2. For Resident #63 the facility staff failed to follow a medical provider's orders to provide a functioning pressure redistribution mattress. Resident #63's diagnosis list indicated diagnoses that included, but were not limited to, Streptococcal Arthritis to Right Knee, Sepsis, UTI (urinary tract infection), Acute Kidney Failure, Hypertensive Chronic Kidney Disease-Stage 4, Peripheral Vascular Disease, Atrial Fibrillation, and Osteoarthritis. The most recent minimum data set (MDS) with an assessment reference date (ARD) of, 8/19/24 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 for cognitive abilities, indicating Resident #63 was cognitively intact. On 8/18/24 at 3:45 PM, surveyor interviewed Resident #63 and she stated her air mattress was not working. Surveyor observed the mattress and the power button located on the footboard of the bed was in the on position, however the mattress was observed to not be functioning or receiving air. A review of the medical providers orders included an order for, Pressure-redistribution mattress to bed with a start date of 8/13/24. A facility assessment titled, Braden Scale for Predicting Pressure Sore Risk, dated 8/13/24, read in part, .1. Sensory Perception .3. Slightly Limited .Responds to verbal commands but cannot always communicate discomfort or the need to be turned or has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities .3. Activity .Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair .4. Mobility .3. Slightly Limited .Makes frequent though slight changes in body or extremity position independently .6. Friction & Shear .2. Potential Problem .Moves feebly or requires minimum assistance. During a move skin probably slides to some extent against sheets .7. Scoring .SCORING .AT RISK 15-18 . The progress note summary attached to the assessment revealed Resident #63 had a score of 16. On 8/18/24 at 3:55 PM, surveyor requested licensed practical nurse #4 (LPN#4) accompany her to resident's room. LPN#4 checked the power button and stated it was not working and she would check to confirm the bed was plugged into the power outlet. LPN#4 stated it was not plugged-in and she plugged it in and stated it should start building pressure now and she was not sure how it got unplugged. On 8/19/24 at 9:45 AM, surveyor and director of nursing (DON) entered Resident #63's room and the pressure redistribution mattress was on and functioning. The DON stated that she would check the provider orders to make sure staff is checking it (pressure-redistribution mattress). An additional review of the medical providers orders revealed a new order dated 8/18/24 with a start date of 8/19/24, that read in part, .Pressure-redistribution mattress to bed, check function Q (every) shift every day and night shift . This concern was discussed at the end of day meetings with the corporate nurse consultant, administrator, and director of nursing on 8/19/2024 at 4:30 PM, 8/20/24 at 4:19 PM, and again at the pre-exit meeting on 8/21/24 at 3:30 PM. Surveyor requested and received a facility policy titled, Skin Integrity and Wound Management, that read in part, .6.8 Implement pressure injury prevention for identified, modifiable risk factors. 6.9 Determine the appropriate support surface for the bed . No further information regarding this concern was presented to the survey team prior to the exit conference on 8/21/24. Based on observation, staff interview, clinical record review and facility document review the facility staff follow physician's orders for 2 of 22 residents, Resident #9 and Resident #63. The findings included: 1. For Resident #9 the facility staff failed to administer the medication carvedilol per the physician's order. Resident #9's face sheet listed diagnoses which included but not limited to hypotension, anemia, and anxiety. Resident #9's most recent minimum data set with an assessment reference date of 08/08/24 assigned the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #9's comprehensive care plan was reviewed and contained a plan for Resident exhibits or is at risk for cardiovascular symptoms or complications related to hypertension. Interventions for this care plan include Administer meds as ordered . Resident #9's clinical record was reviewed and contained a physician's order summary which read in part, Carvedilol Tablet 12.5 mg. Give 1 tablet by mouth two times a day for hypertension with meals. Resident #9's electronic medication administration record for the month of August 2024 was reviewed and contained an entry as above. This entry was blank on 08/06/24 at 5 pm and coded HD on 08/10/24 at 5 pm. Chart code HD is equivalent to hold/see nurses notes. Resident #9's nursing progress notes were reviewed and contained a note which read in part, 08/10/2024 17:18:00 Carvedilol Tablet 12.5 mg. Give 1 tablet by mouth two times a day for hypertension with meals. due to low BP (blood pressure), med held. MD and RP (responsible party) notified. This medication did not have parameters to hold for low blood pressure. Surveyor spoke with the director of nursing (DON) on 08/21/24 at 9:45 am regarding Resident #9's carvedilol. DON stated, If it's blank, they didn't give it. On 08/21/24 at 2:45, DON stated to surveyor, I can't say it was given, I talked with the nurse working that day and they can't remember if they gave it or not. Surveyor requested and was provided with a facility policy entitled Medication Administration General Guidelines which read in part, Medication Administration: 1. Medications are administered in accordance with written orders of the prescriber .4. The resident's MAR/TAR (medication administration record/treatment administration record) is initialed by the person administering the medication, in the space provided under the date, and on the line for that specific medication dose administration time. The concern of not administering Resident #9's medication per the physician's order was discussed with the administrator, DON, and regional nurse consultant on 08/21/24 at 3:30 pm. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review and facility document review the facility staff failed to provide basic life support, including cardiopulmonary resuscitation to one of 57, residents, Resident #2. The findings included: For Resident #2, an agency-contracted staff failed to check code status and failed to initiate basic life support, including cardiopulmonary resuscitation for Resident #2. Resident #2 expired at the facility. Resident #2's face sheet listed diagnoses which included but not limited to acute respiratory failure, chronic obstructive pulmonary disease, chronic kidney disease with heart failure, and diabetes mellitus-type II. Resident #2's most recent minimum data set with an assessment reference date of [DATE] assigned the resident a brief interview for mental status score of 3 out of 15 in section C, cognitive patterns. This indicates that the resident was severely cognitively impaired. Resident #2's clinical record was reviewed and contained a physician's order summary which read in part, Full code. Resident #2's clinical record contained a Virginia Physician's Orders for Scope of Treatment form dated [DATE], which read in part A. Cardiopulmonary Resuscitation (CPR): Person has no pulse and is not breathing. [x] Attempt Resuscitation. [] Do Not Attempt Resuscitation (DDNR/DNR/No CPR). The box for attempt resuscitation was marked on this form. Resident #2's clinical record contained nurse's progress notes dated [DATE], which read in part [DATE] 06:30 Resident unresponsive, no respirations or lung sounds, . [name omitted] RN, DON [registered nurse, director of nursing] to be notified for further instructions-signed by licensed practical nurse (LPN) #3, [DATE] 07:02 Notified . [name omitted] RN, DON to report resident unresponsive, stated 'make a note of it and an RN will be there shortly to pronounce'-signed by LPN #3, [DATE]:40 Notified at approximately 0830 that resident has passed away. DON advised me that resident was a full code but that the nurse assigned to . [Resident #2] got confused about the resident's code status, therefore she did not initiate CPR. The resident was listed as a Full Code but there had been discussion earlier of the resident moving to an end of life comfort care status. The nurse was an agency nurse and her contract was terminated by the facility. MD was notified. Resident son was notified by me of the incident. He was understanding and advised that he felt like it would not have helped. OLC [Office of Licensure and Certification], APS [Adult Protective Services], Ombudsman and DHP [Department of Health Professions] have been notified as well-signed by administrator and [DATE] 14:28 Notified by . [name omitted] Agency nurse at approx. 0702 am via phone that resident had passed away. This nurse advised . [name omitted] to call on call provider and family. This nurse was advised by . [name omitted], resident had DNR on her chart. [name omitted], FNP [family nurse practitioner] advised this nurse via phone that resident had a full code on her chart but nurse . [name omitted] was confused about code status. This nurse called administrator to advise her that . [name omitted] the agency nurse did not start cpr. The resident was listed as a Full Code in pcc [point click care]. Previously, there had been discussion of end of life care. [name omitted], FNP was notified. Resident's son was notified by administrator of the incident. He was understanding and advised that he felt like it would not have helped. The agency nurse . [name omitted] contract terminated by the facility.-signed by DON. During an interview with the facility administrator on [DATE] at 11:40 am, the administrator stated that the resident's family had been to the facility earlier in the week to discuss the possibility of comfort care for Resident #2. Administrator stated, evidently there was some confusion, and a CNA [certified nurse's aide] told the nurse that the resident was DNR. Administrator stated that the nurse's excuse was that the computers were down, but there is a copy of each resident's code status in their paper chart located at the nurse's station. Administrator stated that nurse was an agency staff, and not a facility staff, and that her contract was terminated. Administrator stated that a 100% audit of code orders was completed, and a full plan of correction done immediately. This was provided to the surveyor for review. Surveyor spoke with the director of nursing (DON) on [DATE] at 2:20 pm and asked her to relate the events of [DATE]. DON stated, I was called at home around 7 am by . [LPN #3] and informed that Resident #2 had passed, and she needed someone to pronounce. I told her that an RN was on the way. I called the FNP to let her know that Resident #2 had passed, and she had her computer up, and informed me that Resident #2 was a full code. I then called the administrator. Once I arrived at the facility, I checked Resident #2's chart to confirm code status. She was a full code. Surveyor requested and was provided with a facility policy entitled Procedure: Cardiac and/or Respiratory Arrest. 1. Upon discovery of a patient in cardiopulmonary arrest (e.g., no apparent pulse, blood pressure or respiration, staff will immediately: 1.1 Call for assistance; 1.2 Alert the licensed nurse and CPR/automated external defibrillator (AED) certified staff. 