**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 out of 21 residents (Resident #1) reviewed for adequate supervision. The facility failed to provide adequate supervision to Resident #1 who had a diagnosis of vascular dementia and eloped from the facility to a tire shop two blocks away from the facility for at least an hour. Resident #1 was severey cognitively impaired, which put her at increased risk of injury. An IJ for Past Non-Compliance was called on 2/20/25 at 3:18pm with the facility Administrator and DON. The noncompliance was identified as Past Non-Compliant. The IJ began on 12/2/24 and ended on 12/5/24. The facility corrected the noncompliance by providing in-servicing and hands-on training regarding elopement for facility staff prior to surveyor entrance. The failures placed residents at risk for elopement which could result in injury, hospitalization, and death. Findings included: Record review of Resident #1's admission Record dated 2/20/25 revealed she was a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses, personality disorder (a mental health condition characterized by patterns or behavior, thoughts and emotions that deviate significantly from cultural expectations and cause distress and or impairment of functioning), and vascular dementia moderate without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (term for brain changes that affect memory, thinking and can affect behavior but can occur without behavioral or mood changes). Record review of Resident #1's MDS (Minimum Data Set) dated August 8, 2024, section A revealed Resident #1 admitted from short-term general hospital. Section C revealed a BIMS (Brief Interview for Mental Status) score of 1 out of 15 indicating significant cognitive impairment. Section E regarding Resident #1 behaviors revealed rejection of care occurred 1 to 3 days. Resident #1 had no wandering behaviors. Section GG regarding Resident #1's Activities of Daily Living (ADL) Assistance revealed the resident needed set-up assistance with eating and oral hygiene, supervision with toilet use, moderate assistance with dressing and personal hygiene and maximum assistance with bathing. Section V regarding (CAAs), Care Area Assessments revealed Resident #1 was reviewed for risks in the following areas: Cognitive loss/Dementia-dated 8/9/24, Communication dated 8/9/24, Urinary incontinence/Indwelling catheter dated 8/9/24, Behavioral symptoms (related to refusals of care) dated 8/9/24, falls dated 8/9/24, Nutritional status dated 8/9/24, pressure ulcers dated 8/9/24 and psychotropic drug use dated 8/9/24. Record review of the facility's daily sign-in sheet dated 12/2/24 revealed staff worked 12-hour shifts from 6 am-6 pm and from 6 pm-6 am. LVN A was working on Resident #1's hall on the day shift and ADON was working on Resident #1's hall on the night shift. Continued review revealed MA A and CNA A were working on Resident #1's hall on the day shift and MA B and CNA B were working on Resident's #1 hall on the night shift. Record review of Resident #1's EMR for assessments on 2/3/25 at 12:22pm revealed no admission elopement risk assessment. Record review of Resident #1's nursing progress notes from 8/2/24 through 12/1/24 revealed staff documented by exception, Resident #1 was ambulatory without an assistive device and had no exit seeking or wandering behaviors prior to the incident on 12/2/24. Record review of facility incident and accident report from 8/2/24 through 2/20/25 at 7:53 pm revealed Resident #1 had an elopement incident on 12/2/24. There were no other elopement incidents or accidents from August 2024 through February 2025. Record review of Resident #1's facility provider investigation report dated 12/2/24 revealed Resident #1 was found by police at a tire shop up the road from the facility and returned to the facility by police and a family member unharmed around 7:50pm. Further record review of report revealed Resident #1 was gone from facility for about 1 hour and had gotten out of the facility through a side door that was no alarmed and was not part of the facility's secured unit. Record review of facility map revealed Resident #1 resided on an L-shaped unit that only had 1 unsecured entry/exit door. Continued record review of report revealed CNA B was the last to see Resident #1 around 6pm and staff did not recognize resident was not inside the facility until ADON received telephone call from Resident #1's family member around 6:30pm. Record review of LVN A's nursing note dated 12/2/25 at 5:46pm revealed the following: received phone call residents family member (sic) that resident was (sic) seen several streets down at tire shop and was obtained by the police and take (sic) to the police station. RP family member to pick her up and bring her to facility charge nurse on floor informed. Record review on 2/5/25 at 3:12pm of the ADON's nursing note dated 12/2/25 at 7:44 pm revealed the following: resident returned to facility and stated that (family member) does not want [Resident #1] to go to the secured unit. Education provided. Record review of Resident #1's MAR dated 12/1/2024-12/31/2024 revealed it was documented that Resident #1 received two 4:00 pm medications from LVN A, three 5:00pm medications from MA B, and received two medications from LVN B at 8:00pm. Telephone interview with MA A on 2/4/25 at 3:30 pm said Resident #1 had never tried to leave the facility prior to the incident and received her dinner and evening medications on 12/2/24 and could not have been missing from the facility very long. MA A said they had been trained on ANE upon hire and at least quarterly and had also been trained on elopement policy and procedures prior to and after the incident with Resident #1 on 12/2/24. MA A said that the facility conducted a code orange on the day Resident #1 went missing and searched the entire facility including bathrooms and closets and the interior and exterior of the facility. MA A said it was determined on 12/2/24 after the elopement search, that there were no other residents missing. MA A said they had been re-trained on ANE and elopement drills after the incident as well and that the facility conducted at least monthly elopement drills on each shift. MA A said that all doors were alarmed after the incident. Interview on 2/5/25 at 1:15 pm the DON said Resident #1 should have had an admission elopement assessment. The DON said she was working at the facility and helped complete the investigation involving Resident #1's elopement. The DON said it was determined through investigation that Resident #1 got out of a side facility door, and it was not part of the secured unit. The DON said Resident #1 did not have any exit seeking or wandering behaviors prior to the incident on 12/2/24 and the facility conducted a PIP in December 2024, after the incident with Resident #1 occurred and determined they will conduct more frequent elopement drills on each shift and audit admission assessments for all new admissions. The DON said Resident #1 was not injured during the incident and was reassessed and placed on the secured unit after the incident where Resident #1 remained. The DON said an elopement risk assessment was part of the facility's admission paperwork and should have been completed upon Resident #1's admission. The DON said she started working at the facility after Resident #1's admission in August 2024 and the charge nurse at the time of any resident admission was responsible for completing the required assessments which included an elopement risk assessment. Interview and observation on 02/5/25 at 12:42 pm revealed Resident #1 ambulating in the main activity room of facility's secured unit. Resident #1 had finished eating her lunch and was appropriately groomed and dressed. Resident #1 was awake, alert, and oriented and pleasantly confused. She was easily distracted but also easily redirected. Resident #1 did not want to continue speaking with surveyor and declined to be interviewed at that time or at any other time. The IJ began on 12/2/24 and ended on 12/5/24. The facility corrected the noncompliance by conducting a facility QAPI/PIP on elopement and providing in-servicing and hands-on training regarding elopement for facility staff prior to surveyor entrance. Telephone interview with MA B on 2/20/25 at 11:26 am revealed they could not remember all the specific details about the elopement of Resident #1 but remembered giving Resident #1 her 5pm medications between 5:00-5:30pm. MA B said Resident #1 was returned to facility around dusk and was not injured and placed on the secured unit after the incident. MA B said Resident #1 never wandered or tried to elope prior to the incident on 12/2/24. MA B said they did not know what staff member first identified Resident #1 was missing or when, but said staff immediately conducted an elopement drill and swept the entire building looking for Resident #1 and did a head count to ensure no other residents were missing. MA B said they had been trained both before and after the incident with Resident #1 on elopement procedures. MA B said that they knew how to check to make sure all exit/entry doors were securely closed and that they responded to any alarms or door sounds immediately to ensure there are no residents trying to elope. Telephone interview on 2/20/25 with LVN A on 2/20/25 at 11:37 am revealed Resident #1 walked around a lot and did not require any assistive devices to ambulate. LVN A said they worked the 6am-6pm shift on 12/2/24 with Resident #1. LVN A said that Resident #1 was sometimes confused but was awake, alert, and oriented to person and place and had never tried to leave the facility prior to the incident on 12/2/24. LVN A said Resident #1 would greet other resident's family members and visitors as they arrived and left the facility but had never tried to leave the facility on her own. LVN A said she did not recall any specific times she last saw Resident #1 on 12/2/24 or when Resident #1 returned to the facility but heard about the incident after it happened. LVN A said she would have given Resident #1 her 4:00pm medications. LVN A said they had been trained by the facility on ANE and had elopement drills before and after the incident on 12/2/24. LVN A said they learned how to split up the search to conduct a more thorough and timelier search of the interior and exterior of the facility to get a more immediate head count and to immediately report to the abuse coordinator/administrator. LVN A said they also learned how to check all the exit/entry doors were secured and closed. LVN A said they learned to ensure an admission elopement assessment had been completed on all new admissions and to document any wandering or exit seeking behaviors. LVN A said the ADON was the charge nurse for Resident #1 at the time of the incident because the scheduled charge nurse called in to say they would be late. Telephone interview on 2/20/25 at 4:11pm with LVN B revealed they gave Resident #1 two medications at 8:00pm on 12/2/24. LVN B said Resident #1 was back at the facility and moved to secured unit by that time. LVN B said before the incident Resident #1 had never tried to escape, elope, or leave. LVN B said they were trained upon hire and at least monthly on ANE and elopement procedures. LVN B said they learned how to split up the search to conduct a more thorough and timelier search of the interior and exterior of the facility to get a more immediate head count and to immediately report to the abuse coordinator/administrator. LVN A said they also learned how to check all the exit/entry doors were secured and closed. LVN B said they also learned to ensure an admission elopement assessment had been completed on all new admissions and to document any wandering or exit seeking behaviors. Interview on 2/20/25 at 4:15 pm with MA C revealed they worked the evening shift 12/2/24 and were trained on ANE and elopement procedures prior to the incident with Resident #1 on 12/2/24. MA C said Resident #1 had not tried to elope or get out of the facility prior to the incident on 12/2/24. MA C said Resident #1 liked coffee and walked around the facility but not wandering or going in and out of other resident rooms. MA C said after a couple of times after family members came to see Resident #1 or took her out on pass Resident #1 would seem sad but still never tried to elope until 12/2/24. MA C was unsure if Resident #1 had any visitors that day or if Resident #1 had been out on pass. MA C said the ADON initiated an elopement drill which the facility called a and they searched entire building inside and outside after Resident #1 was missing. MA C said that she knew that code orange was facility code for elopement and that an immediate search and lock down of facility needed to be conducted both inside and outside of the facility in addition to resident head count and Administrator notification if resident could not be found. Telephone interview on 2/20/25 at 4:32pm with CNA B revealed they were the assigned CNA and worked with Resident #1 on 12/2/4 during the evening shift. CNA B said they last saw Resident #1 at 6pm. CNA B said they gave Resident #1 a shower before dinner and remembered seeing Resident #1 seated in the activity room/communal area because there was an activity in progress. CNA B said they went to give another resident a shower and by the time the other shower was finished 30-40 minutes later they were told by LVN A to start a code orange. CNA B said they looked everywhere for Resident #1 and the ADON and other staff also went outside looking for Resident #1. CNA B said they looked in every resident room, every bathroom, every closet, and it was confirmed Resident #1 was missing but all other residents were accounted for. CNA B said they did not see Resident #1 return but heard the resident went to secured unit and ADON was managing it. CNA B said everyone was retrained on ANE and elopement drills and procedures immediately after the incident. CNA B said they had been trained on elopement procedures before the incident on 12/2/24. CNA A said they knew to look in all closets, bathrooms, resident rooms, and areas both inside and outside facility and to conduct a resident head count to ensure which residents were accounted for and which one may be missing. CNA A said they also learned to report any missing resident to administrator immediately if resident not found and to check all entry/exit doors to ensure they were secure. Telephone interview on 2/20/25 at 4:50pm with the ADON revealed they only worked a few months at the facility and remembered the incident