**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility staff failed to notify the physician or the wound Nurse Practitioner of a deteriorating stage II pressure ulcer prior to advancing to an unstageable pressure ulcer for 1 out of 55 residents (Resident #291) in the survey sample. The finding included: Resident #291 was originally admitted to the facility on [DATE]. Diagnosis for Resident #291 included but are not limited to Parkinson disease and muscle weakness. Resident #291's admission Assessment (14-day) with an ARD of 03/19/22 coded Resident #291 Brief Interview for Mental Status (BIMS) scored a 99 indicating short and long term memory problems and severe cognitive impairment - never/rarely made decisions. Resident #291 was coded total dependence of two with toilet use, bed mobility and bathing, total dependence of one with dressing, personal hygiene and eating and for Activities of Daily Living (ADL). Resident #291 was coded as having no mood, rejection of care or behavioral problems. Resident #291's person-centered care plan initiated on 03/21/22 identified the resident has a pressure ulcer in her sacral area, at risk for further skin breakdown related to incontinence and impaired mobility. The goal set for the resident by the staff was that the resident will remain free of new skin breakdown through next review date. Some of the interventions/approaches the staff would use to accomplish this goal is to follow facility policies/protocols for the prevention/treatment of skin breakdown, assess/record/monitor wound healing, measure length, width and depth where possible, assess and document status of wound perimeter, wound bed and healing progress and report improvements and declines to the physician. The skin/wound admission note dated 03/10/22 indicated Resident #291 had a stage II sacral ulcer measuring 2.0 cm x 1.0 cm x 0.2 cm with very dark skin, non-blachable measuring (15 cm x 9 cm) surrounding the sacral ulcer. A review of Resident #291's nurse's note revealed the resident was transferred to the hospital on [DATE] at approximately 6:50 p.m., and returned on 03/15/22 at approximately 4:00 p.m. Further review of the nurse's note revealed no new skin impairments noted since the last admission assessment on 03/10/22. The admission/readmission note on 03/15/22 under skin integrity revealed a stage II sacral pressure. During the review of Resident #291's clinical record revealed there were no weekly wound assessments made to the sacral pressure ulcer for 19 days, after her original admission to the facility. An interview was conducted with the wound NP on 05/17/22 at approximately 3:06 p.m., who said, My first time evaluating Resident #291's pressure ulcer was on 03/29/22. The wound NP said the wound was infected as evidence by the wound having a significant amount of slough with foul odor present and having significant pain over the sacral area when touched or palpated. The wound NP stated, I was never informed that Resident #291's stage II pressure ulcer had deteriorated and had advance to an unstageable. The wound NP initial progress note of the sacral pressure ulcer on 03/29/22 revealed an unstageable ulcer measuring 5 cm x 5 cm x 2 cm. The progress note stated the sacral wound had a moderate amount of serosanquinous drainage, strong odor present with 90 percent (%) slough and 10 % dermis tissue. A new medication order was given for Augmentin (antibiotic) 500 mg/125 mg every 12 hours x 10 days for a sacral wound infection. A new treatment order was given to clean the sacral wound with Dakin's, Santyl on Dakin's gauze, and cover with foam dressing daily and as needed. The wound NP progress note also stated pain is indicative of any movement, at rest she is comfortable. The wound NP also offered further recommendations to turn and reposition per facility protocol, use of a low air loss mattress and to optimize nutrition. A wound NP progress note dated 04/05/22 revealed the sacral wound pressure ulcer remained an unstageable measuring 5 cm x 5 cm x (?). The sacral wound had improved but remain with moderate amount of serosanquinous drainage, strong odor present with 90% slough and 10% dermis tissue. The wound was debrided removing thick slough tissue; pain was present with any movement. Resident #291 remains on antibiotic therapy for a sacral wound infection and will continue with the current wound treatment with Dakin's, Santyl on Dakin's gauze, and cover with foam dressing daily and as needed. A review of the wound NP progress note dated 04/11/22 indicated the following, The wound visit was performed via telehealth with the wound nurse, License Practical Nurse (LPN #3). The sacral wound is deteriorating with moderate amount of purulent drainage, strong odor present with 90% slough and 10% dermis tissue. The wound measured by onsite nurse (LPN #3) measuring 6.5 cm x 5.5 cm x 2.5 cm. The progress note recommended to continue with current sacral wound treatment with Dakin's, Santyl on Dakin's gauze, foam dressing and change daily and as needed. A new antibiotic order was given for Clindamycin 600 mg by mouth every 8 hours for 21 days for a sacral wound infection. The wound NP progress note also stated pain is indicative of any movement, at rest she is comfortable. An interview was conducted with the Medical Director (MD) on 05/18/22 at approximately 11:33 a.m., who said all pressure ulcers are followed by (name of Wound Company.) Resident #291's sacral ulcer should have been monitored, assessed and measured on a weekly basis for signs of decline or improvement. The changes in the wound should have been addressed before the wound was identified as an unstageable pressure ulcer. The MD stated, (name of Wound Company) or myself should have been notified that Resident #291's sacral ulcer was declining. An interview was conducted with the Director of Nursing (DON) and wound nurse LPN #3 on 05/12/22 at approximately 10:00 a.m. The DON said Resident #291's sacral pressure ulcer should have been evaluated by the wound NP or wound nurse, LPN #3 on a weekly basis. The weekly evaluation and monitoring is needed for early detection to determine if the wound is improving or declining. The DON said the nurses should have been assessing and documenting changes on Resident #291's sacral pressure ulcer (description of wound bed, if drainage or odor present and size of the wound) with all changes reported to LPN #3 or the wound NP for evaluation to determine if wound treatment changes were needed. A debriefing was held with the Administrator, Director of Nursing and Corporate support on 05/19/22 at approximately 2:00 p.m. Resident #291's issues was presented again. No additional information was forthcoming. The facility's policy Notification of Changes - revised on 03/10/2022. The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, resident's representative when there is a change requiring notification. Compliance Guidelines: The facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification. -Circumstances requiring notification include but not limited to a new treatment, discontinuation of current treatment due to adverse consequences, acute condition or exacerbation of a chronic condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to ensure resident received her physician prescribed Trulicity Injection for Resident #60 Resident #60 was originally admitted to the facility 08/18/21 from the community. The resident has never been discharged from the facility. The current diagnoses included; Type 2 Diabetes Mellitus and Essential Hypertension. The quarterly Revision, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 04/10/2022 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #60 cognitive abilities for daily decision making were intact. In sectionG(Physical functioning) the resident was coded as requiring total care of one person with bed mobility, transfers, locomotion, dressing, eating, toileting, personal hygiene and bathing, extensive assistance of one person/two people, limited assistance of one person, supervision after set-up. The care plan dated 4/10/2022 reads: Focus: The resident has Diabetes Mellitus. Goals: The resident will have no complications related to diabetes through the review date. Interventions: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. The MAR (Medication Administration Record) Trulicity Solution Pen-injector 0.75 MG/0. 5ML (Dulaglutide) Inject 0.75 mg subcutaneously one time a day every Monday for Diabetes. -Start Date 08/23/2021 1000. Missed dosages: Monday 4/11/22. An interview was conducted with Resident #60 on 5/20/22 at 4:55 PM concerning her missed injection. She stated, I don't know what happened or why it wasn't given. Trulicity treats Diabetes Mellitus Type 2. Indicated as once-weekly SC injection adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus (T2DM). It is also indicated to reduce risk of major adverse cardiovascular (CV) events (CV death, nonfatal MI, or nonfatal stroke) in adults with T2DM who have established CV disease or multiple CV risk factors Initial: 0.75 mg SC once weekly May increase dose to 1.5 mg once weekly for additional glycemic control If additional glycemic control needed, increase to 3 mg once weekly after at least 4 weeks on the 1.5-mg dose If additional glycemic control needed, increase to maximum dose of 4.5 mg once weekly after at least 4 weeks on the 3-mg dose. https://reference.medscape.com/drug/trulicity-dulaglutide-999965. 3. The facility staff failed to follow physician orders by not administering physician prescribed medications for Resident #66. Resident #66 was originally admitted to the facility 10/16/2015 from an acute care facility and discharged on 4/11/22 to an acute care facility and returned to the Long Term Care Facility on 4/13/22. The current diagnoses included; Pneumonia and COPD (Chronic Obstructive Pulmonary Disease). The Significant change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 04/18/2022 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #66 cognitive abilities for daily decision making were intact. In sectionG(Physical functioning) the resident was coded as requiring extensive assistance of one person with bed mobility and dressing. Requiring total dependence of one person with toilet use, personal hygiene and bathing. Requires set-up help only with eating. The care plan dated 4/17/22 reads: Focus: The resident has pain r/t (related/ to) history of pain in left arm and side secondary to CVA (Cerebral Vascular Accident) & polyneuropathy, dental pain. Goals: The resident will not have an interruption in normal activities due to pain through the review date. Interventions: Administer analgesia as per orders. Review of the MAR (Medication Administration Record) reads: Gabapentin Capsule 300 MG Give 1 capsule by mouth one time a day related to POLYNEUROPATHY, UNSPECIFIED (G62.9) -Start Date 04/13/2022 2100 (9:00 PM). Missed dosages: 4/14/22-4/18/22 4/21/22-4/24/22 and 4/27/22-4/28/22. MAR reads: Amoxicillin Tablet 875 MG Give 1 tablet by mouth two times a day for bacterial infection for 10 Days -Start Date 04/13/2022 2100 (9:00 PM). Missed dosages: 4/14/22, 4/18/22, 4/19/22, 4/21/22 and 4/22/22. Cefdinir Capsule 300 MG Give 1 capsule by mouth two times a day for UTI (Urinary Tract Infection) for 10 Days -Start Date 04/07/2022 2100. Missed dosages: 