Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for one (Resident #3) of three residents reviewed for abuse. The facility failed to protect Resident #3 from physical abuse when CNA A force fed her on 03/03/25. The resident suffered psychosocial harm. On 03/20/25 at 1:00 PM, an Immediate Jeopardy (IJ) was identified. The IJ template was provided to the facility on [DATE] at 1:15 PM. While the IJ was removed on 03/20/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk of choking, aspiration, serious injury, harm, and death. Findings included: Record review of Resident #3's Annual MDS, dated [DATE], reflected she was a [AGE] year-old admitted to the facility on [DATE]. Her cognitive skills for daily decision making were severely impaired. Her diagnoses included aphasia (lack of ability to comprehend or communicate), stroke, non-Alzheimer's dementia, and dysphagia (difficulty swallowing). She was dependent on staff for eating. Record review of Resident #3's Care Plan, dated 01/07/14, reflected: 1. The resident had a nutritional problem related to hypertension. The resident was on a regular diet, pureed texture, and nectar thick/mildly thick liquids. Sometimes the resident refused to eat or drink supplements. Facility interventions included provide and serve diet as ordered. 2. The resident had a swallowing problem related to dysphagia. Facility interventions included follow prescribed diet, and to keep head of bed elevated 90 degrees during meals. 3. The resident had an ADL self-care performance deficit related to dementia, activity intolerance, and limited mobility. Facility interventions included the resident required total assistance to eat. Record review of CNA A's personnel file and background checks reflected no issues. An observation on 03/03/25 at 11:47 AM of Resident #3 revealed she was being fed by CNA A. The resident was in her room and the door was slightly open. CNA A forcefully pushed the resident's head back by placing her palm on the resident's forehead and pushing the head back. CNA A forced a large spoonful of food in the resident's mouth very quickly while the resident's head was pushed back. The CNA forcefully fed the resident three times very rapidly. The CNA then picked up a glass of fluids and gave the resident a drink. The resident tried to stop drinking. CNA A kept forcing the resident to drink. The resident began coughing and sputtering. The Surveyor intervened and told the CNA to stop and step away from the resident. Another State Surveyor observed the incident. CNA A said she did not do anything wrong. CNA said she was gently lifting the resident by the side of her side of head to get her to eat. She said she was not forcing her to eat and drink. The State Surveyor asked CNA A to go get the DON. An interview on 03/03/25 at 11:55 AM revealed the DON entered the resident's room. He told CNA A to go to his office. CNA A continued to deny the abuse occurred. The DON told CNA A to go to the Human Resources office. CNA A continued to deny the incident. Resident #3 was non-verbal and did not make any movements to indicate she was still in distress. An interview on 03/03/25 at 11:59 AM revealed the Administrator entered the conference room and said Resident #3 would lean forward and that staff had to place a hand on her and lift her head. State Surveyor informed the Administrator that CNA A was abusive, and force fed the resident. The Administrator said she would self-report the incident. An interview on 03/03/25 at 12:15 PM revealed Resident #3 was in her wheelchair, awake, alert, and non-verbal. The resident was smiling and watching TV. The resident did not respond to questions. The resident did not make any movements to indicate she was still in distress. An interview on 03/03/25 at 1:36 PM with the family member of Resident #3 revealed she was very upset. She said that CNA A was the only staff member who was able to get Resident #3 to eat and meet her needs. The family member said the required technique to feed Resident #3 was a little aggressive. The family member said Resident #3 could speak and she wanted to be present for an interview to show the State Surveyor that the resident could say she was not abused by CNA A. An interview on 03/03/25 at 2:20 PM with the DON revealed the facility was able to meet Resident #3's needs without CNA A. The DON said feeding the resident was not an aggressive technique and the only requirement was to gently hold up the resident's head if it dropped down. An observation and interview on 03/04/25 at 12:07 PM with Resident #3 revealed her family member and the Administrator was in the room. Another State Surveyor was present as a witness. The resident spoke a few words to the family member and smiled. The resident was awake and alert. The resident was asked if she remembered eating lunch on 03/03/25 and if she felt CNA A was abusive during the lunch. The resident did not answer. The family member asked the resident if CNA A was mean to her, and the resident said yes. The family member asked the resident if she was mean to the resident and the resident said yes. The resident was asked if the Administrator was mean, and the resident said no. The family member asked the resident if CNA A ever forced her to do anything. The resident became upset and said yeah. The interview was ended, and the resident was thanked for talking to the State Surveyor. An interview on 03/04/25 at 3:56 PM with the Rehabilitation Director revealed Resident #3 did not require any aggressive or special techniques for feeding. She said Resident #3 had poor trunk control and cervical neck issues. The Rehabilitation Doctor said Resident #3 was usually able to keep her head neutral and that if she leaned to the side, the staff could use their fingertips to gently position her head back up and give her a bite. The Rehabilitation Director said the family member rarely came to visit. The Rehabilitation Director said a CNA should never force feed a resident and that there should be nothing aggressive about feeding Resident #3. The Rehabilitation Director said she never saw CNA A feed Resident #3. An observation on 03/04/25 at 4:41 PM revealed Resident #3 was being fed by LVN B. The resident was sitting up in a wheelchair in the dining room. LVN B offered appropriately sized-bites and the resident swallowed well. Resident #3 drank fluids with no issues. LVN B encouraged the resident to hold her head up and she did so without difficulty. LVN B did not use any abusive or aggressive techniques to feed Resident #3. An interview on 03/05/25 at 1:44 PM with the DON revealed he said the charge nurses were responsible for ensuring residents were fed correctly. The DON said the only resident that CNA A fed on 03/03/25 was Resident #3. The DON said he saw CNA A feed residents with no issues. He said he and Administration did random observations to observe CNAs feed residents. He said Resident #3 did not require any special technique to be fed and would droop her head. The DON said it was easily fixed by placing a towel under her neck to help her sit up more. He said that if a resident was forcefully fed; they were at risk for choking and injury. He said Resident #3 was assessed after the incident and did not have any harm. The DON said CNA A was terminated from employment. An interview on 03/05/25 at 3:48 PM with the Administrator revealed CNA A was terminated from employment. Additionally, the facility conducted in-services with staff for abuse. Record review of the facility policy, Abuse, Neglect, and Exploitation, dated January 2012, reflected: Policy It is the policy of this facility to provide protections for the health, welfare and rights of each resident . This was determined to be an IJ on 03/20/25 at 1:00 PM. The Administrator and the DON were notified. The Administrator was provided with the IJ template on 03/20/25 at 1:15 PM. The following Plan of Removal was submitted by the facility and was accepted on 03/20/25 at 3:20 PM and reflected the following: 1. Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. (Completion Date: 3/3/25) The Administrator or designee immediately ensured the safety and well-being of the residents who alleged abuse by removing the accused staff member, CNA A, from the facility. They were suspended pending investigation. The Administrator or designee immediately initiated abuse investigation into Resident #3's abuse allegation. Physical assessment was completed on Resident #3 to identify any injuries of unknown origin and/or evidence of abuse or neglect. No concerns were identified. Medical Director and resident's Attending Physician were both notified of the issue. 2. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: 3/4/25) Disciplinary action was taken with staff member accused of abuse (CNA A was immediately terminated from her position and never returned to the facility). All Federal and State protocols were followed in investigating and reporting the abuse allegation (Facility immediately completed a Self-Report to Health and human Services. Residents with BIMS scores of 8 or higher were interviewed/assessed to identify if they felt safe and if they had ever experienced abuse while living at the facility. Concerns were not identified. All staff received education on facility abuse policies. All staff received education on abuse prevention and reporting. Facility abuse policies and procedures were reviewed with any staff prior to their shift. Staff members were not permitted to work a shift until education had been completed. The Administrator and DON received education from corporate consultant team member on timely and thorough abuse investigations. The regional/corporate/hired consultant team member will visit the facility twice per week to provide oversight, audits, and additional training as needed. The Activities Director held a Resident Council meeting in which the residents were educated on the facility's abuse policies and procedures. The Social Services Director began discussing facility abuse policies with residents and families at the initial care plan conference. The Administrator or designee will continue to interview residents with BIMS scores of 8 or higher on a monthly basis to ensure they have not experienced abuse. The findings of these interviews will be presented to the Quality Assurance/Performance Improvement (QAPI) Committee as a PIP project. Monitoring of the facility's Plan of Removal included the following: Record review of Resident #3's clinical records revealed the resident had been assessed by nursing after the incident on 03/03/25 and did not have any injuries. Record review of the facility in-services revealed all staff were trained. Interviews were conducted on 03/20/25 from 3:26 PM to 4:05 PM with staff from various shifts. The staff included LVN D, CNA E, LVN F, LVN H, CNA I, LVN J, and CNA K. All staff were able to identify: What abuse was and the different types of abuse. The staff understood that a resident could not be force fed. Observations and interviews with residents on 03/20/25 from 2:50 PM to 3:15 PM revealed they felt safe and were not force fed. An interview on 03/20/25 at 4:00 PM with the DON revealed his roles in the facility plan of removal included: Assisting the Administrator with continued training of staff. He said he would be doing monitoring to ensure residents were fed appropriately. He said that all staff were in-serviced on 03/03/25. An interview on 01/05/25 at 4:05 PM with the Administrator revealed he would be making sure in-services and monitoring were completed to prevent abuse from happening again. He said the issues would continue to be discussed in QAPI. The Administrator and DON were informed the Immediate Jeopardy was removed on 03/20/25 at 4:20 PM. On 03/20/25 at 1:00 PM, an IJ was identified. While the IJ was removed on 03/20/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm 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 interview and record review, the facility failed to notify the physician and resident representative regarding changes in condition for one (Resident #1) of seven residents reviewed for notification of changes. The facility failed to notify Resident #1's physician and resident representative 08/09/23 when he initially developed a wound which deteriorated to a Stage 4 and on 08/20/23 it deteriorated where it was unstageable with wound odor and bloody drainage. Resident #1 was transferred to the ER because of possible infection and need for surgical debridement. Resident #1 was still in the hospital at the time of the investigation and with a diagnosis of sepsis (the body's extreme response to an infection and a life-threatening medical emergency) according to the hospital representative. An IJ was identified on 08/24/23. The IJ template was provided to the facility on [DATE] at 4:36 PM. While the IJ was removed on 08/25/23, the facility remained out of compliance at a scope of actual harm that was not immediate and a severity level of isolated because all staff had not been trained on the facility change in condition policy. This failure could place residents at risk of not having their physician and resident representative notified of changes, a delay in medical intervention, and decline in health, hospitalization, or death. Findings included: Review of Resident #1's face sheet dated 08/23/23 reflected he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses of cerebral infarction (stroke as result of disrupted blood flow to the brain), Parkinson's disease, dementia, hypertensive heart disease (changes of the heart and arteries as a result of chronic blood pressure elevation), and cognitive communication deficit. Review of Resident #1's Quarterly Minimum Data Set assessment dated [DATE], reflected he had a BIMS score of 9 indicating he was moderately cognitively impaired. Resident #1's MDS reflected he required extensive assistance with turning and positioning in bed from side to side with staff providing weight bearing support. Resident #1's MDS reflected he was always incontinent of urine, bowel, and at risk for development of a pressure ulcer injury. Review of Resident #1's care plan dated 08/23/23 reflected he had actual impairment to skin integrity related to small open area on his sacrum found on 08/11/23. Interventions included in the care plan reflected Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx of infection, maceration etc. to MD. Resident #1's care plan also reflected a focus on disease management with the intervention to alert provider of any condition alerts identified during resident evaluations. Review of Resident #1's Braden Scale for Predicting Pressure Ulcer Risk assessment dated [DATE] indicated he was at high risk for development of a pressure ulcer due to his limited sensory perception (ability to feel pain or discomfort over ½ of his body), his skin almost always moist, being chairfast (ability to walk severely limited or non-existent), being completely immobile, and friction and shear to his skin being a problem (due to the requirement for frequent repositioning with maximum assistance). Review of Resident #1's Skin Evaluation completed by LVN B dated 08/07/23 reflected he had no skin issues. Review of Resident #1's Nurse's Note created by LVN A dated 08/09/23 reflected Resident resting in the bed at this time, no s/s of pain/distress noted. Assisted with all ADLS by the staff, wound in between the buttocks fold, skin barriers applied, Low bed, call light and personal items within reach. Review of the facility skin assessments and risk management incident reports did not reflect either skin assessment or incident report was created on 08/09/23 to reflect wound between the buttocks fold of Resident #1. Review of Resident #1's Nurse's Note dated 08/11/23 created by LVN C reflected, Resident resting in the bed at this time, no s/s of pain/distress noted, resp (respiration) even and unlabored, assisted with all ADLS by the staff, wound in between the buttocks fold, skin barriers applied, Low bed, call light and personal items within reach. Review of the facility risk management incident report dated 08/11/23 created by the DON reflected Incident Description: Charge nurse reported a small skin area on the buttocks that required [NAME] (s/p barrier) cream and turning of the resident every 2 hours. Immediate Action Taken: The skin area is likely cause by the resident sliding from the wheelchair. Resident is constantly be pulling up by staff on the wheelchair. Resident has appointment at [hospital name] for a new wheelchair. DR., resident's [family member] notified about the skin area. Left message for Veteran's Administration representative . Review of Resident #1's physician orders created 08/11/23 by LVN C reflected Clean between buttocks with NS, pat dry, apply barrier cream, apply dry dressing until seen by wound doctor. Review of Resident #1's Nurse's Note dated 08/14/23 reflected, Resident in bed to be turn and repositioned every 2 hours until open area healed. Treatment for wound Dr. to see the resident requested from [hospital name] nurse today, pending approval. Left buttocks measure 3x4 and right buttock measure 3.5 x 4cm. Treatment order received from (attending) Dr. to treat until wound Dr. sees the resident. Review of Resident #1's Skin Evaluation completed by LVN C dated 08/14/23 reflected; .Skin issue #1 .r) Pressure Ulcer/Injury .Location between buttock .Pressure ulcer/Injury stage .b) Stage II: Partial thickness skin loss .wound bed .d) granulation .wound exudate .b) purulent: thin, thick, opaque, tan/yellow drainage .periwound condition .a) normal .dressing saturation .c) minimal:<25% .wound odor .b. none .tunneling .b. no .tissue .a. painful .no other skin issues identified .General Note: Head to toe assessment skin warm and dry, pressure injury located between buttock cleaned with NS, pat dry and applied barrier, educate staff to continue to turn q2h and apply barrier until wound doctor come to follow up with order. Review of Resident #1's Physician Order dated 08/15/23 reflected Cleanse all open areas to coccyx and buttocks with Dakin's solution, pat dry and apply Collagen to all areas, cover with a dry dressing; every day and night shift for Skin/Wound Support. Review of Resident #1's Treatment Administration Record for the month of August 2023 reflected; Cleanse all open areas to coccyx and buttocks with Dakin's solution, pat dry and apply Collagen to all areas, cover with a dry dressing. Every day and night shift for skin/wound support start date 08/15/23. Review of Resident #1's Skin Evaluation completed by LVN D at 06:47 PM on 08/20/23 reflected; .Skin issue #1 .e)Deep tissue pressure injury .location: right buttock .pressure ulcer/injury stage .e) unstageable .length 8cm X 5.3 cm X 1cm .wound bed .c) slough (soft area) .wound exudate(drainage) .e)sanguineous (bloody drainage) .periwound condition (tissue surrounding the