The facility reported a census of 44 residents. The sample included 12 residents. Based on observation, interview, and record review the facility failed to administer scheduled pain medication and take action to manage severe pain for Resident (R)32. Additionally, the facility failed to re-order the scheduled pain medication and notify the provider when the pain medication was not available. As a result of the deficient practice, R32 experienced severe pain with ineffective pain relief for two days and had physical symptoms of abrupt withdrawal, including nausea and vomiting, related to the facility not administering the scheduled, physician ordered pain medication. This also placed R32 at risk for discomfort and further decline in her overall well-being.Findings included: - A review of the Electronic Health Record (EHR), documented R32 had diagnoses of osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain) of the right hip, chronic pain, and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear).R32's 02/01/25 Annual Minimum Data Set (MDS) documented a Brief Interview of Mental Status (BIMS) score of nine, which indicated moderately impaired cognition. The MDS documented R32 required supervision for bathing and was independent in all activities of daily living (ADL). The MDS documented R32 received no routine pain medications; R32 did not receive as-needed pain medications or non-medicated pain intervention during the observation period. The MDS noted R1 had reported occasional pain with a pain score of three (pain scale with zero indicating no pain and 10 the worst pain imaginable) during the interview. R32's Pain Care Area Assessment (CAA) dated 02/18/25, documented R32 was at risk for alterations in comfort related to cervical (neck/spine) disc disorder. R32 would maintain current level of function and have minimal risks. R32's 05/05/25 Quarterly MDS documented a BIMS score of 13, which indicated intact cognition. The MDS documented R32 required moderate assistance for bathing and was independent for all other ADLs. The MDS documented R32 received routine pain medications, received non-medicated pain intervention, and did not receive as-needed pain medications during the observation period. The MDS noted R32 reported almost constant pain with a pain score of nine out of 10 during the interview. R32's Care Plan dated 04/19/24 directed staff to notify the physician if interventions were unsuccessful or if the current complaint of pain was a significant change from past experiences. The plan instructed staff to monitor and record pain characteristics every shift and as needed for quality and severity using a pain scale of one to ten, location, onset, duration, aggravating factors, and relieving factors. The plan instructed staff to administer analgesics per orders. The plan, dated 03/28/25, instructed staff R32's acceptable pain level was seven. The plan instructed staff to provide non-pharmacological pain interventions such as heat, ice, coloring, watching television, and plants. The plan, dated 05/08/25, instructed staff to identify, record, and treat existing conditions that may increase pain and or discomfort. R32's Physician Orders documented the following orders:Pain monitoring; (able to communicate) Are you free of pain or hurting? If no, indicate response through chart code Y for yes and N for no. Address new or changes in pain, complete pain evaluation in user define assessment every shift for pain, dated 02/11/25.Pregabalin capsule (medication used to treat nerve pain) 150 milligrams (mg), give one capsule by mouth, three times a day for right hip pain, dated 04/26/25. Acetaminophen (over-the-counter pain medication) oral tablet 325 mg, give two tablets by mouth, every four hours as needed for general discomfort, dated 06/28/25. R32's June 2025 Medication Administration Record (MAR) documented the pregabalin 150 mg capsule was not administered on the following dates:06/28/25 07:00 PM through 10:00 PM.06/29/25 07:00 AM through 10:00 AM, 11:00 AM through 02:00 PM, and 07:00 PM through 10:00 PM.06/30/25 between 07:00AM thru 10:00AM. R32's June 2025 MAR documented R32 received as needed acetaminophen 325 mg tablet two by mouth on 06/28/25 at 05:51 PM for a pain score of seven that was effective. R32's MAR lacked any documentation that R32 received any as-needed acetaminophen for pain on 06/29/25 and 06/30/25.R32's June MAR from 06/28/25 through 06/30/25 documented Y indicating the resident was free from pain each shift. R32's X-ray Report dated 02/22/25 documented severe osteoarthritis of the right hip marked by severe narrowing of the weight-bearing aspect of the hip joint, subarticular sclerosis (a hardening or increased density of the bone located just below the cartilage in the hip joint) and marginal osteophytosis (also known as bone spurs or osteophytes, refers to the formation of abnormal bony growths around the hip joint).R32's Progress Note dated 02/28/2025 at 12:08 PM documented the resident had an orthopedic appointment that day for