**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide adequate supervision for one resident after an aide left the resident unattended in the bathroom during toileting (Resident #33). The resident was found in the hallway across the room, laying on their back on the floor, with a gash to the forehead. The resident was sent to the emergency room and returned with bruising to the head, face, and neck areas. The census was 113. The Administrator was notified on 3/8/24 of the past non-compliance. The nursing staff immediately assessed the resident and treated for injuries. Staff called 911 and reported the unwitnessed fall to the resident's next of kin and physician. The facility immediately in-serviced staff on toileting residents. The subject matter included to never leave a resident unattended in the bathroom or shower. If supplies are needed, pull the call light for staff to come assist and to gather all supplies before giving care. Facility also in-serviced staff on the fall policy and change in condition policy. The subject matter included to notify physician, family, and document all falls regardless of transfer to emergency room. It must be in risk management regardless of witness, unwitnessed, or sent to the hospital. All falls must be notified to manager on call and all transfers to emergency room must be notified to manager on call. The noncompliance was corrected on 2/8/24. Review of Resident #33's annual Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 1/15/24, showed: -Severe cognitive impairment; -Diagnoses included high blood pressure, aphasia (language disorder), diabetes, other fracture, and cataracts; -No range of motion impairment; -Required substantial/maximal assistance. Helper does more than half the effort for toileting hygiene, shower/bath, upper and lower body dressing, putting on/taking off footwear, and personal hygiene; -Required substantial/maximal assistance. Helper does more than half the effort for resident to roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed to chair transfer, toilet transfer and tub/shower transfer; -Walk 10 feet: Not attempted due to medical condition or safety concerns; -Uses manual wheelchair; -Has the resident had any falls since admission or prior assessment: No. Review of the resident's medical record, showed diagnoses of diabetes, respiratory failure, aphasia, muscle wasting and atrophy (muscle shrinking and weakening), history of falling, need for assistance with personal care, mild cognitive impairment, muscle weakness, repeated falls, and mixed receptive-expressive language disorder. Review of the resident's care plan, revised on 1/23/24, showed: -Focus: Resident is incontinent of bowel and bladder due to cognitive impairment. He/She is unable to communicate or unaware of toileting needs and/or follow directions to participate in toileting program: -Goal: Keep clean, dry, and comfortable daily with use of urinary/bowel incontinence products; -Interventions: Check Resident before and after meals and evening (PM) for incontinent episodes. Document incontinency status each shift. Place call light or other communication device within reach at all times. Provide incontinence/perineal care (cleansing of the surface area to include the buttocks and genitals) after each incontinent episode, use barrier cream; -Focus: Resident has an activities of daily living (ADL) self-care performance deficit, impaired balance, and limited mobility: -Goal: ADL function: Resident requires assistance with ADL care and mobility here on a skilled rehab stay to increase in strength, mobility, endurance, and independence; -Interventions: Personal hygiene: One assist. Toilet use: Does not use bed pan, toilet or commode. Utilize check and change to manage incontinence. Transfer: One assist; -Focus: Resident has limited physical mobility related to weakness: -Goal: Will remain free of complications related to immobility, including contractures, thrombus (blood clot) formation, skin-breakdown, fall related injury; -Interventions: Uses a wheelchair: manual. Ambulation: Does not walk. Locomotion: Dependent one assist via wheelchair; -Focus: Resident is unable to communicate due to expressive aphasia. He/She required staff to anticipate and meet needs daily: -Goal: Make basic needs known on a daily basis; -Interventions: Anticipate and meet needs. Encourage resident to communicate needs daily. Ask simple yes or no questions to meet needs. Ensure/provide a safe environment; -Focus: Resident has history of falls due to multiple factors, cognitive deficits, impaired balance, and the use psychotropic medications: -Goal: The resident will not sustain serious injury; -Interventions: nonskid socks. Anticipate and meet the resident's needs. Dycem (non-slip mat) to wheelchair. High visibility area. Staff to assist with transfers. Staff to do frequent rounding 6/18. Toileting schedule. Use stand up lift with transfers. Review of the resident's progress notes showed: -On 1/29/24 at 2:00 P.M., Certified Nurse Aide (CNA) reported resident being on the floor. When entering resident's room, resident sitting on the floor by his/her wheelchair with his/her shoes off. Resident had attempted to get in the bed per self. Resident able to move bilateral (both sides) lower extremities (BLE)/bilateral upper extremities (BUE) without difficulty. Denies hitting head and pain. No injuries noted. Resident assisted to wheelchair x 3 staff with gait belt; -On 1/30/24 at 10:15 A.M., the resident discussed with interdisciplinary team (IDT) related to 1/29 fall. Resident has history of falls. Safety intervention in place is non-skid socks; -On 2/2/24 at 3:07 P.M., resident sent out to hospital via due to a fall; -On 2/2/24 at 3:34 P.M., Resident has an abrasion noted to the center of forehead that is 1.0 x 0.1 centimeter (cm) and a skin tear to the back of the right hand that is 2.5 x 0.3 cm. Resident also has a knot on the right side of his/her forehead that he/she obtained during a fall; -On 2/3/24 at 12:37 A.M., resident returned from hospital at 10:40 P.M., per stretcher escorted by two paramedics. Resident taken back to room and assisted into bed, resident cleaned, dried, and repositioned. Call light placed within reach. Hospital paper received from paramedics. New orders noted and will be placed in computer. During an interview on 3/8/24 at 10:45 A.M., Registered Nurse (RN) X said he/she did wound care on 2/2/24. It was close to end of shift between 2:00 P.M. to 3:00 P.M. and he/she went to get something from the wound closet. The resident was at the doorway to a room. It was not his/her doorway. The resident's room was across the hall from where he/she was found. His/Her pants were down around his/her thigh area. RN X believed the resident was on his/her side, there was blood on the front of his/her head, and he/she had something on the forehead, maybe lip. Blood was pooling on the floor under him/her, and RN X thought he/she might have an injury on the back of his/her head, but after cleaning it up he/she did not. The wheelchair was not anywhere around. There was a skin tear on right hand as well. There were no residents around him/her. He/She asked the resident why his/her pants were down and what he/she was doing. The only thing Resident #33 could say was he/she was hurting and could not sit up because it hurt. The resident was not moved, staff called an ambulance, and they came and took over. Staff knew that the resident was a fall risk, so they would do more frequent rounds. There was a CNA inside the nurse's station. When RN X asked the resident what happened or how did you fall, the CNA came out to assist. He/She did not know the aide because he/she was new. The CNA said he/she had the resident on the toilet and stepped away for a moment. RN X told the aide that he/she should not leave him/her on the toilet, because they do not have the mental capacity to stay when told. The aide did not say what he/she was doing at the nurse's station. Licensed Practical Nurse (LPN) U was on the other side working with someone, but he/she came over and started helping. He/She also called the DON and the DON arrived and helped. The restorative aid arrived while they waited for the ambulance Review of the resident's skin assessment, dated 2/2/24, showed: -Skin tear on right hand (back) that measured 2.5 cm Length (L) x 0.2 cm Width (W) x 0.1 cm Depth (D); -Other that measured 1.0 cm L x 0.1 cm W (No documentation of site or type); -Abrasion to forehead (no