**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility did not ensure quality of care was provided to 3 (R3, R19, and R18) of 24 residents reviewed. *R3 had diagnoses of irritable bowel syndrome and constipation. From 12/19/22 to 12/21/22 R3 experienced severe constipation and was hospitalized due to an obstructed bowel. The facility did not have a comprehensive care plan in place to address R3's bowel management and diagnoses of irritable bowel syndrome and constipation. *R19 had a skin condition that was not comprehensively assessed by the facility or addressed with a comprehensive skin integrity care plan. R19 was admitted on [DATE] with an open wound to the right thigh per facility staff that was not comprehensively assessed until 4/10/2023, no treatment was in place until 4/10/2023, and no Skin Integrity Care Plan was initiated until 4/10/2023. R19 was admitted with documentation of a fluid-filled pocket to the left scalp that was never documented on after that initial assessment. *The facility did not provide R18 with tubigrip stockings per MD order. Findings Include: 1. R3 was admitted to the facility on [DATE] with diagnoses of cardiomyopathy, malnutrition, irritable bowel syndrome, and constipation. Surveyor reviewed R3's comprehensive care plan. Surveyor did not locate a comprehensive care plan to address R3's diagnosis of irritable bowel syndrome, constipation, or bowel management. Surveyor reviewed R3's physician orders. Upon admission to facility (on 11/29/22) R3 was receiving scheduled Lomotil (an anti-diarrheal medication) three times a day. On 12/7/22, R3's physician discontinued the scheduled Lomotil due to drug induced constipation. Surveyor noted R3's physician orders included as needed orders for laxatives including miralax powder daily as needed, milk of magnesia 30 milliliters daily as needed, and bisacodyl suppository daily as needed for constipation. Surveyor noted that R3 had been receiving Miralax powder daily since 12/19/22 and a dosage of milk of magnesia and a bisacodyl suppository on 12/19/22. R3 had a medium soft stool documented on 12/19/22. On 12/21/22 at 10:27 AM, Nursing progress note reads c/o (complains of) abdominal discomfort and feeling urge to have bowel movement nausea .bowel sounds present x (times) 4 (quadrants), bowel sounds hypoactive, ABD (abdomen) tender to palpation, firm. STAT KUB (abdominal X-ray), simethicone ordered for gas pain. On 12/21/22 at 10:44 AM, a STAT KUB abdominal X-ray order was placed with the facility's contracted diagnostic imaging company. On 12/21/22 at 2:43 PM, nursing progress notes indicated STAT KUB abdominal X-ray was completed. On 12/22/22 at 4:26 AM, Nursing progress note reads Resident large dark emesis x (times) 2, called obtained KUB results. Mild colonic ileus, updated NP (Nurse Practitioner) on results and resident having emesis. Resident being his own person and wants to go to the hospital . Surveyor reviewed the STAT KUB X-ray report that had been faxed to the facility at an unknown time or date. The result time of the X-ray was documented by the radiologist on 12/21/22 at 1:49 PM. The facility called an ambulance and R3 was transferred to the hospital. R3 was admitted to the hospital with severe sepsis, a perforated bladder, and small bowel obstruction. On 4/18/23 at 7:14 AM, an interview was conducted with LPN (Licensed Practical Nurse)-U. Surveyor asked LPN-U if they had recalled monitoring R3's bowel management while they were residing at the facility. LPN-U told Surveyor they remembered getting called into R3's room by a Certified Nursing Assistant (CNA) who is no longer employed at the facility who reported R3's large emesis. LPN-U remembers listening to R3's abdomen and their bowel sounds were hard to auscultate and hypoactive. LPN-U remembers updating the acting Director of Nursing (DON) at the time, calling for the KUB results and sending R3 out of the facility by ambulance. Surveyor asked what time R3 was transported to the hospital. LPN-U told Surveyor they thought it was about 3:30 AM when the ambulance left the facility. Surveyor asked LPN-U if they were given report about R3's gastrointestinal status by the previous shift staff on 12/21/22. LPN-U told Surveyor they did not recall whether or not R3's status was reported to them prior to the night shift on 12/22/23. Surveyor asked LPN-U why facility staff did not obtain R3's STAT KUB results until the night shift on 12/22/22. LPN-U did not provide any additional information related to R3's STAT KUB results. On 4/18/23 at 2:30 PM, Surveyor conducted an interview with DON-B. DON-B was not employed at the time R3 was residing at the facility. Surveyor asked DON-B what their expectation would be for ordering and obtaining STAT diagnostic results? DON-B told Surveyor that they would expect that a STAT diagnostic order would be completed and given results within 4 to 6 hours. Surveyor asked DON-B if abnormal diagnostic results are noted by the facility when should the results be reported to a physician? DON-B responded that the results should be reported as soon as possible. Surveyor asked if residents should have a bowel and bladder evaluation completed upon admission to the facility. DON-B responded that all residents should be evaluated for bowel and bladder status on admission. On 4/18/23 at 3:00 PM, Surveyor met with NHA (Nursing Home Administrator)-A. Surveyor informed NHA-A of concerns related to R3's lack of bowel monitoring and patterning upon admission to the facility and lack of care plan to address R3's diagnoses of irritable bowel syndrome and constipation. Surveyor also informed NHA-A of concerns related to R3's STAT KUB x-ray results not being reported to their physician until the night shift of 12/22/23 when the diagnostic results were read by a radiologist on 12/21/22 at 1:49 PM. NHA-A did not provide any additional information at this time. The facility policy and procedure entitled Wound Management - Wound Prevention and Treatment dated 2/24/2021 states: POLICY: The purpose of this program is to assist the facility in the care, services, and documentation related to the occurrence, treatment, and prevention of pressure as well as no-pressure-related wounds. PROVISION AND PROCEDURE: . 2. Upon admission, the resident will receive a head-to-toe skin check to identify any skin issues. A licensed nurse will assess any noted pressure injuries. 7. When the resident is admitted with a pressure ulcer(s), the admitting nurse will document the size, location, appearance, odor (if any), drainage (if any), and current treatment ordered. 8. Interventions will be implemented in the resident's care plan to prevent deterioration and promote the pressure ulcer's healing. 9. The admitting nurse will notify the attending physician of the condition of the pressure ulcer. 2. R19 was admitted to the facility on [DATE] with diagnoses of hydrocephalus, aphasia following cerebral infarction, hemiplegia and hemiparesis following cerebral infarction, a Stage 4 pressure injury to the sacrum, coronary artery disease, congestive heart failure, and peripheral vascular disease. R19 did not have a Minimum Data Set (MDS) assessment completed at the time of the survey. R19 had a court appointed Guardian. R19 was dependent on staff for all activities of daily living (ADL) per R19's ADL Care Plan. On 4/7/2023 at 5:41 PM in the progress notes, Director of Nursing (DON)-B charted R19 was admitted from a neuro rehab facility and has had ongoing coccyx wound since 2022. Surveyor noted no other wounds were described in the progress note. On 4/7/2023 on the admission Data Collection and Baseline Care Plan Tool in the Skin Condition Section of the form, nursing charted R19 had a fluid filled pocket on the left side of the scalp. The form was signed by DON-B on 4/10/2023, three days after admission. Surveyor noted no measurements or wound characteristics were documented for the area on the scalp. No treatment orders were in place. No Skin Integrity Care Plan was initiated. On 4/8/2023 on the Body Check Form, nursing circled the sacral area on the body diagram and charted the dressing was clean, dry, and intact. No other areas on the body diagram were circled indicating a wound was present. On 4/9/2023 on the Body Check Form, nursing circled the sacral area on the body diagram and documented the on-call physician or Nurse Practitioner (NP) was called for treatment orders. Hand-written on the side of the form were measurements of the wound: 3.6 cm x 4 cm x 0.5 cm and per the NP was the treatment order to cleanse the wound with normal saline, pack the wound with hydrofera blue followed by gauze and a 6x6 dressing. Surveyor noted no other areas on the body diagram were circled indicating a wound was present. On 4/10/2023 on the Skin Impairment/Wound Form, Registered Nurse (RN)-K documented the trauma wound to the right thigh measured 2.5 cm x 2.0 cm x 0.1 cm with 100% granulation. RN-K documented the wound was caused from an indwelling urinary catheter digging into R19's skin to the right upper thigh causing the open wound and there was no change in the wound. R19 was seen by the NP with RN-K on that date for the weekly scheduled wound rounds. Surveyor noted the statement there was no change in the wound indicated the wound had been assessed prior to 4/10/2023 and no documentation of an assessment was found. No further documentation was found of the left scalp wound that was noted on admission. On 4/10/2023 on the Treatment Administration Record (TAR), the treatment was initiated for the right thigh opened wound due to trauma: cleanse with wound cleanser and cover with bordered foam dressing every Monday, Wednesday, and Friday and as needed if dressing falls off, is removed, or becomes saturated. On 4/10/2023, R19's Skin Integrity Care Plan was initiated with the following interventions: -Bariatric alternating pressure mattress with foot extender applied to bed due to alternating pressure mattress too small for resident. -Avoid scratching and keep hands and body parts from excessive moisture; keep fingernails short. -Encourage food nutrition and hydration to promote healthier skin. -Facility podiatrist to see resident to trim toenails to bilateral feet. -Follow facility protocols for treatment of injury. -Monitor/document location, size, and treatment of skin injury; report abnormalities, failure to heal, signs/symptoms of infection, maceration etc. to physician. -Perform catheter care as ordered, preventing catheter tubing from digging into resident's skin to thighs. Provide pressure relieving devices: bariatric alternating pressure mattress with foot extender to bed, wheelchair cushion, off-loading using prevalon heel boots and pillows when in bed. -Turn and position as necessary. -Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. -Wound care NP to consult, evaluate, and treat all skin issues with weekly scheduled wound rounds. On 4/17/2023 on the Skin Impairment/Wound Form, Registered Nurse (RN)-K documented the trauma wound to the right thigh had healed. On 4/17/2023 at 2:22 PM, Surveyor observed R19 in bed on a bariatric alternating pressure air mattress with an extended foot piece. R19 was being seen by Speech Therapy at the time of the observation. At 3:27 PM, Surveyor talked with R19 and R19's family member at bedside. R19 did not have any concerns regarding the care that was being provided. In an interview on 4/18/2023 at 11:18 AM, RN-K stated R19's right thigh wound had healed the previous day and Surveyor did not observe a wound on the right thigh. DON-B stated R19 had the right thigh wound on admission. Surveyor noted no documentation was found regarding the right thigh wound until 4/10/2023, three days after admission. In an interview on 4/18/2023 at 11:45 AM, RN-K stated RN-K is responsible for the wounds in the facility and works Monday through Friday. RN-K stated if a new resident is admitted during the time when RN-K is in the facility, then RN-K would do the initial skin assessment. RN-K stated if it is after hours or on a weekend, then the RN in the building or the RN supervisor would be responsible for doing the initial skin assessment and RN-K would see the resident the next time RN-K was in the building. Surveyor asked RN-K if RN-K saw R19 on the day of admission, Friday, 4/7/2023. RN-K stated R19 came in after RN-K had left for the day so RN-K would have seen R19 on wound rounds the following Monday, 4/10/2023. Surveyor asked RN-K what the expectation was for a nurse that was doing the admission skin assessment on a resident. RN-K stated if the resident had any open areas, a skin impairment form should be completed with measurements and a description of the wound tissue. RN-K stated some nurses are not comfortable staging pressure injuries, but they should be able to describe what the wound looked like and the color or type of tissue that was in the wound bed. Surveyor shared the concern with RN-K that R19 was admitted to the facility on [DATE] and no documentation was found of an assessment being completed and no treatment in place until 4/10/2023 when RN-K saw the wound to the right thigh. RN-K stated Surveyor needed to talk to DON-B about the situation because DON-B was the nurse that did the admission assessment of R19 on 4/7/2023. RN-K stated RN-K would expect to see documentation of measurements and wound or tissue description on the day of admission and if treatment orders were not in place, the nurse should call the physician or NP and get treatment orders. In an interview on 4/18/2023 at 1:26 PM, DON-B stated the supervisor or RN in charge at the time a new admission comes in would be responsible for doing the skin assessment of that resident and then RN-K would follow up with any wounds that were discovered at that time. Surveyor asked DON-B what the expectation was of the nurse doing the skin assessment. DON-B stated the RN assessment should include measurement of the wound and a description of the wound. DON-B stated a treatment for the wound should be entered into the Treatment Administration Record (TAR) and if there was no treatment order with the discharge orders, then the nurse should call the physician and get treatment orders. Surveyor shared the concern with DON-B that on admission on [DATE], R19 had a fluid-filled pocket to the left scalp on the admission assessment that was never assessed and a non-pressure injury to the right thigh that was not comprehensively assessed until RN-K saw R19 on 4/10/2023, three days after admission. DON-B stated DON-B would look to see if DON-B had any documentation of the skin and would get back to Surveyor. DON-B stated DON-B knows If it's not written, it's not done. On 4/18/2023 at 3:15 PM, Surveyor shared with Nursing Home Administrator-A and DON-B the concerns R19 was admitted on [DATE] with an open wound to the right thigh per facility staff that was not comprehensively assessed until 4/10/2023, no treatment was in place until 4/10/2023, and no Skin Integrity Care Plan was initiated until 4/10/2023. On the admission Data Collection and Baseline Care Plan Tool on 4/7/2023 there was documentation of a fluid-filled pocket to the left scalp that was never documented on after that initial assessment. No further information was provided at that time. 3. R18's diagnoses includes metabolic enceophalopathy, chronic kidney disease, & hypertension. The potential/actual impairment to skin integrity care plan initiated 3/29/23 & revised 4/17/23 includes an intervention of Apply tubi-grip stockings to BLEs (bilateral lower extremities) daily in AM (morning) & remove daily at HS (hour sleep) for edema management. Initiated 4/13/23. The physician orders with an order date of 4/13/23 documents Apply tubi-grip stockings to BLEs daily in AM & remove daily at HS. every day and night shift for edema management to BLEs. Apply tubi-grip stockings daily in AM and remove daily at HS. On 4/17/23 at 11:59 a.m. Surveyor observed R18 in bed with an air mattress on the bed. R18 is on her right side with a pillow under R18's upper left side. R18 informed Surveyor her knees hurt. Surveyor observed R18 is wearing bilateral pressure relieving boots and is not wearing tubi grips. On 4/17/23 at 1:01 p.m. Surveyor observed R18 continues to be in bed on her right side. Surveyor observed R18 is still not wearing tubi grips. On 4/17/23 at 3:23 p.m. Surveyor observed R18 continues to be in bed wearing bilateral boots with a pillow under R18's lower legs. Surveyor observed R18 is not wearing tubi grips. Surveyor observed a pair of tubi grips on R18's dresser. On 4/18/23 at 8:20 a.m. Surveyor observed R18 in bed on her right side with a pillow under R18's upper left side. Surveyor observed R18 is wearing bilateral pressure relieving boots and is not wearing tubi grips. On 4/18/23 at 10:31 a.m. Surveyor observed R18's coccyx pressure injury treatment with RN (Registered Nurse)/Wound Nurse-K and DON (Director of Nursing)-B. Surveyor observed R18 is not wearing tubi grips and noted the tubi grips on the dresser. At 11:05 a.m. upon completion of R18's treatment, RN/Wound Nurse-K & DON-B placed R18's tubi grips on. On 4/18/23 at 1:47 p.m. Surveyor asked DON-B when staff are doing morning cares for R18 should they place R18's tubi grips on. DON-B indicated they should. Surveyor informed DON-B of the observations of R18 not wearing tubi grips.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) R19 was admitted to the facility on [DATE] with diagnoses of hydrocephalus, aphasia following cerebral infarction, hemiplegia and hemiparesis following cerebral infarction, a Stage 4 pressure injury to the sacrum, coronary artery disease, congestive heart failure, and peripheral vascular disease. R19 did not have a Minimum Data Set (MDS) assessment completed at the time of the survey. R19 had a court appointed Guardian. R19 was dependent on staff for all activities of daily living (ADL) per R19's ADL Care Plan. On 4/3/2023, a fax was sent from the facility R19 was receiving care to the admitting facility with pertinent information and medical record for the facility's review prior to admission. The fax cover sheet stated R19 Requires [sic] simple dressing change to sacrum 3x/week (three times per week). The fax contained diagnoses, a physical exam, speech therapy notes, occupational therapy notes, and wound progress notes. The wound note stated the Stage 4 pressure injury to the sacrum was present on admission 9/26/2022 measuring 2.8 cm x 4 cm x 3.5 cm with thick scar tissue to the wound edges and 20% epithelial tissue and 80% red/moist/smooth/shallow tissue to the wound base. No tunneling was present. A treatment of Dakin's 0.25% and Puracol Plus Ag+ with a foam dressing was to be changed Monday, Wednesday, and Friday. On 4/7/2023 on the Discharge Instructions, the history of the present illness was documented. (R19) was hospitalized from [DATE] through 1/19/2022 and acquired a coccyx wound during that time. (R19) was readmitted to the hospital on [DATE] with a large sacral ulcer with osteomyelitis that underwent surgical debridement and coccygeal ectomy on 4/5/2022. R19 had sacral wound debridement by general surgery on 6/17/2022. Plastic surgery is planning a flap closure in the future when nutritional status is optimized and after a colostomy is placed. R19 was discharged to the facility for continuation of therapies and wound care. The Action Plan portion of the discharge instructions stated wound care nurse consult for the sacral wound. The facility policy and procedure entitled Wound Management - Wound Prevention and Treatment dated 2/24/2021 states: POLICY: The purpose of this program is to assist the facility in the care, services, and documentation related to the occurrence, treatment, and prevention of pressure as well as no-pressure-related wounds. PROVISION AND PROCEDURE: . 