**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, record review, review of hospital records, facility policy review and interview, the facility failed to ensure fall risk/safety interventions were in place to prevent falls for one resident (#103) with known history of falls from bed. Actual harm occurred on 04/20/25 when Resident #103 who had a severe cognitive impairment and required extensive assistance from two staff for bed mobility sustained a fall out of bed resulting in hospitalization and surgical repair for a nondisplaced intertrochanteric fracture with of left femur when Certified Nursing Assistant (CNA) #800 left the room with the resident's bed in high position and the fall mat leaned against the wall to retrieve personal care supplies in the facility supply room. This affected one resident (#103) of three residents reviewed for falls. The facility census was 108. Findings Include: Review of the medical record for Resident #103 revealed an initial admission date of 08/15/22 with the latest readmission of 04/26/25 with diagnoses including nondisplaced intertrochanteric fracture of left femur, anemia, mood disorder, contracture of muscle multiple sites, attention-deficit hyperactivity disorder, overactive bladder, cerebrovascular accident (CVA) with left sided hemiplegia, anxiety disorder, insomnia, depression, adult failure to thrive, osteoarthritis, constipation, personal history of traumatic brain injury and hypertension. Review of the plan of care dated 12/07/22 revealed Resident #103 was at risk for falls and had potential for injury related to confusion, deconditioning, gait/balance problems, incontinence, unaware of safety needs, CVA with left sided hemiplegia, cerebral aneurysm, depression, anxiety, overactive bladder, adult failure to thrive, muscle weakness as well as effects of medications as ordered. Interventions included anticipate needs every shift, assure resident placed in middle of bed at all times, bed against the wall, bed to be in low position when in bed, Dycem to seat of Broda chair, educate the resident/family/caregivers about safety reminders and what to do if a fall occurs, encourage resident to participate in activities that will promote exercise, physical activity for strengthening and improved mobility, fall evaluation per facility protocol, labs as ordered, monitor for changes in gait and/or ambulation, assist with ambulation as needed, monitor for any medication side effects and recent change in medication, abnormal labs, signs/symptoms infection and pain as an increased risk for falls, report abnormal findings to physician, neuro-checks as ordered, nonskid socks when wearing shoes while out of bed, notify family, physician and Director of Nursing (DON) of any fall type incident as soon as possible, therapy to evaluate and treat as ordered or as needed, remind resident to request assistance for transfers if resident is alert and able to comprehend instructions, resident needs activities that minimize the potential for falls while providing diversion and distraction, review information on past falls and attempt to determine cause of falls, record possible root causes, alter remove any potential causes if possible, educate resident/family/caregivers/interdisciplinary team (IDT) as to causes and vision consult as needed. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive deficit. The assessment indicated the resident was dependent on staff for bed mobility. Review of the fall investigation dated 03/20/25 revealed the resident had a fall from her bed and was found to have no injuries. Review of the resident's fall risk evaluation dated 03/28/25 revealed the resident was at risk for falls. Review of the progress note dated 04/20/25 at 5:22 P.M., authored by Licensed Practical Nurse (LPN) #407 revealed Resident #103 was found on the floor by her bed lying on her left side. The note indicated the resident had been put back to bed after lunch. The entry documented the bedside mat was not in place at the time of the fall. The resident complained of pain to her left hip at a pain level of three out of 10 with 10 being the worst pain possible. The resident was given as needed pain medication. Certified Nurse Practitioner (CNP) #801 was notified and a new order was obtained for a left hip x-ray. The resident's husband was made aware of the incident and the staff were educated to make sure all fall precautions were always in place. Review of the fall investigation dated 04/20/25 revealed the resident had a fall from her bed when the staff member removed the mat, placed the mat against the wall and left the room to get disposable wipes from the supply room. Review of the Director of Nursing (DON) comment revealed the