**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility did not ensure 2 (R147 & R350) of 3 residents reviewed with pressure injuries received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new pressure injuries from developing. * R147 developed skin concerns of MASD (moisture-associated skin damage) noted at the facility on 10/28/24. There were no care plan revisions implemented and no comprehensive assessments completed. On 11/04/24, while at the hospital, R147 was found to have an infected sacral wound requiring debridement. After debridement, the wound was classified as a stage 4 pressure injury (PI.) Upon return to the facility on [DATE], the facility failed to comprehensively assess R147's pressure injuries, did not assess the appropriateness of the type of wheelchair cushion and mattress being used, and did not implement interventions to promote healing of PIs. The facility's failure to comprehensively assess and implement an individualized plan of care for R147's pressure injuries created a finding of immediate jeopardy that began on 10/28/24. Surveyor notified the Nursing Home Administrator (NHA)-A, Director of Nurses (DON)-B, and Regional Nurse Consultant (RNC)-N of the immediate jeopardy finding on 2/17/25 at 4:20 PM. The immediate jeopardy was removed on 2/20/25. The deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan and as evidenced by: * R350 was assessed for being at risk for pressure injury. Preventative interventions were not observed being implemented. Findings include: The facility's policy and procedure Pressure Injury Prevention and Managing Skin Integrity dated 12/5/24 documents that preventative measures are put in place to reduce the occurrence of pressure injuries. The procedures include: 2. Identifying Interventions and Care Plan: (a.i.) The care and intervention for any identified skin breakdown or wound is intended to prevent any further advancement of the wound or additional skin breakdown. (a.i.1.) This will be in collaboration with the Interdisciplinary Team regarding the presence of breakdown and the intervention plan. (a.i.3.) The identification of risk factors present or acquired that compromise skin integrity will be considered. (2.b.i.) The Care Plan development will consider: (a.i.2.) Cognitive changes or impairment of the individual. (a.b.3.) Current state of skin integrity and personal hygiene practices of the individual that impact skin health. 3. Skin Checks: (3.a.) Skin check will be done upon admission, readmission or as clinically indicated. 4. Weekly Wound Rounds: (4.a.) Upon identification of abnormal skin findings, a licensed nurse will complete a skin assessment. Individual with abnormal skin concern(s) will be added to weekly wound rounds. (4.b.iii.) Update the Care Plan with any new interventions as applicable. 1.) R147 was readmitted to the facility from the hospital on 3/8/2024, with diagnoses including diabetes, congestive heart failure, and peripheral vascular disease. care plan related to a closed right ankle fracture initiated on 2/6/24 documents under the Goal section: The resident to remain free from skin breakdown due to incontinence and brief use. The initiated date is 2/6/24, and goal date of 3/11/25, and includes these interventions: - 2/6/24 barrier cream as ordered. - 2/6/24 monitor skin for signs of skin breakdown related to incontinence. - 2/15/24 clean peri-area with each incontinence episode. R147's Alternation in Nutrition due to Inadequate Intake care plan dated as initiated on 3/15/24 documents under the Goal section: Weight to stabilize 190 +- 10# (pounds), wound show signs and symptoms of healing, tolerate diet intake of greater than 75%, labs within MD (Medical Doctor) range, and resident will accept supplements: - 3/15/24 provide regular diet, additional protein via prosource twice a day and 6 ounces mighty shake twice a day, meals in dining room, treatment to wounds, confer with wound team, monitor intake, labs, weight, weigh per policy, staff assist/encourage at meals. R147's Quarterly Minimum Data Set (MDS) assessment completed on 9/13/24 documents that R147 had 1 unstageable pressure injury at the time of the assessment and is at risk for the development of pressure injuries. R147 is frequently incontinent of bowel and bladder and requires staff assist with activities of daily living. R147's skin assessment completed by Wound Nurse Practitioner (WNP)-O on 10/28/24 documents: Chief complaint is wound to the right heel, skin tear to left wrist/hand, wounds to R (right) posterior thigh and L (left) buttock. Subjective assessment the Patient is seen resting in bed. Staff report he has new areas of breakdown to buttocks. He denies pain, fevers or chills. He is eating and sleeping well. Medications electronic health record (EHR) reviewed. Diagnoses that could affect wound healing are type 2 diabetes, afib (atrial fibrillation), heart failure (HF), hyperlipidemia, hypertension, (peripheral vascular disease) PVD, hypothyroidism, on Warfarin. Interventions in place are heel offloading with heel offloading boots or pillows as tolerated by patient, turn and reposition every 2-3 hours with assistance as needed, dietary collaboration, physical therapy and occupational therapy (PT/OT) collaboration; Physical Examination: +Right posterior heel (stage 3 pressure ulcer) Full thickness wound measuring 4.5 x 2.5 x 0.1 centimeter (cm). 100% granular tissue. Moderate amount of serous drainage noted, no odor. Peri wound without redness or warmth to indicate infection. Wound status: improving. The Plan: Cleanse with normal saline NS or wound cleanser then apply Hydrofera Blue to the base of the wound, cover with ABD (abdominal) pad and secure with kerlix. Change daily and prn (as needed). Continue offloading with Prevalon Boot. +Right thigh moisture associated skin damage (MASD) Full thickness wound measuring 1.5 x 1.5 x 0.1 cm. 100% granular tissue. Scant serosanguineous drainage. Peri-wound is dry, intact. No sign/symptoms (s/sx) infection. Status is a new area. The Plan is happy butt cream three times a day (TID) and as needed (PRN). +Left buttock (MASD) Full thickness wound measuring 0.5 x 0.8 x 0.1 cm. 100% granular tissue. Scant serosanguineous drainage. Peri-wound is moist, fragile, intact. No s/sx infection. Status is a new area. The Plan is happy butt cream TID and PRN. The Wound Assessment Summary is a pressure ulcer of right heel, stage 3 (not new). The new skin impairment areas are irritant contact dermatitis due friction or contact with other specified body fluids. Reviewed medical records. Discussed plan of care with nurse. Protein supplementation per dietary. Continue aggressive offloading, Prevalon boot to be worn at all times (cannot be used with transfers). Discussed results of X-ray and arterial studies with wife previously. At this time she will think about possible referral to vascular as patient with severe peripheral artery disease (PAD) which will compromise healing. Magnetic resonance imagining (MRI) is also recommended as the X-ray cannot exclude osteo - wife would like to hold off on the MRI at this time and think about getting an MRI in the future. Wound care re-evaluation in 1 week. Surveyor noted that there were new skin impairment areas for R147 that were a result of moisture association that were identified in R147's 10/28/24 assessment. Surveyor noted that there is no documentation of any revisions in the plan of care to promote healing. There were no changes to R147's plan of care for skin impairment and bladder incontinence care despite the new skin impairment areas that were identified in the above assessment. On 2/13/25, at 12:26 PM, Surveyor interviewed WNP-O via telephone. WNP-O assessed R147 on 10/28/24 and did not see any open skin areas. WNP-O stated the skin areas on 10/28/24 