Based on interview and record review, the facility failed to adequately treat pain for one resident (Resident #2) who was actively dying. The sample size was three. The census was 72. Review of the facility's pain management policy, dated 11/15/22, showed:-Policy: The Facility will use a systematic approach to pain management; Recognition, evaluation, treatment, and monitoring of pain. Individuals experiencing pain may receive pharmalogical/non-pharmalogical interventions to assist in pain management. The Facility will provide employees education on pain management & opioid (class of drugs used for pain relief) overdose;-Recognition included recognizing when a resident was experiencing pain and identify circumstances when pain can be anticipated; Evaluate the resident for pain on admission and routinely; Manage/Prevent pain consistent with comprehensive evaluation and plan of care, current professional standards of practice and resident's goal/preferences;-Observe for non-verbal indicators of pain;-Nurses will complete a pain evaluation tool, appropriate for the resident's cognitive status to assist with evaluation of a resident's pain;-Based on the evaluation, Nursing in collaboration with the physician/prescriber, other health care professionals, the resident and/or the resident's representative will develop, implement, monitor and revise, as necessary, interventions to prevent/manage a resident's pain;-Opioids will be prescribed and dosed in accordance with current professional standards of practice and manufacturers' guidelines to optimize their effectiveness and minimize their adverse consequences;-Nursing will notify Practitioner if the resident's pain is not controlled by the current treatment regimen;-Nursing will reassess resident's pain management for effectiveness and/or adverse consequences at established intervals;-If re-evaluation findings indicate pain is not adequately controlled, the Pain Management Regimen and Plan of Care will be revised as indicated.-If pain has resolved or there is no longer an indication for pain medication, the Interdisciplinary Team will work to discontinue or taper analgesics (pain killers) (as needed to prevent withdrawal symptoms). Review of Resident #2's care plan, undated, showed:-Problem: At risk of unmanaged chronic pain related to poly-neuropathy (multiple nerves are damaged in lower body). Interventions included: Administer analgesics as ordered by physician; Document pain on 1-10 scale; Monitor response to analgesics and pain alleviation measures;Observe resident during care for signs of pain; Update physician on effectiveness of analgesics and pain medication;-Problem: The resident was receiving hospice care due to unspecified protein malabsorption. Interventions included: Encourage support system of family and friends; Observe the resident closely for signs of pain, administer pain medications as ordered, and notify physician immediately if there is breakthrough pain. Review of the resident's physician order sheet, showed:-An order, dated 12/29/22, for a pain evaluation, every shift for monitoring of resident's pain level;-An order, dated 8/23/23, for morphine sulfate solution (morphine, opioid pain reliever used to treat moderate to severe pain) 20 milligrams (mg) for every five milliliters (ml), give 0.25 ml every four hours as needed for pain;-An order, dated 1/31/24, may admit to hospice care;-An order, dated 8/22/24, for Hydrocodone-acetaminophen 5 - 325 mg (Norco, opioid pain reliver combined with acetaminophen), take one tablet every eight hours for pain. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff dated 3/1/25, showed:-Severe cognitive deficiency;-Disorganized thinking and inattention present;-Impairment present on both sides of the upper and lower body;-On a scheduled pain medication regimen;-Did not receive pain medication as needed;-Received non-medication intervention for pain;-Resident reported not presence of pain during pain assessment interview;-Received hospice care (provides comfort and support by managing pain and other symptoms at end of life);-Diagnoses included heart failure, aphasia (language disorder that affects ability to communicate) dementia and kidney disease. Review of the resident's Medication Administration Record (MAR), dated March 2025, showed:-On 3/12/25, at 6:00 A.M., the facility administered one Norco to the resident;-On 3/12/25, at 6:30 A.M., the resident had a pain level of 0. Review of hospice focus visit, dated 3/12/25, showed:-The visit was an unscheduled symptom evaluation;-A hospice nurse started the visit at 7:55 A.M. and ended visit at 8:45 A.M.;-Interventions performed: Call for a change in condition and ordered morphine;-The resident started moaning when touched for care;-The resident was nonverbal;-Report was given to the facility nurse who administered morphine 0.25 ml;-Norco 5-325 mg was not given;-The facility nurse administered morphine 0.25 ml to the resident for pain;-Report of visit given to facility nurse, Director of Nursing (DON) and the resident's family member. Review of the resident's controlled substance accountability sheet, undated, for Morphine, showed:-On 3/12/25 at 9:30 A.M., the facility administered 0.25 ml to the resident with 7.75 ml remaining. Review of the resident's MAR, dated March 2025, showed:-No documentation the facility administered morphine to the resident on 3/12/25;-On 3/12/25, at 2:00 P.M., the facility administered one Norco to the resident;-On 3/12/25, at 2:30 P.M., the resident had a pain level of 0;-On 3/12/25, at 10:00 P.M., the facility administered one Norco to the resident;-On 3/12/25, at 10:30 P.M., the resident had a pain level of 0;-On 3/13/25, at 6:00 A.M., the facility administered one Norco to the resident;-On 3/13/25, at 6:30 A.M., the resident had a pain level of 0. Review of the resident's controlled substance accountability sheet, undated, for Morphine, showed:-On 3/13/25, at 6:30 A.M., the facility administered 0.25 ml to the resident with 7.50 ml remaining;-On 3/13/25, at 10:30 A.M., the facility administered 0.25 ml to the resident with 7.25 ml remaining. Review of the resident's MAR, dated March 2025, showed:-No documentation the facility administered morphine to the resident on 3/13/25. Review of the resident's progress notes, showed:-On 3/13/25 at 10:55 A.M., the resident had a change of condition. The resident was nonresponsive. The hospice nurse was here to see the resident and cancelled all prescription medications except for all pain medications. The primary care physician (PCP) was informed of the resident's condition and gave new order for acetaminophen (pain reliver and fever reducer) 650 mg suppository, give every six hours for a temperature of 99 degrees or greater. Review of the resident's MAR, dated March 2025, showed:-An order dated 3/13/25 at 11:50 A.M., for acetaminophen suppository 650 mg, insert 1 suppository rectally every six hours as need for a temperature of 100 degrees or above;-No documentation the medication was administered to the resident;-On 3/14/25, at 6:00 A.M., the facility administered one Norco to the resident;-On 3/14/25, at 6:30 A.M., the resident had a pain level of 1;-On 3/14/25, at 2:00 P.M., the facility administered one Norco to the resident;-On 3/14/25, at 2:30 P.M., the resident had a pain level of 0;-On 3/14/25, at 10:00 P.M., the facility administered one Norco to the resident;-On 3/14/25, at 10:30 P.M., the resident had a pain level of 0. Review of