**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, and staff interview, it was determined the facility failed to ensure residents were free of significant medication errors. This was true for 1 of 7 residents (Resident #8) whose medications were reviewed. This failure created harm to Resident #8 when she received an incorrect administration of medication requiring hospitalization. Findings include: The facility's Medication Errors policy, dated 8/1/23, documented a medication error was the preparation, or administration of drugs or biologicals that were not in accordance with the following: - Prescriber's order - Manufacture's specifications - Accepted professional standards and principles that apply to professionals providing services. This policy was not followed. Resident #8 was admitted to the facility on [DATE], with multiple diagnoses including cerebral infarction (result of disrupted blood flow to the brain), and hypertension (high blood pressure). Resident #8's MAR for August 2023, documented a physician's order for Lisinopril (medication used to treat high blood pressure) oral tablet 20 mg to be administered by mouth one time a day for hypertension and to hold (do not administer) if Resident #8's systolic blood pressure (pressure in the arteries when the heart beats) was less than 150 or diastolic blood pressure less than 60 (pressure in the arteries when the heart rests between beats). A nursing note, dated 8/28/23 at 11:10 AM, documented Resident #8's daughter was notified of Resident #8's acute change in condition with hypotension (low blood pressure) and order to transfer her to the hospital emergency department. An Incident and Accident report, dated 8/29/23, investigating Resident #8's hospitalization, documented her Lisinopril was not held when meeting hold parameters prior to her hospitalization. Resident #8's Lisinopril was discontinued on 8/31/23. A document provided by the facility titled, Attention all Nurses, dated 8/29/23, signed by the CNO, documented Resident #8's medications were reviewed and 21 episodes of the medication Lisinopril was given when it should have been held per parameters listed on the physician order. The document stated this was a huge survey/citation risk and carried weight as it could/would cause harm or there would not be parameters. An attendance roster documented the document was reviewed by 7 facility nurses. Resident #8's MAR, dated 8/1/23 through 8/31/23, documented Resident #8 was given Lisinopril 24 times in August 2023 when his blood pressure was outside of the ordered parameters to receive the Lisinopril. After education was provided to facility nurses on 8/29/23, there was 1 episode of Lisinopril given on 8/31/23 with a blood pressure of 139/62, which was outside of the ordered parameters to administer the Lisinopril. Documentation of the education on 8/29/23 included the nurse who administered the Lisinopril on 8/31/23, which was after the provided education. On 10/4/23, at 11:30 AM, the CNO stated Resident #8 had a change of condition related to low blood pressure. She stated a medication review was completed, and the medication errors were identified. The CNO stated she wrote and presented the nursing staff with education on medication errors and following hold parameters for blood pressure medication administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, it was determined the facility failed to ensure residents were provided with a safe and sanitary environment. This was true for 1 of 12 residents (Resident #3) whose environment was observed. Resident #3, who was unable to express herself, experienced psychosocial harm when she was consistently exposed to a strong odor of urine in her room due to her roommate's lack of compliance with personal hygiene. Findings include: * Resident #3 was admitted to the facility on [DATE], with multiple diagnoses which included Alzheimer's disease. A quarterly MDS assessment, dated 7/22/21, documented Resident #3 was severely cognitively impaired. * Resident #16 was admitted to the facility on [DATE], with multiple diagnoses which included diabetes mellitus, morbid obesity, and dementia. A quarterly MDS assessment, dated 5/21/21, documented Resident #16 was moderately cognitively impaired. The facility's Tracking Rooms record, documented Resident #3 and Resident #16 were transferred to room [ROOM NUMBER] on 7/19/21 and were roommates. On 8/2/21 at 12:05 PM, a urine odor was noted outside room [ROOM NUMBER]. On 8/2/21 at 3:46 PM, when a surveyor entered room [ROOM NUMBER], a strong odor of urine was noted. Resident #3 was in bed, awake. The privacy curtain was drawn between Resident #3 and Resident #16. When asked how Resident #3 was doing, Resident #3 replied Are you [name of her representative]. On 8/3/21 at 5:41 AM and 8/5/21 at 11:28 AM, Resident #3 was observed in the dining room and no urine odor was noted. On 8/5/21 at 111:28 AM, LPN #3 stated the urine odor in room [ROOM NUMBER] was due to Resident #16. LPN #3 said Resident #16 was non-compliant and would only allow certain staff members to change her incontinence briefs. LPN #3 said Resident #16 refused a lot of peri-care and got angry with staff when they asked to change her incontinence brief. LPN #3 also said Resident #16 was able to go to the bathroom on her own and there were times she urinated on her way to the bathroom. On 8/6/21 at 7:46 AM, when a surveyor entered room [ROOM NUMBER] there was a strong odor of urine noted. Resident #3 was not in the room. The privacy curtain was drawn and behind the privacy curtain was Resident #16. She was eating her breakfast and looked appropriately groomed. Resident #16 said she was fine and being assisted by the staff as needed. The urine odor was more pronounced closer to Resident #16's area. On 8/6/21 at 7:52 AM, CNA #10 said Resident #16 had been educated and staff offered many times to change her incontinence briefs, as needed. CNA #10 said Resident #16 got angry when staff approached her to change her incontinence brief. CNA #10 said there were times Resident #16 would wear her regular underwear and staff applied a sanitary pad, but Resident #16 removed it. CNA #10 said the room was always cleaned but the smell lingered in the room because of Resident #16 being non-compliant with her peri-care. On 8/6/21 at 7:57 AM, the DON said Resident #3 was moved to room [ROOM NUMBER] about three weeks ago when the facility had an outbreak with COVID-19 and Resident #16 was also moved to room [ROOM NUMBER] at the same time. The DON said Resident #16 was incontinent of urine and wore incontinence briefs but was non-compliant with her personal hygiene. The DON said Resident #16 would remove her incontinence brief and urinate on the floor at bedside. The DON said Resident #16 was educated many times by the staff and her representative was also informed of her being non-compliant with personal hygiene. When asked about Resident #3 being in the same room with Resident #16, the DON said Resident #3 did not express any concern being in room [ROOM NUMBER] with Resident #16. Resident #3 was unable to express herself appropriately and experienced psychosocial harm when she was placed in a room with another resident who was non-complaint with her personal hygiene causing a strong odor of urine.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based Review of the facility's policy titled, Notification of Change, dated 11/2016, directed the staff as follows: A facility must immediately . consult with the resident's physician . when there is: . 2. A significant change in the resident's physical, mental or psychosocial status . 1. Resident #30 was admitted to the facility on [DATE], and discharged to the hospital on 8/14/18, and re-admitted him on 8/16/18. Resident #30's diagnoses included status-post laminectomy (back surgery) for a ruptured disk, pain, atherosclerotic heart disease (ASHD- also known as coronary artery disease),fractures of thoracic (mid-back) and lumbar (lower back) vertebrae, lumbar spinal stenosis (narrowing of the spinal canal) with neurogenic claudication (pain and cramping in the lower back, buttocks, hips and legs), and nausea with vomiting. Resident #30's Physician Orders for July 2018 through September 2018, documented the resident's medications included: Fentanyl Patch 72-hour, 12 micrograms (mcg)/hour [a narcotic pain medication in a topical patch form that is applied to the skin and delivered in a time-released manner], apply one patch transdermal, one time a day, every three days for pain. (ordered 08/02/18 and discontinued on 09/19/18). Carvedilol 6.25 mg two times a day for hypertension, ordered 7/31/18. Levothyroxine 100 mcg one time a day for hypothyroidism, ordered 08/01/18. Resident #30's History and Physical Evaluation, dated 8/22/18 at 1:20 PM, documented his attending physician saw the resident at the facility and documented the following findings under Review of Systems: Constitutional Negative [for] . Fatigue, . Malaise and Weight Loss . GI [gastrointestinal] Negative [for] Abdominal pain, . Decreased appetite, . Nausea and Vomiting. A quarterly MDS assessment, dated 8/24/18, documented Resident #30 was cognitively intact with mild depression. The MDS documented Resident #30 required extensive assistance of two or more persons for bed mobility, transfer, dressing, and toileting, did not walk in or out of his room, and required extensive assistance of one to two or more persons for wheelchair mobility, but could eat with setup assistance and supervision. Review of Resident 30's care plan indicated the staff developed the following Focus areas, all initiated on 08/01/18: a. The care plan area addressing Resident #30's altered cardiovascular status, dated 8/1/18, documented he had a history of coronary artery disease, hypertension, hyperlipidemia [high cholesterol], and Hx [history] of CABG [coronary artery bypass graft surgery]. The Interventions documented staff were to monitor, document, and report any signs and symptoms of heart related concerns, included nausea and vomiting to the physician. b. The care plan area addressing Resident #30's hypothyroidism, dated 8/1/18, documented the staff were to report signs and symptoms of hypothyroidism such as low blood pressure, decreased breathing, decreased body temp, unresponsiveness; fatigue, impaired memory, and depression. c. The care plan area addressing Resident #30's chronic neuropathy pain [nerve-related pain] and acute back pain, dated 8/1/18, documented he had a T12 [thoracic spine, 12th