**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of hospital records, observations, staff interviews, interview with Wound Physician #500, and review of facility policy, the facility failed to timely assess, monitor, and implement treatments for Resident #43, who was admitted to the facility with a pressure ulcer on the coccyx. This resulted in Actual Harm when Resident #43 was assessed upon admission on [DATE] with a pressure ulcer to the coccyx but the staff failed to accurately assess the wound to include measurements/description and the staff failed to notify the physician to obtain/implement treatment orders. Subsequently, Resident #43's coccyx pressure ulcer was assessed by the wound physician on 03/04/25 to be unstageable with necrosis and the coccyx pressure ulcer required excisional debridement (surgery) on 03/04/25 and again on 03/06/25. This affected one (#43) of three residents reviewed for pressure ulcers. The facility census was 76. Findings include: Review of medical record for Resident #43 revealed an admission date of 02/18/25. The resident was admitted with diagnoses including spinal stenosis, cord compression, malignant neoplasm of bone and protein-calorie malnutrition. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The assessment indicated the resident was dependent on two-assist for activities of daily living care. Resident #43 had one pressure ulcer which was unstageable. Review of the risk assessment dated [DATE] revealed the resident was at risk for skin breakdown. Review of the hospital discharge record on 02/18/25 revealed the resident had a non-blanchable purple wound on the coccyx found in the hospital on [DATE]. Review of the care plan dated 02/18/25 revealed Resident #43 had impaired skin integrity related to recent surgical procedure, pressure area to coccyx on admission, and immobility. Individualized interventions included consult nurse practitioners for evaluation and treatment as indicated, and turn and reposition per protocol with measurable goals. Review of the medical record revealed a skin observation tool assessment was completed for the dates of 02/18/25 and 02/25/25, which indicated a surgical wound and pressure wound to the coccyx; however, there was no further assessment of Resident #43's wounds including no wound measurements, and no wound stage. Further review of the medical record revealed the physician was not notified and no treatment orders were initiated for the coccyx pressure ulcer. Review of Resident #43's weekly physician notes from the dates of 02/18/25 to 03/03/25 revealed wound assessments were completed for a post-surgical wound of the back. However, there was no documented assessment of the pressure area on Resident #43's coccyx. Review of the Treatment Administration Record (TAR) from 02/18/25 through 03/03/25 revealed there was no treatment for the coccyx wound. Review of a nurse's note dated 02/28/25 at 4:03 A.M. revealed Resident #43 had an unstageable pressure ulcer to the sacrum measuring 6.2 centimeters (cm) by 6.9 cm by 0.3 cm. The wound bed had 50 percent (%) slough and 50% eschar. The wound bed was macerated with the peri-wound being red. The wound was noted to be close to the rectum. The manager was updated. The note lacked notification to the physician and or any treatments being implemented. Review of the shower sheets for Resident #43 revealed on 02/28/25 a bed bath was given and the resident was noted to have an unstageable pressure area to the coccyx. Review of the wound monitoring sheets dated 03/04/25 noted as the first evaluation revealed Resident #43 had a wound which was an unstageable pressure ulcer to the coccyx with necrosis. The wound was measured as being 7.0 cm by 7.20 cm, and a depth of 1.40 cm. The wound bed was undefined with treatments which were Alginate calcium once daily and hydrogel with silver once daily. The wound monitoring sheets were reviewed from January 2025 to 03/06/25 and lacked documentation of Resident #43 being assessed or documented for any type of wound. Review of the VOHRA Initial Wound Evaluation and Management Summary, dated 03/04/25 revealed Resident #43 had a wound on the coccyx. The wound examination of the coccyx revealed the wound was unstageable due to necrosis. The duration was greater than 14 days (it was noted to be present upon admission). The wound measured at 7.0 cm by 7.2 cm by 1.4 cm. The wound had exudate moderate serous with thick adherent devitalized necrotic tissue of 100 percent (%). This wound had undergone a surgical excisional debridement procedure. The wound was surgically excised of devitalized tissue and necrotic subcutaneous level tissues were removed at a depth of 1.5 cm. The non-viable tissue in the wound bed decreased from 100% to 95%. Further review, revealed on 03/06/25, the coccyx wound measured 7 cm by 7.2 cm by 1.4 cm with undermining at 3o'clock measuring 3 cm. The wound had moderate serous exudate with thick adherent devitalized necrotic tissue being 100% of the wound. Another surgical excisional debridement procedure to remove necrotic tissue and establish the margins of viable tissue. The surgical procedure excised the devitalized tissue and necrotic muscle level tissue was removed to a depth of 3.3 cm. The non-viable tissue in the wound bed decreased from 100% to 75%. Observation on 03/11/25 at 6:00 A.M. with Wound Nurse #207 of the treatment to Resident #43's pressure ulcer revealed the wound to the coccyx had a foul odor with dark necrotic tissue. The coccyx wound measured 6.5 cm by 5.4 cm by 3 cm. The wound nurse verified the wound was an unstageable pressure ulcer and was unable to confirm the full depth of the wound due to necrotic tissue present. Interview on 03/11/25 at 12:10 P.M. with the Administrator and Regional Nurse #400 verified lack of documentation in the medical record from 02/28/25 to 03/04/25 of orders for treatments to the coccyx, which was noted upon