the hospice focus visit, dated 3/14/25, showed:-The hospice nurse visited the resident at 12:05 P.M. and ended the visit at 1:05 P.M.;-The resident was non verbal;-The resident had a decreased response to verbal and visual stimuli;-The resident had an absent radial (artery found on the thumb side of the wrist) pulse;-The resident had decreased urine output;-The resident's blood pressure was 84/36 and a heart rate of 120 bpm;-Interventions performed: assess for signs and symptoms of pain during visit and assess respiratory (breathing) status during visit;-The resident was unresponsive, not following commands. The facility nurse said the resident had just received morphine and had a fever which was treated by acetaminophen. There was no fever noted by the hospice nurse during assessment;-The resident was on 2.5 liters of oxygen and his/her saturation (amount of oxygen in the blood, typically between 95% and 100%) rate was in the 90s. The facility nurse said he/she would give the resident Ativan. Review of the hospice supplemental interdisciplinary note, dated 3/14/25 at an unknown time, showed:-The writer of the note was a hospice nurse;-Visit type: Patient Services (In person contact);-Reviewed the facility medical record and received report from the facility nurse;-The facility nurse stated the resident had not received any Ativan yet because the in-house physician had not signed the order for it;-The hospice nurse gave the order for Ativan to the facility the day prior, from the hospice physician. Review of the resident's controlled substance accountability sheet, undated, for Morphine, showed:-On 3/14/25, at an illegible time, the facility administered 0.25 ml to the resident with 7.0 ml remaining;-On 3/14/25, at 2:00 P.M., the facility administered 0.25 ml to the resident with 6.75 ml remaining. Review of the resident's MAR, dated March 2025, showed:-No documentation the facility administered morphine to the resident on 3/14/25. Review of the resident's controlled substance accountability sheet for Ativan, undated, showed:-Medication Name/Strength: Ativan 0.5 mg, give by mouth every three hours for pain and anxiety;-On 3/14/25, at 2:25 P.M., the facility administered one tablet of Ativan to the resident, with a remaining quantity of one tablet. Review of the resident's MAR, dated March 2025, showed:-An order, dated 3/13/25, at 3:53 P.M., to give Ativan 0.5 mg, every two hours as needed for pain;-No documentation the facility administered Ativan 0.5 g on 3/14/25 at 2:25 P.M. Review of the hospice supplemental interdisciplinary note, dated 3/14/25 at an unknown time, showed:-At 4:00 P.M., the hospice nurse made a follow up call to the facility and found the resident had not yet received any Ativan, as per physician orders;-The facility nurse said the nurses' cart was stuck or would not open to get the Ativan out. The facility nurse was waiting on the pharmacy to come and fix it. Review of the resident's MAR, dated March 2025, showed:-Documentation showed the facility administered Ativan 0.5 mg as ordered on 3/14/25 at 4:30 P.M.; Review of the resident's controlled substance accountability sheet for Ativan, undated, showed:-No documentation the facility administered Ativan 0.5 mg to the resident on 3/14/25, at 4:30 P.M.-On 3/14/25, at 6:18 P.M., two tablets were added to the controlled substance accountability sheet, showing three tablets available for administration. Review of the resident's MAR, dated March 2025, showed:-On 3/15/25 at 6:00 A.M., the facility attempted to administer one Norco to the resident. The resident refused;-On 3/15/25 at 6:30 A.M., the resident had a pain level of 0. Review of the resident's controlled substance accountability sheet for Ativan, undated, showed:-On 3/15/25 at 12:00 P.M., the facility administered Ativan 0.5 mg to the resident. Review of the resident's MAR, dated March 2025, showed:-No documentation the resident received Ativan 0.5 mg on 3/15/25 at 12:00 P.M. Review of the Hospice RN's focus visit sheet, dated 3/15/25, showed:-The visit started at 12:00 P.M.;-The resident had decreased response to verbal and visual stimuli, hyperextension of the neck, grunting of vocal cord, depression of the jaw on inspiration (when breathing in), death rattle (a gurgling sound heard in a dying person's throat), and Cheyne-Stokes breathing (fast, shallow breathing followed by slow, heavier breathing and moments without any breath at all);-Upon arrival to the facility, the resident was found in bed with the resident's family member at bedside. The resident appeared to be actively dying and displayed signs of discomfort;-Staff stated the resident received comfort medications, however, upon further assessment it was evident the resident exhibited increased respiratory effort and signs of pain;-Review of the resident's MAR showed the resident had not received any comfort medications in almost 24 hours;-The facility nurse assigned to the resident was not present and another nurse on the unit assisted;-The Hospice RN contacted his/her supervisor and the hospice on-call physician, who gave new orders to administer morphine every 15 minutes until the resident was comfortable;-The visit ended at 2:00 P.M. Review of the Hospice RN's supplemental Interdisciplinary note, dated 3/15/25, showed:-The visit stated at 12:00 P.M.;-The resident had a pain level of six, out of a 0 - 10 pain scale (0 was no pain and 10 as the highest level of pain)-Current pain and symptom management was not satisfactory;-A total of three doses (morphine) were given before the resident began to show signs of relief;-Hospice RN expressed his/her concerns directly to the facility Administrator regarding the delay in patient care and the resident's family member's concerns the resident was not receiving adequate attention;-It was also noted the facility was low on morphine;-Hospice RN followed up with the on-call hospice physician who gave verbal orders for morphine give every four hours, scheduled and every two hours as needed, along with staff instructions to assess the resident frequently and administer medication as needed;-Hospice RN was at the facility for approximately two hours to ensure the resident's needs and the resident's family member's needs were addressed;-Hospice RN ensured had clear guidance and new scripts to pull morphine for the resident. Review of the resident's controlled substance accountability sheet, undated, for Morphine, showed:-On 3/15/25 at 12:00 P.M., LPN C administered 0.5 ml to the resident with 6.25 ml remaining. Review of the resident's MAR, dated March 2025, showed:-There was no documentation found the facility administered morphine 0.5 ml to the resident on 3/15/25 at 12:00 P.M. Review of the resident's physician order sheet, showed:-An order, dated 3/15/25 at 1:03 P.M., for morphine 10 mg/5 ml, give 10 ml every two hours as needed for pain. Review of the resident's controlled substance accountability sheet, undated, for morphine, showed:-On 3/15/25, at 2:00 P.M., LPN C administered 0.5 ml to the resident with 5.75 ml remaining. Review of the resident's MAR, dated March 2025, showed:-No documentation the facility administered morphine 0.5 ml on 3/15/25 at 2:00 P.M.