vertebrae] compression Fx [fracture] with disc retropulsion [herniation] with surgical repair. The interventions documented staff were to observe for signs of nausea or vomiting and report to the physician any occurrences. Resident #30's Progress Notes from 09/01/18 through 09/22/18 documented the following: - On 9/1/18 at 11:02 PM, Resident #30 had post-op back surgery and he was to wear a back brace while up in his wheelchair. The note documented Resident #30 denied pain or discomfort and he was alert and oriented. - On 9/2/18 at 8:17 PM, Resident #30 was administered ondansetron HCl (hydrochloride) (Zofran- an anti-nausea medication) 4 milligrams (mg) due to nausea with vomiting. - On 9/2/18 at 11:48 PM, Resident #30 experienced emesis [vomiting] episode this shift, Zofran administered and was effective. - On 9/3/18 at 3:08 AM, Resident #30 was administered Zofran 4 mg due to nausea. - On 9/3/18 at 1:17 PM and at 9:54 PM, and on 09/04/18 at 10:48 PM, the nurses documented Resident #30 was up in his wheelchair with his back brace on, was alert and oriented, participated with PT and OT, and denied pain or discomfort. - On 9/5/18 at 1:09 PM, Resident #30 refused both breakfast and lunch. The Progress Notes did not reflect follow up documentation by the nurse or communication with the physician of the resident's change in status. - On 9/5/18 at 1:33 PM, the LSW met with Resident #30 1:1 and discussed his recent lack of activity and not getting out of bed and his lack of desire to get up and use the restroom. The note documented Resident #30 did not feel up to it. The Progress Notes did not reflect follow up documentation by the LSW or communication with nurses or the physician of the resident's change in status. - On 9/5/18 at 11:02 PM and on 9/6/18 at 11:28 PM, the nurses documented the resident was alert, verbal, oriented x 2, up to his wheelchair with his back brace on, took his medications, and denied pain or discomfort. - Resident #30's MAR documented on 9/14/18, from 4:28 PM through 4:32 PM, Resident #30 was not administered several medication due to nausea and emesis. - On 9/14/18 at 5:44 PM, Resident #30 had a substantial amount of emesis after morning medications. The note documented he did not have much of an appetite for the rest of the day. The note documented his vital signs were obtained and were 88/56 for blood pressure, pulse 59, [and] O2 [oxygen] 94%. The note documented his vital signs were rechecked near dinner time and his [blood] pressure was 102/54, pulse was 70, O2 95%, respirations 16, [and] temp of 96.0. The note documented Resident #30's skin was cold to touch and he was pale. The Progress Notes did not reflect follow up documentation by the nurse or communication with the physician of the resident's change in status. - On 9/15/18 at 4:48 PM, Resident #30's carvedilol (a heart medication) was Held for blood pressure 98/49. - On 9/16/18 at 5:19 PM, Resident #30 experienced episodes of vomited about 5 minutes after evening medications were administered. The note documented he was feeling fine today and his BP was 120/53. - On 9/17/18 at 1:44 PM, Resident #30 remained in bed for most of the day sleeping/resting. The note documented he has not complained of any nausea or had any emesis. - On 9/17/18 at 2:34 PM, Resident #30 was discharged from physical therapy's services. The note documented he did not feel up to participating lately. The Progress Notes from 09/15/18 through 09/17/18 did not reflect follow up documentation with the physician of the resident's change in status. The Progress Notes documented the nursing staff did not document an assessment of Resident #30's medical status from 09/19/18 at 3:34 PM until 09/22/18 at 2:15 AM. - On 09/22/18 at 2:15 AM, Resident #30 experienced an emesis episode at approximately 1:20 AM. The note documented Resident #30 was responsive to verbal and tactile stimuli and continued to vomit while being cleaned up by staff. The note documented his vital signs were taken at this time and his blood pressure was 35/30, pulse 60, temperature 98.3, respirations 10, oxygen saturation 48 percent. The note documented oxygen was applied via nasal cannula while EMR [Emergency Medical Response] were notified. The note documented the responsible party [name] was notified of Resident #30's decline. The note documented his vitals were obtained again and they were BP 58/32, pulse 63, sats [oxygen saturation] 68. The note documented the EMR arrived and Resident #30's breathing had become shallow and his eyes were glazed and fixed. The note documented the EMR was unable to retrieve a pulse. The note documented at 2:00 AM Resident #30 was pronounced dead by EMR staff and the DNS and physician were notified. On 10/12/18 at 1:46 PM, LPN #1 stated that on 9/14/18, he was in facility orientation with and thought he notified the RN (registered nurse) working with him that day of Resident #30's condition but could not recall the name of the RN. LPN #1 stated he did not notify Resident #30's physician of the change in the resident's condition. On 10/12/18 at approximately 2:00 PM, the DNS stated that Resident #30 had exhibited episodes of nausea and vomiting prior to his back surgery, but none of the staff notified the physician when the resident