**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the provider failed to ensure quality care by not promptly implementing physician-ordered treatments for one of one sampled resident (69) with a physician-ordered negative pressure wound (NPWT) and antibiotic medication treatment. Findings include: 1. Review of resident 69's electronic medical record (EMR) revealed:*Her admission date was 3/25/25.*Her 3/31/25, 7/1/25, and 7/29/25 Brief Interview of Mental Status assessment scores were a 15, which indicated her cognition was intact.*She was hospitalized from [DATE] through 7/23/25 and again from 8/7/25 through 8/22/25.*Hospice (a program for terminally ill individuals that focuses on comfort and symptom management) care was initiated on 8/23/25.*She passed away at the facility on 8/24/25. *Her 3/25/25 admission diagnoses included hemiplegia and hemiparesis (partial paralysis affecting one side of the body) following cerebral infarction (brain tissue death caused by a severe and prolonged lack of blood flow) affecting her left non-dominant side, muscle wasting (the loss of muscle tissue), and atrophy (loss of muscle mass), acute respiratory failure with hypoxia (a serious medical condition where the lungs are unable to adequately exchange oxygen and carbon dioxide, leading to low levels of oxygen in the blood), transient ischemic attack (stroke), cerebral infarction without residual deficits (no lasting impacts), other malaise (a general feeling of discomfort, uneasiness, or lack of well-being), lymphedema (swelling, typically in the arms or legs caused by lymphatic system blockage), neuropathy (a condition that damages nerve function), obstructive sleep apnea (repeated episodes of partial or complete airway collapse during sleep, causing breathing to stop or decrease significantly), peripheral vascular disease (a slow and progressive circulation disorder of narrowing or blocked arteries and veins), chronic kidney disease, (a condition in which the kidneys gradually lose their ability to filter waste products and excess fluid from the blood), type 2 diabetes mellitus (a condition involving disruptions in how the body regulates blood sugar) with hyperglycemia (low blood sugar level), hypothyroidism (the thyroid gland does not produce enough thyroid hormone, which is essential for regulating many bodily functions), morbid (severe) obesity (excessive weight that significantly impacts health and well-being) due to excess calories.*Diagnoses added after her admission included:-On 4/8/25 a venous ulcer of her right lower leg and varicose veins.-On 5/23/25 venous insufficiency (a condition where the veins in the legs do not function properly, leading to poor blood flow back to the heart).-On 7/1/25 a non-pressure chronic ulcer (skin injury) of her left calf with unspecified severity.-On 7/23/25 restless leg syndrome (a common sleep disorder characterized by an irresistible urge to move the legs, often accompanied by uncomfortable sensations such as tingling, crawling, or pulling), and necrosis of muscle (muscle tissue death).*Her 3/25/25 Braden Scale (a tool used to assess the risk of developing pressure ulcers) score was eleven, which indicated she was at high risk for the development of pressure ulcers (skin wounds caused by prolonged pressure). Resident 69's 3/25/25 nursing admission assessment indicated:*Her ability to walk [was] severely limited or non-existant [non-existent]. [She] Cannot bear [her] own weight and/or must be assisted into [a] chair or wheelchair.*[Her mobility was] Very Limited: Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently.*[She required] moderate to maximum [staff] assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures or agitation leads to almost constant friction. Resident 69's nurse progress notes indicated:*On 3/25/25, she was admitted to the facility. Her left leg was very weak. She had non-pitting edema [observable swelling of body tissues caused by an accumulation of excess fluid] in her bilateral (both) lower legs. There was an open area to the calf of her right leg.*On 3/31/25, a note that included she required total assistance from a staff member for her oral hygiene, toileting, dressing, bed mobility, transfers, and personal hygiene. She was always incontinent (involuntary urine or bowel leakage) of her bladder and bowels. She had a skin treatment on her posterior [back] right leg . Resident 69's 5/7/25 monthly nursing summary indicated the area to document if she had edema was marked Yes and BLE (bilateral lower extremity). There were no other monthly nursing summaries documented in her EMR. A 5/20/25 nurse progress note included, During weekly wound assessment, states has a scratch to left leg. Upon assessment, open area, measuring 3.8cm [centimeter] x [by] 2.3cm. Depth unknow d/t [due to] slough [dead tissue]. Foul odor noted. Scant serosanguineous [wound drainage that is a mixture of clear, watery fluid and blood] drainage noted. Has left sided weakness. Uses sit stand lift [a mechanical lift used to assist from a seated to a standing position] with leg strap. Open area located where sit stand lift leg strap lays against skin. [The resident] States I was told it was a scratch, but my wheelchair is too small for me and my leg rubs against it. They ordered me a new wheelchair, but it's not here yet. Area noted to be in [the] same location on leg where [the] sit stand lift leg strap lays against [the resident's]skin during transfers. Cleansed with NS [normal saline], pat dry, covered with border foam dressing. Review of physical therapy and occupational therapy documentation from 4/16/25 through 7/15/25 did not indicate that resident 69's wheelchair was too small or that a different-sized wheelchair was obtained for the resident. Resident 69's nurse Wound Summary notes regarding her left lateral calf indicated:*On 5/20/25, the wound was unstageable, had light-serous drainage, infection was present, and the measured size was 3.80 cm by 2.30 cm, and the depth was unknown.*On 5/27/25, the clinical stage of resident 69's wound was documented as Full Thickness with light-serosanguineous exudate, infection was present, and the size was 5.40 cm by 3.00 cm, and the depth was unknown.*On 6/17/25, the wound was full thickness with moderate Serosanguineous, infection was present, and the size was 6.40 cm by 4.50 cm by 0.90 cm.*On 7/8/25, the wound was full thickness with moderate Serosanguineous exudate, infection indicated as not present, and the size was 6.90 cm by 3.8 cm with a depth of 1.20 cm.*On 7/15/25, the wound was full thickness, with moderate Serosanguineous exudate, with no infection present, and the size was 6.90 cm by 3.80 cm with a depth of 1.20 cm. On 5/27/25 a nurse progress note included, Left lateral calf [wound] measures 5.4cm x 3cm, depth unknown. On 6/3/25 a nurse progress note included, Left lateral calf [wound] noted with moderate serosanguineous drainage, no odor noted, Measures 6cm by 3 cm, depth unknown.On 6/10/25 a nurse progress note included, Left lat [lateral] calf [wound] measures 5.5cm x 3.5 cm, depth unknown. Foul odor noted. Light serosanguineous drainage noted. DON/RN, MD [medical doctor], RP [representative] aware. Resident 69's hospital wound care team consultation report indicated:-On 7/16/25, after resident 69's admission to emergency room (ER), Patient does have a chronic leg wound, Over the past couple days worsening wound with malodorous [an unpleasant or offensive odor]. Patient received IV [intravenous] vancomycin [antibiotic] and Zosyn [antibiotic] in the ER along with 1 L [liter] LR [Lactated Ringer's solution, a balanced electrolyte replacement] bolus. Exam concerning for left leg 10 [cm] x 6 cm ulcerating wound lateral [side] calf with purulent [containing or producing pus] malodorous drainage. General surgery was consulted and patient was taken to the OR [operating room] for washout [of the wound] directly from the ER.-- NPWT [a treatment that uses suction to remove fluid and debris from wounds to promote healing] placed, and the treatment plan included the NPWT to be at 125 mmHg (millimeters of mercury, a unit of pressure] continuous suction, and to change the NPWT dressing three times each week.--Wound measurement after the surgical procedure was 15 cm by 6 cm with a depth of 3.5 cm. The treatment included a NPWT to her left anterior [near the front], lower leg. Review of resident 69's 7/23/25 physician hospital discharge orders for resident 69's admission to the provider's facility revealed:*New diagnoses on 7/15/25 of obesity, and open leg wound, left, initial encounter, on 7/17/25 Myofasciitis [painful muscle and connective tissue inflammation), and on 7/22/25 of Necrotizing soft tissue infection (serious infection that destroys tissue under the skin).*An order for cefazolin (antibiotic) 2000 mg/20 mL (mg per milliliter) intravenous (IV) push (delivering the drug through an IV line in a small, concentrated amount over a short period) syringe for Necrotizing soft tissue infection, which had an order change handwritten on the form that indicated 2000mg in 100 mL NS IVPB [intravenous piggyback] (delivers medications at set intervals without interrupting the main IV fluid line) per verbal order of resident 69's physician. The discharge form was noted by a nurse on 7/23/25.-The area for information regarding where to get the cefazolin antibiotic IV push syringe was listed as not yet available.*Wound care instructions treatment plan for her left leg included:- Cleanse with Microcyn [wound cleanser] or NS-Picture frame peri wound with skin prep and drape-Contact layer to exposed tendon/muscle-Black foam to wound bed-125 mmHg low continuous suction [NPWT].- Change NPWT dressing three times each week.- Follow up with the wound care outpatient clinic on discharge.--Resident 69's NPWT was placed on her left lower leg on 7/29/25*Resident 69's first dose of the antibiotic, cefazolin, was administered on 7/24/25.- Patient is preparing to discharge to [provider]. Wound vac dressing to right leg removed and wet-to-dry packing placed for transportation. [Provider] will need to place their own wound vac upon admission to their facility.-She had a surgical wound on her left lower leg, which was described as Full thickness, had Serosanguineous drainage, no odor, well defined edges, and her muscle and tendon remain[ed] exposed.-She had a wound to her right calf, that had a scant amount of Serosanguineous drainage, and well-defined edges. A 7/23/25 nurse progress note included, resident returned to facility early pm [evening] . dressing intact on left lower posterior leg. *A 7/23/25 nurse progress note at 10:35 p.m. included, The resident has an order for cefazolin 2000 MG in 20 mL IV push. Order not sent to pharmacy. called [pharmacy] for clarification and request for medication stat [without delay] delivery. Pharmacy unable to provide ordered dose. Called [resident's primary physician] V.O [verbal order] given to change from IV push to IVPB per pharmacy's recommendation. Initial dose pulled from e-kit [emergency kit]. Medication expected to be delivered stat in AM.