**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and policy and procedure review, the facility failed to maintain acceptable parameters of nutritional status for 1 of 2 sample residents (resident #4) with nutritional status concerns. This failure resulted in harm to resident #4 who experienced severe weight loss. The findings were: 1. Review of the annual MDS assessment dated [DATE] showed resident #4 had a BIMS score of 8 out of 15, which indicated moderate cognitive impairment, and diagnoses which included dementia, depression, and chronic obstructive pulmonary disease. Review of the physician orders showed a regular fortified low sodium diet with snacks 3/8/23. Review of the resident's care plan last updated 2/15/25 showed the resident had the potential for unplanned weight loss related to eating small meals. Interventions included Offer me snacks, and I do prefer ritz crackers. Encourage me to have small, frequent feedings instead of large meals. Give me supplements if needed to maintain adequate nutrition. The following concerns were identified: a. Review of resident's weight history showed the resident weight had decreased from 88.5 lbs. on 2/1/25 to 82.0 lbs. on 3/2/25, a 7.34% weight loss, which was a severe weight loss in one month. b. Observation on 3/11/25 at 8:28 AM showed the resident was seated in his/her wheelchair at the breakfast table eating without assistance. The resident was very thin appearing with hollow cheeks and temples. c. Observation on 3/12/25 from 8:48 AM to 10:30 AM showed the resident was seated in his/her wheelchair at the breakfast table. The breakfast plates had been cleared; however, the resident remained at the table for over 90 minutes. During that time, the resident was offered coffee; however, no snacks were offered or provided. d. Observation on 3/12/25 from 2:04 PM to 4:25 PM showed the resident was seated at the table in his/her wheelchair. No snacks were provided or offered during that time. e. Review of snack documentation from 2/12/25 to 3/12/25 showed no documentation the resident was offered or accepted PRN snacks. f. Review of a progress note dated 3/5/25 at 3:32 PM showed [Resident #4] has continued to lose weight and has triggered for a 5% weight loss in 30 days. [S/he] will be weighed weekly for 4 weeks to monitor weight .RD has encouraged snacks such as cookies with butter, peanut butter on cookies and desserts after each lunch and dinner. 2. Interview with dietitian on 3/13/25 at 10:40 AM revealed her expectation for staff was to offer snacks to the resident, especially between lunch and dinner. She stated, [Resident #4] will never turn down a cookie. If you offer [him/her] string cheese, [s/he] will turn it down. [S/he] might turn down a nutritional supplement, but s/he would not turn down a milkshake. Further interview confirmed offering snacks to the resident was not currently a task in the resident's medical record. 3. Review of facility policy titled Weight Assessment and Intervention Policy last reviewed 5/23/22 showed .5% weight loss [in one month] is significant; greater than 5% is severe and care planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the physician, nursing staff, the dietician, the consultant pharmacist, and the elder or elder's legal surrogate. Individualized care plans shall address to the extent possible: a. the identified causes of weight loss, b. goals and benchmarks for improvement, c. time frames and parameters for monitoring and reassessment .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, facility investigation review, performance improvement plan review, professional standard review, and policy review, the facility failed to ensure timely care and treatment was provided for 1 of 5 sample elders (#90) reviewed for skin conditions. This failure resulted in actual harm to elder #90 who developed a wound infection and had delayed hospitalization. Corrective measures were implemented by the facility prior to the survey and compliance was determined to be met on 1/5/24. The findings were: 1. Review of the significant change MDS assessment dated [DATE] showed elder #90 had short-term and long-term memory problems and diagnoses which included Parkinson's disease with dyskinesia, pain, and a personal history of diseases of the skin and subcutaneous tissue. The elder had a functional limitation in range of motion on one side of lower extremities, required substantial/maximal assistance for rolling left and right, moving from sitting to lying, moving from lying to sitting, moving from sitting to standing, and transfers. Further review showed the elder was at risk for pressure injury development and was marked as having no skin issues. Review of the care plan last revised