**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, it was determined the facility failed to ensure 1 of 1 resident (Resident #53) reviewed for death in the facility was provided CPR per his wishes documented on his POST form. The licensed staff neglected to verify Resident #53's code status when he did not have an apical pulse (heart beat) or respirations and neglected to initiate CPR per his documented wishes. The failure may have contributed to Resident #53's death and placed the other 22 residents residing in the facility with a code status of Full Code (initiate resuscitation) at risk of not receiving CPR per their wishes. Findings include: Resident #53 was admitted to the facility on [DATE], with multiple diagnoses including congestive heart failure (CHF), falls with closed head injury, and current use of anticoagulant medication (blood thinner). Resident #53's hospital admission History and Physical, dated [DATE] at 3:42 AM, documented he his code status was Full Code and was electronically signed by a Nurse Practitioner. Resident #53's Initial Nursing Assessment, dated [DATE], documented he was alert and oriented to person, place, and time. The assessment also documented Resident #53's judgement and insight was intact. Resident #53's POST form, located in his record, documented Resuscitate (Full Code) with aggressive interventions for cardiopulmonary resuscitation in the event he did not have a pulse and/or was not breathing. The aggressive interventions included intubation, mechanical ventilation, and that the receiving hospital may admit him to intensive care. Resident #53 signed the POST form on [DATE], and the physician signed it on [DATE]. Resident #53's [DATE] Physician Orders did not include his code status. Resident #53's care plan, dated [DATE], documented his code status was Full Code. A Nurse's Progress Note, dated [DATE] at 10:34 AM, documented, Resident [#53] passed today approx. (approximately) 0600 (6:00 AM). His body was released to mortuary per family. The Record of Death, dated [DATE] at 6:00 AM, documented Resident #53's principle cause of death was CHF and was signed by the primary care physician. On [DATE] at 5:00 PM, the Clinical Quality Specialist Nurse and DON were present during the interview. The DON stated Resident #53 passed away and the family was okay with his death. The DON stated the nurses should have documented their assessment of Resident #53. The DON reviewed Resident #53's POST form and stated she was not aware his code status was Full Code. The DON stated the facility did not initiate CPR for Resident #53. On [DATE] at 6:10 PM, LPN #4, who admitted Resident #53 to the facility on [DATE], stated she received verbal report on [DATE] at 6:00 AM from RN #2 Resident #53 had passed away. LPN #4 stated she was told by RN #2 that Resident #53's code status was DNR. LPN #4 stated she did not assess Resident #53 or look in his record to validate his code status. LPN #4 stated when she reviewed and filled out the POST form with Resident #53 on [DATE], he was adamant on being a Full Code. On [DATE] at 6:29 PM, RN #2 stated, on [DATE], she provided verbal report to LPN #4 when CNA #2 stated Resident #53 was gone. RN #2 stated she clarified what gone meant and her and LPN #4 went to Resident #53's room to assess him. RN #2 stated Resident #53 was pale, his eyes were halfway closed, and he had his arms by his side. RN #2 stated Resident #53 did not have an apical pulse and was not breathing. RN #2 stated she did not look in Resident #53's record for his code status and did not initiate CPR. On [DATE] at 8:35 AM, the Clinical Quality Specialist Nurse and DON were present during the interview. The DON verified she did not know Resident #53's code status was Full Code until she reviewed his POST form on [DATE] at 5:00 PM. On [DATE] at 9:29 AM, CNA #2 stated she found Resident #53 in bed on [DATE] at 6:15 AM, he was pale and there was no movement in his chest. CNA #2 stated she left the room to notify the nurses. CNA #2 stated she notified RN #2 and the day shift nurse, could not remember who it was, that Resident #53 appeared passed. CNA #2 stated both nurses went to Resident #53's room, and she assisted other residents. CNA #2 said she did not know what the nurses did from there. The facility licensed staff neglected to initiate CPR when Resident #53's wishes per his POST form and care plan documented Full Code. This failure may have resulted in his death.