documentation of measurements). Review of the resident's hospital record, showed: -admitted [DATE]; -discharged [DATE]; -Chief complaint: Patient from facility for ground level fall. Emergency Medical Services (EMS) reports patient was left unattended in bathroom, found on ground calling for help, assumed fall from ground, small lacerations to left forehead, alert and oriented to self only, wheelchair bound, cognitive and expressive language disorder, high blood pressure; -Heads, ears, eyes, nose, and throat (HENT): Comments: Forehead abrasion; -Right frontal and scalp soft tissue swelling/hematoma and overlaying lacerations. Review of the resident's hospital discharge record, showed: -Diagnoses: Injury of head, fall, contusion of scalp, and closed fracture of one rib of left side (unable to determine if it was an old or new fracture); -Instructions: You were seen today after a fall. Computed tomography (CT) head was obtained and did not show any acute bleeding, fractures, or other injury. A neck CT scan was also obtained and showed no injuries. Pelvic x-ray showed no injuries either. A chest x-ray showed a rib fracture on the left. Make sure to use incentive spirometer (device used to ensure deep breaths to prevent pneumonia) and Lidoderm (pain medication) patches for pain. Review of pictures of the resident's injuries, provided 3/8/24, showed: -A large area of dark, purple bruising on the right side of the resident's face, below the jaw line. Bruising around the right side of the neck, fading in color. Bruising to the back of the resident's right ear. Bruising underneath the right ear appeared black and greenish in color; -Dark bruising underneath the right eye. The skin around the right eye reddish in color and appeared swollen; -Dark bruising covering the right eyebrow, which fades to a reddish color from right to left; -Dark bruising and reddish bruising on the right side of the resident's forehead; -A small dark scab on the top of the resident's forehead with light greenish/yellowish bruising in the center of the forehead. The forehead appeared swollen. During an interview on 3/8/24 at 10:45 A.M., Registered Nurse (RN) X said he/she works as needed at the facility. He/She was never worked as the wound nurse, but some days he/she comes in and does wound care. The last week or two he/she came in and rounded with the wound doctor. He/She did not recall the resident having a wound prior to the fall. The resident was transported to the hospital not too long ago. Prior to that, he/she was usually up in a wheelchair with moderate assistance with using the bathroom. The resident needed reminders to stay seated in the wheelchair, because he/she cannot walk. RN X measured the resident's injuries and entered it into the computer and on skin assessment. He/She made a nurses note on what injuries the resident had. He/She did not recall if the resident wore nonskid socks. There was no bruising noted before he/she left to go to the hospital. During an interview on 3/8/24 at 10:20 A.M., LPN U said he/she worked on 2/2/24. The last time he/she saw the resident was on 2/2/24 when the resident was transported to the hospital after a fall. LPN U was assigned two units, one being the residnet's unit, but was working on a different unit when it was reported to him/her by the wound nurse that the resident was on the floor. It was midday and definitely after lunch. When LPN U arrived, the resident was laying on his/her back, pants were down, and he/she lay in another resident's doorway. The resident was known for getting up a lot. The other aides that were assigned to the unit were inside resident rooms at the time. It was an unwitnessed fall. He/She was not crying at the time, but said, I'm hurting. He/she had complaints of pain. The resident had a gash on his/her head, blood running to the back of the head to the floor. There were no wounds on the back of the head. The resident was not able to say what happened, he/she was alert x 1-2 (persona and/or place). He/She was confused at the time and typically sometimes more alert. The resident lay in the hall with his/her feet out in the hallway and head was in the doorway to the room. The aide that was assigned to the resident said he/she was toileting the resident and walked away. The wound nurse assessed the resident and LPN U went to retrieve gauze and called 911, the family was notified, and the ambulance arrived quickly. Other than the gash on the resident's head, he/she had scrapes to the arm. The resident's CNA said he/she was grabbing something for the resident. The CNA that was assigned to the resident was new. During an interview on 3/8/24 at 12:30 P.M., CNA Z said he/she was not the resident's CNA at the time of the fall, but remembered the resident having bruising to the neck and face after the fall on 2/2/24. The resident went out to the hospital and he/she returned from the hospital like that. Interventions in place included bed lowered to floor and mat next to the bed. The resident will stand and attempt to leave the toilet and ambulate on his/her own. Staff must stay with him/her side by side in the bathroom and cannot leave him/her alone so they will not get up on their own, becuase the residnets on the unit have dementia and would not know to stay. During an interview on 3/8/24 at 12:00 P.M., Nurse Practitioner (NP) W said he/she saw the resident on 2/6/24 to assess for a change in condition. He/She remembered the resident having a fall on 2/2/24. On 2/6/24, there was old bruising. During an interview on 3/8/24 at 1:23 P.M., LPN EE said the resident could express his/her needs. He/She was in a wheelchair, but he/she would get up and get in or out of the bed. The resident would need staff assistance. Staff should stay with him/her in the bathroom. LPN EE did not believe the resident had a fall in the bathroom before. After the resident fell on 2/2/24, he/she had bruising on his/her neck. LPN EE saw the resident when he/she came back and saw him/her in the bed and said, wow what happened. The bruises looked fresh, purple, not old bruising. Everything LPN EE saw was dark purple, and believed both eyes were black. He/She believed the resident fell but wondered how he/she fell. The resident was not able to get up on his/her own if there was a fall, but he/she would be able to crawl and/or turn him/herself on his/her back. During an interview on 3/8/24 at 2:22 P.M., the Administrator and DON said CNA FF was assigned to the resident and refused to give a statement. CNA FF was sent home pending an investigation and was terminated. The DON saw Resident #33 before he/she went to the hospital. He/She was across the hall on the floor. There was a nurse helping the resident. He/She was on his/her back and halfway in the door and in the hall. The resident tried to get up. The DON did not see the resident after he/she returned from the hospital. She did not see the bruises as a result and did not know the resident had a fractured rib. The Administrator did not know about the fracture rib. The resident has fallen and did have history of falls. No one saw how the resident fell. The resident could not get himself/herself up. If he/she tried to get up, he/she would need assistance. The Administrator contacted therapy and confirmed that the resident would scoot around if he/she fell. The Administrator said most doorways have a threshold, the resident could have hit the door handle. The resident was in his/her room and went from the bathroom to the hall. The administrator said she would expect staff to provide protective oversight, stay with resident while in the bathroom, and not leave unattended. MO00232813 MO00232138 MO00230981

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure pain management was provided to residents who require such services for one resident (Resident #5), who was placed on hospice and expressed pain. The facility failed to ensure the pain medication ordered by the hospice company was made available timely. This resulted in the resident expressing pain by yelling out with movement and care. In addition, staff completed wound care on the resident without waiting for pain medication to be administered. The census was 128. Review of the facility's Pain Management policy, dated 11/15/22, showed: -The facility will use a systematic approach to pain management, recognition, evaluation, treatment, and monitoring of pain. Individuals experiencing pain may receive pharmacological/non-pharmacological interventions