Based on observation, interview, and record review, the facility did not ensure 1 resident (R2) of 2 sampled residents reviewed for pressure injuries received the necessary care and services to promote healing and/or prevent pressure injuries from developing. R2 was at risk for pressure injury (PI) development. R2 developed a Stage 3 PI to the right ischium. Facility staff did not ensure PI interventions were in place and did not implement appropriate offloading interventions until after the PI was discovered. The facility policy, Pressure Injury Prevention and Management, updated 7/18/23, indicates, in part, as follows: The facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to health [sic] the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. Definitions: Pressure Ulcer/Injury refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. Avoidable means that the resident developed a pressure ulcer/injury and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors; define and implement interventions that are consistent with resident needs, residents goals, and professional standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate. Procedure: There are multiple terms used to describe this type of skin damage, including pressure ulcer, pressure injury, pressure sore, decubitus ulcer, and bed sore. For purposes of this policy, pressure injury, as the current standard terminology, will be used. The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. Interventions for Prevention and to Promote Healing: After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions. Interventions will be based on specific factors identified in the risk assessment, skin assessment, and any pressure injury assessment (e.g. moisture management, impaired mobility, nutritional deficit, staging, wound characteristics). Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include, but are not limited to: Redistribution pressure (such as repositioning, protecting and/or offloading heels, etc.); Minimize exposure to moisture and keep skin clean, especially of fecal contamination; Provide appropriate, pressure-redistributing, support surfaces . Findings Include: R2 was admitted to the facility 5/15/13 with diagnoses including, but not limited to: cerebral palsy (group of movement disorders that affect movement, muscle tone, and/or posture), schizophrenia (mental illness characterized by delusions, hallucinations, disorganized thoughts, speech and behavior), and malignant neoplasm of endometrium (cancer of the uterine lining). R2's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/25/24 indicates a Brief Interview of Mental Status (BIMS) score of 10 indicating she is moderately cognitively impaired. Section GG of the MDS indicates R2 is dependent on staff to roll left and right. Section M of the MDS indicates R2 has a facility acquired Stage 3 PI. R2 is at risk for pressure injuries. Surveyor attempted to speak with R2. R2 did not respond. R2 has an Activated Power of Attorney for Health Care (APOAHC). R2's comprehensive care plan with discontinued entries, dated 12/5/24, documents R2 had no skin interventions in place prior to the development of a Stage 3 PI. On 1/2/24. R2's Progress Notes document the following: admission: Skin Problems: has no skin condition. R2's Braden Scale for Predicting Pressure Sore Risk are as follows: 1/12/24: 12 (10-12=High Risk) - On 1/12/24 the facility determined R2 is at high risk of PI and did not implement skin interventions until after the PI is discovered at a Stage 3 on 1/18/24. Braden Scale: Sensory Perception: slightly limited - responds to verbal commands, can't alwayscommunicate pain or need to reposition. Moisture: constantly moist - related to perspiration, urine, etc. - dampness noted every time resident is moved or turned. Activity: chairfast - ability to walk is severely limited or none, can't bear weight and/or is assisted to chair or wheelchair. Mobility - very limited - makes occasional slight changes in body/extremity position, can't make frequent/significant changes alone. Nutrition: Adequate - eats more than 1/2 of most meals, eats 4 proteins per day, occasionally refuses a meal, usually take a supplement. Friction/Shear: poblem - moderate/maximum assistance to move, can't lift without sliding on sheets, slides in bed/chair, constant fiction. Score: 12 Risk Category: 10-12= high risk of skin breakdown. It is important to note, on 1/12/24, the facility is aware that R2 is at high risk for developing a pressure injury. The facility did not implement skin interventions until after the PI developed. 3/21/24: 13 (13-14=Moderate Risk) 4/25/24: 12 (High Risk) 7/21/24: 9 (9 or below=Very High Risk) 10/22/24: 14 (Moderate Risk) On 1/18/24 at 10:20 PM, R2's Progress Notes document the following assessment by a Registered Nurse: Area 1: Right ischial area; Assessment Type: Initial assessment; Onset/Discovery Date: 1/18/24; Origin: Noted after admission; Initial Stage: stage 3; Tissue Type: granulation; Wound Tissue: pink; Granulation Tissue: Percentage is blank; 100% NECROTIC TISSUE: none viable; Shape of Wound: Irregular; Wound Edges: Distinct, outline clearly visible, attached, even with wound base; Undermining: none present; Tunneling: no tunneling; Surrounding Wound Tissue: Macerated; Surrounding Wound Edema: No swelling or edema; Surrounding Wound Induration: none present; Exudate: Serosanguineous; Exudate Amount: moderate - wound tissues are wet; drinage involves more than 25-75% of the dressing; Condition of the dressing: No dressing; Pain at Pressure Injury Site: unable to answer, no non-verbal signs or symptoms of pain present; Healing Progress: not applicable (new area); Depth/Thickness: depth 0.3 cm Length 2.7 cm Width: 3.0 (Standard Charting: 2.7 cm x 3.0 cm x 0.3 cm) Pressure Injury Infection: non s/s (signs/symptoms) of infection present. Action: Call placed to POA (Power of Attorney) without answer-will await a return response. Therapy referral made for positioning. On 1/19/24 at 11:03 PM, R2's Progress Notes document the following assessment: Incident type: other: skin integrity r/t issues. New open area to R (right) gluteal area to buttock. Ruddy colored skin patchy white colored superior side and inferior lateral side of irregular shaped 2.7 cm x 3.0 cm x 0.3 cm. RN (Registered Nurse) staff nurse also view redness and curled skin edges per circumference. Serosang (Serosanguineous) drainage; Measurement: 2.7 x 3.0. Location on Body: R (right) gluteal cleft/fold of buttock 0.3 depth Stage 3 ulcer per Physician (Physician V). Witnesses: none; Functional Level: visual impairment; Impulsive decision maker, cognitive impairment; Derm incontinence and circulation r/t (related to) issues; Transfer/Assistive Devices: EZ lift; Resident Interviewable: no; Pertinent Diagnosis/Meds/Labs: fragile skin, derm incontinence. Root Cause of Injury: fragile skin and derm incontinence brief irritated skin; Interventions in place to prevent further injury: Resident to lay down off R (right) side post meal time and HS (bedtime). No brief while in bed. Follow up with wound care MD (Medical Doctor) and Primary MD. MD Notification: Physician V; Date Notified: 1/18/24; Time Notified: 10:22 PM; .Teaching Done: none/not applicable. New orders received. R2's current wound care order: Rt (right) ischium - cleanse/dry, apply collagen sheet to wound bed, cover with calcium alginate, cover with gauze island dressing every evening and night shift AND as needed for missing or soiled dressing On 2/8/24, the wound physician assessed R2 for the first time. The physician's assessment is as follows: 2/8/24: Stage 3 Pressure Wound of the Right Ischium Full Thickness Etiology: Pressure Stage: 3 Duration: Greater than 18 days Objective: Healing/Maintain Healing Wound Size: 2.5 x 3.0 x 0.2 cm Exudate: Moderate Sero-sanguinous Thick adherent devitalized necrotic tissue: 20% Granulation tissue: 80% Wound Progress: Not at goal Surgical Excisional Debridement Procedure completed Dressing Treatment Plan: Primary Dressing: Alginate calcium with silver apply once daily for 30 days. Secondary Dressing: Gauze island with bdr (border) apply once daily for 23 days. On 11/4/2024 at 10:42 PM, R2's Progress Notes document the following: Administration Note Note Text: wound care: Rt ischium - cleanse/dry, apply iodosorb to wound bed, cover with calcium alginate, cover with gauze island dressing every evening and night shift wound left open to air this PM shift. Wound dressing becomes saturated with urine and the urine is trapped against skin. Resident is demonstrating greater skin break down at this time. On 12/4/24 at 10:15 AM, Surveyor observed R2's PI. Surveyor asked LPN D (Licensed Practical Nurse) if R2's PI has improved. LPN D stated, it has improved quite a bit and the physician just changed the treatment. LPN D stated, R2 had a foley catheter in for a while as urine would keep going into that area. LPN D stated, R2 was previously on a chux in bed and now they put briefs on R2 while in bed and that seems to be pulling more moisture away from her skin. LPN D added, R2 has a cyst that also drains and she may have cancer. LPN D stated, R2's APOAHC does not want any further interventions done. On 12/5/24 at 1:47 PM, Surveyor spoke with CNA C (Certified Nursing Assistant). CNA C has worked at the facility for one (1) year. Surveyor asked CNA C, did you get R2 up this morning. CNA C stated, yes. Surveyor asked CNA C, was R2's dressing in place when you got her up. CNA C stated, no. Surveyor asked CNA C, did you tell anybody. CNA C stated, it was at shift change and she told both the NOC (night) nurse and LPN D (Licensed Practical Nurse), the AM shift nurse. CNA C stated, usually R2's dressing is on but she has noticed an issue with NOC shift and the dressing not being on when she comes on for the AM shift. CNA C stated, sometimes when she arrives at 6:00 AM, R2 is already up and dressed for the day and we don't realize her dressing is off until later that day. CNA C stated, she does not know if there's miscommunication on the NOC shift or they forget. CNA C stated, usually throughout the day if the dressing is soiled or off we tell the nurse on duty. CNA C stated, the nurse will put the dressing on before the next meal or whenever she has time. Surveyor asked CNA C, how often do you notice that R2's dressing is off. CNA C stated, 2-3 days out of the week R2's dressing is not on. CNA C added, it varies depending on the nurse on. Surveyor asked CNA C, if she has noticed any correlation with the dressing being off and the nurse on duty. CNA C stated, yes, most often