4/08/22-4/12/22, 4/14/22. An interview was conducted on 5/20/22 at 4:40 PM., with the DON (Director of Nursing) concerning the above missed medications. She stated, doing my audit I noticed night time medications on the same exact days as you, aren't being checked off. Residents confirmed they are getting medications on routine at night. Moving forward, I will do an in service on documentation. An interview was conducted with Resident #66 on 5/20/22 at 4:50 PM concerning his missed medications. He stated, As far as I know I guess I'm getting my medications. An interview was conducted with LPN (Licensed Practical Nurse) #8 at 5:00 PM., concerning Missed medication dosages for the above residents. She stated, I forgot to go back and switch the schedule to the right side (Unit). I usually work on the left side (Unit). I sign my meds. (Medications) out at the end of giving meds out. The DON talked to me two weeks ago about this. I will sign out my pills as I finish with each resident. On 05/20/2022 at approximately 3:45 p.m., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. The DON stated, Medications should be administered and documented. On 05/20/2022 at approximately 3:45 p.m., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information but no additional information was provided. COMPLAINT DEFICIENCY Based on information gleamed during a complaint investigation, staff interviews, and clinical record review, the facility staff failed to provide the necessary care and services for 3 of 55 residents (Resident #189) in the survey sample. For resident #189, the facility staff failed to recognize, assess and provide the necessary care and services after the resident experienced a significant change in condition presenting as shortness of breath because of low oxygen saturation 87 percent on room air. At the hospital the resident was diagnosed with acute respiratory failure, severe sepsis, a urinary tract infection and severe dehydration evidenced by a blood pressure reading of 80/50, only 30 milliliter of dark urine when catheterized and dry tongue and mucous membranes and peeling lips. Resident #189's lab values were critical upon arrival to the hospital; they included a glucose of 515 mg/dl, BUN 120 mg/dl, creatinine 6.47 mg/dl and lactic acid 2.6 mmol/L, which required hospitalization and constituted harm. For Resident #60 the facility staff failed to ensure resident received her physician prescribed Trulicity Injection. For Resident #66, the facility staff failed to ensure Gabapentin Capsules, Amoxicillin tablets and Cefdmir capsules were administered per physician orders. The findings included: 1. Resident #189 was admitted to the nursing facility on 2/23/2018 and discharged to the local hospital on [DATE]. The resident's diagnoses included; diabetes, neuropathy, depression and COVID-19 pneumonia. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 3/10/2020 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #189's cognitive abilities for daily (ADL) decision making were intact. In section G (Physical functioning) the resident was coded as requiring total care of one person with bathing, extensive assistance of one person with personal hygiene, extensive assistance of two with bed mobility, transfers, dressing and toileting, and independent after set-up with locomotion and eating. Interviews were attempted with multiple staff regarding Resident #189 but only one nurse stated she remembered the resident. Licensed Practical Nurse #9 stated the resident was transferred from the one Unit to the other Unit after testing COVID-19 positive. LPN #9 stated the resident began to experience breathing difficulties secondary to COVID-19 and his respiratory status deteriorated. LPN #9 stated the resident's appetite also decreased and there was a rapid change in his condition which required hospitalization. A nurse's note dated 5/1/2020 read; the resident wasn't himself. He was less talkative, stayed in bed, and had a non-productive cough without shortness of breath or a fever. The physician was notified and a chest x-ray was ordered and the results were normal. A physician's progress note dated 5/2/2020 read Resident #189 tested positive for COVID-19. He had a cough and the resident stated he felt a little short of breath. The resident's temperature was 98.4 Fahrenheit (°F), pulse 94, respirations 19 and his oxygen saturation was 92% on room air, the mucous membranes were moist and there was no labored breathing. The physician's plan was to obtain a complete blood count, basic metabolic panel, a chest x-ray and follow the resident closely. On 5/3/2020 at 8:03 a.m., nurse's note read; the resident presented with a fever of 99.5 °F, Tylenol was administered and at 3:54 p.m., the resident's temperature was still 99.5 °F , Oxygen (O2) at 2/liter (L) per minute was started and the resident continued with a good appetite. There was no documentation on 5/4/2020 or 5/5/2020, but there was a physician's order dated 5/5/2020 for Lovenox 40 mg every day for 7 days secondary to COVID-19. A nurse's dated 5/6/2020 read the resident's temperature was 99.8 °F and Tylenol was given. No documentation was available 5/7/2020, 5/8/202, 5/9/2020, or on 5/10/2020. A review of the ADL documentation revealed the resident required total care with eating or didn't eat at all from 5/7/2020 through 5/11/2020. There was not documentation of the percent eaten at each meal and there was no evidence the physician was notified of the resident's change in status to feed himself. Neither was the care plan updated to include the resident's diagnosis of COVID-19, cough, shortness of breath and the acute effects on the resident's daily status. There was also no evidence interventions were instituted to ensure the resident received necessary fluids to prevent dehydration On 5/11/2020 at 11:57 p.m., a nurse's note read the Certified Nursing Assistant informed the nurse the resident's O2 saturation was 89% and when the nurse arrived to the resident's room to ensure the O2 was on, she recognized the resident was only responsive to painful stimuli therefore; the physician and responsible party were notified and both elected to transfer the resident to the local hospital for evaluation and treatment. The hospital's Discharge summary dated [DATE] read; Upon the resident's arrival to the hospital on 5/11/2020 the hospital staff documented the resident presented to the emergency room with shortness of breath based on a low oxygen saturation, 87% on room air. The hospital diagnosed the resident with acute respiratory failure, severe sepsis, a urinary tract infection and severe dehydration evidenced by a blood pressure reading of 80/50, only 30 milliliter (ml) of dark urine returned when catheterized and a dry tongue/mucous membranes and peeling lips. Resident #189's lab values were critical upon arrival to the hospital; they included a glucose of 515 mg/dl, BUN 120 mg/dl, creatinine 6.47 mg/dl (indications of acute renal failure) and lactic acid 2.6 mmol/L, which required hospitalization. The hospital report dated 5/11/2020 read; the resident's lab results on 5/5/2020, were as follows; creatinine 1.06 mg/dl, BUN 24 mg/dl and the physician stated there was real concern the resident wasn't receiving appropriate care in the nursing home and was left without hydration resulting in his severe dehydration. The physician's note stated they would notify Adult Protective Services (APS) of the resident's condition. The hospital's documentation dated 5/11/2020, also stated they spoke with the resident's son multiple times and he assured then that his father limitation were in his mobility/walking but his cognition was good, he could communicate effectively, feed himself and participate in his ADL care, prior to this episode of illness. An interview was conducted with the APS worker on 5/18/22 at approximately 3:24 p.m. The APS worker stated Resident #189 the hospital's physician reported the resident was admitted to the hospital COVID-19 positive and it was felt proper care wasn't provided in the nursing home. The APS worker also stated she didn't investigate the concern because the resident was in the hospital. The APS worker stated the hospital reported the resident's status was critical however he wasn't mechanically ventilated because he was admitted to hospice care on 5/15/2020 and passed away on 5/16/2020. On 5/20/22 at approximately 6:00 p.m., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information but no additional information was provided and no concerns were voiced because they all stated they didn't know the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, clinical record review, and review of facility documents, the facility staff failed to ensure a resident received emergency dental services promptly after referrals were made adequately while experiencing the acute dental problem for 1 of 1 resident (Resident #190), with dental concerns in the survey sample. The STAT (now) dental appointment ordered 3/1/22, was scheduled on behalf of Resident #190 on 3/10/22, with a local general practice dentistry office for 3/23/22, which was 22 days after the STAT order. Prior to 3/10/22, the facility's staff was unable to provide evidence of attempting to obtain a dental appointment for Resident #190 and there was no evidence in the resident's clinical record or elsewhere of what extenuating circumstances led to the delay in obtaining the STAT ordered dental appointment. constituting harm for Resident #190. The findings included: Resident #190 was originally admitted to the facility on [DATE] and readmitted on [DATE] after an acute care hospital stay. The current diagnoses included; Alzheimer's dementia, diabetes, and a left jaw swelling/dental abscess. The significant change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 4/7/22 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long and short-term memory problems and severely impaired daily decision-making abilities. In section G (Physical functioning) the resident was coded as requiring total care of one person with bed mobility, transfers, dressing, eating, toileting, personal hygiene, and bathing. On 5/10/22, at approximately 2:25 p.m., Resident #190 was identified residing in a secured unit. He was lying in bed in a fetal position, utilizing oxygen by use of a nasal cannula and the resident didn't respond when spoken to. On 5/10/22, at approximately 3:30 p.m., an interview was conducted with Licensed Practical Nurse (LPN) #11. LPN #11 stated Resident #190 was very active including wandering until two months ago when he experienced a decline after developing a dental abscess. A nurse's note dated 3/1/22 revealed Resident #190 presented with a temperature of 101 degrees Fahrenheit (°F) and swelling was observed on the left side of his face. The nurse's note read that observation of his mouth revealed decayed teeth. The Nurse Practitioner (NP) ordered a STAT (immediately) dental consult and ordered antibiotic therapy; Augmentin 875 mg by mouth two times each day for 7 days. A nurse's note dated 3/2/22 at 6:40 p.m., read the resident remains on an antibiotic nevertheless his temperature was 102.4 °F, Tylenol was administered. Another nurse's note dated 3/4/22, revealed the resident's temperature was again abnormal, 101 °F, and the swelling to the left side of the resident's