wound) .d)fragile .dressing saturation .a)heavy:>75% .wound odor .a. yes .tunneling .a. yes .tissue .a) painful .c) mushy .Skin issue #2 .e) deep tissue pressure injury .location .left buttocks .pressure ulcer/injury stage .unstageable .length 3 cm .width .2.5 cm .wound bed .slough .wound exudate .e) sanguineous (bloody drainage) .peri wound condition .d) fragile .dressing saturation .a)heavy>75% .wound odor .a. yes .tunneling .a. yes .tissue .a. painful .c. mushy. Review of the facility risk assessment/incident reports did not reflect LVN D completed an incident report or notified Resident #1's physician and or resident representative of the change in condition to Resident #1's skin indicated on skin evaluation 08/20/23. Review of Resident #1's Wound Physician's note at 10:05 AM dated 08/21/23 reflected; Stage 4 Pressure Wound Sacrum Full thickness . wound size (LxWxD) .10x 9.5x 4.5cm .exudate: .Heavy Purulent .Slough: .10% .Coordination of Care .The patient's plan of care was discussed with Patient, Family Member and with another health care provided: Primary Care Physician (discussed wound and transfer to the ER) . Review of Resident #1's physician order dated 08/21/23 reflected Send (Resident #1) out to the hospital for wound evaluation dx: possible infection. In an interview with the DON on 08/23/23 at 09:39 AM, she revealed Resident #1 was at risk for skin breakdown due to his age, fragile skin, incontinence for urine and bowel, his limited mobility and fluctuating appetite. The DON stated when there was injury or wound noted to a resident's skin by staff those staff should notify herself, the ADON, physician, and resident representative immediately as they discover an injury or wound. The DON stated Resident #1 had his family member and a Veteran's Administration nurse who served as resident representatives. The DON stated she was not notified by LVN A on 08/09/23 of a wound LVN A found on Resident #1. The DON stated she was first alerted by LVN C of Resident #1's skin breakdown. LVN C described as a little crack on his sacrum that required application of barrier cream, along with turning and repositioning of Resident #1. The DON stated when notified on 08/11/23 of the change to Resident #1's skin she was not in the facility and upon her return 08/14/23 she assessed Resident #1's skin, documented the assessment, consulted the facility wound care physician, and notified the hospital nurse and resident's family member. The DON stated the ADON notified the wound care physician on 08/14/23 and conducted a telehealth visit for Resident #1. The DON stated on 08/14/23 Resident #1's wound appeared to be a Stage II and the wound care physician provided updated treatment orders for Resident #1's wound. The DON stated in addition to wound care Resident #1 was being turned and repositioned every 2 hours, barrier cream was applied to intact skin not associated with Resident #1's wound during incontinent episodes, he was provided toileting assistance a minimum of every 2 hours, and foam repositioning devices were used to position him off of his sacrum where the wound was located. The DON stated on 08/21/23 the wound care physician was able to visualize Resident #1's wound at bedside. The DON stated she was shocked at the appearance of Resident #1's wound on 08/21/23 and could not believe it had deteriorated that much since last seining it on 08/14/23. The DON stated LVN D caring for Resident # 1 did not report to her Resident #1's wound change in getting worse and the last time she visualized the wound which was 08/18/23 it had not appeared as it did on 08/21/23. The DON stated on 08/18/23 Resident #1's wound had no depth and on 08/21/23 the wound was noticeably deep. In an interview with the ADON on 08/23/23 at 12:08 PM she revealed first being notified of Resident #1's wound to his right and left buttocks on 08/14/23 and on 08/09/23 she was not alerted by any staff Resident #1 had a wound. The ADON stated Resident #1's skin was intact, with noted pink color to his skin, and no depth to the wound. The ADON stated on 08/14/23 she conducted a telehealth visit with the wound care physician for Resident #1 and at that time received a physician order to treat the area with Dakin's solution and collagen dressing. The ADON stated from 08/14/23 facility nursing staff had provided wound care as directed by the physician order and notified herself, DON, wound care physician, and resident representative of any improvement and or deterioration of the wound. The ADON stated staff needed to report any changes in Resident #1's wound so wound care treatment changes could be evaluated and changed if necessary. The ADON stated the risk of staff not reporting changes in Resident #1's wound status would be the wound could worsen and or become infected. The ADON stated was not notified by LVN D on 08/20/23 when there was a documented change in Resident #1's wound condition. The ADON stated on 08/21/23 with the wound care physician at Resident #1's bedside there was some noted depth to Resident #1's wound that was not present on her last assessment of the resident's wound on 08/14/23. The ADON stated the change noted by LVN D on 08/20/23 was a change in condition she expected LVN D to be notify herself, the DON, wound care physician, family, and Veteran's Administration of because treatment may have needed to be changed. The ADON stated on 08/21/23 when the wound care physician visited with Resident #1, the physician ordered Resident #1 to be sent to the hospital. In an interview with LVN A on 08/23/23 at 01:36 PM, she revealed she did not remember working 08/09/23 but had cared for Resident #1 while working at the facility. LVN A stated should Resident #1 have wounds she would have documented their presence in a Nurse's note along with the treatment she provided. LVN A stated she had provided care to Resident #1's wound. LVN A stated she was first alerted by LVN C to the presence Resident #1's wound between the cheeks of his buttocks. LVN A stated the last time she had cared for Resident #1's wound was 08/12/23 and it appeared to be open. She stated she provided treatment for Resident #1's wound by following the treatment order by applying barrier cream and did not notice any changes in Resident #1's wound during her shift on 08/12/23. LVN A stated she was not aware if LVN C reported the presence of Resident #1's wound to anyone else. LVN A stated when a wound was noted on a resident's skin the DON, ADON, Veteran's Administration representative, family and physician needed to be notified in order to receive orders for treatment. LVN A stated should a wound get worse the DON, ADON, Veteran's Administration representative, family and physician also needed to notified to receive alternative treatment in order to improve the condition of the wound. LVN A stated she was not the initial nurse who first found Resident #1's wound on 08/09/23 and could not state definitively she placed the Nurse's Note signed by her on 08/09/23 without seeing the note. LVN A stated the nurse who first saw the wound to Resident #1 should have notified the DON, ADON, [hospital name], family, and physician. In an interview with LVN B on 08/23/23 at 02:07 PM, she revealed for any wound found on a resident the DON, ADON, family members, and physician needed to be notified as well as the presence of the wound and who was notified documented in a facility skin assessment and incident report. LVN B stated a change in condition to a resident's skin identified by nursing aides during a resident's shower were communicated to her directly and documented on shower sheets. LVN B stated weekly as she and staff nurses also perform head to toe skin assessments for each resident. LVN B stated she also would communicate to other nursing staff a change in resident's skin by documenting it on a skin assessment and risk assessment incident report. LVN B stated for a change in a resident's skin she would also communicate it directly to the ADON, DON, family and physician. LVN B stated she worked with Resident #1 on 08/07/23 and at that time he had no skin injuries/wounds. LVN B stated she worked again with Resident #1 on 08/12/23 and 08/17/23. LVN B stated when she saw Resident #1's wound on 08/12/23 there was a crack on the resident's coccyx area that appeared to be a shearing injury. LVN B stated Resident #1's wound was not open, there was no noted drainage or odors. LVN B stated there was a treatment order in place, but she was unaware if the physician had been notified of the injury to Resident #1's skin. LVN B stated LVN C and LVN A both reported to her Resident #1 had been scheduled to see the wound care physician. In an interview with LVN B on 08/23/23 at 02:59 PM, revealed she worked with Resident #1 on 08/20/23 and assisted LVN D with the cleaning of his wound and repositioning Resident #1. LVN B stated she last observed Resident #1's wound on 08/19/23 and on 08/20/23 she noted it had changed significantly. She stated it went from a small area to two bigger areas. LVN B stated the wound to Resident #1's left buttocks started to open along with the wound to Resident #1's right buttocks. LVN B stated she texted the DON to notify her of the change to Resident #1's wound but the DON had not responded to her text message. LVN B stated she had also talked to the DON the morning of 08/20/23 about Resident #1's wound and was told by the DON the wound care physician was scheduled to see Resident #1 