2. Upon admission, the resident will receive a head-to-toe skin check to identify any skin issues. A licensed nurse will assess any noted pressure injuries. 7. When the resident is admitted with a pressure ulcer(s), the admitting nurse will document the size, location, appearance, odor (if any), drainage (if any), and current treatment ordered. 8. Interventions will be implemented in the resident's care plan to prevent deterioration and promote the pressure ulcer's healing. 9. The admitting nurse will notify the attending physician of the condition of the pressure ulcer. On 4/7/2023 at 5:41 PM in the progress notes, Director of Nursing (DON)-B charted R19 was admitted from a neuro rehab facility and has had ongoing coccyx wound since 2022. On 4/7/2023 on the admission Data Collection and Baseline Care Plan Tool in the Skin Condition Section of the form, nursing charted R19 had a tunneling pressure ulcer to the coccyx. The form was signed by DON-B on 4/10/2023, three days after admission. Surveyor noted no measurements or wound characteristics were documented for the coccyx wound. No treatment orders were in place. No Skin Integrity Care Plan was initiated. On 4/8/2023 on the Body Check Form, nursing circled the sacral area on the body diagram and charted the dressing was clean, dry, and intact. On 4/9/2023 on the Body Check Form, nursing circled the sacral area on the body diagram and documented the on-call physician or Nurse Practitioner (NP) was called for treatment orders. Hand-written on the side of the form were measurements of the wound: 3.6 cm x 4 cm x 0.5 cm and per the NP was the treatment order to cleanse the wound with normal saline, pack the wound with hydrofera blue followed by gauze and a 6x6 dressing. Surveyor reviewed the Treatment Administration Record (TAR) and the treatment ordered by the NP was not entered onto the TAR. On 4/9/2023 at 9:17 PM in the progress notes, nursing charted the Stage 4 coccyx wound was treated as ordered for bandage soilage. This progress note was written by the same nurse that completed the Body Check Form with the NP with the order hand-written on the side of the form. No treatment order was entered into R19's medical record. On 4/10/2023 on the Skin Impairment/Wound Form, Registered Nurse (RN)-K documented the Stage 4 pressure injury to the coccyx measured 3.5 cm x 4.0 cm x 0.5 cm with 100% granulation. RN-K documented R19 was seen by the NP with RN-K on that date for the weekly scheduled wound rounds. On 4/10/2023 on the TAR, the treatment was initiated for the coccyx pressure injury: cleanse with Dakin's quarter strength solution, apply skin prep to peri-wound, pack wound bed with DermaBlue Foam Transfer dressing cut to size followed by dry 4x4 gauze pads fluffed into the depth of the wound bed and cover with 6x6 bordered foam dressing daily and as needed. On 4/10/2023, R19's Skin Integrity Care Plan was initiated with the following interventions: -Bariatric alternating pressure mattress with foot extender applied to bed due to alternating pressure mattress too small for resident. -Avoid scratching and keep hands and body parts from excessive moisture; keep fingernails short. -Encourage food nutrition and hydration to promote healthier skin. -Facility podiatrist to see resident to trim toenails to bilateral feet. -Follow facility protocols for treatment of injury. -Monitor/document location, size, and treatment of skin injury; report abnormalities, failure to heal, signs/symptoms of infection, maceration etc. to physician. -Perform catheter care as ordered, preventing catheter tubing from digging into resident's skin to thighs. Provide pressure relieving devices: bariatric alternating pressure mattress with foot extender to bed, wheelchair cushion, off-loading using Prevalon heel boots and pillows when in bed. -Turn and position as necessary. -Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. -Wound care NP to consult, evaluate, and treat all skin issues with weekly scheduled wound rounds. On 4/17/2023 on the Skin Impairment/Wound Form, RN-K documented R19's Stage 4 pressure injury to the coccyx measured 3.0 cm x 3.0 cm x 0.5 cm with 100% granulation. RN-K documented R19 was seen on weekly scheduled rounds with the wound NP and the peri-wound was intact with scar tissue and the wound had improved. On 4/17/2023 at 2:22 PM, Surveyor observed R19 in bed on a bariatric alternating pressure air mattress with an extended foot piece. R19 was being seen by Speech Therapy at the time of the observation. At 3:27 PM, Surveyor talked with R19 and R19's family member at bedside. R19 stated the staff change the dressing to R19's pressure injury every day and did not have any concerns regarding the care that was being provided. R19's family member stated R19 was 6 feet 3 inches tall, and the facility had to get R19 a wider, longer bed and that R19 had a history of getting pressure injuries to the feet from being pressed up against the foot board at a previous facility. Surveyor noted R19 had heel boots on, and the feet were not touching the foot board. Surveyor asked R19 if Surveyor could observe wound care to the coccyx the following day. R19 was agreeable. On 4/18/2023 at 11:18 AM, Surveyor accompanied RN-K and DON-B to do wound care to R19's coccyx. R19 was in bed with heel boots on. R19 had a dressing to the coccyx with the previous day's date written on it. The dressing was removed and the blue foam to the wound base fell out of the wound. The wound measured approximately 3 cm x 3 cm x 2 cm with a small open area on the inner right buttock that measured approximately 0.5 cm x 0.5 cm with a shallow depth and pink wound base. RN-K cleansed the coccyx wound with Dakin's solution, applied skin prep to the peri-wound, put the DermaBlue foam cut to fit inside the wound, fluffed gauze into the wound and covered the area with a foam border dressing. Surveyor noted the small open area to the inner right buttock was covered by the foam dressing. Good hand hygiene was observed throughout the dressing change. In an interview on 4/18/2023 at 11:45 AM, RN-K stated RN-K is responsible for the wounds in the facility and works Monday through Friday. RN-K stated if a new resident is admitted during the time when RN-K is in the facility, then RN-K would do the initial skin assessment. RN-K stated if it is after hours or on a weekend, then the RN in the building or the RN supervisor would be responsible for doing the initial skin assessment and RN-K would see the resident the next time RN-K was in the building. Surveyor asked RN-K if RN-K saw R19 on the day of admission, Friday, 4/7/2023. RN-K stated R19 came in after RN-K had left for the day so RN-K would have seen R19 on wound rounds the following Monday, 4/10/2023. Surveyor asked RN-K what the expectation was for a nurse that was doing the admission skin assessment on a resident. RN-K stated if the resident had any open areas, a skin impairment form should be completed with measurements and a description of the wound tissue. RN-K stated some nurses are not comfortable staging pressure injuries, but they should be able to describe what the wound looked like and the color or type of tissue that was in the wound bed. Surveyor shared the concern with RN-K that R19 was admitted to the facility on [DATE] with a known Stage 4 pressure injury to the coccyx and no documentation was found of an assessment being completed and no treatment in place until 4/10/2023 when RN-K saw the pressure injury. RN-K stated Surveyor needed to talk to DON-B about the situation because DON-B was the nurse that did the admission assessment of R19 on 4/7/2023. RN-K stated RN-K wound expect to see documentation of measurements and wound or tissue description on the day of admission and if treatment orders were not in place, the nurse should call the physician or NP and get treatment orders. In an interview on 4/18/2023 at 1:26 PM, DON-B stated the supervisor or RN in charge at the time a new admission comes in would be responsible for doing the skin assessment of that resident and then RN-K would follow up with any wounds that were discovered at that time. Surveyor asked DON-B what the expectation was of the nurse doing the skin assessment. DON-B stated the RN assessment should include measurement of the wound and a description of the wound. DON-B stated a treatment for the wound should be entered into the TAR and if there was no treatment order with the discharge orders, then the nurse should call the physician and get treatment orders. Surveyor shared the concern with DON-B that on admission on [DATE], R19 had a Stage 4 pressure injury to the coccyx that was not comprehensively assessed until RN-K saw R19 on 4/10/2023, three days after admission. DON-B stated DON-B would look to see if DON-B had any documentation of the skin that was not in the chart and would get back to Surveyor. DON-B stated DON-B knows if it's not written, it's not done. Surveyor verified with DON-B that R19 had an alternating pressure air mattress in place on 4/7/2023. DON-B stated yes, there was an alternating pressure air mattress on R19's bed and that was changed to a bariatric alternating pressure mattress. On 4/18/2023 at 3:15 PM, Surveyor shared with Nursing Home Administrator-A and DON-B the concerns R19 was admitted on [DATE] with a Stage 4 pressure injury to the coccyx that was not comprehensively assessed until 4/10/2023, no treatment was in place until 4/10/2023, and no Skin Integrity Care Plan was initiated until 4/10/2023. No further information was provided at that time. Based on observation, interview, and record review, the facility did not ensure that residents with a pressure injury or at risk for pressure injuries received necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 2 (R2 & R19) of 5 Residents reviewed for pressure injuries. * R2 was admitted to the facility on [DATE] without any pressure injuries. The admission assessment dated [DATE] documents R2 was admitted with Mepilex on his right & left trochanter and sacrum, there was no redness or open areas. On 1/27/23 R2 was identified with a DTI (deep tissue injury) on his left upper posterior thigh & left posterior hip. There was no revision in R2's care plan until R2 was identified as having a DTI to left ischium, an unstageable pressure injury to right Achilles, and DTI to the right buttock on 1/30/23. The diabetes mellitus care plan initiated 1/23/23 has an intervention documented of inspect feet daily for open areas, sores, pressure areas, blisters, edema, or redness initiated 1/23/23. There is no evidence in R2's medical record the facility implemented this intervention either prior to the development of R2's unstageable right Achilles pressure injury or after the development. * R19 was admitted to the facility on [DATE] with a Stage 4 pressure injury to the coccyx. The facility did not comprehensively assess and a treatment was not put in place until 4/10/23. Findings include: The Wound Management Wound Prevention and treatment policy & procedure with an effective date of 2/24/21 under provision and policy includes documentation of 1. The facility will ensure that based on the comprehensive assessment of a resident: a) 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 are were unavoidable; and b) a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. For Etiology and Risk Factors for Pressure Injury under accurate documentation documents Accurate documentation is needed to ensure continuity of care. The plan of care should address efforts to stabilize, reduce or remove underlying risk factors; monitor the impact of the interventions; and modify the interventions as appropriate. The care plan should specifically address risk factors, pressure points, under nutrition and hydration deficits and moisture and its impact. 1.) R2 was admitted to the facility on [DATE] and discharged to the hospital on 2/1/23. R2 has an activated power of attorney for healthcare. R2's diagnoses includes multiple sclerosis, diabetes mellitus, moderate protein calorie malnutrition, depressive disorder, anxiety disorder, and dementia. R2 has a suprapubic urinary catheter and a colostomy. The ADL (activities of daily living) self care performance deficit care plan initiated 1/23/23 under interventions documents: * Bed Mobility: The resident requires max assist by 2 staff to turn and reposition in bed Q2H (every two hours) and as necessary. Initiated 1/23/23. The potential/actual impairment to skin integrity care plan initiated 1/23/23 & revised on 1/30/23 has the following interventions: * Encourage good nutrition and hydration in order to promote healthier skin. Initiated 1/23/23. * Follow facility protocols for treatment of injury. Initiated 1/23/23. * Provide pressure relieving device(s): APM (alternating pressure mattress) scoop mattress, w/c (wheelchair) cushion, off-loading heels with pillows when in bed. Initiated 1/23/23 & revised 1/26/23. * Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Initiated 1/25/23. * Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx (signs/symptoms) of infection, maceration, etc to MD (medical doctor). Initiated 1/25/23. * Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Initiated 1/25/23. * WC (wound care) to consult, evaluate, and treat all skin issues with weekly scheduled wound rounds. Initiated 1/25/23. * Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Initiated 1/25/23. * 1/26/23: Requested maintenance to apply APM scoop mattress to bed to prevent skin breakdown d/t (due to) decreased mobility. Initiated 1/26/23. * Prevalon heel lift boots to be applied to bilateral feet when resident is in bed. Initiated 1/30/23. * Resident to not have any briefs/depends on at all times. Initiated 1/30/23. The admission data collection and baseline care plan tool dated 1/23/23 for section H documents for site 25) Right trochanter (hip) and for description documents: Has Mepilex on and has no redness or open areas. For site 26) Left trochanter (hip) and for description documents: Has Mepilex on and has no redness or open areas. For site 53) Sacrum and for description documents: Has Mepilex on, skin is without redness and no open areas. Under admission summary progress note documents: Awake, alert to self. Lung sounds clear anterior, abdomen soft, flat with bowel sounds positive in all four quads. Has Foley patent with clear yellow urine and colostomy with soft unformed stool to right abdomen. Lower abd (abdomen) quads have few scattered injection sites with ecchymosis. Right inner wrist and anticub with ecchymosis from IV (intravenous) sites also left anticub with ecchymosis from IV sites. Has Mepilex to bil (bilateral) hips and coccyx. All three sites do not have redness, no pink, no open areas noted. Has his own teeth and upper front teeth in poor shape, no hearing aides, no glasses. Feet good conditions [sic], will put on list for podiatry to see has a few long toe nails. Pleasant and cooperative at this time, tired, has call light within reach and understands usage. VS (vital signs): 109/57, 66, 18, 98.7, 97% RA (room air). Likes to be called [Name]. This assessment data collection was completed by UM (Unit Manager)-X. Surveyor was unable to interview UM-X as UM-X is no longer employed at the facility. The nurses note dated 1/23/23 documents, Resident arrived into room [number] via ambulance. Awake and alert to self only. VS (vital signs): 109/57, 66, 18, 98.7, 97% on room air. Has Foley catheter draining clear yellow order and colostomy to right abdomen. Right hand and right antecubital with status post IV sites, band aides removed. Has Mepilex to both hips and coccyx, all are without redness and no open areas noted. Does have a few scattered injection sited from anticoagulant therapy noted to lower quadrants. Has own teeth in poor shape, does not have glasses does not have hearing aides. The Braden assessment dated [DATE] has a score of 12 which indicates high risk for pressure injuries. The nurses note dated 1/25/23 documents: Writer was called to room by CNA (Certified Nursing Assistant) stated that the resident had an OA (open area) on the left shoulder, rear, over bone. Area is 1 cm (centimeter) x (times) 1 cm x 0.1 cm. No s/s (signs/symptoms) of infection. No drainage noted. Resident was unaware of it being there. No pain or s/s of pain. Appears to be a skin tear likely caused by shearing. Area was cleaned, medihoney applied to wound bed, gauze island bandage placed to cover the wound. Called and updated POA (power of attorney), wife at 2212 (10:12 p.m.). Called and updated on call at [name of medical group] at 2217 (10:17 p.m.). Surveyor reviewed under the task tab - skin care/monitoring. No is answered for the question Barrier cream applied after cleansing with each incontinent episode and as needed during the shift on 1/25/23 at 3:19 a.m., 1/26/23 at 3:21 a.m., 1/27/23 at 3:32 a.m., 1/28/23 at 4:23 a.m., 1/29/23 at 4:15 a.m., 1/30/23 at 4:36 a.m., 1/31/23 at 3:54 a.m., 2/1/23 at 5:11 a.m. and not applicable on 2/1/23 at 11:37 a.m. There are no other dates or times documented. Yes is answered for the question, Resident repositioned self or was assisted with repositioning every 2 hours and as needed during shift on 1/25/23 at 3:19 a.m., 1/26/23 at 3:21 a.m., 1/27/23 at 3:32 a.m., 1/28/23 at 4:23 a.m., 1/29/23 at 4:15 a.m., 1/30/23 at 4:36 a.m., 1/31/23 at 3:54 a.m., 2/1/23 at 5:11 a.m. and at 11:37 a.m. There are no other dates or times documented. The skin/wound note dated 1/26/23 documents Wound care RN assessed new skin issue on 1/26/23. New skin issue occurred on 1/25/23 on PM (evening) shift. New opened wound to left posterior shoulder d/t (due to) shearing. Wound to left posterior shoulder measures: L (length) = (equals) 1.0 cm, W (width) = 1.0 cm, D (depth) = 0.1 cm. Wound bed to opened wound to left posterior shoulder with 100% red/granulation tissue to wound bed, small amount of serosanguinous drainage, no s/s infection, and skin surrounding opened wound to left posterior shoulder WNL (within normal limits)/intact. Resident denies any pain to opened wound to left posterior shoulder, pain level = 0/10 per resident report. new wound treatment orders obtained as follows: Cleanse NS (normal saline), pat dry, apply skin prep to peri-wound, Cover with bordered gauze dressing or bordered island dressing, change dressing every Mon/Wed/Fri (Monday/Wednesday/Friday) & PRN (as needed). Wound care performed to left posterior shoulder as ordered, resident tolerated wound care well with no complications noted. On 1/26/23 APM scoop mattress to be applied to bed to prevent areas of skin breakdown d/t decreased mobility with physical limitations. Opened wound to left posterior shoulder d/t shearing to be assessed by wound care NP (nurse practitioner) [name] with weekly scheduled wound rounds. Surveyor noted there was no revision to R2's care plan to address/prevent shearing as a risk factor for R2. The left posterior shoulder was healed/resolved on 1/30/23. The skin/wound note dated 1/27/23 documents Wound care RN & DON (Director of Nursing) assessed skin on 1/27/23: New DTI (deep tissue injury) to left posterior upper thigh measuring: L= 6.0 cm, W = 5.0 cm, D = 0 cm, wound bed with 100% dark purplish/red intact non-blanchable skin to wound bed to left posterior upper thigh, no drainage, no s/s of infection, surrounding skin red/intact. Applied skin prep to DTI to left posterior hip f/b bordered foam dressing to protect skin. Orders obtained to change dressing Q (every) M/W/F & PRN. New skin issue discovered on 1/27/23: New DTI to left posterior hip measuring: L= 