when agency staff are working that's when she notices the dressing off. CNA C added, there's more agency on NOC shift than other shifts. On 12/5/24 at 1:50 PM, Surveyor observed R2's dressing in place. On 12/5/24 at 1:15 PM and 4:20 PM, Surveyor spoke with DON B (Director of Nursing). Surveyor asked DON B, when was R2's PI discovered. DON B stated, 1/18/24. Surveyor asked DON B, when was the physician notified. DON B stated, 1/18/24. Surveyor asked DON B, if a resident is at risk of PI's (Braden) would you expect interventions to be in place. DON B stated, yes. Surveyor asked DON B, what stage was R2's PI when it was discovered. DON B stated, a Stage 3. Surveyor asked DON B, did the facility complete a root cause analysis for R2's PI. DON B stated, she has no idea it was before she was working at the facility. Surveyor asked DON B, what skin interventions were in place prior to the PI being discovered. DON B stated, none. DON B stated, that's not a good thing. Surveyor asked DON B, would you expect staff to find a PI before it reaches this point. DON B stated, yes. DON B checked to see if R2 had gone out to the hospital prior to the PI being discovered and stated the resident had not been out to the hospital. Surveyor asked DON B if their wound care nurse is wound care certified. DON B stated, yes, she is. Surveyor asked DON B, did the facility provide education to staff following this PI being discovered. DON B stated, she hasn't seen anything and she has been through the file cabinet in her office. DON B reached out to the facility's wound care nurse regarding training. The facility did not provide any additional information. Surveyor asked DON B, when was R2's last skin assessment prior to the PI being discovered on 1/18/24. DON B stated, the facility does not complete bath sheets and she is unsure. DON B stated, she will check. Surveyor showed DON B the progress note from 11/4/24 indicating, .wound left open to air this PM shift. Wound dressing becomes saturated with urine and the urine is trapped against skin. Surveyor asked DON B, is it acceptable for staff to leave a PI uncovered. DON B stated, no. Surveyor asked DON B, why is it important to keep PI's covered. DON B indicated for infection control. Surveyor asked DON B, is it also important for wound healing. DON B stated, absolutely. DON B stated, she has been told that this nurse doesn't like to change R2's dressing. Surveyor asked DON B, have you provided education to this nurse. DON B stated, no, she has not had a chance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure residents maintain acceptable parameters of nutritional and hydration status for 1 of 1 Residents (R11) reviewed for nutritional status. R11 did not have appropriate interventions put into place to prevent continued weight loss. R11 had a weight loss of 20.6 pounds/12.86% over 2 months and 10 days, indicating a severe weight loss. This is evidenced by: Facility policy titled, Weight Policy, undated, states in part, Goal: To evaluate and meet the nutritional needs of our residents. Objective: Obtain weights as ordered or specified by this policy to monitor changes in weight, weight patterns, and implement appropriate interventions as needed. Procedure: . 3. Each resident will have weight measured at least monthly, unless on hospice. Weight may be obtained weekly, bi-weekly, or daily, depending on the specific needs of an individual resident . 5. If the current weight is +/- 4# (pounds) different than previous weight, resident must be re-weighed. Re-weight must be noted on the weight sheet. If weight changes persist, assess: . For Loss: Changes in condition, chewing or swallowing difficulty, change in diet/appetite/intake, denture fit, oral problems, changes in diuretic medications . 8. Weights are to be recorded on the daily/weekly/monthly weight sheets, located at the nurses station. 9. Each month, the RN (registered nurse) and RD (registered dietician) will assess the weights of the resident's and document this If unexplainable or not anticipated weight changes are significant, (resident gains or loses 5% of their body weight in 30 days or 10% in 180 days) they will be added to New Glarus Home: Critical At Risk monitored to be reviewed by RN/RD. R11 was admitted to the facility on [DATE], with diagnosis that include, in part: Bipolar II disorder (mental illness that cycles through high and low moods), weakness, Major Depressive Disorder, morbid obesity, aortic aneurysm (weak spot in the aorta that begins to bulge), and Type 2 Diabetes Mellitus (chronic insulin resistance or insufficient insulin production). R11's most recent Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/14/24 states in part, R11 has a Brief Interview for Mental Status (BIMS) of 9 out of 15, indicating that R11 has a moderate cognitive impairment. E0100 indicates the resident does not exhibit symptoms of hallucinations or delusions. E0800 also indicates that the resident did not refuse cares during the observation period. GG0115 indicates the resident has no impairment in her upper extremities with bilateral lower extremity impairment. GG0130A states the resident only requires assistance with setup or clean-up. K0100 indicates the resident did not exhibit signs of a possible swallowing disorder. K0300 indicates the resident has had a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months that was not a physician-prescribed weight-loss regimen. R11's Comprehensive Care Plan, states, in part: Focus: [Resident Name] has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) arthritis, I am overweight, hx (history) of bipolar, depression, diabetes. Goal: The resident will maintain current level of function in my ADLs through the review date. Date Initiated: 1/29/24. Revision on: 9/11/24. Target Date: 12/8/24. Interventions/Tasks: . EATING: without help if you set out what I need I would like small portions. Help me to put my glasses on before I eat. Date initiated: 2/8/24. (Of note: After all of R11's weight changes and being added to the facility's Critical at Risk Monitoring meetings, R11's care plan still indicates she is overweight. Additionally, R11 does not have a specific care plan related to her nutrition status or nutrition risk,) R11's Physician Orders state, in part: High Protein/High Calorie diet, Regular texture, Regular/Thin consistency. Start date: 8/29/24. House Supplement (Shakes). Start date: 2/1/24. R11's Meal Card for breakfast on Friday, 12/6/24, indicates the resident has a regular diet, with regular texture and thin fluids. (Of note: R11's previous diet was a carbohydrate control diet as treatment for her type 2 diabetes). R11's weights were documented as follows: 7/1/24: 160.2 lbs. (pounds) 8/22/24: 144.9 lbs. 9/11/24: 139.6 lbs. 10/1/24: 140.9 lbs. 10/2/24: 140.9 lbs 10/19/24: 142 lbs. 10/28/24: 137.8 lbs. 10/31/24: 139 lbs. (Of note: from July 2024 through survey entrance date of 12/2/24, these are all the weights that had been assessed for R11. Facility policy states the resident should be weighed at least monthly, however R11 did not have a recorded weight for November). R11's meal intake documentation indicates, in part: 11/6/24 at 1:58 PM: 51%-75% 11/7/24 at 1:57 PM: 75%-100% 11/7/24 at 9:09 PM: 25%-50% 11/8/24 at 9:00 AM: 51%-75% 11/8/24 at 1:00 PM: 51%-75% 11/9/24 at 11:28 AM: 51%-75% 11/9/24 at 1:00 PM: 51%-75% 11/10/24 at 10:00 AM: 51%-75% 11/10/24 at 1:00 PM: 51%-75% 11/10/24 at 9:56 PM: 75%-100% 11/11/24 at 9:00 AM: 25%-50% 11/11/24 at 1:00 PM: 25%-50% 11/12/24 at 10:20 AM: 51%-75% 11/12/24 at 1:00 PM: 75%-100% 11/13/24 at 9:00 AM: 75%-100% 11/13/24 at 1:00 PM: 75%-100% 11/14/24 at 11:19 AM: 25%-50% 11/14/24 at 1:00 PM: 25%-50% 11/14/24 at 6:00 PM: 51%-75% 11/15/24 at 10:31 AM: 25%-50% 11/15/24 at 1:39 PM: 51%-75% 11/16/24 at 11:00 AM: 51%-75% 11/16/24 at 1:51 PM: 51%-75% 11/16/24 at 8:36 PM: 0%-25% 11/17/24 at 1:35 PM: 75%-100% 11/18/24 at 10:26 AM: 51%-75% 11/18/24 at 12:00 PM: 51%-75% 11/18/24 at 6:00 PM: 25%-50% 11/19/24 at 10:16 AM: 51%-75% 11/19/24 at 1:00 PM: 0%-25% 11/19/24 at 6:00 PM: 25%-50% 11/20/24 at 1:59 PM: 51%-75% 11/20/24 at 9:09 PM: 75%-100% 11/21/24 at 8:54 AM: 25%-50% 11/21/24 at 1:29 PM: 25%-50% 11/21/24 at 9:46 PM: 25%-50% 11/22/24 at 10:35 AM: 0%-25% 11/22/24 at 1:30 PM: 25%-50% 11/22/24 at 6:00 PM: 25%-50% 11/23/24 at 9:56 AM: 51%-75% 11/23/24 at 1:00 PM: 25%-50% 11/23/24 at 9:32 PM: 51%-75% 11/24/24 at 10:44 AM: 25%-50% 11/24/24 at 1:00 PM: 0%-25% 11/24/24 at 8:49 PM: Resident Refused 11/25/24 at 6:00 PM: 75%-100% 11/26/24 at 1:44 PM: 51%-75% 11/26/24 at 7:40 PM: 51%-75% 11/27/24 at 9:42 AM: 51%-75% 11/27/24 at 1:22 PM: 51%-75% 11/27/24 at 6:00 PM: 51%-75% 11/28/24 at 1:47 PM: 75%-100% 11/29/24 at 9:48 AM: 75%-100% 11/29/24 at 1:32 PM: 75%-100% 11/30/24 at 9:00 AM: 25%-50% 11/30/24 at 1:00 PM: 25%-50% 11/30/24 at 6:00 PM: 0%-25% 12/1/24 at 10:28 AM: 0%-25% 12/1/24 at 1:47 PM: 25%-50% 12/1/24 at 6:00 PM: 0%-25% 12/2/24 at 9:00 AM: 25%-50% 12/2/24 at 1:00 PM: 0%-25% 12/2/24 at 9:12 PM: 25%-50% 12/3/24 at 9:31 AM: 51%-75% 12/3/24 at 1:22 PM: 75%-100% 12/3/24 at 9:01 PM: 25%-50% 12/4/24 at 11:00 AM: 0%-25% 12/4/24 at 1:55 PM: 25%-50% (Of note: The facility was only able to provide meal intake data for the past month. Data provided included all recorded meals from 11/6/24 through a partial day on 12/5/24. 16 meals provided to this resident had no recorded intake. 