-On 3/15/25, at 2:30 P.M., the resident had a pain level of 0;-An order on 3/15/25, at 3:18 P.M., discontinued at 11:40 P.M., for morphine 10 mg/5 ml, give 0.5 ml every two hours as needed for pain. There was not documentation found showing the facility administered morphine for this order;-An order on 3/15/25 at 3:18 P.M., discontinued at 3/15/25 at 11:40 P.M., for morphine 10mg/5ml, give 0.5 ml every four hours as needed for pain. Review of the resident's controlled substance accountability sheet for Ativan, undated, showed:-On 3/15/25, at 5:00 P.M., one tablet was administered to the resident, with one tablet remaining. Review of the resident's MAR, dated March 2025, showed:-No documentation the facility administered Ativan 0.5 mg to the resident on 3/15/25 at 5:00 P.M. Review of the resident's controlled substance accountability sheet, undated, for Morphine, showed:-On 3/15/25 at 6:00 P.M., LPN C administered 0.5 mls to the resident with 4.75 ml remaining;-No documentation the facility administered any more doses of morphine to the resident. Review of the resident's MAR, dated March 2025, showed:-The facility administered 0.5 ml of morphine to the resident on 3/15/25, at 6:00 P.M. Review of the hospice telecare call record, dated 3/15/25, showed:-At 7:18 P.M., LPN A called the hospice on-call triage to report the resident was actively transitioning and the resident's Power of Attorney (POA) was requesting an order for morphine, give every two hours;- At 7:19 P.M., a hospice nurse spoke to LPN A who reported he/she did not have any morphine 20 mg/ml on hand for the resident and was requesting medication. The hospice orders were reviewed and noted an order for morphine 20 mg/ml, gave 0.5 ml (10 mg) by mouth every two hours as needed for shortness of breath. LPN A reported the resident's family member was requesting morphine every two hours. LPN A was advised the assigned hospice nurse would get sent out to the facility due to the resident actively transitioning. Hospice would call a pharmacy in regards to getting morphine due to the facility running out/not having any on hand. LPN A was advised to continue to monitor the resident and call back if anything changed. LPN A indicated he/she understood and agreed to the plan;-At 7:30 P.M., hospice called a pharmacy in an attempt to order morphine for the resident. The pharmacy did not work with the facility;-At 7:40 P.M., hospice called the facility pharmacy in regards to medication morphine 20 mg/ml take 0.5 ml (10 mg) by mouth every two hours as needed for shortness of breath. There was no answer;-At 7:46 P.M., hospice called LPN A who said he/she called the facility pharmacy and they were working on having the morphine delivered (waiting call back). LPN A agreed to call back if any changes in pt status; No further needs at this time. Review of the resident's controlled substance accountability sheet for Ativan, undated, showed:-On 3/15/25 at 8:00 P.M., one tablet was administered to the resident, with zero tablets remaining. Review of the resident's MAR, dated March 2025, showed:-No documentation the facility administered Ativan 0.5 mg to the resident on 3/15/25 at 8:00 P.M. Review of the Hospice RN's focus visit sheet, dated 3/15/25, showed:-The visit started at 7:50 P.M.;-The resident had decreased response to verbal and visual stimuli, hyperextension of the neck, grunting of vocal cord, depression of the jaw on inspiration, drooping of the nasolabial folds (lines that run from the sides of the nose to the corner of the mouth), death rattle, and Cheyne-Stokes breathing;-The resident's pain level was 6;-The resident's family member called Hospice RN to report the resident had not received any comfort meds in over four hours. Hospice RN called the facility and they said they were not able to pull morphine out of the ADU for the resident;-Hospice RN sent a script for morphine to a local 24 hour pharmacy, he/she arrived at the local pharmacy at approximately 7:50 P.M., received the morphine from the local pharmacy at approximately 8:30 P.M., then drove back to deliver the morphine to the facility;-At approximately 9:15 P.M., Hospice RN delivered the morphine to the facility staff and ensured the resident received a dose before leaving at approximately 9:30 P.M. Review of the resident's medical record, showed:-A progress note, dated 3/15/25 at 10:08 P.M., said the resident had transitioned at 10:00 P.M. The resident's family was present and aware of the resident's declining condition. Comfort measures were provided including pain management and emotional support for family. Vital signs were absent and postmortem care was provided. The Hospice team and physician was notified. Unable to reach the resident's guardian. Review of the resident's MAR, dated March 2025, showed:-The facility administered 0.5 ml of morphine to the resident on 3/15/25, at 10:00 P.M.-On 3/15/25, at 10:30 P.M., the resident had a pain level of 0. During an interview on 7/25/25 at 9:18 A.M., LPN A said:-He/She checked on residents throughout the day, assessing for pain;-He/She would call the Primary Care Physician to obtain new orders if a resident had pain and no pain management medication available as well as checking the ADU to see if the medication was available to pull before pharmacy delivered;-He/She would call hospice to get a script for Ativan and/or morphine if a resident was on hospice, actively dying and did not have those medications available at the facility to administer;-He/She worked on 3/15/25 from 3:00 P.M. until 7:00 A.M. on 3/16/25, and was assigned to the resident's care;-The resident's family member was at bedside and upset about how nursing staff were administering pain medication to the resident. The family member would ask for pain medication for the resident every couple of hours, just to remind us;-He/She gave the resident one dose of morphine when he/she came on shift. It was the last dose available in the bottle and the resident did not have another bottle of morphine available for his/her next administration;-The off-going nurse (unknown name) told LPN A the resident was almost out of morphine and to get the next bottle from the ADU;-He/She was not able to pull morphine out of the ADU;-He/She called the facility pharmacy who confirmed they had a script for the morphine and it should be available to pull from the ADU. He/She was not sure what time the phone call to pharmacy was made;-He/She called the Hospice RN to notify him/her the resident had run out of morphine and there was some sort of glitch in the ADU which prevented LPN A from pulling morphine out;-He/She informed the resident's family member the Hospice RN had to deliver morphine to the facility and the family member got very upset;-The resident's family member never said he/she was upset about morphine not administered to the resident-The Hospice RN had the morphine ordered and dispensed from a local pharmacy, then delivered to the facility;-LPN A administered morphine to the resident at 10:00 P.M.;-He/She was not sure why the resident's controlled substance accountability sheet for the resident's Morphine showed LPN C administered 0.5 ml of morphine on 3/15/25 at 4:00 P.M.;-He/She was not sure why the resident's MAR and the controlled substance accountability sheet for the resident's morphine showed LPN C administered 0.5 ml of morphine on 3/15/25 at 6:00 P.M.;-LPN A should have documented when the resident ran out of morphine, when the facility pharmacy was notified, when the Hospice RN delivered the morphine from the local pharmacy, and what interventions were done to control the resident's pain;-He/She was expected to document administration of controlled substances in both the resident's MAR and controlled substance