the morning of 08/21/23. LVN B stated other than notifying the DON she should have notified the family and physician of the change to Resident #1's wound. LVN B stated the reason she did not notify anyone other than the DON was because LVN D was assigned to care for the resident and should have notified the DON, ADON, physician, and resident representative. LVN B stated the risk of not notifying the physician, family, resident representative, ADON, DON of a change in resident condition it could be potentially dangerous for the resident and cause a wound to get worse. In an interview with LVN D on 08/23/23 at 02:32 PM, she revealed a change to a resident's skin should be reported by the staff to the family and physician. LVN D stated she is alerted to changes in a resident's skin by performing weekly skin assessments which she documented in a resident's electronic medical record. LVN D stated she assessed a resident's skin for any open areas, maceration, and or rashes. LVN D stated she communicated any changes in a resident's skin to other staff by documenting the skin assessment in the resident's electronic medical record and communicating it directly to the DON, ADON, family and physician. LVN D stated should a resident's wound also worsen by getting bigger in size the family and physician should be notified. LVN D stated she worked with Resident #1 on 08/20/23 and documented a wound to his right and left inner buttocks. LVN D stated it was the first time she cared for Resident #1. LVN D stated LVN B assisted her with assessing Resident #1's wound and LVN B remarked to her at that time the Resident #1's wound worsened. LVN D stated LVN B notified the DON of the change in condition to Resident #1's wound. LVN D stated she had not documented or made any attempts to notify the DON, physician and or Resident #1's family of the change to his wound. LVN D stated she was advised by LVN B the wound care physician was scheduled to visit with Resident #1 and that was why she did not call the physician. LVN D stated the risk of not notifying the physician of the change to a resident's condition was it could pose harm to the resident and looking back on Resident #1's situation, she should have notified the physician on 08/20/23 of the change she observed to his skin. In an interview with Resident #1's secondary attending physician on 08/23/23 at 03:16 PM, he revealed a deterioration of a resident's wound should be reported to him or the wound care physician. The secondary attending physician stated on 08/09/23 when Resident # 1's wound was identified by LVN A neither he nor the resident's primary attending physician was notified. The secondary attending physician stated he started covering for the primary attending physician on 08/19/23 due to her traveling out of the country ( the primary attending physician was not available for interview). The secondary attending physician stated he should have been notified because if treatment was not instituted, Resident #1's wound could have worsened. The wound care physician stated on 08/20/23 he was not notified by LVN D or LVN B about Resident #1's change to his wound condition. The secondary physician stated he should have been notified on 08/20/23 of the deterioration of Resident #1's wound because the wound was worsening, and he would have notified the wound care physician about the worsening of the wound. The secondary attending physician stated if notified of Resident #1's condition on 08/20/23 he would have ordered labs and cultures of the wound. In an interview with the VA resident representative for Resident #1 on 08/23/23 at 3:45 PM she revealed being a registered nurse for the Dallas Veterans Administration whose role was to provide oversight for the clinical care of veterans within the facility. She stated being first notified of Resident #1's wound on 08/11/23 by the facility DON. She stated the facility staff was contracted to provide notice to the Veteran's Administration within 24 hours of any physical or behavioral change in condition to veterans cared for by the facility. The VA resident representative stated she reviewed Resident #1's facility electronic chart and saw his wound was first documented by a nurse on 08/09/23. She stated neither she or her office had been alerted about the presence of Resident #1's wound on 08/09/23. The VA resident representative also stated she could not see where on 08/09/23 facility staff documented notification of Resident #1's physician the change to his skin. The VA resident representative stated the facility should have contacted her on 08/09/23 when the nurse first discovered the wound and at that time she would have obtained authorization for the wound care physician to provide Resident #1 care. She stated the wound care physician visited with Resident #1 at the facility 08/21/23 and decided Resident #1 needed to go to the emergency room because the wound had deteriorated. She stated as of 08/24/23 Resident #1 was at the Dallas Veteran's Hospital and had been diagnosed with a sacral pressure ulcer and sepsis. In an interview with LVN C on 08/24/23 at 8:25 AM revealed LVN A worked the 08/09/23 10:00PM to 6:00AM shift on 08/10/23 and LVN A notified her on 08/10/23 when she assumed care of Resident #1 at 6:00 AM of a small wound to Resident # 1's bottom. LVN C stated being told by LVN A the presence Resident #1's wound was documented in his electronic medical record. LVN C stated Resident #1's wound was an open wound between his buttocks. LVN C stated she worked again with Resident #1 on 08/11/23 and in morning meeting alerted the DON of the resident's wound. LVN C stated she noticed LVN A did not open a risk assessment incident report which was a requirement of staff should a change in resident's skin be identified. LVN C stated she notified the DON the risk assessment incident report was not completed by LVN A and the DON told her she would have LVN A complete the report. LVN C stated a risk assessment incident report would document the family, physician, and Veteran's Administration resident representative who would need to be notified of Resident #1's change in condition. LVN C stated the DON told her she would notify the Veteran's Administration resident representative to receive authorization for the wound care physician to see Resident #1. LVN A stated on 08/11/23 Resident #1's wound appeared to be pink, no slough to the wound, it was located in the middle of his bottom, no signs of infection, with no discoloration to his surrounding skin. LVN C stated she cleaned Resident # 1's wound with normal saline, applied barrier cream, and covered it with a dry dressing. LVN C stated she applied barrier cream to Resident #1 because at the start of any redness or skin breakdown it was nursing judgment to apply barrier cream to the area to keep the area from breaking down. LNV C stated she notified Resident #1s wife, ADON, and DON on 08/11/23 of his skin breakdown. LVN C stated she did not notify Resident #1's physician because LVN A should have notified the physician. LVN C stated she should have notified Resident #1's physician because when there was a change in condition the physician would need to monitor the resident's condition and provide orders as needed for treatment. LVN C stated she also educated nursing aide staff to turn and reposition Resident #1 every 2 hours to relieve pressure to his wound. LVN C stated she worked with Resident #1 again on 08/14/23. LVN C stated she along with the ADON visualized Resident #1's wound. LVN C stated Resident #1's wound had gotten worse since 08/11/23. LVN C stated Resident #1's wound appeared to be spreading from between his buttocks to the outer edges of his buttocks, she stated there was no depth nor slough tissue present. LVN C stated the ADON obtained measurements of the wound provided wound care. LVN C stated the would care physician was scheduled to see Resident #1 on 08/14/23 and she followed up with the ADON and DON who both were going to notify Resident # 1's primary attending physician. LVN C stated 08/14/23 was her last day working at the facility. In an interview with the DON on 08/24/23 at 9:03 AM, she revealed Resident #1's Nurse's Note dated 08/09/23 completed by LVN A indicated there was a wound between his buttocks and skin barrier cream was applied to the wound. The DON stated LVN A's Nurse Note on 08/09/23 for Resident #1 did not indicate who she reported the presence of the wound to; she stated LVN A did not notify Resident #1's family, Veteran's Administration representative, physician, the ADON, or herself of the wound she documented in Resident #1's 08/09/23 Nurse's Note. The DON stated LVN A upon finding a skin change to Resident #1 on 08/09/23 completed a risk assessment incident report and skin assessment. The DON stated a part of the risk assessment incident report would have documented the physician, family, and any other staff she reported the wound to and the time she reported the wound. The DON stated when an initial risk assessment incident report was generated by any staff member it notified all other staff who accessed Resident #1's medical record to follow up on the reported incident over the course of next 72 hours. The DON reviewed the LVN A's Nurse's Note documented on Resident #1 at 07:34pm and stated the risk to resident's should staff not follow the policy and complete a risk assessment incident report when discovering a wound other staff would not