right hip pain. The note documented the following physician communication: The X-rays of the right hip showed advanced arthritis and R32 would need a revision specialist to discuss removal of the hardware and a hip replacement. The Orders Administration Note dated 06/28/25 at 09:40 PM, documented the pregabalin capsule 150 mg was unavailable. The note indicated staff contacted the pharmacy about the medication. The Orders Administration Note dated 06/29/25 at 07:53 AM, documented the pregabalin capsule 150 mg was unavailable. The note indicated staff were waiting on the pharmacy. The Orders Administration Note dated 06/29/25 at 11:16 AM, documented the pregabalin capsule 150 mg was unavailable. The note indicated staff were waiting on the pharmacy. The Orders Administration Note dated 06/29/25 at 09:01 PM, documented the resident refused to take the pregabalin capsules that were in the E-kit (an emergency medication box). The Orders Administration Note dated 06/30/25 at 06:51 AM, documented the pregabalin capsule 150 mg was not administered, but lacked why the medication was not administered. R32's Progress Note dated 06/30/25 at 10:54 AM documented staff called the pharmacy, and they had a prescription for the pregabalin capsule but did not have it ready to go. The note recorded the facility would pick up the medication in 30 minutes. The note said staff offered R32 six capsules of 25 mg pregabalin the previous night and the night before that but R32 declined and said she wanted acetaminophen. R32's Progress Note dated 6/30/25 at 12:09 PM documented R32 did not receive proper medications due to the medication not being available from the pharmacy; the pharmacy stated that they did not have a prescription. The note documented R32 refused to take the medication from the E-kit because she would have had to take six pills instead of one pill of pregabalin. Staff notified the pharmacy, and the medication was picked up. The note documented R32 had been experiencing some nausea and vomiting.R32's EMR lacked evidence staff notified the physician regarding R32's pain medication and unmanaged pain. During an interview on 06/29/25 at 11:03 AM, R32 reported she was in constant pain with a pain scale score of 10 and reported the facility ran out of her pain medication yesterday and she was in severe pain and was not receiving any other medication for her pain. During an observation on 06/30/25 at 09:00 AM, R32 was in her bed with her eyes closed.During an observation on 06/30/25 at 10:48 AM, R32 sat up in bed with her garbage can in front of her and she was vomiting. R32 reported a wave of nausea came over her and not sure why. R32 reported she could not recall if she had been offered the pregabalin from the nurse on 06/29/25 and reported she was still in severe pain at a level of 10. During an observation on 06/30/25 at 11:23 AM, the pharmacy delivered R32's pregabalin. During an observation on 06/30/25 at 03:45 PM R32 remained in bed and reported she felt a little better and was glad she received her pain medication. On 07/01/25 at 08:30 AM R32 sat up on the edge of the bed and reported her pain was now tolerable and was glad she would be able to get out of bed today. On 06/30/25 at 10:01 AM, Certified Medication Aide (CMA) R reported pregabalin was not in the E-kit. CMA R said R32 used her own pharmacy that did not provide an E-kit, so the facility was not allowed to take any medication from the facility's pharmacy E-kit for residents that used their own pharmacy. CMA R reported that she called R32's pharmacy that morning at 09:07 AM to have R32's pain medication delivered. CMA R reported she was not sure if R32's medication had been ordered over the weekend as she did not work and was not certain if R32's pharmacy was open on Sundays. On 06/30/25 at 10:30 AM, Licensed Nurse (LN) H reported if a resident did not have a medication available, the nurse would pull the medication from the E-kit if it was in the E-kit. If the medication was not in the E-kit the pharmacy would be called for an immediate delivery. LN H reported that R32's pharmacy was slower than the facility pharmacy. LN H reported that R32 was offered the pregabalin from the E-kit last night and she declined per the report she received today as the resident did not want to take that many pills. LN H said the E-kit was reviewed and had a stock of eight 25 mg pregabalin capsules available. LN H reported she was not certain if the pharmacy had been called to re-order the medication. LN H reported that the physician should be called when a medication is not available. During an interview on 06/30/25 at 10:52 AM with R32's pharmacy, Pharmacy Staff HH reported that they received no calls over the weekend for a pregabalin refill for R32. Pharmacy Staff HH said the pharmacy has an on-call number when it is closed and reported the facility called this morning for a refill, and they would be delivering the medication soon to the facility. During an interview on 06/30/25 at 11:11 AM with the facility's pharmacy, Pharmacy