32 of the 84, or 38% of the recorded meals indicated R11 consumed less than 50% of the meal. No dietary interventions were added in November 2024 or December 2024.) On 7/29/24 at 10:59 AM, a Progress Note was written by RD O (Registered Dietician). This note states, Ate 50% or less for 2 or more meals in the day. RD aware. Weight continues to remain stable and within baseline weight range. Will continue to monitor. (Of note, the last recorded weight for this resident was 7/1/24, limiting the RD's ability to determine if R11's weight was stable or not.) On 7/29/24 at 2:22 PM, a Progress Note was written by RD O. This note states: Ate 50% or less for 2 or more meals in the day. RD aware and continues to monitor. On 8/5/24 at 1:13 PM, a Progress Note was written by RD O. This note states: Ate 50% or less for 2 or more meals in the day. RD aware and is continuing to monitor her weight status. (Of note: Even after three notes within seven days regarding R11's poor oral intake, R11 was not reweighed until 8/22/24. Additionally, no notes were written regarding R11 refusing to be weighed.) On 8/22/24 at 10:29 AM, a Progress Note was written by RD O. The note states: Ate 50% or less for 2 or more meals in the day. RD continues to remain aware and following weight status. On 8/22/24 R11 weighed 144.9 lbs. (This is a 15.3 pound or 9.55% loss since 7/1/24, this amount of weight loss is considered severe.) On 8/26/24 at 4:03 PM, a Progress Note was written by RD O. The note states: Ate 50% or less for 2 or more meals in the day. RD continues to monitor and follow. On 8/26/24 at 4:08 PM, a Progress Note was written by RD O. This note indicates R11 has had a weight of 144.9 which is a 15.3 lbs. change from her previously recorded weight. The note also states: RD noting significant weight loss over the last 1.5 months. RD updating MD (medical doctor) now, along with requesting the start of House Supplements BID (twice a day) and ordering a High Protein/High Calorie diet. Will additionally add to CAR (Critical At-Risk) monitoring. On 8/29/24 at 10:38 AM, a Progress Note was written by RD O. The note indicates that the reason for monitoring is R11's significant weight loss. It also indicates that the resident has been noted to have lower meal intakes between 25-75% for most recorded meals. RD O recommends offering R11 alternative options if she does not eat enough of her meal. RD O also indicates she has no concern for R11's ability to swallow and make meal preferences known. On 8/29/24 at 10:39 AM, an assessment titled, Mini Nutritional Assessment is conducted in which R11 scores an 8 out of 14, indicating she is at risk for malnutrition. This assessment was completed by RD O. (Of Note, nothing additional was put into place after assessing R11 as being at risk for malnutrition.) On 9/11/24 R11 weighed 139.6 lbs. (12.85% weight loss in a little over 2 months.) On 9/12/24 at 7:31 AM, a Progress Note was written by RD O. The note indicates that the reason for monitoring is R11's significant weight loss. It also indicates R11's meal intakes continue to be lower, between 25%-75%. Additionally, RD O recommends Mirtazapine (antidepressant and appetite stimulant medication). This note indicates RD O sent this recommendation to the MD to consider. (Of note: This medication recommendation never comes up again in RD O notes, MD notes, or NP notes.) On 9/12/24 at 7:32 AM, a Progress note is written by RD O. The note indicates R11 has a weight of 139.6 lbs., which is an additional weight loss of 5.3 lbs. since the previous weight on 8/22/24. The note states, in part: RD aware and continuing to monitor closely at Critical At Risk. RD did fax MD with update. On 9/12/24 at 7:33 AM, a Progress note is written by RD O. This note states: Ate 50% or less for 2 or more meals in the day. RD aware and continues to monitor. On 9/12/24 at 7:31 AM, a Progress Note was written by RD O. This note states, in part: . Current weigh is at 139.6# (from 9/11, however no new weight checks since this time) . On 10/14/24 at 11:05 AM, a Progress Note was written by RD O. This note states: Ate 50% or less for 2 or more meals in the day. RD aware. Continue to monitor resident closely at Critical At Risk. On 10/17/24 at 10:26 AM, a Progress Note was written by RD O. This note states, in part: . Current weigh is at 140.9# (10/2) . On 10/21/24 at 12:56 PM, a Progress Note was written by RD O. This note states: Ate 50% or less for 2 or more meals in the day. RD aware, with resident continuing to be monitored at weekly Critical At Risk. On 10/24/24 at 10:58 AM, a Progress Note was written by RD O. This note states, in part: . Her family does desire comfort for her, however comfort care measures have not been ordered. RD will continue to monitor and follow closely at Critical At Risk, until nutritional status stabilizes. On 10/24/24 at 10:58 AM, a Progress Note was written by RD O. This note states, in part: . Current weight is at 137.8# (down 5# x 1 wk (week)) . She does continue with weekly weight check orders . On 10/31/24 at 11:13 AM, a Progress Note was written by RD O. The note indicates R11 has a weight of 137.8 lbs., which is a weight loss of 10.4% over 180 days. The note states, in part: RD aware and continues to monitor resident closely at Critical At Risk monitoring. On 10/31/24, R11 weighed 139 lbs. which is a 13.23% weight loss in less than 120 days. No documentation/evidence that new interventions were put in place to prevent further unintentional weight loss from occurring for R11 despite being monitored weekly by the RD and IDT team. On 11/8/24 at 9:39 AM, a Progress Note was written by RD O. This note states, in part: . Current weight is at 139.8# . She does continue with weekly weight check orders . R11 was not weight the week of November 3rd thru the 9th. On 11/11/24 at 11:24, a Progress Note was written by RD O. This note states: Ate 50% or less for 2 or more meals in the day. RD aware, with resident continues to monitor resident closely at Critical At Risk. R11 was not weighed the week of November 10th thru the 16th On 11/14/24 at 9:55 AM, a Progress Note was written by RD O. This note states, in part: . Current weight is at 139.8# (from 10/31/24), . She does continue with weekly weight check orders . R11 was not weighed the week of November 17th thru the 23rd On 11/21/24 at 10:24 AM, a Progress Note was written by RD O. This note states, in part: . Last obtained weight check was at 139.8# (from 10/31/24, no new weight checks), . She does continue with weekly weight check orders . On 11/25/24 at 12:24 PM, a Progress Note was written by RD O. This note states, in part: . Last obtained weight check was at 139.8# (from 10/31/24, no new weight checks), . She does continue with weekly weight check orders . R11 was not weighed the week of November 24th thru the 30th. On 12/2/24 at 10:41 PM, a BIMS evaluation is conducted on R11 that indicates she has a score of 4 out of 10 indicating severe cognitive impairment. On 12/2/24, an assessment titled, Mini Nutritional Assessment is conducted in which R11 scores a 9 out of 14, indicating she is at risk for malnutrition. This assessment was completed by RD O. (Of note: At no point was the facility recording weekly weights or documenting resident refusals to obtain weekly weights. RD O made no further recommendations besides the mirtazapine in which there is no documented follow-up.) Surveyor reviewed nutritional assessments located in R11's current electronic medical record and can find no indication of R11's preferred foods or a repeat ability assessment following the change in her BIMS score from 9 (moderate cognitive impairment) to 4 (severe cognitive impairment) on 12/2/24. (Of note: Surveyor has concerns with R11's ability to state meal preferences due to the recent BIMS decline and Surveyor's observations of R11 feeding herself.) On 12/5/24 at 9:44 AM, Surveyor interviewed CNA P (Certified Nursing Assistant). Surveyor asked CNA P how she knows which residents need to be weighed each day. CNA P indicates the nurses tell her who needs to get weighed, but they are also on sheets at the nurses' station. CNA P also indicates she is aware every resident is weighed at least monthly and knows every resident needs to be weighed the first of the month. On 12/5/24 at 10:00 AM, Surveyor interviewed CNA Q. Surveyor asked CNA Q how she knows which residents need to be weighed each day. CNA Q indicates the nurses give the CNAs the list before breakfast and does not think it is written down anywhere. Surveyor asked CNA Q if there is a list or any written papers that list which residents need to be weighed. CNA Q states she does not think so. On 12/5/24 at 10:10 AM, a Progress Note was written by RD O. This note states, in part: . Last obtained weight check was at 139.0# (from 10/31/24, no new weight checks), . She does continue with weekly weight check orders . On 12/5/24 at 10:15 AM, Surveyor observed two binders on the nurse's station desk. The first binder, titled, 300 CNA Binder contained information about resident transfer statuses, and special instructions, however Surveyor could not locate weight frequency in this binder for any resident. The second binder, titled, 300 Wing- Nurse Report Book had residents listed with different weight schedules, such as daily weights. However, no special instruction was given to provide weekly weights to R11. R11 was not weighed December 1st through December 5th, until Surveyor asked staff to weigh R11. On 12/5/24 at 10:28 AM, Surveyor observed CNA P and CNA R weigh the resident utilizing a Hoyer lift. R11 was agreeable to getting weighed and the process was conducted following current standards of practice. R11 weighed 133.7 lbs. at this time, which is another 5.3 lbs. of weight loss since her last weight on 10/31/24. On 12/5/24 at 10:30 AM, Surveyor interviewed CNA R. Surveyor asked CNA R how she knows which residents need to be weighed each day. CNA R indicates the nurses give the CNAs the list. CNA R also indicates she knows every resident is weighed at least monthly and knows every resident needs to be weighed the first of the month. On 12/5/24 at 10:34 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B what interventions the facility has in place to prevent R11 from losing more weight. DOB B indicates R11 is involved in facility Clinical At Risk meetings and has been for the past 13 weeks, she is receiving a house supplement three times a day and is consuming 75%-100% of those. Surveyor asked DON B to describe the Critical At Risk meetings. DON B indicates herself, the registered dietician, the MDS coordinator, and wound nurse are involved in the meetings and they monitor wounds and weight loss in the meetings. Surveyor asked DON B how recommendations from the registered dietician are communicated and put into the electronic medical record. DON B indicates the registered dietician will email her with the recommendation, and if it is a standing order they can approve it right away and then the registered dietician will also fax the doctor for order approval, if required. Surveyor asked DON B how frequently R11 should be weighed. DON B states she should be weighed weekly. DON B indicates she believed R11 had weekly weights scheduled for Fridays, but searched the electronic medical record and was unable to locate the order. Surveyor asked DON B if R11 should have been weighed weekly. DON B states, yes. On 12/5/24 at 12:56 PM, Surveyor observed R11 eat her lunch meal in her room. R11 received her tray placed on her bedside table, over her lap so that it was accessible, at 12:59 PM. R11 was able to pick up, open, and eat a package of crackers by herself. After eating all her crackers, R11 began sticking her fingers into her cake, swirling her fingers around in the frosting, and periodically licking the frosting from her fingers. After two