1.3 Prepare the patient for CPR/AED while determining the presence of a Do Not Resuscitate order (DNR). 2.1 If there is no visual identification of DNR status or no DNR order on the patient's medical record: 2.1.1 CPR/AED certified staff will initiate CPR/AED application. 2.1.4 Continue CPR until one of the following occurs: 2.1.4.1 It is discovered that the patient had a DNR order; 2.1.4.2 Restoration of effective, spontaneous circulation; 2.1.4.3 Care is transferred to a team providing advanced life support . Facility administrator provided the surveyor with a copy of the facility's On-Site Orientation Checklist for agency nurses. This checklist included location of code status and orders, and center process for codes. The administrator also provided an LPN/LVN Skills Checklist for LPN #3 that the nursing agency provided to the facility. This form indicated that LPN #3 was able to perform CPR independently. This surveyor reviewed the plan of correction provided by the facility administrator. Plan of correction reads as follows: Advanced Directives Post Non Compliance Plan of Correction [DATE] Corrective Action: 1. The agency nurse was asked to leave the facility. 2. The MD and RP (responsible party) were notified of the incident. 3. All code status orders will be reviewed and updated to reflect the current wishes. 4. All resident care plans will have their advanced directive care plan updated to reflect the most current status. Completed on [DATE]. Identification of Deficient Practice: All residents in the facility are at risk. A 100% audit will be completed for all residents to ensure that all residents have been offered the ability to complete an advanced directive. All negative findings will be corrected immediately, and their orders will be updated as well as their care plan. Completed on [DATE]. Systemic Changes: The facility policy and procedure on Advanced Directives has been updated and no changes are warranted at this time. All licensed staff will be in-serviced on facilities P&P for Advanced Directives, immediately, but no later than prior to the start of their next shift. Completed on [DATE]. Monitoring: Social Services is responsible for maintaining compliance, all code status orders will be reviewed upon admission and quarterly for updates. Completed on [DATE] and on-going. Date of Completion: [DATE] In-services will continue until all staff are complete. Completed on 09/15 23. Surveyor reviewed credible evidence and confirmed that each item has been completed and on-going monitoring done. Surveyor visualized each resident's code status in the paper charts located at each nurse's station. Interviews with nursing staff conducted on [DATE] confirmed that staff are knowledgeable on what to do in the event of resident being found unresponsive, and where to locate code status for each resident. The concern of an agency staff not providing basic life support to a resident was discussed with the administrator and DON on [DATE] at 10:30 am. No further information was provided prior to exit. This is a past non-compliance deficiency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, resident interview, family interview, clinical record review, facility document review, the facility staff failed to provide wound management as evidenced by the absence of assessments, monitoring, and/or treatment for of 5 out 33 residents. This resulted in wound infections and/or wound deterioration for Resident #10, Resident #4, Resident #42, Resident #36, and Resident #149. The facility also failed to implement provider orders at the time they were ordered for 1 of 33 residents reviewed, Resident #199. On 3/15/23 at 3:50 PM, the surveyors notified the facility of the Immediate Jeopardy determination, Level IV Pattern. The facility staff implemented an abatement plan that was verified by the survey team through additional observations, interviews, and document reviews. The facility staff was notified that the Immediate Jeopardy was removed on 3/17/23 at 4:09 PM. The findings included: 1. For Resident #10 the facility staff failed to provide wound management resulting in a wound infection. Resident #10's face sheet listed diagnoses which included but not limited to anemia, chronic obstructive pulmonary disease, dementia, basal cell carcinoma of skin, and hypertension. Resident #10's most recent minimum data set with an assessment reference date of 02/07/23 coded the resident as 6 out of 15 in section C, cognitive patterns. This indicates that the resident is severely cognitively impaired. Section M, skin conditions, subsection M1040, Other Ulcers, Wounds, and Skin Problems coded the resident as having open lesion(s) other than ulcers, rashes, cuts (e.g., cancer lesion). Resident #10's comprehensive care plan was reviewed and contained a care plan for Resident at risk for skin breakdown r/t (related to) decreased mobility, incontinence, fragility of skin, oxygen use . Interventions for this care plan include Observe skin condition daily with ADL's (activities of daily living) and report abnormalities, provide wound treatment as ordered, and weekly skin checks by license nurse. Resident #10's clinical record was reviewed and contained a physician's order summary for the month of March 2023, which read in part Cleanse growth the center of back with Dakin's solution, pat dry, apply Dakin's wet to dry dressing to wound bed and secure with dry dressing, change BID (twice a day) and PRN (as needed) every day shift for wound care and Cleanse scalp wound (exposed skull) with soap and water, cleanse periwound with Dakin's solution, pat dry, apply TAO to irritated periwound and cover entire scalp wound with dry dressing BID and PRN every day and night shift for