accountability sheet;-He/She rounded on the resident every hour and the resident did not seem to be in a lot of pain or distress;-He/She spoke to the Administrator that day but could not recall why;-The resident never missed any doses of morphine. During s on 7/25/25 at 11:40 A.M. and at 12:42 P.M., the Hospice RN said:-He/She was the nurse assigned to the resident on 3/15/25;-He/She had visited the resident several times that day due to the resident in a state of actively dying;-The resident's family member called him/her several times throughout the day to report different issues;-The resident's family member called the Hospice RN, around 10:30 A.M., to report the resident was in horrible pain, had not received any morphine in the last 24 hours and he/she could not find the resident's nurse;-The Hospice RN went to the facility to assess the resident around 12:00 P.M., and found the resident in pain, very uncomfortable with high respirations and groaning;-The Hospice RN could not find the nurse assigned to the resident and had to get a nurse from another assignment to help him/her;-The Hospice RN looked at the controlled substance accountability sheets for both morphine and Ativan and saw there was no documentation showing either medication was administered to the resident in the last 24 hours;-He/She called the Hospice DON at 12:30 P.M., to notify him/her of the situation;-He/She then called the Hospice Doctor and received a new order to give morphine every 15 minutes until comfort was achieved;-The Hospice RN gave the order verbally to the nurse assigned to another unit;-The nurse from the other unit drew up doses of morphine, gave the medication to the Hospice RN, who then administered it. The Hospice RN believes he/she gave two or three doses of morphine to the resident during his/her visit;-The nurse from the other unit signed out the morphine doses were administered because the nurse assigned to the resident was not found during the Hospice RN's visit;-The Administrator came into the facility at approximately 11:30 A.M.;-The Hospice RN reported to the Administrator the resident's morphine was running low and the Administrator stated the nurses could pull additional morphine from the ADU;-The Hospice RN never saw the nurse assigned to the resident during his/her visit;-The Hospice RN recalled he/she left around 1:30 P.M. and the resident was semi-comfortable;-He/She expected the facility staff to put the order for morphine, to give every 15 minutes until comfortable, to follow physician orders, and to give morphine and/or Ativan as ordered until the resident was comfortable;-The resident's family member called the Hospice RN around 7:00 P.M. to report the resident had not received any morphine and was in pain;-The Hospice RN called the facility and the resident's nurse reported the resident had run out of morphine and the nurse was not able to get morphine out of the ADU;-The Hospice RN made several calls to the facility to see if they were able to get morphine from the ADU after speaking to their pharmacy or if their pharmacy could send out morphine quickly;-The Hospice RN also called the Hospice DON to notify him/her of the situation and to get direction from the Hospice team;-At approximately 8:00 P.M., the Hospice DON called the Hospice RN to report the facility was not able to get morphine to the resident from their ADU nor from their pharmacy. The Hospice RN was asked to try to get a script filled for the resident's morphine at a local pharmacy;-The Hospice RN was able to get the resident's morphine script filled at a local pharmacy and delivered the morphine to the facility at approximately 9:30 P.M. The local pharmacy did not provide a controlled substance accountability sheet for the bottle of morphine;-The Hospice RN assessed the resident for pain at approximately 9:30 P.M. and found the resident was in pain and uncomfortable, although not as bad as when the resident was assessed earlier that day on the Hospice RN's last visit;-The Hospice RN left the facility after the resident received a dose of morphine;-The Hospice RN received a call at 10:03 P.M., from the facility nurse who stated the resident had passed;-He/She expected the facility nurses to assess the resident every two hours for pain and administer medications as ordered for pain control;-He/She expected the facility to document all that happened that day, including documentation from the Administrator showing her involvement in the event;-The Hospice RN expected the facility to notify him/her when the resident had not received pain control medications for so long and to report the resident's pain cycle;-The Hospice RN was only updated on the resident's condition and lack of pain control medications administered by the resident's family member. The facility staff communicate the resident's condition to the Hospice RN. During an interview on 7/25/25 at 1:31 P.M., LPN B said:-He/She worked on 3/15/25 from 7:00 A.M. through 3:00 P.M.;-He/She was assigned to a different unit from the resident's;-The resident's family member was at bedside and kept coming out saying the resident was in pain and needed medication. The resident's family member was being extra;-He/She assessed the resident before the Hospice RN came to the facility and the resident looked comfortable without any facial grimacing. LPN B thought maybe the resident's family member assumed the resident was in pain;-LPN B knew the resident received his/her morphine and Ativan as scheduled. He/She was not sure how he/she knew that, just that he/she did;-The Hospice RN came into the facility at an unknown time and both the Hospice RN and the resident's family member kept coming to LPN B to ask for help for the resident because they could not find the resident's assigned nurse, LPN C;-LPN B called to inform the Administrator the resident's family member was very loud when stating the resident was in pain and was not receiving pain medication;-LPN B did not know where LPN C was when the Hospice RN was in the facility;-LPN B drew up two doses of morphine, around 10:00 A.M. through 12:00 P.M. and gave the opioid to the Hospice RN to administer for pain control;-LPN B informed the Hospice RN he/she would tell LPN C to document the two doses of morphine were administered;-LPN B had a lot going on with his/her own assignment and just gave the morphine doses to the Hospice RN to administer to the resident. LPN B saw Hospice RN administer the morphine doses to the resident;-LPN B was responsible for administering the morphine doses to the resident and was responsible for documenting in the resident's MAR and controlled substance accountability sheet when the doses were administered in real time;-He/She gave the morphine doses to the Hospice RN to try to help as they could not find the resident's assigned nurse;-LPN B told LPN C to document the morphine doses the Hospice RN administered to the resident and watched LPN C sign out the morphine doses on the controlled substance accountability sheet;-The Administrator came into the facility, at an unknown time, and LPN B went back to his/her assignment. He/She did not know what happened after the Administrator came into the facility;-He/She did not know where the resident's assigned nurse, LPN C, was during the period in which the Hospice RN was in the building. LPN B believed LPN C came back when the Administrator entered the facility;-LPN B put in a new order for the resident's morphine;-LPN B should