5.5 cm, W = 4.0 cm, D = 0 cm, wound bed with 100% dark purplish/red intact non-blanchable skin to wound bed to left posterior hip, no drainage, no s/s of infection, surrounding skin red/intact. Applied skin prep to DTI to left posterior hip f/b (followed by) bordered foam dressing to protect skin. Orders obtained to change dressing Q M/W/F & PRN. [Name] NP to assess both new DTI's with weekly scheduled wound rounds. Resident states no c/o (complaint of) pain, pain level = 0/10 per resident report. There is no further assessment of R2's left posterior upper thigh after 1/27/23. The Facility did not initiate the order dated 1/27/23 to apply skin prep followed by bordered foam dressing change dressing every Monday/Wednesday/Friday & PRN to the DTI on R2's left posterior upper thigh & left posterior hip as this order is not included on R2's January treatment administration record. The nurses note dated 1/29/23 documents Alert, responsive. Repositioned off right side often. Resident denies any pain or discomfort to right hip and upper thigh. The Medicare 5 day MDS (minimum data set) with an assessment reference date of 1/30/23 has a BIMS (brief interview mental status) score of 12 which indicates moderately impaired. R2 has no behavior including refusal of care. R2 requires extensive assistance with one person physical assist for bed mobility, did not transfer or ambulate, is dependent with one person physical assist for toilet use, is checked for indwelling catheter & ostomy. R2 is at risk for pressure injury development and is coded as having one unstageable slough &/or eschar not present upon admission and 3 unstageable DTI not present upon admission. NP-V's wound care initial evaluation dated 1/30/23 under physical examination documents Deep tissue injury to left posterior hip Deep purple area with deflated blister measuring 4.5 cm x 5.0 cm x 0.1 cm. Scant serosanguineous drainage. The base is 80% deep purple 20% red. No signs or symptoms of infection. Peri-wound pink and blanchable. Status POA (present on admission) Plan: Zinc oxide on bordered foam change daily. Deep tissue injury to left ischium Deep purple area measuring 5.5 cm x 5.0 cm x 0.1 cm. The base is 100% deep purple and there is no drainage. Peri-wound pink and blanchable. No signs or symptoms of infection. Status: POA Plan: Zinc oxide on bordered foam change daily. Unstageable pressure injury to right Achilles Full-thickness wound measuring 8.0 cm x 1.9 cm x 0.1 cm. The base is 100% slough covered and there is a moderate amount of serosanguineous drainage. Peri-wound with local erythema and slight warmth. Positive pedal pulse Status: POA Plan: Medihoney on bordered foam change 3 times a week, heel offloading boot at all times. Cellulitis to right Achilles wound Plan: Doxycycline twice daily x 10 days. Deep tissue injury to the right buttock. Deep purple area measuring 1.5 cm x 2.5 cm. Intact no drainage. 100% deep purple. Peri-wound pink and blanchable. No signs or symptoms of infection: Status: New Plan: Offload with every 2 hours turns, no briefs. Surveyor noted NP-V's initial evaluation documents R2's pressure injuries were present upon admission but the Facility's admission assessment dated [DATE] documents R2 did not have any open areas. The skin/wound note dated 1/30/23 documents Right side of buttock DTI assessed on 1/30/23 per [name] NP with weekly wound rounds. DTI to right buttock measures: L = 1.5 cm, W = 2.5 cm D = 0 cm, wound bed with 100% deep dark purple non-blanchable tissue to wound bed, no drainage present, no s/s of infection and skin surrounding DT fragile/intact. DTI to right buttock assessed by wound NP [name] NP on 1/30/23 with new orders obtained to apply [NAME] butt paste 16% Zinc oxide paste to be applied every shift & PRN to right buttock DTI. Depends removed from resident on 1/30/23 d/t DTI to right buttock d/t depends rubbing into resident's skin. Resident doesn't requiring to wear brief/depends d/t ostomy and catheter in place. Right Achilles unstageable pressure ulcer assessed on 1/30/23 per [name] NP. Right Achilles unstageable pressure ulcer measures: L = 8.0 cm, W = 1.9 cm, D = 0.1 cm, wound bed to right Achilles with 100% slough tissue to wound bed with moderate amount of serosanguinous drainage present, & surrounding skin to peri-wound red. New orders obtained per [name] NP on 1/30/23 for Doxycycline 100 mg (milligrams) po (by mouth) BID (twice daily) x (times) 10 days d/t infection to right Achilles ulcer. New wound orders obtained on 1/30/23 per [name] NP as follows: Cleanse pressure ulcer to right Achilles with wound cleanser, pat dry, apply medihoney to wound bed, Cover with large bordered foam dressing, Change dressing daily & PRN, applied Prevalon boots to bilateral feet on 1/30/23 to be worn when in bed to off-load heels. The diabetes mellitus care plan initiated 1/23/23 has an intervention documented of Inspect feet daily for open areas, sores, pressure areas, blisters, edema or redness initiated 1/23/23. There is no evidence in R2's medical record the Facility implemented this intervention either prior to the development of R2's unstageable right Achilles pressure injury or after the development. The January TAR with a start date of 1/30/23 documents Staff to turn/reposition resident every 2-3 hours & PRN every shift for several skin issues requiring frequent turning by staff. Surveyor reviewed R2's medical record including January MAR (medication administration record), January TAR (treatment administration record), February MAR & TAR, physician orders, progress notes, and information under the task tab and was unable to locate evidence the Facility was monitoring R2's feet. R2 has a diagnosis of diabetes mellitus. The nurses note dated 2/1/23 documents Family requesting that resident be sent out to hospital for wound evaluation. NP notified and spoke with family. DON and Administrator notified as well. NP called report to ED at [hospital initials]. [Name] ambulance notified of transfer and will be on the way. Family intentions are to have resident placed elsewhere. The hospital ER (emergency room) Provider notes dated 2/1/23 under clinical impression documents Pressure ulcers of skin of multiple topographic sites. Under ED (emergency department) course documents: I reviewed the pressure ulcers on the patient, none look grossly infected and all are in the early stages. The patient himself has no complaints. He has known MS (multiple sclerosis), dementia, diabetes, chronic Foley catheter. Other than feeling generally weak and rundown he has no concerns. Family concerned as he has developed pressure ulcers on his back and heel. They do not clinically appear infected to me. The patient appears well-appearing. Family arrived at bedside. Including wife who is activated power of attorney, concerned that the patient has developed pressure ulcers and may not be receiving ideal care. Plan was for discharge from rehab tomorrow. They would like the pressure ulcers evaluated. I have pictures of them in the chart below. None of them appear to have any necrotizing component or any active infections. Afebrile The nurses note dated 2/2/23 documents: Wound care RN & DON assessed skin on 1/27/23 with two skin issues discovered. Both skin issues discovered by CNA & DON when transferring resident from bed to recliner via Hoyer lift, during transfer Mepilex discovered in several areas, Mepilex dressings removed with two new skin issues present under Mepilex dressings. Resident stated he had skin issues when he was in hospital prior to admit to facility. Resident with diagnosis of: Multiple sclerosis, type 2 DM (diabetes mellitus), moderate protein calorie malnutrition, unsteadiness on feet, immobility with physical limitations. DTI to left posterior upper thigh measuring: L = 6.0 cm, W = 5.0 cm, D = 0 cm, wound bed with 100% dark purplish/red intact non-blanchable skin to wound bed to left posterior upper thigh, no drainage, no s/s of infection, surrounding skin red/intact. Resident with no c/o pain to DTI to left posterior upper thigh, pain level = 0/10. Applied skin prep to DTI to left posterior hip f/b bordered foam dressing to protect skin. Treatment orders in place. Resident second skin issue discovered on 1/27/23: DTI to left posterior hip measuring: L = 5.5 cm, W = 4.0 cm, D = 0 cm, wound bed with 100% dark purplish/red intact non-blanchable skin to wound bed to left posterior hip, no drainage, no s/s of infection, surrounding skin red/intact. Applied skin prep to DTI to left posterior hip f/b bordered foam dressing to protect skin. Wound treatment orders obtained & in place. Resident with no c/o pain to left posterior hip, pain level=0/10 per resident report. RCA (root cause analysis) conducted. New interventions: APM scoop mattress applied to bed 1/26/23 & turning scheduled put in place for staff to turn/reposition resident every 2-3 hours & PRN d/t immobility, orders to apply [NAME] butt paste to bilateral buttock/scrotum for prevention of skin breakdown. Prior interventions: recliner chair in room with Roku cushion to recliner, off-loading bilateral heels with pillows

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the Facility did not ensure Residents with pressure injuries receive appropriate care, treatment, & preventative measures to promote healing for 2 (R36 & R12) of 7 Residents with pressure injuries. * On 2/5/22 R36's right shin was swollen & discolored and R36 was showing signs of pain. An x-ray was ordered of R36's right shin which on 2/6/22 revealed an acute nondisplaced oblique fracture of distal shaft of tibia. R36's power of attorney requested R36 not be sent to the hospital and a brace/splint was applied by therapy. There were no instructions provided regarding assessing R36's foot under the brace and there is no evidence anyone was assessing R36's foot under the brace. R36's skin