face had increased. The NP visited the resident on 3/4/22 to assess the left facial swelling; the assessment read that the resident was frail, in bed making mumbling sounds, while moving his head from side to side, the left face and jaw were inflamed, swollen, tender when touched and the resident was very uncomfortable. The NP assessment also read that an oral exam couldn't be performed in the facility. The NP ordered a three-view facial x-ray which was not a dental xray, but was a general xray that revealed an old non-displaced age undetermined fracture of nasal bone. Morphine Sulfate (an opioid pain medication used to treat moderate to severe pain); 0.25 milliliter by mouth every 4 hours as needed for pain, and an additional antibiotic Ceftriaxone; one dose, and a hospice consult. Resident #190 was evaluated again, on 3/7/22 by the NP. The NP documented the resident continued with facial swelling and a tooth abscess and the plan was for the resident to see the dentist as soon as possible for a tooth extraction. The NP ordered an additional one-time dose of the antibiotic Ceftriaxone. On 3/23/22, Resident #190 was seen by the general practice dentist. The dentist's progress note read, that there remained slight swelling to the left lower vestibular region but she was unable to determine if it was associated with a tooth because the resident was unable to open his mouth and/or follow directions therefore she was unable to clinically see or obtain necessary radiology to determine/diagnose the resident's dental problem. The general practice dentist provided referral information to the nursing facility to schedule an appointment with a sedation dentistry practice hence a thorough assessment could be conducted. On 3/30/22 Resident #190 was transferred to a local hospital for altered mental status. The discharge summary from the hospital dated 4/2/22 read that intravenous Unasyn was ordered for a possible dental abscess for which the resident was being treated at the nursing facility. The discharge summary also stated the resident was admitted with diagnoses of severely elevated blood glucose (417 mg/dl) and a critical blood sodium level (163 mmol/L), requiring intravenous insulin in the emergency room and three days of intravenous fluid resuscitation. During the survey on 5/13/22 at approximately 12:40 p.m., an observation was made of the resident receiving total care with the lunch meal in bed, and approximately 50% of the pureed meal was accepted. Also on 5/19/22 at approximately 5:30 p.m., an observation was made of the resident consuming the dinner meal in bed; he required total care and accepted approximately 50% of the pureed meal. A review of Resident #190's weight revealed on 3/3/22, he weighed 123.4 pounds, and on 5/18/22, 108.0 pounds, a loss of 15.4 pounds. No documentation was identified in the resident's clinical record of the facility's staff actions between 3/1/22 and 3/23/22 to ensure the resident could still eat and drink adequately while awaiting dental services. On 5/17/22 at approximately 5:45 p.m., an interview was conducted with CNA #6. CNA #6 stated she frequently worked with Resident #190 and the resident had experienced a significant decline physically and with meal consumption since the swelling was identified on the left side of his face. She stated many days the resident consumed very little (0-25%) of his meals/fluids but now his intake is better with staff assisting him slowly. On 5/13/22 at approximately 1:20 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated the resident's decline was identified after he presented with a swollen left jaw on 3/1/22, which was diagnosed by the Nurse Practitioner (NP) as a dental abscess. The DON also stated the resident was seen by a local general practice dentist on 3/23/22, but the dentist couldn't examine, diagnose or treat the resident because the resident was unable to open his mouth and/or follow directions; therefore the general practice dentist provided the facility staff with information to schedule an appointment for sedation dentistry for Resident #190. The DON stated LPN #12 was responsible to schedule the sedation dentistry appointment for Resident #190 but she discontinued her employment with the facility and didn't provide the staff with the status of the appointment. As of 5/18/22, there was no evidence that the facility's staff was actively following up on the sedation dentistry appointment. The DON was unable to offer additional information on why there was such a delay in obtaining the necessary dental services or how the delay in services contributed to an additional decline in the resident's health. On 5/13/22 at approximately 4:15 p.m., a phone interview was conducted with LPN #12. LPN #12 stated she was responsible for making the sedation dentistry appointment for Resident #190. She stated she telephoned the practice, left a message with the scheduler, and was awaiting a return call with the appointment information, but she ceased employment with the nursing facility prior to obtaining the sedation dentistry appointment. LPN #12 further stated most likely the sedation dentistry practice left the appointment information on her voicemail after she separated from the facility and the administrative staff at the nursing home has access to the voicemail and can retrieve the message. On 5/19/22 at approximately 2:50 p.m., an interview was conducted with the Administrator. The Administrator stated the facility didn't have a dental contract with a practice but a local dental practice usually accommodates their residents whenever services are needed. The Administrator didn't elaborate on why it took twenty-two days for staff to obtain a dental appointment for Resident #190 but she stated because the in-house NP was monitoring and treating Resident #190's swelling to the left jaw, she felt his dental needs were met. The Administrator didn't address a documented NP progress note in which the NP stated she spoke with the DON on 3/7/22 expressing the need to have the resident evaluated by a dentist. On 5/20/22 at approximately 2:10 p.m., a phone interview was conducted with a representative from the sedation dentistry office. The representative stated a consultation is necessary prior to sedation dentistry services being provided and normally after the consultation the service is rendered within one month. The representative confirmed that an appointment for Resident #190 had not been made for the resident's name wasn't in their system. The representative further stated even in the event an appointment wasn't honored or canceled, the person's name would still be in their system. On 5/20/22 at approximately 6:00 p.m., the above findings were shared with the Administrator, Director of Nursing, and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information but no additional information was provided and no further concerns were voiced. The facility's policy titled Dental Services with a revision date of 01/04/22 read; It is the policy of this facility, in accordance with residents' needs, to assist residents in obtaining routine (to the extent covered under the State plan) and emergency dental care. Emergency dental services include services needed to treat an episode of acute pain in teeth, gums, or palate; broken, or otherwise damaged teeth, or any other problem of the oral cavity that required immediate attention by a dentist.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The facility staff failed to ensure the necessary treatment to prevent the development of a sacral pressure ulcer that was initially identified at an advanced stage (unstageable with 100% necrotic/dead tissue) resulting in harm for Resident #339. Resident #339 was admitted on [DATE] with diagnoses that included osteoarthritis, unspecified vascular dementia. Resident #339 clinical record review revealed a Braden Scale for Predicting Pressure Sores Risk Assessment as being completed on 11/19/21 as being at RISK. On 11/25/21 a clinical record review revealed a second Braden Scale for Predicting Pressure Sores Risk assessment was completed as being at Moderate risk. The admission, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/23/2021 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #339 cognitive abilities for daily decision making were intact. The Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/14/21 reads: M0210. Unhealed Pressure Ulcers/Injuries. Does this resident have one or more unhealed pressure ulcers/injuries? Yes. Unstageable - Slough and/or eschar. Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar? 1. Number of these unstageable pressure injuries that were present upon admission/entry or reentry=0 (none). M1200-Skin and Ulcer Treatments: Pressure reducing device for bed: Checked off. Pressure ulcer care: Checked off. Applications of dressings to feet (with or without topical medications): In section G (Physical functioning) the resident was coded as requiring extensive of assistance of one person with bed mobility and personal hygiene, total dependence of one person with transfers, dressing, toilet use and bathing, independent set-up help with eating. The Care plan dated 12/1/21 read, Focus: The resident has an ADL (Activity of Daily Living) self-care performance deficit. Goal: The resident will maintain current level of function through the review date. Intervention: Reposition (FREQ) and as necessary to avoid injury. Monitor/document/report PRN (as needed) any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. The Care plan dated 12/9/21 read, Focus: Resident at risk for impaired skin integrity and actual open area to sacrum r.t (relating to) incontinence, impaired mobility and dementia. Goal: The resident will maintain or develop clean and intact skin by the review date. The care plan dated 12/09/2021, read the resident will have no complications r/t area to sacrum through the review date, air mattress as per physician orders. The care plan revision dated 01/27/2022 read, avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Educate resident/family/caregivers of causative factors and measures to prevent skin injury. Follow facility protocols for treatment of injury. Treatment as per orders. According to the clinical record Resident #339 was admitted to the facility on [DATE] at 6:38 PM. The skin assessment noted resident to have only red areas to bilateral upper extremities from blood draws from the hospital. The clinical record dated 11/20/2021 at 12:12 PM., reads: Resident is AAOx3 (Alert and Oriented x three to person, place, and time) with no complaints voiced. Resident is incontinent of bladder, requiring assistance from staff. \ A review of the hospital Discharge summary dated [DATE] reveal no pressure ulcers were present before being transferred to the LTC (Long Term Care) facility. A review of the Long Term Care Facility's History and Physical dated 11/23/21 reveal no pressure ulcers were present on admission. Daily Nursing Skin Assessments document dated 11/18/21 read, skin is intact. A review of the ADL (Activity of Daily Living) document for December 2021 reveal that Resident #339 received bed baths from 12/01/21 through 12/08/21 with no notation of skin integrity problems, but according to the nursing notes Resident #339's wound was identified on 12/03/21 by the CNA (CNA #7). A review of the nurse's note dated on 12/03/21 (3:45 PM) read: CNA (Certified Nurse's Aide) #7 notified me (LPN #13, no longer employed at the facility) of area to sacrum. Assessed resident noted open area to sacrum with slough noted. Cleaned area and applied dressing change every 3 days/prn (as needed) until healed. RP (Responsible Party) made aware and placed in communication book. Wound nurse also made aware. The nurse's note dated on 12/5/2021 at 9:00 AM., read, Resident with pain, when asked where she pointed to her sacral area. The nurse's note dated on 12/9/2021 at 12:23 PM., read, Resident being turned every 2 hours from side to side to prevent pressure to sacral area as per order; dressing with serosanguinous drainage, dressing reapplied as needed, skin care given. The nurse's note dated 12/15/2021 at 4:29 PM read that the MDS (Minimum Data Set staff) was in with resident to obtain pain interview for scheduled quarterly for managed care stay. Resident stated that over the past 5 days she has had frequent bottom pain r/t to her wound and that at times it makes it hard to sleep and limits her day to day activity. The nurse's note dated on 12/17/2021 at 8:27 PM revealed that the Resident was medicated for comfort due to dressing change to sacrum, and that the resident was moaning. The nurse's note dated on 12/18/2021 at 10:30 AM read: Resident nonverbal, starring up at the ceiling, and displaying facial grimacing and moaning. VS: 97.3-103-20-114/52. SATS 94% RA. BS: 127. Resident being sent out to ER for further evaluation. 