resident's fall interventions were not in place. Education was completed with staff, like residents identified and assessed for falls and falls were being audited. Review of left hip, unilateral with pelvis x-ray results dated 04/20/25 revealed a comminuted intertrochanteric fracture was identified on the left. Mild inferior lateral displacement of the distal fracture fragment was noted. The fracture does not involve the articular surface. Moderate to severe degenerative changes were noted. The surrounding soft tissues were normal. Orthopedic hardware was noted on the right. Conclusions: Intertrochanteric fracture, as detailed above, age undetermined. Review of the progress note dated 04/21/25 at 9:20 A.M., authored by LPN #530 revealed CNP #801 was notified of the x-ray results, and a new order was obtained to transfer the resident to the emergency room (ER). Review of Resident #103's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was not assessed. The assessment indicated the resident was dependent on staff for bed mobility. Review of a hospital Discharge summary dated [DATE] revealed Resident #103 arrived to the emergency department (ED) with the chief complaint of left hip pain following a fall at the skilled nursing facility (SNF). Following imaging the resident was found to have a closed displaced supracondylar fracture of distal end of left femur with intracondylar extension and a closed wedge compression fracture of the thoracic four (T4) vertebra. The hospital course included a [NAME] resection arthroplasty (used to resect the femoral head, to relieve pain and the source of infection.) of the left hip. On 04/25/25 the resident's plan of care was updated to include floor bed next to bed when resident in bed. Review of the progress note dated 04/26/25 at 8:17 P.M., authored by LPN #472 revealed the resident was re-admitted to the facility with a surgical incision to the left hip and a bruise on the front of the left thigh. The entry documented the resident had screamed out in pain when the nurse and aide tried to change her incontinence brief. The on-call physician was notified and a new order for pain medication was obtained. The entry documented the resident's bed was in the lowest position. Review of the physician progress note dated 05/02/25 revealed the resident was being seen for fall with hip fracture and weakness. The resident was hospitalized from [DATE] to 04/26/25 after a fall and found to have a left intertrochanteric and subtrochanteric hip fracture. The hospital course included a repair of the left hip on 04/24/25. The resident was also found to have a wedge compression fracture of the thoracic T4 with no surgical intervention. On 06/09/25 at 10:11 A.M., an interview with LPN #530 revealed she was notified of the residents' fall the day the fall occurred. The LPN revealed she was informed the resident rolled out of bed when CNA #800 failed to ensure the bed was in the lowest position and the fall mat was in place. On 06/09/25 at 10:32 A.M., observation of Resident #103 revealed the resident was lying in bed on her left side in fetal position. The resident had non-skid socks in place. The resident's bed was observed to be in the lowest position and the bed mattress was next to the bed. On 06/09/25 at 12:38 P.M., an interview with LPN #407 revealed he was the nurse on duty when Resident #103 rolled out of bed. The LPN revealed CNA #800 laid the resident down after lunch and was providing incontinence care. The LPN revealed the CNA left the room to retrieve disposable wipes from the supply room and the bed was not in the low position and the floor mat was leaned against the wall. The LPN revealed the resident rolled out of her bed while the CNA left the room and verified the resident's fall interventions were not in place at the time of the incident. The LPN revealed he notified management immediately and educated the staff on making sure fall interventions were in place at all times. Review of the facility policy titled, Fall Management Guidelines, implemented 12/13/23 revealed a fall is defines as unintentionally coming to resident on the ground, floor or other level with or without injury to the resident, but not as a result of an overwhelming external force. The facility staff with the input of the attending physician, will implement a resident centered comprehensive care plan that addresses the fall management program, the goal for fall management, individualized interventions to address the resident's modifiable fall risk factors, interventions to try to minimize the consequences of risk factors that are not modifiable and the plan for reduction of risk and or risk for injury. The deficient practice was corrected on 05/04/25 when