wound care. Resident #10's treatment administration record (TAR) for the month of March 2023 was reviewed and contained entries as above. The entry for Cleanse growth to center of back . only had one section for initials on the TAR. These entries were initialed as being completed as ordered. This surveyor observed Resident #10 on 03/12/23 at 3:30 pm. Resident was resting in bed; no dressing was observed in place to scalp wound. Exposed skull was observed by surveyor. Resident #10's clinical record contained a Physician's Telephone Order form dated 02/06/23, which read in part Keflex 500 mg TID (three times a day)-wound infection top of head x 10 days. This surveyor, along with licensed practical nurse (LPN) #1 and certified nurse's aide (CNA) #1 observed Resident #10 on 03/13/23 at 1:00 pm. Surveyor observed dressing in place to resident's scalp at this time. CNA #1 and LPN #1 rolled resident onto side, and surveyor observed dressing in place to lesion on resident's upper back. Surveyor asked LPN #1 if dressing had a date on it, and LPN #1 first stated that it did not, then stated Oh, yeah, it does. Surveyor asked LPN #1 what the date on the dressing was, and LPN #1 stated March 9th. Surveyor requested to see the dressing once it was removed and observed the date on the dressing to read 03/09/23 7a-7p along with initials. When LPN #1 removed the dressing from Resident #10's wound, surveyor observed moderate amount of drainage both on the dressing and wound bed. Dressing had a dark brown ring, with drainage in the center of the ringed area. Surveyor asked LPN #1 to describe the wound, and LPN #1 stated greenish-brown, foul-smelling discharge. LPN #1 stated to the surveyor that, according to the date on the dressing, that it appeared that 7 dressing changes have been missed to resident's back lesion. Surveyor asked LPN #1 if lesion had worsened since they last observed it, and LPN #1 stated, It definitely has more drainage. LPN #1 removed the dressing from resident's scalp and stated to surveyor that scalp wound was not supposed to have a dressing on it. This Surveyor observed scant amount of greenish discharge on scalp dressing. LPN #1 later informed surveyor that Resident #10 should have a dressing on scalp lesion. Review of Resident #10's clinical record revealed that resident was placed on oral antibiotic for wound infection starting 03/14/23. This surveyor spoke with the assistant director of nursing (ADON) on 03/14/23 at 10:50 am regarding Resident #10's wound care. Surveyor asked ADON what their expectations were for wound care, and ADON stated they would expect the nurses to follow the physician's orders for each resident receiving wound care. This surveyor reviewed Resident #10's clinical record and could not locate any wound assessments, including measurements, description of wounds, or skin assessments. The survey team spoke with the director of nursing (DON) on 03/15/23 at 10:00 am regarding wound management. DON stated they measure wounds weekly, and that information is located in their office. DON stated that weekly skin assessments were to be performed on all residents and recorded in clinical record. This Surveyor reviewed Resident #10's clinical record and could not locate any skin assessments. The survey team spoke with family nurse practitioner (FNP) on 03/20/23 at 1:25 pm regarding wound management. Surveyor asked FNP if missed assessments and dressing changes not being done as ordered could contribute to wound infections and FNP stated that it could. The concern of not providing wound management was discussed with the administrator, DON, and Market Clinical Lead on 03/20/23 at 3:00 pm. No further information was provided prior to exit. 2. For Resident #4 the facility staff failed to provide wound management which resulted in the resident being treated for a wound infection. Resident #4 was admitted the facility on 02/13/21 and readmitted on [DATE]. Resident #4's face sheet listed diagnoses which included but not limited to multiple sclerosis, depression, anxiety, and contractures of muscles. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 02/06/23 assigned the resident a brief interview for mental status score of 14 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Section M, skin conditions, coded the resident as having one stage 1 pressure ulcer that was present upon admission. Section M, subsection M1040, other ulcers, wounds and skin problems coded the resident as none of the above present. This subsection includes surgical wounds. Section M of Resident #4's admission MDS with an ARD of 02/20/21 coded the resident as having one stage III pressure ulcer present upon admission, one stage IV pressure ulcer present upon admission and one unstageable pressure ulcer present upon admission. Resident #4's comprehensive care plan was reviewed and contained a care plan for Resident at nutrition risk r/t (related to) . Wounds: Surgical PI Open wound to Rt. (right) hip skin fold, healing. PI Rt. Heel . and . is at risk for continuing impaired skin integrity related to diagnosis of MS (multiple sclerosis), impaired mobility . Type: Pressure ulcers. Interventions for both care plans included Provide wound treatment as ordered and Labs per orders. This Surveyor spoke with Resident #4 on 03/12/23 at 3:10 pm. Resident stated they have wounds to right hip and heel and that wound care is supposed to be done twice a day, but there are some nurses that don't do it. Resident #4 stated, I'm lucky if they do it once a day. Resident #4 was concerned that wound care was not being done as ordered. Surveyor spoke with Resident #4 on 03/13/23 at 11:30 am, and asked resident if their wound care had been completed, and