the bedside, suctioning, enhanced barriers, physician orders and care plans. On [DATE], at 9:15 a.m. Director of Clinical Operations, Employee E24 provided the education that staff were trained on. The education included what to do with the emergency tracheostomy kit, what emergency supplies must be available at the bedside, trach care including, cleaning, suctioning, enhanced barriers, physician orders and care plans. On [DATE], at 9:22 a.m. Director of Regional Clinical Operations indicated the facility was reeducating all licensed nurses. The facility failed to ensure all licensed staff were educated prior to the start of their shift. During an interview and observation completed with Resident R32 on [DATE], at 9:31 am Resident R32 stated I have had a trach since 2016. No one changes my tracheostomy neck ties, I can't do that. The resident's suction machine was observed unplugged, on the side table to the left side of her bed. Resident R32 stated I have to stretch to reach it and they have to plug it in. A yellow/tannish substance was observed in the suction tubing and the cannister. The suction tubing was lying over the machine and was not stored properly in a bag. Resident R32 further stated, I have to pull my table over, change the suction catheter, then staff would have to plug it in. I have waited as long as 45 minutes for them to come in. Upon asking about hand hygiene, she replied I did have hand sanitizer in here, I can't find it. Three 6XL cuffed tracheostomy kits were observed at Resident R32's bedside. Resident R32 stated I am cuffless. Resident R32 stated the extra cannulas (2 in white bag in drawer) and the suction kit (on the overbed table) was provided from the hospital, I like them better. The ones they have here are really long. An expired gallon of distilled water dated [DATE], was observed at the resident's bedside. Resident R32 indicated the water was used for her tracheostomy care. A bag of trach ties was noted on the floor, a basin was on the floor that contained a humidifier bottle that was dated [DATE]. A bag was on the floor next to dresser that had some trach supplies in it. During an interview completed on [DATE], at 9:50 am, Registered Nurse (RN) Employee E2 confirmed the above observations. During an observation and interview on [DATE], at 10:13 a.m. Resident R34 indicated staff do not empty the suction canister, they leave it filled, let it go to the top. Resident R34 indicated suctioning is used daily. During an observation and interview on [DATE], at 10:26 a.m. Resident R34 had a sterile tracheostomy care tray with sterile gloves opened located on the bedside table. Resident R34's personal belongings (stress balls) were observed on top of the opened tracheostomy care tray. Distilled water was observed on the floor. The resident stated the water was used for her tracheostomy care. A used, opened tracheostomy kit with a dirty spoon in it was observed behind Resident R34's television. Pipe cleaners were observed lying on the resident's tv stand without a bag. The resident's suction catheter tubing was unbagged lying on the bedside dresser. A 7.5 inner cannula was observed in the resident's top drawer in her dresser and a 5.00 disposable inner cannula was observed under the resident's tv on the dresser. There was oxygen tubing, not store in a bag, located behind the resident's tv. There were no emergency supplies, including ambu bag, obturator, or one size smaller inner cannula at the resident's bedside. During an interview on [DATE], at 10:52 a.m. RN, Supervisor, Employee E2 confirmed the above observations. Review of Resident R34's clinical record on [DATE], at 11:20 a.m. revealed the facility failed to enter an order to change Resident R34's inner cannula and neck ties and include the size of the resident's inner cannula. Resident R34's care plan was not updated, last revised [DATE], and failed to include how often to change/clean the inner cannula and the size of the resident's tracheostomy. During an observation on [DATE], 12:05 p.m. the crash cart located on 4th floor the following was observed. -The cart was unlocked -Oxygen tank failed to have regulator attached (as the checklist located on top of the cart indicated) -No tubing or Yanker connected to suction canister (as the checklist located on top of the cart indicated) -An expired 250 ml 0.9% Normal Saline Solution IV fluid bag (expired 9/22) -Dressing kit tray expired [DATE] During an interview on [DATE], at 12:20 p.m. the DON confirmed the above findings. During interviews completed on [DATE], from 1:30 p.m. until 1:40 p.m. 4 of 4 licensed nurses failed to confirm they were educated on trach care, emergency care, how to obtain a trach culture, and how long to suction. During review of clinical records on [DATE], at 2:06 p.m. 2 of 2 residents failed to have an order for their inner cannula size, how often to clean/change the inner cannula and neck ties. 2 of 2 