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and family and staff interview, it was determined the facility failed to initiate or conduct a thorough investigation of potential neglect for 1 of 1 resident (Resident #53) reviewed for death in the facility. When facility staff found Resident #53 unresponsive, CPR was not initiated, as directed in his POST form which documented his code status was Resuscitation/Full Code with aggressive interventions. The failure placed the other 52 residents at risk of not having their code status wishes honored if they were unable to communicate them. Findings include: Resident #53 was admitted to the facility on [DATE], with multiple diagnoses including congestive heart failure, falls with closed head injury, and current use of anticoagulant medication (blood thinner). Resident #53's hospital admission History and Physical, dated [DATE] at 3:42 AM, documented he his code status was Full Code and was electronically signed by a Nurse Practitioner. Resident #53's Initial Nursing Assessment, dated [DATE], documented he was alert and oriented to person, place, and time. The assessment also documented Resident #53's judgement and insight were intact. Resident #53's POST form, located in his facility record, documented Resuscitate (Full Code) with aggressive interventions for cardiopulmonary resuscitation in the event he did not have a pulse and/or was not breathing. The aggressive interventions included intubation, mechanical ventilation, and that the receiving hospital may admit him to intensive care. Resident #53 signed the POST form on [DATE], and the physician signed it on [DATE]. Resident #53's [DATE] Physician Orders did not include his code status. Resident #53's care plan, dated [DATE], documented his code status as Full Code. A Nurse's Progress Note, dated [DATE] at 10:34 AM, documented, Resident [#53] passed today approx. (approximately) 0600 (6:00 AM). His body was released to mortuary per family. The Record of Death, dated [DATE] at 6:00 AM, documented Resident #53's principle cause of death was CHF and was signed by the primary care physician. On [DATE] at 5:00 PM, the Clinical Quality Specialist Nurse and DON were present during the interview. The DON stated Resident #53 passed away and the family was okay with his death. The DON stated the nurses should have documented their assessment of Resident #53 when he was found unresponsive. The DON reviewed Resident #53's POST form and stated she was not aware his code status was Full Code. The DON stated the facility did not initiate CPR for Resident #53. The DON stated the coroner was notified for all deaths in the facility if the resident was not receiving hospice services. The DON stated the coroner did an investigation of Resident #53's cause of death and determined it was CHF not from the fall that happened on [DATE]. The DON said she was not aware she needed to do an investigation when the coroner did one. The Clinical Quality Specialist Nurse stated the facility should have initiated and completed an investigation into why CPR was not initiated for Resident #53 when his POST form documented his code status as Full Code. On [DATE] at 5:47 PM, Resident #53's son stated Resident #53 had a living will and he was a DNR (Do Not Resuscitate). The son stated he did not provide the living will to the facility and was unaware Resident #53's POST form documented his code status as Full Code with aggressive interventions. On [DATE] at 6:10 PM, LPN #4, who admitted Resident #53 to the facility on [DATE], stated she received a verbal report on [DATE] at 6:00 AM, from RN #2 that Resident #53 had passed away. LPN #4 stated she was told by RN #2 Resident #53's code status was DNR. LPN #4 stated she notified his son and he stated to her, to let him go. LPN #4 stated she did not assess Resident #53 or look in his record to validate his code status. LPN #4 stated she documented on Resident #53's neurological assessment flow sheet, Passed on [DATE] at 6:30 AM. LPN #4 stated when she reviewed and filled out the POST form with Resident #53, he was adamant on being a Full Code. On [DATE] at 6:29 PM, RN #2 stated on [DATE], she provided verbal report to LPN #4 when CNA #2 stated Resident #53 was gone. RN #2 stated she clarified what gone meant and her and LPN #4 went down to his room to assess him. RN #2 stated Resident #53 was pale, his eyes were halfway closed, and he had his arms by his side. RN #2 stated Resident #53 did not have an apical pulse and was not breathing. RN #2 stated she did not look in his chart for his code status and did not initiate