on 1/9/24 showed the resident had potential for impaired skin integrity related to Parkinson's disease, impaired mobility, and a Braden score of 15, which indicated a mild risk for skin breakdown. Further review showed the resident had a Large hematoma L [left] shin The following concerns were identified: a. Review of a Late Entry progress note dated 11/23/23 and timed 3:30 AM showed .This nurse and Shahbaz went in to do rounds on elder .As Shahbaz was drying off the elder I noticed a bruise to left lower leg. Upon assessment of the area it was fluid filled, was cool to the touch and elder denied pain to area. Wound measured 4.5 cm [centimeters] by 3 cm. Applied a dressing to the area at time of assessment to protect area if blisterpops [sic] open. Wound care nurse informed family of wound and treatment plan. b. Review of a Late Entry progress note dated 12/9/23 and timed 2:10 AM showed .wound nurse contacted via email regard L lower shin wound. Read as follows: Hi [wound nurse name], [room number]'s wound looks fairly concerning. The bottom part of the wound is open and red. There's a fair amount of edema in [his/her] ankle and feet, and when you handle the dressing, you can tell it's pretty painful for [him/her]. In the middle of this wound it also feels unnaturally warm, almost hot. I had to get the last allevyn dressing changed tonight, but I didn't see where there were anymore, so I applied an ABD [abdominal] pad held in place with kerlix wrap. Sorry! That's really all I had. Thought you should know. Wound nurse replied at 1049 [10:49 AM] as follows: Hi [nurse name], I sent an email to purpose [sic] to hopefully be available to take a look Monday, however I'd [sic] it continues to get worse please send a cerner [email] and escalate the problem. If [s/he] is showing signs of infection I think it best if [s/he] is evaluated by a provider. Please monitor closely. Thank you, [wound nurse name]. On shift nurse replied once more at 2344 [11:44 PM] stating: Will do [wound nurse name]. I had to change the dressing again tonight, it doesn't look quite as bad as yesterday night. The wound appears pretty much the same, but the pain was a little less when handling [his/her] leg, and there wasn't the localized warmth that I noticed last night. There was I would say a moderate amount of serous drainage on the old pad. When applying the ABD pad, I applied a generous amount of TAO [triple antibiotic ointment], if that'll help . c. Review of a progress note dated 12/11/23 and timed 4:31 AM showed .[S/he] is incredibly uncomfortable and every time you move [his/her] leg or touch around the burn or inflammation [s/he] yelps out in pain. This is becoming increasingly concerning and the redness continues to creep down to [his/her] ankle & toes . d. Review of a progress note dated 12/11/23 and timed 4:32 AM showed .Swelling in left leg diminished, there still is edema right near the edges of wound. Appearance of wound has not changed. No localized warmth noted, and when elder turned in bed [s/he] did not yell out ow! like [s/he has been doing the past couple of nights. Silicone hyrcocellular [sic] dressings remain. Previous dressing that was applied Saturday night had gotten frazzled and needed to be replaced. Only a moderate amount of serous drainage noted. Will report to wound nurse . e. Review of a progress note dated 12/11/23 and timed 4:32 AM showed .Elders burn on [his/her] left leg seems to be increasingly getting worse. [His/Her] shin to ankle is incredibly inflamed and is double the size of [his/her] other leg. The inflammation and burn is hot to the touch and very red . f. Review of a progress note dated 12/11/23 and timed 12:49 PM showed Advance wound care was with nurse to assess the wound. When bandage was taken off wound bed was red, inflamed and had moderate purulent drainage. Wound bed also had areas of necrotic skin and a black whole [sic] to what advanced wound care noted as bone. Dispatch was called right away and elder was sent to ER [emergency room]. POA [Power of Attorney] was notified and incident protocol was initiated . g. Review of a progress note dated 12/13/23 and timed 3:42 PM showed the elder returned from the hospital and an advanced wound care referral request was initiated. h. Review of a progress note dated 12/15/23 and timed 9:41 AM showed .Large hematoma to lower left leg, Black Escar [sic] with moderate purulent drainage. Pt [patient] shows signs of pain such as moaning and pulling back when area is touched. Sent to hospital for assessment, currently following wound care orders, advanced wound care to evaluate and treat on 12/18/23 [5 days after the elder's return to the facility] . 