know to follow up on the progress of the resident's care and the wound could get worse. The DON stated she was not aware of the wound to Resident #1 until 08/11/23. The DON stated on 08/10/23 LVN C worked with Resident #1 and documented also in a Nurse's Note the presence of a wound to Resident #1 and also did not complete a risk assessment incident report or document who she notified. The DON stated she was notified by LVN C on 08/11/23 about Resident #1's wound. The DON stated LVN C stated she did not complete a risk assessment incident report on 08/10/23 for Resident #1 because she was waiting on LVN A to complete the incident report since she was the initial nurse who found the wound. The DON stated it was important for both nurses to have completed a risk assessment incident report and notify the family, physician, ADON, Veteran's Administration representative, and herself to ensure the change in Resident #1's condition could be monitored and treated to prevent it from getting worse. The DON stated on 08/11/23 she completed an incident report for Resident #1 and notified the resident's [hospital name] nurse of the wound to obtain a consult to have the wound care physician visit with the resident. The DON stated LVN C indicated she notified the resident's family member and physician of the wound on 08/11/23. The DON reviewed the physician order on 08/11/23 created by LVN C reflected Clean between buttocks with NS, pat dry, apply barrier cream, apply dry dressing until seen by wound doctor .electronically signed by Resident #1's primary attending physician. The DON stated she visualized Resident #1's wound along with the ADON on 08/14/23 and described the wound as an open area with redness the area to the left buttocks measured 3cm x 4cm and the wound to the right buttocks measured 3.5cm x 4 cm. The DON stated Resident #1's wound had no depth to either of the two wounds. The DON stated on 08/14/23 the wound care physician was consulted and visualized Resident #1's wound and provided updated wound care orders. The DON stated Resident #1 received new wound care orders on 08/15/2 to cleanse all open areas to coccyx and buttocks with Dakin's solution, pat dry and apply Collagen to all areas, cover with a dry dressing; every day and night shift for skin/wound support electronically signed by primary attending physician. The DON stated on 08/20/23 the Skin Evaluation completed by LVN D was a change in condition for Resident #1. The DON stated LVN B also worked with LVN D on 08/20/23 and LVN B reported to her there was a change in Resident #1's wound condition but did not describe the extent of the change. The DON stated the told LVN B the wound care physician would visit with Resident #1 the flowing day 08/21/23 and at that time provide updated treatment orders and or evaluate if Resident #1 needed to be sent out to the hospital for wound evaluation. The DON stated she told LVN D and LVN B to notify Resident #1's family, physician, or [hospital name] nurse of the change in condition to his wound but neither staff member did. The DON stated on 08/21/23 she with the wound care physician and ADON saw Resident #1's wound and at that time the wound care physician provided the order to transfer Resident #1 to the hospital for wound evaluation. In an interview with the wound care physician on 08/24/23 at 10:57 AM, he revealed he had been consulted via telehealth (via telephone) visit for Resident #1's wound. The wound care physician stated when he visualized Resident #1's wound on 08/14/23 it was superficial, appeared to be a skin tear or superficial stage 2 pressure related wound, there was one wound near the center left of his bottom, the surrounding skin was intact, there was no drainage, no edema or mention of odor provided to him. The wound care physician stated the treatment Resident #1 received of clean with normal saline, pat dry, apply barrier cream and dry dressing could have been appropriate when first identified on 08/09/23 up to the given the state of Resident #1's wound when he saw it on 08/14/23. The wound care physician stated he provided updated wound treatment orders to mitigate the risk of infection to Resident #1. The wound care physician stated when he saw Resident #1 on 08/21/23 and saw a significantly different wound than he observed on 08/14/23. The wound care physician described Resident #1's wound on 08/21/23 as deep, much bigger, and had purulent (containing pus) discharge. The wound care physician stated he sent Resident #1 to the ER for surgical debridement of the wound because the resident needed intervention beyond what he could provide in the facility. The wound care physician stated between 08/14/23 and 08/21/23 he had not been informed by anyone on facility staff of the change to Resident #1's condition. The wound care physician stated the change in condition documented on 08/20/23 by LVN D was significant and if noticed within a hour or two of him arriving to the facility to see the resident that may explain why staff had not contacted him. The wound care physician stated due to Resident #1's comorbidities and nutritional status his wound was capable of deteriorating rapidly. Review of the facility's policy titled, Change in a Resident's Condition or Status revised December 2022 reflected; Policy Statement: Our facility shall promptly notify the resident, his or her Attending Physician and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g. changes in level of care, billing/payments, resident rights, etc.). Policy Interpretation and Implementation.1. The nurse will notify the resident's Attending Physician or physician on call when there has been a (an): .b. discovery of injuries of an unknown source; .d. significant change in the resident's physical/emotional/mental condition; .e. need to alter the resident's medical treatment significantly; .g. need to transfer t[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure residents received care consistent with professional standards of practice, to prevent pressure ulcers, to promote healing, prevent infection, and prevent new ulcers from developing for one (Resident #1) of seven residents reviewed for skin breakdown. The facility failed to ensure LVN A, who identified Resident #1's wound on 08/09/23, followed-up to notify his physician, and the facility did not get orders for treatment until 08/11/23. LVN D on 08/20/23 documented Resident #1's wound had an odor, bloody drainage and was unstageable. LVN D on 08/20/23 did not notify Resident #1's physician, DON, or resident representative when she noticed his wound had deteriorated. The facility on 08/20/23 took no additional interventions to care for Resident #1's wound. Resident #1 initially developed a wound which deteriorated to a Stage 4 and on 08/20/23 it deteriorated where it was unstageable with wound odor and bloody drainage. Resident #1 was transferred to the ER because of possible infection and need for surgical debridement. Resident #1 was still in the hospital at the time of the investigation and with a diagnosis of sepsis (the body's extreme response to an infection and a life-threatening medical emergency) according to the hospital representative. The facility failed to ensure Resident #1's wound treatment was completed per physician orders on 08/17/23. An IJ was identified on 08/24/23. The IJ template was provided to the facility on [DATE] at 4:36 PM. While the IJ was removed on 08/25/23, the facility remained out of compliance at a scope of actual harm that was not immediate and a severity level of isolated because all staff had not been trained on the facility change in condition policy. This failure could place residents at risk of new or worsening pressure wounds, serious infections, hospitalization, or death. Findings included: Review of Resident #1's face sheet dated 08/23/23 reflected he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses cerebral infarction (stroke as result of disrupted blood flow to the brain), Parkinson's disease, dementia, hypertensive heart disease (changes of the heart and arteries as a result of chronic blood pressure elevation), and cognitive communication deficit. Review of Resident #1's Quarterly Minimum Data Set assessment dated [DATE], reflected he had a BIMS score of 9 indicating he was moderately cognitively impaired. Resident #1's MDS reflected he required extensive assistance with turning and positioning in bed from side to side with staff providing weight bearing support. Resident #1's MDS reflected he was always incontinent of urine, bowel, and at risk for development of a pressure ulcer injury. Review of Resident #1's care plan dated 08/23/23 reflected he had actual impairment to skin integrity related to small open area on his sacrum found on 08/11/23. Interventions included in the care plan reflected Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx of infection, maceration etc. to MD. Resident #1's care plan also reflected a focus on disease management with the intervention to alert provider of any condition alerts identified during resident evaluations. Review of Resident #1's Braden Scale for Predicting Pressure Ulcer Risk assessment dated [DATE] indicated he was at high risk for development of a pressure ulcer due to his limited sensory perception (ability to feel pain or discomfort over ½ of his body), his skin almost always moist, being chairfast (ability to walk severely limited or non-existent), being completely