**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, hospital record review, review of the facility's incident/accident investigation, staff interview, and policy review the facility failed to develop and implement a comprehensive, individualized and effective fall management program to prevent a fall with injury for Resident #1. Actual harm occurred on 12/01/24 at approximately 12:55 P.M. when Resident #1, who had a diagnosis of dementia, fall risk with history of falls, increased lethargy and confusion sustained an avoidable unwitnessed fall out of bed resulting in head trauma/head hematoma which required hospital treatment. Prior to this fall, the resident sustained an unwitnessed fall out of bed on 12/01/24 at 1:30 A.M. with no evidence the facility implemented timely, adequate and effective interventions/measures to prevent the additional fall with injury on the same date. The resident was hospitalized until 12/09/24. Findings include: Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, epilepsy, dementia, atherosclerotic heart disease, anxiety disorder, presence of a urostomy and colostomy, major depressive disorder, cardiac arrhythmia, sick sinus syndrome, bipolar disorder, and presence of cardiac pacemaker. Review of the Minimum Data Set (MDS) 3.0 assessment revealed Resident #1 had a Brief Interview of Mental Status (BIMS) score of 15 (out of 15). The MDS revealed Resident #1 had no impairment of range of motion to the upper extremities but had impairment of her lower extremities bilaterally and used a wheelchair. Review of the care plan dated 03/24/21 (and updated 12/04/24) revealed Resident #1 was at risk for falls with a history of falls. Falls interventions documented on the care plan included color tape applied to the call light to remind Resident #1 to call for help, declutter pathway in room, digital clock in room in line of site, use a self-releasing seatbelt when in the wheelchair, use of non-skid footwear, non-skid strips in front of the sink, bilateral falls mats, Dycem to wheelchair and encourage use of hipsters. Record review revealed the resident also had a plan of care related to non-compliance with an intervention to educate the resident to notify staff and ask for assistance when changing an ostomy bag. Review of a progress note revealed on 12/01/24 at 1:30 A.M. Resident #1 had an unwitnessed fall. Resident #1 was found lying beside her bed. Resident #1 stated she fell trying to change her colostomy bag. The root cause was determined to be resident the resident was known to be resistant to assistance with colostomy/urostomy bags. Current interventions in place included Dycem, skid strips, color tape to call light, signs as visual cues, and bilateral falls mats were all in place at the time of the fall. Interventions added after the fall included sign placed in room specifically reminding resident to call for assistance for cleaning area or providing direct care. Review of the Incident/Accident Investigation form dated 12/01/24 at 1:30 A.M. filled out by Registered Nurse (RN) #400 revealed Resident #1 had an unobserved fall. The resident's call bell was documented to be in reach and was not activated, personal items were in reach, the bed was locked in the lowest position, bilateral floor mats were documented as in place, the floor was not wet, there was proper lighting, and assistive devices were in reach of Resident #1. Resident #1 was described as following usual routine with the comment non-compliant with the process up to change the colostomy bag. Immediate intervention listed was to keep the door open and to do every 15-minute checks until Resident #1 gets up in the morning. However, the medical record (progress note) contained no evidence 15- minute checks were completed throughout the night until the resident awoke. Post fall neurological checks were completed on 12/01/24 at 1:30 A.M., 1:45 A.M., 2:00 A.M., 2:15 A.M., 2:45 A.M., 3:15 A.M., 3:45 A.M., 4:15 A.M., 5:15 A.M., and 6:15 A.M. that were documented as normal where Resident #1 was fully conscious, moves all four extremities, grasp were equal, pupil size was equal and reactive (brisk), and the resident was documented to have had slurred speech. Follow up neurological check done at 7:15 A.M. by LPN #407 revealed all elements were the same except level of consciousness had changed to lethargic. The next neurological check completed at 11:15 A.M. again reflected the same change in the level of consciousness to now reflect the resident was lethargic. There were no additional assessments or progress note follow up to address or explain Resident #1's