2. Interview with Shahbaz #1 on 1/31/24 at 2:53 PM revealed elder #90 had and area which developed into a wound, became infected, and resulted in the elder's hospitalization. The Shahbaz revealed when the elder returned from the hospital, his/her family initiated comfort care and the elder passed away. 3. Interview with LPN #1 on 1/31/24 at 7:17 PM confirmed he was the night nurse on 12/8/23 through 12/11/23 who was assigned care to elder #90. The LPN revealed the resident had received a burn to his/her shin when the elder's leg had been hanging off the bed and positioned on the heater vent; however, he was not on shift when it was discovered. The LPN revealed the facility had been performing dressing changes for a week or two; however, the wound had deteriorated from what originally appeared as blistering with discoloration to the presence of eschar (dead tissue that forms over healthy skin and then, over time, falls off). The LPN revealed when he was caring for the resident from the evening of 12/8/23 through the morning of 12/9/23, he notified the wound care nurse of an increase in the elder's pain, a fair amount of drainage, and localized warmth to the wound, and was told to monitor the wound and notify the provider if it worsened. The LPN revealed on the Saturday (12/9/23) evening through Sunday 12/10/23 morning shift, the localized warmth was not as severe and the elder's wound continued to have drainage. The LPN revealed on 12/10/23 he did not observe signs of deterioration; however, he confirmed on 12/11/23 the elder was transferred to the hospital after he left the facility. The LPN confirmed he did not call the physician and was unable to say why he notified the wound nurse instead. He stated he may have messaged the physician at that time; however, he could not remember. The LPN revealed the facility policy was to notify the physician if an elder had a need for immediate medical treatment and he confirmed the resident was diagnosed with and infection resulting in treatment while at the hospital. The LPN revealed the elder's wound improved when s/he returned; however, s/he was placed on comfort measures and passed away. Further interview revealed the elder was gradually declining and the wound made day-to-day living more difficult. 4. Interview with Shahbaz #2 on 1/31/24 at 7:40 PM revealed elder #90 had an area with a blister on his/her leg and after the blister popped, the elder developed an infection and was sent to the hospital for treatment. The Shahbaz stated the elder was in a lot of pain and would cry, as a result of the wound. The Shahbaz confirmed the elder was placed on comfort care and passed away after s/he returned from the hospital. 5. Interview with the wound care nurse on 2/1/24 at 8:33 AM revealed elder #90's wound was first identified on a night shift; however, she did not know the date. She revealed initially the area appeared to be a blister with the peri area intact; however, it then began to drain the fluid. She revealed the facility was observing the area daily and during the weekend of 12/8/23 through 12/11/23 the nurse reported the area was more red and more inflamed. She revealed she recommended the nurse escalate it to the provider if it worsened. The wound nurse revealed when she returned on Monday, the area had hardened and deteriorated and the elder was admitted to the hospital. Further interview revealed triple antibiotic ointment and an abdominal pad were not an appropriate treatment for the wound and she would expect the nurses to send an elder out for treatment based on what the nurse had reported to her about the wound's condition and what she observed the following Monday. 6. Interview with the RN QA/Educator on 1/31/24 at 5:42 PM revealed the facility identified concerns with elder #90's wound deterioration and change of condition and as a result initiated an investigation on 12/13/23. She revealed when the investigation was complete, education was provided to all nurses related to wound assessment, wound care, and change of condition. She revealed during the investigation, the facility was unable to identify a wound origin and she revealed she did not observe the wound until after the investigation was initiated, following the elder's return from the hospital. She revealed the expectation was for nurses to notify the physician and family any time there was a change of condition. She revealed LPN #1 notified the physician via cerner, which was an email system; however, in this situation the physician should have been notified via telephone or sent to the ER. She revealed the LPN should not have delayed the resident's treatment and confirmed the elder's treatment was delayed as a result of the nurse's failure to notify the physician or transport to the ER. She revealed corrective action included education and disciplinary action for the LPN. She revealed the facility identified all residents were potentially at risk and as a result the entire staff was educated as part of the facility's system changes. She revealed additional system changes included hiring another nurse to create a wound team. She revealed the facility was monitoring for compliance through weekly audits for wound care, change of condition, and physician notification and were reviewing audits in QA. Further interview revealed the facility's plan was implemented on 1/5/24. 