-That initial dose from the e-kit was given at midnight. A 7/25/25 nurse progress note included, Waiting for wound vac to get to the facility, wet to dry dressings done until wound vac placed. A 7/25/25 nurse progress note included the dressing to her left lower leg was in place. On 7/25/25, a physician order for cefazolin Sodium Intravenous Solution Reconstituted - use 2000 mg intravenously every 8 hours for necrotizing soft tissue infection for 19 days 2 g in 100 mL NS over 30 minutes. On 7/27/25, resident 69's administration documentation for her physician order of metronidazole (antibiotic) 500 mg twice a day for necrotizing soft tissue infection was listed as NN (see nurses' notes). A 7/27/25 nurse progress note included: reached out to provider regarding herbeing [her being] out of b complex-c-folic acid and metronidazole 500 mg . tried calling pharmacy at 20:50 [8:50 p.m.] stayed on hold and finally left [a] message for a call back. A 7/28/25 registered dietitian note included:* Braden score 16 at r4isk; L[left]-lateral calf vascular venous stasis wound and R[right]-lower leg back vascular venous stasis wound; noted edema is 4+ [very deep indentation when pressed] LLE [left lower extremity] especially calf, 3-4+ [deep to very deep indentation when pressed] RLE [right lower extremity].- Weight History-7/23/25 273.4# [pounds] (Current wt [weight])-7/10/25 266.2# (2.63% wt gain)-7/2/25 262.6# (3.95% wt gain)-6/4/25 238.8# (12.66% wt gain - significant)-4/16/25 239.6# (12.36% wt gain - significant)-3/25/25 250# (8.56% wt gain - admit wt)- resident readmit to facility s/p [status post] hospitalization from 7/15/25-7/23/25 for Left leg necrotizing [dying tissue] wound status post extensive operative debridement 7/15/25. A 7/28/25 nurse progress note included that the resident requested to switch to a different primary medical provider, and the resident was switched to a new provider. A 7/29/25 nurse progress note included Weekly wound assessment completed by this nurse. Wound vac in place at this time. A 7/29/25 nurse wound summary included the wound was full thickness, with moderate Serosanguineous exudate, with no infection present, and the size was 6.90 cm by 3.80 cm with a depth of 1.20 cm. An 8/5/25 nurse wound summary note included, the wound was full thickness, with moderate Serosanguineous exudate, with no infection present, and the size was 15.50 cm by 7.00 cm with a depth of 3.30 cm. *There were no documented measurements, after 8/5/25, of resident 69's left lower leg in her nurse wound summary notes. Resident 69's August 2025 medication administration record (MAR) included that a physician ordered treatment to her left leg to change the NPWT dressing three times each week was marked as NN on 8/2/25 and was not documented as completed on 8/5/25. An 8/5/25 nurse progress note included Weekly wound assessment completed by this nurse. Wounds remain stable. Wound vac in place and functioning. Resident 69 was sent to the emergency room on 8/7/25 for a change in condition and returned to the facility on 8/22/25. Resident 69's 8/22/25 hospital discharge summary included:*Diagnoses of: septic shock, recent necrotizing fasciitis, cardiac arrest due to acute hypoxic respiratory failure due to aspiration with successful resuscitation, aspiration pneumonia. An 8/23/25 hospice order included that resident 69 was admitted to hospice care services with a terminal diagnosis of Septic Shock. An 8/24/25 hospice nurse progress note included Resident passed away at 0755 [7:55 a.m.] this morning. 2. Interview on 9/11/25 at 9:25 a.m. and 9:59 a.m. with director of rehab (rehabilitation) I regarding resident 69 revealed:*Regarding resident 69's left leg wound, they had attempted to determine if it was caused by her wheelchair or her use of a sit-to-stand (STS) mechanical lift strap (a strap that goes across the lower calf area to assist in maintaining proper positioning of the person on the STS lift).*They assessed the STS lift strap to determine if it was digging into her calf or if it was from where the foot pedal was attached to her wheelchair.*She did not personally remember any interventions but said she would print all therapy notes for resident 69. *She reviewed resident 69's therapy notes, and reported that therapy had determined that the wheelchair was not the issue that caused the wound on her left leg.*They had determined it was either restless leg syndrome, as her legs rotated outward when she was in bed, or the wound was caused by the STS lift, they were unable to determine the cause.*Therapy did not participate in the residents' wound care.-The facility provided residents' wound care. Interview on 9/11/25 at 2:31 p.m. with infection preventionist (IP)/wound care nurse (WCN) C regarding resident 69 and wound care revealed:*She had been employed at the facility since 6/30/25, and was an IP/WCN for the facility.*She completed wound care rounds on Tuesdays.-She documented wound care in a wound summary or in the resident's progress notes.-Her process was to measure the wound and document that information in the wound rounds (summary).-She had not documented the resident's wound care in the resident's TAR, but she was able to.*She expected that if a resident refused a dressing change or repositioning, it would be documented as a refusal in the resident's TAR or progress notes.*She verified resident 69's left lower leg wound was vascular, and she thought it had started as a scratch.*Resident 69's primary physician had completed rounds (checking on residents' status and assistance needs) and wound care on Tuesday of each week.-He had completed resident 69's wound care on those days prior to her hospitalization on 7/15/25.*Resident 69's significant weight gain would have been a huge concern, her legs would have needed to be elevated, and the edema would have needed to be decreased.*Resident 69's NPWT was to be placed on her lower left leg, after she returned from the hospital on 7/23/25. The NPWT was ordered on 7/24/25 and was received and placed on 7/29/25.*She confirmed resident 69 was without her physician-ordered NPWT from 7/23/25 until 7/29/25, a total of six days.-She confirmed an acceptable amount of time would be 24 hours for a physician-ordered NPWT to be placed on a wound.*She thought the physician was notified that the NPWT was not placed for those days.-She stated resident 69's primary physician was present when the NPWT was put into place on 7/29/25.*Resident 69 had necrosis of muscle (death of muscle tissue).*She was not aware that resident 69's wheelchair was too small for her.-She started working at the facility on 6/30/25 and felt resident 69's wheelchair had been the appropriate size for her at that time.*Regarding CNA documentation for skin alteration, she indicated that when a resident had a skin alteration, the staff member would document Yes instead of No.*Resident 69's surgical wound on her lower left leg was cut open and drained of 4 cm of fluid and infection.*She stated the physician ordered IV medication was started right away.*Resident 69 had not refused care from IP/WCN C.*No staff member had notified IP/WCN C of resident 69 refusing her care. Interview on 9/11/25 at 5:08 p.m. with regional nurse consultant (RNC) L revealed:*She was not familiar with resident 69's physician's order for a NPWT, as she had no direct patient care with her.*Resident 69's IV Push order was changed as the provider had no documented competencies for all of the contracted travel/agency staff LPNs for IV Push administration. The provider would only provide medications [to residents] that everyone can provide.*The provider had no policy regarding the use of a NPWT wound vac for residents who had a physician order for placement of one.-The provider completed an NPWT competency with all nurses.*The provider hired an outside entity to conduct competency training for all nurses for IV push medications. Interview and review of resident 69's nurse progress notes on 9/11/25 at 5:25 p.m. and at 5:30 p.m. with IP/WCN C and RNC L revealed:*There were wet to dry orders [for resident 69's left lower leg wound] until the wound vac [NPWT] arrived on 7/29/25.*IP/WCN confirmed she had documented in resident 69's EMR on 7/25/25 that her left lower leg NPWT was in place and that resident 69 did not have a NPWT on her lower left leg until 7/29/25.-She was unsure why she had documented the NPWT was in place, as it had not been delivered to the provider until 7/29/25. Interview on 9/11/25 at 5:53 p.m. with IP/WCN C revealed:*Resident 69's nurse wound summary measurements from 7/29/25 were documented by herself and those measurements were wrong.*She stated the measurements documented on 8/5/25 were the actual measurements that should have been recorded on 7/29/25.-She knew it was wrong due to the surgical intervention to the wound prior to 7/29/25. 3. Review of the provider's 8/21 IV Push Medication Administration policy revealed:*Purpose-To safely administer small volume IV bolus medications.*Procedure- Consult with IV pharmacist as needed.- Verify medication order. The provider indicated there was no NPWT policy. Review of the provider's 3/13 Training and Knowledge Checklist for V.A.C. Therapy Systems revealed:*Assess wound dimensions, pathology, presence of undermining or tunnels, need for debridement or need for non-adherent layer to protect blood vessels/organs/nerves and measure wound.*Ensure therapy is maintained 22 out of 24 hours. Access therapy history if available.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review the provider failed to identify and implement pressure ulcer (skin and/or underlying tissue injury due to prolonged pressure) preventative interventions for residents identified at risk for developing pressure ulcers for:*One of one sampled resident (31) who developed a pressure ulcer to her right heel, left upper buttocks, and left foot.*One of one sampled resident (11) who developed a pressure ulcer to his left lower and left upper buttocks.Findings include:1. Observation and interview on 9/9/25 at 9:22 a.m. with resident 31 in her room revealed:*There was a sign on resident 31's door that indicated she was on enhanced barrier precautions (personal protective equipment, such as gloves and a gown was to be worn with all close contact resident care) (EBP).*She had an air mattress on her bed.*She was lying in bed on her left side.*She had two Prevalon boots (a cushioned boot that floats the heel off the surface of the mattress, to help reduce pressure) on the counter in her room.*Her feet were not elevated off the mattress with the use of pillows or other devices.*She had foam dressings on both of her feet.*When she was admitted to the facility, she had an abrasion on her buttocks that worsened until a wound vac (a medical device used to promote wound healing by applying negative pressure) was used for wound treatment.