with Resident #1 who somehow got out of the facility side door. The ADON said Resident #1 was calm and had not tried to exit the facility before 12/2/24. The ADON said they were covering for 6pm-6am shift charge nurse and helping the floor because the assigned 6pm-6am nurse was running late. The ADON said they last saw Resident #1 around 6:00pm-6:30pm. The ADON said they were trained on ANE and a code orange before hire and after the incident. The ADON said they believed they were called around 6:30 by Resident #1's family member saying the police had Resident #1 by a tire shop up the road and were bringing Resident #1 back to the facility. The ADON said they immediately initiated a code orange and confirmed Resident #1 was missing but no other residents. The ADON said when police arrived with Resident #1 accompanied by family member, they had staff complete an SBAR, skin, elopement risk and pain assessments as well as an incident report and Resident #1 was placed on secured unit. Interview on 2/20/25 at 4:55pm with Housekeeper said they had been trained monthly on elopement drills and at least quarterly on ANE. Housekeeper said code orange meant a resident had eloped and to monitor exit/entry doors and help search for resident inside and outside of facility as assigned by the charge nurses. Housekeeper said they were to report any resident elopement immediately to Administrator. Interview with CNA C on 2/20/25 at 5:03pm who worked 6am-6pm shift but worked 6pm-6am shift too at times. CNA C said they knew to look in all closets, bathrooms, all resident rooms, and areas both inside and outside facility and to conduct a resident head count to ensure which residents were accounted for and which one may be missing. CNA A said they also learned to report any missing resident to administrator immediately if resident not found and to check all entry/exit doors to ensure they were secure. Interview with SW on 2/20/25 at 5:08pm they said they had been trained on ANE and the facility code orange or elopement drill upon hire in November 2024 and after incident with Resident #1. SW said elopement drills were monthly and they learned to notify Administrator/Abuse Coordinator immediately and do a sweep search of building, all areas inside and outside and monitor and check exit/entry doors to ensure they remained secured. The SW said they would be part of the follow up safety rounds and psychosocial assessments for residents after any elopement. Interview with Receptionist on 2/20/25 at 5:12pm they said they had been trained upon hire 2/3/25 on ANE and resident elopement. Receptionist said they were trained to monitor main front entry/exit and unsure door remained securely closed and only opened via code. Receptionist showed a binder of current facility resident face sheets with resident photos to assist with identifying residents. Receptionist said they were trained code orange meant a resident had eloped and to monitor exit/entry doors and help search for resident inside and outside of facility as assigned by the charge nurses. Receptionist said they also learned to report any missing resident to administrator immediately if resident not found and to check all entry/exit doors to ensure they were secure. Record review of the facility's Elopement policy dated Revised May 2024 revealed the following Elopement Mitigation Strategies: *Appropriateness of resident placement within the facility upon admission and during their stay. *Completion of routine elopement risk assessments. *Providing the resident with appropriate supervision *Conducting routine elopement drills . Missing Resident 1. Once it has been established that a resident is missing, activate the emergency response paging system Code Orange, Room***to engage all staff in the search process. a. Establishing that a resident is missing should involve: i. Reviewing the resident's capacity for leaving the facility. ii. Reviewing if the resident signed out of the facility. iii. Contacting the resident's responsible party/and or family to identify if the resident left with them . 2. The DON/Designee completes/updated a missing resident profile and makes copies to distribute/utilize during the search efforts. 3. The Administrator/Designee organizes and institutes an immediate and thorough search of the facility and surrounding grounds including but not limited to: a. A search of the area outside the nearest exit to the resident's room or exit where he/she was last seen. b. The entire unit of where the resident resides or was last seen. c. The remainder of the facility (all rooms, closets, storage facilities, bathrooms). d. Grounds, extending beyond the fence line . 5.The search should continue with staff members searching the streets and local areas (at least a 2-mile radius). Record review of the facility's grievance log from August 2024 through February 2025 revealed no concerns from Resident #1's family members and no concerns regarding any elopements. Record review of the facility's incident and accident log with a date range of 8/1/24 through 2/20/25 revealed only one elopement incident on 12/2/24 related to Resident #1. There were no other elopements related to any other resident at the facility from 8/1/24 through 2/20/25. Record review of the facility's Reporting incidents and accidents in-service acknowledgement dated 12/2/24 revealed charge nurses, MAs, and CNAs received training for how to investigate and follow up on incidents and accidents and completing incident and accident documentation. The signature page included the ADON, the nurse who was assigned to Resident #1 on 12/2/24 the evening of the elopement. The ADON, LVN A, LVN B, MA A, MA B, MA C, CNA A and CNA B were all interviewed about this in-service. Record review of the facility's Ensuring doors are locked behind staff entering and exiting secured unit in-service acknowledgement dated 12/2/24 revealed nursing staff/nursing administration received education on alarms sounds and doors security. The signature page included ADON, the nurse who was assigned to Resident #1 on 12/2/24 the evening of the elopement. The ADON, LVN A, LVN B, MA A, MA B, MA C, CNA A and CNA B were all interviewed about this in-service. Record review of the facility's Rounding in-service acknowledgement dated 12/2/24 revealed nursing staff received education on being expected to perform room to room rounds during shifts, shift changes and checking the census for their hall. The signature page included ADON, the nurse who was assigned to Resident #1 on 12/2/24 the evening of the elopement. The ADON, LVN A, LVN B, MA A, MA B, MA C, CNA A and CNA B were all interviewed about this in-service. Record review of facility's Abuse and Neglect in-service acknowledgement dated 12/2/24 revealed nursing staff received education on being expected to follow federal guidelines for ANE, prevention of ANE, reporting of ANE, and investigating allegations of ANE. The signature page included ADON, the nurse who was assigned to Resident #1 on 12/2/24 the evening of the elopement. The ADON, LVN A, LVN B, MA A, MA B, MA C, CNA A and CNA B were all interviewed about this in-service. Record review of facility's Elopement in-service acknowledgement dated 12/2/24 revealed nursing staff received education on facility staff received education on what to do when a resident was missing or eloped and calling of a Code Orange, the code used by the facility to communicate to all staff that a resident was missing or eloped. The signature page included ADON, MA A, MA B and CNA A who were the staff assigned to Resident #1 on 12/2/24 the evening of the elopement. The ADON, LVN A, LVN B, MA A, MA B, MA C, CNA A and CNA B were all interviewed about this in-service. Record review of facility's Facility Elopement Drill: Elopement/Missing Resident in-service acknowledgement dated 12/5/24 revealed facility staff received education on what to do when a resident was missing. The ADON, LVN A, LVN B, MA A, MA B, MA C, CNA A and CNA B were all interviewed about this in-service. Record review of facility's Code Orange Drill in-service acknowledgement dated 12/5/24 revealed nursing staff received education on what to do when a resident is missing or eloped. The ADON, LVN A, LVN B, MA A, MA B, MA C, CNA A and CNA B were all interviewed about this in-service. Record review of the facility Wander/Elopement Drill Report revealed there were elopement drills conducted on 12/5/24 at 5:40 am, 10:00 am and 6:45 pm. The signature pages included the ADON, LVN A, MA A, MA B, CNA A and CNA B who were the staff assigned to Resident #1 on 12/2/24 the evening of the elopement. Record review of facility's QAPI Action Plan dated 12/2/24 revealed the following: PIP opportunity Elopement .Date initiated 12/2/24 .Issue: Elopement procedures were not accurately followed .Immediate Intervention: Elopement drill performed. Educated all staff regarding policies and procedures for elopement. Re-education: Inservice all staff on the importance of immediately identifying elopement risks and immediate interventions to ensure the safety of residents . Record review of facility Wander/Elopement Drill Report revealed there was an elopement drill conducted on 1/7/25 at 10:10 am and 8:43pm. Record review of facility's 2025-2026 QAPI Committee Meeting Performance Improvement Plans .Current Active PIP's .Elopement Procedures, admission Process .Incidents and Accidents .Action Items .Ensuring accurate and timely completion of documentation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of five residents reviewed for quality of care. The facility failed to utilize emergency transport after Resident #1 had an unwitnessed fall which resulted in a subdural hematoma and 2.5-hour delay in care. Resident #1 was sent to the hospital and placed in the ICU. An Immediate Jeopardy (IJ) situation was identified on 7/26/24 at 6:10 PM. While the IJ was removed on 07/28/24, the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for delay in needed treatment and care, resulting in further injury, hospitalization, and/or death. Findings included: Record review of Resident #1's face sheet dated 7/26/24 revealed an [AGE] year-old female who was admitted originally to the facility on [DATE] and most recently on 4/24/24 with diagnoses including Dementia (group of symptoms affecting memory, thinking and social abilities), insomnia (Trouble falling and/or staying asleep), glaucoma (eye conditions that damage the optic nerve), blindness right and left eye, bipolar (eye conditions that damage the optic nerve). Record review of Resident #1's MDS dated [DATE], revealed her BIM score was 00 which indicated she had severe cognitive impairment. Resident #1 used a wheelchair for mobility, required supervision or touch to transfer to the wheelchair, sit to stand, and was independent to walk 10 feet. Record review of Resident #1's care plan dated 7/26/24 revealed the following in part: A. Focus: Sits and crawls on floor, will attempt to stand on WC or dining room table, 7.24.24 fall w/injury to face, sent to hospital. Date initiated 10/10/22 and revised on 7/25/24. Goal: none Intervention/Task: Observe for early warning signs of behavior - approach in a calm manner, call by name, remove from unwanted stimuli. Date initiated 10/10/22 . B. Focus: [Resident #1 reside in life engagement unit [secured unit] due to need for structured environment and poor safety awareness. Date initiated 10/10/22. Goal: Dignity will be maintained thru [through] next review. Date initiated 10/10/22. Interventions/Task: .Keep environment free of possible hazards . C. Focus: [Resident #1] is at risk for falls and fall related injuries R/T gait imbalance impaired memory, and Dementia .5/8/24 [Resident #1 on floor, bruises noted to rt back shoulder area, bruises to lt buttocks. 6/14/24 actual fall, lost balance, hitting head. Bruise to head. 7/1/24 unwitnessed fall causing laceration to lip and rt side of forehead. Sent to ER for eval. 7/3/24 put feet on dining room table while still in wheelchair. Pushed and caused self to tip over backwards. No injuries. Date initiated 9/23/23. Goal: [Resident #1] will be free from fall related injuries over the next 90-day review period. Date initiated 9/26/23. Interventions/Task: Anticipate needs - provide prompt assistance. D. Focus: [Resident #1] reside in secure unit for wandering elopement risk need for controlled environment poor safety awareness. Date initiated 4.25.24. Goal: . [Resident #1 will be safe thru [through] next review. Date initiated 4.25.24. Interventions/Task: Keep environment free of possible hazards . Record review of Resident #1's orders dated 7/26/24 revealed that her observation behaviors were crawling on the floor and standing on furniture. Record review of Resident #1's progress notes dated 7/24/24 (written by LVN A) reflected the following: Text: At about 7:45p [pm] pt. was found on floor in room, under her wheelchair with a small laceration above L eye. the L eye is swollen shut and she has a busted lip. [Pain medication] 325mg 2 tabs was given for pain/discomfort and icepack to eye. V/S [vital signs] are 126/71 P [pulse] 54, SpO2 97% and T [temp]-97.2 [degrees]. DON and on-call notified. Pt. to be sent out to [Hospital] for ER CT scan Record review of Resident #1's hospital admission report dated 7/24/2024 revealed the following in part: .07/24/24 2238 [10:48 PM] Presentation Chief Complaint Fall, Head injury Onset Occurred Today, Unknown Symptom Duration Constant Progression since Onset .Notes [AGE] year-old female patient was brought in by EMS alert but nonverbal, found on the floor as an unwitnessed fall. She has a hematoma above the left eye with a small abrasion to that area that caused some bleeding on the scene. Patient had no vomiting no other symptoms. Neurologically at baseline per EMS transport staff from the nursing home . Acute 5.8 mm subdural hematoma [A condition due to bleeding under the membrane covering the brain] along the right tentorium [extension of one of the membranes covering the largest part of the brain] . reviewed the head CT. There is a thin layer of blood overlying the tentorium on the right without mass effect. No convexity subdural hematoma or brain contusion. Plan: 1. Admit to ICU and repeat head CT in AM 2. No need for anticonvulsants [drugs that prevent or reduce seizures by stabilizing nerve cell activity in the brain]. 