**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident and staff interviews, and facility policy review, the facility failed to prevent the development of a pressure ulcer for 1 of 3 (Resident #1) residents reviewed. The resident was admitted with one Stage IV pressure ulcer, having comorbidities which made her susceptible to further impaired skin integrity. The facility failed to provide recommended every 2 hour repositioning, and failed to do all ordered skin treatments. This failure resulted in Immediate Jeopardy to the health and safety of the resident when she developed a second stage IV pressure ulcer, which required multiple antibiotics and medical intervention during a hospital. The facility reported a census of 119 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) on 8/17/24 at 4:05 pm. The IJ began on June 9, 2024. Facility staff removed the Immediate Jeopardy on 8/18/24 through the following actions: -Skin assessments conducted on all residents with active wounds, and reviewed and revised treatments orders as necessary -Braden scale assessments (an assessment to predict pressure ulcer risk) conducted on all residents -Policies regarding Pressure Injury Prevention and Turn/Repositioning reviewed and updated as needed -Education provided to all nursing staff of policies and procedures related to skin/wound care, turning and repositioning -Audits put in place to be completed 5 days a week to ensure accurate and complete documentation of skin related treatments -Audits put in place to be completed on 3 residents per week for observation of treatments, preventative skin care and weekly skin assessments -A QAPI (Quality Assurance Performance Improvement) action plan was initiated The scope lowered from J to D at the time of the survey after ensuring the facility implemented the education, audits and their policy and procedures. Findings include: Determining the Stage of Pressure Injury: Stage 1 Pressure Injury: Non-blanchable erythema of intact skin Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. The Minimum Data Set (MDS) dated [DATE] of Resident #1 identified a Brief Interview of Mental Status (BIMS) score of 15 which indicated cognition intact. The MDS revealed the resident to be dependent on rolling side to side and chair/bed-to-chair transfers. The MDS coded the presence of an indwelling catheter. The MDS reflected the resident always incontinent of bowel. The MDS documented diagnoses that included: Diabetes Mellitus, paraplegia and spinal stenosis. The MDS revealed the resident had one Stage IV pressure ulcer, which had been present upon admission to the facility. The MDS additionally revealed the resident to have Moisture Associated Skin Damage. The MDS documented that resident admission date to the facility as 9/15/2023. The Comprehensive Care Plan of Resident #1, initiated 9/20/23, identified a Focus Area of Skin Breakdown, dated 9/26/23. The Care Plan directed staff to encourage the resident to turn side to side when in bed to decrease pressure, dated 9/26/23. The Care Plan failed to direct staff of a turning/repositioning schedule. The Care Plan failed to document that the Skin Breakdown Focus Area had been updated since 2023. The Focus Area ADL (Activities of Daily Living) self-care performance deficit, dated 9/26/23 directed the resident required 2 staff members to reposition and turn in bed, dated 9/26/23. The Care Plan failed to document the resident to be non-compliant with repositioning. The Nurse's Note dated 6/9/24 at 12:15 p.m. revealed multiple abrasions were noted on the resident's tailbone with small amounts of bleeding. An order was received for topical wound care. The Encounter note dated 6/10/24 at midnight by the house Nurse Practitioner documented the resident to have a wound on her buttocks and stated the resident was seen by and cared for by a wound care provider once a week. She documented the resident does not turn in bed without staff assistance. The resident complained of increased pain from a wound on her buttocks. The Nurse's Note dated 6/10/24 at 2:58 p.m. documented ensure (a protein drink) ordered with meals for wound healing due to the resident refusing liquacel (a high protein supplement). A Skin/Wound Note dated 6/11/24 at 6:13 p.m. documented an open area to the sacrum with a small amount of serosanguinous (a mixture of blood and serum [the liquid part of blood]) drainage noted. It stated the surrounding skin to have blanchable erythema. The Wound Evaluation and Management Summary dated 6/11/24 documented the initial evaluation of a non-pressure wound to the sacrum. The Wound Advanced Registered Nurse Practitioner (ARNP) ordered alginate calcium with a gauze bordered dressing for 30 days. (Alginate is used for wounds with exudate). The Treatment Administration Record (TAR) for June of 2024 revealed the above order was implemented as ordered, documented as being done June 12th through June 16th, 2024. It was discontinued on June 17th, 2024. The Order Audit Report documented the order was discontinued on 6/17/24 by Staff A, Registered Nurse (RN) at 3:47 am. The reason was documented as New Order Received. The Progress Notes failed to document any new orders received on 6/16/24 or 6/17/24. The TAR failed to document any treatment being completed on the sacrum between June 16th and June 21st when a new order was received. The TAR for June of 2024 showed the calcium alginate order with gauze was re-started on 6/21/24 and documented as completed through 6/25/24. On 6/25/24 a new order was given to apply alginate calcium and Santyl (an ointment used to remove damaged tissue from chronic pressure ulcers or burns) and to continue the use of the bordered dressing. There were no wound treatments for the sacral wound documented as being completed 6/17/24 - 6/20/24 or on 6/26/24. The Skin & Wound Evaluation dated 6/18/24 documented the resident to have a new unstageable pressure ulcer, 1 week old, house acquired, which was described as 100% of the wound being filled with eschar (dead tissue which forms over wounds). Per the definition of pressure injuries, eschar is not present until the injury reaches at least a Stage 3 Pressure Injury. The Wound Evaluation and Management Summary dated 6/18/24 documented the sacrum wound to be 4 x 3 x 0.1 cm, listed as moisture associated skin damage and repeated the orders from the prior week of alginate calcium and a gauze island bordered dressing daily. The Wound Evaluation and Management Summary dated 6/25/24 documented the sacrum wound to be 7 x 3 x 0.1 cm. The wound progress was documented as exacerbated due to the patient not offloading as she should and not telling the aides when she is wet. An order was placed to continue the same treatment, but to add Santyl as part of the treatment. (Santyl is an ointment used to remove damaged tissue from chronic skin ulcers, or debriding