to assist in pain management; -Evaluate/prevent: Recognize when resident is experiencing pain and identify circumstance when pain can be anticipated. Manage/prevent pain, consistent with the comprehensive evaluation and plan of care, current professional standers of practice, and resident goals/preferences; -Observe for nonverbal indicators: Facial expression (e.g., grimacing, frowning, clenching of the jaw). Negative vocalization (e.g., groaning, crying, whimpering, screaming). Skin conditions. Review of Resident #5's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 7/6/23, showed: -Severe cognitive impairment; -Extensive assistance required for bed mobility, transfers, dressing, toilet use and personal hygiene; -Total dependence for bathing; -Diagnoses included cancer and dementia. Review of the resident's care plan, in use at the time of the investigation, showed: -Focus: The resident has a stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle) to the sacrum (tail bone area) or potential for pressure ulcer development related to history of ulcers; -Goal: The resident's pressure ulcer will show signs of healing and remain free from infection; -Interventions included: Treat pain as per orders prior to treatment/turning, etc. to ensure the resident's comfort. Review of the resident's medical record, showed: -An order dated 8/23/23, for pain evaluation every shift for monitoring pain level; -An order dated 9/6/23, admit to hospice; -An order dated 9/6/23, for morphine sulfate (narcotic pain medication, can also be used to treat shortness of breath) oral solution 20 milligram (mg) per milliliter (ml). Give 0.25 ml by mouth every 4 hours as needed for shortness of breath or pain. Review of the facility's hospice binder, showed the following for the resident: -A nurse visit assessment dated [DATE] at 11:00 A.M.; -Start date for hospice services to begin 9/6/23; -Medication profile, dated 9/6/23 included an order for morphine sulfate concentrate 0.25 ml every 4 hours as needed for shortness of breath or pain. Observation on 9/7/23 at 7:24 A.M., showed the Certified Wound Care Manager entered the resident's room and said she was coming in to check if the resident had pain. She asked the resident if he/she had pain and the resident said yes. Observation showed the resident had facial grimacing. The Certified Wound Care Manager said she was going to let the nurse know the resident had pain. She usually does the resident's wound treatment at about noon and would let the surveyor know when she is ready, she then left the room. Observation on 9/7/23 at 7:37 A.M., showed the Certified Wound Care Manager returned to the room with treatment supplies. She said the resident's nurse is getting his/her pain medication now. The Certified Wound Care Manager lowered the head of the bed and the resident moaned and had facial grimacing. The Certified Wound Care Manager assisted the resident to his/her right side, the resident moaned loudly. The Certified Wound Care Manager gathered supplies and provided care. The resident yelled ouch as the Certified Wound Care Manager rolled the resident over to his/her right side. After providing incontinence care, the Certified Wound Care Manager cleansed the resident's wound with wound cleanser spray. The resident said ouch and jerked slightly. The Certified Wound Care Manager completed the treatment and the new dressing was applied. She then rolled the resident onto his/her back. The resident yelled out and the Certified Wound Care Manager said I know this part is hard. She continued to roll the resident towards herself, on his/her left side. The resident screamed out. The Certified Wound Care Manager said we are stopping, but continued to finish providing care, only stopping for approximately 2 seconds as she spoke to the resident. The Certified Wound Care Manager then moved the resident's legs and the resident yelled out. She rolled the resident to his/her right side in an attempt to apply the clean brief, and the resident yelled out. The Certified Wound Care Manager allowed the resident to rest on his/her back, then moved his/her pillow under his/her head, causing the resident's head and shoulders to slide over in the bed. The resident yelled obscenities. The Certified Wound Care Manager said I know it hurts. The Certified Wound Care Manager covered the resident with his/her blanket and said let me check on that pain medicine. She removed her gloves, bagged up the trash, gathered the supplies, and left room. Observation on 9/7/23 at 8:01 A.M., showed Therapy Staff A entered the resident's room to see the roommate. The resident told Therapy Staff A that he/she hurt and pointed to his/her buttocks. Therapy Staff A told the resident he/she would talk to the nursing staff. The resident said he/she did not sleep too good. Therapy Staff A raised the resident's head of bed. The resident yelled out loudly. Certified Nursing Assistant (CNA) B entered the room. Therapy Staff A said the resident slid down in bed and needed to scooch up. Staff lowered the head of the bed. The resident yelled out. Staff were then able to pull the resident up in bed. Staff then raised the resident's head of bed, and he/she yelled out. Observation on 9/7/23 at 8:33 A.M., showed CNA C entered the resident's room and said he/she wanted to check on the resident. He/She was day shift and was doing rounds. CNA C lowered the resident's head of bed and the resident yelled out. CNA C said I know, I know, unsecured his/her brief, rolled him/her to the right, and observed the resident was clean. CNA C re-secured the brief. CNA C straightened the resident's bed pad. The resident said ow. CNA C then rolled the resident to his/her back and positioned his/her legs. The resident yelled out. CNA C assisted the resident to his/her left side. The resident yelled out I can't do it. CNA C said I know but I have to get you off your side. CNA C covered the resident with his/her blanket. During an interview on 9/7/23 at 9:35 A.M., the resident's visitor said he/she needs to find the nurse for pain meds. He/She told the nurse the resident needed pain medicine, but he/she still has not received it. During an interview on 9/7/23 at 9:45 A.M., the resident's visitor entered the resident's room and told the resident's spouse the nurse said they are coming with pain medication now, they had to wait for the pharmacy. During observation and interview on 9/7/23 at 9:47 A.M., Licensed Practical Nurse (LPN) D said he/she just got the pain medication order approved from pharmacy. The resident gets morphine 0.25 ml every 4 hours. The order was given last night. Staff have been waiting for pharmacy to approve the order. LPN D administered morphine 0.25 ml under the resident's tongue. LPN D said the time frame to get medications approved and available depends on the situation. If the order is through hospice, the order goes from hospice to the physician. Then, the facility will have to wait for the pharmacy. Staff cannot pull it from stock without pharmacy approval, the machine will not allow it. During a phone interview on 9/7/23 at 10:00 A.M., Pharmacy Representative E said medication orders are sent to the pharmacy from the facility. The morphine order came across this morning, 9/7/23 at 7:41 A.M. Typical turnaround time for pharmacy varies, but Morphine is in the emergency kit and can be pulled by facility staff without waiting for a delivery. During a phone interview on 9/7/23 at 10:17 A.M., the Hospice Administrator said it is the facility's responsibility to ensure the ordered medications are available from pharmacy. If a resident has pain and has orders for pain medication, he/she would expect the resident to get the pain medication as ordered. Comfort is the goal of hospice. During an interview on 9/7/233 at 10:27 A.M., the resident's spouse said he/she wants the resident to be comfortable. During an interview on 9/7/23 at 3:10 P.M., with the Director of Nursing and Administrator, they said when a resident is admitted on hospice and hospice orders pain medications, the process is that the doctor sends the prescription to the pharmacy, but sometimes there is a transmission error. Once the order is received, staff can pull the medication from stock. Ordered medication should be available as soon as possible. The time may vary, but if the hospice company was in at 11:00 A.M. the day before, the medication should have been available by this morning. The wound nurse should have waited to complete the treatment until after the resident had received pain medication. It should not have taken that long to get the resident his/her pain medication. It seems like this was a transmission error with the pharmacy. MO00222814