7. In an interview on 7/26/24 at 4:12 PM, LVN A said she was called to Resident #1's room by CNA B after Resident #1 was found on the floor. She said she completed and documented a head-to-toe assessment, skin assessment and took Resident #1's vitals. She said Resident #1's vitals were stable and within normal range. She said she made notifications, one of which was the on call medical professional. She said NP A directed her to send Resident #1 to the ER. LVN A said she sent Resident #1 via non-emergency transportation to the ER because Resident #1 had falls before, did not have bleeding and her vitals were within her normal limits. LVN A said she called 3 transportation services and selected the services with the shortest response time (1 ½ hour). She said she performed neuro checks for approximately 1 hour and a half until Resident #1 went to sleep approximately around 9:00 PM. LVN A said she passed medications on another hall until EMS picked up Resident #1 approximately at 10:00 PM. She said she was not required to document the neuro check and had not been trained to document the neuro checks. She said she did not think Resident #1 was at risk by going out non-emergency transports versus going out sooner with 911. Interview on 7/26/24 at 10:58 AM, CNA A said she was called around 7:30 PM by CNA B to assist with Resident #1. CNA A said Resident #1 was on the floor under her wheelchair. She said CNA B then went to tell LVN A what happened. CNA A said LVN A came in, completed the assessment and they turned Resident #1 over and placed her back in bed. CNA A said Resident #1 had a bump over her left eye and a cut to her lip. She said she continued her duties after Resident #1 was put back in bed. She said Resident #1 was sent out the emergency room, but it was after 9:30 PM. In an observation on 7/26/24 at 11:55 AM, Resident #1 was in bed in the ICU unit of the hospital. Her eyes were closed and she had the covers to her chin. She had a dark purple bruise above her left eye and a family member stood over her wiping her face. In an attempted interview on 7/26/24 at 11:55 AM, the surveyor introduced themselves to Resident #1 and asked her how she felt. Resident #1 did not respond or open her eyes to acknowledge the surveyor. The family member told the surveyor that she was non-verbal. In an interview on 7/26/24 at 12:05 PM, RN A at hospital stated that Resident #1 was admitted to the ICU on 7/24/24 at 11:30 PM after she had received several CT head scans. Her injuries were bruising of the left eye and a subdural hematoma. She explained that the hospital's EMS had an urgent response time and a 2.5-hour delay in emergency services was detrimental because you could not determine how bad a head injury was until after a resident received their scans. RN stated luckily Resident #1's hemorrhagic area was not too big because if it had been larger, Resident #1 would have needed surgery. In an interview on 7/26/24 at 12:13 PM, a family member of Resident #1, stated she had a missed call from the facility regarding the fall of Resident #1 on 7/24/24 at 8:36 PM. She called the facility back for further information at 9:58 PM and was told that Resident #1 had just left the facility and was headed to the hospital. She stated that she arrived at the hospital after 10 PM and she waited for Resident #1 to arrive at 10:30 PM. She explained that the hospital was not busy and she believed that there was a delay in care on the facility's part. In an interview on 7/26/24 at 1:56 PM with CNA A, she explained that some of Resident #1's behaviors were trying to climb tables, her wheelchair, and she would climb on the floor. In the room, there were two wheelchairs pushed seat first to the opposite wall of Resident #1's bed. CNA A stated that when they were preparing residents for bed, they like to tend to Resident #1 first so they could know her whereabouts as they tended to other residents. She explained that when she would work with Resident #1, she would normally take the wheelchairs out of the room because the resident was a fall risk and liked to stand up on the wheelchair. She explained that on the night on 7/24/24, CNA B called her to come down to Resident #1's room because she found her on the floor. When she came into her room, Resident #1 was laying on the floor in fetal position underneath one of her wheelchairs. They called for LVN A, who came in and assessed the resident. In an interview on 7/26/24 at 2:15 PM with the ADON, she stated that she was off on 7/24/24. She explained that the protocol for an unwitnessed fall with head injury was to call the physician, the DON, then fill out physician orders. Nurses were to perform, vitals, a pain assessment, fall assessment, skin assessment, document any risks, and complete a SBAR (change in condition documentation). She stated that if she saw a situation that seemed to be an emergency, she would use her nursing judgement to call 911 and let the physician know that she did. She stated that all nurses can notify the doctor after hours through an app (online application). She said that she always educated staff that if they could not reach anyone after 20 minutes, they were to contact the physician directly. Interview on 7/26/24 at 2:31 PM, the DON said she was notified Resident #1 was found on the floor with a head injury. LVN A gave Resident #1 ice for the swelling, Tylenol, and sent her a picture. Once she saw the picture, she told LVN A that she thought Resident #1 needed a CT scan and the physician notified, also agreed. She said she initially thought LVN A sent Resident #1 out via 911. She said after an interview with LVN A, she found out that Resident #1 was sent out via non-emergency transport. The DON said Resident #1 was picked up at approximately 10:00 PM. She said LVN A was told by the on call NP to send to the ER which did not necessarily mean 911. She said because Resident #1 was stable, not on anticoagulants, not bleeding, and was at baseline she would have preferred emergency services, but non emergent services was fine in this incident. In an interview on 7/26/24 at 2:55 PM, CNA B said she found Resident #1 on the floor in her room in the fetal position with her wheelchair on top of her. CNA B said she asked for help from CNA A and LVN A. CNA B said LVN A came, removed the wheelchair off of Resident #1 and began the assessments and tookher vitals. She said Resident #1 had a bump over her left eye and her lip was split. She said Resident #1 was sent to the ER but she could not remember what time Resident #1 left. She said Resident #1 did not leave within the first hour after the incident. CNA A said Resident #1 had a behavior of crawling on the floor and standing up on wheelchairs and furniture. In an interview on 7/26/24 at 3:13 PM, the Medical Director said she was notified of Resident #1's unwitnessed fall. The Medical Director said NP A was the on-call respondent. She said based on what she was told, Resident #1 vitals were stable and there was no blood, it was fair to send Resident #1 out within a few hours by non-emergency transportation. In an interview on 7/28/24 at 4:31 p.m., NP A said she was notified Resident #1 was found on the floor with a wheelchair on top of her. NP A said she was told Resident #1 had an injury to her head and was not bleeding. NP A said she was notified Resident #1's vitals were with in normal range. She advised LVN A to send Resident #1 to the ER. NP A said it was a nursing judgement call whether to send out Resident #1 by 911 or non-emergency transport to ER was the facilities choice. Record review of facility policy Nursing Policies and Procedures - Fall Management (revised 1/2019) revealed the following in part: Policy: It is the policy of this facility to evaluate extent of injury after a fall, prevent complications and to provide emergency care . Purpose: 1. To identify resident at risk in a timely manner .4. To respond to a fall in a manner that will ensure the resident is treated timely and safely .In the Event of a Fall: 1. The resident will be checked for any abnormalities: i.e. A. Deformed, discolored or painful body parts. B. Bumps. C. Bruises D. Cuts. E. Abrasions F. Scrapes G. Confusion H. Level of consciousness. 3. Obtain vital signs .5. Initiate neurological checks for any fall where a resident his his/her head or for any unwitnessed fall .Note1. If condition from fall is life threatening, the nurse shall initiate EMS (Emergency Medical Services) stat and then place a call to physician, hospice, and family/responsible party . This was determined to be an Immediate Jeopardy (IJ) on 7/26/24 at 6:10 PM. The DON and ADON were notified. The DON was provided with the IJ template on 7/26/24 at 6:10 PM. The following Plan of Removal submitted by the facility was accepted on 07/27/24 at 4:00 PM: Facility- IJ Plan of Removal for F684 7/26/2024 Allegation F684: Quality of Care The facility failed to obtain emergency services for unwitnessed fall for Resident #1 after a fall on 7/24/24 that resulted in bruising to a subdural hematoma to the left side of her head. Resident #1 arrived at the ER approximately two and a half hours after the injury had occurred. On 7/24/24 Resident #1 was transferred to the hospital. LVN A was suspended pending investigation 7/25/24 based on Self Report to HHSC. The Administrator and Director of Nursing notified the Medical Director of the IJ on 7/26/24. The Regional Nurse Consultant provided 1:1 education with the DON on 7/26/24 on the following topics: o Conducting an Investigation Post Falls o Fall Management o Changes of Condition Warranting 911 Transfer o Neuros Vital Signs Status Post Falls The Director of Nursing initiated education with Licensed staff members on 7/26/24 on: o Fall Management o Change of Condition Warranting 911 Transfer o Neuro Vital Signs Status Post Falls o Incident & Accident Quick Guide *All License Staff will be Educated Prior to Working & Complete Post Test to Demonstrate Competency. All Training to be Completed by 7/27/24. Audit of Resident Falls x last 30 Days Completed; DON & ADON Assessed Residents Identified to ensure there were no adverse effects status post fall that had not been addressed. Assessments Completed 7/26/24. Ad Hoc QAPI Conducted 7/26/24 with Medical Director, Administrator, DON, & ADON. Monitoring Day 1: Saturday July 27th, 2024 In an interview on 7/27/24 at 4:08 PM with the DON, she stated she was educated on doing neuro checks and what the time frame was. The neuro documentation sheets were changed to front and back copies to help keep up with them. She discussed that if there were any changes in neuro responses, it was an acute change and it was an emergency. There was also a quick guide for falls created a copy is held at each nurse's station for them to review. The quick guide gives examples for everything that was required and considerations of what to do after a fall. Fall management covered that prior to a fall, and doing a fall assessment, nurses needed to pay attention to the score. They were responsible for recognizing the score and putting something in place at that time. Some patients have fall injuries and may need a fall mat. If it is a trip hazard, nurses have to wave that out. Nurses need to make sure that anytime there is a fall intervention in place it makes sure that we are looking at each person's care plan. The nurse can add interventions in the risk management, and it will be reviewed by the IDT team and DON in the morning. In the event of a fall, herself and the Regional Nurse covered to make sure they did skin assessment, initiated neuro checks, evaluated cause of fall, and did a complete vital sign, neuro check, and range of motion. Staff must notify her of all falls and if the doctor they are trying to reach had not responded in 1 hour, they must notify the Medical Director. Nurses must notify RP and if a resident is their own RP, instead of leaving blank that section blank in the documentation, nurses are to add the resident's name to state they are their own RP. Everything must be documented and passed on to the report. If the condition was life threatening, they would notify EMS, then they would call the doctor and notify the DON. They also covered in the education that anytime a resident changes the level of plane it is still a fall. Unless there was evident of something otherwise, if a resident is on the floor, then a fall is considered to have happened. The DON stated she discussed with nurses the signs of a head Injury such as unequal pupils, loss of consciousness, change in cognition, nausea and vomiting, and/or a headache. If the resident already had a something nurses were monitoring like aspirin or blood thinners, the nurse would send the resident out to be evaluated. The facility added a table for what type of treatment would need to be done for time frames to be viewed at the nurses station as well. If there were any abnormal neuro changes, muscle or skeletal issues, they needed to be in the ER within an hour. If there was any bleeding or anything with large lacerations, residents could be sent out, stating that They are nurses and should still be ale to use judgement. In an interview on 7/27/24 at 4:38 PM, LVN B stated that she had worked at the facility for 5 months and worked from 6AM- 6PM. She stated for the fall protocol, they covered the procedure for and an unwitnessed and witnessed fall. An unwitnessed fall automatically needed neuro checks. They were to do assessments, vitals before they have been moved, and check for pain and any possible dislocations. Nurses were to do a whole assessment, notify the doctor and receive orders, and notify the DON, and family. Witnessed falls with head injury called for the same procedure except they would medicate immediately, do neuro checks, and vitals. If there was an emergency and they needed to call 911, nurses can call them and let the doctor and family know. Some examples of emergencies were an acute change in cognition, head injuries, suspected dislocation, pain upon movement, headaches, and suspected bleeding. Everything that needed to be documented after a fall would be the SBAR, risk management, pain assessment, skin assessment, fall assessment, and neuros. LVN B stated that the quick guide for fall assessments was located at the nurse's station and they gave each nurses a copy after the in-service. In an interview with on 7/27/24 at 4:47 PM with LVN C, she stated that she had started work at the facility on 6/5/24 and worked the 6AM- 6PM shift. She explained the fall protocol was to assess the patient before the touched them for injuries and check their vitals. If it was an unwitnessed fall she would we do neuro checks and check head to toe to make sure there was no other pain. Nurses will also make sure the doctor and DON was aware. If on