Making CMS Citations Actionable for LTC Providers

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to maintain resident room temperatures within the facility’s own policy range of 71–81°F and to monitor and assess residents for hypothermia when the heating system was not functioning properly. The facility’s Safe and Homelike Environment policy required provision of a safe, comfortable environment, and the Loss of Heating or Cooling policy required immediate actions to maintain temperatures between 71–81°F, including monitoring temperatures, increasing rounding, layering clothing, providing extra blankets and warm foods/fluids, and monitoring for signs of hypothermia with physician notification as needed. The Nursing Home Administrator (NHA) reported being aware that the heat was not working the prior week and that a heating company came on a Saturday to install a control board, later determining that an additional gas valve was needed. The NHA presented audits of only 5–6 random rooms per floor and did not have staff check all resident rooms or assess/interview residents to ensure their needs were being met. Observations on the third and fourth floors showed that the heating system was not working at full capability, with room temperatures ranging from 68°F to 81°F and some residents stating they were cold while others felt comfortable. Some windows were observed not fully closed, and some residents reported they had opened their windows. Although residents had extra blankets and clothing, all interviewed residents stated that no staff member had offered extra blankets or warm fluids. Subsequent facility-provided temperature audits documented that, during early-morning checks, the vast majority of rooms on both the third and fourth floors were below 71°F, with the lowest recorded temperatures at 63°F on the third floor and 58.6°F on the fourth floor. During a tour, surveyors noted that the third and fourth floors felt cold overall, and spot temperature checks with maintenance staff showed multiple rooms in the upper 60s to about 70°F. Multiple residents were observed in bed with three or four blankets, winter coats, or tassel caps, and several reported feeling cold, especially at night or when getting up. One resident stated her legs were cold and that her window had been cracked open the previous night; another said he had been cold and that it gets very cold at night; others reported that their rooms were cold or that they had been cold but were warm at the time due to multiple blankets. Few residents were seen in hallways, and those present were covered with blankets. A nurse stated that residents complained of being cold and that she had brought in two bags of blankets to keep them warm. Record review for selected residents showed that there were no physician orders to monitor for hypothermia or to monitor body temperatures in response to the environmental issue, despite the facility’s policy requiring monitoring for signs of hypothermia when heating is compromised. For one resident, the last documented temperature was from early in the month; for another, the last temperature was several days prior; and for a third, the last temperature was from the previous month. The NHA confirmed that the heaters were not working at 100%, that the facility had noticed the problem in the middle of the prior week, and that repairs were in progress. The NHA also confirmed that the facility failed to ensure comfortable air temperature levels between 71–81°F and failed to monitor and assess all residents for hypothermia, resulting in an Immediate Jeopardy situation for all 82 residents.

Removal Plan

• Complete heating system repair and continue ongoing monitoring of system performance.
• Conduct room temperature audits in every resident room every two hours until all resident rooms are at 71°F or higher, then once every four hours daily for seven days, weekly for three weeks, then monthly for three months.
• Include in temperature audits ensuring windows are closed and residents are offered plastic covering for windows.
• Evaluate all residents for signs and symptoms of hypothermia, including residents unable to independently express needs and residents with a temperature over the last three days and/or during whole house audit of 97.6°F or lower.
• Address any identified concerns immediately with individualized interventions and place orders for ongoing monitoring as needed.
• Document resident temperatures in the weights/vitals section of the electronic medical record and document hypothermia evaluation in progress notes.
• Conduct an audit of resident observations for cold intolerance, distress, or changes in condition related to temperature in every resident room every shift daily for seven days, weekly for three weeks, then monthly for three months.
• Ask interviewable residents about comfort level and offer interventions as needed.
• Evaluate non-interviewable residents for observable signs of discomfort related to temperature.
• Educate nursing staff (including agency) on signs and symptoms of hypothermia, risk factors, interventions to prevent hypothermia, comfort measures, and appropriate response when signs/symptoms are identified.
• Educate nursing assistants on non-clinical signs and symptoms of hypothermia and to alert a nurse if observed.
• Complete staff education; staff educated by phone/email to sign education prior to next working shift; reinforce education as needed.
• Provide additional blankets, layering, and environmental adjustments as needed.
• Offer room relocation as appropriate to maintain resident comfort.
• Implement a plan to utilize outside resources as necessary to maintain safe air temperatures during future weather events or mechanical issues, including an updated rental company in place.
• Review relevant policies and procedures related to environmental safety, resident monitoring, and emergency response.
• Update policies as indicated based on audit findings and QAPI review.
• Report audit findings, trends, and corrective actions to the QAPI committee; QAPI to evaluate effectiveness and recommend changes as needed.
• Apply plastic coverings to every resident room and hallway window in resident care areas to prevent drafts.
• Clarify/register controls after identifying some knobs on registers were turned off to prevent inadvertent turning off of heat.
• Have heating vendor send a technician back to ensure correct functionality and further explore the system for any additional needed corrections and complete repairs as soon as possible pending parts/resources.
• Install rental one-ton heating units and rent for at least one week.
• Order and install additional rental heating units.
• For rooms reading under 71°F with a laser thermometer, re-check using a room air thermometer and verify temperatures above 71°F.
• Order air thermometers for each room.