integrity care plan was not revised to include the brace/splint or assessment of the right foot. On 3/7/22 R36 was identified as having a pressure injury to the top of the right foot. There is no stage or description of the wound bed. There was no revision in R36's skin integrity care plan after R36 was identified as having a pressure injury until 3/9/22. On 3/9/22 R36's pressure injury to the top of the right foot is still not staged and there is no description of the wound bed. Two additional pressure injuries are identified. A DTI (deep tissue injury) to the right heel and a DTI to the right lateral plantar. * R12 was admitted to the facility on [DATE] with right side coccyx Stage 2 pressure injury, left coccyx Stage 2 pressure injury, right medial buttocks Stage 2 pressure injury and left lateral buttocks Stage 2 pressure injury. These pressure injuries were not comprehensively assessed as there is no description of the wound bed. On 1/5/22 the wound assessment documents the coccyx and right upper buttocks were identified as being Stage 3. There were no revisions to R12's skin integrity care plan. R12 was hospitalized from [DATE] to 2/4/22. The admission/re-admission summary and re-admission data collection tool dated 2/4/22 does not comprehensively assess R12's pressure injuries as there are no measurements or description of the wound bed which were completed by an LPN (Licensed Practical Nurse). There is no RN (Registered Nurse) assessment of R12's pressure injuries until 5 days later, on 2/9/22. On 4/25/22 R12's pressure injury was not covered with a dressing for approximately 5 hours. Findings include: 1. R36's diagnoses include diabetes mellitus, chronic kidney disease, dementia, hypertension, moderate protein-calorie malnutrition, and Alzheimer's Disease. The at risk for skin breakdown care plan initiated 10/20/17 & revised 4/9/22 documents the following interventions: * Use a draw sheet or lifting device to move resident initiated 10/20/17 & revised 1/19/21. * Encourage to elevate legs periodically while in W/C (wheelchair) initiated 11/20/17 & revised 1/19/21. * Off load heels while in bed initiated 11/13/17 & revised 1/19/21. * Bilateral leg rests padded with foam initiated 6/26/19 & revised 1/19/21. * Heel lift boots initiated 4/28/21. * Left arm bolster to w/c to assist with upright positioning initiated 7/13/21. * Pressure relieving Wheelchair cushion and air mattress initiated 10/20/17 & revised 4/15/21. * Prevalon boot to right foot at all times initiated 3/9/22. The quarterly MDS (Minimum Data Set) with an assessment date of 1/21/22 documents R36 has short- & long-term memory problems and is severely impaired for cognitive skills for daily decision making. R36 requires extensive assistance with one person for bed mobility, extensive assistance with two plus person physical assist for transfer, does not ambulate and is dependent with one-person physical assist for toilet use. R36 is coded as always incontinent of urine and bowel. R36 is at risk for pressure injury development and is coded as not having any pressure injuries. The SBAR (situation, background, appearance, review & notify) note dated 2/5/22 under appearance documents Med Tech reported that resident displayed s/s (signs/symptoms) of pain and discomfort. Writer looked at right leg and noted that the resident tried to pull away from touch while yelling in pain. Resident had swelling and reddish/purple discolorization (sic) to the right shin. Under review and notify for recommendations of primary clinicians' documents X-ray of right shin ordered by On Call PA (physician assistant). The nurses note dated 2/6/22 documents Resident slept at intervals during night, rouses easily. No complaints offered unless right leg is touched or moved. Heel boots in place bilaterally. Discoloration noted to right shin. Cries out my Leg, My Leg if right leg is touched or moved. Given Tylenol once during night with good effect, then slept again. Vitals stable. Awaiting X-ray to come for right leg X-ray. Call light in reach & toy dog in beside her talking to it at times. Call light in reach. The APNP (Advanced Practice Nurse Prescriber) note dated 2/7/22 documents under chief complaint Right tibia fracture and under assessment documents Patient seen today for follow up on X-ray results. Over the weekend patient developed right leg pain. X-ray was obtained revealing acute nondisplaced oblique fracture of distal shift of tibia. Mild osteopenia. Moderate osteoarthritis demonstrated. Nursing scheduled appointment with orthopedics for this week Thursday. Therapy was able to place splint to right lower extremity. There is no obvious deformity. Unable to obtain pulse due to location of splinting straps. Circulation appears to be intact, capillary refill less than 3 seconds. Patient denies pain while lying still. Does report significant pain with movement. Currently only taking Tylenol. Tramadol 25 mg (milligrams) every 6 hours as needed added today. Prescription sent in. No further concerns today. Surveyor noted there is no revision in R36's at risk for skin breakdown care plan regarding the splint for R36's right tibia fracture. The nurses note dated 2/8/22 documents Resident alert & rouses easily, resting quietly sleeping when undisturbed. Calls out with cares, 2 for all cares to minimize pain in right lower leg. Splint in place on right foot & lower leg. Give 1 dose of Tramadol for pain & slept well afterward, rouses easily & interacts at baseline, good eye contact. Call light in reach. The nurses note dated 2/10/22 documents Resident being monitored d/t LLE [sic] fx. Resident appears comfortable. Resident sleeping between meals. Tramadol given this morning with relief. Splint to RLE (right lower extremity) in place. No swelling or bruising noted. Rounding and safety maintained. Continue with POC (plan of care). The nurses note dated 2/10/22 documents Resident resting in bed, denies pain r/t (related to) fractured Rt (right) tibia at this time, VSS (vital signs stable), splint in place, repositioned by staff. Will cont. (continue) to monitor. The Braden assessment dated [DATE] has a score of 12 which indicates high risk. The skin impairment/wound form dated 3/7/22 for the question does the resident have a pressure injury yes is answered. Location documents top of right foot. Stage is not documented and measure of wound documents approx. (approximately) 1.5 x (times) 1.5 cm (centimeters). The wound tissue bed section has not been completed and is blank. Under additional comments documents area is right where strap for brace lays on top of foot. Under current treatment documents 4x4s to create cushion, strap loosely applied to site. This form was completed by RN (Registered Nurse)-D. The Braden assessment dated [DATE] has a score of 13 which indicates moderate risk. Surveyor noted R36's at risk for skin breakdown care plan was not revised until 3/9/22. The skin impairment/wound form dated 3/9/22 for the question does the resident have a pressure injury yes is answered. Location documents top of right foot. Stage is not documented and measure of wound documents approx. (approximately) 2.5 x (times) 1.3 cm. The wound tissue bed section has not been completed and is blank. Under additional comments documents area is right where strap for brace lays on top of foot. Under current treatment documents Per [Physician's name], do wound cleanse f/b (followed by) Xeroform and Medi honey, cover with gauze island dressing daily. Under Additional Wound # for location documents right heel. Stage is Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Measure of wound 3.1 x 2.4 cm. The wound bed tissue bed section has not been completed and is blank. Under current treatment documents Per [wound doctor name], wound cleanse f/b Betadine daily. Under Additional Wound # for location documents right lateral plantar. Stage is Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Measure of wound 3 x 4.2 cm. The wound bed tissue bed section has not been completed and is blank. Under current treatment documents Per [wound doctor name], wound cleanse f/b Betadine daily. Under wound education provided documents Family called and educated on plan of care for healing. Explained plan of care for healing to resident. She nodded her head, unable to determine understanding d/t (due to) resident speaks Spanish but does indicate understanding at times, Had Dx (diagnosis) of dementia. The nurses note dated 3/9/22 documents Resident's daughter, [name] was called and informed of open area to right dorsal foot and dark areas to right plantar and right heel. Informed of treatment orders given per [wound doctor name] and informed resident will be followed q (every) week by [wound doctor name] for areas. The nurses note dated 3/9/22 documents IDT (interdisciplinary team) met to discuss resident wounds to the right foot. Resident has had a history of foot wounds on/off d/t (due to) DM (diabetes mellitus), poor circulation, malnutrition, and impaired physical mobility. Recently resident had fracture to right leg requiring a brace to ensure no movement and to assist with comfort. Resident with diabetic foot checks nightly. NOR (new order received) to allow brace to be removed indefinitely from resident and ok to put Prevalon boot back on at all times. All wound care orders entered and reviewed. Care plan updated. Family made aware. The nurses note dated 3/10/22 documents Resident being monitored for new suspected DTI (deep tissue injury) to right plantar lateral foot and right heel caused by ankle splint. Betadine applied as ordered. Dorsal portion of (right foot) has a wound and dressing changed per orders. Resident tolerated well. The skin impairment/wound form dated 3/16/22 (completed by DON B) for the question does the resident have a pressure injury yes is answered. Location documents right anterior