blood thinners, they would send the resident to the hospital. Vitals should be monitored and if they have major symptoms like bleeding, unresponsiveness, not alert and oriented, she would send them out because she did not want to take any chances. LVN C also stated that the doctor, family, and DON must be aware. For every fall, nurse complete a SBAR, fall assessment, pain assessment, skin assessment, and do neuro checks. Neuro checks were especially completed if the fall was unwitnessed or witnessed with a head injury. If there was an emergency like the patient was unresponsive or a mood change in condition, she would call 911 first and the call the doctor. She explained that they have quick sheets for fall protocols and book for the neuros that she kept at her desk at the nurse's station. In an interview on 7/27/24 at 4:53 PM with LVN D, she stated she started working at the facility on 06/01/24 and she worked the 6AM- 6PM shift. She explained that in the fall protocol in-service, they covered what to do in a witnessed and unwitnessed fall. Nurses have to do an incident t report and SBAR. If the CNAs found the resident first, she would make sure they don't touch them, and continue with vitals, neuro checks, and check for broken bones. She would also check to see if the resident was on blood thinners and if there was an emergency, she would call 911 immediately without waiting on a response from the doctor. Examples of emergencies would be if they were on a blood thinner and hit their head, visibly bleeding profusely, broken limbs, unconscious, headaches, seizures, and if there was something she couldn't control. She explained when was had to call 911 for emergency, she would notify the DON, she would stay with the resident, and assign someone else to call 911. She would also doctor or on call if they take too long, she would call the Medical Director and notify the family. If the resident was their own RP, she would write that in the risk management assessment and SBAR, as well as in her own progress note. There was a fall protocol quick note sheet she was given during the education that she placed at her desk and she stated that she also kept all of the paperwork from facility in-services in her work bag. Nursing also had a flow sheet for monitoring neuros, which was just updated. LVN C said for neuros, they have to follow up every 30 minutes, for up to 72 hours and it was self-explanatory. In an interview on 7/27/24 at 5:15 PM with the ADON, she stated that in the fall protocol nurses went over the steps of what to do when there was a fall, what documentation, and who to notify when you can and cannot notify the physician. The documentation was the risk assessment of incident report, SBAR, fall assessment, pain assessment, and skin assessment. They were to make sure to notify the physician and RP if there was one and the DON for protocol because there was a change in condition. She stated she also does a progress note. It the fall was unwitnessed and with a head injury, nurses have to start neuros. When a resident falls, they go to the resident and let CNA's know not to touch them. They perform a full head to toe assessment, do range of motion, and check skin integrity for any tears bumps bruising. Then she would assess if they were in pain and if so, immediately address with PRN pain meds, and if none I get an order form the physician. Nurses do not have to contact the physician first if there was a 911 situation. She explained she would do what was best based off her nursing judgment. Emergencies would be any changes in head or skin, nonstop bleeding, headaches non-retractive, unstable vitals, changes in neurological conditions, and vomiting. If they contact the doctor and they have not responded after 15-20 minutes, she would contact the DON and the medical director by phone call to let them know what is going on. The fall quick notes are kept at the nurse's station and it outlined step by step what also needed to be done in care of a fall, including neuro checks done every 30 minutes. In an interview on 07/27/24 at 5:30 PM with the WCN, she stated she been here since 4/22/24, and worked Monday through Friday from 8AM- 6PM. She stated that in the fall protocol, they went over what the policies were if the fall was witnessed or unwitnessed, neuro checks, and what the procedures were. When a resident falls, she would do a head-to-toe assessment, vital signs, and contact the physician and notify the family. If the fall was unwitnessed, she would start her neuro checks. She stated that she would count the vitals she did initially as her first check and start from there. Assessments completed were the neuro assessment, pain assessment, progress note, SBAR, fall assessment, range of motion, and skin assessment. If the resident was nonverbal, we look for verbal cues. Nurses can call 911 if there was an emergency and they needed medical attention before contacting the doctor. These emergencies included bleeding, possible fracture, unresponsiveness, seizures, change in condition, headaches, injuries, or bleeding. If she could not reach the doctor, she would still have to notify the DON, ADON, and the medical director. The fall protocol quick sheets were kept at the nursing stations. If the form said RP on the neuro check sheet and the resident was their own RP, she would still contact the emergency contact because she wanted to let someone know what was going on. Day 2: Sunday July 28th, 2024 In an interview on 07/28/24 at 1:10 PM with LVN E, said she was in-serviced on fall protocol policy. She said a head-to-toe assessment, neuro checks, SBAR, fall assessment, pain assessment and skin assessment had to be completed for residents who had a witness or unwitnessed fall. She said vital signs and range of motion had to be completed and documented. She said a resident who was bleeding, took blood thinners, vital sign out of normal range, unconscious, broken bones would be sent out 911. She said she would make notifications to the RP, Administrator, DON, ADON and the physician. She said there was a cheat sheet located at the nurses' station for reference if needed. In an interview on 07/28/24 at 1:37 PM with LVN F said she was in-serviced on fall protocols. She said there was a binder at the nurse's station to refer to if needed. She said residents who had a change in condition, unresponsive, on blood thinners/had bleeding, fractures would be sent out 911. She said the Doctor, DON, ADON, Administrator and RP would be notified. She said a head-to-toe assessment would be completed along with SBAR, range of motion, pain, skin and fall assessments. She said neuro checks would be completed in various intervals indicated on the neuro check form. In an interview on 07/28/24 at 2:03 PM with LVN G said with a fall and a resident has a head injury he would do assessment head to toe, take vital signs, check range of motion and call the Doctor, DON, Administrator and family. He said he would document in the nursing notes along with neuros checks, pain, fall and skin assessment. If they hit their head, we send the resident out 911 if there was bleeding, on anticoagulants, unresponsive and change of condition that was not at the resident's baseline. He said we have a binder at the nursing station to refer to if needed on the steps to take after a fall. In an interview on 07/28/24 at 2:09 PM with LVN H said she had been in-serviced and was aware of the steps to follow after a witness or unwitnessed fall. She said a head-to-toe assessment would be completed with range of motion to detect any fractures. She said residents with fractures, bleeding, on anticoagulants, and unresponsive would be sent out by 911. She said residents who had a witness or unwitnessed fall, neuro checks, SBAR, fall assessment, pain assessment and skin assessment had to be completed. She said the DON, Administrator, Family and Doctor is notified. He said there was a quick guide at the nurses' station with all of the fall protocol steps. In an interview on 07/28/24 at 2:29 PM with LVN I said he was aware of the fall protocols. He said he would check a resident's vitals, range of motion and head to toe assessment for unwitnessed or witnessed falls. He said if a resident was not responsive, bleeding, on blood thinners, change in condition, or broken bones the resident would be sent out 911. He said after a resident had a fall, neuros, fall, pain, and skin assessments had to be completed. He said there was a reference guide at the nurses' station with the fall protocol. He said the steps taken after a fall had to be documented and notifications made to the doctor, family, DON and Administrator. In an interview on 07/28/24 at 2:48 PM with LVN J said after a fall all steps taken had to be documented. She said a quick guide for falls was located at the nurse's station. She said a SBAR, risk management, pain assessment, skin assessment, fall assessment, and neuros had to be completed. She said when there was a change in condition, bleeding, head injuries, unconscious or fractures a resident would be seen out 911. She said notifications should be made to the family, DON, ADON, Administrator and the physician. In an interview on 7/28/24 at 7:12 AM with LVN K said she was in serviced on the facility's fall policy. She said all actions taken after a fall had to be documented. She said a fall assessment, neuro checks, skin and pain assessments had to be completed. She said notifications to the physician, family and DON should be completed. She said the facility placed a quick guide at the nurses' stations to reference the steps after a fall. She said residents would be sent out 911 after a fall, if they had bleeding, unconscious, range of motion issues that indicated broken bones, and abnormal vitals. Record review of facility Education In-services on Quick Guide - Falls, Change in Condition Communication, Neurological Neuro Checks, Fall Management, Investigation of Falls, Fall Management Post Test dated 7/26/24-7/28/24 revealed all staff were trained on the Fall Management Policies and tested on knowledge of the policies. The Admin was informed the Immediate Jeopardy (IJ) was removed on 7/28/24 at 7:09 PM. While the IJ was removed, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their plan of removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility staff failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the residents' choices for 3 of 15 residents (Resident #1, Resident #4 and Resident #9) reviewed for quality of care. -The facility failed to follow up with physician for Resident #1's legs that were observed to be swollen, red, flaky with drainage. -The facility failed to accurately assess Resident #1's skin weekly as ordered by the physician. -The facility failed to establish wound care services for Resident #1 as ordered. -The facility failed to provide Resident #1 with pain medication as needed, per physician orders. -The facility failed to provide ancillary services for Resident #1 as ordered. -The facility failed to perform proper wound care techniques for all residents needing wound care for Resident #1, Resident #4 and Resident #9. -Resident #4 developed 2 stage 4 pressure ulcers after admission to the facility. One ulcer was measure at 16x8x.5 cm. -Resident #4 was not provided colostomy care/assistance by facility staff An Immediate Jeopardy (IJ) was identified on 4/28/23. The IJ template was provided to the facility on 4/28/23 at 4:30 p.m. While the IJ was removed on 5/3/23 at 10:58 a.m., the facility remained out of compliance at a severity level of actual harm that is an Immediate Jeopardy and a scope of pattern because all staff had not been trained on Quality of Care. These failures placed residents at risk of not receiving quality care and services to meet their physical, mental and psychosocial needs. Findings include: Resident #1 Record review of Resident #1's face sheet revealed he admitted to the facility on [DATE] and re-admitted on [DATE]. He was a [AGE] year-old male with a diagnosis of Peripheral Vascular Disease (a systemic disorder that involves the narrowing of peripheral blood vessels), malaise (general feeling of discomfort), Parkinson's disease (disorder of the central nervous system that affects movement, often including tremors), pain in right shoulder, and cervical region radiculopathy (nerve in the neck is compressed or irritated). Record review of Resident #1's care plan dated 3/7/23 revealed, Focus: Pain [Resident #1] complains of increased pain/discomfort and is at risk for further episodes of increased pain/discomfort and injury. Goal: [Resident #1] will maintain current levels of ADLs and any pain/discomfort will be relieved within 1 hour of delivery of pain medication or other intervention over the next 90 days. Intervention/Tasks: Allow to verbalize feelings of pain/discomfort .Monitor effectiveness of pain medication-report to MD of any noted, observe for s/sx of increased pain/discomfort-assess resident for possible causes, give pain medications, treatments, relaxation modalities, etc., check for relief, and utilize 0-10 numbers pain scale to assess pain level. [Resident #1] is at risk for poor circulation, irregular pulse, and chest pain AEB due to diagnosis of PVD. Goal: [Resident #1] will not develop complications related to disease process over the next 90 days. Intervention/Tasks: Administer medications as ordered, document any s/sx of PVD in the clinical record, encourage resident to be active and exercise within limitations, monitor lab works for abnormalities-report to MD of any noted, monitor for skin breakdown with close attention to lower extremities, and podiatry visits as needed. Record review of Resident #1's admission MAR dated 2/24/23 revealed he was cognitively intact with a score of 14 out of 15 for cognition and was able to recall, understand and make himself understood. Resident #1's functional status revealed he did not walk in corridor, did not have locomotion on or off the unit and activity occurred once or twice with 1 person assist for walk in room, extensive assistance with two person assist for bed mobility, transfer, dressing, toilet use and extensive assistance with one person assist for eating and personal hygiene. Record review of Resident #1's physician orders revealed: Conduct weekly skin evaluation. Document UDA under assessments- skin observations. Notify MD of new skin conditions. Every evening shift every Wednesday for skin Management start date 3/15/23. Doxycycline Monohydrate 100 MG Capsule Give 1 capsule orally two times a day for Related to