7. Review of the Change in Elder Condition policy last updated 12/14/23 showed .1. The Nurse will notify the elder's Attending Physician or On-Call Physician when there has been: .d. A significant change in the elder's physical/emotional/mental condition. e. A need to alter the elder's medical treatment significantly .g. A need to transfer the elder to a hospital/treatment center . 8. According to [NAME], [NAME], [NAME] in Nursing Interventions & Clinical Skills, 7th edition, 2020, page 654: Wound Care and Irrigation .Safe Patient Care .Compare the wound assessment to previous assessment and determine progress toward healing. If there is no movement toward healing or if you notice deterioration, consider a wound care consultation. Lack of wound healing is often related to infection. Notify health care provider and wound, ostomy, continence nurse or wound care team . 9. Review of the facility's investigation showed it was initiated on 12/13/23. The following interventions were implemented: a. LPN #1 received disciplinary action. In addition, the nurse received individual training and signed off on understanding on 1/5/24. b. Quality performance audits were initiated on 1/1/24 to review family/power of attorney notification, physician notification, elder change of condition and transfer, and wound nurse notification. Review of the Facility QAPI meeting minutes performance improvement plan discussed on 1/10/24 confirmed the audits were implemented. c. All nurses were educated on 1/5/24. d. Facility wound care policy updated on 1/5/24. e. Facility compliance was determined to be met on 1/5/24 when all nurses were educated, including LPN #1 and the wound care policy was updated. All other interventions were implemented prior to 1/5/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, facility investigation review, performance improvement plan review, and policy review, the facility failed to implement interventions and treatment to prevent the deterioration of wounds for 1 of 5 sample elders (#90) reviewed for skin conditions. This failure resulted in actual harm to elder #90 who developed a wound infection and had delayed hospitalization. Corrective measures were implemented by the facility prior to the survey and compliance was determined to be met on 1/5/24. The findings were: 1. Review of the significant change MDS assessment dated [DATE] showed elder #90 had short-term and long-term memory problems and diagnoses which included Parkinson's disease with dyskinesia, pain, and a personal history of diseases of the skin and subcutaneous tissue. The elder had a functional limitation in range of motion on one side of lower extremities, required substantial/maximal assistance for rolling left and right, moving from sitting to lying, moving from lying to sitting, moving from sitting to standing, and transfers. Further review showed the elder was at risk for pressure injury development and was marked as having no skin issues. Review of the care plan last revised on 1/9/24 showed the resident had potential for impaired skin integrity related to Parkinson's disease, impaired mobility, and a Braden score of 15, which indicate a mild risk for skin breakdown. Further review showed the resident had a Large hematoma L [left] shin The following concerns were identified: a. Review of a Late Entry progress note dated 11/23/23 and timed 3:30 AM showed .This nurse and Shahbaz went in to do rounds on elder .As Shahbaz was drying off the elder I noticed a bruise to left lower leg. Upon assessment of the area it was fluid filled, was cool to the touch and elder denied pain to area. Wound measured 4.5 cm [centimeters] by 3 cm. Applied a dressing to the area at time of assessment to protect area if blisterpops [sic] open. Wound care nurse informed family of wound and treatment plan. b. Review of a progress note dated 11/23/23 and timed 5:38 AM showed Elder has fluid filled area to upper leg. Has bruising in area the fluid sits. Covered with foam dressing to protect if opens up. c. Review of a progress note dated 11/23/23 and timed 1:37 PM showed Skin Condition Observed via Shahbaz-Nursing to observe and document