**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Example 7 The facility policy titled, Change in a Resident's Condition or Status, revised November 2015, states, in part: . 3. Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the SBAR (Situation, Background, Assessment, and Recommendation) (Interact Version 4.0) Communication Form . 7. The Nurse Supervisor/Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status . The facility policy, Falls Investigation Guideline, undated, states in part: .It is the practice of this facility to evaluate a resident following every fall . 2. Following a fall or when a resident is found on the ground without a witness to the fall, a nurse should note position, record vital signs, perform ROM (Range of Motion) on all extremities to evaluate for upper or lower extremity injuries, and evaluate the patient for possible injuries to the head, neck, spine, or hips . 4. If the fall was unwitnessed or involved a resident hit their head [sic], initiate neurological evaluation . document evaluation and PCC (Point Click Care, electronic health record) . 9. Document relevant post-fall clinical findings such as, but not limited to, vital signs, neurological checks, pain, swelling, bruising, alterations in skin integrity, range of motion, decreased mobility, and changes in level of consciousness in the patient's record. It is also desirable to note the absence of such significant findings to demonstrate that the patient is being monitored appropriately . 11. Monitor resident and observe for changes for a minimum of 72 hours. R42 admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, type 2 diabetes, gout, chronic pain, congestive heart failure, osteoarthritis, and muscle weakness. R42's Minimum Data Set (MDS) comprehensive assessment dated [DATE] indicates a Brief Interview for Mental Status (BIMS) score of 15. A score of 15 indicates R42 is cognitively intact. On 10/28/24 at 8:30 AM, Surveyor was notified R42 was hospitalized over the weekend. Surveyor reviewed R42's medical record. R42's medical record revealed the last progress note made was on 10/23/24. R42's medical record did not include an evaluation on when R42 went to the hospital or the reason for the transfer. R42's medical record census line indicated R42 was transferred from the facility on 10/26/24. On 10/28/24 at 9:56 AM, Surveyor interviewed MT K (Medication Technician). MT K indicated R42 went to the hospital on [DATE]. MT K, indicated on 10/26/24, R42 complained of nausea, constipation, and dehydration. MT K indicated she informed the nurse of R42's complaints. On 10/28/24 at 12:39 PM, Surveyor interviewed LPN M (Licensed Practical Nurse). LPN M indicated MT K reported to LPN M that R42 wanted to go to the hospital. LPN M indicated R42 complained of nausea, constipation, and dehydration. LPN M indicated he offered R42 her PRN (As Needed) medications to resolve R42's complaints of nausea and constipation and offered fluids for R42's complaint of feeling dehydrated. LPN M indicated R42 did not want the PRN medications and wanted to go to the hospital. Surveyor asked LPN M if he assessed or collected data prior to sending R42 to the hospital. LPN M indicated he had reviewed her medical record to ascertain when R42 last had a bowel movement and to review R42s diagnoses. LPN M indicated R42's vital signs were stable, and he looked for signs of dehydration. LPN M indicated he did not listen for bowel sounds or palpate R42's abdomen. LPN M indicated he used the messaging system to notify the on-call medical provider and was given the order to send R42 to the hospital. Surveyor asked LPN M where he documented his observations. LPN M indicated he did not document the encounter with R42. Surveyor asked if the information should have been documented and LPN M indicated he should have documented his findings and the encounter that lead to R42 being sent out. Surveyor asked LPN M how anyone would know what happened to R42 and what interventions the facility did for R42 if there is no documentation. LPN M indicated since there is no documentation, there is not a way of knowing what happened or what was offered. On 10/28/24 at 9:22 AM, Surveyor interviewed RN L (Registered Nurse) regarding change in conditions and transfers to the hospital. RN L indicated a progress note should be made in the resident's medical record to include an assessment of the change in condition including vital signs and where the resident was being transferred to. On 10/28/24 at 3:24 PM, Surveyor interviewed DON B (Director of Nursing). DON B indicated she would expect nurses to document a change in condition. DON B indicated R42 should have had a documented assessment of the change in condition including vital signs, pain rating, bowel sounds and palpitation of the abdomen in her medical record. DON B was unable to provide any documentation that an assessment was completed. On 10/22/24, Surveyor interviewed R42. R42 indicated she was self-transferring into the bathroom over the weekend and had a fall on 10/19/24. R42 indicated she did not have pain initially when she fell. R42 indicated the next day on 10/20/24 she stated to have pain. R42 indicated she had x-rays post fall due to pain in her right wrist, right rib cage, and left knee. R42 indicated she had been given Tylenol (a pain-relieving medication) and Flexeril (a muscle relaxant to treat pain and stiffness). R42 indicated these medications were effective. On 10/23/24, Surveyor reviewed R42's medical record. X-ray results for wrist, rib cage, and knee indicates no acute findings. There were only 2 progress notes made regarding R42's fall. Both progress notes were on 10/19/24. First progress note dated 10/19/24 at 6:34 AM states: Resident was found sitting on the bathroom floor, and barefoot. Resident stated that she was rushing to use the bathroom, peed on the floor and the urine made her slide and land on her buttocks, denied hitting his [sic] head. Resident was assisted from the floor via mechanical lift with 2 staff members, was assessed for injuries, no injuries noted, and ROM (range of motion) and neuros (neurological checks) were WNL (Within Normal Limits). [NP Name], NP, and Nurse on Duty [Name] were updated, resident is her own person. Second progress note dated 10/19/24 at 6:50 AM states: Post-Fall: Total Fall Risk Score is: 10 Fall risk scored above 5, resident is at a HIGH risk for falls. BP (Blood Pressure) 140/77 - 10/16/2024 10:12 Position: Lying l/arm (Left Arm) T (Temperature) 98.0 - 10/7/2024 21:25 Route: Forehead (non-contact) P (Pulse) 70 - 10/16/2024 10:12 Pulse Type: Regular R (Respirations) 18.0 - 10/7/2024 21:25 O2 (Oxygen Saturation) 97.0 % - 10/7/2024 21:25 Method: Oxygen via Mask Pnl (Pain Level) 2 - 10/19/2024 06:46 Pain scale: Numerical Resident is receiving anti-coagulant medication. The resident does not receive anti-diabetic medications. Resident is receiving psychotropic medication. Resident is receiving a laxative. There have not been any changes in the medication. There is no new pain, post fall. There is not a noted pattern to falls. The resident does not have any injury noted. New interventions for this fall that are being implemented: Use gripper socks, use call light for assistance Pain Eval: Pain Scale is at: 0. Location is: Pain does not radiate. Current pain pattern is intermittent. Pain is chronic and onset unknown. Discomfort has NOT changed in the past 7 days; Worst pain in the past 24 hours is 0. Pain Score is: Chronic Satisfactory pain management / Continue with current plan of care. Skin Observation: Resident does not have a new skin issue. Neuro Observation: Resident is alert. Resident is oriented x4 (person, place, time & situation). Pupils: PERRLA (Pupils are equal, round, and reactive to light and accommodation - an abbreviated to describe the normal response of the pupils during a neurological exam). PERRLA Eye evaluation is at resident baseline. Speech is clear. Responds to simple commands. Verbalizes appropriately. There are no noted changes in baseline speech clarity. Hand grasp equal bilaterally. There are no changes to the baseline hand grasp strength. Movement and sensation intact in all 4 extremities. Evaluation indicates no changes from baseline. It is important to note the following: -R42 was found on the bathroom floor, indicating R42's fall was unwitnessed. Neurological observations were not fully completed at the time of the fall nor continued for 72 hours. -There is no other documented monitoring or observation for R42 regarding this fall in her medical records. On 10/23/24 at 11:54 AM, Surveyor interviewed LPN N (Licensed Practical Nurse) regarding post fall monitoring and observations. LPN N indicated at the time of a fall, the nurse should assess the resident for injury, pain, range of motion, vital signs, and initiate neurological observations for an unwitnessed fall or if the resident hit their head. LPN N indicated the nurse will notify the appropriate personnel, the doctor, the activated power of attorney if a resident has one and the facility's on-call nurse manager. LPN N indicated the during shift report, the nurse will pass on to the next shift the sheet of paper containing the neurological observations so the observations will be continued for 72 hours. LPN N also indicated the nurse will do charting every shift for 72 hours in the resident's medical record. LPN N indicated the charting would include vital signs, any potential injury, pain, skin concerns or any noted changes in the resident. On 10/24/24 at 9:49 AM, Surveyor interviewed DON B (Director of Nursing). DON B indicated any resident who has a fall should be monitored for 72 hours. DON B indicated observations and monitoring should be documented in the resident's medical record. DON B indicated R42 should have been monitored and there should have been documentation in her medical record for at least 72 hours. DON B did not provide any additional medical record documentation regarding R42's fall. Example 3 The facility's policy titled, Change in a Resident's Condition or Status, dated 11/2015, states in part: Policy Statement: Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status . 1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: . c. a reaction to medication; . 2. A significant change of condition is a decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting); b. Impacts more than one area of the resident's health status; c. Requires interdisciplinary review and/or revision to the care plan; . The American Medical Directors Association standard of practice for Acute Change of Condition in Long-term Care Setting states in part; immediately notify the physician of a urine culture greater than 100,000 CFU/ML (colony forming units.) According to the American Cancer Society, one of the time periods oncologists will monitor for is the [NAME]. The [NAME] occurs when the number of white blood cells in your body goes down to its lowest levels due to cancer treatments. The [NAME] usually occurs about seven to ten days after receiving chemotherapy treatment and indicates when the person is most at risk for infection. Source: (https://www.cancer.org/cancer/managing-cancer/side-effects/low-blood-counts/neutropenia.html) According to the National Comprehensive Cancer Network, one of the side effects of DLBCL is infections. Infections occur more frequently and are more severe in those with a weakened immune system. During treatment for DLBCL (Diffuse Large B-cell lymphoma (DLBCL) is a fast-growing cancer of the lymphatic system, a major part of the body's immune system) can weaken the body's natural defense against infections. If not treated early, infections can be fatal. Neutropenia, a low number of white blood cells, can lead to frequent or severe infections. When someone with neutropenia also develops a fever, it is called febrile neutropenia. With febrile neutropenia, your risk of infection may be higher than normal. This is because a low number of white blood cells leads to a reduced ability to fight infections. Source: (www.nccn.org/patients/guidelines/content/PDF/nhl-diffuse-patient.pdf) According