Staff II reported when a resident at the facility chose to use their own pharmacy at the facility, those residents would still be able to have staff use the E-kit for medications when their medications were not available. During an interview on 06/30/25 at 11:18 AM, Administrative Nurse D reported she expected the residents to have all their medications available and to be always administered. She expected the nurse to contact the pharmacy to order that medication. Administrative Nurse D reported that the staff is not allowed to use the medications from the E-kit if the residents use their own pharmacy and not the facility pharmacy. Administrative Nurse D also reported that she expected the staff to notify the physician when the medication was unavailable to be administered and that she considered the above concern a medication error. The facility's policy Pain Management dated 02/21/25 documented the facility must ensure pain management is provided to residents who requires such services, consistent with professional standards of practice, comprehensive person-centered care plan, and the resident's goals and preferences. The facility's policy Unavailable Medications dated 11/8/24 documented the facility shall use uniform guidelines for unavailable medications. The facility would maintain a contract with a pharmacy to supply the facility with routine, as-needed, and emergency medications. The facility shall follow established procedures to ensure residents have sufficient medications. Notify the physician of the inability to obtain medications to obtain alternative treatment orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 44 residents with nine residents selected for review, including three residents reviewed for skin conditions. Based on record review and interview, the facility failed to provide appropriate treatment services for one Resident (R)7's pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) at a Stage 3 (full thickness pressure injury extending through the skin into the tissue below), present on admission to her coccyx (area at the base of the spine) when they failed to obtain physician ordered treatment until seven days after admission to the facility, failed to assess the wound until three days after admission to the facility, failed to ensure R7 had a dressing replaced timely when soiled or absent, and failed to provide a pressure reducing device to the seat of her wheelchair until three days after admission. R7's pressure area deteriorated to an unstageable wound, became infected, and she required hospitalization for wound management. Findings included: - The Medical Diagnosis tab for R7 included diagnoses of protein-calorie malnutrition, pressure ulcer of sacral region (large triangular bone/area between the two hip bones), muscle weakness, functional diarrhea, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and tremor. The Admission/Discharge report dated 11/21/23 through 02/20/24 revealed R7 admitted to the facility from the hospital on [DATE] and discharged back to the hospital on [DATE] (the 19th day of stay at the facility). The admission Minimum Data Set (MDS) dated [DATE] assessed R7 with a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. R7 did not reject care, was frequently incontinent of bowel, and used a walker and a wheelchair for mobility. R7 was dependent on staff for toileting and for rolling left to left and right side and returning to her back when in bed. She was at risk for pressure ulcers and had one stage 3 ulcer which was present on admission and skin tears. The MDS revealed she had a pressure reducing device for her chair but not the bed and was not on a turning/repositioning program. R7 received pressure ulcer/injury care and nutrition or hydration to manage skin problems, application of dressings and ointments/medications other than to feet. The Pressure Ulcer/Injury Care Area Assessment dated 02/07/24 revealed R7 admitted from the hospital with a stage 3 pressure ulcer to her coccyx, malnourished, weakness, debility, and a Foley catheter (tube inserted into the bladder to drain urine into a collection bag) that was removed on 02/02/24. R7 preferred to lie on her back and staff encouraged and assist her to turn side to side. The Care Plan initiated on 01/29/24, revealed R7 required partial/moderate assistance for toileting hygiene, moving from sitting to standing, transfers, and toilet transfers. R7 had urine incontinence at times and utilized disposable briefs and staff were to change as needed. R7 was at risk for skin breakdown related to a pressure ulcer present upon admission, frequent loose stools with unawareness of occurring until felt afterwards, refuses to lay down, removes her own dressing, leaving it open to constant diarrhea, adult neglect, and protein-calorie malnutrition. The Nursing Admit/Readmit Assessment dated 01/26/24, revealed a pressure area to R7's coccyx, however the assessment lacked stage of ulcer and measurements of the pressure area. The Skin and Wound Evaluation