care plans failed to be individualized and have information related to how often trach care is performed (cleaning/changing inner cannula and neck ties) and the size of the resident's inner cannula. (Resident R32 and R34). The facility failed to implement their plan of correction. During an interview on [DATE], at 3:19 p.m. the Nursing Home Administrator and DON were notified the facility failed to implement their plan of correction. On [DATE], at 9:45 a.m. the NHA was asked if the facility was ready to verify education competency and if it was okay to re-interview staff. The NHA stated give us a minute and the DON said he already talked with staff. On [DATE], at 10:02 a.m. LPN, Employee E1 was interviewed to verify competency of the education the facility provided on Trach Care, Enhanced Barrier Precautions, and Care Plans. LPN, Employee E1 had the education provided by the facility available in front of him. LPN, Employee E1 failed to know what emergency supplies are readily available at the bedside. When asked what size inner cannulas should be available, LPN, Employee E1 stated 5, 7, 9 then stated Let me cheat for that one and then looked through the education provided from the facility and stated pretty sure size 5, 7, and 9. LPN, Employee E1 failed to indicate the size of the resident's inner cannula and a size smaller. LPN, Employee E1 asked what is an obturator? When asked what would you do if you were unable to reinsert trach tube if smaller cannula does is unsuccessful, LPN, Employee E1 stated Call, 911. and failed to know to cover the resident's stoma with sterile gauze and use a bag-valve mask over mouth and nose as the education provided by the facility revealed. LPN, Employee E1 failed to know how to obtain to culture of the tracheostomy and indicated a culture swab would be used to obtain it from the resident's inner cannula. The facility's education indicated a trach culture is obtained by using a suction catheter, then suctioning the airway secretions into a sterile container, then labeling the specimen with the resident info, date and time. The culture is then sent to the lab immediately. Review of Resident R34's clinical record on [DATE], at 10:40 a.m. failed to include an updated personalized care plan with interventions related trach care. Resident R34's care plan was not updated, last revised [DATE], and failed to include how often to change/clean the inner cannula and the size of the resident's tracheostomy. The facility failed have care plans for tracheostomy updated by the MDS Nurse to reflect current status on [DATE], as the facility plan of correction indicated. On [DATE], at 1:13 p.m. review of Resident R32 's clinical record revealed the resident returned to the facility on [DATE]. Orders and care plans were reviewed and updated to include individualized care for the resident's tracheostomy. Resident R34 's orders for trach care with size of trach tubes, emergency care, and suctioning were entered on [DATE]. The resident 's care plan was updated on [DATE], to include personalized center care for trach care, including size and suctioning. No other residents currently in-house were in need of trach care. On [DATE], at 1:22 p.m. review of the summary sheet provided for the electronic training (Caref[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observations, clinical record reviews, facility documentation, and interviews, it was determined the facility failed to implement interventions to prevent pressure ulcer and injury (PU/PIs- injuries to skin and underlying tissue resulting from prolonged pressure on the skin.) development for residents who were admitted without PU/PIs, but who had multiple co-morbidities; and failed to provide ongoing skin assessments for four of four residents (Resident R5, R63, R68, and R231) that resulted in deterioration of one or more PU/PIs for two of four residents (R5 and R63) and infection for one of four (R68), which resulted in an immediate jeopardy situation for four of 74 residents. Findings: Review of the facility's Pressure Injury Risk Assessment policy dated 1/18/23, stated the purpose of this procedure was to provide guidelines for the structured assessment and identification of residents at risk of developing new pressure injuries or worsening of existing pressure injuries. It was indicated a pressure ulcer risk assessment using the facility's approved tool must be conducted. When a comprehensive skin assessment is completed, the findings are documented on the facility's approved skin assessment tool. If a new skin alteration is noted, a (pressure or non-pressure) form related to the type of alteration in skin must be completed. It stated a care plan and interventions based on risk factors identified in the assessments, the condition of the skin, and the resident's overall clinical condition, and the resident's stated wishes and goals must be developed. Review of the facility's Pressure