cellulitis (x10 days). for 10 Days Administer 1 capsule PO (100 mg Doxycycline) twice daily (for 10 days) related to cellulitis. -Order Date- 04/20/2023 5:15 p.m. was administered. Consult: May be seen and treated by a Dentist order date 3/29/23. Consult: May be seen and treated by a Podiatrist order date 3/29/23. Consult: May be seen and treated by an Optometrist/Ophthalmologist order date 3/29/23. Observation: Pain-Observe every shift. If pain present, complete pain flow sheet and treat trying non-pharmacologic interventions prior to medicating if appropriate. Document in the PNs. Every shift order started 2/18/23 and revision date 2/20/23. Lasix oral tablet 40 mg (Furosemide) give 1 tablet 1 time a day for edema revision dated 4/21/23 Aquaphor External Ointment (Emollient) Apply to lower legs topically two times a day for dermatitis revision date 4/20/23 Acetaminophen-Codeine #3 Oral Tablet 300-30 mg (Acetaminophen w/Codeine) Give 1 tablet by mouth every 6 hours as needed for pain start date and revision date 2/26/23 Tylenol Oral tablet 325 mg (Acetaminophen) Give 2 tablet by mouth every 6 hours as needed for pain start date 3/12/23 revision date 3/13/23 Record review of Resident #1's Medication Administration Record/Treatment Administration Record for April 2023 revealed: Conduct Weekly Skin Evaluation. Document UDA under Assessments - Skin Observations. Notify MD of New Skin Conditions. Every evening shift every Wed for Skin Management-Order Date- 03/09/2023 6:14 a.m. was documented as completed as ordered. Aquaphor External Ointment (Emollient) Apply to lower legs topically two times a day for dermatitis -Order Date- 04/20/2023 10:27 a.m. was administered as ordered. Observation: Pain - Observe every shift. If pain present, complete pain flow sheet and treat trying non-pharmacologic interventions prior to medicating if appropriate. Document in the PNs. Every shift -Order Date- 02/17/2023 at 10:34 p.m. revealed: no pain level recorded on: 4/6/23, resident had 0 pain on 4/4/23, 4/5/23, 4/7/23, 4/8/23, 4/9/23, 4/11/23, 4/13/23, 4/17/23, 4/19/23, 4/20/23, 4/21/23, 4/22/23, and 4/24/23. Acetaminophen-Codeine #3 Oral Tablet 300-30 MG (Acetaminophen w/ Codeine) Give 1 tablet by mouth every 6 hours as needed for pain -Order Date- 02/26/2023 at 3:45 p.m. revealed medication was administered on 4/1/23, 4/4/23, 4/6/23, 4/7/23, 4/8/23, 4/15/23, 4/16/23, 4/25/23, 4/26/23 and 4/27/23. Tylenol Oral Tablet 325 MG (Acetaminophen) Give 2 tablet by mouth every 6 hours as needed for Pain -Order Date- 03/12/2023 at 0931 revealed no medication was administered on 4/1-4/16/23 and 4/20-4/24/23, 4/26/23 and 4/27/23. Record review and interview on 4/26/23 at 10:10 a.m. with LVN A revealed Resident #1's last administration of Acetaminophen-Codeine #3 Oral tablet 300-30 MG was on 4/24/23 at 11:42 p.m. Record review of Resident #1's Skin Observation dated 3/8/23 at 6:11 a.m. revealed skin check was not refused, and skin was intact. Record review of Resident #1's Skin Observation dated 4/12/23 at 6:29 a.m. revealed skin check was not refused, and skin was intact. Record review of Resident #1's Skin Observation dated 4/27/23 at 7:36 p.m. revealed skin check was not refused, and skin was intact. Record review of Resident #1's Braden Scale-Predicting Pressure Score Risk dated 3/3/23 at 11:48 a.m. revealed mild risk with a score of 16. Moisture: Occasionally moist, Bedfast. Confined to bed, mobility slightly limited, Nutrition adequate, friction & Shear: no apparent problem. Record review of Resident #1's Braden Scale-Predicting Pressure Score Risk dated 3/31/23 at 1:54 a.m. revealed no risk with a score of 21. Moisture: Occasionally moist, Walks frequently, mobility no limitation, Nutrition adequate, friction & Shear: no apparent problem. Record review of Physician A Progress note dated 3/14/23 at 7:20 p.m. revealed: 3/14/23 [Resident #1] was seen lying in bed. He was moved to a new room recently. Has been having pain in legs, PRN Tylenol #3 helps. Record review of NP Progress note dated 3/19/23 at 11:51 a.m. revealed: 3/16/23 [Resident #1] was seen lying in bed. He report tingling pain to his LE is not well controlled. Report he was taking gabapentin 800 mg qid at home with good effect, medication currently schedule tid. He has swelling to his LE, denies SOB or cough. Staff report no concern. Record review of Resident #1's Progress notes dated 4/12/23 at 11:53 p.m. revealed Found on floor in front of his wheelchair lying on his left side. Assisted to feet and bedside by CNAx2. Brief dry, changed. VS stable. Denies hitting head. ROM to all extremities at baseline. Skin tear noted to right lateral lower leg. Cleansed with wound cleaner and dry dressing applied. Unit Manager updated, MD updated. Neuro checks initiated. Record review of Resident #1's Progress notes dated 4/16/23 4:40 p.m. revealed Status post related to skin tear. Record review of Resident #1's Progress notes dated 4/24/23 at 10:45 p.m. written by RN B revealed Bilateral lower extremities pain at a 6/10 on a pain scale. PRN pain medication administered. Record review of Resident #1's Progress notes dated 4/24/23 at 11:42 p.m. written by RN B revealed Resident denies pain at this time and is in no apparent distress and/or discomfort. PRN Administration was: Effective. Follow up Pain Scale was 0. Record review on 4/25/23 of Resident #1's Progress notes from the Social worker did not reveal referrals, as of 4/25/23 for the dentist, podiatrist, or ophthalmologist. In an observation and interview on 4/25/23 at 10:15 a.m. with Resident #1 he was observed standing in the hallway wearing a robe, 3 shirts and an adult brief when he asked this Surveyor to speak with him. He stated he had not received any services and his legs were swollen, red and draining blood and fluid. Resident #1 stated he was supposed to have cream to apply on his legs and the staff put the cream on it one day and they (unknown staff) told her (unknown staff) not to do it again. Resident #1 stated the staff do not do it so he has deteriorated. Resident #1 stated his feet were so irritated that they kept him up all night and he could not sleep and could not bear to have socks on them. Resident #1 stated he tells all the staff about what he needs, and he told them that he was in pain, and no one has helped him. Resident #1 stated he just gets the run around and they cover up for one another and they threaten to send the resident to the psychiatric unit. Resident #1 stated he had not received his pain pills for 3 days and he continued asking the nurses and the CNAs about his pain medicine. Observation of Resident #1's legs revealed they were swollen, flaky, red and draining fluid. Resident #1 showed this Surveyor his feet and observation revealed they were swollen, red, flaky, draining, his toenails were very long and his right second toe appeared to cross over the first toe and he stated he needed to see a podiatrist. Observation revealed Resident #1's teeth were observed broken and brown and he stated he had lots of cavities on the top part of his mouth. Resident #1 stated he had an accident and his teeth got broken and some were broken because of a fight. Record review of Resident #1's Progress notes dated 4/25/23 at 1:19 p.m. written by RN C revealed NP notified of need for script for APAP #3 refill. In an interview on 4/25/23 at 2:10 p.m. with Resident #1 he stated he had not had his pain med's all day and he asked since 6 a.m. this morning. Resident #1 stated he asked 2 CNA's (unknown name). Observation revealed Resident #1 was seen walking around the facility by the Nurses desk wearing 3 shirts, an open robe and adult briefs. In an interview on 4/25/23 at 2:25 p.m. with Resident #1 and LVN B at the Nurses Desk. LVN B stated she would check to see when the last time Resident #1 received his pain med's. LVN B was observed administering 2 regular Tylenol pills to Resident #1 and LVN B stated that Resident #1 ran out of Tylenol 3. LVN B stated Resident #1 had orders for PRN-Tylenol and Tylenol 3 and the last time he (Resident #1) received pain meds was late last night on 4/24/23 at 10 p.m. LVN B stated Resident #1 usually asked for the Tylenol 3 once or twice a day. Observation revealed LVN B offered Resident #1 to talk to his Physician to get something scheduled. In an observation and interview on 4/26/23 at 9:58 a.m. with LVN A she called the pharmacy to see if the Tylenol 3 was in the building and she found that Codeine #3 was delivered this morning at 6 a.m. and was signed by the ADON. LVN A stated the last time the Tylenol #3 was given was on 4/24/23 at 10:45 p.m. by RN B. LVN A stated when the resident gets down to 7 pills they have to order the meds electronically, but the pharmacy does not check their records daily. LVN A stated the facility delayed the meds because the pharmacy does not send the meds. In an interview and record review on 4/26/23 at 11:09 a.m. with the Social Worker (SW) he stated if a resident needed services, nursing would give him the information in the morning meeting or the resident would let him know themselves about services needed. The SW stated the family member of the residents also told him about any services they need for the resident in care plan meetings. The SW stated if the resident's insurance is between their Medicare ending for skilled services and there is a period where Medicaid is still processing if they need an appointment ASAP then he would try to get them an appointment outside of the facility with their Medicare insurance. The SW stated Optometry was coming May 1st, and podiatry on 5/4/23. He stated the only way they check to see if a resident needed services is if someone tells him. The SW stated the facility had not checked all the residents to see if they needed ancillary services, because he had never seen the local company the facility used just check all the residents. The SW did print out the list of residents who were scheduled to receive dental, optometry and podiatry services and observation revealed Resident #1 was not listed on any of the scheduled services. The SW stated he just signed Resident #1 up for services on his legs because he received a text message on 4/25/23 telling him he needed an appointment. The SW stated Resident #1 was Medicaid pending, so it's hard-to-get services for him. The SW stated that was the gray area from changing from being short skilled and Medicaid pending. The SW stated he had interacted multiple times with Resident #1 and he also scheduled appointments for him. The SW stated Resident #1 was the type of person who would tell everyone who was willing to listen about what he needed. The SW stated he did not know why Resident #1 did not see the wound care physician. The SW stated he was aware that Resident #1's glasses and clothing had gone missing, and he did go through the process of looking for his items that were missing. He stated the facility policy is that they were not responsible if things are lost or stolen, and it is in the contract the resident's sign when they admit to the facility. The SW stated he just received a text message about all the issues Resident #1 had on yesterday. In an interview on 4/26/23 at 4:10 p.m. with the DON she stated that her expectation was for the floor nurses to do wound care every day. The DON stated on today, the facility was supposed to have a 1 p.m. meeting and her ADON is licensed for wound care, and he was supposed to train the nurses. She lost the wound care nurse about 2 weeks ago. The nurses were supposed to do wound care daily. The DON stated the facility had been hiring Agency staff so they stopped the agency staff from coming on Sunday. The DON stated the ADON, worked on last night to teach the Nurses. The DON stated after the previous Wound Care Nurse left, they were so confused so when the wound care nurse left it took them down quick. The DON stated they will do a course to understand Stage 1 and Stage II. The DON stated the facility hired Agency Nurses a lot. Now on the weekends they have their own nurses to do the weekend wound care. The Wound Care Nurse was also the Manager on duty on the weekends. The DON stated all the nurses have to do their wounds on the floor. She stated a new wound care nurse is supposed to start tomorrow and The Wound Care Physician recommended him. The DON stated she asked LVN A to do the wounds on her day off. The DON stated she is not a wound care nurse. Observation with LVN A for Resident #6's wound care revealed LVN A thought LOTA was Triple antibiotic ointment. On the treatment they write it as TAO-Triple antibiotic ointment. The DON stated they have to show the nurses how to understand the orders and she was planning to complete some in-services. The DON stated Resident #4 almost never got his morning med's and she has been DON for 2 months. The DON stated she was also a Nurse Practitioner. The DON stated Resident #1's legs were swollen and weeping (leaking fluids). She stated Resident #1 was on the list for podiatry services now. The DON stated Resident #1 would have to pay out of pocket because they do not take Resident #1's insurance. The DON stated Resident #1 was diagnosed with PVD and he was taking Lasix. The DON stated Resident #1's skin assessments were not accurate and that her goal was they are supposed to comment on the skin assessments for the skin issues. The DON stated she would address it that they need to address skin issues for Resident #1. She stated the staff must sign the MAR, because it would be considered not done. The DON stated she was not aware of Resident #1 being out of Tylenol 3 for 3 days and the Nurse should have taken the medication from the e-kit. The DON stated Resident #1 takes the Tylenol #3 every 8 hours 3 times a day. The DON stated once a patient is down to 5 days to be taken the nurses were supposed to start following up. The DON stated that is why they changed from agency staff and she had been carrying the load of nursing herself . In an interview on 4/29/23 at 10:16 a.m. with the Regional Nurse she stated the facility failed because wound care was not being completed on a daily basis according to the physician order. The facility did a 100% audit on all narcotic sheets and if it was not at the facility, they ordered it. The Regional Nurse stated she did not know why the nurse did not get Resident #1's med's from the e-kit. In a telephone interview on 4/29/23 at 11:45 a.m. with Physician A she stated Resident #1 had a diagnosis of Parkinson's disease, bilateral low extremity swelling and the NP noted that it looked more like cellulitis. Physician A stated she