11:20 AM., 911 at the facility to transport resident to local Emergency Room/ER for further evaluation. The clinical record dated on 12/18/2021 7:57 PM., reads that Resident #339 was admitted to the local hospital for renal failure, sepsis, necrotizing tissue of the sacrum. During the course of investigation of the sacral pressure ulcer, it was identified when CNA (Certified Nurse's Assistant) #7 saw an area on the resident's butt on 12/03/21 at which time she alerted the nurse, LPN #3. On 5/18/22 at 3:55 pm., an interview was conducted with the WCNP (Wound Care Nurse Practitioner/OSM) #12 concerning Resident #399's sacral wound. She stated, that the wound was facility acquired on 12/03/21 and that she first assessed it on 12/07/21 as an unstageable with 100% necrosis full thickness. She stated, It's not acceptable because as a full thickness wound, I'm not able to see the extent of this wound. It could have been here for who knows how long. I rounded every Thursday. My expectation was that the wound care nurse (facility LPN #3/ADON) Licensed Practical Nurse/Assisting Director of Nursing) perform initial assessments and update me and we round on patients together. She didn't assist me. She wasn't with me consistently every single week. It got worse. Pressure and deconditioning were contributors; turn and reposition assistance, and decreased mobility. Typically residents could get an unstageable pressure ulcer over 2 or 3 days but not overnight. Prevention measures such as low air loss mattress, foam dressing on the sacrum to prevent further decomposition. It had gotten larger, still unstageable, the signs and symptoms were acute infection, malodorous and increase drainage. I cleaned it with dermal wound cleanser, calcium Ag, applied santyl and covered with foam. The Primary physician started her on Levoquin po (by mouth). I received a call from LPN #3 on January 3rd, 2022 after Resident #339 had been admitted to the hospital. Someone from corporate and LPN #3 called me about resident having necrotizing fasciitis. It's a bacterial infection, flesh eating bacteria caused when the skin is disrupted with bacteria that spreaded to her bones. Infection breaking through the skin barriers causes this. On 12/07/21, the WNP consult notes indicated the following, Unstageable sacrum pressure ulcer. Measurements: Length 2.0 x Width 2.5 cm Depth surface area 5.0 cm2. Minimal serosanguinous, 100 % necrosis. Surrounding Tissue is intact. Primary dressing: Santyl, Calcium Alginate Ag, Foam. Surgical debridement procedure was performed: Removal of subcutaneous tissue. An assessment of the sacral wound show the wound has full thickness loss, base covered with slough, consistent with an unstageable pressure injury. Due to the presence of the necrotic tissue bed, the ulcer was debrided. Plan: clean with dermal wound cleanser, pat dry, change daily and as needed. Apply santyl to the wound bed, cover with calcium alginate Ag, then foam dressing, change daily and as needed. Weekly Pressure Wound Observation consult notes dated 12/17/21 by the WNP read, 12/17/21 Pressure ulcer of Sacrum worsening. Malodorous. Wound deteriorating. A review of the medical record revealed no wound measurements until the Wound Care Nurse Practitioner (WNP) arrived on 12/17/21. On 12/17/21 the WNP consult notes read, Unstageable pressure ulcer on sacrum. Measurements: Length 5.5 cm Width 6.1 cm Depth 0.2 cm. Surface area 35.5 cm2. Exudate: moderate, purulent and malodorous. Tissue type: 100% necrosis, full thickness. Surrounding Tissue: Intact. Primary dressing: Santyl, Calcium Alginate Ag, Foam. Progress: deteriorating. Surgical debridement procedure was performed: Subcutaneous Tissue on 12/16/21. At the start of today's procedure, the ulcer is described as follows: Length 5.5 cm Width 6.1 cm Depth 0.2 cm. Surface 33.5 cm2. Exudate: moderate, purulent, malodorous. Tissue type: 100% necrosis, full thickness. The amount of surface area debrided was 100%. Assessment: The unstageable pressure injury to the sacrum is deteriorating. Due to the presence of necrotic tissue in the ulcer bed, the ulcer was debrided. Barriers to healing include infection. Signs and symptoms of acute infection include odor, purulent draining and increased pain. The primary team started the patient on Levaquin PO. A antimicrobial dressing of gentamicin cream and calcium Alginate Ag was applied for control of possible excess bioburden and to promote healing. Plan: Clean with dermal wound cleanser. Pat dry, apply Gentamicin and Santyl to the wound bed. Cover with Calcium Alginate Ag, then foam dressing. Change daily and as needed. Continue PO Levaquin for infection to sacral wound. In addition Resident #339 acquired unstageable DTI (Deep Tissue Injury) of the left heel. The clinical record reveal on 12/18/2021 Resident #339 was admitted to the local hospital for renal failure, sepsis, necrotizing tissue. According to review of the ER/emergency room medical records dated 12/18/21 at 5:14 PM, Resident #339 was presented with AMS (Altered Mental Status) and a Large Sacral Pressure Ulcer. Later tests revealed that Resident #339 was diagnosed with having a sacral decubitus ulcer with infected GAS (Bacteria called group A Streptococcus (GAS) can cause many different infections. These infections range from minor illnesses to very serious and deadly diseases-https://www.cdc.gov/groupastrep/diseases-public/index.html). According to review of the the Emergency Department (ED) report dated 12/18/21 Resident #339 was admitted to the ED in .acute distress and ill appearing. On assessment Resident had a large sacral ulcer present with foul odor. The CT (computerized tomography) scan shows: Sacral decubitus ulcer with likely infectious GAS along the lower back into the left greater than right gluteal musculature and right greater than the left perineum. There is ill defined fluid collection measuring up to 3.3 cm within the left gluteal musculature potentially developing abscess. On 12/18/21 the ED provider note list diagnoses as: Necrotizing soft tissue infection, Renal Failure, Sepsis and Sacral decubitus Ulcer Stage 4. Diagnosis management comments: Multiple conversations were made with Resident's spouse. Call in note says resident is a full code. Husband says this is not correct she is a DNR (Do Not Resuscitate). However, he would like out general surgeon (GS) to attempt to address the significant infection to her sacral region. Causing her severe sepsis and worsening mental status. We discussed comfort measures versus this intervention. Surgery was consulted and she was found to have necrotizing fasciitis and plans were made to go to the OR (Operating Room) for debridement. The OR (Operating Room) procedure note dated 12/18/21 revealed that the patient's decubitus wound was massive and necrotic. The resident had to be taken urgently to the OR to excise the necrotic tissue because the patient is in septic shock. All necrotic tissue was excised. All underlying tissue was involved all the way to the bone. Patient was intubated and critically ill. Consideration for hospice care. On 5/13/22 at 7:44 PM and at 5:00 PM a phone call was made to the Surgeon. Surveyor was not able to leave messages. An interview was conducted on 5/17/22 at 4:25 PM., with LPN (License Practical Nurse, wound care nurse/Assistant Director of Nursing) #3 concerning Resident #339. She stated, It (SACRUM) was first identified as unstageable. It progressed and we had to debride it. I did some of her wound care. It showed no signs of infection after the first surgical debridement. For preventive measures she used a specialty mattress starting 12/10/21. We medicated her before wound care. She was turned and repositioned. An interview was conducted on 5/18/22 at 10:00 AM with the complaintant concerning Resident #339. She stated, The hospital surgeon made a referral to us and he indicated that he had to perform two surgeries on patient's sacral area due to having a large infected wound. The two surgeries resulted from infection of the wound to the bone. My investigation found she had no wounds on her body until December 3rd. (2021) She was bedridden and had physical therapy from her bed. She never got out of bed. She was put on hospice. Her husband would sit with her for hours. The wound nurse (LPN #3) would only see her when the outside Wound Nurse Practitioner came in. An interview was conducted on 5/18/22 at 11:15 am with CNA (Certified Nurse's Aide) #7. Concerning Resident #399. She stated, A few days after she came she complained that her butt hurt. We would get her off her side. When I came back from being off, she had an area on her butt. I reported it to the nurse. That nurse no longer works here. The wound nurse came every week. She was not ambulatory and could not make her needs known. She had good days and bad days. I turned and reposition her every two hours. LPN #13, who was the nurse CNA #7 alerted about the area on Resident #339, was called twice throughout the survey. Voice messages were left with no return call. On 5/19/22 at 1:35 AM., an interview was conducted with RN (Registered Nurse) #1. She stated, I turned her every 2 hours due to the wound on her bottom. She was not able to make her needs known. The wound on her bottom was acquired at the facility. I didn't have to do anything with her wound because I worked the 7 pm -7 am shift. We had an investigation here earlier. I didn't find anything unusual with her vitals. I thought it was odd that she was smiling. I never got to see the wound. If it was soiled I would have changed it and seen it but I didn't have the opportunity. On 05/20/2022 at approximately 3:45 p.m., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information but no additional information was provided. 