exhibited additional episodes of nausea and vomiting, decreased appetite and intake, refusal of therapy services, and preference to stay in bed. The DNS stated she expected the staff to notify the physician of any change in a resident's condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, it was determined the facility failed to ensure residents did not develop avoidable pressure ulcers. This was true for 1 of 2 residents (#25) reviewed for pressure ulcers. Resident #25 was harmed when she developed 2 pressure ulcers. Findings include: The facility's Wound and Pressure Ulcer Management Policy and Procedure, dated 1/17, documented the facility followed protocols and procedures consistent with the Agency for Healthcare Research and Quality (AHRQ), the American Medical Director Association (AMDA), and the Society for Post-Acute and Long-Term Care Medicine. The facility's Positioning Policy and Procedure, dated 10/17, documented staff would reposition residents to reduce their risk of developing pressure ulcers. The 2014 guidelines for staging wounds, from the National Pressure Ulcer Advisory Panel, Prevention and Treatment of Pressure Ulcers: Quick Reference Guide, documented a Stage I pressure ulcer was defined as nonblanchable (Skin that remains red in color after pressure was applied.) intact redness to skin over a bony area. The guidelines documented a Stage II wound was partially skin thickness loss (A Wound that affects the top two layers of the skin.) with red and or pink in the wound bed without slough (A mass of dead tissue that separates from a wound bed.). The guidelines documented a Stage III wound was full skin thickness loss (A wound that affected the layers of skin and into the subcutaneous tissue of fat.) with possible slough present in the wound bed, however, the base of wound is visible. The guidelines documented a Stage IV wound was a full thickness tissue loss with exposed muscle, bone, or tendon. The guideline documented slough or eschar could be present in parts of the wound bed. The guideline documented an unstageable wound was of unknown depth due to the base of the wound covered by slough or eschar. Resident #25 was admitted to the facility on [DATE], with diagnoses which included difficulty walking, muscle weakness, and pain. The care plan area addressing Resident #25's pressure ulcer, initiated 4/14/17, documented Resident #25 had a stage II pressure injury to her coccyx and a Deep tissue injury (DTI) to her buttock. The care plan documented she was risk related to incontinence, impaired mobility, and a history of dermatitis. The care plan documented staff were to encourage Resident #25 to lift her buttock off of her wheelchair seat a minimum of twice per shift. (The facility had two shifts.) The care plan documented Resident #25 was to receive wound care per orders and staff were to encourage her to lay down for pressure relief during the day. Resident #25's clinical record contained Weekly Skin Observation Assessments between the dates of 5/1/18 and 10/10/18. The assessments were completed weekly and PRN. Resident #25's Weekly Skin Observation Assessment, dated 5/8/18, documented her skin was intact. Resident #25 developed and/or re-developed a Stage III pressure ulcer to her coccyx in September 2018, and the facility did not treat, implement interventions, and assess her pressure ulcer when the skin impairment was first discovered in May 2018. Examples include: i. Resident #25's Weekly Skin Observation Assessment, dated 5/15/18, documented Resident #25 had a new area to her coccyx which was red with fragile skin noted. The assessment did not document if the skin was blanchable or provided measurements for the area. Resident #25's clinical records did not contain a Wound Data Collection, dated 5/15/18, describing the skin impairment. Resident #25's May 2018 MAR or TAR and physician's orders did not contain treatment orders for the skin impairment found in May on her coccyx. Resident #25's Weekly Skin Observation Assessment, dated 6/9/18 and 6/12/18, documented Resident #25's coccyx had healing buttocks wound and was healing. The assessments did not document if the skin was blanchable or provided measurements for the area. Resident #25's clinical records did not contain a Wound Data Collection or a progress note, dated 6/9/18 and 6/12/18, describing the skin impairment. Resident #25's Positioning Assessment, dated 6/25/18, documented her Braden score was a 16 which placed her at risk for skin breakdown and she had no current skin breakdown. A quarterly MDS assessment, dated 9/7/18, documented Resident #25 was cognitively intact and documented she required extensive assistance of one to two staff members with all cares except eating. The MDS documented Resident #25's skin was intact, and she did not have a pressure ulcer. Resident #25's Positioning Assessment, dated 9/18/18, documented she was incontinent of bowel and bladder and required assistance with bed mobility and transfers. The assessment documented her skin was in good condition. This assessment was not consistetnt with the 9/18/18 weekly skin observtion assessment or progress notes. ii. Resident #25's Weekly Skin Observation Assessment, dated 9/18/18, documented Resident #25's coccyx had a Stage III