Injuries Overview policy dated 1|/18/23, stated the purpose of this policy was to provide information regarding the definitions and clinical features of pressure injuries. It was indicated avoidable means a resident developed a pressure ulcer of injury and that one or more of the following was not completed: -Evaluation of the resident's clinical condition and risk factors. -Definition or implementation of interventions that are consistent with resident needs, resident goals, and professional standards of practice. -Monitoring or evaluation of the impact of the interventions; or -Revision of the interventions as appropriate. Review of the facility's Wound Care policy dated 1/18/23, stated the purpose of this policy was to provide guidelines for the care of wounds to promote healing. It stated a physician order must be verified and the care plan must be reviewed to assess for any special needs of the resident. The following should be recorded in the resident's medical record: -The type of wound care given. -The date and time the wound care was given. -All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. -If the resident refused the treatment and the reason(s) why. Review of Resident R5's clinical record indicated an admission date of 12/22/21, with diagnoses that included malignant neoplasm of the skin (skin cancer), diabetes, muscle weakness, and dementia (a group of symptoms that affects memory, thinking and interferes with daily life.) Review of Resident R5's physician order dated 12/22/21, indicated Resident R5 may be seen by a wound specialist. Review of Resident R5's physician order dated 3/9/22, indicated a weekly skin assessment must be completed every Wednesday. Review of Resident R5's Braden Scale for Predicating Pressure Sore Risk assessment dated [DATE], identified the resident was at risk with a score of 15. No further Braden Scale Assessments were completed until 6/4/23. The facility's Braden Scale for Predicting Pressure Score Risk assessment instructions indicated assessments are completed when admitted and every quarter. Review of Resident R5's MDS dated [DATE], Section M Skin Conditions, indicated the resident was at risk for developing PU/PIs and the resident did not have one or more unhealed PU/PIs. Review of Resident R5's care plan from 4/7/23 through 5/29/23, failed to include a care plan for pressure ulcers. Review of Resident R5's NG-Weekly Skin Inspection assessment dated [DATE], failed to indicate any abnormalities observed on the resident's skin. It was documented the resident had no skin issues. Review of Resident R5's progress note dated 4/26/23, entered by Licensed Practical Nurse (LPN), Employee E4, indicated the resident had developed a new reddish, purple bruise on left hip that measured 5 cm x 2.5 cm and two new dime-sized reddish, purple areas on the side of left foot. It was indicated the registered nurse supervisor was notified, and that care was provided in accordance with the resident's care plan. Review of Resident R5's care plan dated 4/26/23, failed to include care interventions related to the resident's pressure injury. Measurements for the left foot pressure injury were not documented. Review of the resident's clinical record on 4/26/23, failed to include documentation of the findings on the facility's approved skin assessment tool. Review of Resident R5's progress note dated 4/26/23, entered by wound care consultant, Nurse Practitioner (NP), Employee E5, indicated she was requested by facility staff to have Resident R5's newly discovered deep tissue injuries (DTIs- persistent non-blanchable deep red, purple or maroon areas of intact skin, non-intact skin or blood-filled blisters caused by damage to the underlying soft tissues) to the left hip, left foot, and sacrum evaluated. It was indicated Resident R5 was malnourished, incontinent of urine and feces, and had bilateral lower extremity contractures (a permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen.) It was also indicated Resident R5 was on a regular mattress. The following wounds were documented for Resident R5: -Newly discovered left hip acute DTI that measured 1.9 cm x 3.3 cm. -Newly discovered left lateral foot acute DTI that measured 2.1 cm x 1.6 cm. -Newly discovered left proximal lateral foot acute DTI that measured 1cm x 1cm. -Newly discovered sacral acute DTI that measured 1 cm x 0.7 cm. Review of wound care consultant, NP, Employee E5, progress note dated 4/26/23, indicated Resident R5's DTIs were ordered skin prep and left open to air. Additional orders as of 4/26/23, included pressure relief and offloading, the facility's pressure ulcer prevention protocol, and a pressure redistribution mattress. It was indicated the plan of care and education was discussed with facility staff. Review of Resident R5's physician orders from 4/26/23 through 5/2/23, failed to include the ordered treatment for Resident R5's left hip, left foot, and