observation for new skin observations. Nurse observed left shin. Area is fluid filled and tender to touch. Area is covered with bandage for protection. Compression socks not applied. d. Review of a progress note dated 11/25/23 and timed 11:03 AM showed L [left} lateral shin with dk [dark] purple bruising. Fluid noted to epidermal layer. Approximated edges with erythema/warmth 15x6cm [sic]. Tagederm [sic] in place per/noc [per night] shift. Elder to state discomfort when gently pressed. PRN Tylenol administered. This was stated byelder [sic] to be effective. Fluids encouraged. e. Review of a progress note dated 11/26/23 and timed 2:45 PM showed Large bruise noted on L lower extremity with fluid filled blister on top. Slight clear drainage noted during dressing change. Wound in tact [sic] and cool to touch, pt [patient] states wound only hurts when touched. See PCC [point click care] picture for measurement, Standing orders initiated. f. Review of the Point Click Care Wound Evaluation dated 11/26/23 and timed 2:20 PM showed the elder appeared to have a discolored area to the lower left leg which started just below the knee. The area had red and purple discoloration on the upper portion and what appeared to be a fluid filled area toward the bottom. Further review showed the area measured 12.57 cm by 5.27 cm. g. Review of a Point Click Care Wound Evaluation dated 11/30/23 and timed 3:39 PM showed the elder appeared to have a discolored area to the lower left leg which started just below the knee. The area had red and purple discoloration throughout and what appeared to be an open area toward the bottom. Further review showed the area measured 15.81 cm by 6.39 cm. h. Review of a progress note dated 12/1/23 and timed 1:42 PM showed .large bruise on L shin with popped blister on top. Pictures in PCC. Scant drainage no s/s [signs or symptoms] of infection. Provider notified . i. Review of a Point Click Care Wound Evaluation dated 12/4/23 and timed 3:42 PM showed the elder appeared to have a discolored area to the lower left leg which started just below the knee. The area had red and purple discoloration throughout with a larger open area toward the bottom. Further review showed the area measured 19.34 cm by 6.55 cm. j. Review of a progress note dated 12/7/23 and timed 1:01 PM showed Large bruising on L shin with popped blister on top. Bottom of blister is open. Scant drainage still occurring. Red and inflamed. Not hot to touch, pt has no fever. Pt reports pain on [his/her] leg. Provider notified . k. Review of a Late Entry progress note dated 12/9/23 and timed 2:10 AM showed .wound nurse contacted via email regard L lower shin wound. Read as follows: Hi [wound nurse name], [room number]'s wound looks fairly concerning. The bottom part of the wound is open and red. There's a fair amount of edema in [his/her] ankle and feet, and when you handle the dressing, you can tell it's pretty painful for [him/her]. In the middle of this wound it also feels unnaturally warm, almost hot. I had to get the last allevyn dressing changed tonight, but I didn't see where there were anymore, so I applied an ABD [abdominal] pad held in place with kerlix wrap. Sorry! That's really all I had. Thought you should know. Wound nurse replied at 1049 [10:49 AM] as follows: Hi [nurse name], I sent an email to purpose [sic] to hopefully be available to take a look Monday, however I'd [sic] it continues to get worse please send a cerner [email] and escalate the problem. If [s/he] is showing signs of infection I think it best if [s/he] is evaluated by a provider. Please monitor closely. Thank you, [wound nurse name]. On shift nurse replied once more at 2344 [11:44 PM] stating: Will do [wound nurse name]. I had to change the dressing again tonight, it doesn't look quite as bad as yesterday night. The wound appears pretty much the same, but the pain was a little less when handling [his/her] leg, and there wasn't the localized warmth that I noticed last night. There was I would say a moderate amount of serous drainage on the old pad. When applying the ABD pad, I applied a generous amount of TAO [triple antibiotic ointment], if that'll help . l. Review of a progress note dated 12/11/23 and timed 4:31 AM showed .