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents with pressure ulcers received necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing when facility staff did not provide wound treatments as ordered. This affected three residents (Residents #101, #86, and #92) of 23 sampled residents. The census was 110. Review of the facility's Skin Management Guidelines, revised July 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: -Cognitive impairment; -Exposure of skin to urinary or fecal incontinence; -Under nutrition, malnutrition, and hydration deficits; -Upon admission, all residents are assessed for skin integrity by completing an assessment and documenting in the EHR (electronic health record); -Appropriate preventive measure will be implemented on all residents identified at risk and the interventions documented on the Care Plan, may include: -Turn and reposition; -Promotion of clean, dry and well moisturized skin; -Residents admitted with skin impairments will have: -Appropriate interventions implemented to promote healing; -A physician's order for treatment; -Consultation with Wound Care Nurse or surgeon may be appropriate. 1. Review of Resident #101's admission note, dated 2/17/22, showed the admitting nurse documented open area to coccyx and pressure ulcers to lower legs,. No measurements were documented. Record review of the resident's physician orders showed on 2/17/22 an order was received from the facility's physician for Zinc oxide ointment 10% to be applied topically two times a day for wound. The orders did not include the specific location or type of wound. Review of Resident #101's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/24/22, showed: -admitted on [DATE]; (the resident was originally admitted on [DATE] and then readmitted on [DATE]) -Severely impaired cognition; -Required assistance of two or more staff with bed mobility, transfers, and toilet use; -Required one person assist in dressing and personal hygiene; -At risk for developing pressure ulcers; -Had one or more unhealed pressure ulcers at Stage I (a reddened, intact area on the skin that does not turn white when pressed) or higher; -Diagnoses included high blood pressure, diabetes, dementia, and malnutrition. Review of the resident's medical record showed additional diagnoses of generalized muscle weakness, dysphagia (difficulty swallowing), and cognitive communication deficit. Review of the resident's hospital transfer chart, dated 2/18/22, showed: -Wound to anterior left leg; -Pressure ulcer to medial coccyx (a triangular arrangement of bone that makes up the very bottom portion of the spine below the sacrum); -Pressure ulcer to right hip; -Pressure ulcer to right heel; -Pressure ulcer to left heel; -Pressure ulcer to right medial anterior calf; -Pressure ulcer to left medial posterior calf. The transfer information did not include any orders for wound care. Review of the physician's progress notes, dated 2/19/22, showed an order for a wound physician consultation. Review showed the order was not transcribed to the electronic physician order sheet (ePOS) on 2/19/22. Review of the physician's progress notes, dated 2/23/22, showed an order for wound physician consultation. Review of the resident's physician's progress notes, dated 2/26/22, showed the physician documented obtain wound consultation (buttocks) and discontinue when consultation complete. Review showed no further notes regarding the wound consultation until 3/14/22, when the order was received by the wound physician. Review of the resident's Initial Wound Evaluation and Management Summary, signed by the wound physician and dated 3/14/22, showed: -Chief complaint: The patient had multiple wounds; -Focused wound exam (Site 1) - Pressure: -Unstageable (full thickness tissue loss which actual depth of the ulcer is completely covered by slough (yellow, tan, gray, green, or brown), or eschar (tan, brown, or black) in the wound bed) sacrum (the triangular bone just below the lumbar vertebrae) full thickness; -Wound Size -Length x Width x Depth (L x W x D): 1.4 x 5.3 x 0.2 cm (centimeters); -Exudate (fluid that leaks out of blood vessels): Light serous (liquid part of blood); -Focused wound exam (Site 3) - Pressure: -Unstageable, right heel partial thickness; -Wound Size - L x W x D: 2 x 2 x cm (D was not measurable); -Exudate: none; -Focused wound exam (Site 4) - Pressure: -Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed, without slough) Pressure wound of the left heel partial thickness; -Wound Size - L x W x D: 2 x 1.5 x 0.1 cm; -Exudate: none. Review of the care plan, in use during the survey, dated 3/14/22, showed: -Focus: Impaired skin integrity as evidenced by pressure injury: sacrum, right heel, left heel, diabetic ulcer to right distal leg, at risk of poor healing infection and additional skin breakdown; -Goals: Will exhibit healing without signs and symptoms of infection through review date, interventions will reduce the risk of additional skin breakdown; -Interventions: Apply pressure reducing mattress to bed, wound clinic to follow, perform treatment order, assess wound for signs and symptoms of infection with the dressing change or treatment, report positive findings of redness, warmth, swelling, increased drainage, increased pain, monitor for verbal and nonverbal symptoms of pain, administer analgesics as ordered by physician, update physician regarding effectiveness. Observation on 3/17/22 at 10:06 A.M., showed the resident lay in the supine (face upward) position, with the head of bed elevated at 30 degrees. A strong odor of feces was observed. Observation on the same day at 2:17 P.M., showed the resident lay in the supine position, with a strong odor of feces observed. Observation and interview on 3/18/22 at 10:00 A.M., showed Licensed Practical Nurse (LPN) X assisted the resident onto his/her side, and unfastened a urine saturated brief. An undated dressing was on the resident's right hip. The tailbone (sacral) wound was uncovered and exposed. A light smear of liquid, brown stool was in the sacral wound. The lower right and left buttock wounds were wet with urine and uncovered. The wounds were noted 100% covered with wet slough (yellow, stringy tissue) and the wound edges were red and inflamed. LPN X said all wounds should be covered at all times. The aides should notify the nurse if a wound dressing was uncovered and the nurse was responsible to quickly apply the ordered treatment. He/she pulled the edge of the brief over the resident's hip and said he/she will get wound supplies and apply the ordered treatment. At 11:50 A.M., LPN X assisted the resident onto his/her left side and lowered the sheet below his/her hip. The same urine saturated, loose stool filled brief remained on the resident. The sacral wound remained uncovered and a small amount of stool was smeared in the sacral wound. During an interview on 3/21/22 at 9:17 A.M., Unit Manger C said the wound physician comes to the facility every Monday to see all the residents listed for wound treatments. He/she said when the resident's physician orders a wound consult, the charge nurse fills out a Wound Notification Sheet, and he/she then enters it into the EHR, which linked to the wound physician's system. Unit Manager C was not aware of the resident's wounds upon admission. He/she assists with admission skin assessments at times, but could not recall assessing the resident. He/she expected the charge nurses to transcribe and follow-up with physician's orders appropriately. During an interview on 3/21/22 at 12:54 P.M., the wound physician said he/she did not receive a referral for the resident when the physician requested it on 2/19/22 and 2/23/22. When the facility enters the referral orders to their system, it will take a few minutes to receive the orders. He/she then would initiate an evaluation and treatment on his/her next visit. He/she verified wound treatment orders started on 3/14/22, during his/her initial visit. He/she said the resident could experience other complications if wounds were not being treated as soon as possible. He/she expected the nursing staff to follow-up with wound treatments as ordered. 