CPR. RN #2 stated the last time she assessed Resident #53 was at 2:30 AM on [DATE] when she completed a neurological assessment from a fall he had on [DATE] at 3:00 AM. RN #2 documented on the neurological assessment Resident #53 was alert, pupils were equal and reactive to light, had equal hand grasps and was able to move all extremities. RN #2 stated the nursing staff were unable to obtain Resident #53's temperature. He was cool and clammy with a stable blood pressure, pulse, and respirations. RN #2 stated the facility's protocol was to notify the coroner for all residents' deaths if they were not on hospice services. RN #2 stated when the assistant coroner came to the facility to assess Resident #53's death, she requested his face sheet and POST form. RN #2 stated that was when she realized he was a Full Code and the assistant coroner went to talk with the son, who was in Resident #53's room. RN #2 stated the assistant coroner returned to the nurse's station and returned the POST form to RN #2 and stated to her that she did not need his POST form. RN #2 stated she notified via phone the DON on [DATE], regarding Resident #53 code status being Full Code per his POST form and the facility did not initiate CPR. RN #2 stated on [DATE], during the stand-up meeting, the DON instructed the LSW to review all the residents' charts to assure their Advance Directive and POST form matched. RN #2 stated nothing more was discussed or investigated regarding the death of Resident #53 or why CPR was not initiated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #7 was admitted to the facility on [DATE], with multiple diagnoses including breast cancer and hospice services. Resident #7's admission MDS assessment, dated 10/22/18, documented she was cognitively intact and at risk for pressure ulcers. Resident #7's care plan, dated 10/15/18, documented she was at risk for skin breakdown. Interventions in the care plan directed staff to assist with repositioning every two hours, observe skin condition with ADL care daily and report abnormalities, provide redistribution surfaces to chair and bed as per protocol, provide peri care/incontinence care as needed, float her heels while in bed with pillows, and complete weekly skin assessments by licensed nurse. ADL flowsheets for February 2019 documented Resident #7 was to be turned and repositioned every two hours as specified in her plan of care. There was no documentation Resident #7 was turned and repositioned for all shifts on 2/1/19, and for the day shift on 2/12/19. On 2/9/19, 2/18/19, and 2/27/19, for the day shift staff documented it was not applicable. On 2/13/19 and 2/14/19, for the evening shift staff documented it was not applicable. Resident #7's record included documentation of weekly skin checks. The weekly skin checks dated 2/1/19, 2/4/19, 2/11/19, 2/18/19, and 2/25/19, documented Resident #7 had no skin issues. The skin check, dated 3/4/19, documented there were no skin issues for Resident #7. On 3/6/19, two days later, the skin check documented she had a Stage II pressure ulcer on her coccyx (tailbone). According to the John Hopkins Medicine website, accessed 4/17/19, a Stage II pressure ulcer is partial thickness loss of skin which presents as a shallow open area with a red/pink wound bed, and may also present as an intact or open/ruptured fluid filled blister. An Incident and Accident Report, dated 3/6/19 at 10:00 AM, documented Resident #7 had developed a new in-house acquired Stage II pressure ulcer to the coccyx. A physician assessment, dated 3/6/19, documented Resident #7 developed a pressure injury to the right buttock as a result of immobility and reduced nutrition. Resident #7's TAR for March 2019 included a physician order, dated 3/6/19, for Z-guard (a skin protectant paste) to coccyx each day and night, and to discontinue when resolved. The Z-guard was not applied during the day shift on 3/9/19, 3/11/19, 3/19/19, 3/24/19, and 3/25/19. The Z-guard was not applied during the night shift on 3/12/19 and 3/18/19. An SBAR Communication Form, dated 3/6/19, documented Resident #7 had a 0.3cm x 0.3 cm open area which was non-blanchable and surrounded by blanching redness 7.5 cm x 4 cm x 0.2 cm entire area. The SBAR documented there was no drainage, the wound was intact, and no odor. The SBAR documented licensed staff were to apply a Z-guard twice daily and as needed until the wound resolved, and to notify the physician if it worsened. A skin integrity report, dated 3/6/19, documented Resident #7 had a Stage II