Penalty

Fine: $21,645

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure an area was free from accident hazards and that adequate supervision and assistive devices were provided to prevent accidents, specifically for one resident. The resident was a 78-year-old female with diagnoses including muscle weakness, unsteadiness of feet, lack of coordination, convulsions, osteoporosis, and a history of falls. Her MDS showed moderate cognitive impairment and a need for partial/moderate assistance with sit-to-stand and chair/bed-to-chair transfers. She was identified as high risk for falls, and the NP had ordered strict fall precautions due to impaired balance. Despite these risk factors, her comprehensive care plans only generally stated that she would receive assistance with transfers and ambulation and would use adaptive equipment such as transfer aids, but they did not specify the exact mode of transfer or required transfer device. There was no physician order detailing how she should be transferred. On the day of the incident, CNA A attempted to transfer the resident from bed to wheelchair without using any transfer aid such as a gait belt or sit-to-stand lift. Multiple staff interviews confirmed that the resident’s mode of transfer had been changed from stand-and-pivot to use of a sit-to-stand mechanical lift due to weakness, and that staff, including CNA A, were aware of this recommendation and had previously used the sit-to-stand with the resident. CNA A acknowledged knowing the resident was a sit-to-stand transfer and admitted she did not use the sit-to-stand on the day of the fall. RN B and the Weekend Supervisor both stated that if the resident was a one-person assist, a gait belt should have been used, and that transfer aids such as gait belts and mechanical lifts were expected for safety. RN B reported seeing the gait belt hanging on the wall unused when she entered the room after the incident. During the transfer, the resident lost her balance; staff reported that one of her knees gave out and she ended up kneeling on the floor beside the bed, with her upper body leaning on the bed. The resident complained of severe left hip pain rated 10/10 and requested to be sent to the hospital. She later reported that CNA A did not use a gait belt or a machine, while other CNAs did use a machine when transferring her. The DON and other staff confirmed that prior to the incident the resident was considered a one-person assist and that staff were supposed to use a gait belt and, if ordered, the sit-to-stand lift. The DON also acknowledged that therapy had recommended changing the resident’s mode of transfer to sit-to-stand and that she failed to follow up on whether this recommendation was finalized and implemented. There was no documentation that the resident refused the sit-to-stand prior to the fall. The combination of an unclear, nonspecific care plan, lack of a specific transfer order, failure to follow therapy’s transfer recommendations, and CNA A’s failure to use the required transfer aid during the transfer led to the fall and subsequent left hip fracture. The surveyors determined that this failure to provide adequate supervision and assistance devices to prevent accidents constituted noncompliance with F689 and resulted in an Immediate Jeopardy situation. The incident showed that the resident, who had multiple fall and fracture risk factors and was on strict fall precautions, was transferred without the prescribed or expected transfer aids, and that the facility had not ensured that the care plan and medical record clearly and specifically directed staff on the resident’s required mode of transfer. Interviews with multiple staff members revealed inconsistent understanding and implementation of the resident’s transfer status and highlighted that, at the time of the incident, the resident’s transfer needs were not consistently communicated or followed, directly contributing to the accident.