immobile, and friction and shear to his skin being a problem (due to the requirement for frequent repositioning with maximum assistance). Review of Resident #1's Skin Evaluation completed by LVN B dated 08/07/23 reflected he had no skin issues. Review of Resident #1's Nurse's Note created by LVN A dated 08/09/23 reflected VA Resident resting in the bed at this time, no s/s of pain/distress noted. Assisted with all ADLS by the staff, wound in between the buttocks fold, skin barriers applied, Low bed, call light and personal items within reach. Review of facility skin assessments and risk management incident reports did not reflect either skin assessment or incident report was created on 08/09/23 to reflect wound between the buttocks fold of Resident #1. Review of Resident #1's Nurse's Note dated 08/11/23 created by LVN C reflected, VA Resident resting in the bed at this time, no s/s of pain/distress noted, resp (respiration) even and unlabored, assisted with all ADLS by the staff, wound in between the buttocks fold, skin barriers applied, Low bed, call light and personal items within reach. Review of facility risk management incident report dated 08/11/23 created by the DON reflected Incident Description: Charge nurse reported a small skin area on the buttocks that required [NAME] (s/p barrier) cream and turning of the resident every 2 hours. Immediate Action Taken: The skin area is likely cause by the resident sliding from the wheelchair. Resident is constantly be pulling up by staff on the wheelchair. Resident has appointment at VA for a new wheelchair. DR., resident's family member notified about the skin area. Left message for Veteran's Administration representative . Review of Resident #1's physician orders created 08/11/23 by LVN C reflected Clean between buttocks with NS, pat dry, apply barrier cream, apply dry dressing until seen by wound doctor. Review of Resident #1's Nurse's Note dated 08/14/23 reflected, Resident in bed to be turn and repositioned every 2 hours until open area healed. Treatment for wound Dr. to see the resident requested from VA nurse today, pending approval. Left buttocks measure 3x4 and right buttock measure 3.5 x 4cm. Treatment order received from (attending) Dr. to treat until wound Dr. sees the resident. Review of Resident #1's Skin Evaluation completed by LVN C dated 08/14/23 reflected; .Skin issue #1 .r) Pressure Ulcer/Injury .Location between buttock .Pressure ulcer/Injury stage .b) Stage II: Partial thickness skin loss .wound bed .d) granulation .wound exudate .b) purulent: thin, thick, opaque, tan/yellow drainage .periwound condition .a) normal .dressing saturation .c) minimal:<25% .wound odor .b. none .tunneling .b. no .tissue .a. painful .no other skin issues identified .General Note: Head to toe assessment skin warm and dry, pressure injury located between buttock cleaned with NS, pat dry and applied barrier, educate staff to continue to turn q2h and apply barrier until wound doctor come to follow up with order. Review of Resident #1's Physician Order dated 08/15/23 reflected Cleanse all open areas to coccyx and buttocks with Dakin's solution, pat dry and apply Collagen to all areas, cover with a dry dressing; every day and night shift for Skin/Wound Support. Review of Resident #1's Treatment Administration Record for the month of August 2023 reflected; Cleanse all open areas to coccyx and buttocks with Dakin's solution, pat dry and apply Collagen to all areas, cover with a dry dressing. Every day and night shift for skin/wound support start date 08/15/23 .The night shift of 08/17/23 there were no initials of the staff to indicate the treatment was provided. Review of Nurse's notes on 08/17/23 also did not provide any evidence that the treatment was provided during the evening or night shift staff. Review of the facility's staffing schedule dated 08/17/23 revealed LVN B was assigned to work with Resident #1 on the evening 2:00 PM to 10:00 PM shift and LVN E with Resident #1 on the night 10:00 PM to 6:00 AM shift. Review of Resident #1's Skin Evaluation completed by LVN D at 06:47 PM on 08/20/23 reflected; .Skin issue #1 .e)Deep tissue pressure injury .location: right buttock .pressure ulcer/injury stage .e) unstageable .length 8cm X 5.3 cm X 1cm .wound bed .c) slough (soft area) .wound exudate(drainage) .e)sanguineous (bloody drainage) .periwound condition (tissue surrounding the wound) .d)fragile .dressing saturation .a)heavy:>75% .wound odor .a. yes .tunneling .a. yes .tissue .a) painful .c) mushy .Skin issue #2 .e) deep tissue pressure injury .location .left buttocks .pressure ulcer/injury stage .unstageable .length 3 cm .width .2.5 cm .wound bed .slough .wound exudate .e) sanguineous (bloody drainage) .peri wound condition .d) fragile .dressing saturation .a)heavy>75% .wound odor .a. yes .tunneling .a. yes .tissue .a. painful .c. mushy Review of facility risk assessment/incident reports did not reflect LVN D completed an incident report or notified Resident #1's physician and or resident representative of the change in condition to Resident #1's skin indicated on skin evaluation 08/20/23. Review of Resident #1's Wound Physician's note at 10:05 AM dated 08/21/23 reflected; Stage 4 Pressure Wound Sacrum Full thickness . wound size (LxWxD) .10x 9.5x 4.5cm .exudate: .Heavy Purulent .Slough: .10% .Coordination of Care .The patient's plan of care was discussed with Patient, Family Member and with another health care provided: Primary Care Physician (discussed wound and transfer to the ER) . Review of Resident #1's physician order dated 08/21/23 reflected Send (Resident #1) out to the hospital for wound evaluation dx: possible infection. In an interview with the DON on 08/23/23 at 09:39 AM she revealed Resident #1 was a risk for skin breakdown due to his age, fragile skin, incontinence for urine and bowel, his limited mobility and fluctuating appetite. The DON stated when there was injury or wound noted to a resident's skin by staff those who staff should notify were herself, the ADON, physician, and resident representative. The DON stated Resident #1 had family member and a Veteran's Administration nurse who served as his resident representatives. The DON stated she was not notified by LVN A on 08/09/23 of a wound LVN A found on Resident #1. The DON stated she was first alerted by LVN C of Resident #1's skin breakdown LVN C described as a little crack on his sacrum that required application of barrier cream, along with turning and repositioning of Resident #1. The DON stated when notified on 08/11/23 of the change to Resident #1's skin she was not in the facility and upon her return 08/14/23 she assessed Resident #1's skin, documented the assessment, consulted the facility wound care physician, and notified the Veteran's Administration nurse and resident's wife. The DON stated the ADON notified the wound care physician on 08/14/23 and conducted a telehealth visit for Resident #1. The DON stated on 08/14/23 Resident #1's wound appeared to be a Stage II and the wound care physician provided updated treatment orders for Resident #1's wound. The DON stated in addition to wound care Resident #1 was being turned and repositioned every 2 hours, barrier cream was applied to intact skin not associated with Resident #1's wound during incontinent episodes, he was provided toileting assistance a minimum of every 2 hours, and foam repositioning devices were used to position him off of his sacrum where the wound was located. The DON stated on 08/21/23 the wound care physician was able to visualize Resident #1's wound at bedside. The DON stated she was shocked at the appearance of Resident #1's wound on 08/21/23 and could not believe it had deteriorated that much since last seining it on 08/14/23. The DON stated LVN D caring for Resident # 1 did not report to her Resident #1's wound change in getting worse and the last time she visualized the wound which was 08/18/23 it had not appeared as it did on 08/21/23. The DON stated on 08/18/23 Resident #1's wound had no depth and on 08/21/23 the wound was noticeably deep. In an interview with the ADON on 08/23/23 at 12:08 PM she revealed first being notified of Resident #1's wound to his right and left buttocks on 08/14/23 and on 08/09/23 she was not alerted by any staff Resident #1 had a wound. The ADON stated Resident #1's skin was intact, with noted pink color to his skin, and no depth to the wound. The ADON stated on 08/14/23 she conducted a telehealth visit with the wound care physician for Resident #1 and at that time received an physician order to treat the area with Dakin's solution and collagen dressing. The ADON stated from 08/14/23 facility nursing staff have provided wound care as directed by the physician order and notified herself, DON, wound care physician, and resident representative of any improvement and or deterioration of the wound. The ADON stated staff needed to report any changes in Resident #1's wound so wound care treatment changes could be evaluated and changed if necessary. The ADON stated the risk of staff not reporting changes in Resident #1's wound status would be the wound could worsen and or become infected. The ADON stated was not notified by LVN D on 08/20/23 when there was a documented change in Resident #1's wound condition. The ADON stated when a nurse performed wound care they should document care was on the resident's treatment administration record. The ADON stated blank spaces on a resident's treatment administration record