resident stated, the dressing was changed yesterday (03/12/23) around lunch time and hasn't been changed since. This Surveyor, along with licensed practical nurse (LPN) #1 and certified nurse's aide (CNA) #1 observed Resident #4's dressing on R hip wound on 03/13/23 at 11:45 am. When CNA #1 rolled resident over, and dressing became visible, CNA #1 stated to LPN #1, it (dressing) don't have a date on it. Surveyor asked LPN #1 if dressing should be dated, and LPN #1 stated that it should be. Surveyor observed that dressing was not dated. LPN #1 removed the dressing, and stated, well, that tells me it's not been changed. Surveyor asked LPN #1 how they could tell dressing had not been changed, and LPN #1 stated by the color of the gauze and the amount of drainage on the dressing. Resident #4's clinical record was reviewed and contained a physician's order summary for the month of March 2023, which read in part Cleanse post-surgical wound to right hip with Dakin's solution, pat dry, apply collagen powder to wound bed, cover with calcium alginate and secure with dry dressing BID (twice a day) every day and night shift for Wound Right Hip Order Date 02/28/2023 Start Date 02/28/2023 and Wound(s): Monitor site(s) daily for status of surrounding tissue and wound pain. Monitor for status of dressing(s), If applicable, Additional Documentation in NN (nurse's notes) as needed every day shift. Order Date 03/12/2023. Start Date 03/13/2023. Resident #4's TAR for the month of March 2023 was reviewed and contained entries which read in part, Cleanse post-surgical wound to right hip with Dakin's solution, pat dry, apply collagen powder to wound bed, cover with calcium alginate and secure with dry dressing BID (twice a day) every day and night shift for Wound Right Hip. Order Date 02/28/2023. Start Date 02/28/2023, Cleanse are to right heel with IHWC. Apply betadine, let dry and apply skin prep every night shift for wound care and Wound(s): Monitor site(s) daily for status of surrounding tissue and wound pain. Monitor for status of dressing(s), If applicable, Additional Documentation in NN (nurse's notes) as needed every day shift. Order Date 03/12/2023. Start Date 03/13/2023. These entries were initialed as having been completed for all ordered times. This Surveyor reviewed Resident #4's clinical record from January to present for documentation of wound treatment provided to the right hip, right heel, and healing progress of the wounds. Resident #4's clinical record contained an Acute Care summary form dated 01/25/23, which read in part Chief complaint/Nature of Presenting Problem: Follow-up wounds. Location: Right hip fold. Duration: Chronic. Modifying Factors: Culture done and results pending. Quality: Stable. Review of Systems Skin: Open wound to right hip skin fold. Physical Exam Skin: Wound to right hip skin fold is tender to touch. There is yellow/white drainage to wound, and a foul odor is noted. Optifoam patch in place. Labs/Radiology/Tests. Labs: Wound culture has been collected and results pending per nursing. No results received today. Diagnosis, Assessment and Plan: .Open wound of right hip. Continue current wound treatment. This was signed by the family nurse practitioner (FNP). Resident #4's clinical record contained a physician's telephone order form dated 01/30/23, which read in part (1) Culture R (right) hip wound-redness, drainage, foul odor (2) After culture, start Bactrim DS-1 tab PO (by mouth BID (twice daily) x 10 days wound infection. This order was signed by the FNP. Resident #4's clinical record contained a laboratory report dated 02/10/23 for wound culture which indicated the presence of Proteus mirabilis, a gram-negative bacterium. Resident #4's treatment administration record (TAR) for the month of January 2023 was reviewed and contained and entry which read in part, Cleanse right hip with IHWC (wound cleanser), pat dry, apply Maxsorb, and place Optifoam on wound every night shift for wound healing. This entry had a start date of 01/30/23 listed and was initialed as being completed. There were no previous wound care orders related to right hip noted on this TAR. The TAR for January also contained entries which read in part Cleanse area to right heels with IHWC. Apply 4 x 4 boarder (sic) gauze or optifoam) gauze or optifoam for cushion. every day shift Mon, Wed, Fri, Sun for wound care-start date-01/04/2023, -D/C (discontinue) date-02/02/2023, Cleanse area to right heel with IHWC. Apply 4 x 4 boarder (sic) gauze or optifoam for cushion. every night shift for wound care-start date-01/30/2023, -D/C date-02/09/2023 and Wound(s): Monitor site(s) daily for status of surrounding tissue and wound pain. Monitor for status of dressing(s), if applicable, every day shift. The treatment to the heel wound was not initialed as completed on 01/02, 01/03, 01/06, 01/15, 01/18, and 01/23. Resident #4's TAR for the month of February was reviewed and contained entries which read in part, Cleanse right hip surgical wound with Dakin's solution, pat dry. Apply skin prep to peri-wound. Wet-to-dry dressing using Dakin's to wound bed. Secure with dry dressing. two times a day for wound healing-Start Date-02/09/2023 2000 -D/C Date-02/27/2023 2000, not initialed as completed on 02/18/23 at 8 pm. The TAR for February did not contain any entry for wound monitoring. The TAR for February also contained entries which read in part, Cleanse area to right heel with IHWC. Apply 4 x 4 boarder (sic) gauze or optifoam for cushion. every night shift for wound care-start date-01/30/2023, -D/C date-02/09/2023 and Cleanse area to right heel with IHWC. Apply betadine, let dry and apply skin prep every night shift for wound care. This treatment was not initialed