2. The facility staff failed to identify a sacral wound pressure ulcer prior to advancing to an unstageable pressure ulcer measuring 5 centimeter (cm) x 5 cm x 2 cm for Resident #291. The sacral wound was infected requiring antibiotic therapy and surgical debridement (removal of dead tissue), which constituted harm. Resident #291 was originally admitted to the facility on [DATE]. Diagnosis for Resident #291 included but are not limited to Parkinson disease and muscle weakness. Resident #291's admission Assessment (14-day) with an ARD of 03/19/22 coded Resident #291 Brief Interview for Mental Status (BIMS) scored a 99 indicating short and long term memory problems and severe cognitive impairment - never/rarely made decisions. Resident #291 was coded total dependence of two with toilet use, bed mobility and bathing, total dependence of one with dressing, personal hygiene and eating and for Activities of Daily Living (ADL). Under section H - (Bladder and Bowel) was coded for always incontinent of bladder and bowel. Under section G0400 - Functional Limitation in Range of Motion (ROM) coded Resident #291 with no impairment to her upper and lower extremity. Resident #291 was coded as having no mood, rejection of care or behavioral problems. Resident #291's admission Assessment (14-day) with an ARD of 03/19/22. Under section (M0150) at risk for developing pressure ulcers was coded yes, under section (M0210) for unhealed pressure ulcers was coded yes and under section (M0300) for having current number of unhealed pressure ulcer at each stage present upon admission or reentry into the facility was coded for stage II pressure ulcer. Under section (1200) for skin, ulcer treatments were coded for having pressure reducing device for bed and pressure ulcer wound care. Resident #291's person-centered care plan initiated on 03/21/22 identified the resident has a pressure ulcer in her sacral area, at risk for further skin breakdown related to incontinence and impaired mobility. The goal set for the resident by the staff was that the resident will remain free of new skin breakdown through next review date. Some of the interventions/approaches the staff would use to accomplish this goal is to follow facility policies/protocols for the prevention/treatment of skin breakdown, assess/record/monitor wound healing, measure length, width and depth where possible, assess and document status of wound perimeter, wound bed and healing progress, specialty mattress and report improvements and declines to the physician and administer treatments as ordered and monitor for effectiveness. The person-centered care plan with a revision date of 04/01/22 identified Resident #291 on antibiotics for a sacral wound infection. The goal set for the resident by the staff was that the resident will show signs of healing and remain free of complications related to infection. One of the interventions/approaches the staff would use to accomplish this goal is to administer medications as ordered, monitor/document for side effects and effectiveness. A Braden Risk Assessment Report was completed on 3/15/22. The resident scored a 09 indicating at high risk for the development of pressure ulcers. The assessment coded under sensory perception very limited and responds only to painful stimuli; cannot communicate discomfort except by moaning or restlessness or has a sensory impairment which limits the ability to feel pain or discomfort over ½ of the body. Under moisture was coded skin is occasionally moist, requiring an extra linen change approximately once a day and coded bedfast under activity. The skin/wound admission note dated 03/10/22 indicated Resident #291 had a stage II sacral ulcer measuring 2.0 cm x 1.0 cm x 0.2 cm with very dark skin, nonblachable measuring (15 cm x 9 cm) surrounding the sacral ulcer. The note indicated that Resident #291's pressure ulcer will be evaluated by the wound Nurse Practitioner (NP) during her next visit on 03/15/22. Resident #291 had a physician order dated 03/10/22 to apply an air mattress to the bed for wound prevention and an order dated 03/11/22, for a sacral pressure ulcer treatment to apply a foam dressing every Tuesday, Thursday and Saturday (day shift). A review of Resident #291's nurse's note revealed the resident was transferred to the hospital emergency room for evaluation for an elevated temperature on 03/14/22 at approximately 6:50 p.m., and returned on 03/15/22 at approximately 4:00 p.m. Further review of the nurses note revealed no new skin impairments noted since the last admission assessment on 03/10/22. The resident was readmitted to the nursing facility on 03/15/22. The readmission note under skin integrity revealed the same sacral pressure assessed at a Stage II. A skin/wound note dated 03/22/22 at 12:08 p.m., by the wound nurse License Practical Nurse (LPN #3) revealed the wound NP (WNP) went to assess Resident #291's sacral wound but the resident had pain with body movement, thus the WNP decided to assess Resident #291's sacral wound during her next onsite visit on 03/29/22. During the review of Resident #291's clinical record revealed there were no weekly wound assessments made by the facility licensed nurses of the sacral pressure ulcer for 19 days, after her admission to the facility. An interview was conducted with the WNP on 05/17/22 at approximately 3:06 p.m., I was in the facility on 03/15/22 to assess Resident #291's sacral ulcer, but the resident was discharged to the hospital during my onsite visit. The WNP stated, My first time evaluating Resident #291's pressure ulcer was on 03/29/22. The WNP said the wound was infected as evidence by the wound having a significant amount of slough with foul odor present and having significant pain over the sacral area when touched or palpated. Resident #291 was placed on routine pain medication as well as two rounds of antibiotic therapy to help fight the sacral wound infection. The wound was not cultured due to the location of the wound (sacral area) which put the wound culture at risk for cross contamination. The WNP's initial progress note of the sacral pressure ulcer on 03/29/22 revealed an unstageable ulcer measuring 5 cm x 5 cm x 2 cm. The progress note stated the sacral wound had a moderate amount of serosanquinous drainage, strong odor present with 90 percent (%) slough and 10 % dermis tissue. A new medication order was given for Augmentin (antibiotic) 500 mg/125 mg every 12 hours x 10 days for a sacral wound infection. A new treatment order was given to clean the sacral wound with Dakin's, Santyl on Dakin's gauze, and cover with foam dressing daily and as needed. The WNP progress note also stated pain is indicative of any movement, at rest she is comfortable. The WNP also offered further recommendations to turn and reposition per facility protocol, use of a low air loss mattress and to optimize nutrition. A WNP progress note dated 04/05/22 revealed the sacral wound pressure ulcer remained an unstageable measuring 5 cm x 5 cm x (?). The sacral wound had improved but remain with moderate amount of serosanquinous drainage, strong odor present with 90% slough and 10% dermis tissue. The wound was debrided removing thick slough tissue; pain was present with any movement. Resident #291 remained on antibiotic therapy for a sacral wound infection and continued with the current wound treatment, Dakin's, Santyl on Dakin's gauze, and cover with foam dressing daily and as needed. A review of the WNP's progress note dated 04/11/22 indicated that the wound visit was performed via telehealth with the wound nurse, License Practical Nurse (LPN #3). The sacral wound was deteriorating with moderate amount of purulent drainage, strong odor present with 90% slough and 10% dermis tissue. The wound measured by onsite nurse (LPN #3) measuring 6.5 cm x 5.5 cm x 2.5 cm. The progress note recommended to continue with current sacral wound treatment with Dakin's, Santyl on Dakin's gauze, foam dressing and change daily and as needed. A new antibiotic order was given for Clindamycin 600 mg by mouth every 8 hours for 21 days for a sacral wound infection. The wound NP progress note also stated pain is indicative of any movement, at rest she was comfortable. On 05/16/22 at approximately 2:25 p.m., an interview was conducted with LPN #1. LPN #1 was assigned to performed sacral wound care to Resident #291 on 03/26/22 (7a-7p shift). The LPN stated, I have never measured Resident #291's sacral pressure ulcer. The ulcer was being measured and monitored by LPN #3 and the wound NP. An interview was conducted with the Medical Director (MD) on 05/18/22 at approximately 11:33 a.m., who said all pressure ulcers were followed by (name of Wound Company.) The MD stated, Resident #291's sacral ulcer should have been monitored, assessed and measured on a weekly basis for signs of decline or improvement. The nurses should have been monitoring the sacral pressure ulcer during every wound care dressing change for a change in condition. Apparently, the nurses were not doing a full wound assessment for change in condition because a pressure ulcer cannot go from a stage II to an unstageable requiring debridement overnight. The changes in the wound should be been addressed before the wound was identified as an unstageable pressure ulcer. The extra nutritional element recommended by the dietitian could have help with the wound healing of the sacral pressure ulcer. An interview was conducted with LPN #9 on 05/19/22 at approximately 10:44 a.m. The LPN was assigned to perform sacral wound care to Resident #291 on 03/19/22 (7a-7p shift). The nurse said an open area was noted to the sacrum with shearing/excoriation to the periwound. The LPN stated, I only do the resident's treatment not the monitoring or measuring of the wound that was being done by the wound NP or LPN #3 on a routine basis. A phone interview was conducted with LPN #12 on 05/16/22 at approximately 6:29 p.m. The LPN was assigned to perform sacral wound care to Resident on 03/22/22 (7a-7p shift). The LPN said the sacral wound appeared larger in size but I did not measure or document the change in condition of the sacral wound. The LPN stated, The wound NP and LPN #3 were assessing and monitoring Resident #291's sacral ulcer every week. A dietary/nutrition note dated 03/18/22 at 9:56 a.m., revealed Resident #291 having a suspected deep tissue injury (SDTI) to the left and right heel and a stage II pressure ulcer to the coccyx/sacral area per 03/10/22 (skin assessment). Recommendations were made for fortified foods with meals due to poor oral intake of meals, provide texture-appropriate calorie-dense snacks three times a day between meals due to poor oral intake and thickened house shake (120 mL), pudding / fortified pudding. A Dietary/Nutrition note dated 04/08/22 at 12:33 p.m., revealed the nutritional recommendations made on 03/18/22 were never addressed for fortified foods with meals due to poor oral intake of meals, provide texture-appropriate calorie-dense snacks three times a day between meals due to poor oral intake and thickened house shake (120 mL), pudding / fortified pudding. An interview was conducted with the RD on 05/17/22 at approximately 4:41 p.m., who stated, The nutrition recommendations made for Resident #291 on 03/18/22 and again on 04/08/22 were never addressed. The RD said the extra calories would have given extra protein that's