were from moisture. WNP-O stated they ordered zinc paste for the moisture areas. WNP-O would expect diligent incontinence care. WNP-O does not personally document in R147's plan of care. WNP-O informed Surveyor that WNP-O was not notified of any open areas prior to 11/4/24. WNP-O informed Surveyor that WNP-O relies on the facility to determine types of wheelchair and air mattresses that residents use for off-loading and pressure relief. Surveyor reviewed WNP-O's wound assessment plans. Surveyor informed WNP-O that there were no documented changes with R147's skin assessment on 10/28/24 and 12/2/24. WNP-O stated there was nothing to change in the plan of care. WNP-O stated R147 can be resistant to positioning and doesn't tolerate turning. WNP-O stated WNP-O goes to various facilities and that WNP-O leaves it up to the facility to determine what type of pressure relief intervention devices are used. Surveyor noted that WNP-O's assessments document just an air mattress (not specifics), continue aggressive off-loading, protein supplement per dietary, and Prevalon boots. WNP-O stated that WNP-O relies on the facility to develop an individualized plan of care. On 2/13/25, at 8:12 AM, Surveyor interviewed Director of Nurses (DON)-B. DON-B stated facility staff observed R147's skin on 10/28/24 with the Wound Nurse. DON-B stated there was not an open area that was observed. DON-B stated facility staff were not aware of an open area before 11/4/24. DON-B stated they would attempt to locate for skin sheets for R147. DON-B provided Surveyor with a Skin Sheet dated 10/15/24. Surveyor noted that there were no Skin Sheet or Skin Evaluations completed between 10/28/24-11/4/24. Despite R147 developing pressure injuries, Surveyor noted that there was no documentation of any changes to R147's dietary plan, no changes to R147's incontinent care/product use, and no changes in R147's turning and repositioning timeframes. R147 went to a scheduled imaging appointment on 11/4/24. At the start of R147's appointment, R147 had a change in condition and was sent directly to the emergency room (ER). While in the ER, a comprehensive assessment was completed. The assessment documented there was a pressure injury on the sacrum of R147 that was odorous, with tan drainage, and appeared infected. R147's hospital records included photographs and pre-debridement measurements of the sacral wound that were 6 cm (centimeters) by 6 cm and staged as a stage 4 pressure injury. The post-debridement assessment documents measurements of 6 cm x 8 cm x 2 cm in the deepest dimension. The assessment documents: Coccygeal ulcer with purulent drainage status post (s/p) debridement - 11/4 superficial coccyx wound culture with multiple organisms isolated and 4+ Bacteroides fragilis group. Acute care surgery consulted for coccyx wound with malodor and necrotic tissue on exam and patient ultimately underwent excisional debridement of sacral decubitus ulcer on 11/5/24; operative note reports tissue from wound bed was excised until healthy bleeding was noted at the wound base; no specimens were collected intraoperatively for culture. 11/14 computed tomography (CT) imaging showed appropriately 3.7 x 3 x 6 cm sacral decubitus ulcer/wound without fluid collection. Inpatient wound care team is following, see photos in chart of wounds. Continue local wound cares regularly. Surveyor noted that from 10/28/24 to 11/4/24 there is no facility documentation related to the sacrum pressure injury discovered on R147 on 11/4/24 in the ER. R147 remained in the hospital for multiple medical reasons and was readmitted to the facility on [DATE]. R147's Admit/Readmit Screener completed on 11/25/24 documents under the Skin section: - Unstageable pressure injury to the right heel measuring 2 cm x 3 cm x .1 cm. - Stage 4 pressure injury to the sacrum measuring 5 cm x 5 cm x 1 cm. Surveyor noted that the Admit/Readmit screener completed on 11/25/24 did not include any characteristics, along with percentages, describing the two wound bed or periwound areas. Surveyor noted that there is no documentation of any revisions that were completed to R147's plan of care. Surveyor noted that R147's pressure injuries were not comprehensively assessed when R147 was readmitted to the facility, as the above Admit/Readmit screener did not include wound bed characteristics, along with percentages or a description of the periwound areas on R147. On 2/13/25, at 7:29 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-R. LPN-R stated that R147 is a PM bath and that the CNAs fill out a bath sheet and the nurse does a skin evaluation at this time and that bath sheets are scanned into the EHR. LPN-R informed Surveyor that LPN-R saw R147 before they left the faciity on [DATE]. LPN-R stated R147 had a small open area on the sacrum, and it was red. LPN-R stated that the facility was putting zinc on the area and LPN-R described the area to look like a straw opening. LPN-R could not recall the wheelchair that was used for transporting R147 before he left. During this interview, R147's spouse was wheeling R147 into the dining room and informed Surveyor that the wheelchair that R147 was currently in was the wheelchair used to transport R147. Surveyor noted that the wheelchair R147 was sitting in had a wheelchair cushion in place. Surveyor was unable to locate any documentation that R147's pressure injuries were assessed until 12/2/24, or 7 days after R147 was readmitted to the facility, one week after R147 was readmitted to the facility from the hospital on [DATE]. R147's comprehensive wound assessment dated [DATE] and completed by WNP-O documents: Return from leave assessment, has wound to right heel and sacrum. Subjective assessment: patient is seen resting in bed, recently returned from prolonged hospitalization. During hospitalization, sacral ulcer was debrided on 11/5. Was treated with intravenous (IV) antibiotics for concern for wound infection during hospitalization. R147 is seen resting in bed today. R147 complains of pain with exam. Staff report no fevers, chills or other concerns today. The current Medications in the EHR were reviewed. The diagnoses that could affect wound healing include type 2 diabetes, afib (atrial fibrillation), HF, hyperlipidemia, hypertension, PVD, hypothyroidism, on Warfarin. Interventions in place are heel offloading with heel offloading boots or pillows as tolerated by patient, turn and reposition every 2-3 hours with assistance as needed, dietary collaboration, PT/OT collaboration. Physical Examination: +Right posterior heel (unstageable pressure ulcer) Full thickness wound measuring 4.5 x 3.5 x 0.1 cm. 80% slough, 20% granular tissue. Moderate amount of serosanguineous drainage noted, no odor. Peri wound without redness or warmth to indicate infection. This was present on readmission. Plan: Cleanse with NS or wound cleanser then apply saline moistened Hydrofera Blue to the base of the wound, cover with ABD pad and secure with kerlix. Change daily and prn. Continue offloading with Prevalon Boot. +Sacrum (stage 4 pressure injury) Full thickness wound measuring 4 x 3.5 x 3.6 cm. 100% granular tissue. Moderate serosanguineous drainage. Peri-wound is moist, fragile, intact. No s/sx infection. This was present on readmission. Plan: Gently pack with saline moistened hydrofera blue. Cover with bordered foam. Change daily and PRN The Summary Assessment is an unstageable pressure injury on the right heel, stage 4 pressure injury on the sacrum, and moderate protein-calorie malnutrition. Reviewed medical records. Discussed plan of care with nurse. Protein supplementation per dietary. Continue aggressive offloading, Prevalon boot to be worn at all times (cannot be used with transfers). Wound care reevaluation in 1 week. Patient with multiple comorbidities and multiple risk