as completed on 02/18/23. Resident #4's clinical record contained a physician's telephone order form dated 02/16/23, which read in part (1) Rocephin 1 gm I.V. q (every) day (2) Repeat wound culture x 7 (3) [NAME] consult wound vac R hip. This order was signed by the physician. Resident #4's clinical record also contained a physician's order summary for the month of February 2023, which read in part Culture wound to Right hip one time only for Wound Infection for 1 day This order had a start date of 02/25/23. Surveyor could not locate results of this wound culture. This Surveyor spoke with the assistant director of nursing (ADON) on 03/17/23 at 12:50 pm regarding Resident #4's wound cultures. ADON stated the culture order on 01/30/23 was collected 3 times, and when the lab was contacted for results, they were told the lab did not have a specimen. ADON stated they could not locate results for culture ordered to be done on 02/25/23. This Surveyor spoke with medical technician (MT) at the contracted lab on 03/20/23 at 10:15 am regarding Resident #4's wound cultures. MT stated that the only wound culture orders and specimens they had received were on 01/17/23 and 02/10/23. MT stated they had received no other orders or specimens for wound cultures for Resident #4. This Surveyor spoke with FNP on 03/20/23 at 1:25 pm. Surveyor asked FNP when they expected the wound culture ordered on 01/30/23 to be done, and FNP stated they expected it to be done on the order date. FNP said when they asked about the results, couple of nurses stated they had done it and lab lost it. Surveyor asked FNP if they expected the repeat wound culture to have been done, and FNP stated they did. Surveyor asked FNP if missed assessments and dressing changes not being done as ordered could contribute to wound infections and FNP stated that it could. This Surveyor spoke with the ADON on 03/14/23 at 10:50 am regarding Resident #4's wound care. Surveyor asked ADON what their expectations were for wound care, and ADON stated they would expect the nurses to follow the physician's orders for each resident regarding wound care. Surveyor asked ADON if wound dressings should be dated, and ADON stated that they should be dated and initialed by the nurse completing the wound care. ADON later stated per director of nursing (DON), facility policy did not state that dressings needed to be dated. This Surveyor requested and was provided with a facility policy entitled Wound Dressings: Aseptic which read in part, 2. Gather supplies: 2.7 Prepared label or secondary dressing with date and initials. 27. Apply prepared label. This Survey team spoke with the director of nursing (DON) on 03/15/23 at 10:00 am regarding wound management. DON stated they measure wounds weekly, and that information is located in their office. Surveyor asked DON if dressings should be dated and initialed when changed, and DON stated that is not a part of the facility policy, but they were hoping to have that changed, as that is the expectation. Surveyor referred DON to aforementioned policy, and asked DON what apply prepared label meant, and DON stated they did not know. Surveyor asked DON if Resident #4's hip wound was pressure related and DON stated that Resident #4's hip wound was surgical rather than pressure. Surveyor asked DON what type of surgery the resident had had to the hip and DON stated, Looks to me like he/she has had a hip replacement at some point. He/She has about an 18 scar on that hip. This Surveyor reviewed Resident #4's clinical record and could not locate any wound assessments, including measurements or description of wounds. This Surveyor requested and was provided with Skin Integrity Report forms, which were contained in a notebook housed in the DON's office. The Skin Integrity Report forms for Resident #4 indicated that wound to right hip was both pressure and surgical. The form did not indicate an initial wound date and contained measurements beginning on 01/30/23 and continuing weekly until 03/08/23 that indicate the wound is decreasing in size. A second form with an initial wound date of 02/09/23, indicated a pressure area to right heel, staged as a deep tissue injury. Wound was marked as in-house acquired, with measurements beginning on 02/09/23 and continuing weekly through 03/09/23. These measurements indicate no change to wound. This Surveyor requested evidence that Resident #4's hip wound was surgical rather than pressure and was provided with a surgical consult form which read in part Appt. Date/Time 02/26/2021. Chief Complaint: Skin lesion. HPI (history of present illness): Patient has bilateral hip decubitus ulcers that are necrotic. He/She needs debridement of both. He/She also has been noted to be anemic with hemoglobin in the eight. We will admit him/her to outpatient surgery for transfer transfusion before morning debridement. Plan transfer back to nursing home after surgery. Probable wound VAC application. Patient has severe lower extremity contracture secondary to advanced MS. The concern of not providing wound management for Resident #4 was discussed with the administrator, DON, and Market Clinical Lead on 03/20/23 at 3:00 pm. No further information was provided prior to exit. 3. For Resident #42 the facility staff failed provide wound management, resulting in a wound infection. Resident #42's face sheet listed diagnoses which included but not limited to hypertensive heart disease, heart failure, chronic kidney disease, type 2 diabetes mellitus, peripheral vascular disease, and anxiety. Resident #42's most recent minimum data set with an assessment reference date of 02/04/23 assigned the resident a brief interview for mental status score of 11 out of 15 in