2. Review of Resident #86's admission MDS, dated [DATE], showed: - BIMS score of 15 out of a possible score of 15, showed the resident cognitively intact; -Diagnosis of Huntington's disease (a rare, inherited disease that causes the progressive breakdown of nerve cells in the brain. It usually results in movement, thinking and psychiatric disorders); -Moderate cognitive impairment; -Required extensive assistance of one staff for transfers, dressing, toileting, personal hygiene, and bathing; -Independent with bed mobility and eating; -At risk for pressure ulcers; -No unhealed pressure ulcers; -No venous or arterial ulcers; -No other ulcers, wounds, or skin problems; -Skin and ulcer treatments in place: --Pressure reducing device for chair; --Pressure reducing device for bed; --Turning and repositioning program; --Nutrition or hydration intervention to manage skin problems. Review of the resident's care plan, revised on 3/15/22, showed no care plan for wounds/wound care. Review of the resident's wound clinic Initial Wound Evaluation and Management Summary, dated 3/7/22, showed: -Chief complaint: Patient presented with a wound on his/her right heel; -History of present illness: At the request of the referring provider, a thorough wound care assessment and evaluation was performed today. He/she had a wound of the right heel for at least one day duration. There was no exudate. There was no indication of pain associated with this condition; -Exam: --Neurologic/Psychiatric: Oriented to Person, Oriented to Place, Oriented to Situation; --Mood and affect: Co-operative, Involuntary muscle movements; -Skin: --Right lower extremity Wound present. See Focused Wound Exam Below; -Focused wound exam: wound of right heel, full thickness; --Duration: Over one day; --Objective: Healing, Linear cut with callous and dirt; --Wound Size (L x W x D): 2.5 cm by 0.5 cm by Not Measurable cm; --Surface Area: 1.25 cm; --Exudate: None; --Thick adherent devitalized necrotic tissue: 100%; -Dressing treatment plan: --Primary Dressing(s): Hydrogel (a wound dressing which promotes healing, provide moisture, and offer pain relief ) impregnated gauze apply once daily for 30 days; --Secondary Dressing(s): Gauze roll (kerlix) 4.5 inches, apply once daily for 30 days; --Reason for no debridement (medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue): Debridement refused. Patient/surrogate made aware of risks of not removing necrosis including infection; sepsis; limb loss or death; -Plan of care reviewed and addressed: My goal for this wound was healing as evidenced by a decrease in surface area of the wound and/or a decrease in the percentage of necrotic tissue within the wound bed. The best medical estimate of the time required for this wound to heal with continued physician evaluation and intervention was 47 days. This estimate was made with an 80% degree of certainty. Review of the resident's ePOS showed: -Right heel: apply Hydrogel impregnated gauze and Kerlix (gauze roll) every day shift for wound management. Start date: 3/10/22 and discontinued 3/15/22. Review of the resident's March 2022 TAR showed: -Right heel apply Hydrogel impregnated gauze and gauze roll every day shift for wound management, dated 3/10/22 and discontinued 3/15/22. Out of 6 opportunities, 3 noted blank and no initials. During an observation on 3/14/22 at 10:13 A.M., the resident sat in a chair in his/her room. The dressing to his/her right foot was dirty with brown and black streaks/smears. The dressing was loose and coming off with the wound exposed. The date was illegible due to half of the tape missing and the other portion smeared. No dressings were applied to his/her left lower extremity. The resident did not know when the dressing was last changed. Review of the resident's wound clinic Wound Evaluation and Management Summary, dated 3/14/22, showed: -Chief complaint: This patient had multiple wounds. -History of present illness: At the request of the referring provider, a thorough wound care assessment and evaluation was performed today. He/she has a stage I pressure wound of the left, lateral ankle for at least one day duration. There was no exudate. There was no indication of pain associated with this condition; -Exam: --Neurologic/Psychiatric: Oriented to Person, Oriented to Place, Oriented to Situation; --Mood and affect: Co-operative; --Examination of left lower extremities: No edema, foot warm, wound present. See Focused Wound Exam below; --Examination of right lower extremities: Foot warm, wound present. See Focused Wound exam below, No edema; -Focused wound exam (site 1): wound of right heel, full thickness; --Duration: Over seven days; --Objective: Healing, Linear cut with callous and dirt; --Wound Size (L x W x D): 3.0 cm by 0.3 cm by Not Measurable cm; --Surface Area: 0.90 cm²; --Exudate: None; --Thick adherent devitalized necrotic tissue: 100 %; --Wound progress: improved; -Dressing treatment plan: --Primary Dressing(s): Hydrogel impregnated gauze apply once daily for 23 days; --Secondary Dressing(s): Gauze roll (kerlix) 4.5 inches, apply once daily for 23 days; --Surgical excisional debridement procedure: ---Reason for procedure: Remove Necrotic Tissue and Establish the Margins of Viable Tissue; ---Procedure note: The wound was cleansed with normal saline and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, 15 blade was used to surgically excise 0.9 cm² of devitalized tissue and necrotic subcutaneous fat and surrounding connective tissues were removed at a depth of 0.1 cm and healthy bleeding tissue was observed. Hemostasis (the stopping of a flow of blood) was achieved and a clean dressing was applied. Post-operative recommendations and updates to the plan of care are documented in the Assessment and Plan section below. -Focused wound exam (site 2): Stage I pressure wound of left lateral ankle, partial thickness; --Etiology: Pressure; --Duration: Over one day; --Objective: Healing; --Wound Size (L x W x D): 0.1 cm by 0.3 cm by Not Measurable cm; --Surface Area: 0.03 cm²; --Exudate: None; -Dressing treatment plan: --Primary Dressing(s): Superabsorbent silicone border and faced dressing, apply once daily for 30 days; -Focused wound exam (site 3): Unstageable (due to necrosis-Irreversible cell injury and eventual cell death) of left heel, full thickness; --Etiology: Pressure; --Duration: Over one day; --Objective: Healing; --Wound Size (L x W x D): 0.3 cm by 1.0 cm by Not Measurable cm; --Surface Area: 0.30 cm²; --Exudate: None; -Dressing treatment plan: --Primary Dressing(s): Hydrogel impregnated gauze apply once daily for 23 days; --Secondary Dressing(s): Gauze roll (kerlix) 4.5 inches, apply once daily for 23 days; --Reason for no debridement: Debridement refused. Patient/surrogate made aware of risks of not removing necrosis including infection; sepsis; limb loss or death; -Summarized wound care assessment and individualized treatment plan: --Site 1: Surgical excisional debridement was performed today on this wound. Goal of treatment is healing evidenced by a 28.0% decrease in surface area within the wound bed; --Site 2: This wound is optimized for autolytic debridement using the below treatment plan. My goal for this wound was healing as evidenced by a decrease in surface area of the wound and/or a decrease in the percentage of necrotic tissue within the wound bed; --Site 3: This wound was optimized for autolytic (the destruction of tissues or cells of an organism by the action of substances, such as enzymes that are produced within the organism) debridement using the below treatment plan. My goal for this wound was healing as evidenced by a decrease in surface area of the wound and/or a decrease in the percentage of necrotic tissue within the wound bed. The best medical estimate of the time required for this wound to heal with continued physician evaluation and intervention is 56 days. This estimate was made with an 80% degree the destruction of tissues or cells of an organism by the action of substances, such as enzymes that are produced within the organism of certainty. Review of the resident's medical record showed there was no facility documentation of stage 1 wound on the resident's left ankle and unstageable wound on the resident's left heel. Review of the resident's ePOS showed: -Right and left heels: apply Hydrogel (highly absorbent dressing that promotes healing, provides moisture, and offers pain relief with their cool, high-water content) (delete and define above - 1st time used) impregnated gauze and Kerlix (gauze roll) every day shift for wound management. Start