*She no longer had a wound vac because it became dislodged frequently.*She was able to reposition herself somewhat in bed with the use of her side rails (bar/bars attached to the bed) but often required assistance from staff for complete repositioning.*She stated she often waits a long time for staff to answer her call light when she needed assistance with repositioning.Observation and interview on 9/10/25 at 8:40 a.m. with resident 31 in her room revealed:*She was lying in bed on her left side.*The Prevalon boots were in the same location on her counter as they were on 9/9/25.*Her feet were not elevated off the mattress with the use of pillows or other devices.*She thought her Prevalon boots were missing a part and that was why staff did not put them on her.*There was a gel cushion in her wheelchair.*Resident 31 stated she did not get out of bed as often as she would like to and felt that was due to the staff being busy.*She had difficulty moving her legs when she was in bed because they often got tangled up.Review of resident 31's electronic medical record (EMR) revealed:*She was admitted on [DATE].*She had a 7/24/25 Brief Interview for Mental Status (BIMS) assessment score of 15, which indicated her cognition was intact.*She was involved in a motor vehicle crash which resulted in paraplegia (paralysis that affects all or part of the trunk, legs, and pelvic organs).*She was admitted with pressure ulcers on her left foot and right sacrum (the base of the spine that forms the back wall of the pelvis).*She had pressure ulcers on her right heel, and left buttock area that developed after she was admitted to the facility on [DATE].*Resident 31's 11/5/24 Braden Scale (a tool used to assess the risk of developing pressure ulcers) assessment score was 7, which indicated she was at high risk for developing a pressure ulcer.*The pressure ulcer to her right heel was identified on 12/25/24 as a deep tissue pressure injury (a localized area of tissue damage that occurs when prolonged pressure or shear forces damage the skin and underlying soft tissues) that measured 1.4 centimeters (cm)in length by 1.5 cm in width.*The pressure ulcer to her left buttock area was identified on 1/21/25 as a stage III (3; open wound with full-thickness skin loss. Fatty tissue may be visible) pressure ulcer that measured 4.4 cm in length by 4.5 cm in width by 0.1cm in depth.-On 7/22/25 the pressure ulcer was documented as a stage IV (4; open wound with full-thickness skin and tissue loss. Bone, tendon, or muscle may be visible) pressure ulcer that measured 2.7 cm in width by 3.4 cm in length by 0.6cm in depth.*Review of resident 31's 11/5/25 baseline care plan revealed, a focus area of, I am at risk for impairment to skin integrity r/t [related to] impaired mobility and paraplegia -open wound to.-Resident-specific interventions for that focus area were, Air mattress to bed and w/c [wheelchair] cushion in place and HIGH RISK- skin check every shift. Report abnormalities to the nurse.*Review of resident 31's 9/10/25 care plan revealed a focus area of, I am at risk for impairment to skin integrity r/t impaired mobility and paraplegia -open wound to left medial dorsal [inner top of the] foot -left upper buttocks stage 3 -unstageable to the sacrum -SDTI [suspected deep tissue injury] right plantar aspect [bottom of foot] -SDTI right posterior heel.-Interventions identified related to that focus area in addition to the baseline care plan interventions were:--On 1/7/25 left foot and ankle, two layer wrap in place.--On 1/21/25 I will often refuse to offload [reposition to relieve pressure] and my wound care.--On 3/4/25 Turn and reposition q [every] 2hrs [two hours] per my request -I often refused repositioning when offered -I often request a pillow placed under one side or the other, which doesn't fully offload me.--There were no identified approaches or interventions identified if resident 31 refused repositioning, offloading, or wound care.--On 5/6/25 Double protein for wound healing.Review of resident 31's February 2025 treatment administration record (TAR) revealed:*Wound care to resident 31's right heel was not documented as completed on 2/24/25.*There were no documented resident refusals of the Prevalon boot to right foot to offload every, shift or Offload completely while in bed. Offload sacrum and bilateral feet.-Those were not documented as completed on the evening shift on 2/22/25.*There were no resident refusals documented for, Reposition every two hours to off load.-That was not documented as completed on 2/11/25 at 12:00 p.m. and 2:00 p.m., on 2/20/25 at 2:00 a.m. and 4:00 a.m., on 2/22/25 at 8:00 p.m. and 10:00 p.m., on 2/23/25 at midnight, 2:00 a.m., and 4:00 a.m., and on 2/24/25 at 4:00 p.m.Review of resident 31's April 2025 TAR revealed:*There was no documentation that wound care was completed on resident 31's right heel on the 4/7/25 and 4/29/25 day shift and the evening shifts of 4/8/25, 4/12/25, 4/13/25, 4/16/25, and 4/17/25.Review of resident 31's July 2025 TAR revealed:*There were no documented resident refusals of Reposition every 2 hours to offload.-That was not documented as having been completed on 7/19/25 at 8:00 p.m. and 10:00 p.m., and on 7/20/25 at 4:00 a.m. and 4:00 p.m. 2. Observation and interview on 9/10/25 at 9:24 a.m. with resident 11 in his room revealed:*There was a sign on resident 11's door that indicated he was on EBP.*Resident 11 was sitting in his wheelchair.*He had a cushion in his wheelchair.*He had a stroke, and he was unable to move his left leg without pulling on his pant leg with his right arm.*Resident 11 stated he spent the majority of the day in his wheelchair and only laid down after lunch, so he could take the pressure off his wounds on his buttocks.*He used the side rails to reposition himself in bed.*He had two wounds near the middle of his buttocks that staff had been telling him were improving.*He did not have an air mattress on his bed.*Resident 11 stated he previously had an air mattress, but it would leak air and he would be lying on the springs of the bed.Review of resident 11's EMR revealed:*He was admitted on [DATE].*His diagnoses included hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body) following a nontraumatic intracerebral hemorrhage (a brain bleed) affecting his left non-dominant side and a pressure ulcer of the sacral region.*He had a 7/11/25 BIMS assessment score of 15, which indicted his cognition was intact.*His 3/4/25 admission assessment stated he had no skin alterations, such as a pressure ulcer.*Resident 11's 3/4/25 Braden scale assessment score was 6, which indicated he was at high risk for developing a pressure ulcer.*He had a 4/30/25 physician's order to, avoid prolonged sitting, shift weight every 20-30 [20 to 30] minutes when sitting, and a 5/19/25 physician's order to, Avoid prolonged sitting. Reposition every 15-20 [15 to 20] minutes and Strict offloading by bedrest with HOB [head of bed] lower than 30 degrees with use of pillows. Up for meals only with one hour per meal.*Review of resident 11's 9/10/25 care plan revealed he had a focus area of, I have the potential for impairment to skin integrity r/t impaired mobility that was initiated on 3/5/25 and revised on 8/1/25. -Stage 3 pressure ulcer to left buttock- resolved, -stage 4 [pressure ulcer] to left upper buttock.-3/5/25 interventions for that focus area were, Apply wound treatment as ordered by the physician, Assess for pain and administer pain medication as ordered, observe feedback and notify MD [medical doctor] as necessary, Encourage good nutrition and hydration in order to promote healthier skin, Keep skin clean and dry. Use lotion on dry skin, LOW RISK- Skin weekly. Report abnormalities to the nurse, Monitor/document locations, size and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection, maceration etc to MD, Off load heels, and Turn and reposition frequently.-Interventions for that focus area that had been added or changed since 3/5/25 were, Immersus [Brand of a pressure redistribution mattress] mattress trial on 6/17/25, and wound healing supplement as ordered on 7/14/25.*Review of resident 11's wound care summary for the pressure ulcer on his left upper buttocks revealed:-That pressure ulcer was identified on 3/15/25.-On 3/18/25 it was documented as Superficial and measured 2 cm in length by 2.5 cm in width by 0.1 cm in depth.-It was documented as unstageable (wound bed not visible due to covering such as debris, dead tissue, scabbing, or a non-removeable dressing) from 4/8/25 through 6/24/25.-On 7/1/25 the pressure ulcer was documented as a stage IV and measured 2 cm by 2 cm with an unknown depth.-On 9/9/25 the left upper buttocks pressure ulcer measured 0.4 cm by 0.3 cm by 0.2 cm.*Review of resident 11's wound care summary reguarding the pressure ulcer on his left lower buttocks revealed:-That pressure ulcer was identified on 3/15/25.-On 3/18/25 it was documented as a stage 3 pressure ulcer that measured 4.2 cm by 2.3 cm with an Unknown depth.-On 7/15/25 the pressure ulcer on resident 11's left lower buttocks was documented as healed.Review of resident 11's March 2025 TAR revealed:*The wound care to resident 11's left upper buttocks was not documented as having been completed on 3/22/25.Review of resident 11's April 2025 TAR revealed:* avoid prolonged sitting, shift weight every 20-30 minutes when sitting was not documented as completed for the evening shifts on 4/12/25, 4/13/25, and 4/17/25.* reposition every two hours when in bed every shift was not documented as completed for the evening shift on 4/8/25, 4/12/25, 4/13/25, and 4/17/25.* Offload left buttocks to aid in wound healing was not documented as completed for the day shift on 4/22/25, and the evening shift on 4/8/25, 4/12/25, 4/13/25, and 4/17/25.Review of resident 11's May TAR revealed:* avoid prolonged sitting, shift weight every 20-30 minutes when sitting was not documented as having been completed for the day shift on 5/17/25 and the evening shift on 5/28/25.* reposition every two hours when in bed every shift was not documented as having been completed for the day shift on 5/17/25 and the evening shift on 5/28/25.* Offload left buttocks to aid in wound healing was not documented as completed for the day shift on 5/17/25, and the evening shift on 5/28/25.Review of resident 11's June 2025 TAR revealed:*The wound care for resident 11's left lower buttocks or left upper buttocks wounds were not documented as completed on 6/26/25.* avoid prolonged sitting, shift weight every 20-30 minutes when sitting was not documented as completed for the day shift on the evening shift on 6/26/25.* Avoid prolonged sitting. Reposition every 15-20 minutes was not documented as completed on the evening shift on 6/26/25.* reposition every two hours when in bed every shift was not documented as completed for the evening shift on 6/26/25.