factors for developing and worsening of pressure injuries. Interventions consistent with individual needs, goals and standards of care have been implemented. Revisions to interventions were made as appropriate. Wound is considered unavoidable, and patient is at risk for further worsening or development of additional areas. Surveyor noted that there were no revisions to R147's plan of care that individualized pressure relieving interventions to promote healing. Surveyor was unable to locate any documentation of an assessment that described what an appropriate wheelchair cushion for R147 was to be used due to R147's pressure injury development. Surveyor was unable to locate any documentation of an assessment as to what type of air mattress was appropriate for R147 due to R147's pressure injury development. Despite R147 developing pressure injuries, Surveyor noted that there was no documentation of any changes to R147's dietary plan, no changes to R147's incontinent care/product use, and no changes in R147's turning and repositioning timeframes. R147's Significant Change in Status completed on 12/2/24 documents 1 unstageable pressure injury and 1 stage 4 pressure injury present from R147's readmission to the facility. The MDS documents that R147 is frequently incontinent of bowel and bladder and requires staff assist with activities of daily living. R147's Care Area Assessment for Pressure Injuries documents continue with plan of care-ambitious goal to heal wounds. Immediate goal to keep risk in balance and provide interventions to reduce risk. Surveyor noted that there were no revisions to the plan of care for nutrition with the new onset(s) of R147's skin impairments. R147's current wound assessment completed by WNP-O on 2/10/25 documents: +Right posterior heel (stage 3 pressure ulcer) Full thickness wound measuring 1.1 x 1.3 x 0.1 cm. 100% granular tissue. Moderate amount of serosanguineous drainage noted, no odor. Peri wound without redness or warmth to indicate infection. The wound status has improved. There is no change in the plan of care. +Sacrum (stage 4 pressure injury) Full thickness wound measuring 3.5 x 2.8 x 2.5 cm. Undermining 9-2, 2 cm @ 12 o'clock. 100% granular tissue. Moderate serosanguineous drainage. Peri-wound is moist, fragile, intact. No s/sx infection. The wound status has declined. There is no change in the plan of care. On 2/10/25 at 9:52 AM, Surveyor observed R147 lying in bed. R147 was on their back with the bed in a semi-Fowler_position (head of bed elevated 30-45 degrees.) R147 was on a low air loss mattress set at 10-minute cycles. The bed coverings were over R147's feet. Per the facility pressure injury list that was provided to Surveyor, along with the roster matrix, R147 was reported to have a stage 3 and stage 4 pressure injury. 10 On 2/13/25 at 8:20 AM, Surveyor interviewed R147's Power of Attorney for Healthcare (POAHC)-S. POAHC-S stated R147 had a very small area on their bottom at the facility. POAHC-S stated staff used zinc on it. POAHC-S stated the facility should have treated R147's open area before it got bigger. POAHC-S stated R147 used their current wheelchair for transport and that there is not another wheelchair used by R147. Surveyor observed R147 in his wheelchair in the dining room and Surveyor observed the wheelchair to have a cushion in place. On 2/13/25, at 9:56 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-Q. CNA-Q informed Surveyor that CNA-Q recalls that R147 had a small open area on the buttocks. CNA-Q stated that R147 is a check and change for incontinence. CNA-Q stated R147 can use the urinal at times and ask for a bed pan. CNA-Q could not recall any changes in the air mattress or wheelchair cushion of R147. On 2/11/25, at 10:30 AM, Surveyor interviewed Registered Nurse (RN)-I who completes resident weekly wound assessments with WNP-O. RN-I stated RN-I was on maternity leave from 9/12/24 to 12/10/24. RN-I became the facility's wound nurse when she returned on 12/10/24. RN-I informed Surveyor that with new admissions and readmissions, staff complete the screener information, and that a physical skin check is completed by the admission nurse or floor nurse. RN-I stated that nursing staff will get the discharge orders for any skin concerns and that at the end of the week, RN-I reviews the documentation for wound concerns. RN-I stated that residents with wounds are added to the weekly wound rounds that are completed on Monday with WNP-O. RN-I stated WNP-O documents in the progress notes and that they take a picture of the wounds and generate it into the Point Click Care Skin Evaluation (part of the EHR). RN-I stated that WNP-O documents the initial wound assessment and that RN-I finishes it up. RN-I informed Surveyor that the admission/floor nurse only measures the wounds and makes sure that a treatment is in place. RN-I stated that the admission/floor nurses also put in the initial care plan for any new or readmitted resident. RN-I stated that when a new open skin area on a resident develops, RN-I would update the care plan for that resident. RN-I stated that the facility has weekly meetings to review the plan of care of residents and that all nursing staff can go into the system to update the plan of care for a resident. On 2/11/25, at 2:20 PM, Surveyor observed R147 receive wound care by Assistant Director of Nurses (ADON)-G and Nurse Extern NE-P. R147 was in bed and R147's room had a strong unpleasant odor. The ADON-G is not familiar with the development of R147's pressure injuries. The Nurse Extern (NE)-P assisted in the positioning of R147 in bed. R147 had pressure relief heel boots on, and the air mattress was set to low air loss at 10-minute cycles. Surveyor observed the pressure injury treatment to the right heel was completed as ordered and correlated with wound assessment. The sacrum wound dressing was saturated with urine and drainage. The dressing date was smeared due to the extent of saturation. There was an unpleasant odor. R147 had an incontinence brief on in bed. ADON-G completed the wound treatment as ordered to the sacrum. ADON-G and NE-P provided incontinence care and changed R147's brief. ADON-G stated they had not seen R147's pressure injuries prior to completing the wound treatments. ADON-G is also the Unit Manager for R147. ADON-G stated that residents have weekly skin checks with baths and that skin evaluations are completed and scanned into the EHR. On 2/13/25, at 1:39 PM, Surveyor interviewed Registered Dietitian (RD)-DD. RD-DD stated they have started, and stopped, nutritional supplements for R147 due to weight changes. RD-DD stated the company had a brand change in their protein supplements. RD-DD informed Surveyor that RD-DD has assessed R147's protein needs and feels they are being met. RD-DD stated RD-DD did not change anything when R147 returned from the hospital on [DATE] with a stage 4 pressure injury. RD-DD stated R147 did not receive any additional vitamin supplements. RD-DD stated there has been no discussion about vitamins and minerals for wounds for R147. RD-DD informed Surveyor that R147 is already on a multivitamin. Surveyor noted that there were no changes in R147's nutritional management care plan despite R147 developing pressure injuries. WHEELCHAIR CUSHION INTERVENTION On 2/13/25, at 11:18 AM, Facility Service Manager (FSM)-L provided Surveyor the manufacturer recommendations for the wheelchair cushion that is in R147's wheelchair. The wheelchair cushion used by R147 is an Express Comfort Foam Flat. The product information documents it is for comfort and support. The product information does not document use for a stage 4 pressure injury. On 2/17/25, at 8:01 AM, Surveyor interviewed ADON-G about R147's wheelchair cushion. The ADON-G stated the wheelchair cushion is probably from physical