pressure ulcer to her coccyx, which measured 0.3 cm x 0.3 cm and surrounded by non-blanching redness, 7.5 cm x 4 cm x 0.2 cm. On 3/25/19 at 2:52 PM, Resident #7 was observed sitting in her bed and she stated everything was fine and she was happy with her care. She stated she was well taken care of and had no concerns or issues with the care provided by the facility. Resident #7 stated the facility was taking care of her pressure ulcer. On 3/25/18 at 3:30 PM, RN #2, who was the wound nurse, stated she completed weekly skin checks, changed dressings and provided wound care on her assessments, which included wound measurements. RN #2 stated the nurses provided daily wound care. On 3/28/19 at 9:15 AM, RN #2 reviewed Resident #7's record and stated she completed a skin check assessment on Resident #7 on 3/4/19, and found no skin issues. RN#2 stated the hospice CNA found the pressure ulcer on her coccyx and reported it to her and the hospice nurse. RN #2 stated she assessed the wound and the hospice nurse assessed the wound. RN #2 stated she thought the pressure ulcer developed due to Resident #7 declining in health, not expressing her needs to staff, staff not recognizing the change in condition she had experienced during this time, and due to Resident #7 indicating her care was great. RN #2 stated Resident #7 did not request additional care and did not like to ask for help. On 3/28/19 at 11:20 AM, RN #2 stated the care plan did not get updated with the interventions for wound care for the pressure ulcer identified on 3/6/19. RN #2 stated the nurses should have been updating the care plans. RN #2 stated the facility was going to provide Resident #7 a pressure hybrid bed, and the bed was not ordered, care planned or put in place. RN #2 stated the facility had the bed in-house and did not know why the bed placement was not initiated. RN #2 stated she had additional wound care notes separate from the TAR. RN #2 stated she kept separate notes to make sure the TAR was readily available to staff. The additional notes were not provided for review. RN #2 stated Resident #7's pressure ulcer had improved. Based on observation, staff interview, record review, and policy review, it was determined the facility failed to prevent the development of avoidable pressure ulcers. This was true for 2 of 4 residents (#7 and #33) reviewed for pressure ulcers. Resident #33 was harmed when he developed an unstageable pressure ulcer to his left heel, sacrum, and a Stage II pressure ulcer to his left inner knee. Resident #7 was harmed when she developed a Stage II pressure ulcer to her right buttock. Findings include: The facility's Skin Integrity Management policy, revised 11/28/16, documented, The implementation of an individual patient's skin integrity management occurs within the care delivery process. Staff continually observes and monitors patients for changes and implements revisions to the plan of care as needed. The policy also included the following: * Identify patient's skin integrity status and need for prevention interventions or treatment modalities through review of all appropriate assessment information. * Develop comprehensive, interdisciplinary plan of care including prevention and wound treatments, as indicated. * Review co-morbid conditions that may affect healing. * Notify Dietitian and/or rehabilitation services as indicated. * Notify physician to obtain orders. * Notify patient, family, health care decision maker of plan of care. * Review care plan weekly and revise as indicated. * Document daily monitoring of ulcer site, with or without dressing. This policy was not followed. 1. Resident #33 was admitted to the facility on [DATE], with multiple diagnoses including a stroke with hemiplegia and hemiparesis (paralysis and weakness to one side of the body) affecting his right side. Resident #33's at risk for skin breakdown care plan, dated 9/17/14, included interventions for a Low Air Loss mattress with bolsters, pressure redistribution surfaces to chair, turn and re-position every 2 hours and as needed, float heels while in bed with pillows, observe skin conditions with ADL care, observe skin for signs/symptoms of skin breakdown, and weekly skin checks by the licensed nurse. A facility Guideline for the Low Air Loss mattress, undated, documented, Warning! Do not use as an intervention for heel ulcers. At risk and actual heel wounds should be off the bed surface (off-loaded using a pillow or heel-lift type of device). Resident #33's actual skin breakdown care plan, dated 