sacral PU/PIs. Review of the clinical record revealed no evidence that the physician orders were completed. Review of Resident R5's physician order dated 4/27/23, indicated to turn and reposition as tolerated. Review of Resident R5's April 2023 electronic Treatment Administration Record (eTAR), failed to include documentation that Resident R5 was turned and repositioned as ordered. During an interview on 5/31/23 at 8:32 a.m., the DON, confirmed the order for Resident R5 to be turned and repositioned was entered incorrectly, and there was no way to confirm the resident was turned and repositioned as ordered. Review of Resident R5's NG-Weekly Skin Inspection assessment dated [DATE], failed to indicate any abnormalities observed on the resident's skin, and it was documented the resident's skin was clear and intact. Review of Resident R5's clinical record indicated the facility staff failed to complete weekly skin assessments from 5/1/23-5/31/23. Review of Resident R5's progress note dated 5/3/23, entered by wound care consultant, NP, Employee E5, documented the following for Resident R5: -Left hip acute DTI that measured 1.5 cm x 3 cm. -Left lateral foot acute DTI that measured 1.7cm x 1.3 cm. -Left proximal lateral foot acute DTI that measured 1 cm x 1 cm. -Sacral acute stage two pressure injury that measured 1 cm x 0.7 cm x 0.1 cm. Review of wound care consultant, NP, Employee E5, progress note dated 5/3/23, indicated Resident R5's DTIs were ordered skin prep and left open to air. Additional orders as of 5/3/23, included pressure relief and offloading, the facility's pressure ulcer prevention protocol, and a pressure redistribution mattress. It was indicated the plan of care and education was discussed with facility staff. A further review of Resident R5's physician orders from 5/3/23 through 5/19/23, failed to include the ordered treatment for Resident R5's left hip, left foot, and sacral PU/PIs. Review of Resident R5's physician orders dated 5/16/23, indicated she was admitted to hospice. Review of Resident R5's progress note dated 5/17/23, entered by wound care consultant, NP, Employee E5, documented the following for Resident R5: -Left hip acute DTI that measured 2.9 cm x 3.9 cm. with sloughing of the epithelium (the protective layer of the skin). The wound worsened. -Left lateral foot acute DTI that measured 1.7 cm x 1.3 cm with no measurable depth. -Left proximal lateral foot acute DTI that measured 1cm x 1 cm with no measurable depth. -A newly discovered left medial foot DTI that measured 1.2 cm x 1.2 cm with no measurable depth and had eschar (a collection of dry, dead tissue within a wound). -Sacral acute stage pressure injury that received an outcome of resolved. Review of wound care consultant, NP, Employee E5, progress note dated 5/17/23, indicated Resident R5 was ordered Medihoney (wound gel that helps speed the healing time of existing wounds and reduces pain) to the left hip and covered with a foam dressing and changed daily. On 5/17/23, wound care consultant, NP, Employee E5, ordered skin prep to be applied over the Resident R5's left foot DTIs. Additional orders as of 5/17/23, included the facility's pressure ulcer prevention protocol, side to side offloading every two to three hours while in bed, offloading heels, and a pressure redistribution mattress. On 5/17/23, wound care consultant, NP, Employee E5, also ordered Resident R5 soft heel boots (designed to offload pressure from the heel of a non-ambulatory individual to help prevent the development of pressure ulcers) that were always to be worn, aside from ambulation. It was indicated the plan of care and education was discussed with facility staff. Review of Resident R5's clinical record indicated the facility failed to update Resident R5's physician orders. A further review of Resident R5's physician orders from 5/17/23 through 5/19/23, failed to include the ordered treatment for Resident R5's left hip and left foot PU/PIs. Review of Resident R5's physician order dated 5/19/23, failed to include the ordered treatment wound consultant, Employee E5, ordered to the residents left foot on 5/17/23. It indicated skin prep was to be applied to the left hip and covered with foam dressing, daily, starting 5/20/23. It was indicated this order was discontinued on 5/30/23. A further review of the physician order dated 5/19/23, indicated the resident's right hip was to be cleansed with Dakin's, patted dry, Medihoney and alginate applied, and covered with foam dressing, daily, starting 5/20/23. It was indicated this order was discontinued on 5/30/23. A further review of Resident R5's physician orders from 5/19/23 through 5/29/23, failed to include the ordered treatment for Resident R5's left lateral, proximal, and medial foot PU/PIs. Review of Resident R5's May 2023 eTAR, failed to include documentation that Resident R5 was turned and repositioned as ordered. A further review of Resident R5's May 2023 