**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure one resident sampled (Resident (R)2) sampled received professional standard quality of care. R2 was readmitted to the facility on [DATE] from an acute hospital with an ostomy bag. The facility did not develop care plans, which drives the care of residents for malnutrition, pain, and prevention of pressure injury/pressure ulcer. On admission, the physician identified R2 to be at risk for malnutrition, R2 was not assessed by the Dietician until 9 days after admission when contacted by the facility due to R2's poor oral intake, refusing meals, and having a significant weight loss of 12.09%. R2 was not ordered pain medication for severe pain (7-10 on the Numeric Pain Rating Scale) despite R2 reporting a pain score of 8 on two separate documented occasions, and a care plan was not developed for pain. R2 was not administered pain medication prior to or after treatment of a PU during which the resident verbally and non-verbally expressed pain and during another incident when nursing staff was informed of the resident's request for pain medication. R2 had a decline in mobility which resulted in a decrease of mobility functioning and R2 remained in bed, increasing the risk of developing a new pressure injury/ulcer (PI/PU). A care plan was not developed in response to R2's change in mobility functioning to prevent a new PI/PU and was not developed after staff first identified the sacral PI to prevent it from worsening. As a result of this deficient practice, R2 experienced physical harm and a high potential for psychosocial harm. Findings include: Observations were made of R2 on 07/25/23 at 10:20 AM, 12:10 PM, 01:15 PM, 02:31 PM; 07/26/23 at 09:10 AM, 11:17 AM, 01:35 PM, 03:23 PM; and on 07/27/23 at 08:55 PM, 09:30 AM, 10:15 AM, and 12:45 PM. During these observations, R2 was lying flat on his back, both heels were in direct contact with the air mattress, there was an observable indentation in the air mattress directly under R2's heels, and there were no indication interventions to turn, reposition, or use a wedge/pillow to off-load high contact points were implemented. Observations of R2 with staff present, noted staff did not attempt to reposition the resident or explain to the resident why off-loading the PU was necessary and/or beneficial to prevent worsening of current PU and prevent any new PU. During the observation on 07/25/23 at 12:10 PM, Nursing Staff (NS)38 and a hospice nurse, who was evaluating the resident for hospice services, were providing treatment to R2's PU and changing the dressing. Observed R2 wincing, grimacing, and squeezing his eyes tightly in pain while turning onto his side, also observed that the resident required the assistance of NS38 to turn and could not have turned on his own. While NS38 provided treatment to the wound bed, R2 stated Sore and Ouch in response to any contact with the wound bed. While R2 laid on his side, redness was observed on the outside portion of the resident's right foot. NS38 inquired with R2 if he had any pain, and the resident responded with Sore. At the time, it was unknown if R2 had been premedicated prior to the dressing change to mitigate amount of pain the resident would experience. After the dressing change, this surveyor did not observe NS38 administer pain medication to alleviate the resident's pain. Inquired with NS38 regarding R2's course of treatment at the facility. NS38 stated R2 was a long-term resident at the facility and had recently been readmitted to the facility on [DATE] with an ostomy bag (an external pouch used to catch urine or stool) due to a portion of the intestine twisting around it's blood supply, sigmoid volvulus). NS38 reported that prior R2's discharge, the resident was independent in most areas of care, could ambulate on his own, had a good appetite, and would spend most of the day in the unit dining room with other residents. However, on readmission, R2 hardly ate, continued to lose a significant amount of weight, could no longer walk independently, and just wanted to stay in bed. As a result of these changes, the contracted hospice nurse was there to assess R2 was an appropriate candidate for hospice services. Later in the day, this surveyor was informed that R2 was accepted and admitted to hospice services. On 07/26/23 at 09:55 AM, conducted a review of R2's Electronic Health Record (EHR). R2 was readmitted to the facility on [DATE] with a diagnosis which included a Sigmoid Volvulus, NSTEMI, hypokalemia, epilepsy, diabetes mellitus type 2, and a recent ileostomy resulting in the placement of an ostomy bag. Review of R2's care plan documented a care plan was not developed for the prevention of PU, decline in Activities of Daily Living (ADLs), pain, and risk for malnutrition. ---Record review related to R2's pressure include review of but not limited to multidisciplinary notes, physician orders, and assessments. No care plan was developed for prevention of PU. Review of nursing admission Assessment on 07/12/23 at 08:00 AM documented under Skin, R2 did not have any skin alterations. A skin assessment on 07/21/23 at 04:14 PM, documented in a comment, Comments: Pressure wound to sacrum, Tx (treatment) in place, Triad and silver alginate., on 07/25/23 at 05:32 PM, Comments: Pressure wounds to sacrum persist and worsening. Tx (treatment) in place, Triad around wound border, silver alginate on wound bed and cover w/abd (abdominal) dressing.; and 07/26/23 at 10:35 AM, documented the sacrum wound as unstageable Pressure Injury, obscured full-thickness skin and tissue loss, measuring 4 cm in length 8.5 com in width, and 0.3 cm in depth. 