minutes, CNA S walked into the room. When the CNA introduced herself to the resident, R11 asked what the cake was, and CNA S explained to the resident that it was cake, and asked R11 if she needed help. R11 repeated the phrase, I don't think I need it, whenever CNA S asked if she needed help. CNA donned gloves and stood over the resident asking if R11 wanted any of her stew or vegetables. R11 could not see or did not realize there were vegetables on the plate to the side of her bowl of stew, as she asked, What are those? CNA S explained there was broccoli and cauliflower on her plate and assisted R11 with rearranging the tray so that the vegetables were visible to R11, moving the vegetables from the side of the bowl to the front of the bowl, closer to R11. CNA S then handed R11 her spoon and proceeded to assist R11's roommate. Surveyor observed R11 being able to use the spoon to feed herself the stew, however she appeared to be straining her neck as not to spill stew on her clothes. On 12/5/24 at 1:11 PM, Surveyor interviewed CNA S. Surveyor asked CNA S if R11 needs assistance eating. CNA S indicates that she usually doesn't need help eating, but that there are foods she struggles with eating. Surveyor asked CNA S if she always goes in to assist R11 eat. CNA S indicates she only goes in to check on her periodically. On 12/5/24 at 3:50 PM, Surveyor interviewed RD O. Surveyor asked RD O if R11 was meeting her required nutritional needs. RD O states, no. RD O also indicates the facility has added R11 to the Critical At Risk meetings, added nutritional interventions starting in August 2024, changed R11's diet to high protein and high calorie, and started tracking weekly weights and nutritional intake. RD O also indicates that R11 refuses to eat meals at times and the family is still considering comfort cares. Surveyor asked RD O how often R11 should be getting weighed. RD O states she should be getting weighed weekly, but also notes R11 has a tendency to refuse weights and has refused RD assessments. Surveyor asked RD O if RD O has assessed R11's ability to feed herself. RD O states she has and indicates there are days where R11 is alert and very capable of feeding herself and there are days where R11 is very sleepy and needs more help. RD O also indicates that R11 could use all the encouragement and cues she can get. Surveyor asked RD O if she knew what came of her recommendation for mirtazapine. RD O indicates she is unable to specifically recall, however she believes it was trialed and R11 did not like it or it may have been due to comfort cares. Surveyor asked RD O what she believes is the cause of R11's weight loss. RD O indicates it is a combination of a lack of appetite and overall decline. Surveyor asked RD O if she was aware of the BIMS score of 4 out of 15, obtained on 12/2/24. RD O indicates she was not. Surveyor asked RD O if she would have reassessed R11's capacity to feed herself if she was made aware of the significant decline in BIMS score. RD O indicates she would have reassessed. (Of note, there is no documentation in progress notes or MDS data indicating R11 is refusing weights. There is a single instance of R11 refusing a meal within the 30 days prior to record review. Additionally, Surveyor has reviewed the past 6 months of available nutritional assessments, all of which are complete. There is no documented response to the mirtazapine recommendation.) On 12/5/24 at 4:46 PM, Surveyor interviewed DON B. Surveyor asked DON B if the Mirtazapine recommendation was followed up on with a provider. DON B indicates the physician also saw R11 on 9/12/24, the same day the recommendation was made, however there is no mention of the recommendation in his notes. Surveyor asked DON B if this recommendation should have been followed up on. DON B states, yes. Surveyor described the observation made of R11 eating that is detailed above. Surveyor asked DON B what her conclusion is from hearing this observation. DON B states, somebody should be in there to assist her to eat. Surveyor asked DON B why the house supplement was not increased. DON B states R11 has been three times a day since February 2024 and the facility did not increase this because the supplement they use is ideally given in between meals so it doesn't take up food space in between. Surveyor asked DON B if the facility had assessed R11's preferred foods. DON B searched for a specific nutrition assessment that asked for food preferences. DON B indicates dietary is in charge of this assessment and describes it as a dietary profile, however upon searching, DON B is unable to locate this assessment. (Of note: Some food preferences are listed on a nutrition assessment from 12/8/17, that was found in a different electronic medical record than the one currently being used by the facility. There is no documentation indicating staff are offering R11 her preferred foods to help increase meal intakes.) R11 had severe weight loss due to a decline in nutritional intake. Staff were not monitoring R11's weights and did not consistently monitor meal intakes to ensure she was meeting her estimated daily needs. The facility did not implement appropriate interventions or a care plan to prevent R11 from experiencing further weight loss. Recommendations from the registered dietician did not have a documented response, or trial period from R11's physician. The registered dietician was not informed of R11's cognitive decline to allow for further assessment and any new interventions that may be needed. This resulted in R11 experiencing a sever weight loss in less than 6 months.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure residents have an environment free of hazards and did not provide adequate supervision and assistive devices for 2 of 5 total sampled residents (R2 & R1). R2's care plan was not followed, resulting in a fall with left distal femur fracture on 7/10/24. R1 was an elopement risk and wears a WanderGuard. R1 was known to make attempts to follow others out of the building. On 7/18/24, R1 eloped from the facility and was found by Witness T approximately 0.3 miles down the road across the street from the church. R1's WanderGuard did not alarm when she exited the Memory Care Unit (MCU) and staff were not aware R1 exited the building. Evidenced by: The facility policy entitled Safe Resident Handling/Transfers, dated 7/15/23, states, in part: . Policy: It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. Policy Explanation: All residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them. While manual lifting techniques may be utilized dependent upon the resident's condition and mobility, the use of mechanical lifts are a safer alternative and should be used. Compliance Guidelines:1. The Interdisciplinary team or designee will evaluate and assess each resident's individual mobility needs, taking into account other factors as well, such as weight and cognitive status. 2. The resident's mobility needs will be addressed on admission and reviewed quarterly, after a significant change in condition or based on direct care staff observations or recommendations. 3. Mechanical lifting equipment or other approved transferring aids will be used based on the resident's needs to prevent manual lifting except in medical emergencies .13. Staff members are expected to maintain compliance with safe handling/transfer practices .14. Resident lifting and transferring will be performed according to the resident's individual plan of care. This plan of care is to be reviewed and transfer status verified prior to performance of the mechanical lift/transfer . The facility policy entitled Fall Prevention Program, dated 4/4/23, states, in part: .Policy Statement: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls . Policy: .3. The nurse will indicate on the care plan, the resident's fall risk and initiate interventions on the resident's baseline care plan, in accordance with the resident's level of risk .8. Each resident's risk factors, and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. a. Interventions will be monitored for effectiveness. b. The plan of care will be revised as needed . Example 1: R2 was admitted to the facility on [DATE], and has diagnoses that include unspecified dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgement), repeated falls, osteoporosis (a condition in which bones become weak and brittle), and primary generalized osteoarthritis (type of arthritis that occurs when flexible tissue at the ends of bones wears down). R2's Quarterly Minimum Data Set (MDS) assessment dated [DATE] shows R2 has a Brief Interview of Mental Status (BIMS) score of 7 out of 15, indicating R2 has severe cognitive impairment. R2's Care Plan, dated 2/1/24, states, in part: .Focus: (R2) has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) admission from hospital (11/18/23-11/22/23) for AMS/slurred speech following an unresponsive episode at [Aster ALF], Hx (history) of dementia, CAD (coronary artery disease), arthritis, osteoporosis, depression, HTN (hypertension), HLD (hyperlipidemia), DM2 (Type 2 Diabetes Mellitus), cervicala spondylosis. Date Initiated: 2/1/24 Revision on: 5/9/24. Goal: (R2) will maintain her abilities to participate in her ADLs through the review date. Date Initiated: 2/27/24. Revision on: 7/10/24. Target Date: 8/27/24. Interventions: . *Transfer: EZ Lift 1 assist Date Initiated: 5/9/24 *Transfer: EZ Lift 2 Assist Date Initiated: 2/1/24 Revision on: 7/16/24 . Focus: (R2) is at Low Risk for falls r/t Fall Risk Assessment. Falls: 7/10. Date Initiated: 2/1/24. Revision on: 7/11/24.Goal: (R2) will be free of falls through the review date. Date Initiated: 2/1/24. Revision on: 7/10/24. Target Date: 8/27/24 . *Anticipate and meet the resident's needs. Date Initiated: 2/1/24 . *Follow facility fall protocol. Date Initiated: 2/1/24 . *Staff education provided on proper assistive devices for transfers for resident safety. Date Initiated: 7/11/24 . R2's Fall Report, dated 7/10/24, states, in part: . Incident Location: Resident's room . Incident Description- Nursing Description: Resident was being assisted to pivot transfer into recliner when her knees gave out and CNA (certified nursing assistant) assisted her to the floor . Immediate Action Taken: Description: Vitals obtained and WNL (within normal limits), AROM (active range of motion) in all extremities, assisted into recliner with 2 staff. Resident Taken to Hospital: N (no) . Injury Type: No Injuries observed at the time of incident . Predisposing Environmental Factors: None Predisposing Physiological Factors: None Predisposing Situation Factors: None Other Info: Failure to follow care plan . Notes: 7/18/24 - IDT (Interdisciplinary Team) met and discussed fall- x-rays obtained- fracture noted- transferred to hospital had surgery. Staff educated on transfer status. 