saw Resident #1 on Tuesday, 4/25/23 when she was there, and it had only been 48 hours since he (Resident #1) had been on antibiotics. Physician A stated Resident #1 stated he was in pain, so they discussed scheduled Tylenol 3, PRN and he is on gabapentin. Physician A stated Resident #1 mentioned he had more pain weeks prior, so she increased his dose. She stated Resident #1 had bilateral swelling, so they ordered IV clindamycin but then the nurses called her and said he was refusing the IV line, so it was changed to pills. Physician A stated they want him to keep his legs elevated, they ordered the Aquaphor on Sunday, 4/23/23 and the NP said Resident #1 was not always compliant with the Aquaphor. Physician A stated she knew his (Resident #1) legs were swollen, and he was being treated for cellulitis, but she was not aware Resident #1's legs were weeping. Physician A stated she would leave it up to the wound care team and they might have tried compression wraps. Physician A stated she might have offered Resident #1 compression wraps if she had known. She stated they started him (Resident #1) on ammonium lactate on yesterday, 4/28/23. Physician A stated usually when the facility was low on meds, they should notify the NP to make sure Resident #1 did not run out. Physician A stated they do not want Resident #1 running out of meds. Physician A stated Resident #1 had a pretty good memory, but they did not specifically talk about the Aquaphor on Tuesday 4/25/23, they focused on his pain. In an interview on 4/30/23 at 2:57 p.m. with the SW he stated he knew about Resident #1 needed dental services when he got the text message. The SW stated Resident #1 told him about the dental. The SW stated Resident #1 came into the facility as skilled nursing and he did not know what visit Resident #1 went to outside the facility. The SW stated he just set Resident #1 up to receive all 3 disciplines, but he was not aware of his legs weeping. In an interview on 5/1/23 at 8:08 a.m. with the NP she stated Resident #1 had edema and when she saw him his legs were not weeping. The NP stated they put Resident #1 on Lasix to get the extra fluid out of his legs. The NP stated the treatment for weeping is a diuretic and she would have suggested a different treatment. The NP stated when the legs are weeping the fluid is trying to find a way out. The NP stated if the leaking was too much, they do wraps on the legs so that it does not weep all over the floor. The NP stated they adjusted all of Resident #1's meds and made scheduled and went up on Tylenol 3 and gabapentin. The NP stated now Resident #1 was not only getting the PRN pain meds, he has it scheduled and getting PRN in between. The NP stated Resident #1 also had neuropathy (damage to nerve causing numbness or weakness) in his legs and that was why he took a high dose of gabapentin on the maximum dose. In an observation and interview on 5/1/23 at 12:09 p.m. with Resident #1 revealed he was sitting in a sitting walker with his legs wrapped and dated 4/30/23 and his legs were on top of 2 pillows in a wheelchair with the extenders on it. Observation revealed a skin growth on Resident #1's right side of his forehead and eye lid. Resident #1 stated he was told about the medical appointments. Resident #1 stated the SW continued telling him that he was going to do things and he never did. Resident #1 stated that in 2 months the SW stated he would come back, and he never did. He was supposed to set it up. Resident #1 stated he already told the SW about his teeth, eyes, feet and everything months ago. Resident #4 Record review of Resident #4's face sheet revealed he was admitted to the facility on [DATE]. He was [AGE] years old and was diagnosed with urinary tract infection, hypertension, colostomy status, acquired absence of left leg below knee, acquired absence of kidney, seizures, and pain. Record review of Resident #4's Care Plan dated 4/20/23 revealed pressure wounds and is at risk for further skin breakdown, infection, worsening of existing pressure wounds, new pressure wound formation AEB. admitted with Stage IV sacral pressure ulcer. Goal: [Resident's] skin will remain clean, dry and wound(s) will heal without further complications over the next 90 days. Interventions/tasks: Assist with turning/repositioning during rounds and PRN, encourage po/fluid intake within dietary limits, keep family/RP/MD informed of resident's wound healing progress, perform treatments per order- if no improvement- report to MD, provide pressure reducing device for ed and wheelchair, RD to review resident's medical record and make recommendations. Record review of Resident #4's Care Plan dated 4/20/23 did not reveal Resident #4 refused wound care and assistance for colostomy. Record review of Resident #4's admission MDS dated [DATE] revealed a BIMS score of 13 for cognition and was able to understand and make himself understood. Resident #4 did not walk in room or corridor, required extensive assistance with 1 person assist with toilet use, limited assistance with dressing with 1 person assisting, and personal hygiene with 2 person assisting. Resident #4 had 1 Stage IV pressure ulcer. Record review of Resident #4's Physician's Orders dated 4/26/23, revealed: Clean Stage IV Sacral wound with ns, pat dry, apply alginate and cover with dry absorptive dressing everyday. One time a day for wound care. Record review of Resident #4's Wound Care Physician notes dated 4/18/23 at 7:11 p.m. wound location Sacral, Pressure ulcer, date acquired 4/13/23, wound measurements: 13x18x3 area 234 and volume 702. Wound encounter initial, moderate serous, surrounding skin maceration. Record review of Resident #4's Weekly Wound Observation by MD dated 4/29/23 at 7:27 p.m. Location Left Sacral, Pressure ulcer IV, granulation tissue present (beefy red), serosanguinous (yellowish fluid with a small amount of blood), measurements: 16x8x0.5. Record review of Resident #4's Medication Administration Record/Treatment Administration Record for April 2023 revealed: Colostomy Care every day shift every 3 day(s) Remove - bag/wafer, cleanse site with normal saline, observe for any abnormalities, skin prep stoma border, allow areas to dry, apply new wafer/bag -Order Date- 04/14/2023 12:40 p.m. was marked as completed. Carvedilol Oral Tablet 12.5 MG (Carvedilol) Give 1 tablet by mouth two times a day for Hypertension -Order Date- 04/14/2023 at 11:55 a.m. -D/C Date- 04/15/2023 4:29 p.m. was administered for 1 day. Colostomy Observation every shift Monitor Resident's colostomy. Ensure Colostomy is intact, free from s/s of infection and functioning properly. Notify MD for any changes. -Order Date- 04/14/2023 1240 was not administered on 4/20/23 at 10 p.m., 4/23/23 at 10 p.m. Acetaminophen-Codeine #3 Oral Tablet 300-30 MG (Acetaminophen w/ Codeine Give 1 tablet by mouth every 6 hours as needed for chronic pain -Order Date- 04/16/2023 4:36 p.m. was not administered at all. Cyclobenzaprine HCl Oral Tablet 10 MG (Cyclobenzaprine HCl) Give 1 tablet by mouth every 12 hours as needed for Pain -Order Date- 04/14/2023 12:04 p.m. was not administered at all. Clean Stage IV Sacral wound with ns, pat dry, apply alginate and cover with dry absorptive dressing q day. one time a day for Wound Care -Order Date- 04/20/2023 at 3:06 p.m. was not administered 4/20-4/22/23, and 4/24/23. Record review of Resident #4's Skin Observation dated 4/18/23 at 12:55 p.m. revealed skin check was not refused, skin was not intact, no new areas were identified, and resident did have pressure injuries: right knee (front), left knee (front) and Sacrum wound. Record review of Resident #4's Skin Observation dated 4/29/23 at 7:36 p.m. revealed skin check was not refused, skin was not intact, no new areas were identified, and resident did have pressure injuries: right buttock Stage 4 and left buttock stage 4. Record review of Resident #4's Skilled Progress notes dated 4/14/23 at 12:14 p.m. revealed Wound management: pressure sore in sacrum. In an interview on 4/25/23 at 11:45 a.m. with LVN A she stated Resident #4 refused wound care today when this Surveyor asked to watch her perform wound care. In an observation and interview on 5/1/23 at 1 p.m. with Resident #4 he was observed in the dining area sitting in a wheelchair. Resident #4 stated he was okay if the facility would get the supplies they need. Resident #4 stated he had an ostomy bag, but the facility ran out of the supplies he needed. Observation revealed Resident #4 had an undated wound bandage instead of an colostomy bag, and Resident #4 stated it was because the facility did not have any. Resident #4 stated that for 2 or 3 days the facility staff had started trying to do wound care. Resident #4 stated the facility was giving it an effort now to do the wounds, because they never offered to help him when he was on contact isolation. Resident #4 stated the nurses were not wound care nurses and his wounds were bad. Resident #4 stated that his wounds could kill him. Resident #4 stated when he admitted to the facility, the DON put him on Cipro (not found in orders) to try to knock out some of his UTI because of an indwelling catheter. He stated his catheter was supposed to be changed every 2 and a half weeks according to his urologist. He stated he had a stint in his kidney keeping him alive and they started him on Cipro one day then the next day they d/c'd it, then they wanted to give it and then they d/c'd it again and now his body built up a tolerance to it. LVN A stated she would give him a colostomy bag 4 days ago and he did not give it until 4 a.m. in the morning. Resident #4 stated all around his stomach was bleeding because his stool was real watery. He stated before that he would go to LVN A for her to change the wound. Resident #4 stated he went to LVN A daily to get supplies off of her cart and go do his own wounds and LVN A never offered to help him with the wounds. Resident #4 stated LVN A never asked him if he needed any kind of assistance. Resident #4 stated he found out they lied to the State, saying he was refusing his med's and refusing wound care. Resident #4 stated that it was a lie, and one of the nurses (unknown name) told him. Resident #4 stated he would not refuse his pills, and especially his blood pressure medication. Resident #4 stated he did refuse Keppra and they are supposed to D/c it but they have not done it yet. He stated he was never epileptic and was never on seizure meds and he had not had any seizures in over 2 years. Resident #4 stated you cannot stop taking Klonopin and he said you can look that up on your phone. Resident #4 stated he should not have to tell them how to do their job. He says he needs to go to the hospital on IV antibiotics. In an interview on 5/1/23 at 1:12 p.m. RN A asked what was on Resident #4's colostomy. RN A stated Resident #4 did the colostomy for himself, but LVN A gave him the 4x4's. RN A went to get the colostomy bags in the nurses station supplies and could not find them. Resident #4 stated he had been having a bandage on for 2 days. RN A returned to Resident #4 and gave him a colostomy bag and she offered to put it on for him. Resident #9 Record review of Resident #9's face sheet revealed she was admitted to the facility on [DATE]. She was [AGE] years old and was diagnosed with Fracture of right femur, presbyopia (the gradual loss of your eyes' ability to focus on nearby objects), Chronic obstructive pulmonary disease (constricted in breathing), and chronic atrial fibrillation (irregular and rapid heart beat). Record review of Resident #9's Quarterly MDS dated [DATE] revealed a BIMS summary score of 11 out of 15 indicating moderate cognitive impairment. Resident #9's functional status revealed she required limited assistance for dressing and supervision only for all other activities of daily living. Record review of Resident #9's Care Plan dated 2/22/23 revealed [Resident] is at risk for pressure ulcer due to mobility. Goal: [Resident] will have intact skin, free of redness, blisters or discoloration by/through review date. Complete a full body check weekly and document. Follow facility policies/protocols for the prevention/treatment if skin breakdown. Record review of Resident #9's Order Summary Report dated 4/26/23 revealed: Conduct weekly skin evaluation. Document UDA under assessments-Skin observations. Notify MD of new skin conditions. Every day shift every Monday for skin management started 11/21/22. Record review of Resident #9's Medication Administration Record/Treatment Administration Record for April 2023 revealed: Conduct Weekly Skin Evaluation. Document UDA under assessments-skin observations. Notify MD of new skin conditions. Every day shift every Monday for skin management order date 11/14/22 at 1:20 p.m. revealed evaluations were documented every Monday. Wound: Skin tear to right elbow, clean with NS or wound cleanser, pat dry, apply TAO and dry dressing daily. Ev[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection for 9 of 15 residents (Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #10, Resident #13) reviewed for pressure ulcers. 1. The facility failed to provide wound care for all Residents with wounds according to their physician orders from March and April 2023 and resulting in new pressure ulcers, worsening of existing wounds, and infected wounds for Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #10, and Resident #13. 2. The facility failed to ensure LVN A, who was the interim treatment used proper infection control measures during wound care for Resident #5, Resident #6, and Resident #13, when she did not change her gloves, did not use proper hand washing techniques, she opened wound care supplies outside of the residents room. 3. The facility failed to ensure Resident #2, Resident #4, Resident #6, Resident #8, and Resident #13's wounds were regularly assessed, treated and maintained by a physician. 