date: 3/16/22 and discontinued 3/22/22; -Left ankle: apply superabsorbent silicone bordered and faced (ultra-absorbent dressing) every evening shift for wound management; Start Date: 3/16/22 and discontinued 3/22/22. Review of the resident's March 2022 TAR showed: -Left ankle. Apply superabsorbent silicone bordered and faced dressing every evening shift for wound management, dated 3/16/22 and discontinued 3/22/22. Out of 6 opportunities, 3 noted blank and no initials; -Right and left heels. Apply hydrogel impregnated gauze, gauze sponge, gauze roll every evening shift for wound management, dated 3/16/22 and discontinued 3/22/22. Out of 6 opportunities, 3 noted blank and no initials. Observation on 3/17/22 at 9:52 A.M., showed the resident lay in bed on his/her right side with his/her eyes closed. The dressing to his/her right foot was falling off and dirty with brown and black smears, with yellow areas. The dressing was falling off and not in the appropriate place, with the right heel wound exposed. No dressings were applied to his/her left lower extremity. Observation on 3/18/22 at 12:09 P.M., showed the resident lay in bed on his/her right side. No dressings were applied to his/her feet. His/her left lateral foot had a cracked area that measured approximately 1.5 inches long by 0.2 cm wide by unable to determine depth. The wound was open with the wound bed exposed and red. The resident's right heel had closed cracked tissue, measuring approximately 1.5 inches long by 0.1 cm wide. The skin to his/her feet was very dry. The resident was asleep and the right side of the feet could not be visualized. Further review of the resident's medical record showed there was no facility documentation of the wound to the resident's left lateral foot. Observation on 3/21/22 at 4:19 P.M., showed the resident sat in his/her bed with no dressing on his/her right and left feet. The resident was continuously moving his/her bilateral lower extremities back and forth on the bed, in a rubbing fashion. The wounds were exposed. Review of the resident's wound clinic Wound Evaluation and Management Summary, dated 3/21/22, showed: -Chief complaint: This patient had multiple wounds. -History of present illness: At the request of the referring provider, a thorough wound care assessment and evaluation was performed today. He/she had a wound of the right, lateral heel for at least one day duration. There was light sero-sanguinous exudate. There was no indication of pain associated with this condition; -Exam: --Neurologic/Psychiatric: Oriented to Person, Oriented to Place, Oriented to Situation; --Mood and affect: Involuntary muscle movements; -Focused wound exam (site 1): wound of right heel, full thickness; --Duration: Over 13 days; --Objective: Healing, Linear cut with callous and dirt; --Wound Size (L x W x D): 1.5 cm by 0.2 cm by Not Measurable cm; --Surface Area: 0.30 cm²; --Exudate: None; --Granulation tissue (new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process): 20%; --Other visible tissue: 80%, subcutaneous tissue; --Wound progress: improved; -Dressing treatment plan: --Primary Dressing(s): Hydrogel impregnated gauze, apply once daily for 16 days; --Secondary Dressing(s): Gauze roll (kerlix) 4.5 inches, apply once daily for 16 days; -Focused wound exam (site 2): stage I pressure wound of left lateral ankle, partial thickness; --Etiology: Pressure; --Duration: Over one day; --Objective: Healing; --Wound progress: Resolved 3/21/22; -Focused wound exam (site 3): Stage III (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Some slough may be present. May include undermining and tunneling) pressure wound of left heel, full thickness; --Etiology: Pressure; --Duration: Over one day; --Objective: Healing; --Wound progress: Resolved 3/21/22; -Focused wound exam (site 4): wound of right lateral heel, full thickness; . --Duration: Over 1 days; --Objective: Healing; --Wound Size (L x W x D): 0.2 cm by 1.2 cm by 0.1 cm; --Surface Area: 0.24 cm²; --Exudate: Light sero-sanguineous; --Other visible tissue: 100%, subcutaneous dermis; -Dressing treatment plan: --Primary Dressing(s): Hydrogel impregnated gauze apply once daily for 16 days; --Secondary Dressing(s): Gauze roll (kerlix) 4.5 inches, apply once daily for 16 days; -Focused wound exam (site 5): wound of left lateral foot, full thickness; --Duration: Over 1 days; --Objective: Healing; --Wound Size (L x W x D): 0.3 cm by 2.4 cm by 0.1 cm; --Surface Area: 0.72 cm²; --Exudate: Light sero-sanguineous; --Other visible tissue: 100%, subcutaneous dermis; -Dressing treatment plan: --Primary Dressing(s): Hydrogel impregnated gauze, apply once daily for 16 days; --Secondary Dressing(s): Gauze roll (kerlix) 4.5 inches, apply once daily for 16 days; -Focused wound exam (site 6): wound of left medial foot, full thickness; . --Duration: Over 1 days; --Objective: Healing; --Wound Size (L x W x D): 0.2 cm by 1.5 cm by 0.1 cm; --Surface Area: 0.30 cm²; --Exudate: Light sero-sanguineous; --Other visible tissue: 100%, subcutaneous dermis; -Dressing treatment plan: --Primary Dressing(s): Hydrogel impregnated gauze, apply once daily for 16 days; --Secondary Dressing(s): Gauze roll (kerlix) 4.5 inches, apply once daily for 16 days; -Summarized wound care assessment and individualized treatment plan: --Site 1: This wound is currently being optimized for autolytic debridement using the below treatment plan. Most recent surgical excisional debridement was on 3/14/2022. Goal of treatment is healing evidenced by a 66.7% decrease in surface area and a 100% decrease in necrotic tissue within the wound bed. --Site 2: Resolved on 3/21/22; --Site 3: Resolved on 3/21/22; --Site 4: This wound was optimized for autolytic debridement using the below treatment plan. My goal for this wound was healing as evidenced by a decrease in surface area of the wound and/or a decrease in the percentage of necrotic tissue within the wound bed; --Site 5: This wound was optimized for autolytic debridement using the below treatment plan. My goal for this wound was healing as evidenced by a decrease in surface area of the wound and/or a decrease in the percentage of necrotic tissue within the wound bed; --Site 6: This wound was optimized for autolytic debridement using the below treatment plan. My goal for this wound was healing as evidenced by a decrease in surface area of the wound and/or a decrease in the percentage of necrotic tissue within the wound bed. Review of the resident's ePOS, reviewed on 3/28/22 at 12:05 P.M., showed: -Right heel: apply Hydrogel impregnated gauze and Kerlix (gauze roll) every day shift for wound management. Start date: 3/10/22 and discontinued 3/15/22; -Right and left heels: apply Hydrogel (highly absorbent dressing that promotes healing, provides moisture, and offers pain relief with their cool, high-water content) (delete and define above - 1st time used) impregnated gauze and Kerlix (gauze roll) every day shift for wound management. Start date: 3/16/22 and discontinued 3/22/22; -Right heel: apply Hydrogel impregnated gauze and Kerlix (gauze roll) every day shift for wound management. Start date: 3/22/22; -Left ankle: apply superabsorbent silicone bordered and faced (ultra-absorbent dressing) every evening shift for wound management; Start Date: 3/16/22 and discontinued 3/22/22; -Eucerin Cream (Skin Protectant). Apply topically to bilateral feet twice a day for dry skin. Start Date: 2/23/22; -No noted order for the left lateral foot wound noted on the 3/21/22 wound clinic's Wound Evaluation and Management Summary. -No noted order for the left medial foot wound noted on the 3/21/22 wound clinic's Wound Evaluation and Management Summary. Review of the resident's March 2022 TAR showed: -Left ankle. Apply superabsorbent silicone bordered and faced dressing every evening shift for wound management, dated 3/16/22 and discontinued 3/22/22. Out of 6 opportunities, 3 noted blank and no initials; -Right and left heels. Apply hydrogel impregnated gauze, gauze sponge, gauze roll every evening shift for wound management, dated 3/16/22 and discontinued 3/22/22. Out of 6 opportunities, 3 noted blank and no initials; -Right heel. Apply hydrogel impregnated gauze, gauze sponge, gauze roll every evening shift for wound management, dated 3/22/22. Out of 6 opportunities, 3 noted blank and no initials; -Right heel apply Hydrogel impregnated gauze and gauze roll every day shift for wound management, dated 3/10/22 and discontinued 3/15/22. Out of 6 opportunities, 3 noted blank and no initials; -Eucerin Cream (Skin Protectant). Apply topically to bilateral (both) feet twice a day for dry skin, dated 2/23/22. Out of 54 opportunities, 22 noted blank and no initials -No noted order for the left lateral foot wound noted on the 3/21/22 wound clinic Wound Evaluation and Management Summary; -No noted order for the left medial foot wound noted on the 3/21/22 wound clinic Wound Evaluation and Management Summary. Observation on 3/23/22 at 3:18 P.M., showed the resident sat up in his/her bed with no dressing on his/her right and left feet. The resident was continuously moving his/her bilateral lower extremities back and forth on the bed, in a rubbing fashion. Further observation showed the wounds were exposed. Observation on 3/24/22 at 5:12 P.M., showed the resident sat in the day area feeding himself/herself dinner with no dressing on his/her right and left feet. Observation on 3/25/22 at 12:51 P.M., showed the resident sat in a chair in his/her room with no dressing on his/her right and left feet. The resident's feet were bare and on the floor with wounds exposed. 