7/18/24 - Incident reported to state as SRI (self-reported incident). Allegation substantiated. Employee terminated via progressive disciplinary process . for failure to follow plan of care/Kardex resulting in negative patient outcome. (CNA transfered R2 via stand pivot transfer and did not use the EZstand to transfer R2 per the care plan.) R2's Progress Notes: Dated 7/10/23 at 19:26 (7:26 PM) Type: Communication- with Physician Situation: Resident was lowered to the floor during a pivot transfer after supper. Resident's knees buckled during transfer . Assessment (RN (Registered Nurse))/Appearance (LPN (Licensed Practical Nurse)): Resident sitting on floor in front of recliner. Resident was grimacing d/t (due to) pain in bilateral knees and wanted off of the floor. Vitals WNL, AROM in all extremities. Recommendations: (Physician Name) on call, gave verbal order for Diclofenac Sodium Topical Gel 1% every 6 hours as needed to affected areas for pain. On 7/11/24 at 11:11 AM, Type: Communication- with Physician: .Recommendations: Update NP (Nurse Practitioner) of left leg pain with transfers- x-ray to left leg ordered. On 7/11/24 at 1:42 PM Type: Transfer to Hospital Summary. Note Text: Resident was noted to have fallen on the PM shift on 7/10; resident complaining of left leg pain when transferring with the EZ stand but not when sitting; x-ray order for whole left leg noted fracture; POA (Power of Attorney)(name) called and agreed with transfer to (hospital name) ER (Emergency Room) . R2's Facility Reported Incident, dated 7/18/24, states, in part: .Summary of Incident: Allegation Type: Neglect: Intentionally withholding care, disregard of policy or care plan. Name Affected Person- (R2) .Date occurred: 7/10/24. Time Occurred: 6:00 PM . Brief Summary of Incident: On 7/11/24, it was discovered during review of clinical records that at approximately 18:00 (6:00 PM) on 7/10/24, resident (R2) became weak during a transfer and was lowered to the floor with staff assistance. Resident (R2) was immediately assessed and began to complain of leg pain; a stat x-ray was ordered, revealing the resident had sustained a fracture. The involved staff member was immediately suspended pending the outcome of the investigation. POA and MD (Medical Doctor) were notified, and orders were received to send the resident to the ER for further evaluation and treatment. Investigation initiated, final report to follow . Summary of Incident: .Briefly Describe the incident .On 7/11/24, it was discovered during review of clinical records that at approximately 18:00 on 7/10/24, resident (R2) became weak during a transfer and was lowered to the floor with staff assistance. Resident (R2) was immediately assessed and began to complain of leg pain; a stat x-ray was ordered, revealing the resident had sustained a fracture. Describe the effect that the incident had on the affected person, the person's reaction to the incident, and the reaction of others who witnessed the incident . : Post incident (R2) was complaining of leg pain. POA and MD notified; MD gave orders to apply topical pain-relieving gel every 6 hours as needed for pain, which was effective for the remainder of the day. On 7/11/24, resident (R2) continued to complain of pain in the left leg. The MD was notified, and stat x-rays of the left leg were ordered. Results indicated a mildly displaced, oblique fracture to the left leg, corresponding clinically with osteopenia. The MD was again notified, and this time gave orders for resident (R2) to be sent to the hospital for further evaluation and treatment, as needed. (R2) was admitted and underwent surgical repair to the fracture, returning to the facility on 7/15/24. Based on a review of the hospital records, (R2) has a left distal femur fracture due to a combination of osteoporosis and trauma, as trauma alone would not have caused the fracture. Explain what steps the entity took upon learning of the incident to protect the affected person(s) and others from further potential misconduct . :A further review of the incident revealed that the CNA performed a pivot-style transfer on resident (R2); it was further noted that the transfer status orders for resident (R2) was for an assist of one person using an EZ Stand mechanical lift. This was discovered prior to the CNA reporting to work that day; the CNA was disciplined using the facility's progressive disciplinary process, resulting in termination of employment from the facility on 7/12/24. The CNA did not provide any care to the residents on that day as the termination happened prior to the commencement of the shift . R2's Radiology Report, dated 7/11/24, states, in part: . Femur Min 2 Views, Left: Results: Mildly displaced, oblique fracture through the distal femur metadiaphysis .Conclusion: Mildly displaced, oblique fracture through the distal femur metadiaphysis . R2's Orthopedic Surgery History & Physical, dated 7/11/24, states, in part: . admitted : 7/11/24 7:01 PM .Chief Complaint: Left leg pain. History: . history including dementia, HTN, hyperlipidemia presents today with a complaint of left leg pain. She apparently had fallen yesterday and was complaining of pain. She doesn't remember how she had fallen. She had some x-rays of the left femur done at an outside facility showing she had a distal femur fracture . Date of Injury: 7/10/24 Location (pain): left leg Quality/description (pain): nothing at rest to sharp with movement Severity: (1-10): 0-6/10 Modifying factors: None Associated signs and symptoms: unable to bear weight . Patient Active Problem List: . Closed fracture of left femur, unspecified fracture morphology, unspecified portion of femur, initial encounter . Imaging: I personally reviewed the x-rays of the left femur which demonstrate non-displaced distal femur fracture . Assessment: Left distal femur fracture due to a combination of osteoporosis and trauma . Plan: -Indicated operation: Retrograde nailing of left femur by (Physician name) -Date of operation: 7/12/24 . R2's Discharge summary, dated [DATE], states, in part: .Date of admission: [DATE] Date of discharge: [DATE] Clinical Resume: (R2) . female who suffered the following injury prior to admission: left distal femur fracture . She was evaluated by the orthopedic service and left femur retrograde nailing was recommended . She was taken to the operating room on 7/12/24 where the above procedure was performed .By post-op day number 3, she was found to be both medically and orthopedically stable but not appropriate to return home independently. Therefore, she is being sent to a nursing home for proposed short term nursing home care and therapy . On 8/1/24 at 10:08 AM, Surveyor interviewed CNA I who indicated staff follow resident care plans and Kardex's to care for residents. CNA I indicated staff should never use less assistance than what a resident is care planned for, and no staff should use a pivot transfer if a care plan says to use an EZ stand. On 8/1/24 at 10:13 AM, Surveyor interviewed CNA J who indicated staff follow the Kardex/care plans to care for the residents. CNA J indicated staff should never use less assistance than what the care plan indicates. On 8/1/24 at 12:55 PM, Surveyor interviewed LPN C (Licensed Practical Nurse) and asked LPN C to tell Surveyor about the events on 7/11/24 that led to sending R2 to the ER. LPN C indicated when she came onto shift, she saw the fall report on R2 on 7/10/24 that indicated R2 had fallen from a pivot transfer. LPN C indicated R2 was an EZ stand transfer. LPN C indicated the CNAs reported to her that morning that R2 was complaining of left knee pain with morning care. LPN C indicated she had asked other staff if R2 had been sent out to ER from fall and was told no, the MD had been notified and an order was received to use Voltaren Gel. Surveyor asked if R2 had pain in her knees prior to fall and LPN C indicated no. LPN C indicated she asked RN D (Registered Nurse), who is one of the charge nurses, if facility could get an order for an x-ray. LPN C indicated the facility uses Mobile X that comes to facility to x-ray. An order was obtained from nurse practitioner and Mobile X arrived at facility around 11:00 AM to x-ray R2's left leg. LPN C indicated R2 had stayed in bed after breakfast up until transfer to ER due to pain with any movement to left leg. At 1:30 PM, after receiving the x-ray results the MD was phoned, and orders were received to send R2 to ER. On 8/1/24 at 1:15 PM, Surveyor interviewed RN D and asked what R2's transfer status was at the time of the fall on 7/10/24, and RN D indicated R2 was assist of 1 with an EZ stand. Surveyor asked RN D at the time of the fall how was R2 transferred, and RN D indicated she was not here at the time of the fall but in the clinical meeting it was discussed, and R2 was transferred with assist of 1 pivot transfer. RN D indicated LPN C had come to her the morning of 7/11/24 and indicated R2 was having pain when standing and no pain with resting. RN D sent an urgent email to NP and received orders to x-ray at facility. Surveyor asked RN D if she had assessed R2 and RN D indicated no, it was discussed at the clinical meeting with three nurse managers, DON B (Director of Nursing), and NHA A (Nursing Home Administrator) to get x-ray order. On 8/1/24 at 4:30 PM, Surveyor interviewed DON B and asked if she would expect staff to follow care plans and DON B indicated yes. Surveyor asked DON B if a resident is care planned to transfer with an EZ stand and 1 assist would you expect that to be followed and DON B indicated yes. Surveyor asked DON B if she would have expected an RN to assess R2 for pain the morning R2 was complaining of left leg pain and DON B indicated yes. Surveyor asked DON B what the facility has done at this point to ensure staff are following the care plans and DON B indicated the care plans and Kardexs have been reviewed and updated. Surveyor asked DON B since R2's fall on 7/10/24 has DON B observed any transfers with staff and DON B indicated yes but they are not documented. DON B indicated the facility will be doing audits on transfers. On 8/1/24 at 2:15 PM, Surveyor interviewed NHA A. NHA A indicated he has been working on a PIP (Performance Improvement Plan) regarding R2's fall on 7/10/24 FRI (Facility Reported Incident). NHA A indicated education on Safe Resident Handling and Policy was put out on the work web for staff on 7/19/24. NHA A indicated this will be going to QAPI (Quality Assurance and Performance Improvement) on 8/14/24. NHA A indicated the audits have not been started yet. Of note: Six staff were working on 8/1/24 that had not yet been educated on following the care plan related to R2's fall with fracture. On 8/5/24 at 3:15 PM, Surveyor interviewed RN R. RN R indicated the CNA did not follow R2's care plan and should have. RN R indicated the CNA had came and asked RN R to assist R2 off the floor as she had to lower her to the floor. RN R indicated the CNA had transferred R2 by pivot transfer and R2 should have been a one assist with an EZ stand transfer. RN R indicated she checked ROM to lower extremities and all checked out. RN R indicated R2 was able to lift left leg just not as high as right leg. RN R indicated R2 had no complaints of pain anywhere but in her knees. RN R had phoned the MD and son, received orders for Voltaren gel. Voltaren gel and tylenol was administered to R2 by RN R and was effective. The facility did not follow R2's care plan while transferring R2 resulting in R2 obtaining a left distal femur fracture. The following example is isolated, no actual harm potential for minimum: Example 2: The facility policy, Elopement and Wandering, last revised 6/5/24, indicates the following: The facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Definitions Wandering is random or repetitive locomotion that may be goal-directed (e.g., the person appears to be searching for something such as an exit or non-goal directed or aimless. Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. Procedure: 1. The facility is equipped with door locks/alarms to help avoid elopements. 2. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. 3. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risk, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. Monitoring and Managing Resident at Risk for Elopement or Unsafe Wandering .e. Interventions to staff awareness of the resident's risk, modify the resident's behavior, or minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff. F. Adequate supervision will be provided to help prevent accidents or elopements. Procedure for Post-Elopement .e. Staff may be educated on the reasons for elopement and possible strategies for avoiding such behavior. The facility's Memory Care Unit (MCU) is unlocked and equipped with Wanderguard sensors at each exit. R1 was admitted to the facility on [DATE] with diagnoses that include severe dementia without behavioral disturbance, encephalopathy, muscle weakness, chronic kidney disease stage 3, disorders of bone density and structure. R1's admission Minimum Data Set (MDS) dated [DATE] indicates R1 has a Brief Interview of Mental Status (BIMS) of a 3 out of 15, which indicates she is severely cognitively impaired. R1 has an Activated Power of Attorney for Health Care (APOAHC). R1's Comprehensive Care Plan indicates the following: Focus: I am at risk for elopement as evidenced by a history of wandering r/t Dementia. Goal: I will not leave the facility unescorted through next review. Interventions: (Date Initiated: 7/15/24) Move resident to memory care unit (Date Initiated: 7/22/24) Monitor Wanderguard placement and function every 4 hours. If Wanderguard i s not functioning properly, replace it. (Date Initiated: 7/22/24) If Wanderguard system is not functioning/alerting properly, provide frequent checks on residents at elopement risk, Initiate batch order in TAR (Treatment Administration Record) and monitor until system is functioning properly. (Date Initiated: 7/22/4) I wear a Wander Guard on ankle (Date Initiated: 7/1/24) Anticipate my needs to the extent possible to help alleviate my wandering and exit seeking. (Date Initiated: 7/1/24) Ensure I do not accidentally follow visitors out of the building (Date Initiated: 7/1/24) [NAME] my room door with a familiar object, photo, etc. to aid in remembering its location. (Date Initiated: 7/1/24) Provide me reassurance and comfort when I am anxious. (Date Initiated: 7/1/24) Reassess my elopement at least quarterly. (Date Initiated: 7/1/24) Use diversional activities that I enjoy when exit-seeking behavior is occurring (i.e.: offer snacks, provide tactile stimulation, listen to music with me, etc.) (Date initiated: 7/1/24) Use verbal cues and gentle touch to redirect my exit-seeking behaviors. R1's Elopement Risk Evaluation dated 7/1/24 documents a score of 2, indicating R1 is At Risk of elopement. A score of greater than or equal to 1 = At Risk. R1's Elopement Risk Evaluation dated 7/18/24 documents a score of 4, indicating R1 is At Risk of elopement. On 7/18/24 the facility completed a Self-Report Is the date and time when occurred known: Yes Date occurred: 7/18/24 Time occurred 6:00 PM Is occurred date and time estimated: Yes Date discovered: 7/18/24 Briefly describe the incident: It was reported by facility staff that at approximately 6:00 PM on 7/18/24 staff were alerted to a resident outside the facility. Explain what steps the entity took upon learning of the incident to protect the affected person(s) and others from further potential misconduct: At approximately 5:45 PM, as staff were rounding the unit, it was noted that resident (R1) was no longer in her room. A more thorough search of the unit and immediate area did not reveal the location of R1. A facility-wide search was initiated and the family and Administrator were notified. At approximately 6:00 PM, the facility was notified that R1 was found to be at the Baptist church immediately adjacent to the facility property. The resident was returned to the facility and immediately assessed. There were no obvious signs or symptoms of physical, mental, or psychosocial distress nor new complaint of pain. The POA (Power of Attorney) and MD (Medical Doctor) were notified, and no new orders were received. Resident (R1) was placed on increased staff observation for the remainder of the evening. The facility's Self Report documents the following staff have Information about incident: CNA L (Certified Nursing Assistant), CNA M (Certified Nursing Assistant), RN Q (Registered Nurse) Maintenance Director N, FM O (Family Member) and FM P (Family Member). CNA L's (Certified Nursing Assistant) wrote the following statement: R1 had been in her room with her family member (FM P - Family Member) eating. FM P left to go help her other family member. R1 came to dining room and sat with another resident. R1 went to her room around 5-5:15 PM and had not been seen by myself as I had been feeding other residents, CNA M (Certified Nursing Assistant) was helping a sick resident in his room, RN Q (Registered Nurse) was passing meds (medications). No alarms sounded to alert us to anything wrong. CNA M (Certified Nursing Assistant) wrote the following statement: R1 was here. FM P brought her supper. She left after FM P went home. We did not hear any alarms going off. RN Q (Registered Nurse) wrote the following statement: R1 was reported to last be seen in dining room at about 5:15 PM. Was alerted to resident not being at NGH (New Glarus Home - the facility) by LPN C (Licensed Practical Nurse). LPN C stated that the resident was at the church. R1 was known to be with FM P for dinner at 4:30 PM, seen by me. 6:10 PM, FM P was called for whereabouts of resident (R1) was not with FM P. 6:25 PM DON B (Director of Nursing) was contacted. No alarms were activated on unit from 3:00 PM until R1 was returned to the 400 unit. On 7/18/24 at 7:53 PM, Maintenance Director N sent the following email to NHA A (Nursing Home Administrator). Hello (NHA A's name), After receiving your call at 6:37 PM, I came in to check the Wanderguard system for the 400 wing. I spoke with RN Q (Registered Nurse) who was stationed there and he said it never went off during his shift which started at 3pm. I was in my office until 6pm and I did not hear the Wanderguard go off during that timeline. I asked if I could take her tag (Wanderguard) to test it, however they said they didn't know if they had another band for her. I used our testing tag on the North side of the 400 wing (the side they said she must have left from), and I was unable to get out of the door approximately 7 times that I tested it. I then placed the tag inside my boot. At this point I was able to get through the door without setting the alarm off. I proceeded to test this approximately 3 more times with two more escape successes. I then proceeded to look at the control box and confirm the sensor settings were correct. The sensor sensitivity was set at almost the maximum frequency. I went back into the hallway and adjusted the motion sensor to be more fixated on the door. I proceeded to test the door with the tag in my boot and noticed going back into the 400 the alarm did not go off. I tested the door a few more times with at least one more success. I proceeded back into the control box and this is when I noticed the antenna was hanging from a wire and the sheath was on the floor. I was able to put the antenna back without further damage to it and proceeded to test the door approximately 10 more times. Each time the alarm went off. I tested going fast as well as multiple times going very slowly. Additionally, for a frame of reference, while going slow, I had the door about 1/3rd of the way open before the alarm would go off. At approximately 7:17 (pm), I called Accutech to have a technician to come out and inspect the system to confirm it is working properly. It is after hours, so I left a message for them to come out. Additionally, I purchased a plastic crate to put over the control box to deter damage from happening to the antenna (scheduled to arrive Monday July 22nd). Until a technician comes out with a new antenna and checks over the system to confirm it is working properly, I will do daily checks of the Wanderguard system. (Of note, the technician came out on 7/19/24 and the issue was resolved at that time.) Note there is no statement from FM P (Family Member) in the investigation. On 8/1/24 at 12:20 PM Surveyor spoke with RN Q (Registered Nurse). Surveyor asked RN Q if he put a new Wanderguard on R1. RN Q stated, no, because when we tested it after she returned to the facility it was working. RN Q reiterated that no alarms sounded at the time R1 eloped from the facility. RN Q stated, when she was brought back through the Wellness Center that door alarmed. When we tested her alarm through both doors on the 400 unit, R1's Wanderguard alarmed both times. RN Q stated, he did not change out the Wanderguard because it was working after she returned to the