documented change in level of consciousness. In addition, there was no evidence of changes to the resident's supervisory and/or fall interventions as a result of the identified lethargy on the neurological assessments. The resident's plan of care was updated following the fall on 12/01/24 at 1:30 A.M. with an intervention that signs were placed in Resident #1's room to remind her to call for assistance when getting up. A progress note dated 12/01/24 at 12:10 P.M. revealed Licensed Practical Nurse (LPN) #451 noted the resident was not acting like her normal self. Resident #1's speech was slurred. Resident #1 was very lethargic and seemed confused. LPN #451 contacted the nurse practitioner (CNP) and received new orders for laboratory test of complete blood count, comprehensive metabolic panel, hepatic panel, thyroid stimulating hormone, and a chest x-ray. Resident#1's representative was made aware. However, there were no new fall risk/safety interventions implemented at this time. A progress note dated 12/01/24 at 12:55 P.M. revealed Resident #1 had another unwitnessed fall. Resident #1 was found lying beside her bed. The resident stated she was trying to get up but was unable to answer why. Resident #1 stated she was not in pain but was noted to have a large knot on the back of her head that was bleeding. The CNP was notified, and an order was received to transfer Resident #1 to the hospital for evaluation. The resident representative was notified of fall and transfer to hospital. Review of the hospital after visit summary with a visit date from 12/01/24 to 12/09/24 documented Resident #1's had a hospitalization with diagnoses of hematoma and head trauma. On 01/09/25 at 3:21 P.M. interview with the Director of Nursing (DON) revealed Resident #1 was care planned to request for staff assistance and staff continued to encourage the resident to request help. The DON confirmed Resident #1 had signs in the room to remind the resident to ask for help as a visual cue, and the resident was receiving therapy services to improve strength in her lower extremities to aid in her goal of independence. The DON revealed neurological checks were documented on a form that was included as part of the fall investigation and not in the electronic medical record, and none of the post fall assessment of neurological checks were included in the resident progress notes. The DON verified Resident #1 had a change in her neurological check completed on 12/01/24 at 7:15 A.M. when the resident was documented to be lethargic and the there was no additional neurological checks completed, or assessment of Resident #1 completed until the next routine schedule post fall neurological check at 11:15 A.M. The DON confirmed Resident #1 had progress notes included as part of the medical record dated 12/01/24 at 1:30 A.M. when the resident fell, at 12/01/24 at 12:10 P.M. when the facility notified the practitioner of the change in condition and on 12/01/24 at 12:55 P.M. when the resident had an additional fall which resulted in a hematoma, and head trauma and the need for the resident to have further treatment at the hospital. No other progress notes were part of the medical record on 12/01/24. Review of facility policy titled Fall Prevention dated 01/02/24 revealed each resident's risk factors and environment hazards would be evaluated when developing the resident's comprehensive plan of care. Interventions would be monitored for effectiveness and the plan of care would be revised as needed. When a resident experienced a fall, the facility would assess the resident, complete a post-fall assessment, complete an incident report, notify the physician and family, review the resident's care plan and update as needed, and document all assessments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview, staff interview and policy review, the facility failed to timely implement procedures to minimize the risk for pressure ulcers for one (#59) of three residents reviewed for pressure ulcers. This resulted in actual harm when Resident #59 developed a new stage II pressure ulcer. The facility also failed to follow the wound treatment recommendations for three (#59, #55, and #58) of three residents reviewed for pressure ulcers. The facility census was 102. Findings include: 1. Review of the medical record for the Resident #59 revealed an admission date of 07/28/22. Diagnoses included sepsis, heart failure, respiratory failure, diverticulitis, depression, encephalopathy, and transient ischemic attack. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #59 was cognitively intact with a Brief Interview of Mental Status (BIMS) of 15 and required extensive assistance of two staff members for transfers and required extensive assist of one staff member for eating. The MDS revealed the resident had a greater than 5% weight loss that was unplanned and the resident had a therapeutic diet. Review of the progress notes dated 12/09/22 revealed the dietician reviewed the resident for a significant weight loss of 13 pounds and recommended the supplement Ensure twice daily. The resident had another small weight loss of 3 pounds on 12/14/22 and the dietician had continued to monitor the resident's weights. Review of the Medication Administration report (MAR) dated 12/2022 and 01/2023 revealed the resident had been getting the supplements once daily and twice daily as ordered and the percentage of intake had been documented in the MAR. Review of the plan of care dated 07/29/22 revealed Resident #59 was at risk for potential for nutritional risk related to weight loss with interventions to document food and fluid intakes, honor food preferences, serve diet as ordered provide supplements and dietician to evaluate for diet changes. Resident #59's care plans included a care plan which stated the resident had moisture associated dermatitis to the sacrum dated 10/07/22 and the care plan was updated stating the resident had an unstageable pressure ulcer (the base of the ulcer is covered by a thick layer of other tissue and pus that may be yellow, grey, green, brown, or black and therefore the stage could not be determined) to the sacrum on 12/18/22. Interventions listed on the care plan included to provide incontinence care as needed, wound treatment as ordered, pressure reducing bed, and turning the resident. All interventions were dated 10/07/22. Review of Resident #59's physician orders at the time of the survey revealed the resident had the following wound orders in place: float heels as tolerated dated 07/29/22; air mattress ordered 11/29/22; apply heel protector boots every shift for pressure reduction ordered 11/29/22; apply triad cream (barrier cream) to sacrum two times a day for wound care dated 10/07/22; cleanse buttock ischium with soap and water and apply triad cream twice daily and as needed dated 12/23/22; cleanse left heel with mild soap and water apply triad cream and cover with border foam dressing dated 12/23/22. Review of Certified Nurse Practitioner (CNP) #300's wound documentation revealed the resident was seen weekly and had his wounds measured. The documentation included the wound's size, surface area and condition of the wounds. The documentation also included the current treatment and interventions for each wound. The resident's sacral wound was acquired on 10/06/22 and documented etiology as moisture related to urine and stool incontinence. The wound was classified as moisture associated dermatitis (MASD). Sacral wound documentation was as follows: -MASD measurement on 10/06/22: 5.42 centimeters (cm) x 3.56 cm x 0.1 cm. -MASD measurement on 10/11/22: 1.29 cm x 1.05 cm x 0.10 cm. -MASD measurements on 10/18/22: 0.91 cm x 0.30 cm x 0.1 cm. -MASD measurement on 10/28/22: 1.93 cm x 2.09 cm x 0.1 cm. -MASD measurement on 11/01/22: 3.11 cm x 3.37 cm x 0.1 cm. -MASD measurement on 11/08/22: 5.75 cm x 5.02 cm x 0.1 cm. -MASD measurement on 11/15/22: 3.26 cm x 1.50 cm x 0.1 cm. Resident #59 was in the hospital from [DATE] through 11/29/22 and returned to the facility on [DATE]. Review of the nursing admission/readmission evaluation from 11/29/22 revealed the resident had redness to the coccyx, and a right thigh and a left heel pressure ulcer. No wound measurements or description of the areas were included in the nursing admission/readmission evaluation or in the medical record. A MASD measurement of the sacrum revealed on 12/06/22 the area was 3.84 cm x 4.60 cm x 0.1 cm. The recommended treatment for the 12/06/22 MASD documented in CNP #300's wound documentation was to cleanse the area with normal saline and apply triad paste twice daily and as needed. CNP #300's documentation on 12/13/22 revealed the sacral area was worsening and was now classified as an unstageable pressure ulcer measuring 6.79 cm x 3.83 cm. The treatment was documented as cleanse wound with normal saline, apply hydrogel (keeps the wound moist and helps to remove slough or necrotic tissue), and cover with a border foam dressing daily. Wound care interventions were updated to include a specialty bed. Review of Resident #59's physician orders revealed the facility failed to follow CNP #300's recommended treatment starting on 12/13/22 when the facility continued