**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 9. Review of the provider's 6/10/24 SD DOH FRI revealed: *On 6/10/24 at 12:36 p.m. hospice registered nurse (RN) L contacted interim director of nursing (IDON) G and informed her that resident 1 had open sores on her buttocks. -Dressings had been provided on 6/7/24 by hospice to the provider's staff. -The provider's staff did not use the dressings for resident 1 as they just put her in wheelchair and applied cream to buttocks. -Hospice RN H spoke with the provider's licensed practical nurse(LPN) I and stated to apply the dressing once resident 1 was placed back into her bed. *On 6/10/24 after the conversation between hospice RN L and IDON G, IDON G notified resident 1's family that she had developed pressure sores to her bilateral buttocks likely over the weekend. -IDON G then had LPN J place the standing order dressings on the wounds. Review of resident 1's medical record revealed: *She was admitted on [DATE]. *She was admitted to hospice on 1/9/24. *On 6/6/24 two reddened areas were identified on her buttocks. -On 6/7/24 hospice provided Optifoam (foam dressing with adhesive borders) dressings for the reddened area. *Her family was notified on 6/10/24 of the pressure ulcers and their condition. *On 6/11/24 a Wound Documentation assessment was completed which indicated the onset date as 6/6/24. -The 6/11/24 Wound Documentation indicated there were currently six areas identified as pressure wounds. -Areas identified and the measurements of each were: --Two on her left buttock measured 6.0 centimeters (cm) by 8.0 cm. and the other measuring 2.5 cm by 2.0 cm. --Two on her right buttock measured 7.0 cm by 7.0 cm and the other measuring 1.5 cm by 1.5 cm. --One on her coccyx (tailbone) measured 1.7 cm by 0.8 cm. --One on her left heel measured 2.9 cm by 2.0 cm. *Her family requested an air mattress be placed on her bed. -Hospice ordered that mattress. *Wound care orders included: Applied cavilon advanced [skin protectant] to peri wound area due to erythema [redness]. Applied heel mepilex [absorbent foam] dressing to buttocks to cover the entire area of the wound. Also applied a 4x4 mepilex to the middle of the dressing to ensure it was sealed. Applied betadine to left heel. -Her primary care physician was notified. *On 6/11/24 a hospice standing order for Optifoam Gentle Heel Foam Dressing 9 x 9. Apply to buttock/coccyx area daily. Apply 4 x 4 foam dressing over coccyx area to seal. was entered in her orders. -On 6/12/24 was the first time that order was documented in her treatment administration record as completed for the first time. *She passed away on 6/14/24. Interviews conducted during the survey dates of 6/18/24 through 6/21/24 confirmed resident 1 had developed pressure ulcers and had not received appropriate and timely treatment for those pressure ulcers. Interview on 6/21/24 at 11:25 a.m. with administrator A regarding resident 1's pressure ulcer revealed: *Resident 1 was on hospice. *Two licensed practical nurses had been terminated due to this incident. *Education on abuse and neglect had been provided to all staff. *Her expectation would have been for the pressure ulcer to be checked on daily and documented in the resident's EMR. Interim IDON G was unable to be contacted for an interview. Refer to F686. Based on the South Dakota Department of Health (SD DOH) Facility Reported Incident (FRI), observations, interviews, and record review, the provider failed to ensure: *One of one sampled resident (10) who was mentally incapable of identifying safety risks was free from the potential of abuse and neglect by one of one sampled resident (37). *One of one sampled resident (1) received necessary care related to pressure ulcers. Findings include: 1. Review of the provider's 6/14/24 submitted SD DOH FRI revealed: *On 6/13/2024 at 12:58 p.m. a suspicion/allegation of abuse/neglect regarding resident-to-resident inappropriate sexual behavior involving resident 10 and resident 37. *At 9:01 p.m. licensed practical nurse (LPN) O contacted administrator (ADM) A and informed her of the incident between resident 10 and resident 37. *Resident 10 was found in resident 37's room in her wheelchair next to resident 37 when certified nursing assistant (CNA) E walked by his room and saw resident 10 sitting in there. *CNA E: -Removed resident 10 from resident 37's room and brought her to her room -Noticed that resident 10's blouse was unbuttoned, and her breasts were exposed. *Notified LPN O At 8:58 p.m. of what he had seen. *LPN O contacted administrator A for guidance. *Administrator A advised LPN O to monitor resident 10 through the night. Further information on the SD DOH FRI revealed: *Administrator A had not notified law enforcement or the Department of Human Services (DHS) until after the surveyors had entered the building on 6/18/24. *Both entities were to have been notified if there was reasonable cause to suspect abuse or neglect of any resident by any person. *A conclusion summary indicated resident 37 had been monitored throughout the night of 6/13/24. *Administrator A provided education to all staff on 6/14/24 to monitor residents 10 and 37 and move resident 10 if any interaction between her and resident 37 was happening. *Administrator A instructed CNA E and LPN O to document on 6/13/24 what between residents 10 and 37. *CNA E documentation revealed: -I noticed [resident 37] door was almost completely closed besides a crack. -He knocked on the door and entered to find resident 10 by resident 37. -He (resident 37) was sitting in his recliner with his feet down, leaning and facing toward resident 10 and she was also facing resident 37. -They were about one foot apart from each other while chatting a little bit. -CNA E decided to take resident 10 out of resident 37's room to the hallway, then decided to take her to her room. -[I] noticed her shirt was on weird and completely unbuttoned with both her breasts exposed. -With notice, resident 10 has a crippled arm and is not able to unbutton her shirt herself. *LPN O was called to resident 10's room by CNA E at 8:58 p.m. -LPN O's documentation confirmed CNA E's documentation. -LPN O added that resident 10 was not able to tell her or CNA E what or if anything had happened. *LPN O completed resident 10's 6/13/24 incident report indicating: -On 6/13/24 at 11:15 p.m. LPN O checked on resident 10. -She was restless, wide awake, legs hanging out of bed, and had her arms crossed over her chest. -When asked if she (resident 10) is ok, she quickly states ?no? [no] -LPN O assisted her in getting her legs back in bed and covered up. -Resident keeps trying to say something to [the] nurse but is unable to get the words out. -Nurse sat with resident for about 5 minutes. She was able to relax some and close her eyes. -At 1:45 p.m., She was awake in bed. She appeared to be calm and comfortable. 