have documented his/her assessment of the resident, including the time, any new orders he/she put in the system, the interaction with the resident's family member and the Hospice RN, the morphine doses he/she drew up and gave to the Hospice RN to administer, including the times, who signed out the morphine administration, when he/she called the Administrator and why. LPN B was not sure why he/she did not appropriately document the event on 3/15/25;-LPN B was not interviewed or questioned about his/her involvement on 3/15/25 by any of the administrative staff. During an interview on 5/23/25 at 2:22 P.M., Family Member (FM) F said the facility had all of the resident's orders in the system, but the facility was out of the resident's medications. On the day the resident passed, he/she began experiencing breakthrough pain. Desperate, FM F informed the staff that he/she was going to call an ambulance and have the resident rushed to the emergency room. The nursing staff told FM F that he/she couldn't do that. So, FM F called hospice. Hours later, hospice got the Medical Director to call in a prescription for morphine to a local pharmacy, and hospice picked it up and returned with a big bottle of morphine and administered some to the resident. During an interview on 7/25/25 at 3:06 P.M., the Regional Nurse, the Director of Nursing (DON) and the Area Director of Operations, said:-The Area Director of Operations did not know of any issues regarding the end-of-life care for the resident on 3/15/25. She expected the Administrator to inform her of anything that occurred that was out of the ordinary or if there was an investigation;-They expected nurses to document when they put in a new order as it was best practice;-They expected nurses to document if an actively dying resident was missing any pain medications, including morphine and/or Ativan, what they did to try to remedy the situation who was notified and when, when the pain medications were available at the facility, and the resident's condition;-They expected nurses to put in new orders for pain control immediately for an actively dying resident so the resident could get the pain medications as soon as possible as they did not want the resident in pain;-They expected nurses to be available to their assigned residents while clocked in and if they were on a break, other staff should be able to contact them. Nursing staff had two fifteen-minute breaks and a thirty minute lunch break. Other staff should know when the nurses took a break and where so they could contact them if needed;-Controlled substance accou

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents receive care consistent with professional standards to prevent pressure ulcers (injury to the skin and underlying tissue caused by pressure or friction) from developing and promote healing for one resident (Resident #6), who was admitted with a very red and excoriated buttock that developed into an unstageable pressure ulcer (depth of tissue loss cannot be determined due to covering with nonviable tissue). Staff failed to complete all skin assessments per their policy, ensure nurse's followed up and documented on concerns identified on shower/bath audit forms, ensure only licensed nurses applied treatments, notify the physician of skin concerns, and monitor the area of concern for changes. In addition, the facility failed to ensure they followed the wound company's physician order, to change one resident's treatment from every Monday,Wednesday,Friday to daily for one resident (Resident #15). Six residents were sampled for pressure ulcers and problems were identified with two. The census was 78. Review of the facility Skin Management Guidelines, Practice Guidelines, dated 2/2016 and revised on 7/2017, showed: Purpose: -To identify at risk residents for potential breakdown or ulcerations; -To prevent breakdown of tissue or ulcerations; -To provide treatment that promotes prevention of ulcerations and healing of existing ulcerations; Risk Factors Include: -Impaired mobility; -Cognitive impairment; -Exposed skin to urinary or fecal incontinence; -Under nutrition, malnutrition, and hydration deficits; Newly admitted Residents: -Upon admission, all residents are assessed for skin integrity by completing an assessment and documenting in the electronic health record/EHR; -Following admission; the Braden Scale (an assessment tool) - quarterly, annually, and with change in condition, for their risk for development of pressure injury; -Certified nurse's aides (CNAs) will complete body audits. The body audits post shower will be turned into the licensed nurse to review for changes in skin condition; -Appropriate preventative measures will be implemented on all residents identified at risk and the interventions documented on the Care Plan. This may include: -Turn and reposition; -Pressure reduction surfaces for beds, wheelchairs, etc.; -Floating areas of concern such as heels when appropriate; -Separation of bony prominence's with a pillow or device when lying on side; -Promotion of clean, dry and well moisturized skin; -Reduction of shearing force by appropriate body mechanics when moving, turning or repositioning resident; Residents admitted with skin impairments will have: -Appropriate interventions implemented to promote healing; -A physician's order for treatment; -Wound location and characteristics documented in the EHR; -Referral to rehabilitation services; -Registered Dietician to assess nutritional needs; -Their family notified of presence of skin impairment; -Care plan implemented. A care plan is developed upon admission, identifying the contributing risks for breakdown, including history of skin impairment or the actual impairment and the interventions implemented to promote healing and prevent further breakdown; -At Risk Review Meetings will be conducted to review/discuss: -New admissions with wounds present; -Residents identified at risk or with compromise. Review of the facility Notification of a Change in a Resident's Condition policy, dated 11/1/18 and reviewed on 4/28/21, showed: The attending physician and the resident representative will be notified of a change in a resident's condition, per standards of practice and Federal and/or State regulations. Responsibility: -All licensed nursing personnel; Procedure: -Guideline for notification of physician/resident representative included: Onset of pressure ulcers. 