4. The facility failed to provide wound care according to physician orders for Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #10, and Resident #13. An Immediate Jeopardy (IJ) was identified on 4/28/23 at 4:30 p.m. While the IJ was lowered on 5/3/23 at 10:58 a.m., the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of widespread as the facility continued to monitor the implementation and effectiveness of their plan of removal. These failures placed residents who received wound care at risk of developing new pressure wounds, worsening of existing wounds, decline in quality of care, infection, and experiencing pain. Findings include: Resident #2 Record review of Resident #2's face sheet revealed he was admitted to the facility on [DATE]. He was [AGE] years old and was diagnosed with osteomyelitis (bone infection), pulmonary embolism (blocked flow of blood), anemia, abnormal level of blood mineral, edema (swelling), cellulitis (bacterial skin infection), obstructive and reflux uropathy (disorder of urinary tract), fracture of right femur and neuralgia and neuritis (nerve pain caused by inflammation). Record review of Resident #2's Quarterly MDS assessment dated [DATE] revealed he was cognitively intact with a score of 15 for cognition and was able to understand and make himself understood. Resident #2 was totally dependent with two person assist for bed mobility, personal hygiene, and dressing and had activity that did not occur for transfers, walking in room and corridor, and activity that occurred once or twice with one person assist for locomotion on and off the unit and toilet use. Resident #2's active diagnosis included hip fracture, malnutrition, bacteremia (bacteria in blood), 2 stage 3 pressure ulcers, 2 stage 4 pressure ulcers and a skin tear. Record review of Resident #2's care plan dated 2/22/23 for unavoidable pressure ulcer development route of history of ulcers, immobility, contracture, bowel and bladder incontinence, medication use. Goal: ulcer will show signs of healing and remain free from infection by/through review date. Intervention/tasks: Administer treatment as ordered and monitor for effectiveness, Assess/record/monitor wound healing (Q Weekly and PRN) Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD .[Resident #2] was admitted with deep tissue pressure injury right heel, skin tear to posterior right thigh, [Resident #2] was readmitted with Stage 3 pressure injury to left distal lateral foot (the outside or furthest away from body), unstageable pressure ulcer to right heel, pressure to sacrum with wound vacuum, skin tear to right elbow. Stage 3 route of left dorsal foot, stage 3 to left medial ankle, stage 3 left outer ankle .Goal: [Resident #2's] pressure ulcer will show signs of healing and remain free from infection by/through the review date. Intervention/Tasks: Administer treatments as ordered and observe for effectiveness. Assist [Resident #2] to reposition and/or turn at frequent intervals to provide pressure relief. Complete a full body check weekly and document .Observe dressing q shift to ensure it is intact and adhering. Report lose dressing to treatment nurse. Observe/document/report PRN any changes in skin status: appearance, color, wound healing, s/sx of infection, wound size (length x width x depth), stage .Teach resident/family the importance of changing positions for prevention of pressure ulcers. Encourage small frequent position changes. Record review of Resident #2's Physician's Orders dated 4/26/23, revealed: Wound: Abrasion to anterior right lower leg, clean with NS or wound cleanser, pat dry, apply calcium alginate and dry dressing daily. Every day shift every other day for wound/skin management. Wound: Abrasion to posterior right lower leg, clean with NS or wound cleanser, pat dry, apply calcium alginate and dry dressing daily, every day shift every other day for wound/skin management. Wound: Abrasion to right knee, cleanse with NS or wound cleanser, pat dry, apply calcium alginate and dry dressing daily, every day shift every other day for wound/skin management. Wound: Skin tear to right iliac crest, clean with NS or wound cleanser, pat dry, apply calcium alginate and dry dressing daily. Every day shift every other day for wound/skin management. Wound: Unstageable pressure injury to the left knee, clean with NS or wound cleanser, pat dry, apply calcium alginate and dry dressing daily. Every day shift every other day for wound/skin management. Wound: Unstageable pressure injury to the posterior right knee, clean with NS or wound cleanser, pat dry, apply calcium alginate and dry dressing daily. Every day shift every other day for wound/skin management. Record review of Resident #2's Medication Administration Record/Treatment Administration Record for April 2023 printed on 4/25/23 revealed: Wound: Abrasion to anterior right lower leg, Clean with NS or wound cleanser, pat dry, apply calcium alginate and dry dressing daily. Every day shift every other day for Wound/Skin Management -Order Date-03/23/2023 at 10:42 a.m. revealed on 4/2/23, 4/4/23, 4/6/23, 4/8/23, 4/9/23, 4/10/23, 4/12/23, 4/14-24/23 treatment was not administered WOUND: Abrasion to posterior right lower leg, Clean with NS or wound cleanser, pat dry, apply calcium alginate and dry dressing daily. Every day shift every other day for Wound/Skin Management -Order Date- 04/13/2023 at 10:59 a.m. revealed on 4/13/23-4/24/23 treatment was not administered. WOUND: Abrasion to right knee, Clean with NS or wound cleanser, pat dry, apply calcium alginate and dry dressing daily every day shift every other day for Wound/Skin Management -Order Date- 12/16/2022 at 1:47 p.m. was not treated on 4/9/23, 4/11/23, and 4/15-4/24/23. WOUND: Skin tear to right iliac crest, Clean with NS or wound cleanser, pat dry, apply calcium alginate and dry dressing daily. Every day shift every other day for Wound/Skin Management -Order Date- 03/17/2023 10:33 a.m. was not treated on 4/9/23, 4/11/23, and 4/15-4/24/23. WOUND: Unstageable pressure injury to the left knee, Clean with NS or wound cleanser, pat dry, apply calcium alginate and dry dressing daily. every day shift every other day for Wound/Skin Management -Order Date- 04/13/2023 10:57 a.m. revealed on 4/13-4/23/23 treatment was not administered. WOUND: Unstageable pressure injury to the posterior right knee, Clean with NS or wound cleanser, pat dry, apply calcium alginate and dry dressing daily. every day shift every other day for Wound/Skin Management -Order Date- 04/14/2023 06:40 a.m. revealed on 4/14-4/23/23 treatment was not administered. Record review of Resident #2's Weekly Wound Observation: Wound #7 dated 4/12/23 at 11:21 a.m. revealed: 4/12/23, [Physician] updated on wound status via phone .location right anterior lower leg, abrasion, worsening, granulation ( lumpy, pink tissue containing new connective tissue and capillaries forms around the edges of a wound) tissue present beefy red), 6x4x0.1. current treatment plan: clean with NS or wound cleanser, pat dry, apply alginate and dry dressing daily, wound progress: worsening. Wound #8 dated 4/12/23 at 11:24 a.m. revealed : 4/12/23, [Physician] updated on wound status via phone .location right iliac crest, skin tear, unchanged, granulation tissue present (beefy red), serosanguinous, 1x1x0.1, cleanse with NS or wound cleanser, pat dry, apply alginate ad dry dressing daily. Wound #1 dated 4/13/23 at 11:26 a.m. revealed: 4/13/23, [Physician] updated on wound status via phone .location left knee dated acquired 4/13/23, pressure, Stage X, first observation, no reference, granulation tissue present (beefy red), slough tissue present (yellow, tan, white, stringy), 25% moist yellow slough, moderate serosanguinous, 5x2.5x0, clean with NS or wound cleanser, pat dry, apply alginate and dry dressing daily, new wound. Wound #2 dated 4/13/23 at 11:28 a.m. revealed : 4/13/23, [Physician] updated on wound status via phone .location posterior right knee, date acquired 4/13/23, Stage X, first observation, no reference, granulation tissue present (beefy red), moderate serosanguinous, 2x2.5x0, cleanse with NS or wound cleanser, pat dry, apply alginate and dry dressing daily. Wound #3 dated 4/13/23 at 11:31 a.m. revealed : 4/13/23, [Physician] updated on wound status via phone .location posterior right lower leg, acquired 4/13/23, abrasion, first observation, no reference, granulation tissue present (beefy red), moderate serosanguinous, 4x4x0.1, cleanse with NS or wound cleanser, pat dry, apply alginate and dry dressing daily. Record review of Resident #2's SBAR (Change of Condition) dated 4/13/23 at 11:02 a.m. revealed New Wounds. Record review of Resident #2's Skin Observation dated 4/13/23 at 11:04 a.m. revealed skin check was not refused, resident's skin not intact, Resident has new areas, resident has non-pressure areas, site: left knee (front) unstageable pressure injury, right knee (rear) unstageable pressure injury, right lower leg (rear) abrasion, right iliac crest (illium top border that creates the pelvis) (front) skin tear, right lower leg (front) abrasion, right knee (front) abrasion. Record review of Resident #2's Braden Scale-Predicting Pressure Score Risk dated 4/13/23 at 11:07 a.m. revealed Resident #2 was moderate risk, scoring 13.0 and Resident #2 responded to verbal commands. Had no sensory deficit which would limit ability to feel or voice pain or discomfort. Skin was often but not always moist. Linen must be changed at least once a shift. Confined to bed. In mobility responded only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness or has a sensory impairment which limits the ability to feel pain or discomfort over ½ of body. Nutrition was adequate eats over half of most meals. Ate a total of 4 servings of protein per day. Occasionally refused a meal but would usually take a supplement when offered or is on a tube feeding or TPN regimen which probably meets most of nutritional needs. Required moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slided down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures, or agitation leads to almost constant friction. Record review of Resident #2's Skin Observation dated 4/22/23 at 12:16 p.m. and signed on 4/27/23 at 12:17 p.m. revealed new areas: left knee (front) unstageable pressure injury, right knee (rear) unstageable pressure injury, right lower leg (rear) abrasion, right iliac crest (front) skin tear, right knee (front) abrasion, right lower leg (rear) abrasion. In an observation and interview on 4/25/23 at 10:55 a.m. with Resident #2 and CNA A, Resident #2 stated the last time he had wound care done was 2 weeks ago. Resident #2 stated LVN A did wound care for him on 4/25/23. Observation of Resident #2's left leg revealed his leg was contracted behind him. CNA A stated Resident #2's bandage date was dated 4/12/23, and the Wound Care Nurse had been gone for 2 weeks. Resident #3 Record review of Resident #3's face sheet revealed he was admitted to the facility on [DATE]. He was [AGE] years old and was diagnosed with dementia, hypokalemia (blood level below normal potassium), gastro-esophageal reflux disease (acid reflux), hypertension (high blood pressure), hypothyroidism (low thyroid activity), hypo-osmolality and hyponatremia (sodium in blood low), protein-calorie malnutrition, chronic kidney disease stage 3, and methicillin resistant staphylococcus aureus infection (bacteria with antibiotic resistance). Record review of Resident #3's Quarterly MDS assessment dated [DATE] revealed he was severely impaired with a score of 6 out of 15 for cognition. Resident #3 did not walk in room and walking in the corridor only occurred once or twice with one staff assisting, he was totally dependent with one person assist for locomotion off the unit and required extensive assistance with two staff for bed mobility, and transfers and extensive assist with one person assist for locomotion on unit, dressing, toilet use and personal hygiene. Record review of Resident #3's Care Plan dated 2/22/23 revealed Stage IV pressure ulcer to left heel r/t impaired mobility. Goal: The resident's will pressure ulcer will show signs of healing and remain free from infection by/through review date. Interventions/tasks: administer medications as ordered . Administer treatments as ordered and monitor for effectiveness. Assess/record/monitor wound healing (Q Weekly) Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. The resident requires supplemental protein, amino acids, vitamins, minerals as ordered to promote wound healing. Treat pain as per orders prior to treatment/turning etc. to ensure the resident's comfort. Record review of Resident #3's Physician's Orders dated 5/1/23, revealed: Wound: Stage IV pressure injury to the left heel, Clean with NS or wound cleanser, pat dry, apply silver alginate and dry dressing daily. Everyday shift for Wound/Skin Management -Order Date- 04/06/2023 at 1:02 p.m. starting 4/7/23. WOUND: Unstageable pressure injury to the dorsal left foot, Clean with NS or wound cleanser, pat dry, apply silver alginate and dry dressing daily. Everyday shift for Wound/Skin Management -Order Date- 04/10/2023 at 11:50 a.m. starting 4/11/23. WOUND: Unstageable pressure injury to the left distal lateral foot, Clean with NS or wound cleanser, pat dry, apply silver alginate and dry dressing daily. Everyday shift for Wound/Skin Management -Order Date- 04/10/2023 at 11:49 a.m. starting 4/11/23. Record review of Resident #3's Medication Administration Record/Treatment Administration Record for April 2023 printed on 4/25/23 revealed: Wound: Stage IV pressure injury to the left heel, Clean with NS or wound cleanser, pat dry, apply silver alginate and dry dressing daily. Every day shift for Wound/Skin Management -Order Date- 04/06/2023 at 1:02 p.m. starting 4/7/23 was not administered on 4/8/23, 4/9/23, 4/11/23, 4/14-4/16/23, 4/19-4/24/23. WOUND: Unstageable pressure injury to the dorsal left foot, Clean with NS or wound cleanser, pat dry, apply silver alginate and dry dressing daily. Every day shift for Wound/Skin Management -Order Date- 04/10/2023 at 11:50 a.m. starting 4/11/23 was not administered on 4/11/23, 4/14-4/16/23, 4/19-4/24/23. WOUND: Unstageable pressure injury to the left distal lateral foot, Clean with NS or wound cleanser, pat dry, apply silver alginate and dry dressing daily. Everyday shift for Wound/Skin Management -Order Date- 04/10/2023 at 11:49 a.m. starting 4/11/23 was not administered on 4/11/23, 4/14-4/16/23, 4/19-4/24/23. Record review of Resident #3's Wound Care Physician notes dated 4/18/23 at 3:24 p.m. revealed: Wound Status: left heel, pressure ulcer, since 12/20/22, measurements 2x2.5x1 area 5, volume 5, Stage 4 Pressure injury, moderate, sero-sanguineous. Record review of Resident #3's Wound Care Physician notes dated 4/18/23 at 3:24 p.m. revealed: Wound Status: Right, Dorsal foot, measurements 2x2x0.5 area 4, volume 2, initial exam, Stage 4 pressure injury, moderate, sanguineous Record review of Resident #3's Wound Care Physician notes dated 4/25/23 at 1:34 p.m. revealed: Location: left heel since 12/20/22, measurements 1.5x1.5x1 area 2.25, volume 2.25, wound progress improving, Stage 4 Pressure injury, moderate, sero-sanguineous. Record review of Resident #3's Wound Care Physician notes dated 4/25/23 at 1:34 