2. Interview on 6/18/24 at 3:45 p.m. with ADM A regarding the FRI report regarding residents 10 and 37 revealed: *They had notified the SD DOH of the event on 6/14/24. *They had not notified law enforcement or the Department of Human Services (DHS) because they were waiting for SD DOH to tell them what to do. -They were not done with their investigation. *ADM A confirmed: -Resident 37 had a Brief Interview for Mental Status (BIMS) score of 13, indicating he was cognitively intact. -Resident 10 had a BIMS score of 99, indicating the resident chose not to participate for four or more items, or gave nonsensical responses. -Resident 10 liked to go into residents 37 and 5's room and sit with them often. -It occurred mostly after meals. *Administrator A said resident 37 had a history of calling resident 10 inappropriate names and expressed not wanting her in his room at different times. -She confirmed during the above 6/18/24 at 3:45 p.m. interview that resident 37 was being moved to another on 6/18/24 to put space between resident 10 and resident 37. The following surveyor interviews were completed to support the above staff interviews regarding the resident-to-resident allegation: 3. Interview on 6/20/24 at 4:25 p.m. with CNA E revealed: *He had not seen resident 37 touch resident 10 on 6/13/24, but he (resident 37) quickly jolted back when CNA E walked into his room, so CNA E removed resident 10 from resident 37's room. *CNA E attempted to ask resident 10 questions. -She was cognitively impaired with dementia. -CNA E asked her if resident 37 had touched her, and she said yes. *LPN O had entered resident 37's room and asked him if he had a visitor. -He denied having a visitor and then he became frantic/hesitant after she asked him if resident 10 was in his room with him, and he admitted she was in his room. *CNA E stated: -She could have been in resident 37's room for a while because [LPN O and CNA E] had been busy putting other residents to bed. -He did not remember the exact time, but thought it was between 9:00 p.m. and 10:00 p.m. -Resident 10 was one of the last people to go to bed. -Resident 10 would go into the room shared by residents 37 and 5 often because she thought resident 5 was her son. -He had never seen resident 10 on resident 37's side of the room before 6/13/24. -Resident 5 was in the room at the time of the event but was not facing the same way as the other two residents. -Resident 37 was sitting in a recliner/lift chair tilted forward and fully lifted. --He was facing her, and she was facing him, and they were about one foot apart. *After he had taken resident 10 to her room across the hall he realized: -Her shirt was unbuttoned all the way, and she was not able to unbutton it herself. -She was not wearing a bra or an undershirt. *CNA E stated: CNAs charted when residents had behaviors. -He had never heard resident 10 and resident 37 talk to each other. -Resident 37 had not used inappropriate verbal sexual remarks with other residents. -He heard younger female staff state resident 37 had used inappropriate sexual remarks with younger female staff. -On that night one of the female staff members had said resident 37 used inappropriate verbal remarks toward her. -Another CNA also had inappropriate remarks made to her from resident 37 a few days before the event. --He did not know the names of those female staff members. 4. Interview on 6/21/24 at 8:14 a.m. with LPN O revealed: *She worked on the evening of 6/13/24. *Around 9:00 p.m. CNA E came to get her and told her what he had seen. *She was just told resident 10 required full assistance with unbuttoning of her clothes. -She had never seen her unbutton her shirt. *She was not told about resident 10's shoes being off. - She had seen her take her shoes off before. *CNA E had brought resident 10 to her room and pulled her shirt closed. *LPN O texted administrator A and asked her to call her. -She called back right away, and LPN O explained what had happened. -Administrator A said to make sure she checked on resident 10, documented, and to keep residents 10 and 37 separated. *LPN O stated resident 10 wandered in her wheelchair often, most days going into resident 37's room, even when he was not there. -She had documented that resident 37 had told resident 10 to get the hell out of there (his room) before. -She had educated him to call for help to get her out of his room. *LPN O had not seen resident 37 be inappropriate, but other staff had documented that he has made comments about slapping their butts but not that he had ever done it. -She stated, (Resident 37) had a side that can be inappropriate, not all the time but he has his moments. -He had not been inappropriate with other residents that she was aware of. *She did not know if she had access to the SD DOH reporting system. She would report to administrator A. 5. An interview on 6/21/24 at 10:00 a.m. was attempted with resident 5 (resident 37's roommate) regarding the event that took place on 6/13/24 in his room. Resident 5 was unable to participate in that interview. 6. Interview on 06/20/24 at 4:57 p.m. with resident 37 revealed: *He was moved to a new, private room at the end of the 100 wing on 6/18/24 after an incident with resident 10. *He saw resident 10 wheel herself past his room just before the surveyors entered his room for an interview. -He was afraid she would see him here. -He thought she would have seen him and would have wheeled into his room when she saw him, and he was glad she did not. *She would come into his room when they both lived in the 200 hall, two or three times a week and stare out the window. *She would sometimes go in the bathroom or remove his roommate's socks from his drawer. *She would sometimes go through his refrigerator and try to take his pop. -He would kick the refrigerator door and tell her to Put that back. *On 6/13/24 she came into his room in her wheelchair and tried take a Mountain Dew from his refrigerator. -He would ring my buzzer and she came to get her, referring last week when resident 10 came into his room. -He had not recalled who came into the room to get her on that day. -One time CNA R came to get her. *He stated on the evening of 6/13/24: -Resident 10 was in his room in front of his refrigerator taking off her shoes. -She took off both of her shoes but not her socks. -He helped her put her shoes back on. -He lowered his chair down and reached forward to put her shoes on. -He thought she must have had a sore foot because she said, Oh that hurts. -He said, Her shirt was unbuttoned at the bottom, and she had started unbutton her shirt from the bottom up. *He put his call light on a minute after taking the pop from her. *She was in the room for about 5 minutes. *Her shirt was not unbuttoned at that time. *He did not try to help her button her shirt. *He had not known if she had anything else under her shirt. *He denied touching her. *He denied she touched him. *He denied that she was exposed. *He denied calling resident 10 any names. *He did not enjoy resident 10's visits. *He felt roommate (resident 5) hardly knew she was there. *He stated he was given a new room because resident 10 used to come into his room all the time and he was glad to have his new room. *He stated resident 10 had not been in his room since he moved. 