[S/he] is incredibly uncomfortable and every time you move [his/her] leg or touch around the burn or inflammation [s/he] yelps out in pain. This is becoming increasingly concerning and the redness continues to creep down to [his/her] ankle & toes . m. Review of a progress note dated 12/11/23 and timed 4:32 AM showed .Swelling in left leg diminished, there still is edema right near the edges of wound. Appearance of wound has not changed. No localized warmth noted, and when elder turned in bed [s/he] did not yell out ow! like [s/he has been doing the past couple of nights. Silicone hyrcocellular [sic] dressings remain. Previous dressing that was applied Saturday night had gotten frazzled and needed to be replaced. Only a moderate amount of serous drainage noted. Will report to wound nurse . n. Review of a progress note dated 12/11/23 and timed 4:32 AM showed .Elders burn on [his/her] left leg seems to be increasingly getting worse. [His/Her] shin to ankle is incredibly inflamed and is double the size of [his/her] other leg. The inflammation and burn is hot to the touch and very red . o. Review of a progress note dated 12/11/23 and timed 12:49 PM showed Advance wound care was with nurse to assess the wound. When bandage was taken off wound bed was red, inflamed and had moderate purulent drainage. Wound bed also had areas of necrotic skin and a black whole [sic] to what advanced wound care noted as bone. Dispatch was called right away and elder was sent to ER [emergency room]. POA [Power of Attorney] was notified and incident protocol was initiated . p. Review of a progress note dated 12/13/23 and timed 3:42 PM showed the elder returned from the hospital and an advanced wound care referral request was initiated. q. Review of a progress note dated 12/15/23 and timed 9:41 AM showed .Large hematoma to lower left leg, Black Escar [sic] with moderate purulent drainage. Pt [patient] shows signs of pain such as moaning and pulling back when area is touched. Sent to hospital for assessment, currently following wound care orders, advanced wound care to evaluate and treat on 12/18/23 [5 days after the elder's return to the facility] . r. Review of a progress note dated 12/17/23 and timed 6:33 AM showed .At 4am rounds this nurse noticed that the elder's dressing had moved and needed to be changed. Elder complained of pain while this writer removed the old dressing. Upon removal this writer noticed the wound bed was black in color and around 6 inches long. Attempted to clean the wound with wound wash per wound nurse's orders but elder could not tolerate and was in pain. Unable to locate zincpaste [sic] in the elder's room or in the nurses office. Attempted to apply med honey per wound nurse orders but again elder was in too much pain to continue. Applied antimicrobial dressings per wound nurse orders. This writer brought her concerns to the day shift nurse. Wound nurse notified as well as management . Review of a progress note dated 12/17/23 and timed 2:09 PM showed .Wound nurse received email stating concerns on dressing application. Looked over dressing and noted that dressing was put on well. Wrapping is still in place and no drainage is noted through wrapping. Emailed DON informing her that advanced wound care will be here on 12/18/23 to treat and evaluate lower L wound . s. Review of a progress note dated 12/20/23 and timed 2:39 PM showed .Large hematoma to lower left leg, Black Escar [sic] with moderate purulent drainage. Pt shows signs of pain such as moaning and pulling back when area is touched. Evaluated with advanced wound care- Change in orders per recommendations . t. Review of a Late Entry progress note dated 12/27/23 and timed 11:11 AM showed the elder was placed on comfort care due to the elder's family .does not like seeing Elder in pain and would like to improve [his/her] quality of life . Review of a progress note dated 1/6/23 and timed 12:35 AM showed the elder passed away. 2. Interview with Shahbaz #1 on 1/31/24 at 2:53 PM revealed when elder #90 developed the wound, s/he was assisted to bed and his/her leg was positioned against the heater; however, she did not recall the date of the incident. The Shahbaz revealed when the elder's position was identified, the elder was repositioned, and the nurse was notified. The Shahbaz revealed the resident developed a wound in the area where his/her leg was positioned against the heater; however, some nurses indicated it was a hematoma and others indicated it was a burn. The Shahbaz indicated the area developed into a wound which became infected and the elder was hospitalized . The Shahbaz revealed when the elder returned from the hospital, his/her family initiated comfort care and the elder passed away. 3. Interview with LPN #1 on 1/31/24 at 7:17 PM confirmed he was the night nurse on 12/8/23 through 12/11/23 who was assigned care to elder #90. The LPN revealed the resident had received a burn to his/her shin when the elder's leg had been hanging off the bed and positioned on the heater vent; however, he was not on shift when it was discovered. The LPN revealed the facility had been performing dressing changes for a week or two; however, the wound had deteriorated from what originally appeared as blistering with