the facility implemented the following corrective actions: • On 04/20/25 at approximately 3:30 P.M. Resident #103 sustained a fall incident. An immediate resident assessment was completed by LPN #407. The resident was medicated for complaints of left hip pain with as needed analgesic. The resident's physician and power of attorney (POA) were notified of the incident and a new order for an x-ray of the resident's left hip was obtained. LPN #407 educated Certified Nursing Assistant (CNA) #800 on ensuring fall precautions were in place. • On 04/21/25, the left hip x-ray results were received and communicated to the resident's physician and POA. The DON began the fall investigation and met with the resident. The resident was transferred to the local emergency room (ER) for further evaluation. The DON interviewed LPN #407 related to the fall incident. • On 04/22/25, the DON interviewed CNA #800 and education was provided to CNA #800 on ensuring fall interventions were in place. • From 04/23/25 through 04/28/25, fall risk residents were identified and audits completed for fall evaluations by Unit Manager #456 and #530. Resident Kardex's were modified as needed. The DON educated nursing staff on having fall interventions in place. The facility began audits on fall interventions in place and was ongoing. • On 04/28/25, Quality Assurance Performance and Improvement (QAPI) was signed by the Medical Director and all Department Heads. Fall intervention audits were to be completed on the following schedule: four times a week for four weeks, then three times a week for three weeks, two times a week for two weeks, one time a week for two weeks, and once a week ongoing. • Review of the facility timeline of corrective action and interview with Administrator revealed the facility identified corrective actions were completed as of 05/04/25. • On 06/09/25, interviews conducted from 10:11 A.M. to 2:40 P.M. with the DON, Registered Nurse (RN) #514, LPN #407, #443, #530 and CNA #487 and #552 revealed they had all received education by management staff on or around 04/23/25 through 04/28/25 regarding ensuring resident fall interventions were in place at all times. This deficiency represents non-compliance investigated under Complaint Number OH00166328.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, hospice staff interview, review of hospice visits notes and review of facility policy, the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to timely identify, assess and implement treatment for Resident #51 related to a pressure ulcer to the left lateral foot. Actual harm occurred on 08/09/24 when Resident #51, who was cognitively impaired and dependent on staff for activity of daily living care was first identified by the facility to have an unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) pressure ulcer to the left lateral foot. Prior to 08/09/24 hospice staff had identified this pressure ulcer, however the facility failed to identify the unstageable pressure ulcer prior to 08/09/24, failed to ensure on-going assessments and monitoring of the ulcer were completed and failed to ensure the ulcer was properly treated to prevent deterioration. This affected one resident (#51) of three residents reviewed for skin breakdown. The facility census was 72. Findings Include: Review of the medical record for Resident #51 revealed an initial admission date of 03/12/20 with current diagnoses including cerebrovascular accident with left sided hemiplegia, severe protein calorie malnutrition, pressure ulcer left ankle (added on 08/03/24), Parkinson's disease, major depressive disorder, neuropathy, anxiety disorder, gastro-esophageal reflux disease, atrial fibrillation, overactive bladder, aphonia, dry eye syndrome, hyperlipidemia, constipation, pain, bladder-neck obstruction, chronic sinusitis, ataxic gait, asthma, benign prostatic hyperplasia with lower urinary tract symptoms, insomnia, repeated falls, osteoarthritis and dysphagia. Review of the resident's physician orders identified an order dated 03/15/23 for a skin evaluation to be completed weekly. Check skin for open areas, bruises, abrasions, DTI, and incisions. Review of the medical record revealed the resident was admitted to hospice services on 06/01/23 for the terminal diagnosis of Parkinson's disease with a life expectancy of six months or less if the disease runs its normal course. Review of the care plan dated 04/06/23 revealed the resident was at risk for pressure injury formation related to generalized debility and weakness as evidenced by decreased mobility in bed and wheelchair, incontinence of bowel and bladder, the resident needing assistance with incontinence care, turning/repositioning and the presence of a