to the Center for Disease Control and Prevention, patients can help to prevent infections during cancer treatment by monitoring temperature and taking their temperature any time they do not feel well, washing hands often, healthcare workers washing hands often, prompt identification of symptoms of infection including fever, cough, and diarrhea. Source: www.cdc.gov/cancer/features/preventing-infections.html R66 was admitted to the facility on [DATE] with diagnoses that includes in part: diffuse large B-cell lymphoma (Diffuse Large B-cell lymphoma (DLBCL) is a fast-growing cancer of the lymphatic system, a major part of the body's immune system) enterocolitis due to clostridium difficile, type 2 diabetes, urinary tract infection, neutropenia, other pancytopenia, and calculus of ureter. R66 's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/4/24 indicates R66 has a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicates R66 is cognitively intact. R66's Comprehensive Care Plan states in part: Focus: The resident has a h/o (history of) recurrent UTIs (urinary tract infections) and recurrent C Diff (clostridium difficile). Goal: Resident will be free from s/sx (signs and symptoms) of UTI through review date. Date Initiated: 8/27/24. Target Date: 11/25/2024. Interventions: encourage adequate fluid intake. Date Initiated: 8/27/24. Give antibiotic therapy as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 8/27/24. Focus: The resident requires contact barrier precautions. Date Initiated: 9/5/24. Goal: The resident will have appropriate isolation precautions and procedures followed during the period that isolation is necessary per facility policy. Date Initiated: 8/27/24. Target Date: 11/25/24. Interventions: Ensure that proper enhanced barrier precautions are in place. If resident has a shared room offer appropriate barriers to roommate. Date Initiated: 9/5/24. Focus: The resident has a h/o (history of) diarrhea. Date Initiated: 10/1/24. Goal: The resident will be free from s/sx (signs and symptoms) of dehydration through the review date. Date Initiated: 8/27/24. Target Date: 11/25/24. Interventions: Encourage fluid intake as tolerated. Date Initiated: 8/27/24. Focus: The resident is on antibiotic therapy per orders. Date Initiated: 8/27/24. Goal: The resident will be free of any discomfort or adverse side effects of antibiotic therapy through the review date. Date Initiated: 8/27/24. Target Date: 11/25/24. Interventions: Administer ANTIBIOTIC medications as ordered by physician. Monitor/document side effects and effective Q-SHIFT (every shift). Date Initiated: 8/27/24. Focus: The resident has altered respiratory status/difficulty breathing r/t (related to) morbid obesity with alveolar hypoventilation cough and dyspnea. Date Initiated: 8/27/24. Goal: The resident will have no complications related to SOB (shortness of breath) through the review date. Date Initiated: 8/27/24. Target Date: 11/25/24. Interventions: Elevate HOB (Head of Bed) to alleviate Shortness of Breath. Administer medication/puffers as ordered. Date Initiated: 8/27/24. Monitor for effectiveness and side effects. Date Initiated: 8/27/24. OXYGEN SETTINGS: O2 per orders. Date Initiated: 10/7/24. (Of note: Surveyor could find no evidence in R66's Comprehensive Care Plan relating to her chemotherapy treatment, neutropenia, being immunocompromised, or required monitoring related to these care areas. Additionally, none of these care areas were added following R66's hospitalization even though she had an additional cycle of chemotherapy to receive following her readmission to the facility.) Physician Orders state in part: Sulfamethoxazole-Trimethoprim Oral Tablet 800-160 MG (Sulfamethoxazole-Trimethoprim) Give 1 tablet by mouth in the morning every Mon, Wed, Fri for infection. Azithromycin Tablet 250 MG. Give 250 mg (milligram) by mouth in the afternoon for infection for 4 days. Order date: 9/6/24. Azithromycin Tablet 500 MG. Give 500 mg by mouth in the afternoon for infection for 1 day. Order date: 9/6/24. Vancomycin HCl Oral Suspension (Vancomycin HCl) Give 125 mg by mouth in the morning for C-DIF INFECTION Order date: 8/23/24. End Date: 9/24/2024 Vancomycin Oral Capsule 125 MG (Vancomycin HCl) Give 1 capsule by mouth in the morning for c-diff no stop date given. Order date: 9/30/2024. Macrobid Oral Capsule 100 MG (Nitrofurantoin Monohyd Macro) Give 1 capsule by mouth every morning and at bedtime for UTI for 5 Days. Order date: 9/13/24. Acyclovir Oral Tablet 400 MG (Acyclovir) Give 1 tablet by mouth two times a day for viral infection. Order date: 9/30/24. On 8/1/24, prior to facility admission, R66 received cycle 3 of 6 of her chemotherapy R-[NAME]-CHP. The package insert for this chemotherapy indicates that it is administered in six, 21-day cycles, followed by two additional cycles of rituximab (non-chemotherapy medication used to treat certain types of cancer). The most common adverse reactions to this treatment were peripheral neuropathy, nausea, fatigue, diarrhea, constipation, alopecia (hair loss), and mucositis (inflammation of mucus membranes that line the mouth and digestive tract). Laboratory abnormalities that occur with this treatment include neutropenia, among others. The package insert also notes serious adverse reactions occurred in 34% of patients receiving this treatment, which includes febrile neutropenia and pneumonia. Additionally, neutropenia is listed as a Grade 3-4 adverse reaction. According to the National Cancer Institute, Cancer Therapy Evaluation Program, Grade 3-4 adverse reactions indicate a severe to life-threatening or disabling adverse reaction. Sources: (https://www.accessdata.fda.gov/drugsatfda_docs/label/2023/761121s008lbl.pdf) (https://ctep.cancer.gov/protocoldevelopment/electronic_applications/docs/ctcaev3.pdf) On 8/1/24, labs were also drawn and indicate: white blood cell count (white blood cells fight infection) of 6.2, which is normal, hemoglobin (protein that attaches to red blood cells and carries oxygen and carbon dioxide) of 10.7 which lower than a normal reference range, hematocrit (percentage of red blood cells in blood) of 33.5 which is lower than a normal reference range, a platelet count (cell fragments that help blood clot and heal wounds) of 25.1 which is normal, and an absolute neutrophil count (type of white blood cell, measures the body's capacity to fight infections) of 4.60 which is normal. On 8/5/24, prior to facility admission, R66 was admitted to a hospital with symptoms of abdominal pain and worsening diarrhea. On 8/9/24, prior to facility admission, R66 had labs drawn that indicate white blood cell count: 0.5, which is critically low, hemoglobin of 8.4, which is lower than a normal reference range and decreased from her previous lab results, hematocrit of 25.7 which is lower than a normal reference range and decreased from her previous lab results, and a platelet count of 41 which is critically low. (Of note: These results coincide with the American Cancer Society's reporting of the [NAME] with neutropenia occurring 7 to 10 days following treatment and indicates when the person is most at risk for infection. This demonstrates that the resident has experienced at least one known adverse reaction to the chemotherapy treatment prior to facility admission.) On 8/9/24, a urine culture and sensitivity resulted, which grew two different morphologies of Escherichia coli that was resistant to antibiotics: ampicillin, ampicillin sulbactam, cefazolin, ciprofloxacin, trimethoprim-sulfamethoxazole. The bacteria tested sensitive to antibiotics: ceftriaxone, nitrofurantoin, piperacillin-tazobactam. On 8/22/24, R66 received cycle 4 of 6 of chemotherapy prior to discharge from the hospital. On 8/23/24, R66 was admitted to the facility with a hospital discharge diagnosis of Clostridium difficile colitis. Discharge orders from the hospital state in part: O2 (oxygen) saturation daily. Additionally, the hospitalist documents cough and dyspnea on their assessment and plan, with the plan listed as monitor. Of note, R66's O2 was not monitored daily. On 9/6/24 at 5:45 PM, a Progress Note was written by NP Z (Nurse Practitioner). This note reports that R66 has a chief complaint of a cough, and states in part: .She overall reports that she continues to have her cough, but does find that Mucinex and Tessalon [NAME] are helpful at times. But she does report that overall she is not feeling well. At this time we will also order an azithromycin for coverage of [sic] the lingering URI (upper respiratory infection) versus rhinovirus. UA (urinalysis) collected, results are pending . The physical exam for respiratory status states, clear, no wheeze, no accessory muscle use, fair aeration, symmetric expansion. On 9/8/24, Laboratory paperwork indicates urinalysis results are faxed to the facility at 00:55:03 (12:55 AM) and indicate that a urinary tract infection is present. On 9/9/24 at 11:15 AM, a nursing progress note indicates that NP Z was notified of the results. On 9/10/24 at 12:51 PM, Laboratory paperwork indicates the culture and sensitivity results are sent to the facility. Culture results indicate presence of 20,000 CFU/ML (colony forming units) of Escherichia coli, Greater than 100,000 CFU/ML of Enterococcus faecalis not VRE (vancomycin-resistant enterococcus), and 11,000 CFU/ML of Candida tropicalis. Sensitivity results indicate that the bacteria found in the culture are resistant to ampicillin, ampicillin sulbactam, levofloxacin, and trimethoprim-sulfamethoxazole. The bacteria tested sensitive to cefazolin, cefepime, ceftriaxone, gentamicin, meropenem, nitrofurantoin (Macrobid), and tobramycin. Of note, there is no evidence NP Z was immediately notified of the urine culture results until 9/11/24. It should be noted R66's UA (Urinalysis) is resistant to the prophylactic Bactrim. On 9/10/24 at 2:28 PM vital signs are assessed: BP (Blood Pressure) 118/60, HR (Heart Rate) 63, RR (Respiratory Rate) 18, temperature 97.7F (Fahrenheit), and 93% SpO2 (Saturation of Peripheral Oxygen). On 9/11/24 at 3:45 PM, a Progress Note was written by NP Z. This note reports that R66 has a chief complaint of a cough and UTI (urinary tract infection). The note states in part: . She reports that her cough is not getting better. Mucinex does help slightly. She has rhonchi heard in the bases of her lungs. At this time we will order a chest x-ray. In addition, UA (Urinalysis) suggestive of UTI, reaching out to urology for further recommendations due to upcoming stent removal. She will be out all day tomorrow for treatment . Respiratory assessment indicates: RHONCHI, no accessory muscle use, fair aeration, symmetric expansion. Of note, this is a change from NP Z's previous assessment now noting rhonci. Of note, despite the indication of continued cough, now rhonchi present and R66's extreme risk of infection the facility staff did not complete comprehensive nursing assessments of R66's respiratory system. Additionally, R66 has a renal calculi (Kidney Stone) with a stent placement there is no indication the facility staff are assessing R66's gentiourinary status despite a UTI (Urinary Tract Infection.) It should be noted per phone transcripts with urology clinic facility staff notified urology on 9/11/24, R66 has UTI which was positive for bacteria and yeast. Facility told urology R66 was receiving prophylactic Bactrim however there is no evidence the facility informed urology the urine culture was resistant to Bactrim. Hospital paperwork dated 9/12/24 indicates that R66 receives cycle 5 of 6 at this time. A chest x-ray is conducted at the clinic as ordered and labs are drawn. Labs indicate a white blood cell count of 4.3 (normal), hemoglobin of 10.0 (low), hematocrit of 31.6 (low), platelet count of 212 (normal), and absolute neutrophil of 3.39 (normal). The chest x-ray impression is probable pulmonary vascular congestion. PVC is a condition where the blood vessels in the lungs become enlarged due to an obstruction in the normal flow of blood. This can lead to the alveoli filling with blood. PVC is often associated with heart