11/13/18, included interventions for Sage boots (heel protectors) to be worn to bilateral lower extremities (BLE) while in bed. A Significant Change Braden Scale (a tool used to assess a resident's risk for developing pressure ulcers) assessment, dated 1/20/19, documented Resident #33 was at moderate risk for developing a pressure ulcer. Resident #33's annual MDS assessment, dated 2/19/19, documented he was severely cognitively impaired and required extensive assistance of two staff members for bed mobility and transfers. The MDS documented Resident #33 was at risk for pressure ulcers and had one unstageable pressure with slough (non-viable tissue due to reduced blood supply) and/or eschar (black, necrotic, dead tissue). According to the John Hopkins Medicine website, accessed on 4/17/19, an unstageable pressure ulcer is full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown in color) and/or eschar (tan, brown or black) in the wound bed. a. An SBAR (Situation, Background, Appearance, Review and Notify) Communication Form, dated 11/13/18, documented Resident #33 had an abrasion to his right ankle. Sage boots were initiated to BLE while he was in bed. An SBAR Communication Form, dated 11/21/18, documented Resident #33 had a persistent red area with measurements of 6.0 cm x 5.0 cm to his right heel. The form stated within the reddened area was an intact blister. The measurements of the blister were documented as 3.0 cm x 2.0 cm. The form documented licensed staff were to apply skin prep (a liquid which forms a protective film or barrier) to the wound and cover with a foam dressing. An Incident and Accident Report, dated 11/21/18 at 7:00 AM, documented a new in-house acquired pressure ulcer to Resident #33's right heel. A witness statement by a CNA documented she noticed a pressure ulcer to Resident #33's heel and notified the nurse. The statement did not identify which heel had the pressure ulcer. Resident #33's Weekly Skin Checks, dated 11/16/18 through 12/14/18, did not include documentation of the pressure ulcer to Resident #33's right heel which was identified on 11/21/18. Subsequent skin checks were as follows: - A Weekly Skin Check, dated 12/21/18, documented Resident #33 had a pressure ulcer to his right heel and left lower extremity (LLE). There was no documentation of measurements and/or a description of the appearances of the pressure ulcer to the right heel or the LLE. - The Weekly Skin Checks, dated 12/29/18 and 1/5/19, documented Resident #33 had a pressure ulcer to his right heel with no measurements or description of the appearance of the pressure ulcer. There was no documentation about the LLE pressure ulcer. - The Weekly Skin Checks, dated 1/13/19 and 1/19/19, documented Resident #33 had a pressure ulcer to his left heel, which was not previously identified in documentation, and the dressing was dry and intact. The skin checks did not include appearance or measurements of the pressure ulcer. There was no documentation of the right heel and the LLE pressure ulcers. The TAR's for Resident #33 for November 2018 to March 2019 documented the following: - Resident #33's November 2018 TAR, dated 11/20/18, documented licensed staff applied skin prep and a foam dressing to his right heel pressure ulcer every 3 days. The licensed staff were to ensure Sage boots were on Resident #33's BLE when he was in bed twice a day. - Resident #33's December 2018 TAR documented licensed staff were to ensure Sage boots were on Resident #33's BLE when he was in bed twice a day. The December 2018 TAR did not include documentation on 12/7/18, 12/11/18, 12/15/18, and 12/16/18 the Sage boots were on Resident #33 as directed. - Resident #33's December 2018 TAR documented licensed staff were to float heels with pillows while in bed every night shift. The December 2018 TAR did not include documentation Resident #33's heels were floated as directed on 12/7/18, 12/15/18, and 12/16/18. - Resident #33's January 2019 TAR included orders for licensed staff to apply Sage boots to BLE while in bed every night shift. The January 2019 TAR documented licensed staff were to float heels with pillows when in bed every night shift. The January 2019 TAR did not include documentation on 1/3/19, 1/8/19-1/11/19, 1/14/19-1/16/19, and 1/17/19, these were completed . - Resident #33's January 2019 TAR documented licensed staff were to apply skin prep and foam dressing to Resident #33's pressure ulcer to the left heel every 3 days. There was no documentation on 1/10/19, 1/13/19, 1/16/19, 1/19/19, 