pressure injury to the sacrum. Interventions included treatment per physician orders, barrier cream to buttocks after every incontinent episode, bilateral mobility bars to aide with turning and mobility in bed, Braden scale to be completed per facility policy, consult wound team as needed, encourage and assist as needed to turn/reposition per policy, use assistive devices as needed, encourage intake of 75 to 100% of diet and fluids daily. Dietician to assess dietary needs quarterly and with significant changes, encourage resident to float heels and/or wear heel boots, labs as ordered, report abnormal results to physician, low air loss mattress on bed, monitor skin daily during care for redness, excoriation or breakdown, pressure reduction cushion to broad chair, preventative skin care post incontinence care daily, as needed and skin evaluation weekly and on 08/13/24 the facility implemented the use of a moon boot to the left foot at all times, remove for skin integrity checks every shift. Review of the resident's Braden scale dated 02/05/24 revealed a score of 11 indicating the resident was at high risk for skin breakdown. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive impairment. The assessment indicated the resident was at risk for skin breakdown and had one unstageable pressure ulcer not present on admission. The facility implemented pressure reducing device to bed/chair, pressure ulcer/injury care, application of nonsurgical dressings other than to feet and application of ointments/medications other than to feet. Record review revealed this pressure ulcer was to the resident's sacrum. A second State optional MDS assessment also dated 11/16/23 revealed the resident had a severe cognitive deficit and resident required extensive assistance from two staff for bed mobility, transfers and toileting. Review of a hospice wound note revealed on 02/06/24 the Hospice Registered Nurse (HRN) #295 identified Resident #51 had an unstageable deep tissue injury (DTI) (DTI is defined as a purple or maroon area of discolored intact skin due to damage of underlying soft tissue. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue) to the left lateral foot measuring 2.5 centimeters (cm) by 2.5 cm by 0.5 cm. There were no additional notes from hospice on this date related to the why the ulcer developed. Review of the resident's medical record revealed no documented evidence the facility had identified or addressed the unstageable DTI development, implemented any interventions to prevent the worsening of the DTI or updated the resident's plan of care to reflect the development of the DTI. Review of a hospice wound note revealed on 02/12/24 the unstageable DTI to the left lateral foot measured 1.0 cm by 0.5 cm. The wound was described as square with less than 25% white necrotic tissue and 75 to 100% granulation tissue. Review of the resident's physician orders revealed no treatment was implemented for the DTI pressure ulcer/injury until 02/12/24 (six days after hospice staff first identified the ulcer) when an order was obtained to cleanse with soap and water or wound cleanser, pat dry and apply Allevyn dressing every shift for wound care. The order indicated the facility floor nurse was to complete wound care as needed if the dressing became heavily soiled. The order was discontinued on 02/14/24. On 02/16/24 a new order was noted to cleanse the left lateral foot with soap and water or wound cleanser, pat dry, apply Allevyn dressing every Monday and Friday for wound care. The order indicated hospice would provide all supplies and wound care and the facility floor nurse may complete (dressing change) as needed if heavily soiled. Review of the hospice wound note revealed on 02/19/24 the DTI to the left lateral foot measured 1.0 cm by 1.0 cm and described as round with 100% epithelialization. Review of the hospice wound note revealed on 02/26/24 the DTI to the left lateral foot measured 1.5 cm by 2.0 cm and remained round with 100% epithelialization. Review of the hospice wound note revealed on 03/04/24 the DTI to the left lateral foot measured 1.0 cm by 1.0 cm and remained round with 100% epithelialization. Review of the hospice wound note revealed the next comprehensive assessment of the DTI to the left lateral foot was completed on 03/22/24 and the ulcer measured 1.0 cm by 0.5 cm and was described as 75 to less than 100% necrotic tissue with distinct edges. Review of the hospice wound record report revealed the next comprehensive assessment was completed on 04/22/24 (a month later). The DTI to the left lateral foot measured 0.5 cm by 0.5 cm. The wound was described as round. The hospice nurse implemented a treatment to cleanse the wound to the left lateral foot with soap