discoloration to the presence of eschar (dead tissue that forms over healthy skin and then, over time, falls off). The LPN revealed when he was caring for the resident from the evening of 12/8/23 through the morning of 12/9/23, he notified the wound care nurse of an increase in the elder's pain, a fair amount of drainage, and localized warmth to the wound, and was told to monitor the wound and notify the provider if it worsened. The LPN revealed on the Saturday (12/9/23) evening through Sunday 12/10/23 morning shift, the localized warmth was not as severe and the elder's wound continued to have drainage. The LPN revealed on 12/10/23 he did not observe signs of deterioration; however, he confirmed on 12/11/23 the elder was transferred to the hospital after he left the facility. The LPN confirmed he did not call the physician and was unable to say why he notified the wound nurse instead. He stated he may have messaged the physician at that time; however, he could not remember. The LPN revealed the facility policy was to notify the physician if an elder had a need for immediate medical treatment and he confirmed the resident was diagnosed with and infection resulting in treatment while at the hospital. The LPN revealed the elder's wound improved when s/he returned; however, s/he was placed on comfort measures and passed away. Further interview revealed the elder was gradually declining and the wound made day-to-day living more difficult. 4. Interview with Shahbaz #2 on 1/31/24 at 7:40 PM revealed she was caring for the elder on the day s/he obtained the wound; however, she did not recall the date. The Shahbaz revealed she attempted to get the nurse on shift to assess the elder's leg as the Shahbaz had found the elder with his/her leg wrapped in a blanket and positioned up against the heater. The Shahbaz revealed the blanket and the elder's leg were both hot to the touch and the elder developed a blister in the area. The Shahbaz revealed the nurse observed the area twice; however, there was no documentation in the record. The Shahbaz revealed she was told the wound being caused by a burn was speculation. The Shahbaz revealed after the blister popped, the elder developed an infection and was sent to the hospital for treatment. The Shahbaz stated the elder was in a lot of pain and would cry, as a result of the wound. The Shahbaz confirmed the elder was placed on comfort care and passed away after s/he returned from the hospital. 5. Interview with the wound care nurse on 2/1/24 at 8:33 AM revealed elder #90's wound was first identified on a night shift; however, she did not know the date. She confirmed it was reported the elder's leg was wrapped in a blanket, against the heater, and the blanket was warm to the touch. The wound care nurse revealed initially the area appeared to be a blister with the peri area intact; however, it then began to drain the fluid. She revealed the facility was observing the area daily and during the weekend of 12/8/23 through 12/11/23 the nurse reported the area was more red and more inflamed. She revealed she recommended the nurse escalate it to the provider if it worsened. The wound nurse revealed when she returned on Monday, the area had hardened and deteriorated and the elder was admitted to the hospital. Upon return from the hospital, the facility treated the wound with medi-honey for debridement and as the wound progressed, the eschar moved inwards. The wound nurse revealed she classified the wound as unstageable and the hospital called it a hematoma; however, the facility was unable to identify an origin. She confirmed one thought was the wound could have been a burn; however, physical therapy did not believe it was and the hospital did not classify it as a burn. The wound nurse revealed interventions implemented were the development of a wound care team, advance wound care services, and moving the elder's bed away from the heater. Further interview revealed triple antibiotic oinment and an abdominal pad were not an appropriate treatment for the wound and she would expect the nurses to send an elder out for treatment based on what the nurse had reported to her about the wound's condition and what she observed the following Monday. 