needed to help with healing Resident #291's sacral pressure ulcer. The nursing note dated 04/11/22 at approximately 6:23 p.m., revealed Resident #291 with Altered Mental Status (AMS), tremors and had vomiting during dinner. A new order was given to send Resident #291 to the emergency room (ER) for evaluation and treatment. A review of the hospital records revealed that Resident #291 presented in the Emergency Department (ED) on 04/11/22 from (name of nursing facility) for further evaluation due to Altered Mental Status (AMS) and vomiting. The ED indicated Resident #291 is lethargic, disoriented and is currently on antibiotic for an infected unstageable sacral wound. The wound is observed with a strong foul odor. The sacral wound was evaluated to be a FIST size with partial wet slough, fetid (having a heavy offensive smell-https://www.merriam-webster.com/dictionary) skin and obvious deep tunneling on perimeter. The ED report indicated the resident did not meeting the criteria for Systemic inflammatory response syndrome (SIRS), but had a concerning sacral wound and was referred for evaluation and treatments by the General Surgery. The resident was started on IV Vancomycin (antibiotic) and Zosyn (antibiotic) for empiric coverage of her large sacral decubitus ulcer. After the sacral wound was evaluated by the General Surgery, he felt the wound would benefit from debridement of the wound. On 04/12/22, Resident #291 was taken into the operating room (OR), and the sacral wound was debrided. After debridment the wound was assessed as a stage III decubitus ulcer with no exposed bone at this time. The recommendation was made for a wound VAC to improve the healing process for the resident. It was noted that the resident would also benefit from significant nutritional support and should be fed by staff by the facility. An interview was conducted with the Director of Nursing (DON) and wound nurse LPN #3 on 05/12/22 at approximately 10:00 a.m. The DON said Resident #291's sacral pressure ulcer should have been evaluated by the WNP or wound nurse, LPN #3 on a weekly basis. She stated, the weekly evaluation and monitoring was needed for early detection to determine if the wound is improving or declining. The wound nurse LPN #3 stated, I was not here on 03/17/22 and 03/24/22, when Resident #291 was supposed to have her sacral wound assessed and evaluated a changes in condition. The DON said the nurses should have been assessing and documenting changes on Resident #291's sacral pressure ulcer (description of wound bed, if drainage or odor present and size of the wound) with all changes reported to LPN #3 or the wound NP for evaluation to determine if wound treatment changes were needed. According to the DON, the stage II sacral wound treatment was appropriate when admitted to the facility on [DATE]. The treatment was for a foam dressing, change every 2 days. The DON said, When the wound deteriorated to an unstageable, the treatment should have been changed but it wasn't. The DON further stated, Due to the lack of documentation, there is no way to know when Resident #291's sacral wound deteriorated to the point it had advanced to an unstageable requiring debridement and antibiotic due to infection. A debriefing was held with the Administrator, Director of Nursing and Corporate support on 05/19/22 at approximately 2:00 p.m. Resident #291's issues was presented again. No additional information was forthcoming. Definitions: -Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/). -Pressure Injury - Stage 2 (Partial-thickness skin loss with exposed dermis_ Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages). Pressure Injury - Stage 3 (Full-thickness skin loss) Full-thickness loss of skin,[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to ensure the necessary treatment to prevent the development of a sacral pressure ulcer that was initially identified at an advanced stage (unstageable with 100% necrotic/dead tissue) resulting in harm for Resident #339. Resident #339 was admitted on [DATE] with diagnoses that included osteoarthritis, unspecified vascular dementia. Resident #339 clinical record review revealed a Braden Scale for Predicting Pressure Sores Risk Assessment as being completed on 11/19/21 as being at RISK. On 11/25/21 a clinical record review revealed a second Braden Scale for Predicting Pressure Sores Risk assessment was completed as being at Moderate risk. The admission, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/23/2021 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #339 cognitive abilities for daily decision making were intact. The Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/14/21 reads: M0210. Unhealed Pressure Ulcers/Injuries. Does this resident have one or more unhealed pressure ulcers/injuries? Yes. Unstageable - Slough and/or eschar. Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar? 1. Number of these unstageable pressure injuries that were present upon admission/entry or reentry=0 (none). M1200-Skin and Ulcer Treatments: Pressure reducing device for bed: Checked off. Pressure ulcer care: Checked off. Applications of dressings to feet (with or without topical medications): In section G (Physical functioning) the resident was coded as requiring extensive of assistance of one person with bed mobility and personal hygiene, total dependence of one person with transfers, dressing, toilet use and bathing, independent set-up help with eating. The Care plan dated 12/1/21 read, Focus: The resident has an ADL (Activity of Daily Living) self-care performance deficit. Goal: The resident will maintain current level of function through the review date. Intervention: Reposition (FREQ) and as necessary to avoid injury. Monitor/document/report PRN (as needed) any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. The Care plan dated 12/9/21 read, Focus: Resident at risk for impaired skin integrity and actual open area to sacrum r.t (relating to) incontinence, impaired mobility and dementia. Goal: The resident will maintain or develop clean and intact skin by the review date. The care plan dated 12/09/2021, read the resident will have no complications r/t area to sacrum through the review date, air mattress as per physician orders. The care plan revision dated 01/27/2022 read, avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Educate resident/family/caregivers of causative factors and measures to prevent skin injury. Follow facility protocols for treatment of injury. Treatment as per orders. According to the clinical record Resident #339 was admitted to the facility on [DATE] at 6:38 PM. The skin assessment noted resident to have only red areas to bilateral upper extremities from blood draws from the hospital. The clinical record dated 11/20/2021 at 12:12 PM., reads: Resident is AAOx3 (Alert and Oriented x three to person, place, and time) with no complaints voiced. Resident is incontinent of bladder, requiring assistance from staff. \ A review of the hospital Discharge summary dated [DATE] reveal no pressure ulcers were present before being transferred to the LTC (Long Term Care) facility. A review of the Long Term Care Facility's History and Physical dated 11/23/21 reveal no pressure ulcers were present on admission. Daily Nursing Skin Assessments document dated 11/18/21 read, skin is intact. A review of the ADL (Activity of Daily Living) document for December 2021 reveal that Resident #339 received bed baths from 12/01/21 through 12/08/21 with no notation of skin integrity problems, but according to the nursing notes Resident #339's wound was identified on 12/03/21 by the CNA (CNA #7). A review of the nurse's note dated on 12/03/21 (3:45 PM) read: CNA (Certified Nurse's Aide) #7 notified me (LPN #13, no longer employed at the facility) of area to sacrum. Assessed resident noted open area to sacrum with slough noted. Cleaned area and applied dressing change every 3 days/prn (as needed) until healed. RP (Responsible Party) made aware and placed in communication book. Wound nurse also made aware. The nurse's note dated on 12/5/2021 at 9:00 AM., read, Resident with pain, when asked where she pointed to her sacral area. The nurse's note dated on 12/9/2021 at 12:23 PM., read, Resident being turned every 2 hours from side to side to prevent pressure to sacral area as per order; dressing with serosanguinous drainage, dressing reapplied as needed, skin care given. The nurse's note dated 12/15/2021 at 4:29 PM read that the MDS (Minimum Data Set staff) was in with resident to obtain pain interview for scheduled quarterly for managed care stay. Resident stated that over the past 5 days she has had frequent bottom pain r/t to her wound and that at times it makes it hard to sleep and limits her day to day activity. The nurse's note dated on 12/17/2021 at 8:27 PM revealed that the Resident was medicated for comfort due to dressing change to sacrum, and that the resident was moaning. The nurse's note dated on 12/18/2021 at 10:30 AM read: Resident nonverbal, starring up at the ceiling, and displaying facial grimacing and moaning. VS: 97.3-103-20-114/52. SATS 94% RA. BS: 127. Resident being sent out to ER for further evaluation. 11:20 AM., 911 at the facility to transport resident to local Emergency Room/ER for further evaluation. The clinical record dated on 12/18/2021 7:57 PM., reads that Resident #339 was admitted to the local hospital for renal failure, sepsis, necrotizing tissue of the sacrum. During the course of investigation of the sacral pressure ulcer, it was identified when CNA (Certified Nurse's Assistant) #7 saw an area on the resident's butt on 12/03/21 at which time she alerted the nurse, LPN #3. On 5/18/22 at 3:55 pm., an interview was conducted with the WCNP (Wound Care Nurse Practitioner/OSM) #12 concerning Resident #399's sacral wound. She stated, that the wound was facility acquired on 12/03/21 and that she first assessed it on 12/07/21 as an unstageable with 100% necrosis full thickness. She stated, It's not acceptable because as a full thickness wound, I'm not able to see the extent of this wound. It could have been here for who knows how long. I rounded every Thursday. My expectation was that the wound care nurse (facility LPN #3/ADON) Licensed Practical Nurse/Assisting Director of Nursing) perform initial assessments and update me and we round on patients together. She didn't assist me. She wasn't with me consistently every single week. It got worse. Pressure and deconditioning were contributors; turn and reposition assistance, and decreased mobility. Typically residents could get an unstageable pressure ulcer over 2 or 3 days but not overnight. Prevention measures such as low air loss mattress, foam dressing on the sacrum to prevent further decomposition. It had gotten larger, still unstageable, the signs and symptoms were acute infection, malodorous and increase drainage. I cleaned it with dermal wound cleanser, calcium Ag, applied santyl and covered with foam. The Primary physician started her on Levoquin po (by mouth). I received a call from LPN #3 on January 3rd, 2022 after Resident #339 had been admitted to the hospital. Someone from corporate and LPN #3 called me about resident having necrotizing fasciitis. It's a bacterial infection, flesh eating bacteria caused when the skin is disrupted with bacteria that spreaded to her