7. Interview on 6/21/24 at 9:22 a.m. with business office (BO)/social services designee (SSD) D regarding residents 10 and 37 revealed: *Resident 10 wanders everywhere in a wheelchair. *If you keep your door shut, she is pretty good. *She did go into resident 5's room a lot because he looks like her son. *There has never been a problem between her and resident 5, they both fall asleep in their chairs and seldom talk. *On 6/20/24 resident 37 was worried that resident 10 was going to come into his new room as she had just wheeled herself past his room. *BO/SSD D had not been aware of an incident of resident 37 calling resident 10 inappropriate names. -She could see that might happen. -His use and choice of words were 'crass'. *Resident 37 sees a behavioral health services counselor. *He can be very defensive. *BO/SSD D had never heard him say anything sexual near residents but can be inappropriate with staff. *BO/SSD D's social service (SS) consultant was not called regarding the 6/13/24 event. *Administer A did the investigation, so BO/SSD had not done anything. *BO/SSD D had not checked resident 10 the next day to monitor her emotional status. *BO/SSD D had the SS consultant information and could call her if I needed help. -The SS consultant visited the provider quarterly, and if BO/SSD D needed her she would be able to come. Review of the SSD job description included: *Essential duties: -Work with an interdisciplinary team to provide psychosocial support to residents, families, and or vulnerable populations so they can cope. -Counsel residents, advise family, and assist in the development of their needs and concerns by means of visits, interviews, and care planning. -Assess resident's needs throughout their stay at the facility to maintain a care plan that addresses social, emotional, and psychosocial needs. Continually assess resident needs while they are adjusting to their new home. -Continually maintain contact with residents, and families, concerning all aspects of their residency. -Be firm and be able to take responsibility and take charge of situations. *BO/SSD D stated, I had never visited with anyone about things like that. 8. On 6/20/24 at 4:50 p.m. resident 10 was observed as she wheeled herself up the 100 hall, unsupervised. *Resident 10 had been at the end of that hall, where resident 37 had been moved to separate them. *The surveyors voiced concern to administrator A as resident 10 was wheeling herself down the 100 hall where resident 37 had been moved. *Administrator A asked if the provider must take away resident 10's rights to be down the 100 hall. *Education was provided to her to ensure resident 10's safety, rather than take away her rights. Review of resident 37's 5/23/24 Long Term Care Progress Note by his attending physician indicated resident 37 had inappropriate sexual behaviors. There was an incident where he spoke in a way that was inappropriate to high school CNA.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the South Dakota Department of Health (SD DOH) Facility Reported Incident (FRI), record review, interview, and observation, the provider failed to ensure two of two sampled residents (1 and 4) received necessary care and treatment in a timely manner for the prevention of pressure ulcers. Findings include: 1. Review of the provider's 6/10/24 SD DOH FRI revealed: *On 6/10/24 at 12:36 p.m. hospice registered nurse (RN) L contacted interim director of nursing (IDON) G and informed her that resident 1 had open sores on her buttocks. -Dressings had been provided on 6/7/24 by hospice to the provider's staff. -The provider's staff did not use the dressings for resident 1 as they just put her in wheelchair and applied cream to buttocks. -Hospice RN H spoke with the provider's licensed practical nurse(LPN) I and stated to apply the dressing once resident 1 was placed back into her bed. *On 6/10/24 after the conversation between hospice RN L and IDON G, IDON G notified resident 1's family that she had developed pressure sores to her bilateral buttocks likely over the weekend. -IDON G then had LPN J place the standing order dressings on the wounds. Review of resident 1's medical record revealed: *She was admitted on [DATE]. *She was admitted to hospice on 1/9/24. *On 6/6/24 two reddened areas were identified on her buttocks. -On 6/7/24 hospice provided Optifoam (foam dressing with adhesive borders) dressings for the reddened area. *Her family was notified on 6/10/24 of the pressure ulcers and their condition. *On 6/11/24 a Wound Documentation assessment was completed which indicated the onset date as 6/6/24. -The 6/11/24 Wound Documentation indicated there were currently six areas identified as pressure wounds. -Areas identified and the measurements of each were: --Two on her left buttock measured 6.0 centimeters (cm) by 8.0 cm. and the other measured 2.5 cm by 2.0 cm. --Two on her right buttock measured 7.0 cm by 7.0 cm and the other measured 1.5 cm by 1.5 cm. --One on her coccyx (tailbone) measured 1.7 cm by 0.8 cm. --One on her left heel measured 2.9 cm by 2.0 cm. *Her family requested an air mattress be placed on her bed. -Hospice ordered that mattress. *Wound care orders included: Applied cavilon advanced [skin protectant] to peri wound area due to erythema [redness]. Applied heel mepilex [absorbent foam] dressing to buttocks to cover the entire area of the wound. Also applied a 4x4 mepilex to the middle of the dressing to ensure it was sealed. Applied betadine to left heel. -Her primary care physician was notified. *On 6/11/24 a hospice standing order for Optifoam Gentle Heel Foam Dressing 9 x 9. Apply to buttock/coccyx area daily. Apply 4 x 4 foam dressing over coccyx area to seal. was entered in her orders. -On 6/12/24 was the first time that order was documented in her treatment administration record as completed for the first time. *She passed away on 6/14/24. Interview on 6/19/24 at 1:14 p.m. with hospice registered nurse (RN) H regarding resident 1 revealed: *The hospice certified nursing assistant (CNA) K had notified her on 6/7/24 that she was concerned about resident 1's bottom. *She kept