of a wound). The Wound ARNP did not see the resident again after 6/25/24 until 7/16/24. The Skin and Wound Evaluation dated 7/2/24 documented the sacral wound as being Moisture Associated Skin Damage, house acquired, with measurements documented 9 x 7 x 0.2 cm. The Evaluation documented the wound was 10% filled with granulation and 90% filled with eschar. Additional documentation included a moderate amount of serous exudate, and attached wound edges. The Evaluation documented Provider recommended off-loading the wound and letting staff know when soiled, nursing staff educated on making sure resident's briefs are changed frequently throughout the day. On 8/15/24 at 3:32 pm, the Wound ARNP stated when she saw the wound on 6/25/24 the wound was not a pressure injury. She stated it may have worsened after she saw it prior to admitting to the hospital. She stated the resident can assist in repositioning but is unable to turn herself in bed without staff assistance. The Point of Care charting portion of the resident's record, where the Certified Nurse Aides (CNA) document cares, revealed the section of Rolling left and Right was to be documented 3 times a day (once a shift), every day, for the month of June. The documentation was left blank 17 times during the month of June. The Point of Care charting revealed the section of Skin: Turn and Reposition at least every 2 hours was also left blank 17 times during the month of June. On 8/15/24 at 4:12 pm, the Director of Nursing (DON) stated the CNAs only chart in Point of Care. She stated there is nowhere else the turning is documented to show it is being done. She also stated the resident does not comply with repositioning all of the time. On 8/15/24 at 4:30 pm, Staff B, Registered Nurse (RN), acting in house wound nurse, stated he was not familiar with the wound prior to the resident's hospitalization. He stated he only saw it after she returned from the hospital. He stated based on the description in the Skin and Wound assessment, the wound did not sound like it was Moisture Associated Skin Damage. He stated at times MASD can break down further and lead to pressure ulcers. The Encounter Note dated 7/5/24 by the facility ARNP documented an acute visit was made due to labs showing an elevated white blood cell count (an indication of infection) and a urinalysis which indicated a need for a culture to be done. The WBC count was 20.9 (normal range 4.5 - 11). The resident's blood pressure was slightly low and heart rate was 99. The note documented a concern of sepsis (a serious condition in which the body responds improperly to an infection). The ARNP recommended the resident be sent to the Emergency Department for further evaluation. The records from the acute care hospital documented upon arrival to the Emergency Department, the resident had a WBC count of 23.4 and a C-reactive protein of 27.2 (an indication of inflammation in the body). The Patient Active Problem list identified: - Pressure ulcer of the left ischium, Stage 4 - Pressure injury of sacral region, Stage 4 - Incomplete paraplegia - Diabetes Mellitus, type 2 - Degenerative arthritis of the spine - Lumbosacral spondylosis without myelopathy - Acquired kyphosis - Status post cervical spinal fusion - Lumbar radiculopathy- Lumbar spinal stenosis (all comorbidities which could put the resident at a higher risk of impaired skin integrity). The Computed Tomography (CT) scan dated 7/5/24 documented the pressure ulcers and chronic osteomyelitis of the coccyx (a long-term bone infection which can develop, be treated and return). The CT also showed subcutaneous emphysema (development of air under the skin which may indicate deeper pathological issues). The History and Physical documented a prior history of multiple decubitus ulcers, with admission diagnoses of sepsis secondary to cellulitis and chronic osteomyelitis associated with a large decubitus ulcer. The resident was referred to plastic surgery for wound debridement and was treated with multiple antibiotics. The note stated the resident also had rhinovirus (the common cold) and a UTI which was noted to be another possible source of infection. The resident was discharged from the hospital on 7/15/24, listed in stable condition with wound care orders in place for ischium and sacrum pressure ulcers to be done twice daily. The Wound ARNP visited the resident on 7/16/24 and wrote orders to initiate a wound vac for the pressure ulcers (a vacuum-assisted device used for closure of a wound). On 7/22/24 the Director of Nursing (DON) documented a Nurse's Note that stated the orders that were received on 7/16/24 were being initiated on this date (7/22/24). The note documented the wound practitioner and the spouse of the resident were informed of the late initiation of orders. On 8/17/24 at 10:09 am, Staff C, Licensed Practical Nurse (LPN) stated she had worked with Resident #1 often since beginning employment greater than 6 months ago. She stated the sacral wound was open and she would have considered it a pressure injury, not Moisture Associated Skin Damage. On 8/17/24 at 10:55 am, the Wound ARNP verified wound #1 in her weekly wound charting is referring to the resident's initial pressure ulcer that was present on admission. This pressure ulcer is on her left ischium (the curved bone forming the base of each half of the pelvis). Her notes document this wound as being on her coccyx (tail bone). She stated she considers the buttocks, the coccyx and the ischium to all be basically the same spot. The resident's skin was observed on 8/17/24 at 11:40 am. The wound vac was in place and running as ordered, with the sponges covering two wounds on the left ischium and on the sacral area. On 8/17/24 at 1:22 pm, the DON stated the Wound ARNP comes every Tuesday. She stated the in house wound nurse had been working overnight shifts covering the floor, so Staff B, RN had been acting as the in house wound nurse to assist. She stated each week when the Wound ARNP comes she (the DON) prefers to discuss all of the wounds with the in house wound nurse. She stated it had been very busy and there had not been a discussion of the wound orders from 7/16/22. She said on 7/22/24, she asked to have a conversation with Staff B about the wounds and at that time he informed her he had not implemented any of the orders received that on 7/16/24. He stated he had been busy all week and had not had a chance to place the order in the Electronic Health Records of the residents. She stated there were orders for 4 residents. She stated she immediately contacted the wound vac supplier and it was delivered the following day. On 8/18/24 at 8:25 am, Resident #1 stated she is supposed to be supported by a pillow on one side of her body, and then the pillow is supposed to be switched to the other side of her body every couple of hours. She stated that sometimes it happens