therapy. On 2/17/25, at 9:06 AM, Surveyor interviewed Rehab Director (RD)-T. RD-T stated the wheelchair cushions don't necessarily come from therapy. RD-T informed Surveyor that there is a closet where anyone can take one to use. RD-T stated they will look for an assessment for the wheelchair cushion used in R147's wheelchair. On 2/17/25, at 9:45 AM, RD-T informed Surveyor that therapy does not have an assessment on the wheelchair cushion currently used by R147. On 2/17/25 at 10:02 AM, Surveyor interviewed WN-I. WN-I stated they do not coordinate, or place, the wheelchair cushions used by residents. Surveyor was unable to locate any assessment that described what an appropriate wheelchair cushion for R147 was to be used due to R147's pressure injury development. AIR MATTRESS INTERVENTION On 2/17/25, at 8:01 AM, Surveyor interviewed ADON-G. ADON-G stated the air mattress is programmed by the delivery company. ADON-G stated that the facility does not program the air mattress. On 2/17/25 at 8:24 AM, ADON-G shared with Surveyor that the air mattresses in the facility are programmed by the delivery company. On 2/17/25, at 9:04 AM, ADON-G stated R147's current air mattress was delivered on 8/16/24. The ADON-G provided Surveyor the company invoice of the air mattress delivery. On 2/17/25, at 9:14 AM, Surveyor called the air mattress Contractor-U regarding R147's air mattress. Contractor-U informed Surveyor that upon delivery, they just input the weight of the resident. Contractor-U stated the air mattress delivery staff do not program the minute cycles or anything else. Contractor-U stated the default weight is 150 pounds if there was no weight provided. On 2/17/25 at 10:02 AM, Surveyor interviewed WN-I. WN-I stated they are not involved in setting up air mattresses for residents. WN-I stated that floor staff are supposed to make sure that air mattresses are on and functioning correctly. R147 documented weights in the EHR are: - 8/25/2024: 233.0 Lbs. - 12/1/2024: 189.5 Lbs. - 1/15/2025: 219.4 Lbs. - 2/5/2025: 200.2 Lbs. Surveyor noted that R147's weights have fluctuated. Despite the weight changes in R147, Surveyor was unable to locate any documentation that R147's air mattress was adjusted to accommodate R147's weight changes. Despite R147 developing pressure injuries, Surveyor noted that there was no documentation of any changes to R147's dietary plan, no changes to R147's incontinent care/product use, and no changes in R147's turning and repositioning timeframes. Surveyor was unable to locate any assessment of what type of air mattress was appropriate for R147 due to R147's pressure injury development. Surveyor noted that there were no revisions to R147's plan of care on 10/28/24 when R147 had increased skin moisture. Surveyor was unable to locate any documentation prior to 11/4/24 that R147's stage 4 pressure injury was assessed and treated by the facility. Surveyor was unable to locate a comprehensive pressure injury assessment upon R147's return to the facility on [DATE]. Surveyor noted that a comprehensive pressure wound assessment was completed 7 days after R147 was readmitted to the facility. Surveyor noted that R147's nutritional management did not change despite R147 being readmitted to the facility with a newly acquired stage 4 pressure injury. Surveyor noted there is no documentation of R147's refusing preventative turning and or repositioning. Surveyor was unable to locate any documentation of revisions to R147's turning/positioning timeframes with R147's onset of pressure injury and increased skin moisture. The facility's failure to comprehensively assess and implement an individualized plan of care for R147's pressure injuries led to serious harm for R147, thus leading to a finding of immediate jeopardy that began on 11/4/24. Surveyor notified the Nursing Home Administrator (NHA)-A, Director of Nurses (DON)-B and Regional Nurse Consultant (RNC)-N of the immediate jeopardy finding on 2/17/25 at 4:20 PM. The immediate jeopardy was removed on 2/20/25, when the facility completed the following interventions: - Resident continues to reside in facility and has resolving pressure injury to right heel and stable stage four PI to sacrum - goals of care are currently being met. - Skin sweep completed 2/17/25 to ensure all skin altercations have been identified, documented and have appropriate treatments and interventions in place. - Care plan sweep completed by 2/19/25 to ensure all interventions are individualized (guided by skin sweep results). - All staff educated on standard skin protocol before next shift to work. This includes skin integrity monitoring and change expectations for nurses, aides, dietary and therapy. - All licensed nurses educated on standard skin protocol, and comprehensive wound documentation expectations - including upon admit and recognition of a new skin altercation the licensed nurse will: alert provider and obtain any needed treatment orders, document comprehensive skin observation, interventions to be placed and documented as appropriate for resident, update DON or designee, update POA if applicable; and complete Risk Management for any new skin altercation - before next shift to work, competency quiz to validate understanding. - All nurse managers educated on PI (pressure injury) CEP and comprehensive wound system- this will include daily in stand-up clinical leader to review progress notes, RM, 24 hours boards to ensure all new skin altercations addressed appropriately including assessment and implementation of support surface, along with update to RD and wound team, to ensure compliance of F686. Education provided on 2/18/2025. - Facility skin sweep done by midnight 2/17/25. - All skin care plans updated and individualized per skin sweep observations completed by 2/20/25 which included support surface assessments and updates. - Weekly comprehensive wound rounds to continue with RN and NP. - Skin care plans will be reviewed weekly with clinical IDT focus meeting to ensure support surface interventions, and weekly wound rounds to validate appropriate support surfaces in place. - Standard Skin Protocol reviewed and updated 2/17/25. - Skin policy and procedure reviewed. - Updated and reviewed citation with Medical Director. - DON or designee will audit five residents weekly for comprehensive skin system compliance. Results to QAPI (Quality Assurance and Performance Improvement). The deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as evidenced by the following: 2.) R350 was admitted to the facility on [DATE] with diagnoses that include Alzheimer's disease, Dementia, Pressure ulcer of right buttock, and Pressure ulcer of left heel. R350's admission Minimum Data Set assessment was in the process of being completed. R350's Brief Interview for Mental Status (BIMS) assessment dated [DATE], documents a score of 4, indicating that R350 is severely cognitively impaired. R350's admission Section GG assessment dated [DATE], documents R350 requires substantial/maximum assist for bed mobility and R350 is dependent for transfers. R350's Braden Scale Assessment used for predicting pressure ulcer risk dated 2/6/25, documents that R350 is at risk for pressure injuries. R350 has an activated Power of Attorney (POA). R350's hospital Wound/Skin Nurse Specialist Consult note dated 2/3/25 documents, in part: [R350] has a full thickness, stage 3 pressure injury to right buttock that measures 8 x 8 x 0.1 centimeters (cm) and a stage 1 pressure injury to R350's left heel that measures 2.5 x 2.5 cm. R350's Hospital Discharge (D/C) summary dated 2/6/25 documents, in part: . discharge diagnoses: Pressure ulcers . You need to follow wound care instructions . Wound Care treatment to [Right] buttock: 1. Cleanse wound with Puracyn Plus, saturate gauze and soak 5 minutes. 2. Pat dry with gauze. 