to use the triad paste twice daily to the wound and apply border foam. Resident #59 was hospitalized from [DATE] through 12/21/22. The medical record was silent to the disposition of the resident's skin condition on readmission to the facility from this hospitalization. There was no admission/readmission evaluation in the medical record and no documentation in the progress notes regarding the resident's skin condition. The resident's wounds were re-assessed on 12/27/22 by CNP #300, six days later. CNP #300's documentation of the unstageable area to the resident's sacrum was as follows: -12/27/22 improving wound measuring 3.51 cm x 2.65 cm, continue with normal saline, apply hydrogel and cover with a border foam dressing daily and ensure compliance with turning and specialty bed. -01/03/23 wound is stable measuring 3.67 cm x 2.60 cm, continue normal saline, apply hydrogel and cover with a border foam dressing daily and ensure compliance with turning and specialty bed. -01/10/23 wound is stable measuring 3.13 cm x 2.37 cm, continue normal saline, apply hydrogel and cover with a border foam dressing daily and ensure compliance with turning and specialty bed. Review of Resident #59's physician orders revealed the facility failed to follow CNP #300's wound treatment recommendations when the facility continued to treat the sacrum ulcer with triad paste twice daily. Resident #59's right posterior thigh skin alteration was documented in the medical record by CNP #300 as follows: -10/28/22 skin tear: 1.16 cm x 1.42 cm x 0.10 cm -11/01/22 skin tear: 1.99 cm x 2.68 cm x 0.1 cm -11/08/22 skin tear: 2.08 cm x 1.32 cm x 0.1 cm -11/15/22 skin tear: 1.35 cm 0.98 cm x 0.10 cm Wound care treatment recommendations for the above dates were documented in CNP #300's notes as cleanse with normal saline and apply triad paste twice daily and as needed. Resident #59 was in the hospital from [DATE] through 11/29/22 and returned to the facility on [DATE]. Review of the nursing admission/readmission evaluation documented the resident wounds as redness to the coccyx, a right thigh, and a left heel pressure ulcer. No wound measurements or description of the areas were included in nursing admission/readmission evaluation or in the medical record. The medical record had the ordered treatment for the right posterior thigh from 11/29/22 through 12/06/22 as cleanse the area with normal saline and apply triad paste twice daily and as needed. On 12/06/22 the right posterior thigh wound was assessed by CNP #300 and documented the wound to the right posterior thigh as 1.42 cm x 1.94 cm x 0.20 cm. The wound was classified as a stage III pressure ulcer (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed) with the treatment documented as cleanse with normal saline, apply hydrogel and cover with a border foam dressing change daily. On 12/13/22 CNP #300 documented the right posterior thigh stage III pressure ulcer was 1.31 cm x 1.87 cm x 0.1 cm and the treatment recommendation by CNP #300 was cleanse with normal saline, apply hydrogel, and cover with a border foam dressing change daily. Resident #59 was hospitalized from [DATE] through 12/21/22. The medical record was silent to the disposition of the resident's skin condition on readmission to the facility from this hospitalization. There was no admission/readmission evaluation in the medical record and no documentation in the progress notes regarding the resident's skin condition. The wounds were re-assessed on 12/27/22 by CNP #300, six says later. CNP #300's documentation of the resident's right posterior thigh was as follows: -12/27/22 stage III pressure ulcer to right posterior thigh: 1.59 cm x 1.94 cm x 0.1 cm documented as stable, treatment continued as cleanse with normal saline, apply hydrogel, and cover with a border foam dressing. -01/03/23 right posterior wound classification changed to an unstageable area: 1.16 cm x 2.01 cm x 0.2 cm continue to cleanse with normal saline, apply hydrogel, and cover with a border foam dressing. -01/10/22 right posterior thigh unstageable pressure ulcer: 1.15 cm x 2.12 cm x 0.2 cm documented as stable and to continue to cleanse with normal saline, apply hydrogel, and cover with a border foam dressing. Review of Resident #59 's physician orders revealed the facility failed to follow the CNP #300's wound treatment recommendations when the facility continued to treat the right posterior thigh (buttock/ischium) ulcer with triad paste twice daily and cover with a border foam dressing. Resident #59's medical record revealed the resident acquired an unstageable pressure ulcer to the left