failure. Some causes of PVC include: high blood pressure, infections, cardiac insufficiencies, malnutrition, and rheumatic mitral valve disease. It should be noted per phone transcripts with urology clinic facility staff notified urology clinic on 9/12/24 at 4:17 PM, labs from 9/9 positive urine culture with bacteria and yeast. Treat with Bactrim and Diflucan (antibiotic and antifungal)? On 9/12/24 at 4:49 PM the physician repliced sounds like need final urine culture results prior to treating. On 9/13/24 at 6:15 PM, a Progress Note was written by NP Z. The note reports that R66 has a chief complaint of a UTI and a ureteral stent. The note states in part: . She reports that oncology [sic] obtained a chest x-ray yesterday. Nursing staff reaching out to urology for further recommendations in regards to her urinalysis results. For further discussion was sent over to PCP (Primary Care Provider) office for further management which he PCP has never met or seen her. Writer agreed to continue with managing. Then further follow-up urology is recommending that she follow-up with infectious disease due to specific bacteria in her urine. At this time writer started on Macrobid (antibiotic) for further coverage until infectious disease can make further recommendations . Respiratory assessment indicates: RHONCHI, no accessory muscle use, fair aeration, symmetric expansion. On 9/13/24 at 4:10 PM, an order was placed for Macrobid Oral Capsule 100 MG (Nitrofurantoin Monohyd Macro) Give 1 capsule by mouth every morning and at bedtime for UTI for 5 Days. According to the Medication Administration Record, this medication was administered as ordered through 9/18/24. It should be noted per phone transcripts with urology clinic facility staff notified urology clinic on 9/13/24 at 1:08 PM urine culture came back positive asking if physician wants to proceed with prescription for UTI. 2:13 PM can you confirm if (R66) should be on Bactrim and Diflucan. Response at 3:13 PM stated she needs to go to infectious disease bactrim is resistant and Macrobid is not a great antibiotic. She also has Candida tropiclis (fungal infection.) On 9/16/24, the facility received a referral for R66 to see infectious disease. Appointment was scheduled the same day for 10/7/24. On 9/18/24 at 6:45 PM, a Progress Note was written by NP Z. The note reports that R66 has a chief complaint of stent and UTI and cough. The note states in part: .Further discussion with urology, her procedure for her stent will be postponed until she has a follow-up with infections disease for her bacteria in her urine. In addition she continues to report that she is have continuous cough congestion and is not feeling well . Respiratory assessment indicates: RHONCHI, no accessory muscle use, fair aeration, symmetric expansion. (Of note: 9/19/24 is the start of the [NAME] with neutropenia occurring 7 to 10 days following treatment and indicates when the person is most at risk for infection. No care plan is in place and no facility nursing assessments are completed to monitor for infection. R66 is being treated for a UTI with no evidence of assessment and monitoring of R66's urinary output and no respiratory assessment including physician ordered daily oxygen saturations.) On 9/19/24 at 12:37 PM vital signs are assessed: BP (Blood Pressure) 142/73, HR (Heart Rate) 63, RR (Respiratory Rate) 18, temperature 97.9F (Fahrenheit), and 94% SpO2 (Saturation of Peripheral Oxygen). On 9/20/24 at 2:45 AM, a Progress Note was written by NP Z. The note reports that R66 has a chief complaint of UTI. The note states in part: Patient continues [sic] to have a cough, waiting to hear back from ID (infectious disease) for further recommendations for her UTI. Currently on Macrobid . Respiratory assessment indicates: no accessory muscle use, fair aeration, symmetric expansion. (Of note: No RN assessments could be found since 9/1/24 regarding the resident's respiratory and genitourinary status. R66's temperature was also only taken twice since 9/1/24, on 9/10/24 and 9/19/24.) On 9/20/24 at 4:23 PM, a nursing progress note is written by RN AA. The note states that CNA (CNA Name) approached the writer and reported a change of condition with R66. RN AA went to the room and assessed R66 to be experiencing tremors, she was drowsy, and she was only responding to self. Vital signs listed at this time were BP 108/55, HR 103, Temperature 98.6 F, and blood sugar 95. The physician was called and R66 was ordered to be sent to the hospital. Family was also notified. On 9/20/24 at 4:31 PM, a nursing progress note is written by RN AA. The note states that R66 was sent to the hospital for further evaluation. On 9/20/24, Hospital documentation indicates that R66 presented to the ER (Emergency Room) by EMS (Emergency Medical Services) with altered mental status, lethargy, fevers, cough, and hypoxemia (Low blood oxygen) requiring 4L (liters) of oxygen. In the ER, R66 reports that her nonproductive cough and fatigue have been going on for several weeks and the fever started that day. Initial vital signs in the ER were BP 102/58, HR 97, and Temperature 103.1 F. On 9/20/24 at 8:32 PM, a note was written by a critical care physician upon admission. The note states that R66 was found to be febrile (fever) and hypotensive (low blood pressure) upon arrival to the ER. Initial treatment consisted of a 30 mL/kg (milliliters per kilogram) sepsis fluid bolus and blood cultures were taken. The resident was also treated with antibiotics: vancomycin, cefepime, and azithromycin. The physician lists notable labs of a white blood cell count of 0.1 (critically low), platelets of 18 (critically low), and hemoglobin of 7.9 (low). Chest x-ray shows hazy bilateral opacities that was concerning for pneumonia per the ER physician. Urinalysis also suggests urinary tract infection. Ultimately, R66 required norepinephrine (similar to adrenaline and used to treat life-threatening low blood pressure) for persistent hypotension despite fluid resuscitation. She also required 2 packs of platelets for thrombocytopenia (low platelet count) and admission to the intensive care unit for further care. On arrival to the intensive care unit, R66 reported several weeks of nonproductive cough and fatigue and that her fever started today. The physician also notes that R66 reported dysuria. The reason for admission is listed as neutropenic fever, septic shock. The physician's pulmonary assessment and plan states, Cough. New oxygen requirement. CXR (chest x-ray) with hazy opacities. Possible pneumonia vs pulmonary edema. -supplemental oxygen. The physician's cardiovascular assessment and plan states: Septic shock. Lactate normal. Got seps[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure each resident receives care, consistent with professional standards of practice (SOP), to prevent pressure injuries (PI) and each resident with PIs receives necessary treatment and services, consistent with professional SOP, to promote healing, prevent infection, and prevent new injuries from developing in 1 of 2 sampled residents (R41). R41 developed an in house acquired, stage 3 pressure injury on her coccyx. Surveyor observed R41 to be lying directly on her wound and to have her heels directly on the mattress/not floating several times during survey. The facility delayed changing out R41's bed to a mattress designed to treat pressure injuries stage 3 or higher. The facility did not perform wound care per physician orders. Evidenced by: Facility policy, titled Pressure Injury/Skin Integrity, review date 10/21/24, includes: It is the policy of the facility to enable nursing staff to manage wounds and select appropriate interventions according to the National Pressure Ulcer Advisory Panel . The facility will ensure a resident receives care, consistent with professional standards of practice, to prevent pressure injuries and does not develop pressure injuries unless the individual's clinical condition demonstrates that they were unavoidable; and a resident with pressure injuries receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing . Interventions will be used to mitigate the risk for skin breakdown, based on individual risk factors, and may include, but are not limited to: the use of pressure redistribution devices such as mattresses or cushions; devices to eliminate or reduce friction and shearing; or the implementation of individualized turning and repositioning schedules. Interventions should be documented in the electronic medical record, including the residents individualized resident-centered plan of care . It is important that each pressure ulcer or non-pressure ulcer wound be identified. Identification of factors that may have influenced development of the wound/root cause analysis, the potential for development of additional wounds, or for the deterioration of the pressure ulcers should be recognized and may include: the type of wound: pressure versus non pressure related . the wound stage . describe and monitor the wounds characteristics . monitor the progress toward healing and for potential complications . determine if infection is present . assess, treat, and monitor pain . mind your dressings and treatments . wound documentation is more detailed than routine skin documentation and shall include information related to the wound based on a clinical assessment . wound documentation guidelines: document size: length times width times depth . document any undermining tunneling sinus tract . describe any exudate: type, amount, and/or odor . describe the various types/characteristics of tissue in wound bed . describe wound edges . describe surrounding tissue . R41 admitted to the facility on [DATE] with the following diagnoses: morbid obesity, muscle weakness, asthma, metabolic encephalopathy, heart disease, and age-related osteoporosis. Her most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 8/21/24 indicates R41's cognition is intact with a BIMS (Brief Interview for Mental Status) score of 15 out of 15. R41's Comprehensive Care Plan, initiated 12/22/18, includes: The resident has potential for skin impairment related to incontinence, limited mobility . Goal: 12/22/18 The resident will remain free of new skin impairment through the review date. Interventions: 12/22/18 Apply barrier cream per facility protocol to help protect skin from excess moisture. 1/3/19 ensure heels are elevated while resident is lying in bed. 12/22/18 change bedding/clothing if moist. Determine cause of moisture and eliminate if possible. 12/22/18 Monitor skin when providing cares, notify nurse of any changes in skin appearance. 