1. Review of Resident #6's hospital transfer information, sent to the facility upon the resident's admission on [DATE], showed: admission Information: -admission date (to hospital) of 10/31/22; Hospital Course: -Resident has chronic lower back/sacral/sacrum (the bone below the small of the back and above the coccyx pain; -Wound care team was consulted for skin breakdown to the buttock area, small open area remains with blanching (whitish coloration remains on the skin after pressure is applied) surrounding/peri-wound (the area/skin surrounding a pressure ulcer or wound) darkened tissue; Assessment and Plan: -Chronic lower back pain. Resident states he/she fell onto his/her tail bone at his/her previous facility; Wound Care Notes: 11/11/22 at 10:35 A.M.: Consulted for new skin breakdown to coccyx. Resident has darkened tissue which is blanchable. There is a small open area which is likely due to incontinence. For now there is a sacral dressing in place over site; -11/16/22 at 11:00 A.M.: Consulted for skin breakdown to buttock. Small open area remains with blanchable surrounding darkened tissue. Appears unchanged from last week. This open area was caused by excessive moisture. Meplix dressing (foam - absorbent dressing) is in placed at this time. On low air loss mattress (air mattress that reduces pressure) and turning schedule. Review of the resident's EHR showed: -admission date (to facility) Saturday 11/19/22, from the hospital; -Diagnoses of altered mental status, sacrococcygeal disorders (tailbone pain), fibromyalgia (a condition causing wide spread pain) and weakness. -No completed Skin Observation Tool completed by a nurse upon admission. Review of the resident's baseline care plan (completed upon admission), undated and received via e-mail on 12/14/22, showed: -Daily Preferences: Bed baths; -Personal Hygiene/Bathing/Toilet Use/Bed Mobility and Transfers: One person physical assist; -Always incontinent of bowel and bladder; -Skin Risk: Current skin integrity issues. The care plan did not specify the skin integrity issues; -Signed, but not dated, by the Assistant Director of Nurses (ADON) and Social Service Director. Review of the resident's Pressure Injury Risk assessment (used to determine a resident's risk of developing pressure ulcers), completed on 11/19/22, showed: -Ability to respond meaningfully to pressure-related discomfort: Slightly limited, responds to verbal commands but cannot always communicate discomfort or the need to be turned, or has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities; -Degree to which skin is exposed to moisture: Occasionally moist, skin is occasionally moist, requiring an extra linen change approximately once a day;; -Degree of physical activity: Bedfast, confined to bed; -Ability to change and control position: Completely immobile, does not make even slight changes in body or extremity position without assistance; -Usual food intake: Probably inadequate; -Friction and shear: Problem, requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed, requiring frequent repositioning with maximum assistance; -Score: 11.0, indicating High Risk. Review of the resident's progress notes, dated 11/22/22 at 6:58 A.M. and completed by Nurse E, showed: Late note for 11/19/22. New admission came in with family members. Resident's chief complaint was that he/she fell about 3 months ago and his/her tail bone hurts. Body assessment completed from head to toe. No open areas were noted, but resident's buttock was very red and excoriated; -The nurse did not document if he/she had completed the facility Skin Observation Tool, or notified the resident's physician regarding the very red and excoriated buttock. Review of the resident's physician's order sheet (POS), dated 11/19/22 through 11/30/22, showed: -No treatments for the resident's buttock, sacrum, or coccyx from 11/19/22 through 11/28/22; -An order dated 11/29/22: Butt cream (barrier cream/helps to keep moisture or bowel movement off the skin), Baza cream (barrier cream) or other barrier cream of facility choice may be used to gluteal cleft (the grooves between the buttocks that begins just below the sacrum) three times a day for open area; -An order, dated 11/30/22: Wound care to coccyx: Cleanse with normal saline (salt/water solution) and apply Santyl (ointment that removes dead tissue) and foam dressing every day and as necessary. Review of the resident's treatment administration record (TAR), dated 11/19/22 through 11/30/22, and 12/1/22 through 12/2/22 (resident discharge date ), showed: -11/19/22 through 11/29/22: No treatments for the resident's buttock(s), sacrum, or coccyx. -An order, dated 11/19/22, for weekly skin checks by licensed staff on the night shift, showed: The night nurse completed on 11/23/22 and 11/30/22. No documentation noted on the TAR or in the progress notes by the night nurse completing the skin assessments. -An order dated 11/29/22: Butt cream, Baza cream, or other barrier cream of facility choice. May be used three times a day for open area. -An order dated 11/30/22: Wound care for coccyx. Cleanse with normal saline. Apply Santyl and foam dressing every day and PRN/as necessary. Review of the nurse's progress notes showed: -11/21/22 at 3:30 P.M.: Alert x 2-3 (based on the ability to recall one or more of the following: person, place, time and situation). Maximum assistance of 1-2 staff required for bed mobility and incontinent care; -11/22/22 at 1:27 A.M.: Resident alert and oriented x 2-3. Required maximum assistance of 1-2 with bed mobility and activities of daily living (ADLs/eating, personal hygiene, transfers, bathing, etc.). No complaints of pain or discomfort. Skin warm and dry to touch; -11/24/22 at 10:59 P.M.: Resident complained of back pain. Rated pain as a 6 on a scale of 1-10. Resident was incontinent of bowel and bladder; -11/30/22 at 3:47 P.M., and completed by the facility wound nurse: Initial assessment with the wound care company physician for unstageable pressure ulcer - Known, but not stageable due to coverage of wound bed by slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous) and/or eschar (black, brown or tan tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder than surrounding skin). Wound measures 3.5 centimeter (cm) length by 1.3 cm width by 0.2 cm depth. Thick adherent black necrotic (dead) tissue: 15% (of the wound bed). Thick adherent devitalized (dead) necrotic tissue: 45% (of the wound bed). Slough: 40% (of the wound bed). Treatment plan was to place Santyl to wound bed and cover with gauze daily; -12/2/22 at 11:33 A.M.: Family present for discharge. Wound care education and demonstration provided as well as supplies and instructions on how to clean and dress wound, signs and symptoms of infections as well as when to notify physician. Spoke to Social Services regarding wound care visits at home. During an interview on 12/5/22 at 9:00 A.M., Nurse E said he/she was the day shift nurse. He/she reviewed his/her late progress note, dated 11/22/22 at 6:58 A.M., that referred to the resident on 11/19/22. Nurse E said the resident's coccyx area was red and excoriated, but not open when he/she first saw it on 11/19/22. He/she applied barrier cream, and told the evening shift nurse to call the physician about the coccyx area. Nurse E could not explain why he/she asked the evening shift nurse to call the physician since he/she had completed the assessment at 6:58 A.M. Nurse E said he/she should have called the physician himself/herself. He/she thought he/she had completed a Skin Observation Tool, but could not find one in the EHR. When a CNA completes a shower review form, the nurse was to review it. If there is anything abnormal documented by the CNA, the nurse should assess it and if necessary call the physician and notify the facility wound nurse. Review of the resident's Skin Monitoring: Comprehensive CNA Shower Review forms (completed by CNAs after giving a resident a bath/shower) and reviewed and signed by the charge nurse, showed: -11/21/22, completed by CNA B and signed by an unknown nurse on 11/21/22, showed CNA B circled the buttock on the anatomical figure. No other documentation was on the shower review form. There was no documentation in the nurse's progress notes regarding CNA shower review form; -11/23/22, competed by CNA B and signed by an unknown nurse on 11/23/22, showed the CNA circled the buttock on the anatomical figure. No other documentation was on the shower review form. There was no documentation in the nurse's progress notes regarding