bones. Infection breaking through the skin barriers causes this. On 12/07/21, the WNP consult notes indicated the following, Unstageable sacrum pressure ulcer. Measurements: Length 2.0 x Width 2.5 cm Depth surface area 5.0 cm2. Minimal serosanguinous, 100 % necrosis. Surrounding Tissue is intact. Primary dressing: Santyl, Calcium Alginate Ag, Foam. Surgical debridement procedure was performed: Removal of subcutaneous tissue. An assessment of the sacral wound show the wound has full thickness loss, base covered with slough, consistent with an unstageable pressure injury. Due to the presence of the necrotic tissue bed, the ulcer was debrided. Plan: clean with dermal wound cleanser, pat dry, change daily and as needed. Apply santyl to the wound bed, cover with calcium alginate Ag, then foam dressing, change daily and as needed. Weekly Pressure Wound Observation consult notes dated 12/17/21 by the WNP read, 12/17/21 Pressure ulcer of Sacrum worsening. Malodorous. Wound deteriorating. A review of the medical record revealed no wound measurements until the Wound Care Nurse Practitioner (WNP) arrived on 12/17/21. On 12/17/21 the WNP consult notes read, Unstageable pressure ulcer on sacrum. Measurements: Length 5.5 cm Width 6.1 cm Depth 0.2 cm. Surface area 35.5 cm2. Exudate: moderate, purulent and malodorous. Tissue type: 100% necrosis, full thickness. Surrounding Tissue: Intact. Primary dressing: Santyl, Calcium Alginate Ag, Foam. Progress: deteriorating. Surgical debridement procedure was performed: Subcutaneous Tissue on 12/16/21. At the start of today's procedure, the ulcer is described as follows: Length 5.5 cm Width 6.1 cm Depth 0.2 cm. Surface 33.5 cm2. Exudate: moderate, purulent, malodorous. Tissue type: 100% necrosis, full thickness. The amount of surface area debrided was 100%. Assessment: The unstageable pressure injury to the sacrum is deteriorating. Due to the presence of necrotic tissue in the ulcer bed, the ulcer was debrided. Barriers to healing include infection. Signs and symptoms of acute infection include odor, purulent draining and increased pain. The primary team started the patient on Levaquin PO. A antimicrobial dressing of gentamicin cream and calcium Alginate Ag was applied for control of possible excess bioburden and to promote healing. Plan: Clean with dermal wound cleanser. Pat dry, apply Gentamicin and Santyl to the wound bed. Cover with Calcium Alginate Ag, then foam dressing. Change daily and as needed. Continue PO Levaquin for infection to sacral wound. In addition Resident #339 acquired unstageable DTI (Deep Tissue Injury) of the left heel. The clinical record reveal on 12/18/2021 Resident #339 was admitted to the local hospital for renal failure, sepsis, necrotizing tissue. According to review of the ER/emergency room medical records dated 12/18/21 at 5:14 PM, Resident #339 was presented with AMS (Altered Mental Status) and a Large Sacral Pressure Ulcer. Later tests revealed that Resident #339 was diagnosed with having a sacral decubitus ulcer with infected GAS (Bacteria called group A Streptococcus (GAS) can cause many different infections. These infections range from minor illnesses to very serious and deadly diseases-https://www.cdc.gov/groupastrep/diseases-public/index.html). According to review of the the Emergency Department (ED) report dated 12/18/21 Resident #339 was admitted to the ED in .acute distress and ill appearing. On assessment Resident had a large sacral ulcer present with foul odor. The CT (computerized tomography) scan shows: Sacral decubitus ulcer with likely infectious GAS along the lower back into the left greater than right gluteal musculature and right greater than the left perineum. There is ill defined fluid collection measuring up to 3.3 cm within the left gluteal musculature potentially developing abscess. On 12/18/21 the ED provider note list diagnoses as: Necrotizing soft tissue infection, Renal Failure, Sepsis and Sacral decubitus Ulcer Stage 4. Diagnosis management comments: Multiple conversations were made with Resident's spouse. Call in note says resident is a full code. Husband says this is not correct she is a DNR (Do Not Resuscitate). However, he would like out general surgeon (GS) to attempt to address the significant infection to her sacral region. Causing her severe sepsis and worsening mental status. We discussed comfort measures versus this intervention. Surgery was consulted and she was found to have necrotizing fasciitis and plans were made to go to the OR (Operating Room) for debridement. The OR (Operating Room) procedure note dated 12/18/21 revealed that the patient's decubitus wound was massive and necrotic. The resident had to be taken urgently to the OR to excise the necrotic tissue because the patient is in septic shock. All necrotic tissue was excised. All underlying tissue was involved all the way to the bone. Patient was intubated and critically ill. Consideration for hospice care. On 5/13/22 at 7:44 PM and at 5:00 PM a phone call was made to the Surgeon. Surveyor was not able to leave messages. An interview was conducted on 5/17/22 at 4:25 PM., with LPN (License Practical Nurse, wound care nurse/Assistant Director of Nursing) #3 concerning Resident #339. She stated, It (SACRUM) was first identified as unstageable. It progressed and we had to debride it. I did some of her wound care. It showed no signs of infection after the first surgical debridement. For preventive measures she used a specialty mattress starting 12/10/21. We medicated her before wound care. She was turned and repositioned. An interview was conducted on 5/18/22 at 10:00 AM with the complaintant concerning Resident #339. She stated, The hospital surgeon made a referral to us and he indicated that he had to perform two surgeries on patient's sacral area due to having a large infected wound. The two surgeries resulted from infection of the wound to the bone. My investigation found she had no wounds on her body until December 3rd. (2021) She was bedridden and had physical therapy from her bed. She never got out of bed. She was put on hospice. Her husband would sit with her for hours. The wound nurse (LPN #3) would only see her when the outside Wound Nurse Practitioner came in. An interview was conducted on 5/18/22 at 11:15 am with CNA (Certified Nurse's Aide) #7. Concerning Resident #399. She stated, A few days after she came she complained that her butt hurt. We would get her off her side. When I came back from being off, she had an area on her butt. I reported it to the nurse. That nurse no longer works here. The wound nurse came every week. She was not ambulatory and could not make her needs known. She had good days and bad days. I turned and reposition her every two hours. LPN #13, who was the nurse CNA #7 alerted about the area on Resident #339, was called twice throughout the survey. Voice messages were left with no return call. On 5/19/22 at 1:35 AM., an interview was conducted with RN (Registered Nurse) #1. She stated, I turned her every 2 hours due to the wound on her bottom. She was not able to make her needs known. The wound on her bottom was acquired at the facility. I didn't have to do anything with her wound because I worked the 7 pm -7 am shift. We had an investigation here earlier. I didn't find anything unusual with her vitals. I thought it was odd that she was smiling. I never got to see the wound. If it was soiled I would have changed it and seen it but I didn't have the opportunity. On 05/20/2022 at approximately 3:45 p.m., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information but no additional information was provided. 3. The facility staff failed to identify a sacral wound pressure ulcer prior to advancing to an unstageable pressure ulcer measuring 5 centimeter (cm) x 5 cm x 2 cm for Resident #291. The sacral wound was infected requiring antibiotic therapy and surgical debridement (removal of dead tissue), which constituted harm. Resident #291 was originally admitted to the facility on [DATE]. Diagnosis for Resident #291 included but are not limited to Parkinson disease and muscle weakness. Resident #291's admission Assessment (14-day) with an ARD of 03/19/22 coded Resident #291 Brief Interview for Mental Status (BIMS) scored a 99 indicating short and long term memory problems and severe cognitive impairment - never/rarely made decisions. Resident #291 was coded total dependence of two with toilet use, bed mobility and bathing, total dependence of one with dressing, personal hygiene and eating and for Activities of Daily Living (ADL). Under section H - (Bladder and Bowel) was coded for always incontinent of bladder and bowel. Under section G0400 - Functional Limitation in Range of Motion (ROM) coded Resident #291 with no impairment to her upper and lower extremity. Resident #291 was coded as having no mood, rejection of care or behavioral problems. Resident #291's admission Assessment (14-day) with an ARD of 03/19/22. Under section (M0150) at risk for developing pressure ulcers was coded yes, under section (M0210) for unhealed pressure ulcers was coded yes and under section (M0300) for having current number of unhealed pressure ulcer at each stage present upon admission or reentry into the facility was coded for stage II pressure ulcer. Under section (1200) for skin, ulcer treatments were coded for having pressure reducing device for bed and pressure ulcer wound care. Resident #291's person-centered care plan initiated on 03/21/22 identified the resident has a pressure ulcer in her sacral area, at risk for further skin breakdown related to incontinence and impaired mobility. The goal set for the resident by the staff was that the resident will remain free of new skin breakdown through next review date. Some of the interventions/approaches the staff would use to accomplish this goal is to follow facility policies/protocols for the prevention/treatment of skin breakdown, assess/record/monitor wound healing, measure length, width and depth where possible, assess and document status of wound perimeter, wound bed and healing progress, specialty mattress and report improvements and declines to the physician and administer treatments as ordered and monitor for effectiveness. The person-centered care plan with a revision date of 04/01/22 identified Resident #291 on antibiotics for a sacral wound infection. The goal set for the resident by the staff was that the resident will show signs of healing and remain free of complications related to infection. One of the interventions/approaches the staff would use to accomplish this goal is to administer medications as ordered, monitor/document for side effects and effectiveness. A Braden Risk Assessment Report was completed on 3/15/22. The resident scored a 09 indicating at high risk for the development of pressure ulcers. The assessment coded under sensory perception very limited and responds only to painful stimuli; cannot communicate discomfort except by moaning or restlessness or has a sensory impairment which limits the ability to feel pain or discomfort over ½ of the body. Under moisture was coded skin is occasionally moist, requiring an extra linen change approximately once a day and coded bedfast under activity. The skin/wound admission note dated 03/10/22 indicated Resident #291 had a stage II sacral ulcer measuring 2.0 cm x 1.0 cm x 0.2 cm with very dark