pressure injury to her coccyx. The assessment documented the facility changed out the cushion on her wheelchair and planned to reposition her every 3 hours. A Progress Note, dated 9/18/18, documented Resident #25 was found to have a Stage III pressure injury to her coccyx after being assisted in the shower. A Progress Note, dated 9/20/18, documented Resident #25's wound was assessed, and the dressing was changed. The note documented Resident #25's wound bed did not have slough, no evidence of subcutaneous fat, or full thickness tissue loss. The note documented the wound was a Stage II. Resident #25's Wound Data Collection, dated 9/20/18, documented Resident #25 had a previously identified stage II wound to her coccyx, measuring 1.5 cm by 0.5 cm. The assessment documented the wound was pink and intact. Resident #25's Wound Data Collection assessments for her coccyx were completed between the dates of 9/20/18 and 10/11/18 by 11 different nurses. Thedocumentation of the characteristics of the wound was incomplete and inconsistent as follows: *On 9/27/18 Resident #25's wound worsened in size to 2.5 cm by 1 cm and 0.5 cm in depth. *The 9/27/18 assessment documented the wound remained a Stage II wound and the wound bed had 90% slough covering the surface with 5% granulation tissue [pink or beefy red moist tissue]. (The national standards documented slough present would not be a Stage II wound, but an unstageable wound.) * On 9/29/18 Resident #25's wound was documented as worsening in size to 3 cm by 2 cm by 1 cm, no staging documented. * The 9/29/18 assessment documented 5% granulation and no other tissue type documented. * The 9/30/18 assessment documented the wound size remained the same, however there was 5% eschar in the wound bed, no staging documented. *On 10/2/18 the assessment documented the wound was 2.5 cm by 1.5 cm by 0.1 with 100% slough in the wound bed, no staging documented. (The depth of a pressure ulcer cannot be determined when the wound bed is covered by slough 100%.) * The 10/2/18 assessment documented the pressure ulcer was worsening. *On 10/3/18 the assessment documented the wound was a Stage III pressure ulcer, measuring 2.5 cm by 1.5 cm by 4 cm deep, with 85% slough covering the wound bed, 10% epithelialized tissue (new skin tissue), and 5% granulation tissue. (The depth of a pressure ulcer cannot be determined when the wound bed is covered by slough or eschar.) A day later on 10/4/18 the Stage III pressure ulcer was documented as measuring 2.5 cm by 1.5 cm by 0.5 cm deep with 80% slough in the wound bed. (The wound healed 3.5 cm in one day according to the assessment.) Five assessments on 10/6/18, 10/7/18, 10/9/18, 10/10/18, and 10/11/18 following 10/4/18 documented the presence of slough in the wound bed. The 9/28/18, 10/5/18, and 10/8/18 assessments did not document an assessment of the wound bed to include the presence of granulation tissue, slough, eschar, or epithelial tissue. The wound was last measured on 10/10/18 as 2 cm by 1.5 cm by 2 cm deep as a Stage III pressure ulcer. Resident #25's September 2018 MAR documented staff were to cleanse her stage II Pressure Ulcer wound with [NAME] sterile saline solution and apply foam border adhesion dressing or alginate hydrocolloid dressing every 3-5 days and PRN, beginning 9/21/18 and discontinued 10/6/18. This was ordered three days after the wound was discovered. The order was not specific to the location of the pressure ulcer. The dressing was changed as ordered with the exception of 9/21/18. b. Resident #25 developed and/or re-developed a skin impairment in September 2018 on her left buttocks, and the facility did not treat and implement interventions to her left buttocks when the skin impairment was first discovered in May 2018. Example includes: i. Resident #25's Weekly Skin Observation Assessment, dated 5/19/18, documented Resident #25 had a recurrent area to her left buttock that was a stage II. The assessment document the wound was an open area approximately 0.5 cm by 1 cm that was previously scabbed over. Resident #25's Wound Data Collection, dated 5/19/18, documented Resident #25 had new wound to her left buttock, measuring 0.5 by 0.5 cm by 0.25 cm deep. The assessment documented the wound was reopened. The assessment did not document an assessment of the wound bed characteristics. Resident #25's Wound Data Collection, dated 5/26/18, documented Resident #25's wound to her left buttock, measured 0.5 by 0.5 cm. The assessment documented the wound bed had 100% epithelial tissue present in the wound bed. Resident #25's May 2018 MAR or TAR and physician's orders did not contain treatment orders for the skin impairment found in May on her left buttock. ii. Resident #25's Weekly Skin Observation Assessment, dated 9/18/18, documented Resident #25 had a deep tissue injury to her left buttock. The assessment documented the facility changed out the cushion on her wheelchair and planned to reposition her every 3 hours. A Progress Note, dated 9/18/18, documented Resident #25 had a deep tissue injury to her left buttock. The note documented Resident #25 was being assisted into her wheelchair by two staff members when Resident #25's stated her legs were tired and began to sit down. The note documented Resident #25's legs