eTAR, failed to include documentation from 5/1/23 through 5/30/23, that care was provided as ordered to the resident's left hip, left foot, and sacral PU/PIs. During an interview on 5/31/23 at 8:32 a.m., the Director of Nursing (DON), confirmed the orders for Resident R5 were entered incorrectly for the left and right hip from 5/19/23 through 5/30/23, and there was no way that confirmed the resident received treatment to her PU/PIs as ordered. During an interview with Resident R5's family at bedside on 5/30/23 at 9:49 a.m., it was indicated Resident R5 was recently admitted to hospice on 5/16/23 and was given pressure relieving boots on 5/17/23. It was stated Resident R5's pressure relieving boots went missing after the first day she received them and Resident R5's feet have not been offloaded. During an observation, it was observed Resident R5's feet were not offloaded. Resident R5's granddaughter stated she visits daily and expressed concern with the treatment of Resident R5's pressure ulcers. Resident R5's dressing to her left hip was dated 5/28/23, with a large amount of drainage noted on the dressing. During an interview on 5/30/23 at 10:07 a.m., Registered Nurse (RN), Employee E6, confirmed Resident R5's dressing was dated 5/28/23 and was not changed on 5/29/23 and 5/30/2023. Registered Nurse, Employee E6, also confirmed Resident R5 did not have soft heel protector boots in place and stated they have been missing for over a week. During this interview, RN, Employee E6, confirmed that all weekly skin assessments are documented in the clinical record using the facility's skin assessment tool and if a resident refused, it is documented in the clinical record. During an observation of Resident R5's left hip wound dressing change on 5/30/23 at 11:05 a.m., RN, Employee E6, incorrectly applied the prescribed Medihoney to the wound. RN, Employee E6, confirmed she only applied the Medihoney to the border of the wound. During the dressing change RN, Employee E6, failed to wash her hands in between removing the old dressing and applying a new one. During an interview with the Director of Nursing (DON) on 5/30/23 at 11:53 a.m., the DON, stated that Resident R5's wounds were not considered pressure ulcers although documented in the clinical record as PU/PIs by wound care consultant, NP, Employee E5. During an interview and observation on 5/31/23 at 12:35 p.m., RN, Employee E7, confirmed Resident R5's heels were not offloaded and stated she was aware that Resident R5 should have had pressure relieving boots on. RN, Employee E7, stated I was the one that recommended the boots. Review of Resident R5's progress note dated 5/31/23, entered by wound care consultant, NP, Employee E5, documented the following for Resident R5: -Left hip acute unstageable full-thickness skin and tissue loss (extends beyond the first two layers of the skin and may reveal subcutaneous (fatty) tissue, muscle, tendon, or even bone) pressure injury that measured 5.3 cm x 6.5 cm that had a small amount of serous drainage (a thin, watery, and clear type of fluid that comes out of a wound that had tissue damage.) It was indicated the wound deteriorated. -Left lateral foot acute DTI that measured 1.9 cm x 1.2 cm. -Left proximal lateral foot acute DTI that measured 1cm x 1cm. -Left medial foot DTI that measured 1.2 cm x 1.2 cm with eschar. -Sacral pressure ulcer that received a status of not healed. No documentation of the sacral wound measurements or description of wound bed were provided. -A newly discovered right hip DTI that measured 4.1 cm x 5.4 cm that had a purple base and two small blisters filled with serous drainage. It was documented no drainage was observed. Review of wound care consultant, NP, Employee E5, progress note dated 5/31/23, documented Resident R5's left hip was ordered to be cleansed with 0.125% Dakin's Solution (wound cleanser), Medihoney and calcium alginate applied to the wound bed, and covered with a foam dressing, changed daily. On 5/31/23, wound care consultant, NP, Employee E5 ordered Resident R5 skin prep to be applied over the resident's right hip and left foot DTIs and left open to air. On 5/31/23, wound care consultant, NP, Employee E5, ordered Resident R5's sacral pressure ulcer to be cleansed with normal saline (wound irrigation solution) and zinc (helps fight infection and heal wounds) and a foam dressing was applied, and the dressing was to be changed daily. Additional orders as of 5/31/23, included the facility's pressure ulcer prevention protocol, side to side offloading every two to three hours while in bed, offload heels, and a pressure redistribution mattress. On 5/31/23, wound care consultant, NP, Employee E5, also ordered Resident R5 soft heel boots (designed to offload pressure from the heel of a non-ambulatory individual to help prevent the development of pressure ulcers) that were to be always worn aside from ambulation. It was indicated the plan