3. Review of Resident #92's admission MDS, dated [DATE], showed: -Diagnoses of high blood pressure, coronary artery disease (CAD, caused by plaque buildup in the wall of the arteries that supply blood to the heart), deep vein thrombosis (DVT, a serious condition that occurs when a blood clot forms in a vein located deep inside your body), and diabetes mellitus-type II; -Cognitively intact; -Required extensive assistance of two staff for bed mobility, transfers, dressing, toileting, personal hygiene, and bathing; -Independent with eating; -At risk for pressure ulcers; -Had one unhealed Stage I pressure ulcer; -Had one unhealed Stage III pressure ulcer; -Had one venous or arterial ulcer; -Skin and ulcer treatments in place: --Pressure reducing device for chair; --Pressure reducing device for bed; --Nutrition or hydration intervention to manage skin problems; --Pressure ulcer care; --Applications of ointments/medications other than to feet. Review of the resident's baseline care plan, dated 2/4/22, showed: -admitted on [DATE], with skin integrity issues of lymphedema (the build-up of fluid in soft body tissues when the lymph system is damaged or blocked) and wound bilateral (both) lower extremities (BLE); -No wound description, measurements, treatments, or other details noted. -No interventions for the resident's wounds. Review of the resident's skin assessment, dated 2/4/22, showed: -No documentation of any pressure wounds. Review of the resident's wound clinic Initial Wound Evaluation and Management Summary, dated 2/7/22, showed: -Chief complaint: This patient has multiple wounds; -History of present illness: At the request of the referring provider, a thorough wound care assessment and evaluation was performed today. He/she has a wound of the right abdomen for at least 1 day duration. There is light sero-sanguineous exudate. There is no indication of pain associated with this condition; -Exam: --Neurologic/Psychiatric: Oriented to Person, Oriented to Place, Oriented to Situation; --Mood and affect: Appropriate; -Focused wound exam (Site 1): Stage III pressure wound of the right lateral shin, full thickness; --Duration: Over one day; --Objective: Healing, Acute DVT 1/26/22; --Wound Size (L x W x D): 3.9 centimeters (cm) by 1.3 cm by 0.1 cm; --Surface Area: 5.07 cm²; --Exudate: None; --Granulation tissue: 20% --Other tissue: 70 % subcutaneous, dermis; -Dressing treatment plan: --Primary Dressing(s): Xeroform sterile gauze apply once daily for 30 days; --Secondary Dressing(s): Gauze sponge sterile apply once daily for 30 days; Superabsorbent silicone border and faced apply once daily for 30 days; - Plan of care reviewed and addressed: Recommendation: Off-load wound; Reposition per facility protocol; Turn side to side and front to back in bed every 1-2 hours if able; -My goal for this wound is healing as evidenced by a decrease in surface area of the wound and/or a decrease in the percentage of necrotic tissue within the wound bed. -Focused wound exam (Site 3): Stage III pressure wound of the left lateral shin, full thickness; --Duration: Over one day; --Objective: Healing, Acute DVT 1/26/22; --Wound Size (L x W x D): 3.5 cm by 1.0 cm by 0.1 cm; --Surface Area: 3.5 cm²; --Exudate: slight sero-sanguineous; --Slough: 25% --Granulation tissue: 65% --Other tissue: 10 % subcutaneous, dermis; -Dressing treatment plan: --Primary Dressing(s): Leptospermum honey apply once daily for 30 days: sheet; Superabsorbent silicone border and

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure pain management was provided to residents who require such services, consistent with professional standards of practice by failing to adequately assess and treat pain for one of three residents investigated for pain concerns. The resident fell and suffered a broken hip, experienced severe pain and was not provided effective pain management (Resident #79). The facility also failed to provide ordered Tylenol for one hospice resident in pain (Resident #264). The sample was 23. The census was 110. Review of the facility's Pain Management Guidelines, revised September 2017, showed: -Purpose: To attain and maintain the highest practicable level of well-being and to prevent or manage pain, the facility to the fullest extent possible will: --Recognize when a resident is experiencing pain; --Identify circumstances when pain can be anticipated; --Evaluate existing pain and cause; -Upon admission, residents will be assessed for pain by using the Nursing admission Assessment form; -Residents will be screened for pain by using the assessment form quarterly, annually, and with a significant change and/or new onset of pain; --Pain intensity and pain relief will be assessed prior to administration of medication and post pain medication administration to assess for effectiveness of pain medication; -If any resident reports inadequate pain control, resident will have an assessment performed; -Following the pain evaluation, notify the physician of the findings; -Each resident identified for pain will have a Pain Management Care Plan. The Care Plan will have individualized interventions related to that resident's individual control of pain management. The Care Plan may include both pharmacological and non-pharmacological pain management interventions; -The Licensed Nurse will implement a Medication Administration Record (MAR) as needed (PRN) flow sheet for documentation of pain, medication, interventions and outcomes for all pain medication; -The IDT (interdisciplinary team) will discuss the new onset of pain or change in resident pain at the daily stand-up meeting and the IDT Team conference; -The Licensed Nurse, when administering PRN pain medication, will record the drug administration and the following on the MAR: --Pain level prior to pain medication administration; --Pharmacological interventions attempted; --Non-pharmacological interventions attempted; --Follow-up observations post intervention to determine the effectiveness of PRN pain interventions. If resident is asleep or resting, document as an observation; --Note: Those residents that chose hospice benefits for end-of-life care: Hospice assumes responsibility for the professional management of the resident in accordance to the hospice plan of care, and will be utilized to manage resident pain relief to maintain comfort and dignity. 