dated 01/29/24 (three days after admission) revealed R7 had a stage three pressure area (lacked location), present on admission, which was 100 percent (%) covered with slough (dead tissue, usually cream or yellow in color). The area measured 4.0 centimeters (cm) by 2.9 cm. The Treatment Administration Record (TAR) dated January 2024, lacked treatment orders for the pressure area to R7's coccyx from date of admission [DATE] through 01/31/24. The physician Office Visit note, dated 01/31/24, revealed R7 had sacral ulcers which were unstageable (depth of the wound is unknown due to the wound bed is covered by a thick layer of other tissue and pus) on exam and the areas measured 2.5 cm by 2.5 cm, 1.0 cm by 1.5 cm, and 1.5 cm by 1.5 cm. R7's chronic diarrhea and poor nutrition with hypoalbuminemia (abnormally low levels of albumin in the blood) contributed to the areas. The note revealed an old dressing removed, sterile dressings were applied, and would get R7 set up with wound care services for the unstageable pressure ulcer. R7 reported she had not been receiving her antidiarrheals despite having numerous episodes of diarrhea daily, so will change those medications to be scheduled. The Order Summary Report dated 02/01/24 lacked treatment orders for R7's pressure ulcer to her coccyx. The TAR dated February 2024 revealed a treatment for R7's pressure area to her coccyx as needed began on 02/02/24 (seven days after admission) however lacked documentation the staff completed the treatment order. A routine treatment order began on 02/03/24 (eight days after admission) to R7's coccyx. The staff were to perform the treatment daily. The TAR lacked documentation the staff completed the treatment on 02/09/24. On 02/10/24 a new treatment began which included the use of Santyl (a prescription enzyme used to help break up and remove dead skin and tissue of a wound) ointment was to be done daily and as needed after every incontinence episode. The TAR revealed the staff completed the as needed treatment order twice, on 02/11/24 and 02/12/24. The Medication Administration Record (MAR) dated February 2024, included instructions dated 01/30/24 to administer loperamide (antidiarrheal), two milligrams, by mouth, as needed, every six hours, for functional diarrhea. The MAR lacked documentation the staff administered the medication at any time from 02/01/24 through 02/13/24. The Progress Notes dated 02/02/24 at 10:50 AM revealed a communication was sent to the physician via a fax regarding a referral R7 had for the Wound Care Center [designated hospital]. The note revealed R7 was being seen by the facility wound care Advanced Practice Registered Nurse (APRN), who came weekly, and the facility had been providing daily treatment. R7 was receiving skilled Medicare A services, R7 did not need the referral to the wound care center, and the facility notified the wound care center of lack of need for an appointment at this time. The Skin and Wound Evaluation dated 02/06/24 revealed R7's stage three pressure area to her sacrum had 80 % coverage of slough and 20 % coverage of eschar (dead tissue). The area lacked evidence of infection, however the tissue surrounding the wound had erythema (redness or inflammation of the skin) that measured 5.0 cm and the temperature of the tissue around the area was warm (indicating possible infection). The area measured 2.8 cm by 1.6 cm. The physician Office Visit note dated 02/08/24, revealed R7 had a worsening sloughing sacral wound measuring 3.0 cm by 3.0 cm with 4.0 cm to 5.0 cm surrounding erythema and induration (hardening of the skin and subcutaneous tissues around a wound due to inflammation which could be secondary to infection). The note included R7's treatment orders would be updated to use of Santyl to the wound and change the dressing daily and as needed, and additionally, referral placed to wound care at [specified facility]. The note included R7 recently grew pseudomonas (type of bacteria) in her stool and would treat with Levaquin (antibiotic). The Grievance/Concern Log dated 01/29/24 through 02/09/24 revealed a concern (lacked who reported the concern) of R7 not being cared for properly, the resident and staff were talked to, and the concern resolved on 02/09/24. The Progress Note dated 02/12/24 revealed R7's family member spoke with social services about moving R7 to [specified facility] for one of two reasons being R7 did not feel like she was receiving adequate care. The Skin and Wound Evaluation dated 02/13/24 revealed R7's pressure area had 100 % coverage of eschar (indicating unstageable pressure area). The area had no evidence of infection, however had a moderate odor after cleansing, and the wound increased in size to 6.2 cm by 5.0 cm. The Progress Note dated 02/13/24 at 10:42 AM, revealed R7's wound deteriorated, she was to go out for wound care today (02/13/24), she was encouraged to lay down to offload pressure and refused, and treatment to the coccyx completed for the second time this shift. The Plan of Care Note dated 02/13/24 at 