of care and education was discussed with facility staff. Review of Resident R5's clinical record indicated the facility failed to update Resident R5's physician orders for Resident R5's left lateral, medial, and proximal foot DTIs as of 6/1/23. During an observation on 6/1/23 at 8:37 a.m., Resident R5 was observed lying in bed without pressure relieving boots and her heels were not offloaded. During an interview on 6/1/23 at 2:07 p.m., the DON confirmed the facility failed to implement pressure ulcer interventions and treatments as ordered to prevent the newly developed and deteriorated pressure ulcers for Resident R5. Review of Resident R63's clinical record indicated an admission date of 2/23/22, diagnoses included osteoarthritis (Inflammation of one or more joints), viral hepatitis (an infection that causes liver inflammation and damage.), and anemia (deficiency of healthy red blood cells in the blood). Review of Resident R63's physician order on admission dated 2/23/22, indicated Resident R63 may been seen by a wound specialist. Review of Resident R63's physician order dated 2/23/22, indicated a weekly skin assessment must be completed every Wednesday. Review of Resident R63's Braden Scale for Predicating Pressure Sore Risk assessment dated [DATE], did not identify the resident as a risk at the time of admission, with a score of 19. No further Braden Scale Assessments were completed as of 5/30/23. The facility's Braden Scale for Predicting Pressure Score Risk assessment instructions indicated assessments are completed on admission for four weeks and then quarterly thereafter. Review of Resident R63's MDS dated [DATE], indicated the above-mentioned diagnoses were current. Review of Resident R63's MDS dated [DATE], Section M Skin Conditions, indicated the resident was at risk for developing PU/PIs and the resident had a stage three pressure ulcer. Review of Resident R63's care plan from 3/22/23 through 5/29/23, indicated the resident was at risk for alteration in skin integrity related to incontinence, decreased physical mobility. Interventions included for the resident to be repositioned, observe for skin conditions and report abnormalities, pressure reduction device on bed and chair, and to provide barrier cream to perineal area and buttocks after each incontinent episode and as needed. The facility staff failed to update the resident ' s care plan to include care interventions to treat the resident ' s pressure ulcer. Include that the care plan still says at risk when resident had an actual PU Review of Resident R63's progress note dated 3/22/23, entered by wound care consultant, Nurse Practitioner (NP), Employee E5, documented the resident was complaining of mild pain and burning. The following pressure ulcer was documented for Resident R63: -Left buttock acute stage two pressure ulcer that measured 3.1 cm x 2.1 cm x 0.1 cm. There was a small amount of serous drainage noted. Review of Resident R63's March 2023 eTAR indicated the resident's treatment order to the coccyx pressure ulcer was to be cleansed with normal saline, Medihoney and have calcium alginate applied, and dressed with a border gauze daily and as needed for soil and dislodgement was left blank and not signed off for completion on 3/23/23 and 3/24/23. A further review of Resident R63's progress note dated 3/23/23 and 3/24/23 failed to include a reason Resident R63's dressing was not changed as ordered. Review of Resident R63's progress note dated 3/27/23, documented that a dressing was performed and moderate amounts of pale yellow and greenish drainage from three small dime sized openings was observed. Review of Resident R63's clinical record indicated the facility staff failed to complete weekly skin assessments from 3/27/23-4/10/23. Review of Resident R63's April 2023 eTAR, indicated the resident's treatment order to the coccyx pressure ulcer was to be cleansed with normal saline, Medihoney and have calcium alginate applied, and dressed with a border gauze daily and as needed for soil and dislodgement was left blank and not signed off for completion on 4/2/23 and 4/7/23. A further review of Resident R63's progress note dated 4/2/23 and 4/7/23, failed to include a reason Resident R63's dressing was not changed as ordered. Review of Resident R63's NG-Weekly Skin Inspection assessment dated [DATE], failed to document any abnormalities observed on the resident's skin, however it was documented in the comments section that the resident had area to buttocks, wound care orders in place, will continue to monitor. The facility failed to document size wound size, stage, and description. Review of Resident R63's progress note dated 4/12/23, entered by wound care consultant, Nurse Practitioner (NP), documented the following for Resident R63's left buttock pressure ulcer: -Left buttock acute stage two pressure ulcer that measured 2.1 cm x 3.8 cm x 0.2 cm. There was a small amount of serous drainage