* Strict offloading by bedrest with HOB lower than 30 degrees with use of pillows. Up for meals only with one hour per meal was not documented as completed on the evening of 6/26/25.Review of resident 11's July 2025 TAR revealed:*Wound care for resident 11's pressure ulcer on his left lower buttocks was not documented as completed on 7/7/25.*Wound care for resident 11's pressure ulcer on his left upper buttocks was not documented as completed on 7/7/25 and 7/24/25.* Avoid prolonged sitting. Reposition every 15-20 minutes was not documented as completed on the day shift on 7/7/25 and the evening shift on 7/30/25 and 7/31/25.* Strict offloading by bedrest with HOB lower than 30 degrees with use of pillows. Up for meals only with one hour per meal was not documented as completed on the day shift on 7/7/25 and the evening shift on 7/30/25 and 7/31/25.* reposition every two hours when in bed every shift was not documented as completed for the day shift on 7/7/25 and the evening shift on 7/30/25 and 7/31/25.Review of resident 11's August 2025 TAR revealed:* Avoid prolonged sitting. Reposition every 15-20 minutes was not documented as completed for the evening shift on 8/5/25, 8/9/25, 8/15/25, and 8/25/25.* reposition every two hours when in bed every shift was not documented as completed for the evening shift on 8/5/25, 8/9/25, 8/15/25, and 8/25/25.* Strict offloading by bedrest with HOB lower than 30 degrees with use of pillows. Up for meals only with one hour per meal was not documented as completed on the evening shift on 8/5/25, 8/9/25, 8/15/25, and 8/25/25.3. Interview on 9/11/25 at 9:49 a.m. with certified nursing assistant (CNA) Q revealed:*The staff were to offer repositioning to resident 31 every two hours, but she often refused.*Resident 31 would let staff know when she wanted to be repositioned.*Resident 31 often refused to wear her Prevalon boots but would allow staff to float her heels off her mattress with pillows.*She usually only got up into her wheelchair for appointments, about one to two times per week.*Staff would chart in the resident's EMR if the resident refused repositioning or the use of items such as resident 31's Prevalon boots as a refusal of care under behaviors, but that did not be specify the care area that was refused.*Resident 11 would let staff know if he was uncomfortable in his chair and needed to be repositioned.*Resident 11 would get out of his wheelchair three to four times per day.4. Interview on 9/11/25 at 9:58 a.m. with licensed practical nurse (LPN) K revealed:*Resident 31 was difficult to reposition and did not want to be offloaded.*If she refused to be offloaded staff would attempt to educate her on why she needed to be repositioned, but she was not always receptive to that education.*Resident 31 would allow staff to float her heels on pillows but usually refused her Prevalon boots.*Resident 11 was receptive to repositioning and often would seek out staff to assist him with repositioning.*He was able to reposition his buttocks in his chair but had a more difficult time adjusting his left leg.5. Interview on 9/11/25 at 2:31 p.m. with infection preventionist (IP)/wound care nurse C revealed:*She worked at the facility since 6/30/25, when she became the IP/wound nurse.*The wound nurse prior to her had documented resident 31's wounds as different location descriptors but she had two wounds on her buttocks and one wound on each of her feet.*Resident 31 has refused wound cares from IP/wound nurse C.*IP/wound nurse C completed wound care rounds on Tuesdays. She did not document her wound cares in the TAR, but she could do so.*Resident 31 often refused to wear the Prevalon boots, but IP/wound nurse C had not witnessed the resident refuse to have her heels floated off the mattress with a pillow.*She expected that if resident 31 refused the Prevalon boots, her heels would be floated off the mattress with a pillow.*She expected if a resident refused a dressing change or repositioning that would be charted as a refusal.*She stated if a resident was not repositioned the staff were not preventing pressure ulcers from developing or worsening.*She reviewed resident 11's and resident 31's TAR documentation and verified there were several missed intervention opportunities that could have resulted in the development or worsening of a pressure ulcer.*She verified both resident 11's pressure ulcers were considered facility-acquired pressure ulcers because his admission and 3/11/25 skin assessments documentation stated he had no skin alterations and noted the 3/11/25 assessment stated resident 11 refused to undress for evaluation of his skin.*Resident 11 has only been compliant with lying in his bed one time a day, after lunch.*She agreed when resident 11 laid on the mattress springs due to a deflated air mattress that created pressure to his skin and underlying tissues.*She agreed that the missing documentation did not support that the interventions were implemented to prevent pressure ulcers.6. Interview on 9/11/25 at 4:46 p.m. with director of nursing (DON) B revealed:*She expected the documentation of wound care and resident repositioning to be signed off in the TAR when completed.*If a resident refused wound care or repositioning, she would expect the refusal to be documented as a refusal.*If a wound care or repositioning documentation was left blank, she would consider it did not occur.*Due to the missed documentation on resident 11's and resident 31's TARs she considered those as missed intervention opportunities to prevent and treat a pressure ulcer.7. Review of the provider's 9/11/24 Skin and Pressure Injury Prevention Program revealed:* To ensure a resident who enters the facility without pressure injuries does not develop pressure injuries unless the individual's clinical condition demonstrates that they were unavoidable.* To provide care an services to prevent pressure injury development and to promote the healing of pressure injuries/wounds that are present.* A baseline assessment of the resident's skin status will be completed upon admission/readmission by completing the Nursing Admission/readmission UDA.* Risk Assessments (Braden or PUSH) will be completed with admission/readmission weekly for four weeks, and then monthly thereafter.* A wound assessment will be completed:-A) When a pressure injury is identified: This assessment will include,--a) Site, stage, size, appearance of wound bed, (use %) undermining, depth, drainage (amount, color, type, consistency and odor) and status of peri-wound tissue'--b) Treatment of the pressure injury, (cleansing, debridement, dressings);--c) A review of the resident's current POC [plan of care] and medical status- any other possible risk factors, impaired healing due to diagnoses;--d).Reassess he wound at least weekly (If the wound has not improved within 2-3 weeks, contact MD [medical doctor]/Provider for a change in treatment).* Nursing personnel will develop a plan of care (POC) with interventions consistent with resident and family preferences, goals and abilities, to create an environment to the resident's adherence to the pressure injury prevention/treatment plan. POC to include: Impaired mobility, including turning and repositioning at least every two hours or more if indicated by assessment. Pressure relief, Nutritional status and interventions, Incontinence, Skin condition checks, Treatment, Pain, Infection, Education of resident and family, Possible causes for pressure injury and what interventions have been put into place to prevent. Skin checks to be completed at least weekly by a Licensed nurse.* Pressure injuries are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area and subsequent destruction of tissue.* If pressure injuries are not treated when discovered, they quickly get larger, become very painful for the resident, and often times become infected.* The most common site of a pressure injury is where the bone is near the surface of the body including the back of the head around the ears, elbows, shoulder blades, backbone, hips, knees, heels, ankles, and toes.

Based on observation, interview, record review, and policy review, the provider failed to ensure: Interventions were implemented or updated to mitigate falling incidents for one of one sampled resident (14) identified at risk for falling who fell and sustained facial bruising and to have completed and documented a thorough investigation of that fall.Findings include:1. Observation on 9/9/25 at 8:46 a.m. of resident 14 in her room revealed she was lying on her side in bed. There was purple colored bruising beneath and above her right eye, extending to her forehead hairline. The resident stated she had fallen but was not sure how that had occurred. Her bed was low to the floor. Her call light was held inside the top closed drawer of a three-drawer plastic storage container near the head of her bed. A fall mat was folded against the wall on her roommate's side of the room. A walker and a wheelchair were also by that wall. Observation and interview on 9/9/25 at 11:35 a.m. with occupational therapist (OT) X in resident 14's room revealed she was encouraging the resident to reach towards the walker in front of her and pull herself to a standing position. OT X stated resident 14 took a couple falls when she was recently sick. Observation on 9/9/25 at 3:30 p.m. revealed resident 14 was asleep in bed. Her call light remained positioned in the above manner inside the plastic storage container. The above fall mat, walker, and wheelchair remained near or against the wall. Review of resident 14's electronic medical record (EMR) revealed her diagnoses included Alzheimer's, anxiety, depression, and high blood pressure. Resident 14's 9/2/25 revised fall care plan included the following fall prevention interventions: Ensure that [resident 14's] FWW (front wheeled walker) is within her reach when she is in bed. Initiated on 5/24/23.Fall mat at bedside while in bed to prevent injury. Initiated on 9/2/25.Keep call light within reach when in bedroom and bathroom. Initiated on 4/18/22.Sign in room to remind resident to ask for assist with transfers. Initiated on 6/14/23.Signs in room to remind resident to lock wheelchair. Initiated on 8/4/22. Observation on 9/10/25 at 7:50 a.m. revealed resident 14 was asleep in bed. Her call light was inside the drawer of the plastic storage container. A wheelchair and one end of an over-the-bed table were positioned in front of the exit side of her bed. The fall mat was folded against the wall on her roommate's side of the room. Interview on 9/10/25 at 8:55 a.m. with certified nurse aide (CNA) T regarding the positioning of the above equipment in front of resident 14's bed revealed that it was done to create a clutter-free path for resident 14's roommate. Observation and interview on 9/10/25 at 3:50 p.m. with resident 14 revealed that she sat in her wheelchair in her room. Her call light remained inside the drawer of the plastic storage container. When she was shown the call light, she was able to