section C, cognitive patterns. Section M, skin conditions coded the resident as having five stage II pressure ulcers that were present upon admission, and no other skin conditions. Resident #42's comprehensive care plan was reviewed and contained a care plan for Resident has actual skin breakdown related to top of right foot, right heel, left upper buttocks, left lower buttock, right buttock, coccyx, and sacrum related to decreased activity, incontinence. Interventions for this care plan included Observe skin for signs/symptoms of skin breakdown, provide wound treatment as ordered, weekly skin checks by licensed nurse, and weekly wound assessment to include measurements and description of wound. Resident's clinical record was reviewed and contained a physician's order summary for the month of March 2023, which read in part . consult for necrotic wound to R ankle. Needs to be done as soon as possible, Cleanse area to top of right foot with Dakin's solution, 25%, pat dry. Apply Santyl on nonstick pad to wound bed. Cover with dry dressing daily and prn (as needed) every day shift for wound care, Cleanse stage 3 PU (pressure ulcer) to L (left) lower buttock with Dakin's solution, pat dry, apply skin prep to periwound, apply Dakin's wet to dry to wound bed and secure with dry dressing BID (twice a day) and PRN every day and night shift for wound care, Cleanse stage 3 PU to L upper buttock with Dakin's solution, pat dry, apply skin prep to periwound, apply Dakin's wet to dry to wound bed and secure with dry dressing BID and PRN every day and night shift for wound care for 2 weeks, Cleanse stage 3 PU to R buttocks with Dakin's solution, pat dry, apply skin prep to periwound, apply Dakin's wet to dry to wound bed and secure with dry dressing BID and PRN every day and night shift for wound care for 2 weeks, Cleanse unstageable PU on coccyx with Dakin's solution, pat dry, apply skin prep to periwound, apply Dakin's wet to dry to wound bed and secure with dry dressing BID and PRN every day and night shift for wound care for 2 weeks, Cleanse unstageable PU to center sacrum with Dakin's solution, pat dry, apply skin prep to periwound, apply Dakin's wet to dry dressing to wound bed and secure with dry dressing BID and PRN every day and night shift for wound care for 10 days, Cleanse unstageable PU to R heel with Dakin's solution, pat dry, apply skin prep to periwound, apply Santyl on nonstick pad and secure with dry dressing BID and PRN every day and night shift for wound care for 14 days, and Bactrim DS oral tablet 800-160 mg (Sulfamethoxazole-Trimethoprim). Give 1 tablet by mouth one time a day for wound infection for 14 days. Resident #42's clinical record contained a Physician's Telephone Orders form dated 02/27/23, which read in part (1) DC (discontinue) Macrobid. (2) Bactrim DS 1 tab PO (by mouth) BID (twice a day) x 10 days-wound infections R ankle, foot. This order was signed by the family nurse practitioner (FNP). Resident #42's treatment administration record (TAR) for the month of March 2023 was reviewed and contained entries as above. Each of these entries had not been initialed as completed on two separate occasions. Resident #42's February 2023 TAR contained entries, which read in part Cleanse area to right heel with IHWC (wound cleanser), pat dry and apply bordered foam dressing every day shift for open area, Cleanse area to right posterior thigh with IHWC, pat dry, and apply 4 x 4 bordered foam dressing every day shift for open area, Cleanse top of right foot with IHWC, pat dry, and apply bordered foam dressing every day shift for abrasion, and Cleanse area to coccyx with IHWC, pat dry, and apply bordered foam dressing every day shift for open area. Each of these entries had not been initialed as completed on three separate occasions. This Surveyor, along with licensed practical nurse (LPN) #1 observed Resident #42's dressings to sacrum, coccyx, and buttocks on 03/13/23 at 2:30 pm. Dressing to sacrum did not have a date on it. Dressings to resident's foot, heels, and ankles all had dates and initials. LPN #1 stated they had completed wound care to these area's earlier in the day. Surveyor asked LPN #1 how they knew when the dressings to the sacral area had last been changed, and LPN #1 stated that without a date, there was no way to know when wound care was last completed. This Surveyor spoke with the assistant director of nursing (ADON) on 03/14/23 at 10:50 am regarding Resident #42's wound care. Surveyor asked ADON what their expectations were for wound care, and ADON stated they would expect the nurses to follow the physician's orders for each resident regarding wound care. Surveyor asked ADON if wound dressings should be dated, and ADON stated that they should be dated and initialed by the nurse completing the wound care. ADON later stated per DON, facility policy did not state that dressings needed to be dated. This Surveyor requested and was provided with a facility policy entitled Wound Dressings: Aseptic which read in part, 2. Gather supplies: 2.7 Prepared label or secondary dressing with date and initials. 