4/23/23 Apply barrier cream per orders as needed with episodes of incontinence. R41's TAR (Treatment Administration Record) for September 2024, includes Order: Barrier cream to buttocks/coccyx every shift and as needed. Start date: 12/27/18: This is signed out as completed on all three shifts 9/1/24-9/30/24, except for on the following dates where each date on one of the shifts is left blank or not signed off as completed: 9/3 PM shift not completed, 9/6 PM shift not completed, 9/7 NOC shift not completed, 9/10 PM shift not completed, 9/15 AM shift not completed, 9/27 AM shift not completed. Order: Start date: 1/14/20 Resident may wear double briefs every shift for FYI (For Your Information) this is signed out as completed on 85 of 90 shifts. Order: Float heels using pillows while in bed every shift. Start date: 12/27/18. This is signed out as completed all but 3 shifts. (It is important to note double briefing is not a current SOP, double briefing adds another layer between R41 and her pressure reducing mattress and it can significantly increase the risk of developing pressure injuries due to excessive moisture trapped against the skin, creating a hot and humid environment that can break down skin integrity.) R41's Braden Scale for Predicting Pressure Sore Risk, dated 9/4/24, indicates R41 is at risk for pressure injury development with a score of 15. R41's Comprehensive Care Plan entry, added on 9/12/24, includes the following: 9/12/24 The resident has an actual skin impairment to sacrum. Goal: 9/12/24 Resident's skin impairment will improve by review date. Intervention: 9/12/24 evaluate and treat per physician orders. (It is important to note R41's Medical Record does not contain any measurements or character description of this skin impairment. There is no evidence that the facility contacted R41's MD regarding this skin impairment.) R41's Nurse Note, dated 9/18/24, includes Enabler bar/assist bar: Resident has been assessed for risk of entrapment . Observed that there is proper fit to the bed frame. Bed dimensions are appropriate for the resident's size and weight . Resident is able to safely utilize grab bar . R41's Skin Observation Tool, dated 9/23/24, indicates R41 has redness under her breasts, but no other skin concerns. (It is important to note there is no mention of R41's skin impairment that is mentioned on R41's comprehensive care plan.) R41's Nurse Notes, dated 9/29/24, include CNA (Certified Nursing Assistant) informed this writer that resident had small amount of blood and was not sure where it was from when doing cares. This writer observed small amount of vaginal bleeding when wiping. Also, a small skin impairment noted to coccyx. Area cleaned and Mepilex applied. PCP (Primary Care Physician) notified via fax due to not using facility provider. (It is important to note there is no description of this skin impairment in R41's medical record. There is no evidence the wound is stable, if it is worsening, or if it is improving. It is also important to note R41's care plan was not updated with this new skin impairment.) An email correspondence with R41's physician group, dated 10/2/24, includes, in part: . I will be sure to add (R41's name) to NP F's (Nurse Practitioner) wound schedule for tomorrow. R41's Skin Observation Tool, dated 10/3/24, includes: No new skin issues observed. (It is important to note R41's Skin Observation Tool does not reflect her skin impairment while her medical record indicates in two separate documents she has a skin impairment, on 9/12/24 in her care plan and on 9/29/24 in her nurses notes. There are no measurements, no description of characteristics, no monitoring of the impairment to compare if the impairment is stable, worsening, or improving. It is important to note there is no root cause analysis completed in R41's medical record to indicate what could have been the cause of this skin impairment.) R41's TAR, October 2024, includes Order: Sacrum: Apply bordered foam dressing to prevent further skin breakdown in the morning for wound care Start date: 10/2/24. End date: 10/10/24 . This treatment is signed as completed on all days, except for on 10/3/24 and 10/9/24. These boxes are blank. Order: Sacrum: Apply Medi honey followed by bordered foam. To be done daily in the morning for wound care. Start date 10/10/24. End date 10/17/24 . This treatment is signed out as completed all days except for 10/12/24. This box is blank. Order: Sacrum: Cleanse with normal saline. Fit collagen to wound bed followed by duoderm. To be done Monday, Wednesday, and Friday for wound care. Start date: 10/17/24. These treatments were signed out as completed on all days. Order: Float heels using pillows while in bed every shift. Start date: 12/27/18. This is signed out as completed all but 3 shifts. Order: Air mattress for wound care. Check function every shift for wound healing. Start date: 10/16/14. These are all signed as completed. Order: May wear double briefs every shift for FYI. Order date: 1/14/20. These are signed off as completed all but 3 shifts. (It is important to note R41's medical record had no evidence in it of R41's treatment being completed or R41 refusing wound care on 10/9 or 10/12.) R41's Nurse Practitioner Note, dated 10/10/24, includes: Patient seen today for initial evaluation of coccyx wound. Wound has been open for greater than 2 weeks however she declined assessment last week. She is lying in bed, no acute distress. She denies any pain, fever, or chills. Wound examined with full assessment and plan . Stage 3 pressure injury to coccyx, measuring 1.0cm x 0.6cm x unable to determine . 100% slough with scant serous drainage . Plan: cleanse wound, apply Medi honey to wound bed followed by bordered foam to be changed daily . Continue offloading measures per facility protocol, continue nutritional support, continue medical management of multiple comorbidities, continue wound assessment weekly with treatment plan as directed . R41's Nurse Practitioner Note, dated 10/17/24, includes: Patient seen today for follow up of coccyx wound. Wound appears improved with decrease in slough. No current signs and symptoms of infection. Patient reports pain with any palpation to area is 7 out of 10. She is now on offloading mattress . Stage 3 pressure injury to coccyx, measuring 1.2cm x 0.6cm x 0.2cm, 10% slough, 90% granulation tissue with scant serous drainage . Plan: Continue offloading measures per facility protocol, continue nutritional support, continue medical management of multiple comorbidities, continue wound assessment weekly with treatment plan as directed . Cleanse wound, apply collagen followed by duoderm to be changed 3 times a week and as needed . R41's Skin Observation Tool, dated 10/17/24 includes: No new skin issues observed. (It is important to note R41 has a stage 3 pressure injury that is not captured on her skin observation tool.) R41's Nurse Practitioner Note, dated 10/24/24, includes chief complaint - evaluation to coccyx . Patient seen today for reevaluation of coccyx wound. She is lying in bed. No acute distress. Denies pain at rest. She has mild pain with any pressure to coccyx. Wound without signs and symptoms of infection . Stage 3 pressure injury to coccyx, measuring 0.6cm x 0.5cm x 0.1cm, 100% smooth red with scant serous drainage . Plan: Continue offloading measures per facility protocol, continue nutritional support, continue medical management of multiple comorbidities, continue wound assessment weekly with treatment plan as directed . Cleanse wound, apply collagen followed by duoderm to be changed 3 times a week and as needed . On 10/23/24 at 9:44 AM, Surveyor observed R41 to be lying on her back, directly on her pressure injury with her heels in direct contact with her mattress. R41 indicated staff did not offer to put pillows or other offloading device under her feet but that she should have them up on pillows. R41 indicated she had a concern that the facility did not give her an air mattress until a few days ago. (It is important to note on or before 10/10/24, R41 developed a stage 3 pressure ulcer, and an air mattress was not placed until 10/16/24.) On 10/23/24 at 2:39 PM, Surveyor observed R41 to be lying on her back, directly on her pressure injury with her heels in direct contact with her mattress. R41 stated, They do sometimes put my feet up on pillows, but they didn't today. On 10/23/24 at 2:40 PM, CNA KK stated, R41's heels should be floated with pillows. I don't know why the first shift did not float them. Surveyor asked if R41 should be lying directly on her wound. CNA KK indicated she should not be. CNA KK indicated R41 was on a regular foam, bariatric mattress before she received this air mattress. On 10/23/24 AT 9:46 AM, DON B (Director of Nursing) indicated R41 was on a bariatric foam mattress until 10/16/24. Then R41 was given a bariatric air mattress. On 10/23/24, NHA A (Nursing Home Administrator) indicated R41 was on a Medline bariatric foam mattress until 10/16/24 when she was given a Proactive Protekt Aire, air mattress. Medline Bariatric Foam Mattress manufacturer recommendations for use, Medline.com, includes, in part: Three-layer foam mattresses helps prevent formation of pressure injuries . pressure injury risk level: high risk stage 1 and 2 . Proactive Protekt Aire Mattress 8000BA42 manufacturer's recommendations for use, undated, includes: 10x20 cells . prevention and treatment for pressure ulcers stage 1 to stage 4 On 10/23/24 at 4:34 PM, ADON X (Assistant Director of Nursing) indicated R41's heels should be floated. ADON X indicated R41's skin was fragile looking but there was no open area on 9/29/24. ADON X indicated she should have described the skin impairment in R41's medical record. ADON X indicated it was not open until the facility had her added to NP F's list to be seen. (It is important to note the facility sent an email on 10/2/24 asking that R41 be added to the list for NP F's wound rounds.) On 10/24/24 at 7:44 AM, CNA CC indicated she never saw the wound uncovered after initially finding it on 9/29/24. At the time she found it, it was not opened but was reddened and fragile looking. On 10/24/24 at 9:02 AM, NP F (Nurse Practitioner) indicated she has only seen R41's wound three times. NP F indicated the wound had 100% slough over the wound bed the first time she saw it and it was a stage 3 caused by pressure. NP F stated, It had been present for greater than a week when I first saw it. She refused to let me see it the week before. NP F indicated she expects the facility to follow SOP(Standard of Practice) for wound care including description and measurements to be completed weekly. NP F stated, I would expect them to be monitoring it. I don't know exactly what day it opened. They should have notified me when it opened or changed. I expect the facility to follow physician orders for wound care and heels floated. It was open for a week when I saw it, because the first time we went in on October 3rd, she refused to allow me to see it. She (R41) kicked us out of her room. (Of note, a wound with 100% slough should be classified as unstageable.) On 10/24/24 at 9:48 AM, Surveyor observed R41 to be lying directly on her wound with her heels in direct contact with her mattress. Surveyor observed R41's wound to be bright red without slough present. Facility staff had already completed wound care and did not inform Surveyor to be able to observe the wound care. During an interview, LPN C (Licensed Practical Nurse) indicated she and NP F did wound rounds together this morning. LPN C indicated NP F debrided the wound during wound rounds. LPN C described the debridement to Surveyor, stating, She took a q tip and roughed it up a little to remove the biofilm and to increase blood flow. LPN C indicated on 10/3/24, she was on vacation when NP F came to do wound rounds and R41 refused to allow NP F to assess the wound. LPN C stated, We don't usually reapproach for wound assessment. If NP F doesn't get it done or if R41 doesn't let NP F complete wound care, we wait until the next week. Surveyor asked how often wounds should be assessed. LPN C indicated she was not sure. LPN C indicated she added the air mattress on 10/16/24, stating, I asked (R41) if she wanted an air mattress and she did so I got her one on the 16th. After wound observation, Surveyor observed LPN C assist R41 back to lying directly on her wound and with her feet in contact with her mattress. LPN C exited the room. Surveyor asked LPN C if R41 should be lying directly on her wound and if her heels should be in direct contact with R41's mattress. LPN C began to walk down the hallway, Surveyor asked if LPN C was able to assist R41 with positioning off her wound and getting her heels floated. LPN C indicated she was, and she went back into R41's room and assisted R41 off her wound and positioned her heels to be floating. On 10/24/24 at 4:05 PM during an interview, DON B (Director of Nursing) and NHA A (Nursing Home Administrator) indicated R41 should not be positioned directly on her wound and her heels should be floated, not in direct contact with her mattress. DON B indicated R41's mattress should have been changed when her wound was staged at a stage 3 pressure injury, on 10/10/24. DON B and NHA A indicated when R41 refuses to be assessed by NP F another staff should attempt to complete the wound assessment, because the standard of practice and facility policy is to assess wounds weekly. DON B indicated a description should have been recorded in R41's medical record of R41's skin impairment when it was noted on 9/12/24 and on 9/29/24. DON B indicated she is unsure how the