wound dressings in her car and went to gather them. *When she returned with the dressings, the facility staff had already assisted resident 1 from her bed to her wheelchair. *Hospice RN H asked licensed practical nurse (LPN) I to evaluate resident 1's bottom after lunch that day. *When hospice RN H returned on 6/10/24 she was informed the dressings were not applied over the weekend. -Hospice did not inform the family of the wound as the provider was the primary caregiver. *The provider managed routine and regular dressing changes of wounds and completed measurements. -Hospice would record those measurements in their notes. *During a hospice nurse visit, contact would be made with the provider's nurse on duty and information would be shared by verbal reports. Interview on 6/19/24 at 2:10 p.m. with hospice RN L regarding resident 1 revealed: *Resident 1 previously had skin breakdown off and on for a few months but was healed before she started to decline. *On 6/6/24 hospice CNA K had provided her pictures of resident 1's skin breakdown of her upper right hip area and her bottom. -Hospice RN L had informed hospice CNA K by telephone to have the facility use Optifoam and reposition her often. *On 6/7/24 hospice RN H was notified there was no Optifoam at the facility. -Hospice RN H brought Optifoam dressings to the facility and gave them to LPN I. *Hospice RN K came to the facility on 6/10/24 and LPN J reported to her that resident 1's buttocks were much worse. -LPN J told her that the Optifoam was not applied over the weekend and did not think that resident 1 had been repositioned. *Hospice RN L notified IDON G and requested that she call resident 1's family and notify them that the recommendations hospice made on 6/7/24 had not been followed. *Resident 1's daughter then came to facility and took pictures resident 1's buttocks, sent them to hospice RN L and she identified an area as a Stage III pressure ulcer. *Hospice RN L stated that the hospice agency does not manage pressure ulcer care. -They would make recommendations and assist the provider's licensed nurses with changing of the dressings when they were at the facility. -The hospice agency had not required physician orders for Optifoam. *An order on 6/12/24 Optifoam heel dressing order was by the provider's consulting wound nurse. *RN L stated the typical hospice communication with the provider's nurses included verbal contact when the hospice nurse arrived, the hospice nurse would visit the resident, and discuss with the provider's nurse again regarding any concerns they had found. *She thought the communication between the provider and the hospice agency was poor. -The hospice agency would find information regarding the hospice resident through review of the provider's medical records for that resident. *Hospice RN L stated, She [resident 1] had a history of just being pushed to the side and she was very disappointed in the provider's management of her pressure ulcers. Interview on 6/19/24 at 3:49 p.m. with hospice CNA K regarding resident 1's pressure ulcer revealed: *On 6/6/24, in the afternoon, she had provided hospice care to resident 1. -During this visit, she found resident 1 in her bed soaking wet with urine although she had a catheter in place. --The catheter was removed from underneath of her leg, and it stopped leaking. -While providing cares, she identified that resident 1 had redness to her buttocks. --There had been two areas on the right buttock, about as long as her thumb and the other one higher up by her butt crack and a little longer than the first one. -She notified hospice RN L at that time and was instructed to notify the facility nurse on duty. *On 6/10/24 hospice CNA K has shown by LPN J resident 1's buttocks. -CNA K stated she was disturbed and astounded by the change in the appearance of her buttocks. -She had notified hospice RN L of that change. *On 6/11/24 IDON G and administrator (ADM) A had called her and asked her who had seen resident 1's pressure ulcer and what had happened, she provided them with same information as above. Interview on 6/19/24 at 10:26 a.m. with CNA R regarding resident 1 revealed: *She had assisted hospice CNA K in repositioning her on 6/9/24. *She had been told that resident 1 had sores and to reposition her more often. -Resident 1 had refused a couple of times. Interview on 6/21/24 at 11:25 a.m. with ADM A regarding resident 1's pressure ulcer revealed: *Resident 1 was on hospice. *Two licensed practical nurses had been terminated due to this incident. *Education on abuse and neglect had been provided to all staff. *Her expectation would have been for the pressure ulcer to be checked on daily and documented in the resident's EMR. Interim IDON G was unable to be contacted for an interview. 2. Observation on 6/19/24 at 10:30 a.m. of resident 4 revealed: *She had been in the hallway sitting in a wheelchair (w/c). *Her feet had been resting on the foot pedals and were covered with small foam boots. *She was alert, answered only when spoken to, and had denied any foot pain. Observation on 6/20/24 at 2:00 p.m. of resident 4 revealed she had been: *Sitting in a recliner with legs elevated and with her feet crossed at the calf. *Wearing small foam boots. Observation on 6/18/24 at 1:30 p.m. of resident 4 revealed: *She had been lying in bed on her left side with foam boots on. *No other pressure-relieving measures were in place. 3. Review of resident 4's 8/20/23 through 6/21/24 electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her diagnoses included the following: Alzheimer's disease and dementia (forgetfulness), psychotic disturbance, major depression with mood disturbance, Type 2 diabetes with neurological complication, degenerative joint disease, and malnutrition. *She had poor memory recall and was unable to participate in decision-making for her care. *She was dependent upon the staff for: -The development of her plan of care and to ensure the interventions were implemented for quality of care. -Assistance with all activities of daily living (ADLs) to include bed mobility, repositioning, and positioning pressure relieving devices. *On 2/10/24 she was admitted to Hospice for end-of-life care. *While under the care of the provider she had acquired seven pressure ulcers. *She had: -One stage 2 pressure ulcer (partial thickness loss) located on her right lateral ankle had worsened to a stage 3 (full thickness skin loss). That wound had been identified on 12/28/23. -A callous formation on her right mid-lateral foot that was identified on 2/21/24 and had worsened to a stage 3 pressure injury. -A deep tissue pressure injury was identified on 3/4/24 to the right lateral foot. It was a deep purple/brown color and unstageable. -Two large intact blisters on her left