3. Apply 3M Cavilon barrier to peri-wound skin. 4. Apply [NAME] Tul A over wound. 5. Cover with Sacral Mepilex. [Registered nurse (RN)] to assess wound and change dressing three times a week. [NAME] dressings with date applied. Wound Care treatment to heels: 1. Cleanse wound with Puracyn Plus, saturate gauze

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** [NAME] is the IJ Level example Resident #27 Pressure Ulcer/Injury 01/03/24 12:56 PM Per 12/6 MDS BIMS 3 Understand/understood Functional assess: needs partial assistance to complete tasks Skin asses no pressure wounds PROGRESS NOTE: 12/16/2023 23:56 eINTERACT SBAR Summary for Providers Situation: The Change In Condition/s reported on this CIC Evaluation are/were: Change in skin color or condition At the time of evaluation resident/patient vital signs, weight and blood sugar were: - Blood Pressure: BP 141/73 - 12/17/2023 01:08 Position: Lying r/arm - Pulse: P 69 - 12/17/2023 01:07 Pulse Type: Regular - RR: R 20 - 12/17/2023 01:07 - Temp: T 97.8 - 12/17/2023 01:07 Route: Axilla - Weight: W 103.6 lb - 12/8/2023 23:52 Scale: Wheelchair - Pulse Oximetry: O2 97.0 % - 12/12/2023 23:13Method: Room Air - Blood Glucose: Resident/Patient is in the facility for: Post Acute Care Primary Diagnosis is: Relevant medical history is: Dementia Code Status: DNR Advance directives are: Resident/Patient had the following medications changes in the past week: Resident/Patient is on Coumadin/warfarin:No The result of last INR: Date: Resident/Patient is on anticoagulant other than warfarin: No Resident/Patient is on: Outcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were: - Mental Status Evaluation: No changes observed - Functional Status Evaluation: No changes observed - Behavioral Status Evaluation: - Respiratory Status Evaluation: - Cardiovascular Status Evaluation: No changes observed - Abdominal/GI Status Evaluation: - GU/Urine Status Evaluation: - Skin Status Evaluation: Pressure ulcer/injury - Pain Status Evaluation: Does the resident/patient have pain? Yes - Neurological Status Evaluation: Nursing observations, evaluation, and recommendations are:Rt heel reddened and blanchable, Left heel discolored and non-blanchable. Both areas painful during touch. Heel protectors were removed and floatedwith pillows related +2 pitting edema noted to Bilateral Feet. It is recommended to float patient heels while in bed, reposition q 2hr per patient tolerance and continue to monitor this matter until healed 01/02/24 01:28 PM 12/17/2023 19:29 Nurse's Note Note Text: Pressure sores to both heels.Heels floated with protectors in place.Change position q2h. CARE PLAN: • The resident has actual impairment to skin integrity DTI of the LT. heel Date Initiated: 12/18/2023 Revision on: 12/18/2023 • The resident will have no complications r/t DTI of the LT. heel through the review date. Date Initiated: 12/18/2023 Revision on: 12/18/2023 Target Date: 03/07/2024 • Encourage good nutrition and hydration in order to promote healthier skin. Date Initiated: 12/18/2023 LPN RN • Follow facility protocols for treatment of injury. Date Initiated: 12/18/2023 LPN RN • heel boots Date Initiated: 12/18/2023 CNA LPN RN • Identify/document potential causative factors and eliminate/resolve where possible. Date Initiated: 12/18/2023 LPN RN • Keep skin clean and dry. Use lotion on dry skin. Date Initiated: 12/18/2023 Revision on: 12/18/2023 CNA LPN RN • Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx of infection, maceration etc. to MD. Date Initiated: 12/18/2023 Revision on: 12/18/2023 CNA LPN RN • Obtain blood work such as CBC with Diff, Blood Cultures and C&S of any open wounds as ordered by Physician. Date Initiated: 12/18/2023 LPN RN • Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Date Initiated: 12/18/2023 LPN RN 01/03/24 01:47 PM Shawanna - CNA Round reddened area at center of heel bottom, left. Right heel - clear 01/03/24 09:22 AM up in wheel chair - Heel boots on - aductor on - per CNA after lunch will go in recliner - can see heels easier then 12-16 (saturday)SBAR done Rt heel reddened and blanchable, left heel discolored and non-blanchable by Lowonder [NAME] lpn 12-18 (monday)Lachiquita [NAME] ADON progress note r/t Lt heel 12-18 Weekly wound tool assessment completed (Wound - Weekly Wound Tool (Licensed Nurse) Complete Wound #1 900.0 lparker ) 12-18 care plan updated and orders for skin prep and heel boots added 01/04/24 08:49 AM Lowonder JohnsonLPN states PI was reported to her from another nurse - process is to let NP know and complete risk management and skin assessment, also DON and POA advised. She did not do process since another nurse told her she assumed they did. 01/04/24 11:20 AM Per ernesha, LPN: Staff nurse discovers measurements and skin only evaluation. Previous DON wanted to be notified. Multiple DON changes. Current DON, Every Monday [NAME] comes to assess. The DON will look at it. The floor nurse measures and does the skin only evaluation. The wound nurse [NAME] comes Monday and assesses all wounds, except surgical. Based on observation, record review, and interview, the facility did not ensure residents at risk for pressure injuries received care consistent with professional standards of practice to prevent pressure injuries from developing for 5 (R137, R40, R41, R27, and R18) of 8 residents reviewed for pressure injuries. *R137 was admitted to the facility on [DATE] after sustaining a right femur fracture following a fall at home. R137 had a Braden score of 11 indicating high risk for development of pressure injuries. R137 developed a skin tear and a reddened area on 10/25/23 and 10/30/23 respectively. The facility did not have a Care Plan to address bed mobility, repositioning, or incontinence until 11/8/2023, when R137 developed an unstageable pressure injury to the coccyx. There was not a comprehensive assessment of the pressure injury nor was the dietitian alerted to address dietary needs. On 11/06/23, the nurse practitioner (NP) ordered an antibiotic for a wound infection and indicated the resident should be seen by the wound nurse practitioner. R137 was not seen by the wound nurse practitioner. Seven days later, R137 was hospitalized and found to have necrotizing fasciitis. The facility's failures to implement preventive interventions for a resident at risk of developing pressure injuries, to determine the etiology of skin tears to the coccyx, to comprehensively assess a pressure injury, to involve the Wound NP, and to notify the dietician of the development of a pressure injury created a finding of immediate jeopardy that began on 10/25/2023. Surveyor notified Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, and Clinical Nurse Consultant (CNC)-F of the immediate jeopardy on 1/8/2024 at 3:00 PM. The immediate jeopardy was removed on 1/12/24, however, the deficient practice continues at a scope/severity of G (actual harm/isolated) as evidenced by the following examples. R40 and R41 are being cited at severity level 3. * R40 developed an unstageable pressure injury to the coccyx on 6/11/2023 that was not comprehensively assessed until 6/14/2023. R40 did not have a comprehensive care plan that addressed pressure injury preventative measures. * R41 developed a Deep Tissue Injury (DTI) to the right heel and a DTI to the left heel on 10/12/2023 that were not comprehensively assessed until 10/16/2023. R41 did not have a comprehensive care plan that addressed preventative measures. * R27 developed a Deep Tissue Injury (DTI) to the left heel which was discovered on 12/16/2023. There was no RN (Registered Nurse) assessment until 12/18/2023 (two days later.) R27's care plan was not updated to reflect the use of heel boots until 12/18/23. The facility did not get treatment orders for the DTI until 12/18/23 when at that time, the physician and R27's representative were notified of the DTI. * R18 developed a Stage 2 pressure injury to the left buttock on 12/7/2023 that was not comprehensively assessed. Findings include: The facility policy and procedure entitled Pressure Injury Prevention and Managing Skin Integrity dated 8/10/2023 states: I. Policy: Prevention measures are put in place to reduce the occurrence of pressure injuries. II. Procedure: 1. Risk Assessment a. Upon admission: Braden Scale will be completed to evaluate individual's risk for developing a pressure injury at admission, and weekly for four weeks for all new admissions. b. Re-evaluation: Braden Scale will be completed upon change of condition and quarterly. c. Based on the individual's Braden Scale Score, pressure reduction interventions will be implemented by nursing and documented in the individual's medical record. 