staff are monitoring the skin impairment without measurements or a description. NHA A and DON B indicated wound care should be completed as ordered and refusals should be charted in resident's medical record. DON B indicated a blank box on the TAR indicates the wound care was not completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, facility staff did not ensure that each resident who required pain management received such services according to the comprehensive person-centered care plan and the resident's goals and preferences for 1 of 2 residents (R26) reviewed for pain management resulting in R26 experiencing uncontrolled pain. R26 was experiencing breakthrough pain at 9 out of 10 severity and the facility staff did not provide her with pain medication over a period of 5 hours on 10/22/24. The facility had R26's as needed pain medication in contingency stock, however R26 was told the facility was out of her medication. R26's comprehensive care plan does not include individualized non-pharmacological interventions, and the medical record does not indicate any of these interventions being performed. This is evidenced by: The facility policy titled, Pain Management, dated 11/28/17, states in part: Purpose . Residents are observed for pain regularly during daily care and interactions. The facility clinicians use standardized pain scales when caring for residents that are able to assist in determining the severity of pain and effectiveness of interventions . The Interdisciplinary team (IDT), together with the resident and/or resident representative develop a Care Plan that will address the individual goals of comfort and individualized interventions to [NAME] those goals . General Guidelines . The resident experience of pain is highly individual and subjective. Pain is what the resident says it is . Be familiar with the physiological and behavioral signs of pain . Acute pain should be assessed every 30-60 minutes after the onset and reassessed as indicated after analgesic relief is obtained. Pain observation consists of gathering both subjective and objective data .Observation . Pain in our residents will be evaluated and/or observed as needed and: . before and after PRN analgesics . Suggestive Signs and Symptoms of Pain: . sighs, groans, crying, labored breathing .facial grimacing . Documentation: The resident's clinical record will include documentation on pain, pain medications and their effects. Specific areas include: -Each pain observation -Pharmacological and non-pharmacological interventions and their effects. Documentation should be recorded on the pain monitoring tool provided each residents individual Medication Administration Record (MAR) and should including the following, with regard to observation, evaluation and/or report of pain: Date, Time, Pain Rating, Pain Location, Pain Quality, Pain Duration, Non-Pharmacological Interventions, PRN Analgesics if provided and initial, Follow up Pain Rating, Time and Initial . Follow Up: Pain will be assessed regularly, Follow Up: . The resident's response to interventions and comfort level will be monitored. Side effects of pain medications will be monitored . If an acceptable comfort range is not met the interdisciplinary team, along with the physician shall reconsider approaches and make adjustments as indicated. R26 was admitted to the facility on [DATE] with diagnoses that include in part: Acute on Chronic Diastolic (Congestive) Heart Failure, Acute and Chronic Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation, Infection, and Inflammatory Reaction due to Internal Right Hip Prosthesis, and Presence of Right Artificial Hip Joint. R26's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/24/24 indicates R26 has a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicates R26 is cognitively intact. Section J indicates R26 is on a scheduled pain regimen, is receiving PRN (As Needed) pain medication, and receives non-medication pain intervention. Section J also indicates R26 occasionally has pain and that her pain occasionally affects sleep, therapy activities, and day-to-day activities. R26's Comprehensive Care Plan states, in part: Residents Acceptable Level of Pain is 1 on a 0-10 scale. Focus: The resident is on pain medication therapy per orders. Date Initiated: 9/27/24. Goal: The resident will be free of any discomfort or adverse side effects from pain medication through the review date. Date Initiated: 9/27/24. Target Date: 12/19/24. Interventions: Administer ANALGESIC medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT (every shift). Date Initiated: 9/27/24. Focus: The resident has the potential for pain. Date Initiated: 9/19/24. Goal: The resident will not have an interruption in normal activities due to pain through the review date. Date Initiated: 9/19/24. Target date: 12/19/24. The resident will not have discomfort related to side effects of analgesia through the review date. Date Initiated: 9/19/24. Target Date: 12/19/24. Interventions: Provide the following non-pharmacological pain interventions: (specify: Heat/Ice as ordered/tolerated, Distraction/Quiet Room, Repositioning). Date Initiated: 9/19/24. Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Date Initiated: 9/19/24. R26's Physician Orders state in part: Acetaminophen Capsule 500 MG (Milligrams) Give 2 capsule by mouth three times a day for pain Not to exceed 4000 MG APAP (Acetaminophen)/24 Hours. Start date: 9/25/24. Tramadol HCL Tablet 50 MG Give 1 tablet by mouth every 6 hours as needed for moderate and severe pain. Start date: 9/25/24. Tylenol Extra Strength Oral Tablet 500MG (Acetaminophen) Give 2 tablet by mouth at bedtime for pain Not to exceed 4000MG APAP/24 hours. Start date: 9/25/24. R26's Medication Administration Record (MAR), from October 2024, indicates, in part: 10/21/24: 12:03 AM- Tramadol 500MG x1 tablet administered for pain . Pain rating: 4 out of 10. Medication indicated to be effective. 8:00 PM- Acetaminophen 500MG x2 capsules administered as scheduled for pain . Pain rating: 0 out of 10. 8:00 PM- Tylenol Extra Strength 500MG x2 tablet administered as scheduled for pain . Pain rating 0 out of 10. 10/22/24: 8:00 AM- Acetaminophen 500MG x2 capsules administered as scheduled for pain . Pain rating: 4 out of 10. 1:00 PM- Acetaminophen 500MG x2 capsules administered as scheduled for pain . Pain rating: 4 out of 10. 1:55 PM- Tramadol 500MG x1 tablet administered for pain . Pain rating: 4 out of 10. No indication provided at time document was printed on 10/22/24 at 17:59:33 (5:59 PM) On 10/22/24 at 8:55 AM, Surveyor observed R26 tell a facility CNA (Certified Nursing Assistant) that she wanted her pain medication. CNA acknowledged R26 then went directly to speak to LPN HH (Licensed Practical Nurse). On 10/22/24 at 8:56 AM, Surveyor interviewed R26. R26 was seated in a wheelchair during the interview. Surveyor observed R26 to be tremorous and visibly winced whenever she moved. R26 stated that she noticed her pain start to become worse when they started to reduce her prednisone (steroid). R26 confirmed that she had just requested her pain medication from the CNA. On 10/22/24 at 11:44 AM, Surveyor was in the process of interviewing LPN HH, when Surveyor and LPN HH were approached by RN LL (Registered Nurse). RN LL is employed by an outside agency. RN LL advised LPN HH that R26 was in severe pain and was requesting pain medication. LPN HH stated that R26 had already received her scheduled pain medication. RN LL asked LPN HH if R26 had any PRN (as needed) pain medications available. LPN HH stated the resident is out of her PRN pain medication. RN LL asked if maybe a provider should be called then so that R26's pain can be treated. LPN HH stated, I was just getting to that. RN LL provided LPN HH her business card and requested a phone call once R26's pain medication was provided. LPN HH indicated she would call RN LL. On 10/22/24 at 11:55 AM, Surveyor interviewed R26. R26 appeared visibly upset. Surveyor observed R26 to be teary-eyed and wincing with movement. Surveyor asked R26 if she had received her pain medication as she requested. R26 stated she had not. R26 also stated that she can't bend down due to the pain and was crying before her (Agency Nurse's Name) arrival because she was in so much pain. R26 stated, I've just been sitting here suffering. On 10/22/24 at 3:19 PM, Surveyor interviewed R26. R26 confirmed that facility staff did come in and administer her pain medication. Surveyor advised R26 that the MAR (Medication Administration Report) indicates she reported a pain level of 4 out of 10 today to facility staff, Surveyor asked R26 if this is correct. R26 appeared visibly angry and stated If I'm crying you know I'm in pain. I don't cry over a 4. R26's Medication Administration Record (MAR), from October 2024, indicates, in part: 10/22/24: 1:55 PM- Tramadol 500MG x1 tablet administered for pain . Pain rating: 4 out of 10. (Of note, R26 waited 5 hours for pain medication for breakthrough pain. It should be noted the pain medication was available in the facility contingency.) On 10/22/24 at 4:34 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B to show Surveyor how the contingency stock worked. DON B led Surveyor to the medication room and to a machine containing a variety of medications. While DON B was accessing R26's contingency stock, Surveyor asked DON B what she what the expectation is for staff prior to administering pain medication. DON B states, she would expect a resident assessment and based off assessment findings, appropriate interventions would be decided, either non-pharmacological or pharmacological interventions. Surveyor asked DON B how soon an assessment or treatment should be provided to the resident following a complaint of pain. DON B states as soon as possible. DON B demonstrated that the facility has a machine that is stocked with R26's PRN pain medication. Surveyor asked DON B which staff members in the facility have a code for the contingency stock. DON B stated all licensed nurses who are directly employed by the facility staff along with some agency nurses. DON B also states that per diem nurses who are not regularly on the schedule do not have a contingency code and should seek assistance from facility nurses. Surveyor asked DON B what the process is for pulling medication from the contingency stock. DON B states, nurses are expected to call the pharmacy for a contingency code, and once they have the code the medication should be pulled from the machine and administered to the resident. Surveyor asked DON B if the medication is available in contingency stock, would she expect it to be administered to the resident if no stock is available in the medication cart. DON B states, yes. Surveyor asked DON B if she would expect agency staff without contingency codes to seek assistance from other staff members to obtain contingency stock medication. DON B states, yes. On 10/23/24 at 11:35 AM, Surveyor interviewed RN LL. RN LL is employed by an outside agency. Surveyor asked RN LL if R26 told her she was in pain during her visit on 10/22/24. RN LL stated that she was told the resident asked for her pain medication, but that facility staff told her they had nothing to give R26. RN LL also stated that R26 told her that her pain was at 9 out of 10 severity. Surveyor asked RN LL if she made any visible observations of the resident's status. RN LL stated that she could visibly see that the resident was in pain. Surveyor asked if the facility ever returned the call that RN LL had requested. RN LL stated they did not, so she called R26 directly to check on her. R26 was admitted with diagnosis including Acute on Chronic Diastolic (Congestive) Heart Failure and Infection and Inflammatory Reaction due to Internal Right Hip Prosthesis. R26 was in severe, breakthrough pain and the facility did not provide R26 with her prescribed PRN pain medication or document non-pharmacological pain management causing the resident to experience severe pain for 5 hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, prevent new ulcers from developing, and a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable in 1 of 3 residents reviewed for pressure injury concerns (R32) out of a total sample of 18. R32 was at risk for PI (Pressure Injury) development due to his diagnoses and health history. The facility failed to follow physician's orders and ensure interventions were in place to prevent the PI from developing or worsening. Evidenced by: According to the NPUAP's (National Pressure Ulcer Advisory Panel), Prevention and Treatment of Pressure Ulcers/Injuries Quick Reference Guide 2019: .Risk Factors and Risk Assessment 1.1 Consider individuals with limited mobility, limited activity and a high potential for friction and shear to be at risk of pressure injuries . 