lateral foot that were identified on 4/14/24. -An unstageable pressure ulcer located by her right little toe that was black in color and was identified on 5/30/24. -An open pressure area to her left buttock/sacrum was identified on 4/11/24. *Hospice and a wound nurse had been involved with the care and treatment of her wounds. -The wound nurse was not available for an interview. Review of resident 4's 8/20/23 through 6/21/24 progress notes revealed: *On 12/3/23 at 9:38 p.m. the nurse documented, Nurse was at the nurses station when a loud noise was heard and resident began yelling. Nurse went to room and found resident sitting on the floor of her room near her sink. She was incontinent of stool and had some blood coming from a spot on her R [right] outer ankle. *On 12/28/23 the director of nursing (DON) B documented, During bath skin assessment, it was noted that resident has a new pressure injury to her right ankle. See wound assessment for details. *Her Braden score fluctuated between 16 and 18 and indicated she was at risk for skin breakdown. -She had a potential problem with friction and shearing due to moving feebly and/or requires minimal assistance. *She had pressure-reducing devices for her chair and bed. -There was no documentation of a repositioning plan. *On 1/23/24 the Minimum Data Set coordinator (MDS)/RN C documented, Charge nurse reported that resident's ankle wound looks worse today and has eschar [dead tissue that sloughs off healthy skin after an injury] in the wound bed. FNP [practitioner's name] saw resident today to evaluate the wound. Orders received If no improvement in wound bed by Thursday afternoon, schedule appointment with [practitioners name] on Friday for the area to be debrided. *On 1/24/24 it was decided with the help of hospice to change the treatment and not debride the wound. *On 2/21/24 DON B spoke with the hospice nurse and confirmed the wound appeared to be larger based on the measurements completed the day before. -There was no documentation to support the callous formation on the lateral side of her right foot had been identified. *On 3/4/24 MDS/RN C documented, Wound to right lateral ankle dressing change noted. Slough covers 95% of the wound bed, edges are round, and wound appears to be larger. Resident also has a DTI [deep tissue injury] to lateral edge of right foot. It is dark purple in color. It is pea-size. Resident shoes were removed and gripper socks applied. -On 3/8/24 the wound had worsened, and MDS/RN C documented: Dressing change completed to right lateral ankle. Wound appears larger and now measures 3.1 x [by] 2.5 x 0.4. There is a small necrotic dark are [area] at 12 o'clock that measures 0.4 x 0.6. -On 3/9/24 both of the wounds had worsened, and MDS/RN C documented: Wound care provided to right lateral ankle this morning because resident had the dressing off. The wound appears swollen and red and warm to the touch. The wound base is 100% green/yellow slough, there is a necrotic area at 12 o'clock that appears larger than yesterday and then redness and the skin is boggy just above and to the right of necrotic area. Swelling noted to distal end of wound when leg is elevated. Hospice nurse updated this morning. TED hose left off the foot so no pressure is applied to area. New wound care orders received from Hospice. *On 3/17/24 the charge nurse documented: Wound dressing changed to R [right] lateral ankle per orders. Peri-wound has increased redness and inflammation. Fax sent to PCP [primary care provider] requesting to consider ABX [antibiotic] tx [treatment]. -The physician ordered an antibiotic to be given every 6 hours for 10 days due to right lateral ankle inflammation. *On 4/11/24 DON B documented: Upon assisting resident to the bathroom, it was noted that resident has an open pressure area to her left buttock/sacrum. Applied a thick layer of calmoseptine over it. -Twelve days later, on 4/23/24, DON B documented that the wound on the left buttocks had closed. -There was no other documentation in the EMR to support the size, appearance, drainage, and pressure relieving measures put in place to promote healing of that wound. *She had a care conference review on 4/11/24. -She had started to decline further and was sleeping more. *On 4/14/24 the nurse documented: Resident has a large fluid filled blister to lateral left heel and a medium sized blister to the medial left heel, both intact. Right ankle is larger in size, with foul smelling drainage. Peri-wound bright red, swollen and warm to touch. Wound to lateral right foot open with slough and necrotic tissue. Per-wound bright red, swollen and warm to touch. -The physician was called, and orders were given to start another antibiotic. *On 4/15/24 the nurse and DON consulted with the Hospice nurse regarding the resident's wounds. -They had decided to discontinue all wound care and provide comfort care for wounds due to poor circulation. *On 4/18/24 the physician was notified of the current status of wound care and the physician advised to continue the wound care to the right ankle to maintain current status. They were to paint the left lateral and medial heel wounds with betadine. -These orders were received three days after the discontinuation of wound care had been decided. *On 4/28/24: -Was the first documentation to support a comprehensive skin and positioning evaluation had been completed for her. -Her Braden score had dropped to 12 and identified her as high risk for skin breakdown. --That was the first Braden score that supported her at high risk due to her gradual failing condition that was identified when she was admitted to Hospice care on 2/10/24. -That was the first documentation that indicated: --Pressure-relieving approaches and interventions were implemented. --A turning and repositioning program had been implemented. Review of resident 4's weekly wound documentation revealed there were five separate wounds assessed and documented on weekly versus the seven that had been identified in the progress notes from 12/28/23 through 4/28/24. Review of resident 4's closet care plan revealed: *Those care plans were placed in the residents' closets for the certified nursing assistants and temporary staff use for providing care. *On 1/3/24 a closet care plan was placed in her closet. -She needed the assistance of one staff member with a walker and transfers. -Her only indicated special need was oxygen. *The closet care plan was not updated until 5 months later on 6/4/24. -She was non-ambulatory and needed the assistance of two staff members with transfers. -She was to be repositioned on rounds and was to be provided with offloading. --There was no documentation on what should have been should have been offloaded. -Pressure ulcer was marked. -Special needs