explain that its purpose was to bring help to her. There was no fall prevention signage posted on resident 6's side of the room. Review of the 9/1/25 Fall Scene Investigation (FSI) Report revealed that at 4:00 a.m. that morning, resident 14 was found on the floor of her room after an unwitnessed fall. Per the report, the resident had stated she was going through cards in her three-drawer plastic storage container and fell out of her wheelchair. She had refused the staff's assistance to get into her bed. She had been agitated and confused before that fall had occurred. She was last assisted to use the bathroom at 2:00 a.m. The section in the above report used to identify the root cause of the fall was blank. The section on that same report used to identify interventions to prevent future falls was blank. The checkbox to indicate if the resident's care plan had been updated was unchecked. The space for the nurse who had completed the form to sign and date it was blank.The last section of the above report was titled Falls Team Meeting Notes and it included the following meeting summary: Resident [14] anxious and exhibiting behaviors. Staff checked on resident at 0355 [3:55 a.m.] and resident was medicated for anxiety. Placed floor mat to prevent injury.There was no indication if the fall prevention interventions that were identified in resident 14's care plan were implemented at the time of her fall. There was no indication whether those same fall prevention interventions were reviewed to determine if they remained appropriate after she fell on 9/1/25.Observation and interview on 9/11/25 at 11:05 a.m. with director of nursing (DON) B in resident 14's room revealed the cause of the resident's facial bruising was a result of her 9/1/25 fall. The resident had tested positive for COVID-19 at the end of August 2025 and was expected to isolate in her room until her isolation precautions were lifted on 9/4/25. Resident 14's anxiety and restlessness had increased during that isolation period. She had not understood why she was expected to stay in her room. Resident 14 had no fewer than three falls during that isolation period.Regarding resident 14's fall care plan interventions, DON B confirmed that having a walker in reach when the resident was in bed was no longer indicated due to a decline in the resident's physical abilities. A fall mat was still expected to have been placed on the floor at the exit side of her bed when the resident was in her bed. That intervention should have been added to the resident's care plan. Resident 14's call light was to be accessible to her when she is in her room. Fall prevention signage was expected to have been posted in a location visible to the resident. DON B stated the FSI regarding resident 14 was incomplete. Resident 14's fall prevention interventions had not been but should have been updated to reflect short-term strategies to mitigate her risk for falls, such as increased staff observation of and interaction with the resident, knowing that the isolation precautions had increased her agitation and restlessness.Review of the provider's revised 2/20/24 Falls Management policy revealed:Fall Injury Prevention-Post Fall:1. Assess the resident and ascertain the reason for the fall (resident interview, environmental causes/hazards, footwear, functional impairment, acute change in condition, resident poor safety awareness, responding to toileting needs, etc). 2. Determine and implement [a] new intervention for fall prevention and record on [the] care plan.7. Provide appropriate training for caregivers, noting any changes implemented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to ensure pain management interventions were implemented and effective for one of one sampled resident (6).Findings include:1. Observation and interview on 9/9/25 at 9:53 a.m. in resident 6's room revealed he was lying on his back in bed wearing a hospital gown. He had a U-shaped pillow around the back of his neck. The resident had a grim expression on his face, and he strained to answer simple questions. He complained of being cold. Observation on 9/9/25 at 12:00 noon outside of resident 6's room revealed he was overheard telling an unidentified caregiver, I wish that nurse would come. I need that oxy [oxycodone, pain medication that is a controlled medication meaning at risk for abuse and addiction].Observation on 9/9/25 at 12:03 p.m. revealed licensed practical nurse (LPN) E entered resident 6's room. She explained to him that he had a physician's order for Tylenol, but there was no order for him to have oxycodone. LPN E stated she would have to call the resident's physician to discuss his request for oxycodone. She adjusted the resident's U-shaped neck pillow.Without first asking the resident what his pain level was or where his pain was, she administered two Tylenol tablets to resident 6. Observation and interview on 9/9/25 at 12:05 p.m. with resident 6 revealed he was lying on his back in bed, rubbing his forehead back and forth repeatedly and moaning, uh, uh. He stated on a scale of one to ten, with ten being the worst possible pain, that his pain was a ten. He identified his left ankle as the source of his pain. He described his pain as hot and stabbing and nearly constant. His eyes watered as he described his pain. Review of resident 6's electronic medical record (EMR) revealed he was admitted to the facility on [DATE]. His diagnoses included multiple sclerosis (MS), metastatic malignant neoplasm (cancer), depression, peripheral vascular disease (circulation disease), a history of left lower leg pain, and a history of cellulitis (bacterial infection of the skin) of his left lower limb. His 6/18/25 Brief Interview for Mental Status (BIMS) assessment score was 10, which indicated he had moderate cognitive impairment. Review of resident 6's September 2025 medication administration record (MAR) revealed a 6/12/25 physician's order for acetaminophen (generic Tylenol), 325 milligrams (mg), two tablets every eight hours for pain rated one to seven on a pain scale from zero to ten. There was a 6/12/25 physician's order for oxycodone HCI (hydrochloride), one tablet every eight hours as needed for pain rated eight to ten on a pain scale from zero to ten. Review of resident 6's September 2025 MAR and interview on 9/9/25 at 2:00 p.m. with LPN E revealed it's [the oxycodone order] right below the Tylenol. She had not known that resident 6 had an order for oxycodone; otherwise, she would have administered the oxycodone instead of the Tylenol as the resident had requested.When asked why resident 6 had pain, she stated, I'm not honestly sure the cause of his pain. It may be related to an accident. She thought he had pain in his leg or his neck. She was not sure how often or if resident 6 had gotten out of bed. She had not reassessed resident 6's pain level after she administered the two Tylenol tablets two hours earlier.LPN E administered resident 6's oxycodone after she was made aware of his physician's order for oxycodone.Review of resident 6's September 2025 MAR revealed LPN E had reassessed the resident's pain after she administered the above oxycodone. That administration was documented as having been an effective response to his pain.Interview on 9/10/25 at 2:40 p.m. with director of nursing (DON) B revealed LPN E had not administered resident 6's pain medication per his physician's order. That had potentially caused resident 6 unnecessary pain. DON B had expected LPN E to have thoroughly reviewed resident 6's MAR for all physician-ordered pain medication options and to have administered the most appropriate pain medication to him based on his level of pain. LPN E should have assessed and documented resident 6's pain level before administering any pain medication. That assessment should have identified whether his pain was new, acute, chronic, or related to an injury and what medication to administer for effective pain relief. Observation and interview on 9/10/25 at 1:30 p.m. with resident 6 revealed he was lying in his bed on his back in a hospital gown. He was watching television. He stated his MS had worsened, and caused a decline in his physical abilities. He thought his MS was also partially to blame for his near-constant pain. Observation on 9/11/25 at 8:30 a.m. of resident 6 revealed he was lying in his bed on his back in a hospital gown. His television was on, and his eyes were closed.Interview on 9/11/25 at 2:15 p.m. with resident 6 revealed he had no significant pain and stated, in a minute or so the pain will start back up at a ten.Review of resident 6's EMR revealed:On 7/26/25, he was transferred to the local emergency room due to left lower leg pain. No pain medication changes were made, and the resident was referred to his primary care physician for follow-up.His 9/9/25 Monthly Nursing Summary describing his pain revealed, Hurts a whole lot. Review of resident 6's June 2025 MAR revealed that during that month, he was administered as-needed oxycodone on 17. The frequency of those administrations was either one or two times per day. His July 2025 MAR revealed that during that month, he was administered as-needed oxycodone 17 days. The frequency of those administrations was between one and three times per day.His August 2025 MAR revealed that during that month, he was administered as-needed oxycodone 10 days. The frequency of those administrations was either one or two times per day.Review of resident 6's 6/14/25 revised pain care plan revealed the following interventions: Evaluate efficacy [effectiveness] of pain management. Notify MD [medical doctor] if inadequate pain relief. Observe for non-verbal signs of pain. Provide analgesic as ordered. Utilize non-pharmacological intervention.Review of resident 6's June 2025 through August 2025 MARs and interview on 9/10/25 at 2:40 p.m. with DON B regarding the management of resident 6's pain revealed that she stated resident 6's pain descriptions were accurate. His pain was most likely related to his MS. The stabbing that resident 6 described was consistent with the neurological nature of MS.DON B confirmed resident 6's Tylenol and oxycodone frequency and dosing had remained unchanged since he was admitted . He had no scheduled pain medications that could have provided him with more consistent pain relief. When asked why, she stated, That's what I was wondering. I don't have an answer for that. She indicated that resident 6's physician should have been contacted to explore this and other, more effective pain management options, but that had not occurred.Review of the provider's 4/28/25 Pain Management policy revealed:5. Strategies that may be employed when establishing medication regimen include:a. Starting with lower doses and titrating upward as necessary.b. Administering medications around the clock rather than PRN [as needed]. c. Combining long-acting medications with PRNs for breakthrough pain;d. Combining several analgesics or analgesics with other drug classes; .