6. Interview with the RN QA/Educator on 1/31/24 at 5:42 PM revealed the facility identified concerns with elder #90's wound deterioration and change of condition which resulted in hospitalization, and as a result initiated an investigation on 12/13/23, 20 days after the first wound note was documented. She revealed when the investigation was complete, education was provided to all nurses related to wound assessment, wound care, and change of condition. She revealed during the investigation, the facility was unable to identify a wound origin and she revealed she did not observe the wound until after the investigation was initiated, following the elder's return from the hospital. She revealed the expectation was for nurses to notify the physician and family any time there was a change of condition. She revealed LPN #1 notified the physician via cerner, which was an email system; however, in this situation the physician should have been notified via telephone or sent to the ER. She revealed the LPN should not have delayed the resident's treatment and confirmed the elder's treatment was delayed as a result of the nurse's failure to notify the physician or transport to the ER. She revealed corrective action included education and disciplinary action for the LPN. She revealed the facility identified all residents were potentially at risk and as a result the entire staff was educated as part of the facility's system changes. She revealed additional system changes included hiring another nurse to create a wound team. She revealed the facility was monitoring for compliance through weekly audits for wound care, change of condition, and physician notification and were reviewing audits in QA. 7. Review of the Change in Elder Condition policy last updated 12/14/23 showed .1. The Nurse will notify the elder's Attending Physician or On-Call Physician when there has been: .d. A significant change in the elder's physical/emotional/mental condition. e. A need to alter the elder's medical treatment significantly .g. A need to transfer the elder to a hospital/treatment center . 8. Review of the facility's investigation showed it was initiated on 12/13/23. The following interventions were implemented: a. LPN #1 received disciplinary action. In addition, the nurse received individual training and signed off on understanding on 1/5/24. b. Quality performance audits were initiated on 1/1/24 to review family/power of attorney notification, physician notification, elder change of condition and transfer, and wound nurse notification. Review of the Facility QAPI meeting minutes performance improvement plan discussed on 1/10/24 confirmed the audits were implemented. c. All nurses were educated on 1/5/24. d. Facility wound care policy updated on 1/5/24. e. Facility compliance was determined to be met on 1/5/24 when all nurses were educated, including LPN #1, and the wound care policy was updated. All other interventions were implemented prior to 1/5/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records, and staff and elder representative interview, the facility failed to demonstrate the need for an elder to be discharged due to a facility inability to meet their needs for 1 of 6 (#6) elders reviewed for transfer or discharge. This failure resulted in harm to elder #6, who was discharged from the hospital to a different nursing home and was unable to return to his/her home at the facility as desired; events a reasonable person would find distressing. The findings were: Review of the 10/28/22 admission minimum data set assessment showed elder #6 was admitted to the facility on [DATE]. Review of a progress note dated 10/20/22 and timed 9:38 AM showed the elder had a BIMS score of 8 of 15, indicating moderate cognitive impairment. Review of progress notes showed the elder was sent to the hospital on [DATE] for a surgical procedure. The following concerns were identified: a. Interview with the elder's representative on 3/30/23 at 4:33 PM revealed when it came time for the elder to be discharged from the hospital, the facility refused to allow the elder to return, stating they did not have the capability to provide the care the elder required. The representative stated the elder had been stressed by all the confusion. b. Review of the medical record showed no evidence the elder's physician documented the specific elder needs the facility could not meet, the facility's efforts to meet those needs, and the specific services the receiving facility would provide to meet the needs of the elder that could not be met at the current facility, as required. c. Interview with the DON and ADON on 3/31/23 at 11:35 AM revealed after hospitalization the elder required the infusion of an intravenous antibiotic 3 times daily for an extended period of time, and the facility had a limited number of RNs working at the facility. Further, nursing staff did not have the experience or the equipment to safely perform the intravenous antibiotic infusions. They stated the decision not to readmit the elder was made by the administration at the facility, and confirmed there was no physician documentation, or any other documentation of efforts made by the facility to allow the elder to return to his/her home at the facility.