included: Heel boots/gripper sock at all times. O2 [oxygen] at night - HOSPICE. Review of resident 4's ongoing comprehensive care plan revealed: *Focus area: ADL [activities of daily living] Self Care Performance Deficit . -Was created on 1/25/23 and revised on 2/10/23. *Goals: Will maintain current level of function through the review date. Will not develop complications of immobility. With a target date of 7/27/24. *Interventions: -Dressing: [Resident name] requires assistance of 1 with cue with dressing/undressing. -Oral Care: Independent after set up. *A 1/25/23 focus area that was revised on 11/28/23 indicated: has limited physical mobility as e/b [evidenced by] shuffling gait r/t dementia and Alzheimer's. will participate in restorative program. *Goals: Will maintain current level of mobility through review date. -Will remain free of complications related to immobility including skin-breakdown. --Was created on 2/10/23 and has a target date of 7/27/24. *Interventions: -Ambulation: requires walker and 1 assist. -Ambulatory status: 1 assist with gait belt and walker for ambulation. When not walking with staff must use a wheelchair. --Encourage reposition/position changes during rounds. --Transfer: Can transfer independently with walker in room and with supervision when on the unit. *Focus area: [Resident's name] has the potential for a Nutritional problem r/t dementia and Alzheimer's, and episodes of dysphagia needing nectar thick liquids. -Was created on 1/25/23 and revised on 2/10/23. -The focus area had not been updated to include her declining condition and wound care nutritional support requirements. *Focus area: [Resident's name] has potential for impairment to skin integrity r/t cardiac history, fall risk and dementia. -Was created on 2/10/23 and revised on 4/25/23. *Goal: Will be free from skin alteration/injury through the review date. -Target date was 7/27/24. *Interventions: -Reposition frequently. No documentation on how frequently she was to have been repositioned. -Required a pressure-relieving mattress when in bed/chair. -No documentation on other pressure relieving measures to promote the health of her skin. *Focus area: [Resident's name] has Pressure injury to Right Lateral Ankle, Right Lateral foot and Bilateral heels r/t Braden score of 10 - 12 (high risk), immobility, terminal diagnosis, -Was initiated on 4/28/24 and created/revised on 5/5/24. That had been four months after the identification of her first pressure ulcer. -It did not include all seven of her pressure ulcers. *Goals: Will participate with repositioning. Pressure injury will show signs of healing and will remain free from infection by/through review date. Will have intact skin, free from redness, blisters or discoloration by/through review date. -These goals were created on 5/5/24 and had a target date of 7/27/24. -Interventions: Pressure relieving support surfaces in bed and chair: Standard reduction necessary to reduce pressure and to improve comfort level in relation to positioning/repositioning in bed and chair. 4. Interview on 6/20/24 at 2:44 p.m. with MDS/RN C regarding resident 4's pressure ulcers, pressure ulcer care, and the documentation of the pressure ulcer care was difficult to follow revealed: -She stated she would bring the timeline and care provided together so the surveyor could review it. -She stated resident 4's physician would be visiting resident 4 on 6/20/24 and she would discuss the pressure ulcers and possible changes in her pressure ulcer care and the two pressure ulcers on her right lateral foot had worsened and were red in color. 5. Interview on 6/21/24 at 11:30 a.m. with MDS/RN C regarding the pressure ulcers revealed: -She had not put together the documentation of the timeline of the pressure ulcer care. -She had discussed with resident 4's physician and was told he was not going to change her ulcer orders. -She stated the new director of nurses (DON) was wound certified and MDS/RN C felt that the wound care would be changing for the better. *She stated: -Hospice cannot provide an air bed because she did not meet the hospice guidelines. -The provider could provide an air bed, but she was scared the resident would break a hip because she moved in bed. -Resident 4 had used her own mattress when the pressure ulcers started. -She accepted a provider pressure relief mattress, and it did provide better relief than her mattress. -She had long pressure relief boots, but she was too hot in them, and she would take them off. --She had accepted the small foam boots. -The first thing resident 4 would do when she would lie in bed was to place her feet sideways, so they are lateral to the mattress, and she felt that caused pressure ulcers. Review of the provider's undated Charting Expectations policy revealed: *Rounds: -The night CNA and the night nurse are expected to do rounds on residents at 1:00 a.m. AND 4:00 a.m. You cannot skip a round as that can be considered neglect Review of the provider's 10/01/21 Pressure Ulcer Prevention policy revealed: *Purpose: -To promote the prevention of pressure ulcer development. -To promote the healing of pressure ulcers that are present including prevention of infection to the extent possible. -To prevent the development of additional pressure ulcer. *Policy: -It is the policy of [facility name] to prevent a resident who enters the facility without pressure sores from developing pressure sores unless the individual's clinical condition demonstrates that they were unavoidable and to provide necessary treatment and services to a resident having pressure sores to promote healing, prevent infection and prevent new sores from developing. Review of the provider's 9/18/19 Care Plan Policy and Procedure revealed: *Purpose: -Care plans will be developed by an interdisciplinary team with participation of the resident, family, and/or representative . -Care plans include active and historical diagnoses, goals and/or expected outcomes, specific nursing interventions so that any nursing staff member is able to quickly identify a resident's individual needs and to decrease the risk of incomplete, incorrect, or inaccurate care, and to enhance continuity of nursing care. *General instructions: -Care Plans will be reviewed quarterly, annually, and with any significant change in resident condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to ensure three of three sampled residents (14, 23, and 174) who had developed pressure ulcers had been assessed, received care, on-going assessments, and interventions to prevent new ulcers from developing or prevent wounds from worsening. Findings include: 1. Observation and interview on 12/20/21 at 8:07 a.m. with resident 174 revealed: *He was lying on a pressure-reducing alternating air mattress in