noted and slough. The wound deteriorated and increased in size. Review of wound care consultant, NP, Employee E5 progress note dated 4/12/23, indicated Resident R63's left buttock pressure ulcer was ordered to have it cleansed with normal saline and Santyl applied to base with a calcium alginate and bordered gauze dressing daily and as needed. Additional orders as of 4/12/23, included side to side offloading every two hours with wedge. It was indicated the plan of care and education was discussed with facility staff. Review of Resident R63's physician orders from 4/12/23 through 5/25/23, failed to include the order to change the resident's left buttock pressure ulcer as needed, which was ordered by wound care, NP Employee E5. Review of Resident R63's April 2023 eTAR, indicated the resident's treatment order to the left buttock pressure ulcer was to be cleansed with Dakin's, Santyl and have calcium alginate applied, and dressed with a border gauze daily was left blank and not signed off for completion on 4/20/23. A further review of Resident R63's progress note dated 4/20/23, failed to include a reason Resident R63's dressing was not changed as ordered. Review of Resident R63's April 2023 eTAR, failed to include an order to offload the resident from side to side with a wedge. Review of the resident's clinical record failed to include documentation the resident was offloaded as ordered. Review of Resident R63's clinical record indicated the facility staff failed to complete weekly skin assessments from 4/13/23-5/8/23. Review of Resident R63's NG-Weekly Skin Inspection assessment dated [DATE], failed to document any abnormalities observed on the resident's skin, however it was documented in the comments section that the resident had area to buttocks, wound care orders in place, will continue to monitor. Review of Resident R63's progress note dated 5/10/23, entered by wound care consultant, NP, Employee E5, documented three wounds measured as one which indicated a new wound developed. The following pressure ulcer was documented for Resident R63: -Left buttock acute stage three pressure ulcer that measured 1.6 cm x 3.9 cm x 0.1 cm. There was a small amount of serous drainage noted. The wound had slough. A debridement was performed at bedside that removed the slough. Post debridement measurements remained the same, and measured 1.6 cm x 3.9 cm x 0.1 cm. Review of wound care consultant, NP, Employee E5, progress note dated 5/10/23, indicated Resident R63's left buttock pressure ulcer was ordered to have it cleaned with normal saline and Santyl applied to the base with a calcium alginate, and it covered with bordered gauze, daily and as needed. Additional orders as of 5/10/23, included side to side offloading every two hours with wedge. It was indicated the plan of care and education was discussed with facility staff. Review of Resident R63's clinical record indicated the facility staff failed to complete weekly skin assessments from 5/8/23-5/24/23. Review of Resident R63's progress note dated 5/24/23, entered by wound care consultant, Nurse Practitioner (NP), Employee E5, documented left buttock and sacrum have separated enough now considered two different wounds. The following pressure ulcer was documented for Resident R63: -Left buttock acute stage three pressure ulcer that measured 1 cm x 0.5 cm x 0.1 cm. There was a small amount of serous drainage noted. -Sacral chronic stage three pressure ulcer that measured 1.4 cm x 1.4 cm x 0.1 cm. Review of wound care consultant, NP, Employee E5, progress note dated 5/24/23, indicated Resident R63's left buttock wound was to be cleaned with normal saline and calcium alginate applied to the wound base, and covered with a border gauze daily and as needed. As of 5/24/23, the resident's sacral pressure ulcer was ordered to have it cleansed with normal saline and Santyl applied to base with a calcium alginate and bordered gauze dressing daily and as needed. Additional orders as of 5/24/23, included side to side offloading every two hours with wedge. It was indicated the plan of care and education was discussed with facility staff. Review of Resident R63's physician orders from 5/24/23 through 5/30/23, failed to include an order to change the resident's left buttock pressure and sacral pressure ulcer as needed, which was ordered by wound care, NP Employee E5. Review of Resident R63's NG-Weekly Skin Inspection assessment dated [DATE], failed to document any abnormalities observed on the resident's skin, however it was documented in the comments section that the resident had area to buttocks, wound care orders in place, will continue to monitor. The facility failed to document size wound size, stage, and description. Review of Resident R63's Corner View Skin Observation Tool (Licensed Nurses) dated 5/27/23, indicated the resident had a left rear thigh nickel size greenish yellow pus-filled cyst. No measurements were documented. Resident