were tired and gave out on her and she was lowered to the floor. The note documented Resident #25's deep tissue injury may have come from this incident as she hit her buttock on the arm rest of the wheelchair. Resident #25's Wound Data Collection, dated 9/20/18, documented Resident #25 had a previously identified deep tissue injury wound to her left buttock, without measurements. The assessment documented Resident #25's left buttocks had a bruised area. Resident #25's Wound Data Collection assessments for her left buttock were completed between the dates of 9/20/18 and 10/4/18 by 3 different nurses. The documentation of the characteristics of the wound and wound size, were inconsistently documented between nurses as follows: * On the 9/20/18, 9/22/18, 9/23/18, and 9/28/18, Resident #25's wound was not documented as measured. *The 9/23/18 assessment documented the wound bed had 3 small areas open. *The 9/24/18 assessment documented the wound was open and measured 1 cm by 1 cm with 65% granulation and 35% epithelial tissue. * On 9/27/18 Resident #25's wound was documented as worsening in size to 1.5 cm by 3 cm, with 100% granulation tissue. The 9/27/18 assessment documented the area was no longer bruised, but there were two open areas present. *The 10/4/18 assessment documented the deep tissue injury was 0.5 cm by 0.5 cm with 95% epithelial tissue present. This was the last assessment of the wound. Resident #25's clinical record did not document when her left buttock wound resolved. Resident #25's September 2018 MAR or TAR and physician's orders did not contain treatment orders for the skin impairment found in September on her left buttock. c. Resident #25 developed new a skin impairment on her left gluteal fold and the facility did not implement interventions or consistently assess the wounds. Example includes: Resident #25's Weekly Skin Observation Assessment, dated 10/2/18, documented Resident #25 had an abrasion to her left gluteal fold. The assessment did not document a size of the wound. Resident #25's Wound Data Collection, dated 10/3/18, documented Resident #25 had previously identified wounds to her left gluteal fold. The assessment documented there were three areas that were connecting with excoriated (rubbed off skin) skin. The assessment documented one area was 1 cm by 0.5 cm by 0.2 cm deep. The assessment documented the biggest wound had slough present in the wound bed and one wound appeared to be a Stage I. The assessment documented there was 85% slough present in the wound bed. A Progress Note, dated 10/3/18, documented Resident #25 had three sores located on her coccyx, right [NAME], and crease of buttock and leg on the right hand side. The 3rd sore is a cluster of satellite open areas with one main area measuring 1 cm x [by] 0.5 cm. Resident #25's Wound Data Collection, dated 10/4/18, documented Resident #25 had previously identified wounds to her left gluteal fold. The assessment documented there were three areas, measuring 1 cm by 1.5 cm with 85% slough present in the wound bed. The assessment documented there was a 3 cm by 3 cm excoriated area surrounding the open area. The assessment documented the other two area look like potential problem. The assessment documented there was 85% slough present in the wound bed. Resident #25's clinical record did not contain documentation of the progression of the three areas to the left gluteal folds or documentation of further assessments after 10/4/18. Resident #25's October 2018 MAR or TAR and physician's orders did not contain treatment orders for the three areas of skin impairment found in October on her left gluteal fold. d. Resident #25 was not repositioned consistently and every 3 hours as follows: On 10/11/18 at 10:44 AM, the DNS stated the staff were instructed to document repositioning of residents in their chair and beds under the bed mobility section of the charting system. The DNS stated the staff were to document each occurrence of repositioning they provided to residents. The DNS stated the staff were to reposition Resident #25 mininally every 3 hours. The September 2018 ADL Bed Mobility record documented the following: - There was no documented evidence she was turned/repositioned between 9/1/18 through 9/18/18 day shift, except once on 9/7/18 and 9/15/18. - There was no documented evidence she was turned/repositioned between 9/1/18 through 9/18/18 evening shift, except once one evening shift on 9/5/18 when she was documented as she was able to do it herself. - There was no documented evidence she was turned/repositioned between 9/1/18 through 9/18/18 night shift, except once per shift on 9/1/18, 9/4/18, 9/5/18, 9/10/18, and 9/18/18 and twice per shift on 9/3/18. The ADL sheet documented Resident #25 was able to provide bed mobility independently once per shift on 9/1/18, 9/6/18, 9/10/18, 9/12/18, 9/13/18-9/15/18 and twice per shift on 9/7/18, 9/8/18, and 9/16/18. * The bed mobility between 9/19/18 through 9/30/18 day shift documented she was repositioned the following hours a day: - 9/19/18- Resident #25 was repositioned at 8:28 AM and again at 3:54 PM (7 1/2 hours). - 9/20/18- Resident #25 was repositioned at 1:10 AM and again at 12:20 PM (9 hours). - 9/22/18- Resident #25 was repositioned at 12:51 AM and again at 