heel on 11/14/22. CNP #300's wound documentation for the left heel was as follows: -11/15/22 unstageable: 3.14 cm x 3.99 cm cleanse with normal saline, apply hydrogel, cover with Army Battle Dressing (ABD) pad, and wrap with Kerlix/Kling. -12/06/22 unstageable: 2.79 cm x 2.64 cm, wound stable continue treatment of cleanse with normal saline, apply hydrogel, cover with ABD pad, and wrap with Kerlix/Kling. -12/13/22 unstageable: 3.50 cm x 3.81 cm, wound stable continue treatment of cleanse with normal saline, apply hydrogel, cover with ABD pad, and wrap with Kerlix/Kling. Resident #59 was hospitalized from [DATE] through 12/21/22. The medical record was silent to the disposition of the resident's skin condition on readmission to the facility from this hospitalization. There was no admission/readmission evaluation in the medical record and no documentation in the progress notes regarding the resident's skin condition. The wounds were re-assessed on 12/27/22 by CNP #300, six days later. CNP #300's documentation of the resident's left heel was as follows: -12/27/22 unstageable: 2.16 cm x 2.14 cm, wound stable, continue treatment of cleanse with normal saline, apply hydrogel, cover with ABD pad, and wrap with Kerlix/Kling. -01/03/23 unstageable: 2.13 cm x 2.39 cm, wound stable continue treatment of cleanse with normal saline, apply hydrogel, cover with ABD pad, and wrap with Kerlix/Kling. -01/10/23 left heel classification was changed to a stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling) :1.24 cm x 1.64 cm x 2.03 cm, documented as an improving wound and to continue treatment of cleanse with normal saline, apply hydrogel, cover with ABD pad, and wrap with Kerlix/Kling. Review of Resident #59's physician orders revealed the facility failed to follow CNP #300's wound treatment recommendations from 12/27/22 to 01/10/23 when the facility continued wound care to the left heel ulcer as cleanse left heel with mild soap and water apply triad paste and cover with border foam dressing. Interview on 01/09/23 at 12:13 P.M. with Resident #59 revealed he used the call light to get assistance and it typically took 30 to 60 minutes for staff to come to the room. He revealed he wears incontinence briefs and revealed he will be left to sit in his urine and feces for hours at times. Observation on 01/12/23 at 11:00 A.M. of Resident #59 with Unit Manager #75 revealed the resident was agreeable to have his incontinence brief checked. Upon observation of the resident's incontinence brief, it was noted to be saturated with urine and this was verified by Unit Manager #75. Resident #59 stated during the observation, he last received incontinence care on 01/12/23 at 5:00 A.M. Interview on 01/12/23 at 11:10 A.M. with STNA #55 revealed she was the staff assigned to care for Resident #59 on this day. The STNA was observed in another resident's room sitting in a resident's wheelchair and stated she was waiting to assist another staff member to get this resident ready for an appointment and then she would go to provide care to Resident #59. STNA #55 verified she had not provided any personal care to Resident #59 on this day and verified her shift started at 7:00 A.M. STNA #55 was asked how often incontinence care was to be provided and she stated twice. STNA #55 was asked to clarify what she meant by twice and she stated twice a shift. She then stated incontinence care should be provided every two hours or as needed. STNA #55 stated she checked on Resident #59 at the beginning of her shift at 7:00 A.M and he was dry and that the night shift had changed the resident prior to going off shift. STNA #55 then confirmed the present time was after 11:00 A.M. Interview on 01/12/23 at 11:11 A.M. with Unit Manager #75 confirmed STNA #55 was currently assisting get another resident ready. Unit Manager #75 was questioned if there was enough staff to complete the workload if STNA #55 had not yet provided care to a resident on her assignment and it was 11:00 A.M. and her shift had started at 7:00 A.M. Unit Manager #75 stated there should be four STNA's on the hall and revealed STNA #55 was new to the facility. Observation and interview with Resident #59 on 01/17/22 at 9:15 A.M. revealed the resident's call light was activated and the resident stated he needed to be changed. The resident stated he had last been provided incontinence care on 01/17/22 at approximately 3:00 A.M. The facility's Assistant Director of Nursing (ADON) #67 entered Resident #59's room on 01/17/22 at 9:35 A.M. The resident's incontinence care product was checked and ADON #67 verified the incontinence care