on time and sometimes it takes a long time to get somebody. She stated she thinks part of the reason it takes a long time is the staff thinks it takes two people to reposition her but she feels if the staff know how to do it, it can be done with one person. She stated at that moment, she was lying on her back with no pillows under her. She stated she was not sure how long it had been since anyone had been in to reposition her. She said occasionally she has a staff member who will stick to the schedule and let her know exactly when they will be back to reposition again, but she considers it rare when staff follow through. On 8/18/24 at 8:37 am, Staff C, LPN stated Resident #1 prefers to be on her back during meals. But with encouragement she will reposition. She stated she has never had the resident refuse to reposition during times she has cared for her. On 8/18/24 at 8:41 am, Staff D, CNA stated the resident occasionally says no when she is asked about repositioning. On 8/18/24 at 8:46 am, Staff E, CNA stated at times when she offers to reposition Resident #1, the resident will tell her she is ok for now. She stated she can ring her call light when she wants repositioned. She stated if the resident refuses repositioning, it should be charted in Point of Care as refused. On 8/18/24 at 9:05 am, Staff F, Certified Medication Aide (CMA) stated Resident #1 is to be turned side to side only. He stated Resident #1 has never refused repositioning when he has worked with her. On 8/18/24 at 9:09 am, Staff G, RN, stated she works all over the building but is familiar with Resident #1. She stated to turn the resident and prop a pillow, it can be done with one staff member but she generally also needs to be boosted up in bed which requires 2 staff members. She stated the resident is fully alert and oriented and she has never refused cares for her. She stated the resident will ring her call light and also request to be turned at times. The undated facility policy Turning and Repositioning documented It is our policy to implement turning and repositioning as part of our systematic approach to pressure injury prevention and management. This policy establishes responsibilities and protocols for turning and repositioning. The Policy Explanation and Compliance Guidelines documented: Repositioning will be documented in the resident's plan of care, and will be determined by the resident assessment which may include Braden Scale for predicting Pressure Sore Risk and/or like assessment as determined by the facility. The facility policy Pressure Injury Prevention and Management, review date 10/22/22 documented This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. Point 2: The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. Point 4d. -Evidence-based treatments in accordance with current standards of practice will be provided for all residents who have a pressure injury present. -i. Pressure injuries will be differentiated from non-pressure injuries, such as arterial, venous diabetic, moisture or incontinence related skin damage. -ii. Treatment decisions will be based on the characteristics of the wound, including the stage, size, exudate (if present), presence of pain, signs of infection, wound bed, wound edge and surrounding tissue characteristics.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews, provider interviews and facility policy review the facility failed to provide skin assessments per policy and provide treatments per physician's orders to prevent the development and worsening of a facility acquired pressure ulcer which required the physician to complete a debridement of a Stage IV pressure ulcer to the coccyx for 1 of 3 residents (Resident #11) reviewed for pressure ulcers. There was an immediate need for the facility to take steps to ensure residents were protected from risk of development or worsening of wounds. The facility reported a census of 110 residents. On February 22, 2024 at 3:05 PM, the State Survey Agency informed the facility of the staff's failure to assess and provide treatments per physician's orders created an Immediate Jeopardy situation resulting in the development of a Stage IV pressure ulcer as discovered on February 14, 2024. The facility staff removed the immediacy on February 23, 2024 at 1:37 PM when the staff implemented the following Corrective Actions: The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. (Completion Date: 16 [DATE]) a) The Director of Nursing (DON) and designee(s) conducted skin assessments on all residents. Concerns were not identified. b) An audit was conducted to ensure all treatments, supplies, and equipment were readily available for ordered wound treatments by Nursing Supervisors and designee(s). c) A medical records review was completed on all residents by Nursing Supervisors and designee(s) to ensure weekly skin assessments were completed and treatment recommendations/orders were in place. The facility took the following actions to prevent an adverse outcome from reoccurring: (Completion Date: 22 [DATE]) a) The facility policies on Skin Assessment and Pressure Injury Prevention and Management were reviewed and revised as needed. b) An audit of all pressure relieving devices and support surfaces was conducted by the Nursing Supervisor(s) to ensure proper use. c) The DON or designee provided education to all licensed nurses on facility policies and procedures related to skin/wound care, as well as appropriate wound treatment measures. This included ensuring residents had necessary support surfaces and pressure relieving devices. d) The DON or designee educated all nurse aides on preventative skin care. e) The DON or designee conducted treatment record and nursing documentation audits 5 days a week to ensure accurate and complete documentation of skin related treatments and preventative measures. f)The DON or designee will continue to monitor/audit 3 residents each week for the following: 1)Observation of treatments 2)Preventative skin care 3)Weekly skin assessments g) A QAPI PIP has been initiated to report on the above monitoring and auditing procedures. All findings from the PIP will be presented at the monthly The scope lowered from a J to a D at the time of the survey after ensuring the facility implemented education, their policy and procedures. Findings include: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue). may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound bed. Other staging considerations include: Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (unstageable, stage 3, or stage 4). Do not use DTI to describe vascular, traumatic, neuropathic, or dermatologic conditions. The admission Minimum Data Set (MDS) assessment tool with a reference date of 12/11/23 documented Resident #11 had a Brief Interview of Mental Status (BIMS) score of 9. A BIMS score of 9 suggested she had mild