1.3 Consider the potential impact of an existing pressure injury of any Category/Stage on development of additional pressure injuries . 1.7 Consider the impact of diabetes mellitus on the risk of pressure injuries. 1.8 Consider the impact of perfusion and circulation deficits on the risk of pressure injuries . 1.10 Consider at the impact of impaired nutritional status on the risk of pressure injuries . 1.17 Consider the impact of time spent immobilized before surgery, the duration of surgery and the American Society of Anesthesiologists (ASA) Physical Status Classification on surgery-related pressure injury risk . 1.24 When conducting a pressure injury risk assessment: o Use a structured approach o Include a comprehensive skin assessment o Supplement use of a risk assessment tool with assessment of additional risk factors o Interpret the assessment outcomes using clinical judgment . According to the www.npuap.org <http://www.npuap.org> the NPUAP (National Pressure Ulcer Advisory Panel): 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. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 2 Pressure Injury: 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). Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose is visible in the ulcer and granulation tissue and epibole are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e., dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. The Facility's Policy and Procedure titled, Skin Management Guideline, with an effective date of 11/28/17, indicates, in part: Purpose: To ensure residents that are admitted to the facility are evaluated to determine appropriate measures to be taken by the interdisciplinary care team to determine appropriate measures and individualized interventions to prevent, reduce and treat skin breakdown. It is the practice of this facility to properly identify and evaluate residents whose clinical conditions increase the risk for impaired skin integrity, and pressure ulcers; to implement preventative measures; and to provide appropriate treatment modalities for wounds according to industry standards of care .Procedure: I. Prevention of Pressure Ulcers * All residents admitted to the facility will be evaluated for actual and potential skin integrity issues . An individualized plan of care will be developed upon admission, reviewed, and updated quarterly and with a change in condition as needed. The plan of care will identify impairment and predicting factors. Interventions for prevention, removing and reducing predicting factors and treatment for skin may include: * Pressure redistribution surface for bed and seating surfaces: Specified through clinical evaluation and determination * Adaptive equipment and seating to support and encourage correct anatomical alignment . *Specified turning and repositioning . *Pressure, friction, shear reduction . B. Monitoring of Skin Integrity . *The Care Plan for Skin Integrity is to be evaluated and revised based on response, outcomes, and needs of resident . II. Treatment of Pressure Ulcers .If a resident is admitted with or there is a new development of a pressure ulcer or lower extremity ulcer the following procedure is to be implemented:1. Review the wound formulary for guidance 2. Consult with the Physician/NP and Resident Representative .6. Re-evaluate turning and repositioning interventions 7. Initiate Braden Scale and initiate investigation process if new onset .10. Initiate the Wound Initial Documentation Observation in PCC (Point Click Care) .The Weekly Wound Documentation Observation in PCC should only have ONE WOUND per observation . The Facility's Policy and Procedure titled, Skin Protection Guideline, with an effective date of 7/7/21, indicates, in part: Purpose: To provide evidenced based practice standards for the care and treatment of skin. To ensure residents that admit and reside at our facility are evaluated and provided individualized interventions to prevent, reduce and treat skin breakdown .Evaluation .The process includes evaluating: *Specific risk factors and changes in the resident's condition that may impact the development and/or healing of a PU/PI (Pressure Ulcer/Pressure Injury) *Implementing, monitoring, and modifying interventions to stabilize, reduce or remove underlying risk factors *If a PU/PI is present, provide treatment to heal and prevent the development of additional PU/PIs . The NPIAP (National Pressure Injury Advisory Panel) outlines the following (this list is not all inclusive and each resident must be reviewed for potential, individualized risk factors). Some factors are modifiable [NAME] [sic] others are not: *Limited mobility and activity *Friction *Shearing *Presence of current injuries: Risk for worsening and / [sic] or additional development *Alterations in skin status over pressure points *Diabetes *Disease or condition that alters perfusion and create circulatory deficits . *Alterations in sensory perceptions *Immobilization before a surgery, the duration of surgery and related impacts on skin including: -Duration of crucial care stay -Mechanical ventilation -Use of vasopressors . An admission evaluation helps identify residents at risk of developing a PU/PI, and residents with existing PU/PIs. Because a resident at risk can develop PU/PI within hours of the onset of pressure, the at-risk resident needs to be identified and have interventions implemented promptly to attempt to prevent PU/PI . The admission evaluation helps define those initial care approaches. In addition, the admission evaluation may identify pre-existing signs suggesting that tissue damage has already occurred, and additional tissue loss may occur . Some situations, which may have contributed to this tissue damage prior to admission, include pressure resulting from immobility during hospitalization or surgical procedures, during prolonged ambulance transport, or while waiting to be assisted after a debilitating event, such as a fall or a cerebral vascular accident . Interventions Interventions for prevention, removing and reducing predicting factors and treatment for skin may include (This list is not all-inclusive): *Selection of an individualized support surfaces (A specialized device for pressure re-distribution designed for management of tissue loads, micro-climate and / or [sic] other therapeutic functions) for bed and seating to enhance pressure re-distribution *Specified through clinical evaluation and determination *Adaptive equipment and seating to support and encourage correct anatomical alignment . *Specified turning and repositioning . *Pressure, friction, shear reduction . R32 was admitted to the facility on [DATE], with diagnoses that include, in part: Displaced intertrochanteric fracture of right femur; Acute embolism and thrombosis of unspecified deep veins of right lower extremity; Rhabdomyolysis; Wedge compression fracture of unspecified thoracic vertebra; Unspecified Fall; Moderate Protein-Calorie Malnutrition; and Type II Diabetes Mellitus . R32's most recent MDS (Minimum Data Set) with a target date of 6/12/22, documents a BIMS (Brief Interview of Mental Status) score of 7, which indicates, a severe cognitive impairment. R32's Adult Hospital Medicine admission History and Physical Note, with a date of service of 5/24/22, indicates, Pt reports having fallen four days ago in his kitchen after losing his balance. He landed on his right hip, crawled back into bed and has been there since. He had some food and drink near his bed, but that is all he has had since then. He did take his medications. The pt. endorses that he was urinating into bottles because he was unable to get up due to the pain . R32's Physician Transfer Order Report, indicates, in part: Active Problems: Acute deep vein thrombosis (DVT) of right lower extremity . It is important to note R32's report of decreased mobility while in bed for a 4-day period, decreased perfusion due to an acute DVT of the right lower extremity, decrease nutrient intake and the potential for friction and shear while crawling back to bed would increase R32's risk for developing PIs. R32's Physician Transfer Order Report, indicates, in part. Discharge Orders: Admit to: Skilled Nursing Facility . Dressing and Wound Orders: -Minimize pressure with frequent repositioning, scheduled turning every 2 hours with a 30-degree tilt -Therapeutic support surface (low air loss mattress). -Minimize friction and shear by keeping skin clean and moisturized (use lift sheet or TAPS (Turning and positioning system) system. -Incontinence management Current wound care recommendations include: Location: Left posterior thigh Frequency: Every 3 days and as needed if soiled, saturated, or loose. Cleanse wound gently with normal saline and gauze - Apply a thin layer of the Medihoney directly to the wound bed (approximately a nickel thickness) or onto a dressing. Additional Dressing and Wound Instructions: -Minimize pressure with frequent repositioning, scheduled turning every 2 hours with a 30-degree tilt. -Therapeutic support surface (low air loss mattress) -Minimize friction and shear by keeping skin clean and moisturized (use of lift sheet or TAPS system) Expected Discharge & Plan (recommendations) Discharge cares as follows: Same as above. Manufacturer's recommendations were requested for R32's wheelchair cushion, mattress on admission, and current air mattress. On 8/17/22 at 2:49 PM Recommendations were provided for Direct Supply Panacea Immerse Mattress. The documentation does not note what stage PI the mattress is rated for. DOO R (Director of Operations) indicated she is still working on finding more information. The following information was provided to the Surveyor by the facility: -R32's mattress, on admission to the facility, is noted to be a Direct Supply Panacea Immerse Mattress with the following information noted on the manufacturer documents provided to Surveyor: *The mattress manufacturer has tested the technology used in the Panacea Immerse mattress to assess its comfort and pressure redistribution properties. A full study, entitled A prospective Study of a Unique Open-Cell Foam Mattress with a Modified Top Layer in hospitalized General Medical-Surgical Patients, is included for your convenience. The findings show that, when used properly as part of a comprehensive care program, the Panacea Immerse technology did not lead to skin breakdown in patients with intact skin at the time of admission, and improved existing skin integrity in over 75% of patients with existing decubitus ulcers . The facility also provided the Surveyor with information for Direct Supply Panacea ImmersaGel Mattress and highlighted the following information: These pressure redistribution support surfaces are appropriate for use as part of an overall care plan to prevent and treat decubitus ulcers. Resident-specific assessment could alter your usage of these mattresses. It is unclear based on the differing mattress information documents received from the facility, which mattress the resident was using on admission. The facility failed to implement physician admission orders for a low air loss mattress (LAL). Of note, there was no information regarding pressure injury prevention/treatment rating in the manufacturer's recommendations obtained from the facility. There is no evidence that the mattress R32 was using on admission was appropriate for his PI present on admission or to prevent future injury. Of note, R32's Hospital Physician Transfer Report indicates Dressing and Wound orders for Left Posterior Thigh Wound, indicating a wound was present on discharge from the hospital. R32's Facility wound evaluation, dated 6/7/22, denotes an area of 5.53 cm x 4.07 cm to Left Thigh Lateral, with the wound bed documented as 100% eschar. Of note, a wound described as 100% eschar under current standards of practice would be categorized as an unstageable PI. -R32's current mattress, implemented on 6/22/22, is noted to be an Integra Healthcare Equipment True LAL (Low Air Loss Mattress) System. Product Description: Our True Low Air Loss System with Pulsation offers an extraordinary therapeutic mattress system for the prevention and treatment of pressure ulcers . Of note, R32 did not receive the LAL until 6/22/22, 10 days after the first documentation, on 6/12/22, of the left and right buttock pressure ulcers starting and 7 days after the coccyx wound can be seen on the June 15, 2022, Wound Evaluation picture. According to the NPUAP's (National Pressure Ulcer Advisory Panel), Prevention and Treatment of Pressure Ulcers/Injuries Quick Reference Guide 2019: .Support Surfaces 7.1 Select a support surface that meets the individual's need for pressure redistribution based on the following factors: o Level of immobility and inactivity o Need to influence microclimate control and shear reduction o Size and weight of the individual o Number, severity, and location of existing pressure injuries o Risk for developing new pressure injuries . 