Removal Plan

• Resident #1 evaluated by nursing staff
• Resident #1 care plan updated to reflect current transfer status (requires sit-to-stand lift)
• Order placed in the electronic medical record for mechanical lift transfers for Resident #1
• Physical Therapy referral placed in the electronic medical record for evaluation and treatment for Resident #1
• All licensed nurses, CNAs, and therapy staff educated on Safe Resident Handling/Transfers policy prior to working their next shift (including telephone education for absent staff)
• All new hires and agency staff to receive Safe Resident Handling/Transfers policy education before providing resident care
• 1:1 education provided to the Director of Nursing on following therapy recommendations for resident transfers and discussing transfer needs in clinical meetings and Standards of Care meetings
• DON/designee reassessed all residents using the Fall Risk Assessment Tool
• MDS/MOS nurse ensured all residents identified as at risk for falls had safety measures and resident-specific interventions added to their care plans
• MDS/MOS nurse ensured added safety measures/interventions were reflected in both electronic and paper medical records so CNAs had access
• DON/designee instructed CNAs to review the updated paper medical record prior to their next shift
• Audit of all residents requiring assistance with transfers to ensure accuracy of transfer status and updated care plans
• Audit of all therapy recommendations to ensure they were reviewed and followed
• Safe Resident Handling/Transfers policy reviewed
• DON/designee to audit new admissions daily to ensure Fall Risk Assessment completion and that risk factors, safety measures, and resident-specific interventions are reflected on the care plan and updated on the Kardex
• Regional Nurse Consultant to review all falls within 72 hours to ensure an RCA is conducted and resident-specific interventions are reflected in the care plan and updated in paper/electronic care plans
• DON/designee to review all falls at the daily stand-up meeting with the IDT to ensure appropriate fall interventions are implemented, the care plan is reviewed/revised, and the Kardex is updated
• Interdisciplinary team to review all audit results in QAPI with additional training provided if trends are identified
• Medical Director notified of the deficient practice/Immediate Jeopardy and the Plan of Removal

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to implement contact isolation precautions for a resident who developed signs and symptoms consistent with Clostridioides difficile infection (CDI) and was later confirmed positive. The resident was admitted with diagnoses including pulmonary embolism and sepsis and subsequently developed diarrhea meeting the facility’s criteria for suspected CDI on 1/18/2026. A physician ordered a stool test for CDI on that date, but the resident was not placed on contact precautions at the time of suspicion, despite facility policy requiring contact precautions for residents with diarrhea and suspected CDI while awaiting laboratory results. The resident’s change in condition evaluation on 1/20/2026 documented CDI with onset of symptoms on 1/18/2026, and the resident was not placed on contact isolation until 1/20/2026, after the physician ordered contact isolation for a positive CDI result. During this period, the CDI-positive resident continued to share a room with two roommates. One roommate had diffuse large B-cell lymphoma, was actively receiving antineoplastic chemotherapy, and was identified as immunocompromised and at high risk for infection. This roommate’s care plan, initiated later, identified her as at high risk for nosocomial infection and indicated staff should perform hand hygiene and wear gowns and gloves during high-contact activities, but there was no evidence that this high-risk status was used to prevent her from being cohorted with a resident with active CDI. The other roommate had multiple chronic conditions, including hypertrophic cardiomyopathy, chronic kidney disease, type 2 DM, depression, and anxiety, and required substantial assistance with ADLs. Both roommates remained in the same room with the CDI-positive resident while an isolation cart and contact precaution sign were posted outside the room. The facility did not complete infection risk assessments for either roommate before or during their cohorting with the resident who had CDI. The DON confirmed there was no documented evidence of infection risk assessments for these roommates between 1/17/2026 and 1/30/2026, and stated that such assessments should have been completed by the Infection Preventionist or a licensed nurse to determine appropriate roommate placement when a resident had an infection. The Infection Preventionist Nurse and DON acknowledged that the immunocompromised roommate should not have been placed with the CDI-positive resident and that the facility failed to follow its own CDI and isolation policies, which required private rooms when possible or cohorting only with low-risk roommates. The facility also failed to inform and educate the two roommates about their potential risk of acquiring CDI and the infection control guidelines they should follow. One roommate reported not understanding why the room was on isolation and stated that staff did not provide any explanation when asked. The other roommate, aware of her compromised immune system and ongoing chemotherapy, stated she was not told why staff were wearing gowns when caring for her roommate and was reassured that it had nothing to do with her, despite her expressed concerns. The Infection Preventionist Nurse confirmed there was no documented evidence that staff notified or educated the roommates about their risk for CDI or appropriate precautions. Additionally, the facility did not monitor the two roommates for signs and symptoms of CDI after their exposure to the infected resident. The Infection Preventionist Nurse stated that no monitoring was conducted for these roommates for CDI-related symptoms such as fever, abdominal pain or spasms, diarrhea, nausea, or vomiting. The Medical Director stated that staff were aware of appropriate infection control measures but failed to implement them, and that staff did not follow facility policy or CDC guidelines regarding cohorting and isolation for CDI. The DON described this as a failure in the facility’s system process, including lack of staff training on isolation precautions and infection risk assessments, which contributed to the deficient practice. The facility’s written policies required that residents with diarrhea and suspected CDI be placed on contact precautions while awaiting lab results, and that residents with diarrhea associated with CDI be placed on contact precautions. The isolation policy further required that residents on contact precautions be placed in a private room if possible, or, if not, that the Infection Preventionist assess risks and cohort only with low-risk roommates. Despite these written requirements, the resident with CDI remained in a shared room with an immunocompromised roommate and another medically complex roommate, without documented risk assessments, without timely initiation of contact precautions at the time of suspicion, without education of roommates about their risk and needed precautions, and without monitoring of the roommates for CDI symptoms. These actions and omissions formed the basis of the cited infection control deficiency under F880.