cognitive impairment. An admission date was documented at 12/7/2023. Resident #11 did not exhibit rejection of care during the 7-day review period. The MDS indicated Resident #11 was at risk for the development of pressure ulcers/injuries and had no unhealed pressure ulcers/injuries. Resident #11 had moisture associated skin damage (MASD), had a pressure reducing device for her chair and bed, was not on a turning/repositioning program, did not utilize nutrition or hydration interventions to manage skin problems and had ointments/medication other than to her feet. The MDS documented her weight in pounds was 327 and was 64 inches tall. The following diagnoses were listed: stroke, cancer, diabetes mellitus, hemiplegia, seizure disorder, anxiety, morbid obesity, and body mass index (BMI) 50.0-59.9. The discharge-return anticipated MDS assessment tool with a reference date of 2/16/24 documented Resident #11 had severely impaired cognitive skills for daily decision making. She did not exhibit rejection of care during the 7-day review period. She was dependent on staff for toileting hygiene, showering, dressing, chair/bed to chair transfer. The MDS documented she had an unhealed stage 4 pressure ulcer/injury that was not present upon admission. The active diagnoses portion of the Electronic Health Record (EHR) of Resident #11 documented diagnoses of: hemiplegia (paralysis of one side of the body) affecting left dominant side, muscle weakness, reduced mobility, need for assistance with personal care, seizures, malignant neoplasm of endometrium, anxiety disorder, atrial fibrillation, lymphedema, morbid obesity, obstructive sleep apnea, BMI 50-59.9, spinal stenosis, type 2 diabetes mellitus, vitamin D deficiency, cerebral infarction due to thrombosis of right cerebellar artery. The Baseline Care Plan for Resident #11 dated 12/7/2023 documented the following skin integrity issues: slight redness to groin, abdominal folds, and groin. Her bilateral lower extremities and feet dry and scaly. The Comprehensive Care Plan of Resident #11 initiated 12/13/2023, identified a Focus Area of an Activities of Daily Living (ADL) self care performances deficit related to hemiplegia, impaired balance, limited range of motion and stroke. The Care Plan indicated she required two staff members to reposition and turn in bed. Staff directed to use a mechanical lift for transferring and two staff members. She is totally dependent on staff for bathing and toileting. A second Focus Area documented she is at risk for skin breakdown due to diabetes, immobility, and incontinence. Staff directed to administer treatments as ordered and monitor for effectiveness. Staff also encouraged to follow facility protocols for prevention/treatment of skin breakdown. The care plan documented she had a pressure reducing cushion in her chair and mattress on her bed. A Focus Area with an initiated date of 2/18/24 documented she had a stage IV pressure ulcer to her coccyx. Staff directed to measure length, width, and depth where possible. Assess and document the status of wound perimeter, wound bed and healing progress and report improvements and declines to the physician. Staff to consult the wound specialist as ordered and his physician will see her in the facility. Staff to encourage frequent repositioning. Resident #11 will require supplemental protein, amino acids vitamins, minerals as ordered to promote wound healing. While completing dressing changes staff to monitor the wound for signs and symptoms of infection/worsening (redness, increased pain/tenderness/drainage, edema, warmth). Resident #11 had a low air loss mattress placed. The following Braden scales for predicting pressure sore risk completed as following: -On 12/7/23 at 7:37 PM documented a score of 13, indicating Resident #11 was at moderate risk for developing pressure sores -On 2/14/24 at 10:00 PM documented a score of 13, indicating resident #11 was at moderate risk for developing pressure sores -On 2/15/24 at 1:01 PM documented a score of 10, indicating Resident #11 was at high risk for developing pressure sores The admission assessment dated [DATE] at 5:21 PM documented slight redness to abdominal folds, bottom and groin with treatment in place. Bilateral lower extremities and feet dry and scaly. The admission Skin One Time Observation Tool dated 12/7/23 at 7:39 PM documented the following impaired skin areas: slight redness to her groin, abdominal folds and bottom; bilateral lower extremities and feet dry and scaly. The total body skin assessments completed on 12/22/23, 12/29/23, 1/5/24, 1/9/24, 1/12/24, 1/19/24, 1/26/24, and 2/2/24 documented 0 when asked to enter the # of new wounds. The plan of care response history review completed on 1/29/24, 2/4/24, 2/5/24, 2/6/24, 2/7/24, 2/8/24, 2/11/24, 2/12/24, 2/13/24, and 2/15/24 instructed staff to complete skin observations and notify the nurse immediately of any new areas of skin breakdown: redness, blisters, bruises, discoloration noted during bath or daily care. Staff documented yes when asked if an observation of resident's skin completed. The Skin and Wound Evaluation dated 2/15/24 at 9:21 AM documented it was still in progress. The evaluation documented Resident #11 had a new Stage III: full-thickness skin loss, pressure ulcer on her intergluteal cleft (butt crack) that was acquired in-house with the following measurements 43.9 centimeters (cm) x 10.2 cm x 6.9 cm. The depth, undermining, and tunneling were not applicable. Review of Resident #11 orders revealed the following order with a start date of 12/7/23 and end date of 2/15/23: cleanse resident's buttocks with soap and water, apply a layer of Z-guard paste every shift for skin integrity. The paste is to be applied during the day, evening and night shifts. Review of the December 2023 Treatment Administration Record (TAR) revealed the order not signed out as being completed on: a. 12/10/23 day shift b. 12/13/23 night shift c. 12/15/23 day and evening shifts d. 12/16/23 evening shift e. 12/17/23 day shift f. 12/20/23 day shift g. 12/21/23 day shift h. 12/22/23 day shift i. 12/26/23 day, evening and night shifts j. 12/27/23 night shift k. 12/28/23 day shift l. 12/29/23 evening shift m. 12/30/23 evening and night shifts Review of the January 2024 TAR revealed the order not signed out as being completed on: a. 1/2/24 evening shift b. 1/3/24 day shift c. 1/4/24 day and evening shifts d. 1/5/24 day and evening shifts e. 1/9/24 day and evening shifts f. 1/12/24 day shift g. 1/13/24 evening shifts h. 1/15/24 day shift i. 1/16/24 evening shift j. 1/18/24 evening shift k. 1/19/24 evening shift l. 1/20/24 day shift m. 1/22/24 day shift n. 1/23/24 day shift o. 1/26/24 evening shift Review of the February 2024 TAR revealed the order not signed out as being completed on: a. 2/14/24 night shift The Occupational Therapy (OT) Discharge Summary with a date of service