and water or normal saline (NS), pat dry and apply a small Allevyn to pad and protect every Monday and Friday per the hospice nurse. Review of physician's orders dated 04/23/24 revealed an order for Enhanced Barrier Precautions every shift related to the resident's pressure ulcer. Review of the hospice wound record report revealed the next assessment for the DTI to the left lateral foot was completed on 05/31/24 (over 30 days later) and the ulcer measured 0.5 cm by 0.5 cm and was described as being round. The same treatment continued, including the facility were to change the dressing as needed for dislodgement or soiled. Review of the resident's physician orders revealed the treatment order that was implemented on 02/16/24 to resident's left lateral foot was discontinued on 06/05/24. Review of the corresponding June 2024 Treatment Medication Record (TAR) also revealed the facility discontinued the treatment to the left lateral foot on 06/05/24. Record review revealed no facility assessments or progress notes from 02/2024 through 06/05/24 related to the resident's left lateral foot pressure ulcer. Review of a hospice wound record report revealed an assessment for the DTI to the left lateral foot was completed on 06/14/24 and the ulcer now measured 1.4 cm by 1.5 cm. The wound was described as round with 75 to 100% yellow slough. Despite the presence of yellow slough tissue, it appeared the treatment order that had been discontinued on 06/05/24 continued to be provided at this time. Review of the hospice wound record report revealed the next assessment for the DTI to the left lateral foot was completed on 06/21/24 and the ulcer measured 0.5 cm by 1.5 cm. The wound was described with 26 to 50% white necrotic tissue. No changes were made to the resident's treatment. Review of physician's orders revealed an order dated 07/25/24 for house liquid protein 30 milliliters (ml) three times a day for wound healing. There was no additional information as to why this nutritional supplement was not added until 07/25/24 when the pressure ulcer was first identified in February 2024. Review of the hospice wound record report revealed the next assessment for the DTI to the left lateral foot was completed on 08/02/24 (over 30 days from the previous assessment completed on 06/21/24). The ulcer was assessed to measure 2.0 cm by 1.5 cm by 0.5 cm. The wound was described as round with 50 to 75% white necrotic tissue with purulent drainage. Review of the hospice wound record report revealed the next assessment of the DTI to the left lateral foot was completed on 08/05/24 with the ulcer measuring 1.0 cm by 0.5 cm by 0.2 cm with 75 to 100% yellow necrotic tissue. Record review revealed no facility assessments or progress notes from 06/06/24 through 08/05/24 related to the resident's left lateral foot pressure ulcer. A facility incident report dated 08/09/24 at 11:47 A.M. revealed Resident #51 was found to have a new pressure ulcer to the left lateral foot during a skin assessment. The facility implemented a treatment to cleanse with NS, apply calcium alginate and cover with boarder dressing. Record review revealed the facility also implemented protective boots at this time. Review of the progress note dated 08/09/24 at 11:55 A.M. revealed during skin assessment a new area was found, the Nurse Practitioner (NP), hospice and family were notified of the new area. The resident was referred to for wound care and a new order to cleanse with normal saline, apply calcium alginate and cover with foam border dressing was implemented. Although this area was consistent with the ulcer being treated by hospice, since February 2024, the first identification of the ulcer by the facility did not occur until 08/09/24 when the facility assessed the resident to have an unstageable pressure ulcer to the left lateral ankle. Review of the medical record revealed no documented evidence the facility comprehensively assessed the unstageable pressure ulcer to the resident's left lateral foot including measurements, description of the wound and exudate when found on 08/09/24 Review of a hospice wound record report revealed the next assessment of the DTI to the left lateral foot was completed on 08/12/24 measuring 1.0 cm by 2.0 cm with 75 to 100% yellow necrotic tissue, although the facility was classifying the DTI as an unstageable pressure ulcer on 08/09/24. Record review revealed the facility first weekly skin and wound evaluation was completed on 08/13/24 (four days after facility staff noted the ulcer) and revealed the resident had an unstageable pressure ulcer to the left lateral foot measuring 1.6 cm by 1.3 cm. The wound was described as having 100% slough with a moderate amount of serous exudate. The edges were described as non-attached. The facility documented the new area was found when doing skin assessment. The facility continued the 08/09/24 treatment to cleanse with normal saline (NS), apply calcium alginate and foam border dressing daily for wound care. Review of a physician order dated 08/13/24 revealed an order for a moon boot to the left foot at all times, remove for skin integrity check every shift. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. Review of the mood and behavior revealed the resident displayed physical behaviors directed towards others, however the resident did not reject care. The assessment indicated the resident was always incontinent of both bowel and bladder. The assessment indicated the resident was at risk for skin breakdown and had 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) pressure ulcer that was not present on admission (ulcer to the coccyx) and one unstageable pressure ulcer that was not present on admission (to the left lateral foot). The assessment indicated the resident also had an infection to the foot and skin tears. The facility implemented pressure reducing device to bed/chair, nutrition or hydration intervention to manage skin problems, pressure ulcer/injury care, application of nonsurgical dressings other than to feet, application of ointments/medications other than to feet and application of dressings to feet. Record review revealed beginning on 08/14/24 facility staff completed wound assessments which included the following: A facility weekly skin and wound evaluation dated 08/14/24 revealed the unstageable pressure ulcer to the left lateral foot measured 1.5 cm by 1.2 cm by 0.2 cm. The wound was described as 100% slough with a moderate amount of serous exudate. The edges were attached and appeared as flush with wound bed or a sloping edge. The wound was new, and the wound physician made the initial visit and implemented the treatment to cleanse with normal saline (NS), pat dry, apply calcium alginate and foam border dressing. A facility weekly skin and wound evaluation dated 08/21/24 revealed the unstageable pressure ulcer to the left lateral foot was classified as Stage IV pressure ulcer measuring 1.3 cm by 0.7 cm by 0.2 cm. The wound was described as having 40% slough and 50% granulation tissue with a moderate amount of serous exudate. The assessment had no documentation of the edges. The facility determined the wound had improved. The facility documented a Curette was used to surgically excise devitalized tissue including slough, biofilm and nonviable muscle level tissues were removed at a depth of 0.2 cm and healthy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 40 percent to zero percent. Hemostasis was achieved and clean dressing was applied. The wound consisted of 40% slough, 50% granulation tissue and 10% other viable tissues. A facility weekly skin and wound evaluation dated 08/28/24 revealed the unstageable pressure ulcer to the left lateral foot was classified as Stage IV pressure ulcer measuring 1.5 cm by 1.2 cm by 0.3 cm. The wound was described as 30% slough and 60% granulation tissue with a moderate amount of serous exudate. The edges were described as non-attached. The facility determined the wound had improved. A facility weekly skin and wound evaluation dated 09/04/24 revealed the unstageable pressure ulcer to the left lateral foot was classified as Stage IV pressure ulcer measuring 1.5 cm by 1.2 cm by 0.3 cm. The wound was described as 30% slough and 60% granulation tissue with a moderate amount of serous exudate. The edges were described as non-attached. The facility determined the wound was stable. Review of a physician order dated 09/05/24 revealed an order for Resident #51 to be seen by wound consultant. A facility weekly skin and wound evaluation dated 09/11/24 revealed the unstageable pressure ulcer to the left lateral foot was classified as Stage IV pressure ulcer measuring 1.4 cm by 1.0 cm by 0.2 cm. The wound was described as 30% slough and 60% granulation tissue with a moderate amount of serous exudate. The edges were described as non-attached. The facility determined the wound had improved. A facility weekly skin and wound evaluation dated 09/18/24 revealed the unstageable pressure ulcer to the left lateral foot was classified as Stage IV pressure ulcer measuring 2.6 cm by 1.8 cm. The wound was described as 80% slough and 20% granulation tissue with a moderate amount of serous exudate. The edges were described as non-attached. The facility determined the wound was stable. A facility weekly skin and wound evaluation dated 09/24/24 revealed the unstageable pressure ulcer to the left lateral foot was classified as stage IV pressure ulcer measuring 2.4 cm