facility. On 8/1/24 at 12:38 PM, Surveyor spoke with FM P (Family Member). Surveyor asked FM P to tell surveyor about R1 and what occurred on 7/18/24. FM P stated she took care of R1 prior to her admission to the facility. FM P stated, R1 is more of a handful with her memory. FM P stated, R1 never wandered away from her home prior to moving to the facility. FM P stated, when R1 was still living at home she found her trying to open a bottle of toilet bowl cleaner that R1 verbalized she was going to to put in her mouth. Surveyor asked FM P, does R1 have decreased safety awareness. FM P stated, Oh god, yes! FM P stated R1 is in excellent physical shape and she used to walk 2 1/2 miles every day. FM P stated, R1 fell at home many times, cracked her head on a TV stand but never broke any bones. FM P stated, on 7/18/24 she brought R1 Culvers and they had dinner together in R1's room. FM P stated, I told them (staff) I was leaving. FM P stated, she suspects that R1 saw her leave the facility and attempted to follow her. FM P stated, she was home for 45 minutes before she received a call from the facility asking if R1 was with her. FM P stated, It was very messed up. FM P stated, RN Q (Registered Nurse) told her, We don't know where R1 is. FM P stated, hearing that the facility does not know where R1 is made her feel, Really, really, really upset. FM P stated, she can easily see R1 going for a walk in the woods next to the facility. FM P stated, R1 does not like to be alone, she likes to talk with others. FM P stated, she later found out a couple found R1 near the Baptist church down the road from the facility and they returned her safely to the facility. FM P stated, her understanding from the facility is if the bracelet (Wanderguard) is exposed it works if covered by a pant leg it would not work. FM P stated, R1 will make statements that She wants to go home and that she's Going home. FM O (Family Member) is R1's APOAHC (Activated Power of Attorney for Health Care). Surveyor attempted to speak with FM O without success. On 8/1/24 at 1:50 PM, Surveyor spoke with LPN C (Licensed Practical Nurse). Surveyor asked LPN C to tell surveyor about what occurred on 7/18/24. LPN C stated, she was working on the 100 and 200 units and took the phone call. LPN C stated, she received a phone call from Activ Asst S (Activity Assistant) who was not working at the time. Activ Asst S's family member, Witness T, saw R1 walking down the road near the church and contacted Activ Assist S to see if she knew R1. Activ Asst S told Witness T, R1 lives at the facility to bring her back to the facility to the Wellness Center (Rehab entrance) and wait until a staff member meets them at the door. Activ Asst S reiterated, she told Witness T to not leave R1 until somebody comes to get her. Activ Asst S stated, That's a long walk, thank god she didn't get hurt. Surveyor requested Witness T's name and phone number. Activ Asst S provided Witness T's name and phone number. On 8/1/24 at 2:06 PM, Surveyor spoke with MR U (Medical Records). Surveyor asked MR U to describe her system for Wanderguards. MR U stated, the only things she does is to purchase the bands and tags and when she receives a tag she uses a tester box. MR U stated she does not have a spreadsheet or any system to know which resident has what Wanderguard or to know when they expire. MR U stated, when staff report a Wanderguard is not working they give it to her or leave it in her mailbox and she returns it to the manufacturer. On 8/1/24 at 2:47 PM, Surveyor spoke with Witness T. Surveyor asked Witness T to tell Surveyor what happened on 7/18/24. Witness T stated, she and her family were going to church for supper. Witness T stated, she saw R1 walking slowly by the church and She couldn't walk well. Witness T stated, R1 looked out of place. Witness T stated, I was worried she was really hunched over. Witness T as[TRUNCATED]

**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 injuries 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 2 of 5 residents reviewed for pressure injury concerns (R43 and R44). R43 was at risk for pressure injury (PI) development due to a malformed extremity. The facility failed to ensure interventions were in place to prevent pressure, follow physician's orders for treatment and ensure offloading to prevent pressure. R43 developed an unstageable PI. R44 was admitted to the facility with reddened heels. There was no care plan intervention to offload the heels. R44 developed blisters on his right ankle on 6/10/22 there is no intervention to prevent pressure to this mallelous the mallelous worsened to a stage II pressure injury on 6/15/22. Evidenced by: Facility policy, entitled Pressure Ulcers/Skin Breakdown, revised April 2018, includes, the nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers . In addition, the nurse shall describe and document/report the following: full assessment of pressure sore including location, stage, length, width, and depth, presence of exudates or necrotic tissue . pain assessment . resident's mobility status . current treatments, including support surfaces . all active diagnoses . The physician will assist the staff to identify the type of an ulcer . Current approaches should be reviewed for whether they remain pertinent to the resident's medical conditions, are affected by factors influencing wound development or healing, and the impact of specific treatment choices made by the resident or substitute decision maker . The physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions. Example 1 R43 was admitted to the facility on [DATE] with diagnoses including: peripheral vascular disease and hemiplegia following cerebral infarction right side. R43's current signed Physician Orders, include, in part: start date 5/31/22 skin: apply skin prep to bottom of second toe on right foot, and wedge cotton between knuckles. Twice a day . end date: open Blue suspension boot to right foot at all times . check three times a day administer until resolved . end date: open R43's Comprehensive Care Plan, printed 6/14/22, includes in part: skin care: reduce pressure and friction between myself and my bed or chair . use pressure redistribution devices mattress, gel cushion, right blue suspension boot . help me with hygiene and general skin care .avoid using hot water for washing and use moisturizer on my skin . help me reposition at least every one to two hours while I'm in bed keep good padding around my bony areas . offer me fluids when I change position . elevate my heels in bed . use skin protective devices . skin barrier cream after each incontinence episode . use pillows for supporting me . help me stay clean and dry . R43's CNA Care Card, dated 6/14/22, includes in part: skin care: reduce pressure and friction between myself and my bed or chair . use pressure redistribution devices mattress, gel cushion, right blue suspension boot . help me with hygiene and general skin care .avoid using hot water for washing and use moisturizer on my skin . help me reposition at least every one to two hours while I'm in bed keep good padding around my bony areas . offer me fluids when I change position . elevate my heels in bed . use skin protective devices . skin barrier cream after each incontinence episode . use pillows for supporting me . help me stay clean and dry . R43's Medical Record includes, in part: 5/6/22 Nurse Note: . this morning resident reported that her toes hurt, the first 2 on right foot and great toe on left . right great toe is reddened, no warmth, slightly swollen, foot cradle put back on bed to reduce pressure to feet . 5/8/22 Nurse Note: . right great toe red, R43 denied discomfort/pain to area . no s/sx of infection foot cradle used to reduce pressure to feet. 5/9/22 Nurse Note: . foot cradle in place, sleeping well, no nonverbal, signs of pain present during assessment. 5/11/22 Nurse Note: . denies discomfort to great toe cradle in use in bed . 5/23/22 Nurse Note: late entry for 6:31 PM on 5/22/22 Resident c/o mild pain to toes R foot . Toe #2 edematous/erythematous. Erythema extends from tip of toe to PIP joint (extends slightly beyond PIP joint when foot in dependent position) . Blanchable except over distal / ventral surface of toe where is a C shaped dark purple area noted. Toe tender to light palpation. No increased temperature of skin to affected area. No palp pedal/PT pulse R foot. Weak PT pedal pulse palpable left foot Great toe pink dorsal surface, toe #3 dark pink distal portion . Hospice RN notified arrived to evaluate resident at 9:40 pm family notified related to change in condition. RN orders continue using bed cradle to protect feet or leave feet uncovered when in bed, may wear socks. Apply skin prep to toe #2 every shift. Physician contact- Hospice triage . 5/24/22 Nurse Note: . R foot monitored, dark pink slightly reddened. Continue to reposition resident to keep weight of blankets off of bilateral feet. Preventative to maintain skin integrity. Offer and provide fluid intake. 5/24/22 right second toe sore, dark purple on plantar side, skin prep applied . 5/25/22 Nurse Note: .tx per orders, D2 plantar side dark purple with surrounding skin drying, no spreading redness, further breakdown, or drainage noted. Tolerated well foot cradle in place to assist with maintaining skin integrity . dark pink in color/reddened skin R foot second digit toe. Plantar side old darked purple color bruise . 5/26/22 Nurse Note: . skin issues noted, RLE D2 plantar area darkened purple, dark pink surroundings, no warmth, or temp changes noted from other digits, bed cradle in place to reduce pressure from blankets . 5/27/22 Nurse Note: . writer placed call to Hospice Registered Nurse at 3:30 PM to report that residents right toe 2nd has worsened since her last visit in the past two hours, toe rubbing on foot rest . thin layer of skin/blister opened and resident had a scant sanguineous discharge continues to be painful . [Hospice Name] placed low air loss mattress on resident's bed, the alternating pressure mattress and pump was returned . right second toe continues to increase in redness and swelling, may have had superficial blister on plantar aspect which opened when resident rubbed foot on foot rest, increased pain and warmth, hospice notified . (It is important to note, this is the first mention of the blister being open and caused by pressure/shearing from her footrest. Of note there is no measurements of this area.) 5/28/22 Nurse Note: . reddened 2nd toe right foot plantar aspect dark in color skin prep applied sensitive to touch swollen . Rt second digit plantar side, dark in color, hard center, skin periwound red, skin prep applied per order 5/29/22Nurse Note: . New order for skin issues noted right 2nd foot, continues to be dark in color, hard upon palpation, resident reports tenderness, skin prep applied . right second toe, area cleansed with normal saline, skin prep applied, reported tenderness to area during skin treatment, on antibiotics for skin infections . right second toe continues with black eschar bottom side of toe, peri skin continues to be red, toe is tender to touch, normal temp. Res started on antibiotics for skin infection, skin prep applied after cleansing toe. 5/30/22 Nurse Note: .skin issues noted, right second toe red; black eschar area to the pad of toe (underside), tender touch, cleansed with normal saline, skin prep applied, continues oral antibiotics. 