Removal Plan

• Moved Resident 2 to Room B with no roommates due to immunocompromised condition and initiated RN Supervisor monitoring every shift for 40 days for CDI signs/symptoms.
• Designated Room A as a single isolation room and assigned Resident 1 no roommates.
• Reviewed and revised Resident 2’s care plan to reflect immunocompromised status and that Resident 2 should not share a room with a resident who has an active infection.
• Conducted in-service training for all nursing staff on Infection Control policy, with written quizzes to validate understanding; provided phone/follow-up training for staff not present prior to next shift; removed from schedule any staff who did not complete training until completed.
• Provided one-on-one in-service to the Administrator and DON on the admission process for residents requiring isolation precautions and appropriate cohorting.
• Provided one-on-one in-service training to the Infection Preventionist Nurse on infection control practices, including proper PPE use and appropriate cohorting.
• Conducted record review of all residents with changes in condition to identify residents with signs/symptoms consistent with CDI; found no other affected residents.
• Assessed all residents for CDI signs/symptoms; found no additional affected residents.
• Implemented process for DON and Infection Preventionist Nurse to review all incoming admissions to determine need for isolation/precautions and arrange appropriate room placement/cohorting.
• Implemented Infection Preventionist Nurse tracking log for all residents with active infections, including CDI, to prevent spread.
• Established monthly infection control meetings led by Administrator and IDT to ensure adherence to infection control and PPE policies and to promptly identify/address room placement and cohorting issues.
• Developed a QAPI plan for Infection Control practices including root cause analysis to be reviewed and updated during monthly QAPI meetings for three months to ensure corrective actions are effective and sustained.