Based on interview, record review, observation, South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, and policy review, the provider failed to ensure an assessment, physician notification, initiation of a skin treatment, and monitoring for one of one sampled resident's (2) newly discovered skin injury. This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the incident. Findings include: 1. Review of resident 2's electronic medical record (EMR) revealed: *Her admission date was 12/12/23 and her 2/21/25 Brief Interview for Mental Status (BIMS) assessment score was 0 which indicated she was severely cognitively impaired. *Her diagnoses included: hemiplegia, stroke, stage IV chronic kidney disease, diabetes, vascular dementia, and anxiety. She had a suprapubic catheter (tube inserted into the bladder to drain urine) related to acute cystitis (inflammation of the bladder). *She had a change in her medical condition on 2/17/25 and received intravenous (IV) fluids and an IV antibiotic for treatment of a urinary tract infection. *Her 2/7/25 Braden scale (pressure sore risk indicator) score was 18 which indicated she was at high risk for pressure ulcer development. *A 2/27/25 physician's progress note indicated: -Patient [resident] with progressive decline over the past several weeks, now with rapidly progressive ulcer to sacrum [bone at the base of the spine]. Reviewed picture on HUCU, [a type of electronic medical record] dark purple border, rapidly progressive over [the] past week and large necrotic appearing center. In context of poor oral intake, declination in health generally, this certainly appears to be a Kennedy ulcer [a type of skin breakdown that occurs in people who are nearing the end of their life. The cause is unknown but believed to be related to the physiological changes that occur during the dying process]. She is on comfort cares currently, DNH [do not hospitalize]. Review of resident 2's 3/4/25 physician's orders summary revealed: *She had received a twice daily liquid protein supplement ordered on 4/4/24. *A topical wound paste was applied to her buttocks once daily for excoriation and sequelae (a long term residual effect after an initial skin trauma has resolved) was ordered on 5/9/24. *She was laid down between meals to offload her buttocks, initiated on 5/9/24. *She had a pressure-relieving mattress for her bed, initiated on 8/22/24. *Weekly skin assessments, initiated on 8/24/24. *Wound care instructions: Cleanse sacrum with NS [normal saline], pat dry, apply hydrogel to wound bed, cover with border foam. Change every other day and PRN [as needed] every day shift every 2 day(s) for wound care, ordered on 2/25/25. Review of resident 2's February 2025 weekly skin assessments revealed: *On 2/15/25: Redness to buttocks with treatment in place. *On 2/22/25: Area on both buttock[s] is still there. *On 2/24/25: A left buttock wound measurement was 5 cm (centimeters) by 5 cm. -That same wound had measured 8.70 cm X 8.30 cm on 2/25/25, and on 3/4/25 the wound had measured 8.20 cm X 8.00 cm. Observations on 3/4/25 at 2:30 p.m. and again at 4:00 p.m. of resident 2 in her room revealed: *She was sleeping on her back in bed lying on top of a pressure-reducing mattress. *She was wearing protective heel boots. *There was a pressure-reducing cushion on her wheelchair seat. *She remained asleep in her bed, but she had been repositioned. Interview on 3/4/25 at 2:40 p.m. with doctor of nursing practice (DNP)/registered nurse (RN) B regarding the provider's FRI submitted to the SD DOH on 2/26/25 at 1:30 p.m. revealed: *While performing resident 2's personal cares on 2/20/25, certified nurse aide (CNA) J observed resident 2 had a new skin injury on her buttock. -She described the size of that injury as quarter-size. *CNA J had notified unit manager/licensed practical nurse (LPN)/wound care nurse H and RN E of the above observation. -RN E was responsible for resident 2's nursing care on 2/20/25. *After the above notification from CNA J, RN E failed to: -Complete and document an assessment of resident 2's new skin injury. -Notify resident 2's physician, obtain, and implement the physician's order for treatment of that skin injury. -Report to the oncoming shift that resident 2 had a new skin injury. *Resident 2's weekly skin assessment was completed on 2/22/25 by RN F. RN F failed to: -Document a measurement or a description of the new skin injury in his assessment. -Notify the resident's physician, obtain, and implement the physician's order for treatment of that skin injury. *During the evening/overnight shift on 2/22/25 through the morning of 2/23/25 it was reported to RN G that resident 2's buttock dressing was coming off. -She had not known resident 2 had a skin injury to her buttock. *She had completed a skin assessment and measured the skin injury as having been 5 cm (centimeters) by 5 cm. -RN G failed to initiate wound care standing orders (written protocol allowing certain healthcare staff to perform certain tasks without a specific order from a medical provider) for treatment of that skin injury until the resident's physician was able to be reached during regular business hours. *RN G had reported resident 2's skin injury to assistant director of nursing (ADON)/C the morning of 2/24/25. -ADON C and other management team members investigated and identified the root causes for the above process failures then developed and implemented corrective actions to mitigate the likelihood of them reoccurring. Interview on 3/4/25 at 3:00 p.m. with RN E revealed: *She stated she was busy and failed to complete a skin evaluation for resident 2 after it was reported to her by CNA J resident 2 had a new skin injury on her buttock. -She had not asked for assistance from another licensed nurse working that day to have ensured the skin assessment was completed. *RN E had worked on 2/21/25 and had not completed resident 2's skin assessment on that date. Telephone interview on 3/4/25 at 3:30 p.m. with physical therapist (PT)/certified wound therapist (CWT) K revealed: *He was employed by a company specializing in wound care that consulted with the nursing home on their residents' wound care. -He had reviewed the facility's residents who had skin wounds with unit manager/LPN/wound care nurse H on 3/4/25. *After reviewing documentation regarding resident 2's skin injury and observing that injury, he had concurred with the above 2/27/25 physician's progress note that resident 2's skin injury was appropriately classified as a Kennedy terminal ulcer based on its size, appearance, and the rapid development of that ulcer. -He felt the skin injury was unavoidable. The facility had identified resident 2 was at high risk for pressure ulcer development and had implemented appropriate preventative measures to mitigate her risk for pressure ulcer development. Resident 2's current treatment plan was appropriate. Interview on 3/4/25 at 4:15 p.m. with unit manager/LPN/wound care nurse H revealed: *On 2/20/25, CNA J had reported resident 2's new skin injury to her. -She had directed CNA J to notify resident 2's nurse, RN E. *Unit manager/LPN/wound care nurse H confirmed RN E, RN F, and RN G failed to follow the facility's process for the management of resident 2's new skin injury. CNA J, RN F and RN G were not available to interview. Review of the provider's revised 9/11/24 Skin and Pressure Injury Prevention Program revealed: *Section 1: -5. A wound assessment will be completed: A) When a pressure injury is identified: This assessment will include, a) Site, stage, size, appearance of wound bed, undermining, depth, drainage, and status of peri-wound tissue; b) Treatment of the pressure injury, c) A review of the resident's current POC (plan of care) and medical status-any other possible risk factors, impaired healing due to diagnoses; d) Type of skin injury, and provide skin treatment orders. Reassess the wound at least weekly. The changes the provider implemented to ensure the above deficient practices did not reoccur was reviewed and confirmed on 3/5/25. Those changes were based on a Root Cause Analysis of the FRI and resulted in the development of multiple improvement plans. The plans and actions included resident interviews regarding staff compliance with their repositioning schedules, staff interviews regarding their knowledge and understanding of the process and expectations after identification of new resident skin injuries, staff education and re-training related to the care and treatment of residents' skin, audits of all residents' skin, and staff-specific disciplinary action. Staff interviews confirmed those actions. Based on the above information, non-compliance at F686 occurred on 2/22/25. Based on the provider's implemented corrective actions for the deficient practice confirmed on 3/5/25, the non-compliance is considered past non-compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the provider failed to ensure the physician and family had been notified for a change in condition for one of one sampled resident (1) following a laceration to her left leg. Findings include: 1. Review of resident 1's medical record revealed: *She had been admitted on [DATE]. *Her (Brief Interview for Mental Status (BIMS) was 11 which indicated her cognition was moderately impaired. *Her diagnoses included paroxysmal atrial fibrillation, abrasion left lower leg, secondary malignant neoplasm of bone marrow, acute kidney failure, malignant neoplasm of unspecified site of left female breast and congestive heart failure. * She received a skin tear to her left lower leg on 6/21/24. *The on-call care provider was notified of her left leg laceration and agreed it could be addressed in the facility. *Resident 1's son was informed of her left leg laceration and provider's recommendation. *A physician's notes on 6/21/24 stating Staff called Friday 6/21 10 p.m. Staff stated she had abrasion/skin tear to leg from catching it on wheel chair. Verbal order for steri-strips and bandage. Will monitor close. Staff agreed with plan. *A progress note on 06/22/24: Call from RN L on Sat 6/21 at 1 p.m. Nurse stated wound was bleeding and with blood thinners was weeping. She recommended she can do pressure dressing. Verbal order for pressure dressing to stop bleeding and monitor close. Discussion with nurse-she was on blood thinners. Pt has severe hx [history] of PAD [peripheral artery disease] and CAD [coronary artery disease]- medical discussion making considered and elected to not stop blood thinner due to PAD. Discussed with nurse to continue to monitor close and continue pressure dressing. If worse can consider sending to ED. Will f/u this week for eval. *A progress note on 06/22/24 at 14:24: Resident has skin tear to LLE [left lower extremity] that is bleeding. Skin has been approximated, putting pressure dressings on and change dressing when resident bleeds through the dressing. Dressing has been changed x2 [two times] so far. [NAME] notified and stated to keep putting pressure dressing on. *A wound note on 06/23/24 at 12:00 a.m.: This RN changed residents dressing on L calf. Bandage was saturated in blood. No steri-strips available at this time. *A wound note on 06/23/24 at 4:11 a.m.: This RN changed dressing on L calf. Bandage was saturated with blood. No steri-strips available at this time. *A wound note on 06/23/24 at 1:51 p.m.: Skin tear to LLE still bleeding but has lessened. This nurse has changed the dressing x2. There are blood clots present. Monitor. *A wound note on 06/24/24 at 4:29 a.m.: Resident dressing on L calf was saturated in blood, observed blood clots within the saturated bandage. Removed, cleaned the area gently and applied new sterile dressing. *A wound note on 06/24/24 at 8:33 a.m. Was notified at arrival to facility of wound to her left pretibial surface. Pictures obtained with size documented. Pressure bandage reapplied. Will do dressing change later this morning. Follow up on wound care orders. Patient expressed that she was not in pain. She is on Eliquis. *No wound care notated for residents left lower leg skin tear in treatment administration record (TAR). *She passed away on 6/24/24 at 10:45 a.m. 2. Interview on 0709/24 at 10:20 a.m. with certified nursing assistant (CNA) H revealed: *She was not working during the time resident 1 received the skin tear to her left leg. *She stated when residents have accidents CNAs know to let the nursing staff know and they will advise on what the next step is. *Staff had training monthly on how to deal with different issues that may arise. 