the CNA shower review form; -11/28/22, completed by CNA B and signed by an unknown nurse on 11/28/22, showed the CNA circled the buttock on the anatomical figure. No other documentation was on the shower review form. There was no documentation in the nurse's progress notes regarding the CNA shower review form. During an interview on 12/2/22 at 3:05 P.M., CNA B reviewed the Skin Monitoring: Comprehensive CNA Shower Review forms dated 11/21/22, 11/23/22 and 11/28/22. The CNA confirmed he/she completed the resident's bed baths on those days and circled the buttocks area on the anatomical figures. He/she was new at the facility, and did not know most of the nurse's by name. He/she said the resident did not have a lot of independent mobility, relied on staff to turn and reposition, and seems to have a lot of pain on his/her bottom. He/she said: -11/21/22: This was the first time he/she was assigned to the resident. He/she noticed something on the resident's bottom and turned on the overhead light. The resident's bottom (sacrum/coccyx area) was red and there was a small open area. He/she found the nurse (name unknown) who was busy passing medications. The nurse said he/she would check the area later, and for him/her to go ahead and apply zinc oxide (a cream/paste used as a preventative treatment and/or for stage II pressure ulcers (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough)). The nurse looked at the area later that evening and told him/her to keep putting the zinc oxide on it and he/she would call the resident's family; -11/23/22: One of the resident's family members were present. The resident's bottom was still red with an open area. There was no dressing on the area. He/she did not know if the open area was larger than on 11/21/22. He/she did not recall seeing necrotic tissue though. He/she and the resident's family member changed the resident and the family member applied the zinc oxide on the open area. He/she told the nurse (name unknown, but not the same nurse as 11/21/22) on duty again about what he/she observed. He/she was not sure if the nurse went into the room to assess the open area or not; -11/28/22: The resident's area did not have a dressing on it and it was red and puffy looking. It still had an open area, but he/she was not sure if it was larger than when he/she saw it on the previous dates. He/she did not recall if there was necrotic tissue or not. The resident complained of the area hurting more on 11/28/22 than previously. He/she cleaned the area and put the zinc oxide on it. The resident said it felt better after he/she cleaned it and applied the zinc oxide. He/she told the nurse (name unknown, but not the same nurse as on 11/21/22 or 11/23/22). Review of the resident's Skin Observation Tool, showed: -11/24/22 at 1:12 P.M., showed: Notes: Buttocks slightly reddened, no open areas noted to skin; -11/29/22 at 2:54 P.M., showed: Site: Sacrum, Type: Pressure, Measurements: 3.5 cm by 1.3 cm by 0.2 cm, Stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling (damaged tissue under the surface of a wound)). Notes: Followed by wound care company physician. Treat daily with Santyl daily. Monitored daily by facility wound nurse and nursing staff. Review of the wound company evaluation and summary note, dated 11/29/22, showed: Focused Wound Exam (Site 1): -Unstageable (due to necrosis). Sacrum full thickness; -Etiology (cause/origin): Pressure; -Duration: Greater than 14 days; -Objective: Healing; -Wound Size (Length-Width-Depth): 3.5 cm by 1.3 cm by 0.2 cm; -Surface Area: 4.55 cm; -Exudate (drainage): Light serous (pale red or pink drainage); -Thick black necrotic tissue: 15%; -Thick devitalized necrotic tissue: 45%; -Slough: 40%; Dressing Treatment Plan: -Santyl apply once daily for 16 days; -Off-load wound. Reposition per facility protocol. Turn side to side and front to back in bed every 1-2 hours if able; Surgical Excesional Debridement Procedure: The wound was cleansed with normal saline and anesthesia was applied using topical benzocaine (ointment applied topically to relieve pain). Then with clean surgical technique, a #15 blade (surgical scalpel) was used to surgically excise (remove) devitalized tissue and necrotic subcutaneous (the layer just beneath the skin) tissues along with slough at a depth of 0.2 cm and healthy bleeding tissue was observed. As a result of this procedure, the nonviable (dead tissue) in the wound bed decreased from 100% to 70%. A clean dressing was applied; Plan of Care: The best medical estimate of the time required for this wound to heal with continued physician evaluation and intervention is 42 days. This estimate is made with an 80% degree of certainty. Observation on 12/2/22 at 10:20 A.M., showed the resident lay in bed. The facility wound nurse positioned the resident onto his/her side and removed a dressing dated 12/2/22 from the resident's sacrum/coccyx area, revealing a pressure ulcer. The wound nurse said she did not feel comfortable staging pressure ulcers. She described the appearance of the pressure ulcer as having a red peri-wound and the wound bed being covered by 90% gray necrotic slough. She measured the pressure ulcer and said it was 4.2 cm by 2.9 cm. She had not been told that the resident admitted with a red coccyx/sacrum or a stage II pressure ulcer. The resident's family member was present at the time of the assessment. He/she said he/she saw the pressure ulcer at the hospital prior to the resident being discharged to the facility. The resident's pressure ulcer was red and had a small open area, but it did not look like this. There was no necrotic tissue and it was not as large as it was now. The wound nurse said the first time she saw the pressure ulcer was on 11/29/22, with the wound care company physician. It looked like it did at this time. During an interview on 12/5/22 at 11:05 A.M., the facility wound nurse said she had been the wound nurse since August 2022. She works Monday through Friday. She was not here on 11/19/22 (Saturday) when the resident was admitted . If a resident is admitted with a red area, pressure ulcer/wound and she is not here, the admitting nurse is responsible to complete a Wound Observation Tool/skin assessment and include a description and measurement. The admitting nurse should contact the physician for an order and enter it into the EHR, including the TAR. She and the Director of Nursing (DON) should be notified as well. Once a pressure ulcer or wound has been identified, only the nurses, not the CNAs, should be applying treatments. Nurses should assess the pressure ulcer or wound daily noting any changes including healing or deterioration. Had she been aware of the pressure ulcer upon admission, she would have ordered a low air loss mattress, contacted the physician and obtained a treatment order. During an interview on 12/5/22 at 12:00 P.M., the resident's physician, who was also the facility Medical Director, said she expects staff to follow the facility policy regarding pressure ulcers. Staff should complete a skin assessment when any new resident is admitted . She was not notified the resident was admitted with a red or open area on the coccyx/sacrum area. Had she been notified, she would have ordered zinc oxide every shift and given an order for staff to contact the wound company's physician for further assessment and treatment. It's important for nurses, not CNAs, to apply treatments. CNAs are not trained to assess pressure ulcers for changes. Any