2. Identify Interventions and Care Plan a. Identify Interventions i. The care and intervention for any identified skin breakdown or wound is intended to prevent any further advancement of the wound or additional skin breakdown. 1. There will be collaboration with the interdisciplinary team (IDT) regarding the presence of breakdown and the intervention plan. 2. When indicated, a referral to additional resources (ie. Wound Care Specialist, Registered Dietician, Physical Therapist, Occupational Therapist) may occur. 3. Identification of risk factors present or acquired that compromise skin integrity will be considered. b. Care Plan i. In developing a plan of care, the following will be considered: 1. Individual Pressure Injury History 2. Cognitive changes or impairment of the individual 3. Current state of skin integrity and personal hygiene practices of the individual that impact skin health 4. Any cultural practices that impact the health or integrity of the skin 5. Risk for pressure ulcer development (Braden Scale) 3. Skin Checks a. Skin check will be done upon admission, readmission or as clinically indicated. b. While providing routine care, a licensed nurse is to monitor the skin condition of each individual weekly and document the Skin Check in the medical record. 4. Weekly Wound Rounds a. Upon identification of abnormal skin findings, a licensed nurse will complete a skin assessment. Individual with abnormal skin concerns(s) will be added to weekly wound rounds. b. Registered Nurse (RN) or designee will: i. Conduct weekly skin evaluation. ii. Update the (PCP) with any decline in wound appearance, or as necessary iii. Update the Care Plan with any new interventions as applicable iv. Update Individual Representative as indicated 5. Administrative Review a. Interdisciplinary Team (IDT) reviews Pressure Ulcer/Abnormal Skin Findings through Quality Assurance Committee. 1. R137 was admitted to the facility on [DATE] with diagnoses of displaced intertrochanteric fracture of the right femur, anemia, Type 2 Diabetes Mellitus, congestive heart failure, osteoarthritis, spinal stenosis, and osteoporosis. R137 had a fall at home, sustained the fracture to the right femur, and was admitted to the facility for Physical and Occupational Therapy. On 10/24/2023 at 4:57 PM in the progress notes, nursing charted R137 was admitted to the facility with a left hip fracture (Surveyor noted R137's right hip was fractured.) The Elopement Evaluation form on 10/24/2023 documented R137 was not an elopement risk because R137 was immobile. The Braden Scale score on 10/24/2023 was 11 indicating R137 was at high risk for skin breakdown. The Admit/Readmit Screener form on 10/24/2023 documented R137 had a pressure area to the sacrum that was red and blancheable and a rash under the left and right breast. On 10/24/2023 at 11:41 PM in the progress notes, nursing charted R137 was a new admission that day after a fall resulting in a right femur fracture. Nursing charted R137 was incontinent of bowel and bladder. The Baseline Care Plan initiated on 10/24/2023 was a tool for gathering information but did not implement any interventions. Bed mobility, toileting, and transfers were not assessed per the Baseline Care Plan. The Skin section of the Baseline Care Plan documented R137 had blancheable area to the coccyx and a rash under both breasts. Surveyor noted R137 did not have a Care Plan implemented to address Activities of Daily Living (ADLs) regarding the amount of assistance needed for bed mobility, incontinence care, or the prevention of pressure injuries such as developing a turning and repositioning program. R137 had limited mobility due to the healing right femur fracture. On 10/25/2023 at 10:18 AM in the progress notes, nursing charted R137 had a skin tear to the coccyx. Nursing charted the site was cleaned and Mepilex was applied per Nurse Practitioner (NP) verbal orders. Surveyor noted the treatment order was not entered into R137's Medication Administration Record (MAR) or Treatment Administration Record (TAR) and no etiology of how the skin tear developed was documented. No Care Plan preventative measures were initiated to prevent further skin breakdown. On 10/29/23, R137's ADL Care Plan was initiated with the following interventions: -Discuss with R137/family/POA (Power of Attorney) care any concerns related to loss of independence, decline in function. -Encourage R137 to discuss feelings about self-care deficit as needed. -Encourage R137 to participate to the fullest extent possible with each interaction. -Encourage R137 to use bell to call for assistance. -Monitor/document/report as needed any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. -Praise all efforts at self-care. -PT/OT evaluation and treatment as per physician orders. Surveyor noted R137's ADL Care Plan did not address the level of assistance needed for bed mobility, incontinence care, transfers, a turning and repositioning program or any other activity of daily living. On 10/30/2023 at 9:45 AM in the progress notes, nursing charted R137 had redness on the buttocks and a small skin tear. The documentation did not elaborate on the location of the skin tear and give the etiology of how the skin tear developed. No Care Plan interventions or preventative measures such as a turning and repositioning program were initiated to prevent further breakdown. On 10/30/2023 at 1:48 PM in the progress notes, Social Services charted a care conference was held for R137 and a medication list and care plan were given to R137 and family for review. Social Services charted R137 was non-weight bearing on leg and was working on standing and transfers. R137 did well with a slide board transfer and the plan was for R137 to discharge to home or an assisted living facility. R137's admission Minimum Data Set (MDS) assessment dated [DATE] indicated R137 had a severe cognitive deficit with a Brief Interview for Mental Status (BIMS) score of 6 and the facility assessed R137 as needing moderate assist for rolling in bed, was dependent for toileting, was always incontinent of bowel and bladder. The MDS indicates R137 was admitted with no unhealed pressure injuries and was at risk for a pressure injury with a pressure reducing device in the chair only. Surveyor noted the MDS was not checked for a turning/repositioning program. The MDS indicates R137 was checked for having a surgical wound. The Pressure Injury Care Area Assessment (CAA) stated R137 was at risk for impaired skin with incontinence exposing skin to moisture and waste. R137's admission Braden score was 11 placing R137 at high risk and proceed to plan of care to assist R137 with repositioning needs and peri hygiene. The CAA stated open wound or skin places R137 at risk for infection. Surveyor noted R137's skin tear was not indicated on the MDS assessment, and no care plan was developed to assist R137 with positioning or peri hygiene at that time. On 11/6/2023 at 10:36 AM