3. Interview on 06/10/24 at 7:32 a.m. with CNA J regarding resident 1 revealed: *She was in resident 1's room assisting her roommate. *on 6/21/24 she saw resident 1 slipping out of her wheelchair, stopped her from falling, and assisted her to her bed. *She stated that resident 1 had cut her left lower leg on her wheelchair at which point she notified the nurse. *She checked on resident 1 twice throughout the night between 8:00 p.m. and 5:00 a.m. on 6/22/24 and had to change dressing twice due to it being soaked. *She had to change resident 1's bedding before leaving due to the bedding being soaked in blood. 4. Interview on 06/10/24 at 10:00 a.m. with Licensed Practical Nurse (LPN) F revealed: *She did not work the weekend of resident 1's injury but had heard about it. *She stated that when a resident would have an injury the CNAs would inform the nurses who would then evaluate the injury and inform the provider, management and family if needed. *The nurse would measure skin tears and inform the wound nurse. *She would have pushed for resident 1 to be sent to the emergency room if she had seen the injury. 5. Interview on 06/10/24 at 10:53 a.m. with RN L revealed: *She was working the weekend that resident 1 cut her left lower leg on her wheelchair. *The resident's family, management, and physician's assistant (PA) K were notified of the injury. *PA K never mentioned taking resident 1 to the emergency department. *PA K advised there was not much to be done about the injury and to keep putting a pressure dressing on it. *She applied non-adherent ABD (abdominal) pads and Coban (self-adherent wrap) to the wound. *She changed resident 1's dressing four times from Friday 06/21/24 to Saturday 06/22/24 and twice from Saturday 06/22/24 to Sunday 06/23/24. *The bleeding had lessened on 06/23/24. *If the bleeding had not lessened, she would have called PA K back. *She would not have done anything differently and that there was not much you could have done for that skin tear. 6. Interview on 06/10/24 at 4:06 p.m. with RN M revealed: *She was working the weekend resident 1 cut her left lower leg on her wheelchair. *She was informed of resident 1's skin tear then called on-call provider PA K. *She was told by PA K that resident 1 did not need to go to the emergency department and was told to call her son. *On 06/22/24 the skin tear was still bleeding, and she did not have any steri-strips. *She called management who advised that the wound nurse would be in on Sunday 06/23/24 to look at the wound. She was not sure if the wound nurse came in that Sunday. *She called the provider again, but no one directed to send the resident out to the emergency department. *She did not think sutures, staples or going to the emergency department would have helped the resident. *She was upset that she did not have the right supplies to assist the resident. 7. Interview on 06/10/24 at 3:12 p.m. with CNA I revealed: *He worked the weekend resident 1 cut her left lower leg. *He was informed that she had a small abrasion on her left leg at the shift change meeting. *He stated when he checked on resident 1 the dressing was soaked through and there was a pool of blood in the resident's bed. *He notified RN L every hour that the dressing needed to be changed. *He asked RN L multiple times if resident 1 would be sent to the emergency department and did not get an answer from her. *When he came back to work on Sunday 06/23/24 resident 1's wound looked the same to him as it had on 06/22/24. * He watched the resident go from vibrant on 06/22/24 to pale and quiet on 06/23/24. 8. Interview on 06/10/24 at 1:51 p.m. with assistant director of nursing (ADON) D revealed: *She was the nurse on-call on the weekend resident 1 cut her left lower leg. *She stated she had made notes for this incident to keep her thoughts straight. *She provided a color picture of the wound and stated that the blood in the picture was moderate and called the wound an abrasion. *She stated that she did not believe anything was done incorrectly and she trusted her nurses. *She was never contacted about not having enough steri-strips for the wound. *She stated in hindsight the family could have been notified again and been asked to have made the decision to send to the emergency department or the provider could have been contacted to come and look at the wound. *She stated that the incident was not reported to the Department of Health (DOH) due to it not being an unknown injury and she did not think that it needed to be reported, even though it did not stop bleeding for three days. 9. Interview on 06/10/24 at 4:07 p.m. with Administrator A revealed: *She did not think anything had been done incorrectly. *She stated due to having advanced cancer she did not think sending the resident to the emergency department would have been beneficial. *She stated that in hindsight she would not have done anything differently. *She stated that she expected her staff to treat the resident, notify the provider and the family and to monitor the situation. 10. Review of provider's February 2024 Abuse and Neglect policy revealed: *Neglect -Neglect is the failure to provide necessary and adequate (medical, personal, or psychological) care. Neglect is the failure to are for a person in a manner, which would avoid harm and pain, or the failure to react to a situation which may be harmful. Staff may be aware or should have been aware of the service the resident requires but fails to provide that service. 11. Review of provider's June 2024 Wound Care Protocol by Wound Type revealed: *Cleanse with normal saline. -Reapproximate skin over wound when possible. -Xeroform or Vaseline gauze to skin tear. -Silicone border dressing, when possible ,otherwise ABD and roll gauze to secure dressing. -Change dressing every 3 days and as needed until resolved to keep dressing clean, dry, and intact. Do not remove to shower, cover to bathe. Do not soak. Change dressing if it becomes saturated with drainage, shower water or becomes compromised.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, and policy review, the provider failed to assess, and implement preventative pressure injury interventions for one of one sampled resident (2) who was identified as at risk for pressure injuries and developed a pressure injury. Failure to assess and implement pressure injury prevention interventions potentially contributed to resident 2's development of a pressure injury. This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the incident. Findings include: 1. A review of facility reported event (FRI) for resident 2 revealed: *He admitted to facility on 6/5/24. *He was at risk for skin breakdown at admission. *He should have been turned and repositioned every two hours. *Only intervention in place at admit was heel lift boots for skin integrity. 2. A review of resident 2's electronic medical record (EMR) revealed: *He was admitted on [DATE]. *He had diagnoses of: -Cerebral infarction (stroke). -Hypertensive emergency. -Acute respiratory failure. -Epilepsy (seizure disorder). -Spinal stenosis. *His 6/5/24 Braden scale (assessment for predicting pressure injury risk) score indicated he was at high risk for developing pressure ulcers. *His care plan dated 6/6/24 revealed: -He was to turn and reposition every two hours and as needed (PRN). -He needed total staff assistance with activities of daily living (ADLS) including bed mobility, dressing, hygiene, and locomotion. -Staff were to use a full-body mechanical lift with the assistance of two staff. -Staff were to apply a moisture barrier product to his peri-area after incontinent episodes. *On 6/7/24 a request was made for a bariatric air mattress and wheelchair cushion for skin integrity as he cannot move independently. *On 6/9/24 his family and provider were notified he had a blister on his coccyx (tailbone). *On 6/9/24, the provider ordered a foam border dressing and barrier cream to be applied to his coccyx. *On 6/11/24 orders were received for: -Bariatric air mattress. -Pressure redistribution wheelchair cushion. -Wound care referral for new wound on coccyx -Reposition every two hours (was a verbal order). *On 6/13/24 his Braden scale score indicated his risk had increased to being at very high risk for developing pressure ulcers. *His weekly skin assessments dated 6/10/24, 6/17/24, and 6/24/24 were signed off as being completed, but were not completed. 3. Review of provider's wound report dated 5/1/24 to 7/9/24 revealed resident 2 had a Stage one Pressure/Ulceration wound to the right outer rim of his ear identified on 6/14/24. 4. Interview on 7/9/24 at 1:05 p.m. with Administrator A regarding weekly skin assessments revealed: *Resident 2's skin assessments 6/10/24 and 6/17/24 had not been completed, but were signed off as completed. *His skin assessment dated [DATE] was signed off, but the resident was admitted to the hospital on [DATE] and then discharged . *An audit was completed on 6/21/24 for wound/skin documentation and follow-up. 5. Interview on 7/9/24 at 1:12 p.m. with certified nursing assistant (CNA) G revealed: *Skin alterations were documented under the skin task in the EMR system. *She would report those to the nurse. *Red skin would be observed and placed on the wound watch list. 6. Interview on 7/9/24 at 1:16 p.m. with licensed practical nurse (LPN) F revealed: *She would check skin notes first to see if something was documented. *A risk management report would be completed for all skin areas/concerns. *She would then contact the resident's family and provider. *Wound nurses would do rounds on Tuesdays. *Floor nurses were responsible for doing the weekly skin assessments on residents. *She would notify the on-call RN for management, of any immediate concerns/problems. 