100% eschar with attached edges and moderate serosanguinous drainage, the surrounding peri area is described as non-blanchable erythema: red. it documents that R2 does not have pain associated with the wound. Review of the physician orders documented the air mattress was ordered and applied on 07/20/23. Review of the Braden Scale for Predicting Pressure Sore Risk documented three assessments were completed. On 07/12/23 at 02:26 AM, Braden score was 21 indicating the resident was NOT AT RISK; on 07/19/23 at 01:25 AM Braden score was 14 indicating the resident was Moderate Risk, despite staff documenting a quarter sized dark non-blanchable discoloration to the resident's sacrum, a previous PU in the same spot in 2019 due to moisture; and on 07/26/23 at 01:12 AM, R2 remained as a Moderate Risk despite having an open sacrum unstageable PU. Review of the Aloha Wound Care Nursing Facility Service consultation, on 07/20/23, documented R2's wound was located on the sacrum. Wound previously occurred by pressure mechanism in March 2019 (healed). R2 was recently hospitalized on [DATE] to 07/11/23 for sigmoid volvulus and re-admitted to the facility. The wound occurred after admission per staff. ---Record review related to R2's pain include review of but not limited to multidisciplinary notes, physician orders, and Medication Administration Record (MAR). No care plan was developed for pain. Review of physician orders related to PUs documented only Acetaminophen 650 mg (oral and suppository) were ordered to treat R2's mild to moderate pain. No medication was ordered to treat severe pain. On 07/12/23, a physician's order documented, Nutrition risk, Special Instructions: At risk for malnutrition. Review of the July 2023 Medication Administration Record (MAR) documented R2 was administered Acetaminophen 650 mg four times (since readmission on [DATE]). - 07/23/23 at 04:18 AM, pain 8 of 10 a whole lot of pain, located in the buttock - 07/23/23 at 01:38 PM, pain 5 of 10, located in the bilateral lower extremities - 07/23/23 at 08:10 PM, pain 5 of 10, located in the buttock - 07/25/23 at 06:22 AM, pain 5 of 10, for general body pain A progress note on 07/24/23 documented R2 refused therapy due to his/her pain level being an 8 out of 10, however, R2 did not have a medication order to treat the resident's severe pain. Review of NS38's progress note on 07/25/23 at 03:55 PM, NS38 documented R2 denies pain, which contradicts this surveyor's observations and R2 verbalizing pain sore and expressing pain indicators (wincing, squeezing eyes closed tightly) while providing treatment to the PU. Also, on 07/27/23, after the Director of Nursing (DON)1 observed and assessed R2 and the resident reported pain, DON1 informed NS4 of R2's pain and request for pain medication, however, review of the MAR documented NS4 did not administer Acetaminophen 650 mg for pain as instructed by DON1. ---Record review of the EHR related to R2's nutrition include review of but not limited to multidisciplinary notes, physician orders, weights, and assessments documented there was a delay in addressing R2's risk for malnutrition, addressing R2's refusal of meals and potentially adding an appetite stimulant or other intervention, and the effects of untreated pain on R2's appetite, and the delay in identifying the resident significant weight loss. No care plan was developed for R2 related to the resident's risk of malnutrition related to the resident returning to the facility with a newly placed ostomy bag. A physician's order on 07/12/23 identified R2 was at risk for malnutrition. On 07/18/23 R2 was ordered and received 3 liters (L) of D5 1/2NS intravenous fluid (IV) on 07/18/23 for dehydration related to poor oral (PO) intake. On 07/11/23 (day of admission), R2 weighted 137 lbs. (pounds); 07/20/23 weight was 125.6 (11.4 lbs. loss in 9 days); and 07/24/23 weight was 121.4 lbs. (15.6 lbs. loss in 13 days). Although, there was a physician's order identifying R2 at risk for malnutrition on admission, the dietician did not assess the resident on admission to prevent R2 from experiencing malnutrition. The dietician was contacted via email on 07/20/23 to assess R2 after the resident had experienced a decline in ADLs, significant weight loss, received IV fluid for dehydration, and developed a new pressure injury. Progress notes documented a nutritional supplement was ordered on 07/20/23 to address the immediate issue, but the dietician did not come into the facility to conduct an in-person assessment of R2 until 5 days later (07/25/23). During that visit, the dietician documented R2 had experienced a significant weight loss of 12.09% since 07/11/23 (14 days after admission). Review of R2's intake of meals prior to the facility contacting the dietician from 07/11/23 to include 07/20/23, out of a total of 28 possible meals, R2 refused 10 meals, consumed 1-25% of 11 meals (staff documented resident had only eaten a couple of bites on more than one occasion), consumed 26-50% of 6 meals, and