1/22/19, 1/25/19, 1/28/19, and 1/31/19, this was completed. - Resident #33's January 2019 TAR included a physician's order, dated 1/10/19 through 1/15/19, for licensed staff to apply a wet to dry dressing daily to his left heel. A physician's order, dated 1/16/19, stated licensed staff were to leave the dressing to the left foot clean, dry, and intact until his next podiatry appointment. - Resident #33's February 2019 TAR, dated 2/1/19 to 2/21/19, documented licensed staff were to leave the dressing to the left foot clean, dry, and intact. On 2/21/19, the TAR documented licensed staff were to change the dressing to his left heel twice a day using a wet to dry gauze and secure with Kerlix (cotton wrap). The February 2019 TAR did not include documentation the treatment was completed on 2/23/19, 2/24/19, and 2/28/19. A Physician's Order, dated 1/2/19, documented Resident #33 was referred to podiatry for care of the unstageable pressure ulcer to his left heel. The podiatry notes were as follows: - An initial assessment Podiatrist Progress Note, dated 1/9/19, documented Resident #33 had a Stage III pressure ulcer to his left heel. According to the John Hopkins Medicine website, accessed 4/17/19, a Stage III pressure ulcer is full thickness skin loss and slough may be present but does not obscure the depth of tissue loss and the ulcer may have undermining/tunneling. The measurements of the ulcer were 5.0 cm x 5.0 cm x 0.3 cm. The podiatrist documented the ulcer had a foul smell, slough, and drainage. The progress note documented Resident #33 was very contracted in his lower extremities and the facility recently applied heel boots for protection. The left heel pressure ulcer was debrided (removal of the dead tissue) to ensure adequate healing, reduce risk of infection, and improve overall health of the pressure ulcer. - A Podiatrist Progress Note, dated 1/16/19, documented Resident #33 had Methicillin-resistant Staphylococcus aureus (MRSA) in the left heel pressure ulcer and oral antibiotics were started. The left heel pressure ulcer measurements were 5.0 cm x 5.0 cm x 0.3 cm. The progress note documented the pressure ulcer had a foul smell, slough, and drainage with mushy eschar on part of the wound. - A Podiatrist Progress Note, dated 1/25/19, documented Resident #33 was going to continue with oral antibiotics for the infection to his left foot ulcer. The left heel wound measurements were 4.9 x 5.0 x 0.3 cm. The wound characteristics documented foul smell had improved some, slough, and drainage. - A Podiatrist Progress Note, dated 2/6/19, documented the left heel pressure ulcer measurement was 4.9 cm x 4.9 cm x 0.3 cm with the entire wound being covered with a dry eschar present, continued mushiness on the distal wound. A new superficial blister with intact skin underneath was present. The progress note documented the foul smell and the infection were improving and will continue with the antibiotics for another 14 days. - A Podiatrist Progress Note, dated 2/21/19, documented Resident #33 was supposed to have x-rays on 2/13/19 to his left heel. The Podiatrist stated the x-rays were not completed as ordered. The Podiatrist ordered the x-rays again to rule out a bone infection. The progress note documented the Podiatrist spoke to Resident #33's primary care physician to start IV antibiotics. Resident #33's record did not include IV antibiotics were initiated. - A Podiatrist Progress Note, dated 3/5/19, documented the left heel pressure ulcer had worsened. The measurements were 4.9 cm x 6.4 cm x 0.5 cm with improved odor. The wound base was covered with wet eschar and continued mushiness that was worsening and some purulent (fluid containing pus) drainage. - A Podiatrist Progress Note, dated 3/12/19, documented the left heel pressure ulcer was worse at every visit. The measurements were 5.5 cm x 7.3 cm x 1.5 cm. The podiatrist documented the foul odor was much worse on this visit with significant discolored drainage which was purulent in nature. The mushiness was worsening and the wound was deepening. The podiatrist documented he was going to notify Resident #33's primary care physician for a plan. The progress note documented the wound was worsening rapidly and he feared Resident #33 may get sepsis (bacterial infection in the bloodstream). The podiatrist referred Resident #33 to a vascular surgeon or orthopedic for possible below the knee amputation (BKA). - A Podiatrist Progress Note, dated 3/19/19, documented the left heel continued to worsen at every visit. The