7. Interview on 7/9/24 at 1:28 p.m. with CNA H revealed: *Skin issues were reported to the charge nurse. *She documented them in the skin task in the EMR system. *Nurses assessed the area and took over from there. 8. Interview on 7/9/24 at 2:13 p.m. with assistant director of nursing (ADON) B revealed: *When resident 2 came to the facility she had just started her position. *There was a lesion/blister found on his coccyx over the weekend. *A silicone barrier was placed per standing orders. *On 6/11/24 on wound rounds she and ADON C had removed the old dressing. -Another blister under the adhesive had occurred. -When the dressing was removed the blister popped. -They cleaned the area and replaced the dressing. *She was unaware why every two-hour repositioning was not initiated per his care plan. *On-call was also notified of skin issues. *Weekly wound rounds are done every Tuesday. *Management meeting's were on Wednesdays, and they discussed patients who were at risk for skin breakdown. 9. Interview on 7/10/24 at 12:36 p.m. with Minimum Data Set (MDS) coordinator E revealed: *She completed the care plans for all residents. *She opened the sections for completion by other disciplines. *The floor nurses completed the user-defined assessments on admission. *She put every two-hour repositioning for resident 2 in his care plan dated 6/6/24. *Based on diagnosis and history and physical data on admission. *ADON C would have put in the treatment administration record order for every two-hour repositioning. -She was unsure of the date of that order. 10. Follow-up interview on 7/10/24 at 12:43 p.m. with ADON C revealed: *She had entered the every two-hour repositioning order in resident 2's chart on 6/11/24 most likely due to observations during wound rounds. *She would have expected the nurse's to verify the repositioning was being completed by the CNA's. *MDS coordinator E would have put the task in the system for CNAs to complete the repositioning. 11. Follow-up interview on 7/10/24 at 12:58 p.m. with MDS coordinator E revealed: *She thought it was, a miscommunication on who was doing what. *For resident 2 It was not in the CNAs tasks (to reposition). *The order for nurses to sign off on the repositioning was initiated on 6/11/24. *She was no longer able to access any tasks for resident 2 because, he had discharged from the facility. 12. Interview on 7/10/24 at 4:02 p.m. with Administrator A revealed: *The standard of care would be something that should be followed, the task are just extra items for the CNA's and that would be that they checked on and reposition every two hours. 13. Review of providers Skin and Pressure Injury Prevention Program policy last reviewed on 3/23/23 revealed: *To ensure a resident who enters the facility without pressure injuries does not develop pressure injuries unless the individual's clinical condition demonstrates that they were unavoidable. *To provide care and services to prevent pressure injury development and to promote the healing of pressure injuries/wounds that are present. *A plan of care will be put in place for residents that are identified with actual skin breakdown or at-risk for skin breakdown. The provider's implemented actions to ensure the deficient practice does not reoccur was confirmed on 6/24/24 after: record review and staff interviews revealed the facility had followed their quality assurance process, education was provided to all nursing care staff regarding wound/skin documentation and follow-up, and staff were aware of the provider's procedure for assessing, monitoring, implementing interventions, and documentation of interventions provided to prevent the development of pressure injuries. Based on the above information, non-compliance at F686 occurred on 6/9/24, and based on the provider's implemented corrective action for the deficient practice confirmed on 7/9/24, the non-compliance is considered past non-compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and policy review, the provider failed to ensure: *A bowel management program was monitored for one of one sampled resident (9) who had multiple diarrhea consistency stools and unintentional weight loss. *Appropriate and necessary notification of resident 9's physician assistant (PA) H and registered dietician (RD) I about the consistency and amount of her stools. Findings include: 1. Observation on 5/13/24 from 5:30 p.m. to 6:00 p.m. of resident 9 while in the dining room during the evening meal revealed: *She was sitting in a wheelchair and had a small, frail, bony appearance. *She was eating a meal from a fast-food restaurant. Interview on 5/14/24 at 9:30 a.m. with resident 9 revealed: *She felt she was losing weight because she poops all the time and everything goes right through me. -She stated she was having a watery bowel movement (BM) with every toileting and often had incontinent (uncontrolled) BMs. -She stated, I have had water poop for a long time. I think it is those pills they give me. Review of resident 9's electronic medical record (EMR) revealed: *She was admitted on [DATE] with the primary diagnosis of ataxic (impaired coordination) cerebral palsy. *Her weight on admission was 115.8 pounds. *On 2/6/24 the resident weighed 99.7 pounds. -On 5/7/24 her weight was 93.6 pounds. -That was a 6.12% weight loss within a three month time period. *She was not on a physician prescribed weight loss program. *She was eating between 50 and 100 percent of her meals and also accepted a snack most evenings. *Her medication administration record (MAR) revealed she was drinking 100% of Liquacel dietary supplement, one ounce, twice a day, and a 2.0 calorie supplement drink, four ounces, three times a day. *Her 4/12/24 Brief Interview of Mental Status (BIMS) score was 14, indicating she was cognitively intact. Review of resident 9's Point Click Care (PCC) BM record from 4/14/24 to 5/14/24 revealed: *Resident 9 had 48 BMs in a 30-day period. -33 of those stools were documented as diarrhea loose. -8 stools were putty like and 7 were formed stools. Further review of resident 9's April and May 2024 MARs revealed the following: *A 7/19/23 physician's order for a MiraLax (a laxative)17 gram oral packet to have been mixed with fluid daily in the morning. *A 11/25/21 physician's order for docusate sodium (stool softener)100 milligram tablet to be given daily in the morning. *The MiraLax was refused by the resident seven times on 4/5, 4/7, 4/8, 4/10, 5/11, 5/13, and 5/14. -There was no documentation found that indicated staff had held her laxative or stool softener due to diarrhea (loose) stools. Further review of resident 9's EMR revealed: *There was no documentation found that indicated the physician had been notified of her frequent loose stools. *Her 4/12/24 quarterly Minimum Data Set (MDS) assessment's section H revealed she was occasionally incontinent of BM. *Her 4/12/24 Braden skin assessment revealed a score of 18, indicating she was at high risk for skin breakdown. Interview on 5/14/24 at 3:38 p.m. with certified nursing assistant (CNA) G regarding resident 9 revealed: *She was aware the resident was having frequent loose stools. -She stated the CNA's charted the consistency of the BMs in PCC for the nurses to use as a reference. Interview on 5/14/24 at 3:42 p.m. with registered nurse (RN) F revealed she: *Stated since PCC was updated, she was unable to view CNA charting on BM consistency. *Was aware resident 9 had loose stools and stated that was normal for her. -Was unable to explain why the resident was taking both a laxative and a stool softener every day if she was having loose stools. *Was unsure if the physician had been notified of the resident's loose stools. Interview on 5/14/24 at 4:05 p.m. with MDS coordinator E revealed: *She was aware resident 9 was having loose stools. -Stated resident 9's loose stools were sporadic and she expected the nurses to have held the laxative medication when her stools were loose. *Stated the nurses were able to view a resident's BM consistency in PCC. -It was located under a separate tab in the bowel documentation area. *She was unaware if the physician had been notified of the resident's loose stools. 2. Interview on 5/15/24 at 8:30 a.m. with resident 9's physician assistant (PA) H regarding weight loss and loose stools revealed: *She was not aware the resident was having multiple loose, diarrhea consistency stools. -It was her expectation for staff to have notified her about that issue. -She stated that during her monthly visits with the resident, she had never complained of having loose stools. *She confirmed multiple diarrhea stools could be a factor in the resident's weight loss. Interview on 5/15/24 at 9:40 a.m. with administrator A, director of nursing (DON) B, and nurse supervisor D regarding resident 9's weight loss and loose stools revealed: *They stated it was the resident's normal to have loose stools on occasion, but were unaware of how frequently it was occurring. *They were aware of the resident's weight loss despite nutritional interventions. -They had attributed the weight loss to her progression of cerebral palsy disease and mental decline. *Their expectation was for the aides to communicate to the nurses when the resident was having loose, diarrhea stools. Interview on 5/15/24 at 10:54 a.m. with consulting dietitian I regarding resident 9 revealed: *She had worked as the provider's dietitian on a consultant basis for at least 2 years. *She reviewed the resident's charts remotely and performed an on-site visit with the residents and the interdisciplinary team once a month. *She was aware the resident had been losing weight and was monitoring her as a nutritionally high-risk resident. *She was able to view a resident's BM frequency in PCC, but had not known how to view the BM's consistency. *Staff had not informed her of the resident's loose stools. -She depended on staff to notify her of changes in a resident's condition. Review of the provider's 8/23/23 Notification of Change of Condition policy revealed: *1. The facility must immediately inform the resident; consult with the resident's medical provider; and notify, consistent with his or her authority, the resident representative(s) when: -c. A need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or . Review of the provider's 12/1/19 CNA and RN job description and the March 2021 Toileting and Incontinence policy revealed: *There was no mention of reporting frequent loose stools to the nurse or the physician. *There was no mention of holding laxatives or stool softeners during episodes of loose stools.