foot. Stage is Stage 4 Pressure Injury: Full-thickness skin and tissue loss. Measure of wound documents 2 x 3.5. The wound tissue bed is 10% granulation and 90% eschar. Under additional comments documents debridement completed by MD (medical doctor) to remove necrotic tissue, resident tolerated well with no c/o (complaint of) pain. Under current treatment documents wound cleanser wash, Medi honey, Xeroform, cover with bordered gauze dressing daily. Under Additional Wound # for location documents right heel. Stage is Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Measure of wound 3 x 3.5 cm. The wound bed tissue bed is 100% eschar. Under current treatment documents skin prep daily. Under Additional Wound # for location documents right lateral plantar. Stage is Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Measure of wound 3 x 4. The wound bed tissue bed is 100% eschar. Under current treatment documents skin prep daily. Surveyor noted R36's pressure injuries were assessed by the wound MD M on 3/16/22. On 3/16/22, wound MD M doctor staged the right heel and right lateral planter as unstageable DTI's. The quarterly MDS (Minimum Data Set) with an assessment date of 4/7/22 documents R36 has short- & long-term memory problems and is severely impaired for cognitive skills for daily decision making. R36 requires extensive assistance with one person for bed mobility, dependent with two plus person physical assist for transfer, does not ambulate and is dependent with one person physical assist for toilet use. R36 is coded as always incontinent of urine and bowel. R36 is at risk for pressure injury development and is coded as have one Stage 4 pressure injury and 2 unstageable DTI (deep tissue injury) pressure injuries. Surveyor noted weekly pressure injury assessments by wound MD M and facility staff dated 3/23/22, 3/30/22, 4/6/22, and 4/13/22. The skin impairment/wound form dated 4/20/22 for the question does the resident have a pressure injury yes is answered. Location documents right dorsal medial foot. Stage is Stage 4 Pressure Injury: Full-thickness skin and tissue loss. Measure of wound documents 0.8 x 0.5 x 0.1 cm. The wound tissue bed is 70% granulation and 30% eschar. Under additional comments documents debridement completed by MD to remove necrotic tissue, resident tolerated well with no c/o pain. Wound progress improved. Under current treatment documents wound cleanser f/b Collagen gel, cover with bordered gauze dressing daily. Under Additional Wound # for location documents right heel. Stage is Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Measure of wound 3 x 2 x not measurable cm. The wound bed tissue bed section has not been completed and is blank. Under current treatment documents skin prep daily. Under Additional Wound # for location documents right lateral plantar. Stage is Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Measure of wound 2.5 x 3.5 x not measurable cm. The wound bed tissue bed section has not been completed and is blank. Under current treatment documents skin prep daily, Moisturizers per wound daily. On 4/24/22 at 12:04 p.m. Surveyor spoke with R36's power of attorney and inquired how R36 received her right foot pressure injuries. R36's power of attorney informed Surveyor they happened after a brace was put on her leg following a fall to immobilize her leg. R36's power of attorney informed Surveyor the brace caused the pressure injuries and R36 was sitting in her chair for extended periods of time. On 4/26/22 at 9:26 a.m. Surveyor asked CNA-H if she knew how R36 developed the pressure injuries on her right foot. CNA-H informed Surveyor R36 had a funky brace, and she broke down. Surveyor asked CNA-H if she was given any instructions about the brace and was the brace/splint removed. CNA-H replied no and explained after R36 fractured her leg they weren't putting pants on her. R36 would wear a top, brief and was covered with a warming blanket. Surveyor asked who noticed the pressure injuries first. CNA-H replied, think me. Surveyor asked how she noticed the pressure injuries. CNA-H informed Surveyor she was going to put pants on R36, removed the brace and saw the sores. Surveyor asked if she reported this to anyone. CNA-H replied [first name] of RN (Registered Nurse)-D. On 4/26/22 at 1:02 p.m. Surveyor asked RN-D how she became aware of R36's pressure injuries. RN-D informed Surveyor staff came one day to her and informed her on the top of R36's right foot there was a pressure injury. RN-D informed Surveyor it was where the strap was. RN-D informed Surveyor after this was reported to her, she assessed R36, called the doctor, did a skin assessment and risk management form. Surveyor inquired how many pressure injuries did she observe. RN-D informed Surveyor she only remembers the one on top of her foot. On 4/26/22 at 1:45 p.m. Surveyor met with RN-J with DON (Director of Nursing)-B to discuss pressure injuries. RN-J informed Surveyor she works per diem at the Facility and goes on wound rounds on Wednesday with the wound doctor. Surveyor inquired about staging pressure injuries. DON-B informed Surveyor their nurses are instructed not to stage a wound unless they are wound certified. RN-J informed Surveyor she's not wound certified. DON-B informed Surveyor the wound physician stages the pressure injuries. Surveyor asked who revises the skin integrity care plans. RN-J informed Surveyor she has not worked on these. On 4/26/22 at 2:21 p.m. Surveyor observed the treatment for R36's right heel, right lateral plantar and right dorsal medial foot pressure injury with RN-I. Treatments were observed according to physician orders and there was no deficient practice identified with this observation. On 4/27/21 at 8:21 a.m. Surveyor spoke with DON-B regarding R36's right tibia fracture with a splint being applied after and inquired if R36 was evaluated in the hospital. DON-B informed Surveyor R36 was not sent to the hospital. DON-B explained she contacted R36's daughter to see which pathway she wanted for her mother. Did she want R36 sent to the ER or follow up with orthopedics as this is what the ER would probably say. DON-B informed Surveyor the daughter agreed to send R36 to the orthopedics at [name of orthopedics] as R36 had been seen there prior. DON-B indicated she contacted the orthopedics for an appointment and since R36's power of attorney was activated she (the daughter) would have to go with her. DON-B informed Surveyor due to her work schedule R36's daughter wouldn't be able to go with her, so the decision was to send the X-ray to [name of] orthopedics and they made a recommendation for a brace for comfort. DON-B informed Surveyor the Facility's therapy department had a brace which R36 could use and therapy placed the brace on R36. Surveyor asked if therapy gave any instructions for the brace. DON-B replied no explaining it was the orthopedics that recommended the brace for comfort. Surveyor asked if there were any instructions from therapy for nursing to assess R36's foot. DON-B replied no. Surveyor asked DON-B what would be the expectation for a Resident wearing a brace. DON-B informed Surveyor they should be checking skin integrity once a day under any kind of brace. Surveyor asked where Surveyor would be able to locate an order regarding R36's brace. DON-B replied I can tell you the order wasn't put in. We identified it was missed. DON-B informed Surveyor R36 is a diabetic and they do daily foot checks. Surveyor asked DON-B if the nurses were doing daily diabetic foot checks why didn't anyone observe the three pressure injuries before they were reported by a CNA. DON-B replied, I can only assume that they didn't look under the brace. Surveyor informed DON-B R36's pressure injury was not revised after receiving the brace. DON-B replied, typically it is. 2. R12 was admitted to the facility on [DATE] with diagnoses which include diabetes mellitus, morbid obesity and multiple myeloma. The admission/re admission summary dated [DATE] includes documentation of Has bordered dressings to coccyx and right ischial area. Both dressings covered with BM, Areas cleansed with normal saline and new dressings applied. Please see skin assessment for measurements . The skin impairment/wound form dated 1/3/22 answers yes for the question does the resident have a pressure injury. Location is right side coccyx. Stage is Stage 2 pressure injury: partial thickness skin loss with exposed dermis. Measurement of wound documents 0.5 cm (centimeter) x (times) 0.5 cm. There is no description of the wound bed. Under additional comments documents resident admitted with pressure area. Under current treatment documents NS (normal saline) cleanse F/B (followed by) Medi honey, cover with gauze island dressing daily and prn (as needed). Additional wound # for location documents Left coccyx. Stage is Stage 2 pressure injury: Partial-thickness skin loss with exposed dermis. Measurement of wound documents 1.5 cm 0.4 cm. The wound tissue bed is not completed and is blank. Additional comments documents Resident admitted with pressure area. For current treatment documents NS cleanse F/B Medi honey, cover with gauze island dressing daily and prn. Additional wound # for location documents right medial buttock. Stage is Stage 2 pressure injury: partial thickness skin loss with exposed dermis. Measurements of wound documents 1.5 x 1.5 cm. The wound tissue bed is not completed and is blank. Under additional comments documents 'resident admitted with pressure area.' Current treatment documents NS cleanse F/B Medi honey cover with gauze island dressing daily and prn. Additional wound for location documents left lateral buttock. Stage of pressure injury documents Stage 2 and measurement of wound documents 1.5 x 1.0 cm. The wound tissue bed is not complete and is blank. Under additional comments documents resident admitted