wound measurements are 5.8 cm x 7.8 cm x 1.7 cm, most of the wound was covered with a wet eschar. The progress note documented the podiatrist was still trying to reach Resident #33's primary care physician to refer him for a bone scan and a vascular surgeon or orthopedic surgeon for consult. On 3/25/19 at 3:30 PM, RN #1 and CNA #4 were observed wearing gowns and gloves, while RN #1 was providing wound care to Resident #33's left heel. RN #1 stated he had MRSA in his left heel. RN #1 stated Resident #33 had the pressure ulcer for quite a while. RN #1 was observed removing the dressing to Resident #33's left heel. RN #1 was attempting to remove the dressing to his left heel wound without success, then after several unsuccessful attempts, while Resident #33 was hollering out in pain and flinching his left leg in pain, she used wound cleanser to moisten the dried dressing, and then it removed easily from his wound. RN #1 applied two sprays of wound cleanser to the 4 x 4 clean gauze, applied it to his left heel, then applied dry 4 x 4 gauze over the moist gauze, then wrapped his left foot with Kerlix for security. RN #1 stated the dressing was not to be too moist for the wet to moist dressing. On 3/26/19 at 3:20 PM, the Wound Nurse/RN #2 was observed providing wound care to Resident #33's left heel. RN #2 removed the Kerlix dressing, then moistened the dirty 4 x 4 gauze from the wound bed to remove without Resident #33 experiencing pain. RN #2 removed her gloves, washed her hands, and applied a new pair of gloves. RN #2 described Resident #33's left heel wound as pale granulation, slough with moist eschar, and moderate serosanguineous drainage. The measurements were 6.0 x 8.5 x 1.0 cm. RN #2 stated Resident #33's left heel was debrided by a podiatrist back in January and continued with the same wet to dry dressing change and the wound became worse. On 3/27/19 at 1:20 PM, RN #2 stated Resident #33 developed a blister to his left heel, on 11/21/18, and the nurses were documenting that it was his right heel when it should have been his left heel. RN #2 stated the Sage boots were initiated on 11/13/18 when Resident #33 developed an abrasion to his right ankle. RN #2 stated the blanks in the TARs meant the treatment was not completed. RN #2 stated she was the Wound Care Nurse up to November 2018 and then was the ADON (Assistant Director of Nursing) and the facility identified in February 2019 residents' were developing facility acquired pressure ulcers and was switched back to the Wound Care Nurse in March 2019. RN #2 stated the floor nurses were responsible for the wound care and the weekly skin checks. RN #2 stated she did the weekly skin assessments and measurements. RN #2 stated Resident #33's unstageable pressure ulcer to his left heel was facility acquired and should have been prevented. b. A Weekly Skin Check, dated 1/13/19 and 1/19/19, documented Resident #33 had a moisture associated skin damage to his sacrum. There were no measurements documented or a description of the appearance of the skin damage to Resident #33's sacrum. A Weekly Skin Check, dated 2/3/19, documented Resident #33 had moisture associated skin damage with blanchable redness to his sacrum. There were no measurements documented. A Weekly Skin Check, dated 2/22/19, documented Resident #33 had an open area to his sacrum. There were no measurements documented or a description of the appearance of the open area. A Weekly Skin Check, dated 3/1/19, documented Resident #33 had a pressure ulcer to his sacrum. There were no measurements documented or description of the appearance of the pressure ulcer. A Weekly Skin Check, dated 3/8/19, documented Resident #33 had an open area to his sacral area. There were no measurements documented or description of the appearance of the open area. A Skin Integrity Report for Resident #33 was initiated on 1/28/19 to his sacrum. The report documented the appearance was 100% epithelial (ex. stg 2), measured 2.0 cm x 3.0 cm, and with minimal serous drainage. A physician's order, dated 3/15/19, documented the licensed staff were to cleanse the coccyx with wound cleanser, pat dry, apply anti-microbial gel (debridement to infected tissue), and cover with a dry dressing every day. On 3/26/19 at 3:33 PM, RN #2 was observed providing wound care to Resident #33's sacrum. RN #2 stated the wound bed measured 4.0 x 2.5 cm and was covered with slough. RN #2 stated the sacrum wound was unstageable due to the slough in the wound and worsened in size and description. c. An SBAR, dated 