product was saturated with urine. Interview with STNA #102 on 01/17/23 at 9:37 A.M. confirmed Resident #59 was on her assignment and she had not provided any care to the resident on this day. Resident #59 was provided incontinence and wound care on 01/17/23 at 9:40 A.M. When the incontinence brief was removed the resident's border foam dressing to the sacrum was only attached to the resident's skin at the top of the dressing; the other three sides of the dressing were no longer attached to the resident's skin and the border foam dressing was saturated. During the incontinence care the border foam dressing to the sacrum fell off the resident. Additionally, Resident #59's left buttock was observed to have an open area to the skin that was not documented in Resident #59's medical record. The area was red in appearance with the top layer of skin missing. Interview with Regional Nurse Consultant (RNC) #100 on 01/17/23 at 9:42 A.M. who was present during the incontinence and wound care verified Resident #59's incontinence brief was saturated with urine and the sacrum dressing to the sacral pressure ulcer was so saturated with urine the dressing fell off the resident during incontinence care. RNC #100 confirmed there was a new open area to the resident's left buttock which was observed during the incontinence and would care and the area was a stage II pressure ulcer. The new stage II pressure ulcer to the resident's left buttock was cleansed with normal saline and measured as 5.0 cm x 2.0 cm. The staff stated CNP #300 would be notified and the facility would obtain a dressing order for the area from CNP #300. The resident's right posterior thigh border foam dressing was removed, and an unidentified white cream was noted on the skin around the wound. It could not be determined if the cream was in the wound bed. The wound was observed to have an area on the top left side of the wound that was covered in slough. RNC #100 and Assistant Director of Nursing (ADON) #67, who was performing the dressing change, both verified the current dressing orders did not include the use of any cream to the resident's skin/wound as part of the ordered treatment. RNC #100 and ADON #67 verified the wound dressing which was removed from the right posterior thigh was not the correct dressing. RNC #100 verified neither the sacrum wound, nor the right thigh wound border foam dressing was dated indicating when the dressing was last changed. Observation of the left heel pressure area revealed when ADON #67 removed the Kerlix wrap from the wound the wound was covered with a border foam dressing and not the ordered ABD pad. ADON #67 and RNC #100 both verified this at that time. The border foam dressing was not the current ordered treatment and should not be in place over the resident's left heel pressure ulcer. The border foam dressing was dated of 01/16/23 on the 7:00 A.M. to 7:00 P.M. shift. ADON #67 stated she thought the dressing was to be completed once per day with hydrogel being placed in the wound bed and covered with an ABD pad and then wrapped in Kerlix. Interview with RNC #100 on 01/17/22 at 11:30 A.M. verified Resident #59 was not provided incontinence care timely and his incontinence brief was saturated with urine at the time of the incontinence and wound care on 01/17/23 at 9:40 A.M. RNC #100 verified the etiology of the sacrum wound was documented by CNP #300 as moisture related to urine and stool incontinence. RNC #100 also verified that during the observation of incontinence and wound care Resident #59 had a new stage II pressure ulcer identified to his left buttock. RNC #100 also verified the resident did not have his skin and wound assessments completed when the resident was re-admitted on [DATE] and the wounds had no documented assessment in the medical record until six days later when wound CNP #300 assessed the resident's wounds on 12/27/22. During multiple observations of Resident #59 during the days of the survey there were no observed heel boots on the resident or in the resident's room for the resident as ordered on 11/29/22. During an observation of Resident #59 with RNC #100 on 01/17/23 at 1:20 P.M. it was confirmed the resident did not have heel boots in use. RNC #100 verified the treatment orders for Resident #59 were not updated to the recommended wound treatments CNP #300 had in the wound notes for Resident #59. RNC #100 verified the treatments in place during the dressing change observation on 01/17/23 at 9:40 A.M. were not the ordered treatment for the right posterior thigh and the left heel pressure ulcer, and RNC #100 verified the resident did not have the ordered heel boots in place as ordered. Interview with ADON #67 on 01/17/22 at 1:25 P.M. confirmed the resident's orders did not match the treatments CNP #300 recommended. ADON #67 also verified she had not seen the resident use heel boots in the facility. 