7.4 Use a high specification reactive single layer foam mattress or overlay in preference to a foam mattress without high specification qualities for individuals at risk of developing pressure injuries. 7.5 Consider using a reactive air mattress or overlay for individuals at risk for developing pressure injuries . 7.7 Assess the relative benefits of using an alternating pressure air mattress or overlay for individuals at risk of pressure injuries . 7.9 For individuals with a pressure injury, consider changing to a specialty support surface when the individual: o Cannot be positioned off the existing pressure injury o Has pressure injuries on two or more turning surfaces (e.g., the sacrum and trochanter) that limit repositioning options o Has a pressure injury that fails to heal or the pressure injury deteriorates despite appropriate comprehensive care o Is at high risk for additional pressure injuries o Has undergone flap or graft surgery o Is uncomfortable o 'Bottoms out' on the current support surface . R32's Skin and Wound Evaluation with an effective date of 6/7/22 indicates the following: A. Describe 1. Type 5. Bruise .22. Location Right Antecubital Space 23. Acquired .2. Present on admission 24. How long has the wound been present? 2. Exact Date .24a. Exact Date: 6/6/22 .I. Progress .3. Notes: Bruising noted to Right Antecubital Space. No open measurable areas noted. No concerns noted. Resolved on admission assessment . Of note: No other Skin or Wound areas are noted on this evaluation. R32's Braden scale evaluations (an evidenced-based tool that predicts the risk for developing a pressure injury) noted the following: *Effective date of 6/6/22, noted a score of 17 (at risk) *Effective date of 6/13/22, noted a score of 16 (at risk) *Effective date of 6/20/22, noted a score of 16 (at risk) R32's care plan documents the following, in part: Focus: The resident has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) fx. (fracture) of right femur, malnutrition, wedge compression fx. of thoracic spine, falls, malaise, alcohol abuse, heart disease and weakness. Date Initiated 6/6/22. Interventions/Tasks: Bed Mobility: Physical Assist x 2. Date Initiated 6/11/22. Transfers: Resident requires: 1 assist stand-pivot with 2ww (wheeled walker) to/from WC (wheelchair) to/from edge of bed . Focus: The resident has limited physical mobility r/t fx. of right femur, malnutrition, wedge compression fx. of thoracic spine, falls, malaise, alcohol abuse, heart disease and weakness. Date Initiated: 6/6/22. Interventions/Tasks: * Resident has a weight bearing restriction (NWB (non-weight bearing) to Right leg r/t hip fx.) Date Initiated: 6/6/22. *Uses Wheelchair (ensure foot pedals are in place). *Provide supportive care, assistance with mobility as needed. Document assistance as needed. Date Initiated: 6/6/22 . Focus: The resident has potential for impairment to skin integrity r/t limited mobility. Date Initiated: 6/6/22. Interventions/Tasks: *-Monitor skin when providing cares, notify nurse of any changes in skin appearance. Date Initiated: 6/6/22 . Focus: The resident has actual impairment to skin integrity to left and right buttocks and Right Thigh (Lateral) r/t abrasions and surgical incision. Date Initiated: 6/30/22. Interventions/Tasks: * Evaluate and treat per physicians' orders. Date Initiated: 6/6/22 . * 6/22/22: The resident needs pressure relieving/reducing mattress i.e.: air mattress while in bed and continued use of cushion in wc. Date Initiated: 6/30/22 . * The resident needs assistance and reminding to reposition every 2-3 hours while in bed or in wheelchair. Date Initiated: 6/22/22 . Focus: The resident has bladder incontinence r/t limited mobility. Date Initiated: 6/6/22. Interventions/Tasks: * Clean peri-area with each incontinence episode. Date Initiated 6/6/22 . R32's CNA (Certified Nursing Assistant) care plan, documents the following in part: Skin: * 6/22/22: The resident needs pressure relieving/reducing mattress i.e.: air mattress while in bed, and continued use of cushion in the wc .Bed Mobility: * Bed Mobility: Physical Assist x 2 .Resident Care: *The resident needs assistance and reminding to reposition every 2-3 hours [NAME] in bed or in wheelchair . R32's Progress Notes document the following: 6/6/22 3:52PM Nursing Evaluation: (Admit, Readmit, Qtly, Annual Sig Change) . Resident admitted from: (Hospital Name) Skin Integrity: The resident has skin integrity concerns. 0 .Musculoskeletal: Resident has weakness. Location: Left hand and legs Resident has weight bearing restriction. Location: Weight bearing as tolerated right lower extremity. No ROM (Range of Motion) impairment to upper extremities. ROM impairment to RLE (Right Lower Extremity). The resident needs assistance with ADL's. Resident uses assistive device/s: Wheelchair . 6/12/22 5:55 PM (Created Date) Health Status Note (nurses note): Placed dressing to buttocks, pressure ulcers starting to bilateral buttocks, cleansed, and dressed with bordered gauze. Blanchable purple discoloration to buttocks/coccyx area. Educated resident to reposition q2hours (every), placed pillow under left side. Reported to oncoming nurse to reposition resident q2hours. Unstageable pressure ulcer to left gluteal fold noted, cleansed and Medahoney [sic] applied with bordered gauze. It is important to note the wound evaluation notes for the right and left buttock denote wound evaluation dates of 6/13/22 and note minutes old. 6/23/22 1:01 PM Health Status Note (nurses note). Note Text: Roho cushion ordered today for resident to use while in wheelchair. New wound care orders were obtained per discussion with provider .Re-education given to resident on importance of repositioning every two-three hours to promote healing and prevent further breakdown, resident was able to verbalize and understanding and repeat back education . Of note, Information obtained from the facility regarding R32's wheelchair cushion notes it is a Direct Supply Foam Cushion, not a Roho. Surveyor also observed R32's wheelchair with staff and noted a Foam Cushion with Direct Supply Label. 6/27/22 3:25PM Health Status Note (nurses note) Note Text: During dressing change to left and right buttocks and coccyx, it was noted that wound continues to deteriorate. Slough noted to wound bed on coccyx with opening noted to center. Increased depth noted and tunneling at 12 o'clock of 3.8cm. Wound bed with foul smell. Moderate serosanguineous drainage. Provider, NP contacted. NP ordered to have resident sent out for further wound evaluation due to rapid deterioration . Of note, R32 declined to be interviewed or allow Surveyor to observe wound care. R32's Wound Evaluations documents include the following, in part: ---Left Thigh Lateral Evaluated on 6/7/22 #3 Abrasion Body Location: Left Thigh Lateral New - 1 day old Acquired: Present on Admission Dimensions: Length: 5.53cm Width 4.07cm Deepest Point 0cm Wound Bed: % Eschar 100% . Periwound: Edges - Epithelialization; Surrounding Tissue - Intact; Induration - None Present; Edema - No swelling or edema; Change in Temperature (Degrees) - 0; Periwound Temperature - Normal . Progress: New Notes: Wound noted to Left Thigh (Lateral) with complete eschar to wound bed. Small amount of old serosanguineous drainage noted to old dressing. No s/s of infection. Wound cleansed with wound cleanser, pat dried. Medihoney applied to eschar, covered with foam border, resident tolerated well. Provider updated . Of note, a wound described as 100% eschar, under current standards of practice, would be categorized as an unstageable PI. Evaluated on 6/8/22 #3 Abrasion Body Location: Left Thigh Lateral Stable - 2 days old Acquired: Present on Admission Dimensions Length: 3.89cm Width 3.88cm Deepest Point 0cm Wound Bed: % Slough 10%; % Eschar 90% Periwound: Edges - Epithelialization; Surrounding Tissue - Intact; Induration - None Present; Edema - No swelling or edema; Change in Temperature (Degrees) - 0; Periwound Temperature - Normal . Progress: Stable Notes: Eschar noted to wound bed. Small amount of slough noted around the outer edges of wound bed. Small amount of serosanguineous drainage noted to old dressing. No s/s of infection. Wound care provided per order; resident tolerated it well. Evaluated on 6/15/22 #3 Abrasion Body Location: Left Thigh Lateral Stable - 9 days old Acquired: Present on Admission Dimensions: Length: 4.88cm Width 3.39cm Deepest Point 0.2cm Wound Bed: % Slough 10%; % Eschar 90% . Periwound: Edges - Epithelialization; Surrounding Tissue - Intact; Induration - None Present; Edema - No swelling or edema; Change in Temperature (Degrees) - 0; Periwound Temperature - Normal . Progress: Stable Notes: Wound bed with eschar and slough. Small amount of drainage noted. No s/s of infection. Wound care provided per order. Resident tolerated it well. Evaluated on 6/22/22 #3 Abrasion Body Location: Left Thigh Lateral Stable - 16 days old Acquired: Present on Admission Dimensions: Length: 4.2cm Width 3.84cm Deepest Point 0.4cm Wound Bed: %Granulation 10%; % Slough 60%; % Eschar 30% . Periwound: Edges - Epithelialization; Surrounding Tissue - Erythema; Induration - None Present; Edema - No swelling or edema; Change in Temperature (Degrees) - 0; Periwound Temperature - Normal . Progress: Stable Notes: Wound bed with eschar and slough. Heavy serosanguineous drainage noted. Foul smell noted to wound bed. Wound care provided per order; resident tolerated well. Provider updated. It is important to note the following: R32's Physician Transfer Order Report, which includes a picture of R32's left posterior thigh, indicates under the picture: Large open wound, appears as this may have been a caused by traumatic injury. This is a typical for a pressure related injury. Measures 7.5cm x 7.5cm partial thickness wound. Further documentation notes: .Appraisal: -R32 with anasarca. -Wound to the posterior left upper posterior thigh appears as a possible skin tear with full flap loss. There is no surrounding tissue erythema and is a typical for pressure related injury . -Low air loss mattress in place d/t R32's low mobility status . Based on Surveyor review of wound care documentation and pictures (Best seen on June 22, 2022, documentation) provided by the facility, along with review of The Physician Transfer Report documentation, the body location appears to be the same posterior aspect of the left thigh versus the lateral thigh description given in facility wound evaluations. R32's Physician order, dated 6/6/22, includes in part: Left Posterior thigh. Cleanse wound with normal saline and gauze. Apply thin layer of Medihoney directly to wound bed. Use Mepilex sacral dressing . ---Left Buttock Evaluated on 6/13/22 #5 Abrasion Body Location: Left Buttock New - Minutes old Acquired: In-House Acquired Dimensions: Length: 2.8cm Width 2.8cm Wound Bed: %Granulation 100% . Periwound: Edges - Attached; Surrounding Tissue - Erythema Fragile; Induration - None Present; Edema - No swelling or edema; Change in Temperature (Degrees) - 0; Periwound Temperature - Normal . Progress: New Notes: Abrasion noted to left buttock. Open area with granulation tissue. Peri-wound very fragile, erythema noted, area non-blanchable. Wound cleansed with wound cleanser, pat dried. Covered with foam border. Provider updated. Evaluated on 6/15/22 #5 Abrasion Body Location: Left Buttock Stable - 2 days old Acquired: In-House Acquired Dimensions: Length: 3.74cm Width 3.91cm Wound Bed: %Granulation 100% .Other - Pink or red . Periwound: Edges - Attached; Surrounding Tissue - Erythema; Induration - None Present; Edema - No swelling or edema; Change in Temperature (Degrees) - 0; Periwound Temperature - Normal . Progress: Stable Notes: Wound bed with granulation tissue. Peri-wound with erythema. Moderate amount of drainage noted. No s/s of infection. Wound care provided per order; resident tolerated it well. Education: Educated resident on the importance of repositioning every 2-3 hours to promote healing, resident verbalized an understanding . Evaluated on 6/22/22 #5 Abrasion Body Location: Left Buttock Stable - 9 days old Acquired: In-House Acquired Dimensions: Length: 3.5cm Width 3.23cm Wound Bed: %Epithelial 10% .