only one instance of R2 eating 51-75% of a meal. ---Record review of R2's EHR related to ADL decline included review of but not limited to the Minimum Data Set (MDS) and progress notes. The facility failed to identify R2's increased risk of PU due to a decline in the resident's mobility. Point of Care History documented R2 did not walk in room or out of unit starting on 07/13/23, prior to that the resident attempted but required 2+ person assist, extensive assist, or set-up. R2's discharge MDS with an Assessment Reference Date (ARD) of 06/14/23, prior to R2 discharge to an acute hospital, the resident required limited assistance from staff and was highly involved in the activity, staff provided guided maneuvering of limbs or other non-weight-bearing assistance for walking in the room, moving on the unit, bed mobility, transfer between surfaces (ex. bed to chair/wheelchair etc.), dressing, eating, toilet use, and personal hygiene. A nursing progress note written on 07/18/23 at 04:33 PM documented staff used a maxi lift to transfer R2 to and from the shower chair; 07/19/23 at 04:05 PM, R2 needed some help from staff with eating his meal; 07/24/23 at 04:42 PM, R2 requires 1 person assist for bed mobility, dressing, and personal hygiene care. On 07/27/23 at 12:30 PM, conducted a concurrent interview and record review of R2's EHR with the Director of Nursing (DON)1, then a subsequent observation of R2 with DON1 related to surveyor's concerns of the quality of care the resident received for risk malnutrition, prevention of PUs, pain, and ADL decline. DON1 reviewed R2's care plan and confirmed the current care plan did not include R2's risk for malnutrition, prevention of PUs, pain, or ADL decline on readmission from an acute hospital in accordance with professional standard of care. Inquired what would DON1 expect to see in a care plan to properly address prevention of a PU. DON1 stated R2 should be turned frequently, if the resident refuses staff can use pillows and wedges to off load the resident's weight on high-risk areas. The dietician should have been contacted shortly after R2 was re-admitted addressing the resident's malnutrition, newly identified skin issues, and the resident's refusal to eat. Inquired if the team could have considered administering an appetite stimulate for a decline in the resident's appetite. DON1 confirmed it could have been considered but was not brought up as an option. DON1 reviewed the Braden Scale for Predicting Pressure Injury assessments completed by nursing staff. DON1 reviewed the assessments and stated that staff did not properly complete the for and if staff had identified R2 would be occasionally moist, the score would have prompted a care plan for PU to be developed and R2's assessment completed after the opening on the PI, R2 should be High Risk and not Moderate Risk. Informed DON1 of my observation of R2 while NS38 was providing treatment of the PU. DON1 reviewed the MAR and confirmed R2 had not received pain medication prior to or after treatment of the sacral PU, despite multiple pain indicators expressed by R2 and only had medication orders to treat mild to moderate pain and did not address severe pain. Informed DON1 of observations of R2's heels in direct contact with the bed and lying flat on the bed and requested for DON1 to assess the resident. At 12:55 PM, DON1 conducted a physical assessment of R2. DON1 observed R2's heels in direct contact with the mattress, the indentation of his heels on the air mattress, the outer part of R2's feet and heels were reddened, but blanchable and was at risk for developing a new PU. Also, on the bony prominence of R2's left ankle appeared to be the start of a sore and around the ankle, R2's skin was purple with extremely poor profusion, indicating the development of a PU. DON1 assisted R2 with turning so we could assess the resident's back. The bony prominence (spine, shoulder blade etc.) was in constant direct contact with the bed and were reddened indicating the resident had not been turned or repositioned to periodically off-load the areas. On the upper portion of the resident's back there were approximately four 1 inch (in.) by 1 in. patches of petechiae bruises. DON1 could not identify the source of or how the resident sustained those bruises. DON1 observed R2's non-verbal expressions of pain, assessed the resident's pain, asked R2 if he wanted medication for the pain, and R2 agreed. DON1 confirmed R2 appeared to be in constant pain, his pain was unmanaged, and pain most likely contributing to a decrease in ADL functioning and affecting the resident's appetite. DON1 and this surveyor went back to the unit nursing station where DON1 reported R2's pain to NS4 and requested that staff administer pain medication to R2. Later review of R2's MAR with another nursing staff on 07/28/23 confirmed NS4 had not administered pain medication to R2 as requested by DON1 and had not documented that R2 had refused NS4's attempt to administer the pain medication. After reviewing R2's EHR, inaccurate assessments of R2's risk for developing a PU on the Braden scale, and no care plan was developed and no interventions were implemented to prevent a new PI/PU DON1 confirmed R2's PI/PU was avoidable and R2's pain was not managed in accordance with professional standards of care.