could indicate treatment was not provided. The ADON stated treatment was not indicated on a resident's treatment administration record it might also be documented in a Nurse's Note. The ADON reviewed Resident #1's treatment administration record and stated 08/17/23 there was no documentation provided by any staff member that treatment was provided nor was there a Nurse's note which indicated Resident #1's treatment was provided. The ADON stated on 08/21/23 with the wound care physician at Resident #1's bedside there was some noted depth to Resident #1's wound that was not present on her last assessment of the resident's wound on 08/14/23. The ADON stated the change noted by LVN D on 08/20/23 was a change in condition she expected LVN D to be notify herself, the DON, wound care physician, family and Veteran's Administration because treatment may have needed to be changed. The ADON stated on 08/21/23 when the wound care physician visited with Resident #1, the physician ordered Resident #1 to be sent to the hospital. In an interview with LVN A on 08/23/23 at 01:36 PM she revealed she did not remember working 08/09/23 but had cared for Resident #1 while working at the facility. LVN A stated should Resident #1 have wounds she would have documented their presence in a Nurse's note along with the treatment she provided. LVN A stated she had provided care to Resident #1's wound. LVN A stated she was first alerted by LVN C to the presence Resident #1's wound between the cheeks of his buttocks. LVN A stated the last time she had cared for Resident #1's wound was 08/12/23 and it appeared to be open, stated she provided treatment for Resident #1's wound by following the treatment order by applying barrier cream, and did not notice any changes in Resident #1's wound during her shift on 08/12/23. LVN A stated she was not aware if LVN C reported the presence of Resident #1's wound to anyone else. LVN A stated when a wound is noted on a resident's skin the DON, ADON, VA, family and physician needed to be notified in order to receive orders for treatment. LVN A stated should a wound get worse the DON, ADON, VA, family and physician also needed to notified to receive alternative treatment in order to improve the condition of the wound. LVN A stated she was not the initial nurse who first found Resident #1's wound on 08/09/23 and could not state definitively she placed the Nurse's Note signed by her on 08/09/23 without seeing the note. LVN A stated the nurse who first saw the wound to Resident #1 should have notified the DON, ADON, Veteran's Administration representative, family and physician. In an interview with LVN B on 08/23/23 at 02:07 PM she revealed for any wound found on a resident the DON, ADON, family members, and physician needed to be notified as well as the presence of the wound and who was notified documented in a facility skin assessment and incident report. LVN B stated a change in condition to a resident's skin identified by nursing aides during a resident's shower were communicated to her directly and documented on shower sheets. LVN B stated weekly as she and staff nurses also perform head to toe skin assessments for each resident. LVN B stated she also would communicate to other nursing staff a change in resident's skin by documenting it on a skin assessment and risk assessment incident report. LVN B stated for a change in a resident's skin she would also communicate it directly to the ADON, DON, family and physician. LVN B stated she worked with Resident #1 on 08/07/23 and at that time he had no skin injuries/wounds. LVN B stated she worked again with Resident #1 on 08/12/23 and 08/17/23. LVN B stated when she saw Resident #1's wound on 08/12/23 there was a crack on the resident's coccyx area that appeared to be a shearing injury. LVN B stated Resident #1's wound was not open, there was no noted drainage or odors. LVN B stated there was a treatment order in place but she was unaware if the physician had been notified of the injury to Resident #1's skin. LVN B stated LVN C and LVN A both reported to her Resident #1 had been scheduled to see the wound care physician. LVN B stated she worked with Resident #1 on 08/17/23 during the 2:00 PM to 10:00 PM shift. LVN B stated she was aware of what treatment a resident requires because it is noted on the resident's treatment administration record. LVN B stated she did not provide wound care because the resident's dressing had been changed during the morning shift and was scheduled to be changed again on the night 10:00 PM to 6:00 AM shift. LVN B stated she turned and repositioned Resident #1 off of his wound throughout her shift and each time applied barrier cream to his thighs and intact skin of his sacrum. In an interview with LVN B on 08/23/23 at 02:59 PM revealed she worked with Resident #1 on 08/20/23 and assisted LVN D with the cleaning of his wound and repositioning Resident #1. LVN B stated she last observe Resident #1's wound on 08/19/23 and on 08/20/23 she noted it had changed significantly, she stated it went from a small area to two bigger areas. LVN B stated the wound to Resident #1's left buttocks started to open along with the wound to Resident #1's right buttocks. LVN B stated she texted the DON to notify her of the change to Resident #1's wound but the DON had not responded to her text message. LVN B stated she had also talked to the DON the morning of 08/20/23 about Resident #1's wound and was told by the DON the wound care physician was scheduled to see Resident #1 the morning of 08/21/23. LVN B stated other than notifying the DON she should have notified the family and physician of the change to Resident #1's wound. LVN B stated the reason she did not notify anyone other than the DON was LVN D was actually assigned to care for the resident and should have notified the DON, ADON, physician, and resident representative. LVN B stated the risk of not notifying the physician, family, resident representative, ADON, DON of a change in resident condition it could be potentially dangerous for the resident and cause a wound to get worse. In an interview with LVN D on 08/23/23 at 02:32 PM she revealed a change to a resident's skin should be reported by the staff to the family and physician. LVN D stated she is alerted to changes in a resident's skin by performing weekly skin assessments which she documented in a resident's electronic medical record. LVN D stated she assessed a resident's skin for any open areas, maceration, and or rashes. LVN D stated she communicated any changes in a resident's skin to other staff by documenting the skin assessment in the resident's electronic medical record and communicating it directly to the DON, ADON, family and physician. LVN D stated should a resident's wound also worsen by getting bigger in size the family and physician should be notified. LVN D stated she worked with Resident #1 on 08/20/23 and documented a wound ot his right and left inner buttocks. LVN D stated it was the first time she cared for Resident #1. LVN D stated LVN B assisted her with assessing Resident #1's wound and LVN B remarked to her at that time the Resident #1's wound worsened. LVN D stated LVN B notified the DON of the change in condition to Resident #1's wound. LVN D stated she had not documented or made any attempts to notify the DON, physician and or Resident #1's family of the change to his wound. LVN D stated she was advised by LVN B the wound care physician was scheduled to visit with Resident #1 and that is why she did not call the physician. LVN D stated the risk of not notifying the physician of the change to a resident's condition was it could pose harm to the resident and looking back on Resident #1's situation she should have notified the physician on 08/20/23 of the change she observed to his skin. In an interview with Resident #1's secondary attending physician on 08/23/23 at 03:16 PM he revealed a deterioration of a resident's wound should be reported to him or the wound care physician. The secondary attending physician stated on 08/09/23 when Resident # 1's wound was identified by LVN A neither he or the resident's primary attending physician was notified. The secondary attending physician stated he started covering for the primary attending physician on 08/19/23 due to her traveling out of the country. The primary attending physician was not available for interview. The secondary attending physician stated he should have been notified because if treatment was not instituted Resident #1's wound could have worsened. The wound care physician stated on 08/20/23 he was not notified by LVN D or LVN B about Resident #1's change to his wound condition. The secondary physician stated he should have been notified on 08/20/23 of the deterioration of Resident #1's wound because the wound was worsening and he would have notified the wound care physician about the worsening of the wound. The secondary attending physician stated if notified of Resident #1's condition on 08/20/23 he would have ordered labs and cultures of the wound. In an interview with the VA resident representative for Resident #1 on 08/23/23 at 3:45 PM she revealed being a registered nurse for the Dallas Veterans Administration whose role was to provide oversight for the clinical care of veterans within the facility. She stated being first notified of Resident #1's wound on 08/11/23 by the facility DON. She stated the facility staff was contracted to provide notice to the Veteran's