Penalty

Fine: $414,390

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision for residents at risk of elopement, particularly two residents with known risk factors, and the failure to complete required elopement risk assessments for nearly all residents. One resident with alcoholic cirrhosis, alcohol dependence, ascites, and hepatic encephalopathy was cognitively intact per BIMS and independent in transfers and walking, and he frequently went to the facility’s garden. Staff reported that he had previously left the facility in the morning and returned intoxicated in the evening, and that this incident should have been reported to management. Despite a physician’s order for an Elopement Evaluation and an order that he could only leave the SNF/hospital property with a responsible party, no Elopement Evaluation Assessment was completed upon admission, and staff confirmed there was no tool in use to assess elopement risk. The nurse manager stated the assessment was not done because the resident was alert, oriented, and independent. The same resident’s preference for frequent independent garden time was documented in his activity preferences, but the activity staff did not develop a comprehensive activity care plan that included objectives, interventions, supervision requirements, or monitoring of his whereabouts during garden time. The activities coordinator and nursing staff acknowledged that the existing documentation did not constitute a true care plan and that there was no constant monitoring of the resident while he was in the garden. In addition, the facility did not follow its Leave of Absence (LOA) policy requiring a complete mental, physical, and functional assessment within 30 minutes before leaving and upon return, documented in the nursing progress notes. Multiple LOA forms for this resident showed times out with no times in, missing nurse initials, and incomplete destination information, and the nurse manager confirmed that nurses did not complete or document required assessments on numerous dates. Staff interviews revealed that nurses and CNAs did not routinely check on residents in the garden, did not sign the resident back in when he returned for medications, and believed that the resident’s signature on the LOA form released the facility from responsibility. On the day of the fatal incident, the resident signed out in the morning to go to the garden, was seen on surveillance video leaving and re-entering the building, and later left again in the early afternoon without signing out. He took his medication early that afternoon, but staff did not verify his whereabouts afterward. Surveillance footage reviewed by the director of quality showed the resident exiting through the lobby doors and heading toward a nearby street, after which he was no longer visible until a truck stopped in front of the hospital later that evening, coinciding with the time of a motor vehicle accident in which he was struck as a pedestrian. He was subsequently admitted to the acute hospital as a trauma patient with extensive injuries and an elevated blood alcohol level and later died; the hospital death summary listed multiple traumatic injuries and alcohol intoxication among the diagnoses and contributing conditions. A second resident, with diagnoses including alcoholism, diabetes mellitus, hemiplegia due to prior stroke, hypercholesterolemia, hypertension, and wheelchair dependence, had a BIMS score indicating severe cognitive impairment. No Elopement Evaluation Assessment was completed upon his admission. The nurse manager stated that such assessments were only done when residents were “triggered” by an elopement incident or a change in condition, rather than upon admission. This resident routinely signed LOA forms and left the facility or went to the garden unassisted, propelling his wheelchair using his left arm and leg, often in the early morning hours. CNA staff reported that he preferred to go out alone to stores to purchase lottery scratcher tickets and that staff did not take his vital signs each time he returned from LOA. Review of his LOA forms showed numerous entries with times out but no times in, missing nurse initials, missing destinations, and lack of documentation of assessments before leaving or upon return, contrary to facility policy. Beyond these two residents, the facility failed to complete Elopement Evaluation Assessments upon admission for 39 of 40 residents reviewed. The report states that this failure could result in not identifying residents’ elopement risk levels and not implementing resident-centered plans of care, with the potential to result in harm, injury, or death for residents at high risk of elopement. The cumulative failures to assess elopement risk, to develop and implement individualized care plans for residents with known preferences for independent outdoor time, and to follow the LOA policy for assessment and documentation led to an immediate jeopardy situation, as the noncompliance caused or was likely to cause serious injury, harm, impairment, or death to residents, exemplified by the elopement and subsequent fatal motor vehicle accident involving the first resident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide adequate pressure ulcer prevention, assessment, and treatment, and to prevent the development and worsening of pressure ulcers for multiple residents, most extensively documented for Resident #29. Resident #29 was admitted without pressure ulcers and initially assessed with a Braden score of 20 (not at risk), later decreasing to 16 (at risk) and then to 9 (very high risk). An in-house acquired Stage 2 sacral pressure ulcer was first documented on 11/28/25 with measurements, and