1. Review of Resident #79's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, incomplete and with a target date of 2/17/22, showed: -Brief Interview for Mental Status (BIMS-tool used to assess cognition) score: blank; -Activities of daily living (ADLs, the tasks of everyday life including eating, dressing, transfers, bed mobility, bathing and using the toilet): blank; -Presence and level of pain: blank. Review of the resident's progress notes showed: -3/14/22 at 3:52 A.M., Nurse's note: certified nurse aide (CNA) staff reported resident complains of pain during repositioning, bilateral lower extremities from dangling off bed. Assessment findings: Left leg appears shorter than the right leg and painful to touch. Asked resident if he/she had a fall, he/she replied yes and continued mumbling and grimacing during assessment, with communication barrier noted. Roommate (alert and oriented) stated the resident had fallen yesterday morning, and was usually up walking during the day, but had been lying in bed moaning for some time, Vital signs (VS): Temperature (T)-98.1, pulse (P)-84, blood pressure (B/P)-148/67, oxygen (O2) saturation (sat)-98%/room air (RA). Tylenol administered for pain. Call placed to resident's physician. New order received for STAT x-ray. X-ray ordered, currently awaiting arrival; -3/14/22 at 9:30 A.M., Nurse's note: Physician in this morning and saw resident. Order given to transfer resident to the hospital; Review of the resident's progress notes showed: -3/19/22 at 8:06 P.M., Nurse's note: Patient readmitted back to facility at approximately 3:35 P.M., Dressing intact to left hip. -3/19/22 at 9:31 P.M., Nurse's note: Resident anxious/moaning, laying sideways in bed with feet on the floor. Resident had removed his/her dry dressing from his/her left hip. PRN Tylenol 650 milligrams (mg) was given. Assisted resident back into bed and replaced nasal prongs. Resident did appear a little more comfortable afterwards; -3/20/22 at 3:49 P.M., Nurse's note: Call placed to pharmacy regarding Hydromorphone (Dilaudid, pain medication) medication. Medication was scheduled to come out on tonight's delivery; -3/21/22 at 4:45 A.M., Nurse's note: Resident in bed with bed in lowest position. Resident calling out help. When asked if he/she was in pain, resident answered no. When touched, he/she said yes. Tylenol suppository 650 mg given as ordered, with very short positive results. Pharmacy called about pain medications. Responded they should be on next delivery; -3/21/22 at 6:28 P.M., Resident was observed in bed with complaints of pain to his/her hip. He/she was given pain medication as ordered. It was becoming effective, he/she seemed to be a little more comfortable. Review of the resident's electronic physician's order sheet (ePOS), showed: -Tylenol suppository Insert 650 mg rectally every 6 hours as needed for pain, start date 3/19/22. -Hydromorphone liquid 1 mg/milliliter (ml), give one ml by mouth every two hours as needed for pain, start date 3/19/22 and discontinued 3/28/22; -Hydromorphone liquid 1 mg/ml, give one ml by mouth every four hours as needed for pain, start date 3/21/22 and discontinued 3/28/22. Review of the resident's March 2022 MAR, showed: -Tylenol suppository Insert 650 mg rectally every 6 hours as needed for pain, start date 3/19/22. Signed out as provided on 3/20/22 at 8:40 A.M. and 3/20/22 at 8:44 P.M.; -Hydromorphone liquid 1 mg/ml, give one ml by mouth every two hours as needed for pain, start date 3/19/22 and discontinued 3/28/22. Review showed the medication was not documented as administered from 3/19/22-3/21/22; -Hydromorphone liquid 1 mg/ml, give one ml by mouth every four hours as needed for pain, start date 3/21/22 and discontinued 3/28/22. Signed out as provided on 3/23/22 at 8:22 A.M. Observation on 3/21/22 at 4:39 P.M., showed Licensed Practical Nurse (LPN) P sitting at the [NAME] unit nurse's station CNA FF yelled across to LPN P, saying Resident #79 was still waiting for some pain medication. LPN P yelled back I will get to it. Observation on 3/21/22 at 4:46 P.M., showed LPN P leave [NAME] headed towards the elevator. CNA FF was standing at the [NAME] unit nurse's station, saw LPN P and asked about the resident's pain medication again as LPN P walked past the opening to the nurse's station. LPN P said he/she will have to wait, boarded the elevator and the door shut. During an interview on 3/21/22 at 4:48 P.M., CNA FF said the resident had been complaining of pain and asking for some pain medication since 3:00 P.M. He/she had asked LPN P to give the resident something for pain, but he/she kept saying he/she would get to it. Observation and interview on 3/21/22 at 4:52 P.M., showed the resident's Family Member (FM) A exited the resident's room and told CNA FF the resident was in pain and still waiting on his/her pain medication. CNA FF assured FM A the nurse was aware and would provide the pain medication as soon as he/she could. Family member B said the resident had been moaning and calling out I hurt for at least two hours. FM B said they had asked staff several times for something to ease the pain and nothing had been provided. The resident was observed moaning and crying out at that time. Resident kept repeating it hurts and I hurt. The FMs were very upset they had to sit there and watch the resident suffer in pain for such a long amount of time. FM A said to his/her knowledge, the facility had only provided the resident with Tylenol for pain since the resident had returned from the hospital. He/she did not know why they did not give the resident ordered pain medication when the resident was in so much pain. Observation and interview on 3/21/22 at approximately 4:59 P.M., showed LPN P entered the locked [NAME] unit. When asked about the resident's pain medication, LPN P said, I can't do it right now, but will get to it when I can. LPN P said his/her priority was doing insulin's and passing medications on both halls and would give the resident some pain medication when he/she got to him/her. LPN P walked to the unit exit door at that time and started inputting the door code. FM A asked LPN P about the resident's pain medication and LPN P said, I will do it when I can and exited the unit. During an interview on 3/21/22 at 5:17 P.M., this surveyor notified the Corporate Nurse and Administrator B the resident was in pain and had been waiting approximately two hours for pain medication per family and staff. The Corporate Nurse said that was unacceptable and they would look into it. Administrator B instantly called the unit. The Corporate Nurse said pain was a priority, and the resident had a hip fracture and needs his/her pain medication. When asked if he/she should have been receiving ordered pain medication since his/her readmission, the Corporate Nurse said absolutely. Pain should be assessed on a routine basis and documented in the resident's echart. During an interview on 3/21/22 at 5:27 P.M., Administrator B notified the surveyor that the resident is getting (his/her) pain medication at this time. 2. Review of Resident #264's medical record, showed: -An admission date of 1/14/22; -Discharge/death in facility, 1/17/22. Review of the resident's hospital discharge instructions, dated [DATE], showed he/she was admitted for cardiac arrest. Multiple goals of care discussions were had with family and the decision to artificially prolong life was not something the resident would want. He/she was transitioned to comfort care measures. He/she was discharged to the facility on hospice (hospice care focuses on making you comfortable during the last months of life). Review of the resident's nurse's notes showed: -On 1/4/22 at 12:30 P.M., resident arrived to facility via ambulance. Resident's eyes closed, resting in bed at this time. admitted to facility for hospice care with diagnosis of cardiac arrest; -On 1/14/22 at 1:21 P.M., medication verified with physician, noted and ordered. Review of the resident's ePOS, showed: -An order dated 1/14/22, for acetaminophen suppository, 650 mg. Insert 1 suppository rectally every 4 hours as needed for pain or fever; -An order dated 1/14/22, for morphine sulfate (concentrate) solution (narcotic pain medication) 20 mg/ml. Give 0.5 ml by mouth every 2 hours as needed for pain/shortness of breath (SOB); -An order dated 1/14/22, for pain evaluation every shift for monitoring of patient's pain level. Review of the resident's electronic MAR, showed: -Order dated 1/14/22, for acetaminophen suppository, 650 mg. Insert 1 suppository rectally every 4 hours as needed for pain or fever. 1/14 through 1/17, blank, not documented as administered; -Order dated 1/14/22, for morphine sulfate (concentrate) solution 20 mg/ml. Give 0.5 ml by mouth every 2 hours as needed for pain/SOB, 1/14 and 1/15, blank, not documented as administered; -Order dated 1/14/22, for pain evaluation every shift for monitoring of patient's pain level. On 1/14, evening and night shift, blank, on 1/15, day shift, blank, evening shift, recorded pain level as 5, night shift, recorded pain level as 5. 3. During an interview on 3/29/22 at 9:02 A.M., the Corporate Nurse said if there are holes (blank areas) in the eMAR, it means it was not done. A lot of medications are available in the facility for new admissions, but if medications are not available, the hospice medical director can write a prescription and the facility can get the medications sent over within two hours. Medications should be administered as ordered. Pain should be assessed on a regular basis.