by 2.2 cm by 0.4. The wound was described as 50% slough and 50% granulation tissue with a heavy amount of serous exudate. The edges were described as curled under. The facility determined the wound was stable, however the facility changed the treatment to cleanse with NS, apply Medi-honey then calcium alginate and cover with foam border dressing daily. Review of physician's orders for September 2024 revealed an order dated 09/24/24 to cleanse left lateral foot wound with normal saline (NS), apply Medi-honey then calcium alginate and foam boarder dressing every night shift, cleanse wound to sacrum with NS, moisten gauze with NS then pack gently into wound and cover with foam dressing. A facility weekly skin and wound evaluation dated 10/01/24 revealed the unstageable pressure ulcer to the left lateral foot was classified as Stage IV pressure ulcer measuring 1.6 cm by 1.6 cm by 0.2. The wound was described as 20% slough and 80% granulation tissue with a light amount of serous exudate. The edges were described as non-attached. The facility determined the wound had improved. On 10/01/24 at 2:20 P.M., Licensed Practical Nurse (LPN) #209 and LPN #241 were observed to provide the physician ordered treatment to Resident #51's pressure ulcer. LPN #209 measured the wound at 1.6 cm by 1.6 cm by 0.2 cm. The wound bed was reddish with white rolled edges. LPN #241 applied Medi-honey to the wound bed, applied calcium alginate and covered with a foam border dressing. On 10/02/24 at 8:17 A.M., interview with Hospice Case Manager (HCM) #294 revealed the resident had multiple pressure ulcers, however the DTI on the left lateral foot was first identified as a DTI in February 2024 and Hospice Registered Nurse (HRN) #295 found the wound. During the interview, HCM #294 revealed it was difficult to communicate with the facility Unit Managers (UM) as well as the Director of Nursing (DON) due to facility having a lot of turnover (in staffing). On 10/02/24 at 9:14 A.M., interview with HRN #295 revealed she found the resident had a left lateral foot pressure ulcer/wound in February 2024. She said it was a deep tissue injury (DTI) and they were using a pad to protect the area due to the resident's contractures. She said then it just got worse. She said she gave the facility orders for the wound of pad and protect. She said the left lateral foot wound was almost healed and then opened again. She said when she was there on 09/30/24 during her routine visit his foot was soaked with drainage and she changed the dressing. She said the facility doesn't always date or initial the dressing, so she did not know how long this dressing was actually on the wound. She said the use of a moon boot as a preventative measure was not implemented until August 2024. She said the wound was just a red spot and then in August 2024 it deteriorated and opened. On 10/03/24 at 10:30 A.M. interview with the Director of Nursing (DON) verified the facility had no documented evidence that facility staff identified the development of the resident's pressure ulcer, assessed or monitored Resident #51's DTI/unstageable pressure ulcer with the onset of 02/06/24 until 08/13/24. Per record review, facility staff first documented the presence of the pressure ulcer on 08/09/24. On 10/03/24 at 2:10 P.M., interview with LPN #209 and #241 revealed a treatment to the DTI was initiated on 02/07/24 to pad and protect twice weekly until 02/12/24 when the treatment was changed to pad and protect daily. The treatment was discontinued on 02/14/24 and the wound did not have treatment until 02/16/24 when the pad and protect twice weekly on Monday and Friday was implemented. The treatment was discontinued on 04/12/24 when the facility implemented the same pad and protect treatment twice weekly on Monday and Friday. The facility then documented the ulcer was healed on 06/05/24 (which was not accurate). LPN #209 and #241 verified they were unaware of hospice continuing the assessment and treatment of the wound following this date. LPN #209 revealed on 08/09/24 facility staff identified the resident had an unstageable pressure ulcer to the left lateral foot in the same area as the DTI. LPN #209 verified the facility had no comprehensive assessments of the DTI prior to the 08/13/24 assessment. Review of the facility policy titled, Skin and Wound Guidelines, last revised on 03/20/24 revealed skin alterations and pressure injuries were evaluated and documented by the licensed nurse. Weekly evaluations of the skin alteration in the resident's medical record by the wound team or licensed nurse per state and federal regulations. This deficiency represents non-compliance investigated under Complaint Number OH00158032 and Complaint Number OH00157831.