5/31/22 Nurse Note: .continues antibiotic for skin infection to right foot second toe, toes are cool, underside of toe continues with black eschar area 0.5 cm x 0.5 cm cleansed site area with skin prep. 5/31/22 Initial Wound Assessment . onset discovery date: 5/24/22 noted after admission . initial stage: suspected deep tissue injury . tissue type: necrotic/eschar . wound tissue: black . necrotic tissue: firmly adherent, hard, black eschar . necrotic tissue amount: 75% - 100% wound covered . shape of wound: oval/round . wound edges: distinct, outline clearly visible, attached, even with wound base . surrounding wound tissue: bright red and/or blanches to touch . surrounding wound induration: non-pitting edema extends less than 4 cm around wound . length: 0.8 cm . width: 0.8 cm . interventions: remains on antibiotic . other support surfaces: heel lifts or heels suspension device . minimize risk for shear and friction . physician notified . skin treatment done per order . (It is important to note the wound was measured twice this day 0.5 x 0.5 and 0.8 x 0.8. This is the first time since the area was discovered that the wound was measured.) 5/31/22 Physician Order, includes, in part: start date 5/31/22 . skin: apply skin prep to bottom of second toe on right foot, and wedge cotton between knuckles. Twice a day . end date: open Blue suspension boot to right foot at all times . check three times a day administer until resolved . end date: open 5/31/22 Hospice Progress Note, includes, in part: Registered Nurse performed focused visit related to decline in condition and wound assessment . collaborated with facility wound care nurse . Patient sleeping on and off throughout visit. Patient on antibiotics, missed 3 doses on Saturday, has not missed any since then. Writer collaborated with daughter . active wounds: pressure injury plantar pressure . placement date: 5/22/22 .site toe; right foot second toe . primary wound type: pressure injury . wound description: pressure injury . 0.8cm x 0.8cm moist, painful, red . wound surface area: 0.64cm R43's Medication Administration Record for 5/2022 and 6/2022 indicated R43 missed 4 doses of her antibiotic on the following medication passes: 5/28/22 12:00, 17:00, HS and on 6/2 8:00. (It is important to note the facility had no investigation conducted regarding the missed doses of medication.) 6/6/22 Hospice Progress Note, includes, in part: Assessment: Patient reports I hurt a lot and points to right knee and leg . Changes reported from prior assessment: Black necrotic appearing scab noted to second toe, measurements noted to be 1.3 cm x 1.0 cm, surrounding skin dry, intact, and red . Based on assessment, notified provider for: continuing current plan of care . 6/7/22 Wound Follow Up Assessment note, includes, in part: onset: 5/24/22 . noted after admission . initial stage: Suspected Deep Tissue Injury . wound tissue: necrotic/eschar 100% . necrotic tissue: firmly adherent, hard, black eschar . necrotic tissue amount:100% wound covered . shape of wound: oval/round . wound edges distinct outline, clearly visible, attached, even with wound base . surrounding wound tissue: dark red or purple and non-blanchable . surrounding wound edema: non-pitting edema extends less than 4 cm around wound . length: 1.5 cm x 1.0 cm .healing process: worsening . interventions: . minimize risk for shear and friction . other supportive surfaces: heel lifts or heel suspension device . On 6/13/22 at 1:38 PM Surveyor observed R43 in bed with a suspension boot on her right foot. The boot extended pass her toes by approximately 3 inches Surveyor could see R43's toes in the boot and her second toe curled downward. No cotton was observed between R43's toe knuckles. On 6/14/22 at 2:13 PM RN C (Registered Nurse) and Surveyor observed R43's right foot second toe. RN C described what she observed, round black necrotic area on second toe of the right foot. R43 stated, It hurts something fierce too. RN C indicated the wound is a deep tissue injury caused by pressure from being up in Broda chair without shoes on. RN C indicated R43's second digit is curled under so the tip of toe was in direct contact with the wheelchair's footrest. Surveyor asked RN C if R43's curled toe is in direct contact with her suspension boot? RN C stated, Yes, it is and especially when she is up in chair. RN C indicated she would loosen the strap on R43's suspension boot so the boot does not put pressure on R43's curled toe. Surveyor observed no cotton wedged between R43's knuckles per Physician order. On 6/15/22 at 7:47 AM Surveyor observed R43 in bed with her feet elevated and uncovered. R43 had a blue suspension boot on her right foot that came out 3 inches pass the end of R43's toes. The suspension boot had two straps secured tightly with Velcro: one over the top of her foot and one over her ankle. Surveyor observed R43's second toe on the right foot curled under and this toe was in direct contact with blue suspension boot. On 6/15/22 at 7:56 AM RN O and Surveyor observed R43's toe together. RN O indicated she observed R43's second toe on right foot to be in direct contact with the boot and this could be causing pressure to R1's toe. RN O indicated she could loosen the suspension boot. Surveyor observed RN O rotate R43's foot and place in boot so her toe was not touching the boot and RN O did not secure the Velcro tightly on the top of R43's foot. RN O indicated 43's second toe on her right foot had a dime size black eschar covered area on the end and side of it and this all started when she had her foot rubbing on the foot pedals of her wheelchair. RN O indicated she did not see cotton or gauze between R43's toes or knuckles. Surveyor asked if RN O has ever seen cotton or gauze used with R43's toes. RN O replied she hadn't, but she thought she would call R43's MD and see if he wants to try this. RN O indicated she was unaware the current order was for cotton to be wedged between the knuckles. (It is important to note RN O was unaware of the current order to wedge cotton between R43's knuckles. It is also important to note the boot extended pass R43's toes by three inches and was secured tightly to her foot causing pressure to her one curled toe.) On 6/15/22 at 8:00 AM DON B (Director of Nursing) and Surveyor observed R43's toes. DON B indicated she did not see any cotton wedged in between R43's knuckles and she was unaware this was the current Physician order. DON B indicated she would expect cotton to be in place if that is what the order says. On 6/15/22 at 10:30 AM Surveyor and DON B reviewed R43's current Physician orders. DON B indicated she would expect to see wound measurements completed on 5/27 if blister opened on 5/27. DON B indicated the blister could be a deep tissue injury from shearing, but she has not had time to read any nurses notes regarding the wound. On 6/16/22 at 3:08 PM During an interview, Hospice Registered Nurse P indicated she was unaware that the Physician order included cotton between the knuckles. The facility failed to put interventions in place to protect R43's malformed toe, R43 developed an unstageable PI, failed to measure the pressure injury once discovered, ensure antibiotics were administered as prescribed, follow physician orders for treatment, and failed to offload the toe causing the wound to worsen. Example 2 R44 was admitted to the facility on [DATE] with diagnoses that include arthritis and dementia. R44's progress note dated 5/7/22 as part of the initial skin assessment states in part; skin issues noted on back of left heel, reddened, heels elevated with pillow off mattress. Progress notes on 5/17/22 documents heels no longer red. (It's important to note there is no skin documentation regarding the reddened heels from 5/7/22 to 5/17/22.) R44's Skin Care Plan does not have an intervention for floating heels. On 6/14/22 at 11:00 AM, Surveyor spoke with RN C (Registered Nurse). RN C said if a resident is admitted with reddened heels-there should be a full skin assessment, nutrition assessment, low air loss mattress and boots should be applied. I was not made aware of this res with reddened heels. Surveyor asked RN C if R44 received all these interventions. RN C said no. On 6/10/22 at 1:52 PM, R44's skin care note documents .right ankle (lateral side), two blisters' measurements (1.7 x 1.3) and .5 x .5) cm (centimeters). Areas cleansed, dried, and two foam dressing applied over areas. Both appear to be where side of shoe would rub up against. On 6/14/22 at 3:05 PM, Surveyor spoke to RN I. Surveyor asked RN I when you did the dressing change this morning for R44's right ankle how did it look? RN I said it was flat, no drainage. Surveyor asked RN I, what color is the wound? RN I said the wound was pink. On 6/15/22 at 9:29 AM Surveyor observed R44's right ankle wound with DON B (Director of Nursing). There was no dressing on wound when socks removed. The periwound skin was pink and there was an open area with yellow wound bed on right malleolus. DON B did not measure the wound. Surveyor asked DON B what the wound was. DON B said she had not seen it before, and she will have to review the documentation before she says what the wound is. Surveyor asked DON B how she thought the wound happened. DON B said she was not sure; the resident shoes were a little large and may have rubbed on his feet. On 6/16/22 at 1:18 PM, Surveyor spoke to DON B. the wound on R44's right ankle was a blister and now it's a stage II pressure injury (PI) and his shoe has rubbed on that part of the foot because the shoe is a little too big. R44 developed a facility acquired pressure injury to the malleolus which worsened to a stage 2. The facility failed to ensure aggressive PI interventions were in place to prevent PI development or worsening of the PI.