10:58 AM by Administrative Staff A revealed R7's care plan reviewed related to R7 refusing to lay down, taking off the wound dressing, and refusing supplements recommended by the Registered Dietician. R7 was aware of skin issues but continued to refuse to help herself by not laying down and taking pressure off, taking bandage off the wound and letting loose stools come in contact with the wound, the resident does very little for herself, and expected one on one care. The staff encouraged R7 to let them know as soon as she can that she needed a dressing changed and her changed (from incontinence). R7 was able to take herself to the bathroom but not always aware of the diarrhea until after it had happened, which according to nursing staff was almost constant. The Progress Note dated 02/13/24 at 03:50 PM revealed R7 went to [specified hospital] for wound care appointment and admitted to the hospital due to her wounds. The electronic medical record (EMR) lacked notes to indicate R7 was seen by wound care other than on 02/13/24. The Wound Clinic Consult Note dated 02/13/24 revealed R7 was there for consultation regarding multiple sacral ulcers that were necrotic (pertaining to the death of tissue in response to disease or injury) with a foul odor. The note revealed R7 reported the small wound she had at home increased in size since admitted to the facility and the nursing facility was not prompt about changing after bowel incontinence episodes and she had sat in a dirty brief for up to an hour and a half. R7 required two to three staff to transfer her at the appointment and stated, I need to be in the hospital, and I am not getting the proper care that I need. The assessment of the wound revealed multiple wounds measured together 9.5 cm by 7.0 cm by 0.1 cm, wound bed appearance was black, eschar, grey, and yellow, surrounding tissue was warm and appeared pink and erythematous, and the wound drainage had a foul odor. The note revealed R7's sacral ulcers would mostly likely need antibiotic, and debridement and they referred R7 to the emergency room for further evaluation. The Progress Note dated 02/14/24 at 11:32 AM, revealed R7 was in the intensive care unit due to having low blood pressure in the night and receiving intravenous (into the vein) medications for the low blood pressure and for her wounds. R7 was to have surgery in the afternoon (of 02/14/24) for coccyx wound debridement (medical removal of dead, damaged, or infected tissue to improve the healing potential for the remaining healthy tissue). On 02/21/24 at 09:33 AM, R7's family member stated, the spot on her back went from half dollar size to size of a dinner plate. The family member stated he was in the facility with R7 at times when she needed a new dressing and the staff would not do it or do it later the next [explicit language] day. The family member stated on the day of the Superbowl (02/11/24), family stopped at the nurse's desk and told the nurse she was ready for her medications and she needed a new dressing. The nurse came with medications and when R7 asked about a dressing, the nurse responded nobody had told her, and the nurse did not return to apply a new dressing while there, which was sometime after 08:00 PM. On 02/21/24 at 10:58 AM, an additional family member stated him and R7 spoke with Administrative Nurse D about the lack of wound care, however, could not recall what day, and was told R7 would get better care. When R7 went to see the wound care doctor it was much worse, so they admitted her to the hospital. On 02/21/24 at 12:13 PM, Certified Nurse Aide (CNA) M stated R7 was not resistive to cares, she used her call light to get help, she was incontinent of bowel and bladder and wore a brief that the staff changed, and she needed help to get to the bathroom. CNA M stated when R7 first came to the facility, she required two people to assist her, then she started walking when getting her strength up. CNA M stated R7 had constant diarrhea of large amounts that would soil the dressing on her coccyx, he would not remove the dressing, the nurse would come and take care of it. On 02/21/24 at 12:36 PM, Licensed Nurse (LN) I stated she mostly did skin care; however, she did not do weekly wound measurements, other staff were to complete those. LN I stated she did not know R7 had a wound on her bottom for a few days and thought it was Thursday or Friday after she came (02/01/24 or 02/02/24) she had physician orders for a treatment. LN I stated she put a patch on R7 the first day she was on treatments. LN I stated she put a dressing on R7 every day, multiple times because she had a lot of diarrhea, we could not keep a dressing on her bottom, and R7 expected a dressing to be put on right away. LN I stated R7 needed to tell someone and not complain for two hours later and say she had not had a dressing on stating how long it had been. LN I stated she does not take residents to the bathroom so she would not know when another dressing needed to be placed, the CNA's were not letting her know, and R7 