with pressure area. Current treatment documents NS cleanse F/B Medi honey, cover with gauze island dressing daily and prn. Surveyor noted the Facility did not comprehensively assess R12's pressure injuries as there are no description of the wound beds. The actual skin impairment care plan initiated 1/3/22 and revised on 3/2/22 has the following interventions: * Encourage good nutrition and hydration in order to promote healthier skin initiated 1/3/22. * Follow facility protocols for treatment of injury initiated 1/3/22. * [R12's name] will be encouraged to adhere to wound physician's recommendation to reposition side-to-side while in bed, avoiding sitting or laying (sic) on back initiated 3/2/22. * [R12's name] will be encouraged to limit time out of bed to less than 1 hour for each meal to promote wound healing initiated 3/2/22. * Provide pressure relieving devices, off-loading cushion to heels initiated 1/3/22. The skin impairment/wound form dated 1/5/22 answers yes for the question does the resident have a pressure injury. Location is coccyx. The stage is documented as Stage 3 pressure injury: full-thickness skin loss. Measurement of wound documents 2 x 2.2 x 0.1 cm. The wound bed is 40% slough and 30% granulation. Additional wound for location documents right upper buttock. The stage is Stage 3 Pressure injury: full thickness skin loss. Measurement of wound documents 4 x 0.6 x 0.1 cm. The wound bed is 70% granulation. Additional comments documents [name of wound doctor] to follow weekly on wound rounds. Current treatment documents NS cleanse F/B Medi honey, cover with gauze island dressing daily and prn. Under current wound/skin integrity interventions documents Pressure relief mattress, offloading cushion for heels, pressure relief cushion in w/c (wheelchair), incontinence care and Foley catheter cares. Left buttock open area assessed by [name of wound doctor] as a shear wound, not pressure. R12's skin integrity care plan was not revised until 3/2/22. R12 was hospitalized from [DATE] to 1/18/22. The admission/re- admission summary dated [DATE] includes documentation of .Skin intact, to feet and legs, lower legs red ruddy in color. Bruises noted to bilateral hands and arms. Puncture sites to bilateral antecubital sites. 11 sheer areas noted scattered across bilateral buttocks. [name of wound doctor] to assess in AM (morning). [Name of] NP (nurse practitioner) updated on readmit. The skin impairment/wound form dated 1/19/22 answers yes for the question does resident have pressure injury. Location is coccyx. Stage is Stage 3 pressure injury: full thickness skin loss. measure of wound is 1.6 x 0.7 x 0.1 cm. The wound bed is 60% granulation and 40% slough. Additional comments documents Pressure area to coccyx has improved since last assessment done by [name of wound doctor] on 1-5-22. Resident went out to hospital on 1-9-22 with critical INR (international normalized ratio). This is the initial exam since returning from hospital. Current treatment documents normal saline cleanse fb Medi honey, cover with gauze island dressing daily. Additional wound for location documents right upper buttock. Stage is Stage 3 pressure injury: full thickness skin loss. Measurement of wound is 0.5 x 0.6 x 0.1 cm. Wound bed is 100% granulation. Additional comments documents This is the initial exam since readmission from hospital on 1-18-22. Last wound care assessment prior to hospital was 1-5-22. Wound progress improved per MD. Current treatment is normal saline cleanse fb Medi honey, cover with gauze island dressing daily. R12 was hospitalized from [DATE] to 2/4/22. The admission/re- admission summary dated [DATE] includes documentation of .Sacrum has two small open areas and a non-blanchable area was noted on the left buttock. Brownish decolorization noted on bilateral lower legs. Resident seemed content being back at the facility. The readmission data collection tool dated 2/4/22 for sacrum documents 2 open areas were noted in the sacrum. Both small in size. For left buttocks documents Small red, non-blanchable area noted on the left buttock. This data collection tool was completed by LPN (Licensed Practical Nurse) Supervisor-G. The Braden assessment dated [DATE] has a score of 12 which indicates high risk. The skin impairment/wound form dated 2/9/22 yes is answered for the question does the resident have a pressure injury. Location is left lower buttock. Stage is not completed. Measurement of wound is 1.3 x 0.4 cm and the wound tissue bed is not completed and is blank. Under current treatment documents wound cleanse f/b Medi honey, cover with gauze island dressing daily. Additional wound for location is right upper buttock. The stage is not completed, and measurement of wound is 1.5 x 0.6 x 0.1 cm. The wound bed is not completed and is blank. Current treatment is wound cleanse fb Medi honey, cover with gauze island dressing daily. Surveyor noted this RN assessment is 5 days after R12 was readmitted to the Facility and is not comprehensive as there are no description of the wound beds and the pressure injury is not staged. Surveyor noted the wound doctor did not assess R12 on 2/9/22. R12' skin integrity care plan was not revised until 3/2/22 and there are no further revisions after this date. The admission MDS (Minimum Data Set) with an assessment reference date of 2/11/22 has a BIMS (brief interview mental status) score of 12 which indicates moderate impairment. R12 requires extensive assistance with two plus person physical assist for bed mobility, does not ambulate, is checked for indwelling catheter and is frequently incontinent of bowel. R12 is at risk of pressure injury development and is coded as having two Stage 3 pressure injuries which were present upon admission. The skin impairment/wound form dated 2/16/22 answers yes for the question does the resident have a pressure injury. Under location documents coccyx. The Stage is not completed. Measurement of wound documents 0.5 x 0.5 x 0.1 cm. Wound tissue bed is 80% granulation and 20% slough. Under additional comments documents Debridement procedure done by [name of wound doctor], resident tolerated well. Current treatment documents wound cleanse f/b Medi honey, cover with gauze island dressing daily. Wound doctor's note dated 2/16/22 documents resolved 2/16/22 for right and left lower buttocks and stages the coccyx as Stage 3. Surveyor noted weekly pressure injury assessments by the wound doctor and facility staff dated 2/23/22, 3/2/22, 3/9/22, 3/16/22, 3/23/22, 3/30/22, 4/6/22, and 4/13/22. The skin impairment/wound form dated 4/20/22 answers yes for the question does the resident have a pressure injury. Location is coccyx. Stage is Stage 3 Pressure Injury: full thickness skin loss. Measurement of wound documents 1.8 x 0.7 x 0.2 cm. Granulation is 80% and slough is 20%. Additional comments documents Debridement procedure done by [name of wound doctor], resident tolerated well. Wound progress deteriorated. Current treatment is wound cleanse f/b collagen gel, cover with gauze island dressing daily. There were no revisions to R12's skin integrity care plan. On 4/24/22 at 11:59 a.m. Surveyor observed R12 in bed on her back with the head of the bed elevated high. Surveyor observed R12 is wearing bilateral Prevalon boots. On 4/25/22 at 7:08 a.m. Surveyor observed CNA (Certified Nursing Assistant)-E in the process of morning cares. CNA-E informed Surveyor she completed R12's upper body as R12 has a doctor's appointment. With gloves on CNA-E washed under R12's abdominal fold and then washed R12's perineal area from front to back. CNA-E covered R12's lower half with a blanket, informed R12 she was going to have you turn over for me, R12 grabbed onto the left transfer bar and CNA-E assisted R12 with positioning on her left side. CNA-E then went into the bathroom changed the water in the basin, removed her gloves, washed her hands, and placed gloves back on. CNA-E informed R12 she was going to wash her bottom. Surveyor observed there is stool in R12's rectal area and the dressing was coming off. CNA-E removed the dressing and soiled incontinence product, removed her gloves, washed her hands and placed gloves on. CNA-E washed R12's rectal area to remove the stool, and washed R12's right buttocks. Surveyor observed R12's coccyx pressure injury. CNA-E had R12 position on her back while CNA-E removed her gloves, washed her hands, and placed new gloves on. R12 was positioned on her right side, CNA-E washed R12's left buttock. Surveyor asked CNA-E if R12 only has one open area. CNA-E replied just this one pointing to R12's coccyx pressure injury. CNA-E removed her gloves, washed her hands, and placed gloves on. CNA-E placed a product under R12, applied periguard to R12's buttocks, positioned R12 on the other side, applied periguard and straightened out & fastened the incontinence product. CNA-E removed her gloves, washed her hands, and placed new gloves on. CNA-E removed R12's pressure relieving boots, placed pants on. CNA-E placed a sling under R12 and informed R12 she was going to find gripper socks. CNA-E removed her gloves, washed her hands, and left R12's room at 7:37 a.m. At 7:39 a.m. CNA-E returned with gripper socks, washed her hands and placed gloves on. CNA-E placed gripper socks and pressure relieving boots on R12. At 7:42 a.m. CNA-E informed R12 she was going to get the Hoyer, removed her gloves and washed her hands. At 7:45 a.m. CNA-E entered R12's room with a Hoyer lift and CNA-K entered with a high back wheelchair with a panacea cushion in the wheelchair. R12 was then transferred from the bed into the wheelchair by CNA-E & CNA-K. At 7:50 a.m. Med Tech-F entered R12's room stating the van is here and gave R12 an envelope. CNA-K combed R12's hair and then R12's placed a hat on. CNA-E and CNA-K placed a jacket on R12 and R12 was wheeled out of the room. At 7:53 a.m.