p.m. revealed: Wound Status: Right, Dorsal foot, measurements 2x2x0.5 area 4 and volume 2, wound progress no change, Stage 4 pressure injury, moderate, sanguineous. Record review of Resident #3's Wound Care Physician notes 4/25/23 Wound #2 Left, Dorsal foot, post debridement (removement of damaged tissue) measurements 2x2x0.6 area 4, percent debrided 50, total area debrided: 2 sq cm and volume 2.4. Record review of Resident #3's Physician progress note dated 4/23/23 revealed: Chief complaint: MRSA infection on left food wound. Skin: left heel stage 4 wound, measuring 2x2.5x1cm, 76-100% granulation; right dorsal foot stage 4 2x2x0.5x1 cm, 76-100% granulation. Labs:4/17/23 Reported left foot stage 4 wound, measuring 2x2.5x1 cm, wound culture reviewed is positive for MRSA with heavy growth, contact isolation. Record review of Resident #3's Skin Observation dated 4/10/23 at 11:45 a.m. by Physician revealed skin was not intact, resident had new areas identified, resident had pressure injuries, resident did not have non-pressure areas: left heel pressure injury, left distal lateral foot pressure injury, top of left foot pressure injury. Record review of Resident #3's Skin Observation dated 4/18/23 at 10:24 p.m. by Physician revealed skin was not intact, resident did not have new areas, resident had pressure injuries and no non-pressure areas: left ankle (outer) open area noticed dressing intact. Record review of Resident #3's Skin Observation dated 4/26/23 at 9:28 p.m. by Physician revealed skin was not intact, resident did not have new areas, resident had pressure injuries and no non-pressure areas: left heel, left lateral and distal foot-pressure area. Record review of Resident #3's Skin Observation dated 4/29/23 at 7:54 p.m. by Physician revealed skin was not intact, resident did not have new areas, resident had pressure injuries and no non-pressure areas: left ankle (inner), left ankle (outer), left heel. Record review of Resident #3's Weekly Wound Observation dated 4/11/23 at 11:16 a.m. by Physician revealed MD was updated on 4/11/23, left heel, acquired 12/20/22, pressure, granulation tissue present (beefy red), serosanguinous, moderate, measurement 3x1.6x0.7. Record review of Resident #3's Weekly Wound Observation dated 4/11/23 at 11:18 a.m. by Physician revealed MD was updated on 4/11/23, Dorsal left foot, acquired 4/10/23, pressure, original X, first observation, no reference, granulation tissue present (beefy red), slough tissue present (yellow, tan, white, stringy), 50% moist yellow slough, moderate serosanguinous, measurement 1.5x1.5x0. Treatment: Clean with NS or wound cleanser, pat dry, apply silver alginate and dry dressing daily. Wound Progress New. Record review of Resident #3's Weekly Wound Observation dated 4/11/23 at 11:21 a.m. by Physician revealed MD was updated on 4/11/23, Left Distal Lateral Foot, acquired 4/10/23, pressure, original X, first observation, no reference, granulation tissue present (beefy red), moderate serosanguinous, measurement 3x1.6x0.5. Treatment: Clean with NS or wound cleanser, pat dry, apply silver alginate and dry dressing daily. Wound Progress New. Record review of Resident #3's Weekly Wound Observation dated 4/18/23 at 1:40 p.m. by Physician revealed MD was updated on 4/18/23, Dorsal left foot, acquired 4/18/23, pressure, original IV, first observation, no reference, granulation tissue present (beefy red), moderate serous, measurement 2x2x0.5 area 4 volume 2. Treatment: Clean wound to left dorsal foot with ns/wound cleanser, pat dry, apply calcium alginate with silver and dress with dry dressing daily. Wound Progress initial exam. In an interview on 4/25/23 at 11:04 a.m. Resident #3 he stated he had not had wound care for 2 weeks, and the nurse just did wound care on him on 4/25/23. In an interview on 4/25/23 at 11:27 a.m. with LVN A she stated Resident #3 had a dressing on, but there was no date before she went in on 4/25/23 to complete Resident #3's wound care. LVN A stated she only did wound care on her days off at the facility for the entire building. In an observation and interview on 5/2/23 at 11:07 a.m. with LVN D, she stated Resident # 3 has an infection, MRSA, of the wounds. LVN D stated she had to make sure because she did not want to lie about what their isolation precaution was because this surveyor asked. LVN D stated it was staph infection and Resident #3 was on an antibiotic. Observation of wound care administered for Resident #3 revealed her techniques were good. Resident #4 Record review of Resident #4's face sheet revealed he was admitted to the facility on [DATE]. He was [AGE] years old and was diagnosed with urinary tract infection, hypertension (high blood pressure), colostomy status, acquired absence of left leg below knee, acquired absence of kidney, seizures, and pain. Record review of Resident #4's admission MDS dated [DATE] revealed a BIMS score of 13 for cognition and was able to understand and make himself understood. Resident #4 did not walk in room or corridor, required extensive assistance with 1 person assist with toilet use, limited assistance with dressing with 1 person assisting, and personal hygiene with 2 person assisting. Resident #4 had 1 Stage IV pressure ulcer. Record review of Resident #4's Care Plan revealed pressure wounds and is at risk for further skin breakdown, infection, worsening of existing pressure wounds, new pressure wound formation AEB. admitted with Stage IV sacral pressure ulcer. Goal: [Resident's] skin will remain clean, dry and wound(s) will heal without further complications over the next 90 days. Interventions/tasks: Assist with turning/repositioning during rounds and PRN, encourage po/fluid intake within dietary limits, keep family/RP/MD informed of resident's wound healing progress, perform treatments per order- if no improvement- report to MD, provide pressure reducing device for ed and wheelchair, RD to review resident's medical record and make recommendations. Record review of Resident #4's Physician's Orders dated 4/26/23, revealed: Clean Stage IV Sacral wound with ns, pat dry, apply alginate and cover with dry absorptive dressing every day. One time a day for wound care. Record review of Resident #4's Wound Care Physician notes dated 4/18/23 at 7:11 p.m. wound location Sacral, Pressure ulcer, date acquired 4/13/23, wound measurements: 13x18x3 area 234 and volume 702. Wound encounter initial, moderate serous, surrounding skin maceration. Record review of Resident #4's Weekly Wound Observation by MD dated 4/29/23 at 7:27 p.m. Location Left Sacral, Pressure ulcer IV, granulation tissue present (beefy red), serosanguinous, measurements: 16x8x0.5. Record review of Resident #4's Medication Administration Record/Treatment Administration Record for April 2023 revealed: Clean Stage IV Sacral wound with ns, pat dry, apply alginate and cover with dry absorptive dressing q day. one time a day for Wound Care -Order Date- 04/20/2023 at 3:06 p.m. was not administered 4/20-4/22/23, and 4/24/23. Record review of Resident #4's Skin Observation dated 4/18/23 at 12:55 p.m. revealed skin check was not refused, skin was not intact, no new areas were identified, and resident did have pressure injuries: right knee (front), left knee (front) and Sacrum wound. Record review of Resident #4's Skin Observation dated 4/29/23 at 7:36 p.m. revealed skin check was not refused, skin was not intact, no new areas were identified, and resident did have pressure injuries: right buttock Stage 4 and left buttock stage 4. Record review of Resident #4's Skilled Progress notes dated 4/14/23 at 12:14 p.m. revealed Wound management: pressure sore in sacrum. In an observation and interview on 5/1/23 at 1:00 p.m. with Resident #4 he was observed in the dining area sitting in a wheelchair. Resident #4 stated that for 2 or 3 days the facility staff started trying to do wound care. Resident #4 stated the facility was giving it an effort now to do the wounds, because they never offered to help him when he was on contact isolation. Resident #4 stated the nurses were not wound care nurses and his wounds were bad. Resident #4 stated that his wounds could kill him. He stated before that he would go to LVN A for her to change the wound dressing. Resident #4 stated he went to LVN A daily to get supplies off of her cart and go do his own wounds and LVN A never offered to help him with the wounds. Resident #4 stated LVN A never asked him if he needed any kind of assistance. Resident #4 stated he found out they lied to the State, saying he was refusing his meds and refusing wound care. Resident #4 stated that it was a lie, and one of the nurses (unknown name) told him. Resident #4 stated he would not refuse his pills, and especially his blood pressure medication. Resident #4 stated he should not have to tell them how to do their job. Resident #5 Record review of Resident #5's face sheet revealed he was admitted to the facility on [DATE]. He was [AGE] years old and was diagnosed with functional quadriplegia, urinary tract infection, hypertension (high blood pressure), pressure ulcer of sacral region, Stage 3, and chronic pain. Record review of Resident #5's Quarterly MDS dated [DATE] revealed a BIMS score of 15 for cognition indicating he was cognitively intact and was able to understand and make himself understood. Resident did not walk in room, corridor, no locomotion on and off the unit, transfer occurred once or twice with 2 person assist, he was totally dependent on two staff for dressing, toilet use, extensive assistance with two person assist for bed mobility, and extensive assistance with one person assist with eating and personal hygiene. Resident #5 had 1 Stage 3 pressure ulcer. Record review of Resident #5's Care Plan dated 3/30/23 revealed a stage III pressure ulcer to the left hip r/t functional quadriplegia, incontinence bowel and bladder, impaired mobility. Goal: the resident's pressure ulcer will show signs of healing and remain free from infection by/through review date. Intervention/Tasks: Administer treatments as ordered and monitor for effectiveness. Assess/record/monitor wound healing (Weekly) measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. Follow facility policies/protocols for the prevention/treatment of skin breakdown. The resident requires supplemental protein, amino acids, vitamins, minerals as ordered to promote healing. Treat pain as per orders prior to treatment/turning etc. to ensure the resident's comfort. Record review of Resident #5's Physician's Orders dated 5/1/23, revealed: Treatment Clean pressure wound to left lateral ankle with ns/wound cleanser, pat dry, apply calcium alginate and dress with dry dressing daily every day shift started on 4/27/23. License nurse to monitor: Left Ankle for any abnormalities or changes to surrounding skin for s/s of infection, pain associated with site, and for presence of dressing every shift. Document plus(+) sign for no observed changes and a minus (-) sign for any observed changes, notify MD, and document findings in a progress note. Every shift started 4/30/23. License nurse to monitor: Left Hip for any abnormalities or changes to surrounding skin for s/s of infection, pain associated with site, and for presence of dressing every shift. Document plus(+) sign for no observed changes and a minus (-) sign for any observed changes, notify MD, and document findings in a progress note. Every shift started 4/30/23. License nurse to monitor: Right Hip for any abnormalities or changes to surrounding skin for s/s of infection, pain associated with site, and for presence of dressing every shift. Document plus(+) sign for no observed changes and a minus (-) sign for any observed changes, notify MD, and document findings in a progress note. Every shift started 4/30/23. Wound: Stage III pressure injury to the left hip, clean with NS or wound cleanser, pat dry, apply calcium alginate and dry dressing daily. One time a day for wound/skin management started 1/20/23. Wound: Stage III pressure injury to the right hip, clean with NS or wound cleanser, pat dry, apply calcium alginate and dry dressing daily. One time a day for wound/skin management started 4/29/23. Conduct weekly skin evaluation. Document UDA under assessments skin observations. Notify MD of new skin conditions. Every evening shift every Wednesday and Saturday for skin management started on 12/31/22 at 2 p.m. Wound: Stage III pressure injury to the left hip, Clean with NS or wound cleanser, pat dry, apply calcium alginate and dry dressing daily started 1/20/23 at 6 p.m. Record review of Resident #5's Medication Administration Record/Treatment Administration Record for April 2023 printed on 4/25/23 revealed: WOUND: Stage III pressure injury to the left hip, Clean with NS or wound cleanser, pat dry, apply calcium alginate and dry dressing daily. Everyday shift for Wound/Skin Management -Order Date- 01/19/2023 at 11:41 a.m. was not administered on 4/2/23, 4/8/23, 4/11/23, 4/14/23, 4/19-22/23, and 4/24/23. Record review of Resident #5's Wound Care Physician notes dated 4/4/23 at 1:34 p.m. revealed: Wound Status: Left hip, pressure ulcer, measurements 6x4x1 area 24 and volume 24, Wound progress no change, Stage 4 pressure injury, and moderate sero-sanguineous. Debridement Details: left hip, surgical, measurements 6x4x1.1 area 24 and percent debrided 25. Total area debrided: (sq cm) 6, volume: 26.4. Record review of Resident #5's Wound Care Physician notes dated 4/18/23 at 3:24 p.m. revealed: Wound Orders: left hip: Cleanse wound with Normal saline, apply alginate, cover wound with dry absorptive dressing, change dressing daily, reposition per facility protocol, off-load wound. Wound Left lateral ankle: Cleanse wound with normal saline, apply alginate, cover wound with dry absorptive dressing, change dressing daily, reposition per facility protocol, off-load wound. Record review of Resident #5's Wound Care Assessment Details dated 4/18/23 at 3:24 p.m. revealed: Left hip, pressure ulcer, date acquired 1/16/23, acquired at facility, wound measurements: 2.5x4.5x1 area 11.25 and volume 11.25. Wound description: wound progress deteriorating, Stage 4 pressure injury, moderate sero-sanguineous. Record review of Resident #5's Wound Care Assessment Details dated 4/18/23 at 3:24 p.m. revealed: Left lateral ankle, pressure ulcer, acquired at facility, wound measurements: 0.8x0.5x0.2 area 0.4 and volume 0.08. Wound description: wound progress initial exam, Stage 4 pressure injury, moderate serous. Record review of Resident #5's Wound Care Assessment Details dated 4/25/23 at 1:34 p.m. revealed: Left hip, pres[TRUNCATED]