again on 12/6/25 with increased size. On 12/16/25, the wound was documented as a Stage 2 ulcer but without any measurements. From 12/16/25 through 1/3/26, there were no complete wound assessments with measurements, descriptions, or photos, despite ongoing skin check entries that noted a pressure injury on the coccyx/sacrum without measurements or detailed description. During this period, the care plan did not reflect new or updated interventions in response to the in-house acquired Stage 2 ulcer or its deterioration. Resident #29’s wound worsened significantly without timely or adequately documented provider notification or changes in treatment. Infection documentation from 1/1/26 through 1/5/26 noted a sacral ulcer infection with odor but lacked measurements, wound description, and MD notification. On 1/3/26, an unstageable sacral pressure ulcer with slough/eschar, strong odor, and a much larger area was documented. A subsequent 1/5/26 skin and wound evaluation described an unstageable ulcer with slough/eschar and large dimensions, again without physician notification. The DON acknowledged that weekly wound assessments with measurements and descriptions were not completed between 12/16/25 and 1/3/26 and that the wound did not change from a Stage 2 to a large unstageable ulcer overnight. Interviews with nursing staff indicated that the wound had gotten larger and worse, that the NP was told it looked worse, and that treatment orders were not changed from 12/16/25 until the resident was seen at a wound clinic on 1/2/26. Hospital records later documented a sacral decubitus ulcer with foul odor, significant necrotic tissue, and debridement down to ligamentous structures and exposed bone. The deficiency also includes failures in basic preventive care such as repositioning and incontinence management for Resident #29. The resident, who had multiple sclerosis and could not reposition herself, reported that staff were not turning her every 2 hours as ordered and that she had to set an alarm on her phone to prompt staff. She stated that some overnight shifts only repositioned her once late in the night and that she had reported these concerns multiple times. Staff interviews corroborated concerns that the resident was not being repositioned appropriately and that CNAs had reported the wound was not improving but were told to apply cream without the nurse assessing the area. There were also reports that a CNA refused to change the resident’s saturated brief, allegedly stating there were no briefs and reapplying the same brief, while another CNA described only “freshening up” the resident and not returning later in the shift. The DON and nursing staff acknowledged that CNAs may not recognize or report early pressure injuries, that CNA reports to nurses were sometimes undocumented, and that “a lot of balls were dropped” regarding wound care. For Resident #2, the deficiency includes incomplete and inaccurate wound assessment and documentation, and failure to align the care plan with identified skin risks and conditions. Resident #2 was admitted with a Braden score of 17 and a documented need for repositioning at least every 2 hours, and had incontinence-associated dermatitis (IAD) on the buttocks present on admission. Wound evaluations showed large fluctuations in the documented size of the IAD over time, including a significant increase in area on 12/5/25 and later a marked decrease by 12/30/25, followed by another large increase on 1/6/26. The 12/12/25 wound evaluation lacked any measurements, and a photo from 1/6/26 showed two areas consistent with Stage 2 pressure ulcers on the sacrum/coccyx that were not documented as such in the record. The MDS identified that the resident was at risk for pressure ulcers and had MASD, and that interventions such as pressure-reducing devices and nutrition/hydration interventions were in place, but the care plan only reflected a generic potential for pressure injury and did not include the specific skin issues or interventions identified on the MDS. Interviews and record reviews further demonstrated systemic issues contributing to the deficiencies. The NP reported that she was shown a picture of Resident #29’s wound on 12/16/25 and then only heard again around Christmas via a text that the wound looked worse and needed a wound care visit; she did not receive updates on the wound clinic’s findings and was not informed when the wound became unstageable or significantly deteriorated. She stated she would have expected notification with such changes and that the wound appeared preventable and should not have progressed to its current state. Nursing staff acknowledged expectations to notify physicians of wound changes, lack of improvement, or deterioration, but also acknowledged that this did not occur consistently for Resident #29. The DON confirmed that physician notifications and wound assessments were missing or incomplete, that CNA reports were sometimes not documented, and that there were multiple failures in wound care practices across the facility. Overall, the documented actions and inactions include failure to perform consistent, measurable weekly wound assessments; failure to document and communicate wound deterioration and infection to providers; failure to update care plans and interventions in response to new or worsening pressure ulcers; failure to ensure regular repositioning and timely incontinence care; and failure to accurately identify and document pressure ulcers versus dermatitis. These failures affected multiple residents, with detailed evidence for Residents #29 and #2, and were acknowledged by the DON and nursing staff as significant lapses in wound care and skin integrity management.