of 12/8/23-1/4/24 documented an Assessment and Summary of Skilled Services: trialed multiple interventions to promote out of bed activity. Resident able to tolerate an average of 15 minutes of sitting in her wheelchair before requesting to go back to bed. Trialed sitting unsupported, averaging about 5 minutes of sitting with minimum to moderate assistance. Resident dependent with peri cares and toileting due to inability to tolerate out of bed activity. Discharge Recommendations and Status: recommend 15-20 minutes of sitting in wheelchair with the use of the mechanical lift to transfer. The Physical Therapy (PT) Discharge Summary with a date of service of 12/8/23-1/4/24 documented a Discharge Recommendations and Status: resident requires assistance for all ADL's and is dependent on staff for all functional mobility to prevent skin breakdown. The Progress Notes documented the following: a) On 2/14/24 at 10:00 PM the charge nurse called asking this nurse to come to Resident #11's hall right away. The charge nurse for unit stated that she had a skin issue she would like for this nurse to look at. They entered the resident's room and two Certified Nursing Assistants (CNAs) were present providing peri cares to resident. Resident turned on her left side. Charge nurse stated that she would like for this nurse to see resident's bottom. This nurse assessed peri-rectal area. Resident had a pressure area the size of a baseball with undetermined depth/tunneling to coccyx site. Edges are irregular and macerated. Wound bed with dark red, black tissue present. Serosanguinous (bloody drainage) drainage noted to site with other areas of excoriation surrounding wound. Current treatment regimen that has been in place to site since admission is Z-guard ointment to site. Z-guard treatment discontinued as it was no longer effective for deteriorated site. Treatment initiated as follows to coccyx: (1) cleanse site; (2) apply skin prep to intact skin surrounding site; (3) pack wound with saline soaked gauze; (4) cover with protective dressing every shift and as needed (PRN). Order written to have wound assessed/followed by the physician who will be in house tomorrow. Resident not on an air mattress and will need one due to the wound. Staff educated that resident is to be turned and repositioned frequently off-loading off of bottom as much as possible and is also to be checked and changed frequently. Resident incontinent of urine and consideration may need to be suggested for a Foley catheter placement for wound management. Note left for Accredidated Registered Nurse Practitioner (ARNP) regarding area who will be in house on rounds tomorrow. Attempted to notify emergency contact with no answer. Message left requesting returned call to facility. Will continue to monitor for any change in status. b) E-signed by ARNP on 2/15/24 at 3:22 PM notified by nursing this morning of newly discovered wound to resident's coccyx. On assessment she has a decubitus ulcer, stage 3 to intergluteal cleft. Gauze packing present with gauze covering dressing. Wound with mild serosanguinous drainage. Second open more superficial wound to about 4:00. Peri wound with redness to deep purple discoloration. Wound is painful to resident with dressing change. Orders left in facility for dressing changes. Resident is incontinent of urine, order given for Foley catheter for wound care. Consult placed for physician for wound care. She is planning to see resident tomorrow morning. Date wound was identified 2/15/24 on her coccyx, stage 3, measured at 10.17 cm x 6.94cm, 3.08cm x 1.76cm with moderate amount of serosanguinous drainage, no odor. Orders left in facility for: wet to dry dressing pack with gauze soaked in Dakins (clean infected wounds) solution. Cover with boarder Mepilex (absorbent foam dressing). Change BID. Skin prep to peri wound. Insert Foley catheter for wound care, liquicel (liquid protein) twice a day (BID), consult dietician for nutritional support for wound healing, consult Doctor of Osteopathic medicine (DO) for continuing wound care, complete blood count (CBC) with differential, sedimentation rate (look for inflammation in body), basic metabolic panel (BMP) today, air mattress, and frequent repositioning of patient. c) On 2/16/24 11:07 AM resident seen by DO today for an assessment of her coccyx wound, wound debrided during today's visit. Wound measured 14cm x 13cm x 3.5cm, moderate serosanguinous drainage noted, noted redness to surrounding skin area, resident tolerated procedure well, no complaints of pain, treatment orders in place, family updated and plan of care ongoing. An Initial Wound Evaluation and Management Summary dated 2/16/24 documented by DO. The following was documented: resident present with a wound on her coccyx. At the request of the referring provider a thorough wound care assessment and evaluation performed today. Focused wound exam (site 1): stage 4 pressure wound that measured 14 cm x 13 x 3.5cm with a surface area of 182cm. There was moderate serosanguinous drainage with 70% thick adherent devitalized necrotic tissue, 20% slough and 10% other viable tissue (muscle, bone). Site 1 Surgical Excisional Debridement Procedure: to remove necrotic tissue. The wound cleansed with normal saline and anesthesia achieved using topical benzocaine. Then with clean surgical technique, 15 blade, pick-ups used to surgically excise 36.4cm of devitalized tissue and necrotic periosteum and bone along with slough and biofilm were removed at a depth of 4 cm and healthy bleeding tissue observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 90 percent to 70 percent. Hemostasis achieved and a clean dressing applied. Observation on 2/21/24 at 2:45 PM revealed resident had an air mattress on her bed. There was a pair of Prevalon boots in her chair, a black wedge, two chair cushions and a U-shaped chair cushion in her room. Only two pillows noticed in her room, rested on her bed. On 2/22/24 at 1:45 PM resident remained at the hospital. On 2/21/24 at 4:12 PM Staff K Registered Nurse (RN) called. The number stated the party was unavailable, please try again later and the call ended. On 2/21/24 at 4:18 PM Staff M LPN stated total body skin assessments are usually completed in the morning or evenings and when there is a new skin area of concern. They do have a wound physician that will come in and assess and complete the treatments if the wounds are chronic or in bad shape. When asked how she completes the skin assessment she stated she usually goes in while they are getting their shower to check everything. She will also let staff know so she can do a skin check during cares, then they will come get her. She did take care of Resident #11 and when she did care for her she spent most of her days in bed. When staff would get her up in her wheelchair she instantly wanted to go to bed. Staff M added the resident