6:00 AM (5 hours). Resident #25's ADL documentation documented similar findings for the remainder of September 2018. The 10/1/18 through 10/11/18 ADL Bed Mobility record documented the following: -10/9/18- Resident #25 was repositioned at 1:33 PM and again at 7:21 PM (6 hours). - 10/10/18- Resident #25 was repositioned at 8:02 AM and again at 1:18 PM (5 hours) and at 2:43 PM and again at 7:34 PM (5 hours). - 10/11/18 Resident #25 was repositioned at 6:15 AM and again at 10:01 AM (4 hours). Resident #25's 10/1/18 through 10/8/18 ADL documentation documented similar findings. On 10/9/18 from 2:15 PM through 4:33 PM, Resident #25 was observed positioned in her wheelchair located in the activity room by the window without staff offering to reposition her or staff providing assistance with repositioning. Resident #25 was observed positioned in her wheelchair on 10/10/18 at 8:38 AM through 12:25 PM, on 10/10/18 at 1:58 PM, and on 10/11/18 from 6:54 AM through 10:01 AM, and 10:15 AM through 11:45 AM, and 12:50 PM through 3:25 PM. On 10/11/18 at 6:10 AM, Resident #25's wound care was observed. RN #1 was observed instructing CNA #1 to assist Resident #25 onto her left side from her back while in bed. CNA #1 rolled Resident #25 onto her left side and Resident #25 began to immediately cry out, Oh, oh! That hurts! CNA #1 reassured Resident #25 that she would not let her fall and adjusted her legs to try and help ease her pain. CNA #1 unfastened the brief on Resident #25's right hip and pulled it down to reveal an intact foam dressing at the midline of her coccyx. RN #1 began to remove the dressing and Resident #25 again cried out in pain and complained of pain. RN #1 continued to dispose of the old dressing and then used her gloved right hand to hold up Resident #25's right buttock to view the pressure ulcer. The pressure ulcer was observed located in the midline of Resident #25's coccyx at the top of the gluteal fold. The pressure ulcer measured approximately the size of a quarter with a depth of approximately 1.5 cm. The wound bed had a pale-yellow appearance with 30% stingy slough present that was moveable after cleansing. The wound was observed with no signs of infection, exudate, eschar, or tunneling of the pressure ulcer, but also no signs of granulation tissue, or re-epithelization. Wound margins were well-defined, with no undermining noted. The peri-wound skin was observed light pink in color with no signs and symptoms of irritation or infection, and no odors were noted. RN #1 disposed of the old dressing and she picked up a can of saline wound cleanser and sprayed the wound bed with a wound cleanser. RN #1 patted the pressure ulcer dry with a sterile 4 x 4 and removed her gloves, sanitized her hands, and re-gloved. While RN #1 was cleansing the wound Resident #25 continued to complain of pain and cry out, That hurts. RN #1 covered Resident #25's pressure ulcer with a cut small piece of oil emulsion dressing, and with a self-adhering antimicrobial foam dressing. On 10/11/18 at 10:44 AM, the DNS stated the wounds to Resident #25's coccyx and buttock were both found in September 2018. The DNS stated the September 2018 assessment documented the wounds being previously identified was a mistake. The DNS stated she was unsure where that information came from. The DNS stated she was unsure what the wounds found in May 2018 were and she suspected these wounds healed and resolved without facility staff documenting resolution dates and updating the care plan. The DNS stated the staff should be completing a Wound Data Collection assessment when they resolve a wound. The DNS stated staff should notify her when new skin areas were found. The DNS stated she could see there was inconsistency with the documentation of the wounds. The DNS stated the facility did not have a wound certified nurse for wound care and all nurses on the floor completed wound assessments. The DNS stated the staff should be repositioning Resident #25 minimally every 3 hours, and she could see this was not documented as completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interview, and review of residents' clinical records, it was determined the facility failed to ensure a method for evaluating the effectiveness of residents' pain management plans was in place. This was true for 1 of 5 residents (#25) reviewed for pain. Resident #25 was harmed when she experienced increased pain during cares and a dressing change and the facility did not identify and treat it. Findings include: The facility's Pain Management Policy and Procedure, dated September 2012, documented when a resident was identified to be in pain a registered nurse would assess the residents current pain level and offer non-pharmacological interventions and provide medication interventions as needed. Resident #25 was admitted to the facility on [DATE], with diagnoses which included difficulty walking, muscle weakness, and pain. A quarterly MDS assessment, dated 9/7/18, documented Resident #25 was cognitively intact and documented she required extensive assistance of one to two staff members with all cares except eating. The MDS documented Resident #25's did not have pain. The care plan area addressing Resident #25's chronic pain, revised 6/6/18, documented Resident #25 had generalized pain and could verbalize her pain. The care plan area addressing Resident #25's pressure ulcer, initiated 4/14/17, documented Resident #25 had a Stage II pressure injury to her coccyx and a DTI to her buttock. Resident #25's Physician Orders Included the following: * Staff were to monitor her pain every shift, ordered 5/16/18. * 650 mg of Tylenol by mouth every 6 hours PRN for pain, ordered 7/27/17. Resident #25 did not have orders for scheduled pain medications. The Wound Data Collection Assessments from 9/20/18, 9/24/18, 9/30/18, 10/3/18, 10/4/18, 10/6/18, 10/7/18, and 10/11/18 documented Resident #25 complained of pain during the dressing changes. Resident #25's Weekly Skin Observation Assessment, dated 9/18/18, documented Resident #25 had a deep tissue injury to her left buttock. The assessment documented the facility changed out the cushion on her wheelchair and planned to reposition her every 3 hours. On 10/11/18 at 6:10 AM, Resident #25's wound care was observed. RN #1 was observed instructing CNA #1 to assist Resident #25 onto her left side from her back while in bed. CNA #1 rolled Resident #25 onto her left side and Resident #25 began to immediately cry out, Oh, oh! That hurts! CNA #1 reassured Resident #25 that she would not let her fall and adjusted her legs to try and help ease her pain. CNA #1 unfastened the brief on Resident #25's right hip and pulled it down to reveal an intact foam dressing at the midline of her coccyx. RN #1 began to remove the dressing and Resident #25 again cried out in pain and complained of pain. RN #1 continued to dispose of the old dressing and then used her gloved right hand to hold up Resident #25's right buttock to view the pressure ulcer. RN #1 disposed of the old dressing and she picked up a can of saline wound cleanser and sprayed the wound bed with a wound cleanser. RN #1 patted the pressure ulcer dry with a sterile 4 x 4 and removed her gloves, sanitized her hands, and re-gloved. While RN #1 was cleansing the wound Resident #25 continued to complain of pain and cry out, That hurts. While the wound care was being provided, Resident #25 stated the pain was located in, My back, and from the wound when they clean it. Resident #25 stated staff had not provided pain medication prior to wound care nor offered. Resident #25 stated, No, but that would probably help. On 10/11/18 at 6:27 AM, RN #1 was observed leaving Resident #25's room. RN #1 stated she had just given Resident #25 Tylenol for pain. On 10/11/18 at 6:28 AM, Resident #25 was observed sitting in her wheelchair with CNA #1 assisting her with her morning cares. While CNA #1 wheeled Resident #25 into the bathroom, Resident #25 was crying out, Ow, ow, ow, ow. CNA #1 proceeded to position Resident #25's wheelchair in the bathroom doorway, and asked Resident #25 stand up and reach for the assist bar on the wall by the toilet. Resident #25 was observed trying to stand up and stated, Nope, I can't stand. Oh, it hurts so bad. It's hurting can you hold my feet. Its hurting so bad. My legs hurt, my whole body hurts, God, that hurts. Resident #25 asked CNA #1 to please use the Hoyer lift. CNA #1 left the room to obtain a mechanical lift. On 10/11/18 at 6:32 AM, CNA #1 returned with a sit-to-stand mechanical lift and placed a body sling around Resident #25's torso, just below her breasts. The CNA asked her to place her feet on the machine's foot plate, and hold onto the lift bars, which she did. Then CNA #1 lifted Resident #25 off her wheelchair and asked her to stand so she could remove her incontinence brief. While Resident #25 was being lifted in the air she said, Hurry, it hurts, ow, hurry it hurts. CNA #1 removed the soiled brief. Resident #25 stated she needed to sit down, and she was going to fall. CNA #1 stated she was almost done and assisted Resident #25 onto the toilet. Then the CNA removed the sling while Resident #25 used the toilet. After Resident #25 used the toilet and CNA #1 provided pericare, the CNA assisted her with applying a clean brief and clean pants. On 10/11/18 at 6:48 AM, CNA #1 was observed as she applied the sit-to-stand sling around Resident #25's torso, just below her breasts, and asked her to place her hands on the lift bars. The sling was slightly loose. As Resident #25 was raised up she cried out, Ow, ow, ow, hurry, I'm going to fall, it hurts, it hurts, it hurts. On 10/11/18 at 6:35 AM, RN #1 stated she had not administered pain medications prior to Resident #25's wound dressing change. RN #1 stated she had not spoken with Resident #25's physician about obtaining a pre-treatment pain medication order. RN #1 stated, Giving her [the resident] pain medication at about 5:00 AM every morning would probably work well. On 10/11/18 at 10:45 AM, the DNS stated she would expect the staff to pre-medicate Resident #25 prior to the dressing change. The DNS stated the nurse told her about the resident's complaint of pain during the dressing change and that Resident #25 had not complained of pain during dressing changes in the past. The DNS stated she would expect staff to wait for pain medications to be effective before providing cares and if a resident verbalized pain during the dressing change or cares the staff should stop and try and address the situation.