would take herself to the bathroom. LN I stated she did not think R7 would take the dressing off, it would fall off when she wiped. LN I stated she felt like R7 could have done more to get more attention, rather than be caddy about it three hours later and tell other people sitting at the table, turning it into gossip rather than an actual request, or would get on the phone and tell her husband. LN I stated she most often would know what she needed by overhearing what she was saying on the phone to her husband and her friend. LN I stated the dressing would not stay on due to the diarrhea and she tried three different kinds of dressings, but they would not stick. LN I stated every day she came in the wound would be worse. LN I stated she was not sure if the Nurse Practitioner came in weekly to see her as she was scheduled opposite of her and if a resident was going to wound care the APRN could not see her as it would be double billing. On 02/21/24 at 01:05 PM, R7's friend stated one day when she was at the facility R7 had diarrhea and when heading back to her room the nurse was told she needed a diaper change. R7's friend stated they waited an hour and a half before anyone came to change her, and another time when she was there R7 waited 45 minutes after turning on her call light before anyone came to change her. R7's friend could not recall dates of occurrences, as she did not write it down. R7's friend stated she went to the doctor with her four or five days before R7 went to the wound care specialist and R7 had soiled herself before they got ready to leave and the staff said they could take care of it when she got to the doctor's office. R7's friend stated when they arrived at the doctor's office, R7 had feces all the way up to her belly button and to her back and lacked a bandage on her sore. R7's friend stated she went to the wound care appointment with her and when they took the bandage off the smell was so bad I almost puked and the nurse could not believe how bad the wound smelled and R7 was put in the hospital for the infection. R7's friend stated when she was at the facility, the staff had to help her out of the wheelchair, she could not take herself to the bathroom or get out of bed without help. R7's friend stated the wound went from a size of a ping pong ball to the size of a softball in a short time and the wound was black. On 02/21/24 at 01:27 PM, Administrative Nurse D stated the in house wound care nurse was in the facility on 02/06/24, however she did not see R7. On 02/08/24, R7 went to the doctor due to swelling and warmth to her left breast and was started on an antibiotic, a new wound treatment, and staff was to schedule for an appointment for regular wound care, which she went on 02/13/24. Wound care did a direct admit for R7 to the hospital. Administrative Nurse D stated wound measurement for newly admitted residents should be done within 24 hours of admission, and as needed treatments completed should be documented on the TAR. On 02/21/24 at 02:04 PM, CNA N stated R7 required one person to assist her with toileting and would let the staff know when she needed to go the bathroom. CNA N stated R7 had to go to the bathroom quite a bit for her bowels and at times when getting her in the bathroom and getting her brief down she had already went and would get her up and change her and she went again. CNA N stated she reported to the nurse every time R7 had diarrhea. CNA N stated two or three times when she first arrived in the morning, R7 lacked a dressing in place to her wound when they went to get R7 up, and one of those times she had bowel incontinence when doing a check and change and dressing removed due to bowel under the dressing but not on top of it. CNA N stated R7' s dressing needed to be changed two to three times an eight-hour shift because of bowel incontinence. CNA N stated when R7 first got to the facility, she did not have a cushion in her wheelchair, but therapy placed one on the following Monday (three days later). CNA N stated R7 would only lay down if really tired, which was not often and mainly stayed in the wheelchair when she was not in bed. On 02/21/24 at 02:20 PM, Administrative Nurse D stated every morning when she came in if R7 was up and said she did not have a patch on, she would have R7 go with the nurse and aides to clean her up and do a treatment. Administrative Nurse D stated in the morning when she arrived, she would make sure R7 was the first wound care patient done. Administrative Nurse D stated one day, R7 went to the dining room and was sitting at the table with her husband on the phone getting ready to eat and was waiting on the wound care nurse to come in, R7 had told her the dressing was off as she was going to the table, but Administrative Nurse D was to pass medications that day. R7's dressing was not changed until after she ate breakfast. Administrative Nurse D stated R7 talked to her and Social Service Staff X on 02/12/24, and prior to that on 02/09/24, R7's family member talked to her about the same