3/18/19, documented redness to Resident #33's left inner knee with measurements of 0.5 cm x 0.5 cm. On 3/25/19 at 3:40 PM, RN #1 stated Resident #33 developed a pressure ulcer to his left inner knee caused by putting pressure on his right inner knee. CNA #4 was observed applying a pillow between Resident #33's knees. CNA #4 stated after Resident #33 developed the pressure ulcer he had been applying a pillow between his knees. A physician's order, dated 3/25/19, documented cleanse left inner knee with wound cleanser, pat dry, apply silvasorb (antimicrobial gel) to the wound bed, apply skin prep to peri-wound, and cover with a dry dressing every 3 days for an unstageable pressure ulcer. A Nurse's Progress Note, dated 3/26/19 at 6:53 PM, documented Resident #33 had a 3.0 cm x 2.0 cm open area with black coloring to 75% of the wound bed/edges. Resident #33's care plan did not include licensed staff were to place a pillow between his knees. On 3/27/19 at 1:42 PM, RN #2 stated Resident #33 developed the unstageable pressure ulcer to his left knee was caused by the Sage boots being poofy, which positioned his knees together and that added more pressure. On 3/28/19 at 10:06 AM, the DON stated Resident #33's care plan did not include nursing staff were to place a pillow between his knees to prevent further breakdown.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, policy review, and record review, it was determined the facility failed to ensure residents' pain levels were assessed and treated prior to wound care. This was true for 1 of 3 residents (Resident #33) reviewed for pain management. Resident #33 was harmed when he experienced increased pain during a dressing change and the facility did not identify and treat it. Findings include: The facility's Pain Management policy, dated 3/1/18, documented nursing staff to maintain the highest possible level of comfort for patients by providing a system to identify, assess, treat, and evaluate pain. An individualized care plan will be developed and address and treat underlying causes of pain and using specific strategies for preventing or minimizing different levels or sources of pain or pain related symptoms. Resident #33 was admitted to the facility on [DATE], with multiple diagnoses including a stroke with hemiplegia and hemiparesis (paralysis and weakness to one side of the body) affecting his right side. Resident #33's skin breakdown care plan, dated 10/29/18, documented licensed staff were to monitor for verbal and nonverbal signs of pain related to wound or wound treatment and medicate him as ordered. A physician's order, dated 2/21/19, documented Resident #33 received a Fentanyl patch 12 mcg/hr apply 1 patch every 3 days; Tylenol 325 mg two tablets every 4 hours as needed for mild pain; and Norco 5/325 mg 1 or 2 tablets every 6 hours as needed for moderate or severe pain. On 3/25/18 at 3:30 PM, RN #1 was observed providing wound care to Resident #33's open area to his left heel. Resident #33 hollered out in pain and was flinching his left leg in pain during the removal of the dressing. RN #1 was attempting to remove the dried dressing by tugging on the dressing while it was stuck to the open wound. RN #1 stated to Resident #33 she would provide a pain pill after the wound care was completed. RN #1 stated she administered pain medication prior to the wound care. RN #1 continued to remove the dried dressing without success, while Resident #33 was hollering and flinching his left leg in pain and she did not stop the procedure to relieve the pain. Resident #33's March 2018 MAR, documented Resident #33 received a Fentanyl patch of 12 mcg/hr on 3/23/19 and it was due to be changed on 3/26/19. Resident #33's MAR did not include documentation he received the as needed Tylenol or Norco on 3/25/19. Resident #33's Narcotic Count Sheet for Norco 5/325 mg did not include documentation Resident #33 received Norco as needed pain medication on 3/25/19. On 3/26/19 at 3:20 PM, RN #2 stated Resident #33 should receive pain medication 30 to 45 minutes prior to the dressing change. On 3/28/19 at 9:09 AM, the DON stated there was no documentation in Resident #33's record that he received as need pain medication on 3/25/19. The DON stated RN #1 should have administered pain medication prior to the dressing change and should have stopped when he was hollering out in pain. Resident #33 was harmed when the facility failed to administer pain medication prior to a dressing change or stop the dressing change when he hollered out in pain.