2. Review of Resident #58's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, bipolar disorder, suicidal ideations and history of traumatic brain injury. Review of the most recent quarterly MDS assessment dated [DATE] revealed the resident had mild cognitive impairment, required limited assist for bed mobility, transfers, and locomotion on and off the unit. Resident #58 was occasionally incontinent with bowel and bladder, had a current pressure ulcer coded as a stage III ulcer that was present on admission or re-entry to the facility. The resident was noted to have an area to his lower spine on admission/readmission evaluation dated 10/28/22. Resident #58's medical record revealed the resident's wound was followed by CNP #300 and was regularly assessed with the area being described as a stage III pressure that was stable or improving on the weekly documentation. CNP #300's recommended treatment for the stage III pressure ulcer was cleanse wound with normal saline, apply hydrogel and border foam dressing from 11/01/22 to 01/03/23. Resident #58's physician orders for the stage III pressure ulcer were documented as open area to right upper back cleanse with saline, pat dry and apply dry dressing from 10/30/22 to 01/04/23. Open area to right upper back cleanse with saline, pat dry, apply calcium alginate (dressing used for wounds with moderate to heavy drainage) and foam dressing daily dated 01/05/23 to 01/18/23. There were no other orders present for any wound or skin alteration on the resident's back during the listed time frames. Interview on 01/17/23 at 4:55 P.M. with RNC #100 verified the facility was not following CNP #300's recommended treatment of hydrogel and border foam dressing 11/01/22 to 01/03/23. 3. Review of Resident # 55's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included cerebral atherosclerosis, contracture, dementia, pseudobulbar affect, and schizoaffective disorder. Resident #55's physician orders at the time of the survey included may use barrier cream as needed, may keep at bedside dated 04/11/17; Calmoseptine (barrier cream) to buttock after each incontinence episode dated 05/20/21; Remedy Calazime (barrier cream) skin protectant, apply to wound to left inner thigh three times daily and as needed dated 01/19/22; Cleanse inner left thigh with normal saline, apply silver alginate (moist dressing used for infected chronic wounds) and cover with ABD dated 10/07/22; Pillow between legs to help with contraction dated 10/06/22; Cleanse right posterior thigh with normal saline, pat dry, apply hydrogel and cover with border foam dressing dated 10/12/22. Review of 12/2022 treatment administration record (TAR) for Resident #55 revealed the treatment for the right posterior thigh was cleanse right posterior thigh with normal saline, pat dry, apply hydrogel and cover with a border foam dressing, and apply skin prep to right posterior thigh. Both treatments were on the same order and were to be completed daily with a start date of 10/12/22. Review of Resident #55's 01/2023 TAR revealed the treatment for the right posterior thigh was cleanse right posterior thigh with normal saline, pat dry, apply hydrogel cover with border foam dressing and apply skin prep to right posterior thigh. Both treatments were on the same order and were to be completed daily with a start date of 10/12/22. The treatments were signed off daily as completed except 01/01/23 and 01/17/23 when the resident refused the treatment. Review of CNP #300's wound documentation revealed Resident #55's right posterior thigh wound was assessed weekly and the wound was noted as either stable or improving on all notes. CNP #300's listed the treatment for the right posterior thigh wound on 10/06/22 was cleanse with normal saline and apply skin prep. CNP #300's note from 10/13/22 revealed the treatment recommendation changed to cleanse the area with normal saline, apply hydrogel and cover with border foam dressing and to place pillows between knees for offloading for stage III pressure ulcer. This dressing remained the recommended dressing for the right posterior thigh pressure ulcer until 12/13/22 when the recommended treatment was changed to triad cream to stage III pressure ulcer, complete twice daily, place pillows between knees for offloading for stage III pressure ulcer. CNP #300 