thing (fault of wound getting worse). Administrative Nurse D stated she watched several days and would get on the nurse if she did not have a bandage on and to get on her treatment. Administrative Nurse stated she talked to the night nurse about making sure if the dressing came off to replace it, and there were a couple of times R7 did not have a treatment in place when she came in, however she had chronic diarrhea and believed we were doing the best we could. and R7 had poor nutrition. Administrative Nurse D stated R7 had a cushion in her wheelchair the Monday after she came in (01/29/24), and R7 lacked documentation of wound measurements when admitted , and lacked a treatment order until 02/02/24 (seven days after admission). On 02/21/24 at 02:51 PM, CNA O stated she helped R7 everyday she worked and there were a couple of time R7 lacked coverage to her wound, she would tell the nurse and they usually drop what they were doing except for one, who would not acknowledge the need for a dressing when reported to her or would say she was in the middle of report or she was busy and R7 would have to wait. CNA O stated there was two or three times at the start of her shift, the wound would not have a dressing in place and R7 would have diarrhea four to six times a shift. On 02/21/24 at 03:09 PM, CNA P stated she provided care to R7 for a few days and one of those days she lacked a dressing in place to her wound and when reporting to the nurse, the nurse responded she had not had a chance to do that yet, she had constant diarrhea, and the dressing would not stay. On 02/21/24 at 04:30 PM, CNA Q stated she provided cares to R7 and a couple of times she did not have a dressing in place, one time she told the nurse and the other time I think I forgot, I was doing something else. CNA Q stated she did not think R7 removed her dressings herself. On 02/21/24 at 04:40 PM, LN J stated one time during her shift R7 did not have a dressing in place, but she had just been changed. LN J stated she was getting report at the time and that was first, so I did it after shift report. LN J stated R7 would have diarrhea constantly and would change the dressing four or five times during the night. LN J stated she worked the day R7 admitted , and she completed a skin assessment on her, and remembered sometime removing a dressing to take pictures, but could not recall if it was when R7 admitted . LN J stated she could not remember if R7 admitted with treatment orders. LN J stated for new resident admissions, therapy determines if the resident needs a cushion or not. On 2/21/24 at 04:57 PM, LN K stated one day Administrative Nurse D and said as soon as report was done, R7 needed a dressing put on. Administrative Nurse D thought it had already been asked at report but that was to LN I and not to her. LN K stated R7 had less episodes of diarrhea at night than during the day. LN K stated R7 did not toilet herself and was a check and change at night. LN K stated R7 would require assistance to reposition, R7 could help some, but not completely and she laid mostly on her right side. On 02/22/4 at 10:37 AM, attempted to reach Consultant Physician GG and was unsuccessful. The facility policy Wound Treatment Management dated 01/01/20, revealed the policy was to promote wound healing of various types of wounds and provide evidence-based treatments in accordance with current standards of practice and physician orders. In the absence of treatment orders, the licensed nurse will notify the physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse. Dressing changes may be provided outside the frequency parameters in certain situations: feces seeped underneath the dressing, dressing dislodged, dressing soiled otherwise or wet. Treatments will be documented on the Treatment Administration Record. The effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modification include lack of progression towards healing and changes in characteristics of the wound. The facility policy Documentation of Wound Treatments dated 01/02/20, revealed wound assessments were to be documented upon admission, weekly, and as needed if the resident or wound condition deteriorates. The wound assessment documentation should include the type of wound, stage of the wound, measurements of the height, width, depth, undermining, tunneling, description of wound bed, tissue around wound bed, presence and amount of drainage, presence or absence of odor, and presence or absence of pain. Wound treatments documented at the time of each treatment. The facility failed to obtain physician ordered treatment until seven days after R7's admission to the facility, failed to assess the wound until three days after admission to the facility, failed to ensure R7 had a dressing replaced timely when soiled or absent, and failed to provide a pressure reducing device to the seat of her wheelchair until three days after admission. R7's pressure area deteriorated to an unstageable wound, became infected, and she required hospitalization for wound management.