in the progress notes, nursing charted R137 did not have any new skin concerns. Surveyor noted no further documentation was found on the skin tear to the buttocks/coccyx. On 11/7/23, R137's Impairment to Skin Integrity related to fragile skin Care Plan was initiated with the following interventions: -Encourage good nutrition and hydration in order to promote healthier skin. -Keep skin clean and dry; use lotion on dry skin. Surveyor noted R137's Impairment to Skin Integrity care plan did not include a turning and repositioning program. On 11/8/2023 at 1:10 PM in the progress notes, Social Services charted a care conference was held for R137 and R137 had been working on slide board transfers but due to redness on bottom, they put the slide board transfers on hold. On 11/8/2023 at 4:13 PM in the progress notes, Director of Nursing (DON)-B charted R137 had an unstageable pressure injury to the sacrum that measured 3 cm x 3 cm with slough, eschar, and a slight odor. Surveyor noted no depth was measured and the wound bed did not have percentages of tissue type documented to accurately describe the wound bed; this pressure injury did not have a comprehensive assessment. DON-B notified NP-J and the physician of the new pressure injury. An order was obtained to cleanse the wound with Puracyn, apply Medihoney, and cover the wound with Allevyn daily. Surveyor noted the Dietician was not notified of the new pressure injury. No supplements were ordered to address the increased protein need. On 11/8/23 R137's Pressure Ulcer to sacrum Care Plan was initiated with the following interventions: -Administer medications as ordered; monitor/document for side effects and effectiveness. -Administer treatments as ordered and monitor for effectiveness. -Assess/record/monitor wound healing; measure length, width, and depth where possible; assess and document status of wound perimeter, wound bed, and healing progress; report improvements and declines to the physician. -Bed rest; up with therapy only. -Educate R137/family/caregivers as to causes of skin breakdown, including transfer/positioning requirements, importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. -Follow facility policies/protocols for the prevention/treatment of skin breakdown. -If R137 refuses treatment, confer with R137, IDT (Interdisciplinary Team), and family to determine why and try alternative methods to gain compliance; document alternative methods. -Inform R137/family/caregivers of any new area of skin breakdown. -Monitor dressing to ensure it is intact and adhering; report loose dressing to treatment nurse. -Monitor nutritional status; serve diet as ordered. -Monitor/document/report as needed any changes in skin status: appearance, color, wound healing, signs/symptoms of infection, wound size (length x width x depth), stage. -Obtain and monitor lab/diagnostic work as ordered; report results to physician and follow up as indicated. -Staff to assist with routine toileting and skin care for incontinence. -Treat pain as per orders prior to treatment/turning to ensure R137's comfort. -Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. On 11/9/2023 at 10:46 AM in the progress notes, nursing charted wound care was completed to the pressure injury which was yellow odorous eschar with pain to the touch. The DON and NP-J were aware and R137 was repositioned as needed. On 11/9/2023 at 11:29 AM in the progress notes, nursing charted R137 complained of chills and body aches; R137 was warm to the touch with a temperature of 102.4. Nursing charted NP-J was notified of the fever, Tylenol was given, and the rechecked temperature was 100.8. On 11/9/2023, R137 was evaluated by NP-J. NP-J documented R137 complained of occasional right hip pain and pain secondary to a wound on the sacrum which was being treated with daily local wound care. NP-J documented the Unstageable sacral wound had necrotic edges and the peri wound area was erythematous. NP-J documented the treatment plan for the Unstageable sacral wound was to start doxycycline (antibiotic) 100 mg twice daily for seven days for wound infection, continue daily local wound care with Medihoney, and resident will be followed by the facility Wound NP. Surveyor noted with record review the Wound NP did not evaluate or treat R137. On 11/9/23, R137's Pressure Ulcer to sacrum Care Plan was revised with the following interventions: -Avoid positioning R137 on back. -Staff to assist with turning and repositioning every 2-3 hours. -R137 requires air mattress; check function every shift and as needed. On 11/10/2023 at 9:17 PM in the progress notes, nursing charted oxycodone 5 mg was administered for pain to the sacral/coccyx area from sitting and repositioning and rest were ineffective. Surveyor noted R137 was to be on bedrest, yet pain was caused from sitting. On 11/11/2023 at 9:17 PM in the progress notes, nursing charted R137 had poor appetite and oral fluids were offered and accepted. Nursing charted incontinence rounds and wound care were completed; R137 had an air mattress and was repositioned frequently. R137 was currently resting in bed and in no distress with call bell and oral fluids in reach. Surveyor noted there was no dietician reassessment of R137's nutritional needs after R137 developed an unstageable pressure injury and was charted as having a poor appetite. On 11/13/2023 at 12:48 PM in the progress notes, nursing charted oxycodone 5 mg was administered for pain prevention prior to wound care. On 11/14/2023, R137 was evaluated by the physician. The physician documented R137 had an Unstageable sacral pressure ulcer with eschar and was tolerating doxycycline. The physician documented daily wound care was in progress with Medihoney and pressure relief and position changes were the treatment plan. On 11/16/2023, R137 was evaluated by NP-J at the request of R137's family for depressed mood and decreased appetite. On assessment, R137 was lying in bed and participated minimally in the conversation. The family reported R137 was more depressed that week, was lying in bed a lot, and sleeping more during the day. Family reported R137 was not eating unless the family fed R137, and the family requested a medication for depression. NP-J documented the Unstageable pressure injury to the coccyx had improved since the previous exam (on 11/9/2023). NP-J documented the treatment plan for the Unstageable sacral wound was to continue daily local wound care with Medihoney and will be followed by the facility Wound NP. Surveyor noted with record review the Wound NP did not evaluate or treat R137 and no weekly comprehensive assessment of the pressure injury to include measurements of the area (width, length, depth, type of tissue and exudate) was completed. On 11/16/2023 at 3:29 PM in the progress notes, DON-B charted R137 was assessed by NP-J with a new order received for Mirtazapine 7.5 mg every evening for depression/appetite. On 11/16/2023 at 3:51 PM in the progress notes, DON-B charted R137's family member was at bedside and stated R137 had increased confusion. DON-B charted DON-B attempted to ask R137 questions, but DON-B was unable to understand R137's answers. Per the family member, this was a change for R137. DON-B charted NP-J was made aware and new orders for labs were obtained. On 11/16/2023 at 10:47 PM in the progress notes, nursing charted R137's vital signs at 9:55 PM were as follows: blood pressure 95/48, pulse 101, temperature 99.7, respirations 30, oxygen saturation 91% on room air, and blood sugar 507. Nursing charted R137 was crying and whimpering at that time and was confused and disoriented. The NP was notified of the findings and an order was given to send R137 to the emergency room for further evaluation. Surveyor noted R137's blood sugar readings from 11/2/2023-11/16/2023 ranged from 115 to 507 