%Granulation 10% .%Slough 80% .Other - Pink or red . Periwound: Edges - Epithelialization; Surrounding Tissue - Erythema; Induration - None Present; Edema - No swelling or edema; Change in Temperature (Degrees) - 0; Periwound Temperature - Normal . Progress: Stable Notes: Wound bed with slough, granulation tissue and epithelial tissue. Moderate amount of serosanguineous drainage noted. No s/s of infection. Wound care provided per order; resident tolerated it well. Provider contacted with update on wound . Of note, a wound described as 80% slough, 10% Epithelial, and 10% Granulation, under current standards of practice, would be categorized, at a minimum, as a stage III PI. This would be considered a deterioration in this wound. It is important to note that on Surveyor review of the different wound evaluation pictures provided of Left Buttock, there are areas of dark purple discoloration noted to right and left buttock. ---Right Buttock Evaluated on 6/13/22 #6 Abrasion Body Location: Right Buttock New - Minutes old Acquired: In-House Acquired Dimensions: Length: 1.49cm Width 1.79cm Deepest Point 0cm Wound Bed: %Granulation 100% .Other - Pink or red. Periwound: Edges - Attached; Surrounding Tissue - Erythema Fragile; Induration - None Present; Edema - No swelling or edema; Change in Temperature (Degrees) - 0; Periwound Temperature - Normal. Progress: New Notes: Abrasion noted to right buttock. Open area with granulation tissue. Peri-wound with erythema, blistering and fragile skin. Small amount of serosanguineous drainage noted. No s/s of infection. Wound cleansed with wound cleanser, pat dry. Covered with foam border dressing. Provider updated. Of note, a wound described as 100% Granulation, under current standards of practice, would be categorized as a stage III PI. It is important to note that on Surveyor review of the picture provided for the 6/13/22 wound evaluation documentation, it appears there is an area dark purple/red discoloration noted on right buttock, sacral/coccyx area, and left buttock. Evaluated on 6/15/22 #6 Abrasion Body Location: Right Buttock Deteriorating - 2 days old Acquired: In-House Acquired Dimensions: Length: 6.5cm Width 3.44cm Deepest Point 0.1cm Wound Bed: %Epithelial 40% .%Granulation 50% .%Slough 10% .Other - Pink or red . Periwound: Edges - Attached; Surrounding Tissue - Blister Fragile; Induration - None Present; Edema - No swelling or edema; Change in Temperature (Degrees) - 0; Periwound Temperature - Normal . Progress: Deteriorating Notes: No dressing in place upon assessment. New open areas noted to coccyx area, granulation tissue noted. Epithelial and granulation tissue noted to other areas. Periwound with erythema, blister, and fragile skin. Moderate amount of serosanguineous drainage noted. No s/s of infection. Wound care provided per order; resident tolerated it well. Provider updated. It is important to note that on Surveyor review of the picture provided for the 6/15/22 wound evaluation documentation, it appears there is an area of slough on the coccyx area. There [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not ensure each resident receives adequate supervision and assistive devices for 1 of 2 residents (R20) reviewed for supervision and accidents out of a total sample of 18. R20 fell 10 times from 3/2/22 to 8/17/22 and fractured her nose and shoulder during two separate falls. Root cause analysis was not complete for each fall and R20 was not assessed for possible bladder and bowel changes as a potential root cause to the falls. Evidenced by: The facility's Fall Evaluation Safety Guideline dated 11/28/2017, includes: -Multiple Falls: *Trend falls for the resident-time of day, reason for fall location of fall, etc; *Refer to Therapy; *Restorative Nursing Programming. R20 was admitted to the facility on [DATE] with diagnoses that include respiratory failure, general muscle weakness, encephalopathy, polyneuropathy, osteoarthritis, history of falls and difficulty walking. R20's Care Plan documents: - Difficult breathing due to history of COVID 19 and respiratory failure; - Impaired visual function; -Bladder incontinence; -Communication problem related to encephalopathy; -Requires physical assistance of two staff to transfer; -Potential for constipation; -Risk for falls includes ensure footwear fits properly, non skid socks/footwear, anticipate and meet resident's needs. R20's MDS (Minimum Data Set) dated 6/2/22 measures R20's BIMS (Brief Interview for Mental Status) as 3 which is cognitively severely impaired. R20 requires limited assistance for bed mobility and transfers. She requires extensive assistance with toileting and scores occasionally incontinent for bladder and bowel. R20's Post Fall Evaluations include: -3/2/22 6:20 AM (Fall with major injury) On 3/2/22 at 6:20 AM, R20 was found on the floor of her room with a bloody nose. The fall incident report indicated R20 was wearing gripper socks at the time of the fall. The Root Cause analysis indicated R20 has history of forgetfulness and did not ask for assistance to get out of bed. Resident was attempting to self transfer. The Intervention for the fall was leave the resident's door open, make sure the floor mat is on floor by her bed and keep bed in low position. Hospital radiology report dated 3/2/22, documents R20 has bilateral comminuted nasal bone fractures with slight displacement. There also seems to be a minimally displaced fracture of the ossified anterior cartilaginous nasal septum. On 8/18/22 at 1:00 PM, Surveyor spoke with LPN D (Licensed Practical Nurse). LPN D said he did not know what the root cause of the fall was; he found her on the floor with a bloody nose and sent her out. LPN D said the fall committee does the fall interventions. -4/3/22 6: 15 AM-Fell on her buttocks-no injury. No Root Cause defined. The Intervention for the fall was keep wheelchair at bedside. -4/9/22-7:00 AM (Injury)-no description of how resident found-no Root Cause defined-R20 had a scalp laceration on left temporal side of head 1.5 centimeters-The Intervention for the fall was mat to floor, door open, wheelchair away from bed (out of reach), call bell within reach and educate on using call bell with every interaction. Note, R20 has cognitive impairment with a BIMS of 3; educating R20 would not be an effective intervention. -5/12/22 2:00 PM-Found resident on floor-wedged between the bed and her wheelchair-Root Cause -is resident may have attempted to transfer and slipped to the floor-and wheel chair may not have been locked-stated she hit the floor with her head but there was no bump or bruise-after neurological check she was lifted back to bed with a hoyer lift-The Intervention for the fall was mat, call bed instruction and keeping wheelchair out of sight initiated. -5/23/22-9:45 AM-Found resident lying on floor trying to get up-lying in her room between her bed and wheelchair-no injury-Root Cause- is it appears resident may have attempted to self transfer-the Intervention for the fall was discussed relocating resident closer to nurses station-all other fall interventions in place. -6/5/22 4:00 AM-(Fall with major injury)-nurse heard noise-resident was sitting in bathroom floor leaning to the left holding her shoulder-unsupervised fall-skin tear to back upper deltoid-assisted resident to wheelchair-ice applied to (guarded area) left shoulder-Hospice, physician and son notified and sent to emergency room-interventions in place-Root Cause -is resident self ambulated to bathroom, did not call for assistance, may be used to getting up early or needed to use the restroom, poor safety awareness-no new Interventions put in place.The hospital radiology report dated 6/5/22 documents R20 had a comminuted fracture involving the surgical neck of the left proximal humerus with posterior angulation of the humeral head with respect to the humeral shaft. On 8/18/22 at 2:00 PM, Surveyor spoke with RN C (Registered Nurse). RN C said she thinks R20 was in the wheelchair and going to the bathroom. RN C did not know the root cause of the fall -7/6/22 5:00 PM-Found on floor on mat beside bed-resident said she was trying to get out of bed-small skin tear to lower leg-Root Cause -is resident attempted to self transfer-resident unable to state why she was trying to get out of bed-it was around dinner time, resident may have been hungry-bed remains in lowest position with fall mat-and call light in place; -7/25/22 8:05 AM-Found on floor at bedside-resident said she was trying to go to the bathroom, crawled/rolled out of bed-Root Cause - it appears resident rolled out of bed-resident stated she needed to use the restroom-resident unable to use call call related to dementia. -8/10/22 3:00 PM-(Injury)-Nurse summoned to resident's room-received report resident had fallen and head was bleeding-sent to emergency room for evaluation-Root Cause-resident appears to have dozed off in her chair and fallen forward-no new Interventions put in place; -8/17/22 4:49 PM-(Injury)-Found in front of her wheelchair lying on the floor on her left side-new laceration of scalp and opening of old laceration of scalp. It's important to note the facility did not have the resident on a toileting program, did not assess her bowel and bladder status with a bowel and bladder diary and did not have the resident on a restorative nursing program to help prevent falls. On 8/18/22 at 2:30 PM, Surveyor spoke to HA E (Hospice Aide). HA E said she always toilets R20 when she is here and does not resist to be toileted. HA E said R20 should be toileted regularly. On 8/18/22 at 2:45 PM, Surveyor spoke to CNA F (Certified Nurse Assistant). CNA F said she offers to toilet R20, but R20 will say no. Surveyor asked CNA F if R20 understands her when she verbally offers R20 to go to the bathroom. CNA F said she was not sure. On 8/18/22 at 3:00 PM, Surveyor spoke to DON B (Director of Nursing). DON B said R20 has many interventions in place and that R20 is very independent. DON B said they have not completed a bowel and bladder diary. DON B said she completes the root cause analysis of each fall. DON B said the root cause analysis and intervention for R20's fall on 8/17/22 has not been completed yet. DON B said they have tried the intervention of toileting R20 every two hours, and that intervention agitated her. Surveyor asked for documentation about R20 being toileted every two and how it agitated her. Surveyor has not received any documentation on the intervention of toileting R20 every two hours and that it agitated her.