was incontinent of urine and bowel. Since she met her she could tell her cognition had decreased due to her brain tumor. At the beginning of her time at the facility, Resident #11 was more active with movement but now she does not move at all. When asked how Resident #11 would reposition, Staff M stated she would do little movements but would not roll over on to her side for offloading, staff would do that. When asked if she noticed her offloading she stated she's not sure because she was a bigger lady and would flatten the pillows or anything they put under her to offload. She does not remember seeing positioning wedges or body pillows of any kind in her room. When asked if Resident #11 had skin issues, Staff M stated just on her buttocks, they were putting triad cream on it for a little while. Then they started to discontinue a lot of the treatments because it was too expensive so they either changed to no treatment or to A&D ointment, creams like that. Her bottom had a pinkish tint to it but did not know how long ago it started. Staff M stated she had a regular mattress and that did not make sense to her since she was a bigger woman. The last few times they repositioned her, staff went to pull the sheets from under her and they found a big wound on her buttock that required cleansing and packing. She indicated this was found on the morning of February 15th. She believed staff had known about it for a day or two before that. Staff M was asked if she felt the facility did everything they could to prevent this wound from developing she stated she was unsure but felt they could have done more. When asked what she would have done differently she stated for a woman her size she would get overlooked. Staff would not want to do cares on the bigger residents because they were harder to do. Plus, when they run short on the overnight shifts it's harder for staff to do cares like they would like to do. Once the wound was discovered they inserted a Foley catheter, repositioned her more and an air mattress was put in place. On 2/21/24 at 4:34 PM Staff B Licensed Practical Nurse (LPN) stated the Director of Nursing (DON) makes a list on paper of what skin assessments she wants checked, then leaves it at the nurse's station for the nurses to complete. When asked how those assessments are completed she stated the nurse goes in and checks the skin, then will go to the computer and chart in the Electronic Health Record (EHR) this includes any new areas. She likes to do them while the residents are in bed before they get dressed. Staff B stated she was recently educated to look at every skin area, separate the buttocks and lift folds to see if there are any wounds. When asked why this education was provided she stated they recently had a large woman that had a wound but all she knew she had was an area where they were putting cream on it. She admitted before she was not separating the skin to look for wounds, she would just turn the resident side to side, not open up the buttocks to see if there were wounds. She never saw the wound that was developed but was told it was between her buttocks and since she was obese you would have to separate the butt cheeks. Other staff members told they would have to lift the excess skin to see the wound. Staff B stated nobody noticed that wound, not even the DON when she went in to her room, no one noticed it because she was a bigger lady. Staff B stated when she would work on Resident #11's hall, she was always in bed, was not up in her wheelchair but when they tried to get her up she would cry to go back to bed. She could not recall what kind of bed the resident had and indicated she was not sure if the CNAs were turning her or not. Staff B stated Resident #11 was incontinent of urine and bowel. When asked if the resident was ever in bed offloading, she acknowledged when she would go in to do the cream treatment she never saw pillows under her. When asked if she felt the facility could have done more to prevent the pressure ulcer from developing she stated she felt bad that no one noticed it. She felt there was too much to do with what staff they had on the floor working. She felt staff are over worked and under staffed. She added Resident #11 was on the skilled unit and they need more staff on that unit. She felt if they been staffed well, this would not have been an issue but everyone is rushed there. On 2/21/24 at 4:59 PM Staff C LPN stated skin assessments are completed dependent on what resident the DON tells nurses that need an assessment completed. When asked how they are completed she stated she will go to their rooms to complete the skin assessment while they are in bed. When asked to talk about Resident #11 she stated she liked to spend most of her time in bed, and did not recall if she got out of bed. When the resident was first admitted she was working with therapy and got her up maybe one time. She would get up to shower maybe twice. Staff C was asked if staff assisted Resident #11 with repositioning and she stated the resident could not do that herself, staff would have to do it but was unsure how they repositioned her. When asked what she meant she stated that floor is busy but when she would go in there she would see her on her side, not sure for how long those. When staff are busy they can't pay attention to everything. Staff C unsure what kind of bed the resident had because she was always in it. She recalled Resident #11 had superficial areas on her bilateral buttocks that they were applying creams to. Staff C added only nurses could apply those creams and would be signed out on the TAR every shift. When asked if Resident #11 had any open wound, she stated they were not open just superficial, and two areas. She did not see anything else, she couldn't see anything else. When asked what she meant by that she stated unless you were looking for something or aware of it, you would need to separate her butt cheeks. She indicated Resident #11 was a big lady and when she would lie down the skin lays over itself making it hard to see anything. To see anything, you have to move the area, lift the buttocks with two hands to see the superficial areas. On 2/21/24 at 6:19 PM Staff L Certified Medication Aide (CMA) stated she never assisted with any personal cares and was unsure what kind of bed she had. When asked if she noticed Resident #11 being repositioned she stated she had not noticed her being repositioned on her sides. She had witnessed some CNAs telling nurses that Resident #11's bottom needed attention but that was it. On 2/22/24 at 8:14 AM Staff F CNA stated Resident #11 would get out of bed with therapy and with staff. Once she was up she would not want to stay up long because she complained of back pain. She had a regular mattress, no air mattress but did get an air mattress after they found the wound. Resident #11 required staff