with an average reading of 282 and only three of the 29 blood sugar readings were less than 200. On 11/17/2023 at 5:49 AM in the progress notes, nursing charted R137 was admitted to the intensive care unit for possible necrotizing fasciitis. R137 did not return to the facility and passed away on 11/19/2023. In an interview on 1/4/2024 at 8:54 AM, NP-J stated NP-J remembered seeing R137's sacral wound at least twice and was aware the physician saw R137's wound once, maybe twice. NP-J stated NP-J first saw R137's sacral wound on 11/9/2023. Surveyor asked NP-J if NP-J took any measurements of the wound. NP-J stated facility nursing staff was responsible for measuring the wound. NP-J recalled ordering an antibiotic for the wound on 11/9/2023 because the wound was foul smelling, and the peri wound was reddened and inflamed. NP-J stated the physician comes to the facility on Tuesdays and NP-J had the physician look at the wound on 11/14/2023 for a follow up visit. NP-J stated NP-J saw R137 on 11/16/2023 because the family said R137 was depressed and not eating. NP-J stated that was the initial reason NP-J saw R137 that day and since NP-J was there, NP-J checked on everything else including the pressure injury. NP-J stated the pressure injury looked better at that time compared to the previous week when NP-J had ordered the antibiotic. NP-J stated the skin around the wound and the wound itself had improved with the antibiotic and Medihoney. NP-J stated there was no visual presentation of anything brewing underneath the wound. NP-J stated NP-J would not have guessed necrotizing fasciitis was present and was shocked when that was reported to NP-J from the hospital. In an interview on 1/4/2024 at 9:34 AM, Surveyor asked MDS Registered Nurse (RN)-C what the process was for a resident that develops a pressure injury while a resident at the facility. MDS RN-C stated the floor nurse does the initial assessment and notifies the Assistant DON (ADON) or the DON of the new area; the DON or ADON will do a complete assessment and document the new areas in either the progress notes or in the assessment tab of the computer charting system. Surveyor asked MDS RN-C how the Wound NP was notified of a resident that needed an assessment and where that assessment would be documented. MDS RN-C stated the Wound NP is notified by either the DON or ADON and will put their own note into the computer charting system. Surveyor noted R137 did not have an initial comprehensive assessment on 11/8/2023 of the new pressure injury, was not comprehensively assessed weekly, and was not seen by the Wound NP. On 1/4/2024 at 10:16 AM, Surveyor shared with Clinical Nurse Consultant (CNC)-F the following concerns regarding R137: -R137's baseline care plan did not have any interventions to address R137's bed mobility with the right hip fracture. -R137 had a Braden score of 11 on admission placing R137 at high risk for a pressure injury and no preventive interventions were implemented. -R137 had a skin tear to the coccyx on 10/25/2023 and 10/30/2023 that were not assessed for etiology of the wounds to prevent future skin breakdown. -The skin tear on 10/25/2023 had a treatment applied that was not documented in the MAR/TAR. -When the ADL care plan was initiated on 10/29/2023, bed mobility and repositioning were not addressed. -On 11/8/2023 a pressure injury to the sacrum was discovered and the wound measurements did not include a depth or a complete description of the wound bed. -The dietician was not notified of the new pressure injury. -An air mattress and repositioning were not implemented on the care plan until after the development of a pressure injury. -On 11/9/2023 the pressure injury required antibiotics for an infection. -On 11/9/2023, NP-J requested the Wound NP be involved in R137's care; no documentation was found by the Wound NP of any assessment of R137's pressure injury. -R137 required opioids for pain control due to the pressure injury. -The pressure injury was not assessed weekly, and no documentation was found of the pressure injury being comprehensively assessed. -R137 was sent to the hospital on [DATE] due to unstable vital signs and was admitted with necrotizing fasciitis. Surveyor shared with CNC-F no documentation was found for a comprehensive assessment or a weekly assessment of the pressure injury. CNC-F stated CNC-F had looked for that documentation the day before and did not see any but would look again. On 1/4/2024 at 10:54 AM, CNC-F stated CNC-F was not able to find any comprehensive skin assessments for R137 other than the admission assessment when R137 did not have any skin concerns for pressure injuries. CNC-F stated the DON at that time (November 2023) simply walked out on the job and they did not know if the DON had a wound log at that time; if the DON did have a wound log, they were not able to find it. CNC-F stated the Wound NP was not involved with R137 like NP-J wanted. In an interview on 1/4/2024 at 11:20 AM, Surveyor asked Licensed Practical Nurse (LPN)-E what the facility protocol was for a resident with a new pressure injury. LPN-E stated the staff nurse that discovers the wound gets the measurements and does the Skin Only Evaluation in the computer charting system. LPN-E stated the previous DON wanted to be notified of any new skin concerns, but there have been multiple DON changes, so it was changing all the time. LPN-E stated the current DON wants the nurse on the floor to get a measurement of the wound and let the NP and DON know about it so the DON will look at the area right away and the Wound NP can look at it on Mondays when the Wound NP assesses all wounds except the surgical wounds. In an interview on 1/4/2024 at 1:18 PM, Surveyor asked Registered Dietician (RD)-K how they are notified of residents with pressure injuries. RD-K stated the facility has wound meetings every week, but with the change in management, those meetings were changing all the time. RD-K stated they are starting to get into a routine with wound rounds on Mondays followed by a wound and nutrition risk meeting right after that on Mondays. RD-K stated that started in the last month. RD-K stated they have a new DON, so things have changed with meeting times and days. RD-K stated RD-K gets a list or report on Mondays of all the residents with skin issues; in the past RD-K had to hound them to get that information. Surveyor asked RD-K if RD-K was aware of R137 having a pressure injury. RD-K stated RD-K was not aware of R137 having a pressure injury. RD-K stated RD-K did the initial nutrition assessment upon admission and R137 was eating well so did not order supplements at that time. RD-K stated RD-K reviewed their notes to see if RD-K was ever told of R137's pressure injury and RD-K did not have any notes so was not aware of the pressure injury. In a phone interview on 1/4/2024 at 1:18 PM, Surveyor asked DON-B if DON-B recalled R137, a resident in the facility 10/24/2023-11/16/2023. DON-B denied having any knowledge of R137 because DON-B had just started working at the facility on 11/6/2023. Surveyor shared with DON-B that DON-B had documented in R137's record on 11/8/2023 of a new pressure injury to the sacrum. DON-B did not recall any information regarding R137 and DON-B did not have R137's medical record available for review at that time. Surveyor asked DON-B what documentation would be expected for a resident that sustained a skin tear. DON-B stated the skin tear should be documented in the progress notes and should include a treatment if that was ordered and the notification of the skin tear to the physician and the family. Surveyor asked DON-B if a treatment was ordered, where would that treatment be documented. DON-B stated the treatment would be on the TAR. Surveyor noted the treatment to the skin tear on 10/25/2023