deterioration should be documented and either she or the wound company physician should be notified. She expects staff to document information about pressure ulcers/wounds in the resident's EHR. During an interview on 12/5/22 at 3:35 P.M., the DON said she expects staff to follow the facility policies. Upon admission, a skin assessment should be completed and documented. If there is an abnormal finding, staff should call the resident's physician. This includes redness, excoriation or an open area. CNAs can apply ointments and/or creams, but only as a pressure ulcer prevention. Once an area is identified, CNAs are no longer allowed to apply anything. It must be the nurse applying the treatment so the pressure ulcer can be monitored for healing or deterioration. Nurses should be documenting in the EHR any areas noted, treatments and assessments. She could not determine who the three nurses were that signed the shower review forms on 11/21/22, 11/23/22 and 11/28/28. She did not know why those nurses did not contact the resident's physician and/or document their follow-up in the EHR. 2. Review of Resident #15's quarterly Minimum Data Set, a federally mandated assessment instrument completed by facility staff, dated 10/27/22, showed: -Cognitively intact; -Clear speech, distinct intelligible words; -Makes Self Understood: Understood; -Ability to Understand Others: Understands; -Limited assistance of one person required for bed mobility and transfers; -Extensive assistance of one person required for toilet use, personal hygiene and bathing; -Functional limitation in range of motion in both upper and lower extremities; -Always incontinent of urine and bowel; -Diagnoses of high blood pressure, renal (kidney) insufficiency, stroke, and paraplegia (paralysis of the lower limbs); -Unhealed pressure ulcers (bedsores): Yes; -Two stage IV pressure ulcers. Review of the resident's care plan, completed on 9/24/22, showed: Focus: -ADL Function: Needs assistance with ADLs due to paraplegia and weakness. He/she is a total assist for transfers and utilizes a sit to stand lift (a machine used to transfer a resident that can bear weight while standing). He/she was 1-2 extensive assistance for bed mobility, personal care and grooming; -Incontinent of bowel and bladder; -At risk for delayed wound healing and decline in over all health. He/she was admitted with three pressure ulcers; -Impaired functional mobility as evidenced by muscle weakness and need to assist in personal care; Interventions: -Provide more assistance in the evening or at night when tired or in pain; -Assist with toileting needs/incontinence care on routine rounds and as needed; -Wound management company for wound care; -Perform treatment to wounds per current treatment order; -Follow pressure ulcer prevention guidelines to prevent additional skin problems, promote healing and prevent complications; -Sit to stand transfers and motorized wheel chair for mobility. Review of the resident's POS and TAR, dated 11/1/22 through 11/30/22, and 12/1/22 through 12/31/22, showed: -An order dated 11/4/22, and discontinued on 12/5/22, for Collagen Matrix- Silver Sheet (Collagen sheet/a treatment that aides in the formation of granulation (healthy) tissue) to the right and left buttock every Monday-Wednesday-Friday; -An order, dated 12/6/22, for collagen sheet daily. Review of the resident's Pressure Injury Risk assessments, showed on 12/5/22, a score of 13, or moderate risk to develop pressure ulcers. Review of the wound company evaluation and summary notes showed: On 11/1/22: Site 9: Stage IV Pressure Wound of the Right Buttock: -Etiology: Pressure; -Duration: Greater than 769 days; -Objective: Healing; -Wound Size: 1.8 cm by 0.4 cm by 0.4 cm; -Exudate: Light Serous; -Granulation Tissue: 100%; -Wound Progress: Improved; -Primary Dressings: Collagen sheet, apply three times per week for 30 days; Site 10: Stage IV Pressure Wound of the Left Buttock: -Etiology: Pressure; -Duration: Greater than 770 days; -Objective: Healing; -Wound Size: 6.5 cm by 2.3 cm by 1.9 cm; -Exudate: Moderate serous; -Granulation Tissue: 100%; -Wound Progress: Improved; -Primary Dressings: Collagen sheet, apply three times per week for 30 days; On 11/8/22 (Primary dressing order changed from Monday-Wednesday-Friday to daily on this date): Site 9: Stage IV Pressure Wound of the Right Buttock: -Wound Size: 1.6 cm by 0.4 cm by 0.4 cm; -Exudate: Light sero-sanguinous (thin/watery fluid that is pink in color); -Granulation Tissue: 100%; -Wound Progress: Improved; -Primary Dressings: Collagen sheet, apply daily for 16 days; Site 10: Stage IV Pressure Ulcer of the Left Buttock: -Wound Size: 5.3 cm by 1.5 cm by 0.6 cm; -Exudate: Moderate Sero-sanguinous; -Granulation Tissue: 100%; -Wound Progress: Improved; -Primary Dressings: Collagen sheet, apply daily for 16 days; On 11/15/22: Site 9: Stage IV Pressure Wound of the Right Buttock: -Wound Size: 2.1 cm by 0.3 cm by 0.5 cm; -Exudate: Light sero-sanguinous; -Thick adherent devitalized necrotic tissue: 20%; -Slough: 10%; -Granulation Tissue: 70%; -Wound Progress: Improved; -Primary Dressings: Collagen sheet, apply daily for 9 days; Site 10: Stage IV Pressure Ulcer of the Left Buttock: -Wound Size: 5.7 cm by 1.3 cm by 0.4 cm; -Exudate: Light sero-sanguiness; -Granulation Tissue: 100%; -Wound Progress: Improved; -Primary Dressings: Collagen sheet, apply daily for 16 days; On 11/23/22, the resident's visit had to be rescheduled because the resident was out for dialysis (a treatment that does some of the things done by healthy kidneys); On 11/29/22: Site 9: Stage IV Pressure Ulcer of the Right Buttock: -Wound Size: 1.9 cm by 0.3 cm by 0.3 cm; -Exudate: Moderate serous; -Thick adherent devitalized necrotic tissue: 15%; -Slough: 15%; -Granulation Tissue: 70%; -Wound Progress: Improved; -Primary Dressings: Collagen sheet, apply once daily for 16 days; Site 10: Stage IV Pressure Ulcer of the Left Buttock: -Wound Size: 5.5 cm by 1.4 cm by 0.6 cm; -Exudate: Moderate Sero-sanguiness; -Granulation Tissue: 100%; -Wound Progress: Improved; -Primary Dressings: Collagen sheet, apply daily for 16 days; On 12/6/22: Site 9: Stage IV Pressure Ulcer of the Right Buttock: -Wound Size: 1.2 cm by 0.5 cm by 0.3 cm; -Exudate: Moderate sero-sanguiness; -Thick adherent devitalized necrotic tissue: 10%; -Slough: 15%; -Granulation Tissue: 75%; -Wound Progress: Improved; -Primary Dressings: Collagen sheet, apply once daily for 9 days; -Surgical Excisional Debridement: Nonviable tissue decreased from 25% to 10%; Site 10: Stage IV Pressure Ulcer of the Left Buttock: -Wound Size: 5.2 cm by 1.0 cm by 0.5 cm; -Exudate: Moderate Sero-sanguiness; -Granulation: 100%; -Wound Progress: Improved; -Primary Dressings: Collagen sheet, apply once daily for 9 days. Further review of the residnet's POS and TAR dated 11/1/22 through 11/30/22, and 12/1/22 through 12/31/22, showed, showed resident's treatment was not changed to daily on 11/8/22 as per the wound company's orders and was not changed to daily until 12/6/22. Observation on 12/5/22 at 9:50 A.M., showed the resident lay in bed prior to a skin assessment. The resident said his/her treatments should be completed two times a day, but most of the time they are doing his/her treatments every other day based on his/her dialysis days. He/she said staff completed his/her pressure ulcer treatments yesterday. During an interview on 12/8/22 at 9:13 A.M., the facility wound nurse said she makes rounds with the wound co