Administration within 24 hours of any physical or behavioral change in condition to veterans cared for by the facility. The VA resident representative stated she reviewed Resident #1's facility electronic chart and saw his wound was first documented by a nurse on 08/09/23. She stated neither she or her office had been alerted about the presence of Resident #1's wound on 08/09/23. The VA resident representative also stated she could not see where on 08/09/23 facility staff documented notification of Resident #1's physician the change to his skin. The VA resident representative stated the facility should have contacted her on 08/09/23 when the nurse first discovered the wound and at that time she would have obtained authorization for the wound care physician to provide Resident #1 care. She stated the wound care physician visited with Resident #1 at the facility 08/21/23 and decided Resident #1 needed to go to the emergency room because the wound had deteriorated. She stated as of 08/24/23 Resident #1 was at the Dallas Veteran's Hospital and had been diagnosed with a sacral pressure ulcer and sepsis. An attempt to interview LVN E was made on 08/24/23 at 8:10am and again at 11:17 AM. voice messages indicated she was not accepting calls. In an interview with LVN C on 08/24/23 at 8:25 AM revealed LVN A worked the 08/09/23 10:00PM to 6:00AM shift on 08/10/23 and LVN A notified her on 08/10/23 when she assumed care of Resident #1 at 6:00 AM of a small wound to Resident # 1's bottom. LVN C stated being told by LVN A the presence Resident #1's wound was documented in his electronic medical record. LVN C stated Resident #1's wound was an open wound between his buttocks. LVN C stated she worked again with Resident #1 on 08/11/23 and in morning meeting alerted the DON of the resident's wound. LVN C stated she noticed LVN A did not open a risk assessment incident report which was a requirement of staff should a change in resident's skin be identified. LVN C stated she notified the DON the risk assessment incident report was not completed by LVN A and the DON told her she would have LVN A complete the report. LVN C stated a risk assessment incident report would document the family, physician, and Veteran's Administration resident representative who would need to be notified of Resident #1's change in condition. LVN C stated the DON told her she would notify the Veteran's Administration resident representative to receive authorization for the wound care physician to see Resident #1. LVN A stated on 08/11/23 Resident #1's wound appeared to be pink, no slough to the wound, it was located in the middle of his bottom, no signs of infection, with no discoloration to his surrounding skin. LVN C stated she cleaned Resident # 1's wound with normal saline, applied barrier cream, and covered it with a dry dressing. LVN C stated she applied barrier cream to Resident #1 because at the start of any redness or skin breakdown it was nursing judgment to apply barrier cream to the area to keep the area from breaking down. LNV C stated she notified Resident #1s wife, ADON, and DON on 08/11/23 of his skin breakdown. LVN C stated she did not notify Resident #1's physician because LVN A should have notified the physician. LVN C stated she should have notified Resident #1's physician because when there was a change in condition the physician would need to monitor the resident's condition and provide orders as needed for treatment. LVN C stated she also educated nursing aide staff to turn and reposition Resident #1 every 2 hours to relieve pressure to his wound. LVN C stated she worked with Resident #1 again on 08/14/23. LVN C stated she along with the ADON visualized Resident #1's wound. LVN C stated Resident #1's wound had gotten worse since 08/11/23. LVN C stated Resident #1's wound appeared to be spreading from between his buttocks to the outer edges of his buttocks, she stated there was no depth nor slough tissue present. LVN C stated the ADON obtained measurements of the wound provided wound care. LVN C stated the would care physician was scheduled to see Resident #1 on 08/14/23 and she followed up with the ADON and DON who both were going to notify Resident # 1's primary attending physician. LVN C stated 08/14/23 was her last day working at the facility. In an interview with the DON on 08/24/23 at 9:03 AM she revealed Resident #1's Nurse's Note dated 08/09/23 completed by LVN A indicated there was a wound between his buttocks and skin barrier cream was applied to the wound. The DON stated LVN A's Nurse Note on 08/09/23 for Resident #1 did not indicate who she reported the presence of the wound to; she stated LVN A did not notify Resident #1's family, Veteran's Administration representative, physician, the ADON, or herself of the wound she documented in Resident #1's 08/09/23 Nurse's Note. The DON stated LVN A upon finding a skin change to Resident #1 on 08/09/23 completed a risk assessment incident report and skin assessment. The DON stated a part of the risk assessment incident report would have documented the physician, family, and any other staff she reported the wound to and the time she reported the wound. The DON stated when an initial risk assessment incident report was generated by any staff member it notified all other staff who accessed Resident #1's medical record to follow up on the reported incident over the course of next 72 hours. The DON reviewed the LVN A's Nurse's Note documented on Resident #1 at 07:34pm and stated the risk to resident's should staff not follow the policy and complete a risk assessment incident report when discovering a wound other staff would not know to follow up on the progress of the resident's care and the wound could get worse. The DON stated she was not aware of the wound to Resident #1 until 08/11/23. The DON stated on 08/10/23 LVN C worked with Resident #1 and documented also in a Nurse's Note the presence of a wound to Resident #1 and also did not complete a risk assessment incident report or document who she notified. The DON stated she was notified by LVN C on 08/11/23 about Resident #1's wound. The DON stated LVN C stated she did not complete a risk assessment incident report on 08/10/23 for Resident #1 because she was waiting on LVN A to complete the incident report because she was the initial nurse who found the wound. The DON stated it was important for both nurses to have completed a risk assessment incident report and notify the family, physician, ADON, VA nurse, and herself to ensure the change in Resident #1's condition could be monitored and treated to prevent it from getting worse. The DON stated on 08/11/23 she completed an incident report for Resident #1 and notified the resident's Veteran's Administration representative of the wound to obtain a consult to have the wound care physician visit with the resident. The DON stated LVN C indicated she notified the resident's wife and physician of the wound on 08/11/23. The DON reviewed the physician order on 08/11/23 created by LVN C reflected Clean between buttocks with NS, pat dry, apply barrier cream, apply dry dressing until seen by wound doctor .electronically signed by Resident #1's primary attending physician. The DON stated she visualized Resident #1's wound along with the ADON on 08/14/23 and described the wound as an open area with redness the area to the left buttocks measured 3cm x 4cm and the wound to the right buttocks measured 3.5cm x 4 cm. The DON stated Resident #1's wound had no depth to either of the two wounds. The DON stated on 08/14/23 the wound care physician was consulted and visualized Resident #1's wound and provided updated wound care orders. The DON stated Resident #1 received new wound care orders on 08/15/2 to cleanse all open areas to coccyx and buttocks with Dakin's solution, pat dry and apply Collagen to all areas, cover with a dry dressing; every day and night shift for skin/wound support electronically signed by primary attending physician. The DON reviewed Resident #1's treatment administration record and stated on 08/17/23 there was no documentation to reflect LVN E assigned during the night 10:00PM to 6:00 AM shift completed Resident #1's wound care. The DON also reviewed nursing notes for 08/17/23 and stated there was no documentation by LVN E in the Nurse's notes either to indicate treatment was provided to Resident #1. The DON stated LVN E should have documented the completion of Resident #1's wound treatment on his treatment administration record. The DON stated the risk to Resident #1 should he not receive his wound treatment as ordered was that his wound would not improve. The DON stated she attempted to call LVN E and find out why she did not document the treatment but was unable to reach her by phone. The DON stated on 08/20/23 the Skin Evaluation completed by LVN D was a change in condition for Resident #1. The DON stated LVN B also worked with LVN D on 08/20/23 and LVN B reported to her there was a change in Resident #1's wound condition but did not describe the extent of the change. The DON stated the told LVN B the wound care physician would visit with Resident #1 the flowing day 08/21/23 and at that time provide updated treatment orders and or evaluate if Resident #1 needed to be sent out to the hospital for wound evaluation. The DON stated she told LVN D and LVN B to notify Resident #1's family, physician or Veteran's Administration representative of the change in condition to his wound [TRUNCATED]