skin, nonblachable measuring (15 cm x 9 cm) surrounding the sacral ulcer. The note indicated that Resident #291's pressure ulcer will be evaluated by the wound Nurse Practitioner (NP) during her next visit on 03/15/22. Resident #291 had a physician order dated 03/10/22 to apply an air mattress to the bed for wound prevention and an order dated 03/11/22, for a sacral pressure ulcer treatment to apply a foam dressing every Tuesday, Thursday and Saturday (day shift). A review of Resident #291's nurse's note revealed the resident was transferred to the hospital emergency room for evaluation for an elevated temperature on 03/14/22 at approximately 6:50 p.m., and returned on 03/15/22 at approximately 4:00 p.m. Further review of the nurses note revealed no new skin impairments noted since the last admission assessment on 03/10/22. The resident was readmitted to the nursing facility on 03/15/22. The readmission note under skin integrity revealed the same sacral pressure assessed at a Stage II. A skin/wound note dated 03/22/22 at 12:08 p.m., by the wound nurse License Practical Nurse (LPN #3) revealed the wound NP (WNP) went to assess Resident #291's sacral wound but the resident had pain with body movement, thus the WNP decided to assess Resident #291's sacral wound during her next onsite visit on 03/29/22. During the review of Resident #291's clinical record revealed there were no weekly wound assessments made by the facility licensed nurses of the sacral pressure ulcer for 19 days, after her admission to the facility. An interview was conducted with the WNP on 05/17/22 at approximately 3:06 p.m., I was in the facility on 03/15/22 to assess Resident #291's sacral ulcer, but the resident was discharged to the hospital during my onsite visit. The WNP stated, My first time evaluating Resident #291's pressure ulcer was on 03/29/22. The WNP said the wound was infected as evidence by the wound having a significant amount of slough with foul odor present and having significant pain over the sacral area when touched or palpated. Resident #291 was placed on routine pain medication as well as two rounds of antibiotic therapy to help fight the sacral wound infection. The wound was not cultured due to the location of the wound (sacral area) which put the wound culture at risk for cross contamination. The WNP's initial progress note of the sacral pressure ulcer on 03/29/22 revealed an unstageable ulcer measuring 5 cm x 5 cm x 2 cm. The progress note stated the sacral wound had a moderate amount of serosanquinous drainage, strong odor present with 90 percent (%) slough and 10 % dermis tissue. A new medication order was given for Augmentin (antibiotic) 500 mg/125 mg every 12 hours x 10 days for a sacral wound infection. A new treatment order was given to clean the sacral wound with Dakin's, Santyl on Dakin's gauze, and cover with foam dressing daily and as needed. The WNP progress note also stated pain is indicative of any movement, at rest she is comfortable. The WNP also offered further recommendations to turn and reposition per facility protocol, use of a low air loss mattress and to optimize nutrition. A WNP progress note dated 04/05/22 revealed the sacral wound pressure ulcer remained an unstageable measuring 5 cm x 5 cm x (?). The sacral wound had improved but remain with moderate amount of serosanquinous drainage, strong odor present with 90% slough and 10% dermis tissue. The wound was debrided removing thick slough tissue; pain was present with any movement. Resident #291 remained on antibiotic therapy for a sacral wound infection and continued with the current wound treatment, Dakin's, Santyl on Dakin's gauze, and cover with foam dressing daily and as needed. A review of the WNP's progress note dated 04/11/22 indicated that the wound visit was performed via telehealth with the wound nurse, License Practical Nurse (LPN #3). The sacral wound was deteriorating with moderate amount of purulent drainage, strong odor present with 90% slough and 10% dermis tissue. The wound measured by onsite nurse (LPN #3) measuring 6.5 cm x 5.5 cm x 2.5 cm. The progress note recommended to continue with current sacral wound treatment with Dakin's, Santyl on Dakin's gauze, foam dressing and change daily and as needed. A new antibiotic order was given for Clindamycin 600 mg by mouth every 8 hours for 21 days for a sacral wound infection. The wound NP progress note also stated pain is indicative of any movement, at rest she was comfortable. On 05/16/22 at approximately 2:25 p.m., an interview was conducted with LPN #1. LPN #1 was assigned to performed sacral wound care to Resident #291 on 03/26/22 (7a-7p shift). The LPN stated, I have never measured Resident #291's sacral pressure ulcer. The ulcer was being measured and monitored by LPN #3 and the wound NP. An interview was conducted with the Medical Director (MD) on 05/18/22 at approximately 11:33 a.m., who said all pressure ulcers were followed by (name of Wound Company.) The MD stated, Resident #291's sacral ulcer should have been monitored, assessed and measured on a weekly basis for signs of decline or improvement. The nurses should have been monitoring the sacral pressure ulcer during every wound care dressing change for a change in condition. Apparently, the nurses were not doing a full wound assessment for change in condition because a pressure ulcer cannot go from a stage II to an unstageable requiring debridement overnight. The changes in the wound should be been addressed before the wound was identified as an unstageable pressure ulcer. The extra nutritional element recommended by the dietitian could have help with the wound healing of the sacral pressure ulcer. An interview was conducted with LPN #9 on 05/19/22 at approximately 10:44 a.m. The LPN was assigned to perform sacral wound care to Resident #291 on 03/19/22 (7a-7p shift). The nurse said an open area was noted to the sacrum with shearing/excoriation to the periwound. The LPN stated, I only do the resident's treatment not the monitoring or measuring of the wound that was being done by the wound NP or LPN #3 on a routine basis. A phone interview was conducted with LPN #12 on 05/16/22 at approximately 6:29 p.m. The LPN was assigned to perform sacral wound care to Resident on 03/22/22 (7a-7p shift). The LPN said the sacral wound appeared larger in size but I did not measure or document the change in condition of the sacral wound. The LPN stated, The wound NP and LPN #3 were assessing and monitoring Resident #291's sacral ulcer every week. A dietary/nutrition note dated 03/18/22 at 9:56 a.m., revealed Resident #291 having a suspected deep tissue injury (SDTI) to the left and right heel and a stage II pressure ulcer to the coccyx/sacral area per 03/10/22 (skin assessment). Recommendations were made for fortified foods with meals due to poor oral intake of meals, provide texture-appropriate calorie-dense snacks three times a day between meals due to poor oral intake and thickened house shake (120 mL), pudding / fortified pudding. A Dietary/Nutrition note dated 04/08/22 at 12:33 p.m., revealed the nutritional recommendations made on 03/18/22 were never addressed for fortified foods with meals due to poor oral intake of meals, provide texture-appropriate calorie-dense snacks three times a day between meals due to poor oral intake and thickened house shake (120 mL), pudding / fortified pudding. An interview was conducted with the RD on 05/17/22 at approximately 4:41 p.m., who stated, The nutrition recommendations made for Resident #291 on 03/18/22 and again on 04/08/22 were never addressed. The RD said the extra calories would have given extra protein that's needed to help with healing Resident #291's sacral pressure ulcer. The nursing note dated 04/11/22 at approximately 6:23 p.m., revealed Resident #291 with Altered Mental Status (AMS), tremors and had vomiting during dinner. A new order was given to send Resident #291 to the emergency room (ER) for evaluation and treatment. A review of the hospital records revealed that Resident #291 presented in the Emergency Department (ED) on 04/11/22 from (name of nursing facility) for further evaluation due to Altered Mental Status (AMS) and vomiting. The ED indicated Resident #291 is lethargic, disoriented and is currently on antibiotic for an infected unstageable sacral wound. The wound is observed with a strong foul odor. The sacral wound was evaluated to be a FIST size with partial wet slough, fetid (having a heavy offensive smell-https://www.merriam-webster.com/dictionary) skin and obvious deep tunneling on perimeter. The ED report indicated the resident did not meeting the criteria for Systemic inflammatory response syndrome (SIRS), but had a concerning sacral wound and was referred for evaluation and treatments by the General Surgery. The resident was started on IV Vancomycin (antibiotic) and Zosyn (antibiotic) for empiric coverage of her large sacral decubitus ulcer. After the sacral wound was evaluated by the General Surgery, he felt the wound would benefit from debridement of the wound. On 04/12/22, Resident #291 was taken into the operating room (OR), and the sacral wound was debrided. After debridment the wound was assessed as a stage III decubitus ulcer with no exposed bone at this time. The recommendation was made for a wound VAC to improve the healing process for the resident. It was noted that the resident would also benefit from significant nutritional support and should be fed by staff by the facility. An interview was conducted with the Director of Nursing (DON) and wound nurse LPN #3 on 05/12/22 at approximately 10:00 a.m. The DON said Resident #291's sacral pressure ulcer should have been evaluated by the WNP or wound nurse, LPN #3 on a weekly basis. She stated, the weekly evaluation and monitoring was needed for early detection to determine if the wound is improving or declining. The wound nurse LPN #3 stated, I was not here on 03/17/22 and 03/24/22, when Resident #291 was supposed to have her sacral wound assessed and evaluated a changes in condition. The DON said the nurses should have been assessing and documenting changes on Resident #291's sacral pressure ulcer (description of wound bed, if drainage or odor present and size of the wound) with all changes reported to LPN #3 or the wound NP for evaluation to determine if wound treatment changes were needed. According to the DON, the stage II sacral wound treatment was appropriate when admitted to the facility on [DATE]. The treatment was for a foam dressing, change every 2 days. The DON said, When the wound deteriorated to an unstageable, the treatment should have been changed but it wasn't. The DON further stated, Due to the lack of documentation, there is no way to know when Resident #291's sacral wound deteriorated to the point it had advanced to an unstageable requiring debridement and antibiotic due to infection. A debriefing was held with the Administrator, Director of Nursing and Corporate support on 05/19/22 at approximately 2:00 p.m. Resident #291's issues was presented again. No additional information was forthcoming. Definitions: -Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/). -Pressure Injury - Stage 2 (Partial-thickness skin loss with exposed dermis_ Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages). Pressure Injury - Stage 3 (Full-thickness skin loss) Full-thickness