assistance for positioning because of her left sided weakness. Staff F stated when she would go in to Resident #11's room she would put a pillow under her arm or lower back because she would not roll on her own. It usually took 3-4 staff to do this. When asked if she noticed any skin issues Staff F stated she had one open area by her tailbone but it was not big. Staff F stated she was off when the bigger wound was discovered but when she came back to work they told her about it. She indicated the resident was incontinent of bowel and bladder. When the resident first came to the facility she would let staff know when she needed changed but when she started to decline she would not use her call light to be changed so they would just check and change her. On 2/22/24 at 8:40 AM the ARNP stated she was not aware that Resident #11 had wounds prior to the wound found on her buttock. When asked on the day she went to the facility to assess the wound what kind of mattress Resident #11 was laying on she indicated a regular mattress. She added after she completed her assessment she did order an air mattress for the resident as well as an order to insert a Foley catheter. The ARNP indicated the wound was located on Resident #11's coccyx and could be seen if you separated her butt cheeks. If they were not separated you could see there was something there but could not see the entire wound that way. She was unsure how long it took for the wound to develop but added Resident #11 has poor nutrition, would refuse cares at times which included repositioning but she could not speak for what took place the week prior to finding it. She added since she was incontinent of urine a catheter was inserted to promote wound cleaning. When asked if she felt the facility did what they could to prevent this wound from developing she indicated she was not sure what they were doing to prevent it from happening since she was admitted . On 2/22/24 on 9:21 AM the DO stated when she went to the facility February 16th that was the first time she saw Resident #11 and the first time she was aware of any skin issues. She was asked if you could see the wound without separating her butt cheeks, she stated it was a large wound and once the dressing was removed you could see it. The wound was not small and it's not hidden. She has had patients of that size with the same wound and would need to separate the fatty tissue to see it. She added this wound did not just happen, it was past that point because it was advanced. She added she was unsure when it started. When she went to see the resident on February 16th, she was lying on her side, uncovered and staff had her butt cheeks separated. With the size of the wound she believed you could see it if you went in to do cares. Once she assessed the wound she debrided it, she was concerned about Resident #11 being in pain but she slept through it. When asked what stage the wound was she stated stage IV because she could probe bone during the treatment. Her assessment note would be in the resident's medical record. When asked if this wound was avoidable or unavoidable she indicated she does not use those terms. She has seen a lot of residents in situations where they are prone to the development of wounds or susceptible to pressure ulcers because they are bed bound, hardly out bed, does not move themselves, or needs to be repositioned. The resident was immobile, had chronic medical conditions and at high risk of pressure wounds so it's not black and white when it comes to avoidable and unavoidable. On 2/22/24 at 9:34 AM and 2/26/24 at 10:27 AM attempts were made to speak with Staff I Unit Manager. At the conclusion of the survey, no return call received. On 2/22/24 at 11:31 AM the DON stated total body skin assessments are completed upon admission and once a week. When asked how they are completed she stated whenever they have time to do them, they are to do a head to toe to look at all the skin either in the shower or before getting out of bed. The DON indicated when Resident #11 was admitted the assessment documented redness to her buttock but unsure what interventions were put in place and she would have to look. When asked about offloading she stated Resident #11 would be repositioned frequently, with pillows to keep pressure at a minimum. They would attempt to get her up in the wheelchair throughout the day but did not do well with that. She believed they would attempted to get her up for an hour a day. She had a standard pressure relieving mattress prior to getting the air mattress. Resident #11 weighed 318 pounds and felt the pressure relieving mattress was sufficient for her because it was wider than a standard mattress. When asked where the skin assessments were from 12/7/23-12/22/23 she obtained daily skin assessment sheets from her office. She was able to find assessments on 12/8/23:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, pharmacist interview, physician interview, clinical record review and facility policy review, the facility failed to prevent significant medication errors which included: Staff A, LPN crushed morphine extended release medication 90 milligrams (mg) and administered it to Resident #1. The facility also administered 16 mg of Dexamethasone (steroid) instead of 4 mg as ordered for Resident #2. Additionally, Resident #3 received a narcotic medication on an as needed dose without an order. On 8/2/23 at 1:30 PM, the State Agency (SA) notified the Administrator and Director of Nursing (DON) of the Immediate Jeopardy of F 760 significant medication error. The Immediate Jeopardy began on 7/24/23 at 6:40 AM when Staff A, LPN crushed morphine extended release medication 90 milligrams and administered it to Resident #1. The facility removed the immediacy on 8/3/23 at 8:25 AM with the following removal plan: 1. The DON or designee re-educated licensed nurses and certified medication aides (CMA) regarding facility policy Medication Administration and Medications Not to Be Crushed. Education initiated 8/2/23 at 2:00 PM. All nurses and CMA's are educated prior to working their next shift. 2. The DON completed corrective action and one-to-one education on above listed topics with licensed nurse/CMA identified as being deficient in their practice resulting in this citation. This was completed on 8/2/23. 3. The DON or designee identified all residents with orders to crush and administer medication and reviewed medication storage to ensure medications not to be crushed were labeled as such. This was completed on 8/2/23. 4. The DON or designee will randomly observe medication passes for five (5) residents each week with orders to crush medications to ensure compliance. 