documented the right posterior thigh pressure ulcer as healed on 12/20/22 and no treatment recommendation was included in the wound documentation. The facility failed to follow CNP #300's recommendations when the facility treated the right posterior thigh with normal saline, patted dry, applied hydrogel and covered with border foam dressing from 10/12/22 and continued through 01/03/23. Review of the 12/2022 treatment administration record (TAR) for Resident #55 revealed the treatment for the left inner thigh, dated 10/07/22, was cleanse left inner thigh with normal saline, apply silver alginate and cover with ABD, change daily. Review of Resident #55's 01/2023 TAR revealed the treatment for the left inner thigh was cleanse the left inner thigh, apply silver alginate cover with an ABD pad perform daily. The treatment was initialed as completed daily except on 01/01/23 and 01/17/23 where it was documented the resident refused the treatment. Review of CNP #300's wound documentation of the left inner thigh wound revealed on 10/06/22 the wound was a new pressure ulcer, called a suspected deep tissue injury with the recommended treatment of cleanse the wound with normal saline, apply silver alginate and cover with an ABD pad. CNP #300 documented the left inner thigh wound as a pressure ulcer, called a suspected deep tissue injury that was either improving or stable, with the recommended treatment of cleanse the wound with normal saline, apply silver alginate and cover with an ABD pad through 12/06/22. The wound note from 12/13/22 changed the recommended treatment to triad cream, place pillows between knees for offloading of contractions. This remained the recommended treatment through 01/03/23. Review of progress note dated 01/10/23 at 11:06 A.M. revealed the resident refused wound care from the nurse and CNP #300. No wound measurements were in the medical record for the wound from 01/03/22 through 01/10/23. Review of weekly nursing evaluation completed on 01/11/23 revealed the resident had no new skin conditions. There was no assessment of the resident's left posterior thigh in the evaluation. Review of the weekly nursing evaluation dated 01/17/23 revealed the form had the resident's vital signs but the rest of the evaluation was blank including the resident's skin evaluation and the additional comment field was also blank. Interview with RNC #100 on 01/18/22 at 9:00 A.M confirmed the facility did not follow the wound treatment recommendations from CNP #300 for Resident #55. Review of policy titled, Skin Management, dated 10/2019, revealed it is the policy of [NAME] Care to assess each resident to determine the risk of potential skin integrity impairment. Residents will have a skin assessment completed upon admission and no less than weekly by the licensed nurse in an effort to assess overall skin condition, skin integrity, and skin impairment. A head to toe assessment will be completed by a licensed nurse upon admission/re-admission and no less weekly. Residents identified at risk for skin breakdown will have appropriate preventative interventions put in place. All alterations in skin integrity will be documented in the medical record. Residents admitted or readmitted with alterations in skin integrity will be documented on admission evaluation. All newly identified areas after admission will be documented on the weekly pressure/non-pressure evaluation. The facility assigned wound nurse will complete further evaluation of the wounds identified and complete the appropriate skin evaluation on the next business day. A plan of care will be initiated to include resident specific risk factors with appropriate interventions. Review of policy titled, Wound Care, dated 2001 and revised on 10/2010, revealed staff were to verify that there is a physician's order for this procedure. Review the resident's care plan to assess for any special needs of the resident. The following information should be recorded in the resident's medical record: The type of wound care given; the date and time the wound care was given; the position in which the resident was placed; the name and title of the individual performing the wound care; any change in the resident's condition; all assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound; how the resident tolerated the procedure; any problems or complaints made by the resident related to the procedure; if the resident refused the treatment and the reason(s) why; the signature and title of the person recording the data. This deficiency represents non-compliance investigated under Complaint Number OH00139013 and OH00138817.