R63's left buttock's pressure ulcer was not documented. The instructions state to Document any open area. If NO open area; no documentation required. Complete Braden Scale. Review of Resident R68's assessments dated 5/27/23, failed to include a completed Braden Scale assessment. Review of Resident R63's progress note dated 5/30/23, indicated the resident's dressing was changed due to soilage and moderate amount of greenish yellow drainage was observed. Review of the clinical record failed to include interventions that addressed the signs and symptoms of infection of Resident R63's pressure ulcer. During an interview on 6/1/23 at 2:07 p.m., the DON confirmed the facility failed to follow physician orders, complete timely assessments, and update the resident's care plan to include PU/PIs for Resident R63. As a result of the facility's extensive noncompliance in multiple areas of pressure ulcer care, Resident R63 developed recurrent and/or multiple, avoidable Stage III pressure ulcer(s), and signs and symptoms of infection. Review of Resident R231's MDS dated [DATE], indicated an initial admission date of 6/11/22 and a reentry date of 11/25/22. It was indicated the resident had peripheral vascular disease, diabetes, and a hip fracture. Review of Resident R231's MDS dated [DATE], Section M, Skin Conditions, indicated the resident was at risk for developing PU/PIs and indicated the resident did not have a pressure ulcer. Review of Resident R231's Census List from 12/1/22 through 5/24/23, indicated the resident had multiple transfers to the hospital. The resident went on an unpaid hospital leave on 12/31/22 and returned to the facility on 1/17/23, then went on an unpaid hospital leave on 1/23/23, was discharged on 2/7/23, and returned to the facility on 3/16/23. The resident then went on an unpaid hospital leave on 3/29/23 until 4/10/23, and on 5/11/23 and returned 5/24/23. Review of Resident R231's NG-Admission/readmission Evaluation dated 12/1/22, indicated the resident was at risk for developing pressure ulcer with a score of 14, and it was documented there was skin breakdown present. It was documented in the comment section, that there were areas to the right outer foot, left heel, and lower extremity. The facility failed to document measurements and the types of wounds with staging and a description. Review of Resident R231's clinical record indicated the facility staff failed to complete weekly assessments from 12/1/22-12/13/22. Review of Resident R231's NG-Weekly Skin Inspection assessment dated [DATE], documented the resident had mushy areas to the left heel. No documentation was provided on the resident ' s right outer foot or lower extremity. Mushy is a descriptive term that is an indicator of a DTI. Review of Resident R231's clinical record indicated the facility staff failed to complete weekly assessments from 12/15/22-12/28/22. Review of Resident R231's NG-Weekly Skin Inspection assessment dated [DATE], documented the resident had mushy area to the left heel. No documentation was provided on the resident ' s right outer foot or lower extremity previously documented on 12/1/22. Review of Resident R231's progress note dated 12/28/22, entered by wound care consultant, NP, Employee E5, the resident was being seen for the first time as a consultation for evaluation of the resident ' s wounds. It stated the resident was bedridden and complained of moderate pain with wound care. The following was documented for Resident R231: -Left heel full thickness venous ulcer (A sore caused by poor circulation in the veins. They usually develop on the inside of the leg, just above the ankle.) that measured 3.5 cm x 3.7 and the depth could not be determined due to the presence of eschar. There was a small amount of serous-sanguineous drainage (discharge that contains both blood and a clear yellow liquid known as blood serum) present. PU/PIs are usually located over a bony prominence, such as the sacrum, heel, or ankle. PU/PIs on the sacrum and heel are most common. Review of wound care consultant, NP, Employee E5, progress note dated 12/28/22, indicated Resident R231's left heel was ordered to have it cleaned with normal saline and Medihoney applied to the base with a calcium alginate, and it covered with ABD gauze and wrapped in Kerlex. Additional orders as of 12/28/22, included pressure relief and offloading. Review of Resident R231's progress note dated 12/31/22, indicated the resident was admitted to the hospital with hyperglycemia. Review of Resident R231's progress note dated 1/17/23, indicated the resident returned from the hospital. It was documented the resident had bilateral heel pressure ulcers that were unstageable due to the presence of eschar. A right foot pressure ulcer, unstageable due to eschar, and a pressure ulcer on the scrotum. It was documented the resident was on IV antibiotics due to osteomyelitis. Review of Resident R231's[TRUNCATED]