5. The Administrator implemented a QAPI PIP as a means to gather and process information from the observations. Findings will be reported at the monthly QAPI committee meetings for a minimum of three (3) months. The facility lowered the scope and severity from a J to a G after the SA verified the facility staff had implemented the education and additional corrective actions. The facility reported a census of 108 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #1 as cognitively intact with a BIMS (Brief Interview for Mental Status) of 13 out of 15 points and had the following diagnoses: cancer, deep vein thrombosis and diabetes mellitus. The MDS identified Resident #1 required staff supervision for most activities of daily living. The MDS identified Resident #1 complained of pain occasionally and the worst he rated the pain level was 9 out of 10. The MDS documented the resident received opioid medication 6 of the last 7 days. The Care Plan dated 7/5/23 identified Resident #1 with the problem of pain related to pancreatic cancer and directed staff as follows: -Administer pain medication as ordered. -Educate resident regarding side effects of the pain medication and the potential for falls: dizziness, drowsiness, nausea, constipation, and notify physician as needed. -Refer to opioid orders for black box warnings. A review of the Facility Incident Report dated 7/31/23 had documentation of the following: On 7/24/23 at 6:40 AM Resident #1's long acting Morphine Sulfate 90 mg was crushed with is morning medications due to the resident's decreased alertness. A review of the July 2023 MAR (Medication Administration Record) revealed the following orders: Morphine Extended Release oral tablet 30 mg one tablet every 8 hours. Morphine Extended Release one tablet 60 mg tablet every 8 hours. On 6/24/23 both of the above doses were signed out as given at 6:00 AM. Naloxone Hcl 0.4 mg/ml give 0.4 mg IM every 30 minutes PRN (as needed) for sedation x 6 hours one dose signed out as given on 7/24/23 at 12:09 PM. A review of the Progress Notes dated 7/24/23 at 12:01 PM, revealed Staff A, LPN documented the following: Hospice nurse gave Narcan 0.4 mg at 10:15 AM. Electronic medical record would not allow her to enter 10:15 and this nurse gave him a dose at 12:00 PM. Resident #1 was talking after Narcan was given. A review of the Progress Notes dated 7/24/23 at 1:09 PM, revealed Staff B, Nurse Practitioner, documented the following: Resident received 90 mg extended release Morphine this morning crushed. Hospice nurse reports resident more lethargic with pulse ox in the 70's. After discussion with hospice medical director and primary care physician, the decision was made to give Narcan for respiratory distress for the next 6 hours. One dose IM (intramuscular) was given. Resident became more alert with improved speech, pulse ox in the 80's. Order left in the facility to repeat Narcan for the next 6 hours for respiratory distress. Requested close monitoring for 2 hours. A review of the Progress Note dated 7/25/23 at 11:23 AM, revealed Staff A, LPN documented Resident #1 was seen by this nurse at 7:30 AM this morning, he was alive and breathing. No respiratory distress observed, no signs of pain or discomfort. At 8:25 AM, this nurse observed resident chest not raising and falling. Upon assessment no pulse, no BP (blood pressure) noted. In an interview on 7/31/23 at 11:17 AM, Staff A, LPN reported she did not pay attention when she crushed the Morphine Extended Release pill when she gave it to him sublingually on 7/24/23. When the hospice nurse came in that morning, she asked what he had for pain and when she told her, the hospice nurse stated, you shouldn't have crushed it. Staff A also reported she usually had a CMA scheduled to help her pass medications and that day, there was no CMA scheduled and she had a total of 33 residents that she had to check blood sugars on 12 residents that morning. In an interview on 7/31/23 at 1:11 PM, Staff D, NP reported if a resident receives a long acting opioid crushed, it could cause respiratory distress. She stated if a hospice resident had problems with swallowing, other routes that could have been ordered for pain medication could have been sublingual. In an interview on 7/31/23 at 3:10 PM, Staff D, RN reported that before she left the faciity on 7/24/23 she gave report to Staff A, LPN. She did not witness it, but stated Staff A gave the Morphine ER to the resident before Staff D left the facility. Resident #1 did not have other routes ordered to administer pain medication and on that day, he was not able to swallow any liquids. In an interview on 8/1/23 at 11:09 AM, the consultant pharmacist reported if Morphine Sulfate ER had been crushed and given sublingually, she would want to have the resident observed closely and have Narcan ready as it could cause severe respiratory depression. In an interview on 8/1/23 at 12:18 PM, the ADON (Assistant Director of Nursing) reported when she spoke to Staff A, they reviewed the blisterpack which contained the Morphine ER. The label which provided instructions not to crush was in very small font, and very difficult to read if a nurse is trying to administer medications to 33 residents. When asked what could have been done to prevent the error, she reported the nurse should have followed the 5 rights of medication administration and it would have helped to have an agency staff come in to help pass medications. In an interview on 8/1/23 at 2:13 PM, the DON (Director of Nursing) reported for the unit Resident #1 resided, the facility tries to staff with one nurse, one CMA (Certified Medication Aide) and 3 CNAs. On 7/24/23 there was no CMA scheduled. She stated there is no unit secretary to answer the phones while the nurse passes medications and the nurse is expected to answer it. That morning, Staff A also was responsible for 33 residents and when there is no CMA to help pass meds, the nurse is responsible for checking blood sugars, giving insulins and medications, skin checks, processing orders which involves calling pharmacy, entering the orders into PCC, tube feedings, and wound care. When asked what could have been done to prevent the error, she reported the blisterpack labeling could have been different to make the do not crush instructions easily identifiable. In an interview on 8/2/23 at 8:06 AM, Staff M, RN reported the error could have been prevented if the MAR's and blisterpacks had instructions not to crush on non-crushable medications. The facility's policy titled: Medication Administration dated as last revised 5/3/22 had documentation of the following: -Review MAR to identify medication to be administered. -Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time. -Refer to drug reference material if unfamiliar with the medication, including its mechanism of action or common side effects. -Administer medication as ordered in accordance with manufacturer specifications. Do not crush medications with do not crush instructions. -Report and document any adverse side effects or refusals.