his room. *When asked if he had any skin problems, he replied he had sores on his bottom. Review of resident 174's electronic medical record (EMR) revealed: *He had been admitted to the facility on [DATE]. *His diagnoses included: -Cerebral infarction. -Unspecified disturbances of skin sensation. -Other Reduced Mobility. *An 11/30/21 nursing admission assessment indicated no pressure ulcer was present. *A 12/6/21 comprehensive skin and positioning evaluation did not identify a pressure ulcer. -No other skin evaluation had been completed. -The evaluation was locked and signed on 12/20/21 at 10:01 a.m. *A 12/6/21 Braden scale assessment revealed he was at moderate risk for skin breakdown. *A 12/11/21 Nursing Order identified an open area to coccyx [tail bone] measuring 9 centimeters (cm) by 8 cm. -Order summary for every day and night shift monitor every shift for dressing, drainage, wound bed, periwound area, pain, and status. *A progress note to the above order entered on 12/14/21 at 11:26 p.m. by licensed practical nurse (LPN) D clean, dry and intact. *A fax information sheet dated 12/16/21 at 2:49 p.m. to resident 14's physician. -Information: Resident has had a decline in overall function, he has developed an unstageable pressure wound to his coccyx, he has started to complain of more pain, and his wife feels like he is giving up. Wife and I discussed a hospice consult and she would like to proceed. -Request: OK to consult [hospice provider]. -It had been signed by director of nursing (DON) B. -Physician's Response: OK for Hospice. --It was signed by medical doctor (MD) on 12/17/21. *A Braden scale assessment dated for 12/17/21 had not been started. *A Fax Order Request - hospice in LTC [Long Term Care] standing orders. -He had been admitted to hospice on 12/17/21. -Skin care products/interventions of choice to prevent or treat skin care problems. -MD Signature was signed on 12/20/21. *Active physician orders as of 12/21/21 had no treatment order for his pressure ulcer. *No initial skin wound assessment was found. *No weekly skin or wound assessments were found. Review of resident 174's treatment administration records (TAR) revealed: *There had been many gaps with treatments related to the resident's 9 cm by 8 cm pressure wound since the identified start date of 12/11/21 at 6:00 p.m. *A current treatment plan for care was not identified. Interview with on 12/20/21 at 2:04 p.m. with DON B revealed: *She had worked for the provider for five years and had been in the DON position for the past two years. *She had monitored resident skin/wounds every week, but stated, I don't always get the paperwork done. *Resident 174's pressure ulcer was first noticed on 12/11/21 with his complaint of pain. -It had appeared suddenly. *She confirmed the 12/11/21 order was a nursing order. Interview on 12/21/21 at 8:27 a.m. with LPN D revealed: *The current treatment plan for resident 174's pressure ulcer was an Opti foam dressing. -It was part of out standing orders. *Resident 174's pressure ulcer was not healing but getting worse. *She was not sure if his physician was aware of his pressure ulcer. Interview with administrator A and DON B on 12/21/21 at 2:47 p.m. revealed and and confirmed: *DON B was the provider's wound care nurse. -Resident 174 did not have weekly skin assessments documented. -She had not been able to get to the weekly wound/skin assessments. -The nurse(s) working the floor was to communicate resident conditions to the residents' primary physician. *She could not confirm if resident 174's physician had been notified of his pressure ulcer. *Resident 174 did not have an initial wound assessment. -His pressure ulcer was not on his care plan. 2. Observation and interview on 12/20/21 at 9:59 a.m. with resident 14 in her room revealed: *She was sitting in her wheelchair in her room. *When asked if she had any skin problems, she replied she had a sore on her bottom that hurts a little at times. -The staff told her, it was getting better. Review of resident 14's electronic medical record (EMR) revealed: *She had been admitted to the facility on [DATE] on hospice care. *Her diagnoses included: -Cerebral Vascular Accident -Osteoporosis -Immobility/Contractures -Urinary Incontinence *A 6/20/21 comprehensive skin and positioning evaluation did not identify a pressure ulcer. -The Braden scale assessment revealed she was at risk for skin breakdown. *An 8/30/21 comprehensive skin and positioning evaluation identified a pressure ulcer. - Stage 1 or greater. -The Braden scale assessment revealed she continued at risk for skin breakdown. *A Braden scale assessment dated [DATE] revealed she was at high risk. *A 12/11/21 nursing order identified a red/open area to the coccyx. -Red area measured 7 cm by 7 cm. -Open area to the center measured 4 cm by 4 cm. -Order summary for every day and night shift Monitor every shift for dressing, drainage, wound bed, periwound area, pain, and status. *A 12/12/21 skin/wound progress note by LPN F revealed: -Resident has open area to coccyx. -Dressing is soiled with yellow/tan drainage. -Wound measures 1.5 cm X 1 cm sacrum dressing applied. *A 12/14/21 Hospice communication at 6:30 p.m. by hospice registered nurse (RN) H revealed: -Pressure ulcer area to coccyx is now stage 2, shallow, deep purple around edges. -LPN D states they will start using medihoney and continue to cover with mepilex dressing. -Wound measured 1 cm by 1 cm. *A 12/17/21 hospice communication at 4:17 p.m. by hospice RN H revealed: -Cleansed coccyx wound with sterile saline, did not have wound cleanser, applied medihoney and covered with Mepilex. -Wound measured 1.5 cm by 0.8 cm, oblong shape. *Active physician orders as of 12/21/21 had no treatment order for his pressure ulcer. *No initial wound assessment was found. *No weekly skin or wound assessments were found. Review of resident 14's TAR revealed: *There were three shifts with no documented treatments related to the resident's red/open area to coccyx since the start date of 12/11/21 at 6:00 p.m. *A current treatment plan was not identified. 