27. Apply prepared label. The Survey team spoke with the director of nursing (DON) on 03/15/23 at 10:00 am regarding wound management. DON stated they measure wounds weekly, and that information is located in their office. Surveyor asked DON if dressings should be dated and initialed when changed, and DON stated that is not a part of the facility policy, but they were hoping to have that changed, as that is the expectation. Surveyor referred DON to aforementioned policy, and asked DON what prepared label meant, and DON stated they did not know. This Surveyor requested and was provided with Skin Integrity Report forms, which were contained in a notebook housed in the DON's office. This notebook contained six forms for Resident #42, which addressed unstageable pressure areas to right heel, right achilles, sacrum/coccyx, right buttock, left outer thigh/lower buttock and a stage II pressure areas to upper left buttock. Each of these areas were marked as present upon admission, with weekly measurements beginning on 02/01/23 and continuing through 03/14/23. These measurements indicated the right heel wound was unchanged, right achilles wound had decreased from 2.5 cm x 1.7 cm to 2.1 cm x 1.3 cm, sacram/coccyx wound had decreased in length from 2 cm to 1 cm, but increased in width from 1 cm to 2.6 cm and went from a depth of 0 to .25 cm. Right buttocks wound decreased in length from 1 cm to 0.8 cm, and increased in width from 0.5 cm to 0.6 cm, and went from a depth of 0 to 0.25 cm. Right outer thigh wound decreased in length from 2 cm to 1.4 cm, and increased in width from 1 cm to 1.5 cm, anad went from a depth of 0 to .25 cm. Left buttock wound decreased in length from 2 cm to 1.8 cm, increased in width from 1.5 cm to 1.7 cm, and went from a depth of 0 to 0.25 cm. Two surveyors, along with LPN #1 observed Resident #42's wounds on 03/14/23 at 4:45 pm. LPN #1 stated that areas to the top of resident's right foot and right ankle/lower leg were arterial rather than pressure. Resident's right heel had dark brown eschar and LPN #1 stated that area was unstageable pressure ulcer. Areas to resident's sacral area (sacrum, coccyx, buttocks) were red with slough present in wound bed. This Survey team spoke with family nurse practitioner (FNP) on 03/20/23 at 1:25 pm regarding wound management. Surveyor asked FNP if missed assessments and dressing changes not being done as ordered could contribute to wound infections and FNP stated that it could. The concern of not providing wound management was discussed with the administrator, DON, and Market Clinical Lead on 03/20/23 at 3:00 pm. No further information was provided prior to exit. 6. The facility staff failed to ensure provider orders for Clindamycin (antibiotic) by mouth, Lasix (diuretic) injectable and Promod (protein supplement) were implemented when ordered for Resident #199. Resident #199's admission record listed his diagnoses included but were not limited to, Covid-19, Type 2 Diabetes Mellitus, and Encephalitis (inflammation of the brain) and Encephalomyelitis (inflammation of the brain and spinal cord). The minimum data set (MDS) with an assessment reference date of 12/16/21 coded the resident's brief interview for mental status (BIMS) a 01 out of 15 in Section C (cognitive patterns). Section G (functional status) coded him needing extensive assistance with bed mobility, eating, and toilet use. The clinical record contained a nurse practitioner (NP) Acute Visit Document with a date of service on 3/02/22. The diagnosis, assessment and plan portion of the document listed provider orders which included, but were not limited to: 1. Lasix 20mg intramuscular injection in AM. 2. Clindamycin 150mg by mouth twice a day for 5 days for cellulitis of bilateral lower extremities. 3. Promod (or other protein supplement) 30ml by mouth daily. A review of Resident #199's March 2022 Medication Administration Record (MAR) noted: 1. Lasix 20mg IM injection was administered on 3/05/22. 2. Clindamycin 150mg orally was administered on 3/04/22. 3. Promod 30ml by mouth was administered on 3/05/22. The nurse practitioner (NP) who wrote the orders on 3/02/22 was interviewed via phone on 3/17/23 at 2:20 p.m. The NP stated her expectation was for those orders to be implemented the next day, 3/03/22. The administrator was informed of these findings on 3/17/23 (via phone) and again on 03/19/23 in person. No further information was provided prior to the exit conference. 4. For Resident #36, facility staff failed to provide ordered wound care to promote healing. Resident #36 was admitted to the facility with diagnoses including (by listed date of diagnosis) type 2 diabetes mellitus with diabetic polyneuropathy, peripheral vascular disease, morbid obesity, obstructive sleep apnea, muscle weakness, hypertensive heart and chronic kidney disease with heart failure, local infection of the skin and subcutaneous tissue, methicillin resistant staphylococcus aureus infection, chronic obstructive pulmonary disease with acute exacerbation, atrial fibrillation, sepsis due to escherichia coli, bacteremia. On the minimum data set assessment with assessment reference date 2/1/23, the resident scored 14/15 on the brief interview for mental status and was assessed as without signs of delirium, psychosis, or behaviors affecting care. This surveyor interviewed the resident on 3/12/23 concerning life in the facility. Clinical record review revealed two recent hospitalizations with wound infections: 12/27/22 through 1/3/23 and 1/14 through 1/20/23. Prior to the hospitalization on 12/27/22, clinical record review revealed A physician order dated 11/7/22 through 1/3/23 for Cleanse area to right stump with WC/VASHE (wound cleanser). Apply xeroform, then cover with border foam each day shift Tue, Thu for wound care. The treatment was not documented as completed 12/1, 12/6, 12/8, 12/13, 12/15, and 12/22. The resident was hospitalized for sepsis and right below the knee amputation infection on 12/27. A nursing progress note dated 12/26/22 stated Note: Resident noted to have scab on LLE front lower area. Redness, swelling and pain surrounding scabbing with bleeding present. This nurse contacted Dr. with new orders: 1) Culture wound in AM 2) CBC (complete blood count) and BMP (basic metabolic panel) 3) Keflex PO BID x 7 days. The most re[TRUNCATED]