3. Interview on 12/19/21 at 4:51 p.m. with resident 23 revealed: *She had a history of pressure sores. *She tended to get sores on the back of her legs. *She currently had a sore on the back side of her right thigh that was caused by rubbing against a metal piece on her wheelchair. *She could not remember when the area had opened, but thought that it had been sometime in September 2021. *The provider had added padding and adjusted her wheelchair to eliminate further issues. *Nursing put bandages on the area every day. *The facility had recommended she get a new wheelchair but she wanted to keep the one she had. Review of resident 23's medical record revealed: *An admission date of 12/27/18. *Her diagnosis included: multiple sclerosis, edema, anemia, reduced mobility, muscle weakness, and bladder dysfunction. *She had a Brief Interview Mental Status (BIMS) score of fifteen indicating her cognition was intact. *A 12/1/21 Braden Scale assessment score of 14 which put her at moderate risk of skin integrity issues. *A 12/10/21 MDS nursing summary had not identified the open area on her thigh. *A 12/16/21 care conference review note that mentioned she had an open area on the back of her right thigh. *There had been no documentation to support: -Her physician had been notified of the pressure ulcer she had developed. -When that pressure ulcer had been discovered or by whom. Review of resident 23's 12/1/21 Minimum Data Set (MDS) assessment revealed: *She had been at risk for developing pressure ulcers. *No pressure ulcers had been identified. Review of resident 23's 12/10/21 revised care plan revealed: *A focus area for skin impairment potential due to immobility and diagnosis of multiple sclerosis. *Interventions for: *4 inch x 4 inch hydrocellular dressings placement to bilateral thighs where the wheelchair meets thighs at her request to provide cushioning. *Observe skin during cares. Report any changes to nurse. Surveyor 45383 4. Observation on 12/21/21 at 10:41 a.m. with certified nurse practitioner (CNP) G assessing resident 23's skin revealed: *CNP G had been nearby and able to come to the facility if the need to assess a resident came up and the primary physician was not available. *This had been the first time she had been made aware of the need to assess resident 23 for a pressure ulcer. *The resident had an open area on the back side of her right thigh that measured 2 centimeters in length through the epidermis (outer layer of skin) . Interview on 12/21/21 at 1:33 p.m. with bath aide H regarding resident skin assessment with bathing revealed she: *Had just returned from a three week absence. *Was the person that had completed most of the baths for the residents. *Checked the residents closely for any skin concerns. *Reported any skin concerns to the nursing staff. *Had not been required to document any skin findings. *Was not sure when resident 23's sore had opened up but it had been there prior to her absence. Interview on 12/21/21 at 2:00 p.m. with licensed practical nurse (LPN) C and LPN D regarding skin documentation revealed: *They had been aware of the above resident skin concerns. *Due to scope of practice concerns they had not assessed the wounds. *They had reported any resident skin concerns to DON B for further assessment. *Confirmed they had not documented skin findings. Surveyor 41088 Interview on 12/21/21 at 2:48 p.m. with DON B and administrator A regarding resident skin and wound assessment revealed: *DON B stated she: -Had been responsible for the wound care for all residents. -Had not ensured weekly skin assessments or wound assessments for the above residents had taken place. -Had not considered resident 23's wound to be a pressure ulcer. -Thought her skin injury had been cause by sheering and not pressure at the time. -Agreed that rubbing from a metal piece on her wheelchair had caused the injury. -Would expect: --Newly admitted residents to have a comprehensive skin assessment and then on a quarterly basis. --All residents' skin was to be assessed during weekly bathing by the bath aide. --Any concerns discovered by the bath aide were to be reported to the nurses. --The nurses would report any skin concerns to the resident's primary physician for further instruction. --Agreed that documentation had been lacking regarding weekly skin assessments and wound assessments. --Confirmed they had not followed their policy for skin and wound care. *This surveyor asked for any documentation that would support skin assessment or wound assessments had taken place for resident 23. No further documentation had been provided prior to the survey exit. Review of the provider's 10/15/21 Pressure Ulcer Prevention policy revealed: It is the policy of [facility name] to prevent a resident who enters the facility without pressure sores from developing pressure sores unless the individual's clinical condition demonstrates that they were unavoidable and to provide necessary treatment and services to a resident having pressure sores to promote healing, prevent infection and prevent new sores from developing. Procedure: 1. Skin checks/assessments to be completed weekly (likely following bath schedule) for each resident within the skilled nursing facility. Initial skin assessment to be completed and documented upon admission, with skin assessments continuing weekly thereafter. 2. Any identified new skin injury/wound shall be reported to the charge nurse on duty. Nursing will then complete an evaluation of the injury inclusive of wound measurements. Nursing staff will report the skin injury/wound to the designated wound nurse. An initial wound assessment (UDA) [user defined assessment] will be started in [name of facility computer program] under the assessment tab by the wound nurse (charge nurse to complete if wound nurse unavailable) and continue weekly until healed. A nurse progress note should accompany each wound UDA completed. 3. Charge nurse will notify the physician of skin injury/wound when discovered and obtain any treatment orders recommended. The skin injury/wound will be treated according to physician orders. If there is no order, the skin injury/wound will be placed on the ETAR [electronic treatment administration record] to be monitored daily until healed. 4. If the cause of the skin injury is unknown at the time of the occurrence, an incident report (risk management) shall be completed by the nurse completing the skin assessment. Nursing management or DNS [director of nursing services] will complete an investigation within facility to determine the cause of the skin injury. If the cause of the skin injury is not determined, the proper course of action will be taken by guidelines of Reporting of Injuries of Unknown Source and Reasonable Suspicion of a Crime form. 5. Document in the nurse's notes the following information: *Mechanism of skin injury/wound if known or applicable [if determined after investigation, complete a follow up note with unknown cause found]. *Size of injury. *Treatment if applicable. *Notification of family and physician. 6. Include new skin injury in daily nursing report. 5. A review of the provider's undated Director of Nursing job description revealed: *Essential duties included: -Assures that there is compliance with the regulations pertaining to care plans and resident assessments. -This person monitors the quality of care provided and assists in the assessment process for admission to and exit from all units.