admission, and notification to the physician. Interview with Wound Physician #500 on 03/11/25 at 2:15 P.M. verified the coccyx wound for Resident #43 was not observed until 03/04/25. There was a consultation on 02/25/25 but the physician did not see the resident due to resident being seen by general surgery. The wound physician was not aware of the status of the coccyx wound until 03/04/25. The wound physician performed a debridement but was unable to remove all the necrotic tissue due to the procedure causing the resident pain. The nurse practitioner had to return two days later and perform another surgical procedure to remove more of the necrotic tissue. Review of the facility's policy, Documentation of Wound Treatments dated 10/10, revealed the facility completes accurate documentation of wound assessments and treatments, including response to treatment, change in condition, and changes in treatment. Wound assessments are documented upon admission, weekly, and as needed if resident or wound condition deteriorates. The following elements are documented as part of a complete wound assessment; type of wound, and anatomical location, stage of the wound, measurements (height, width, depth, undermining or tunneling. The description of the wound should include the color of the wound, type of tissue in the wound, condition of peri-wound, presence, amount, and characteristics of wound drainage, presence or absence of odor, and presence of pain. Additional documentation shall include notification to physicians. Review of the facility's policy, Pressure Injury Risk Assessment dated 03/20, revealed the purpose for this procedure is to provide guidelines for the structured assessment and identification of residents at risk for developing new pressure injuries or worsening of existing pressure injuries. The following information should be recorded in the resident's medical record: the condition of the skin (the size, location and description) if any identified areas are present. Initiation of pressure or non-pressure form related to the type of skin alteration and documentation addressing the physician notification. This deficiency represents non-compliance investigated under Complaint Number OH00163267.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, review of fall investigations, staff and resident interviews, review of hospital records, and review of the facility policies, the facility failed to ensure a safe environment to prevent falls, resulting in actual harm when Resident #23 tripped over the legs of an improperly stored mechanical lift resulting in a facial laceration requiring stitches and a fractured left olecranon (elbow) fracture. Further, the facility failed to ensure neurological checks were completed after falls for Resident #22, failed to ensure fall incidents were thoroughly investigated for Resident #22 and Resident #63, and failed to ensure fall preventions were in place for Resident #22. Lastly, the facility failed to ensure a safe environment to prevent falls for Resident #52. This affected four residents (#23, #22, #63, #52) of five residents reviewed for falls. The facility census was 80. Findings include: 1. Review of the medical record for Resident #23 revealed an admission date of 04/16/12 with diagnoses of cerebral infarction, dementia, and epilepsy. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23's cognition was assessed via staff, and Resident #23 had impaired cognition. Resident #23 required supervision or touching assistance for chair to bed transfers and walking. Review of the Fall Risk Evaluation dated 06/27/24 revealed Resident #23 had a score of 9.0 and was not at high risk for falls. Review of the current care plan revealed Resident #23 was at risk for falls due to decreased safety awareness, impaired balance and unpredictable seizures. Interventions in place prior to the fall on 09/05/24 included having his bed against the wall, staff to report adverse effects of medications, and therapy to screen if indicated. Review of a progress note dated 09/05/24 at 2:00 A.M. revealed Resident #23 fell in the hallway near the nurses' station. Resident #23 was walking with aides to get a soda and tripped on the legs of a parked mechanical lift and hit his head resulting in a 2-3 centimeter laceration near the corner of his left eye. The fall was witnessed by staff. The physician was notified via voicemail. Review of a progress note dated 09/05/24 at 2:30 A.M. revealed Resident #23 was sent to the Emergency Department (ED) via ambulance. Review of a progress note dated 09/05/24 at 5:48 A.M. revealed Resident #23 received stitches and a CT (computed tomography) scan was negative. Review of a progress note dated 09/05/24 at 6:44 A.M. revealed Resident #23 returned to the facility with no new orders. Review of a progress note dated 09/05/24 at 12:53 P.M. revealed Resident #23's left forearm and elbow appeared swollen and bruised and Resident #23 was guarding. An order was received for an x-ray of the left arm. Review of a progress note dated 09/05/24 revealed Resident #23 was sent to the ED for evaluation of his left arm. Review of a progress note dated 09/05/24 at 7:00 P.M. revealed Resident #23 returned to the facility via stretcher with no new orders. Review of the Interdisciplinary Team progress note dated 09/05/24 at 9:48 A.M. revealed the cause of the fall was equipment in the hallway and the intervention was to educate staff regarding appropriate storage of equipment. Review of the hospital discharge paperwork dated 09/05/24 at 4:41 A.M. revealed Resident #23 received stitches. Review of the hospital discharge paperwork dated 09/05/24 at 3:33 P.M. revealed Resident #23 presented to the ED for evaluation of a fall. Resident #23 was diagnosed via x-ray with a fractured left olecranon (elbow). Resident #23 received fentanyl (pain medication) at the ED. Resident #23's left arm was placed in a long-arm splint and sling. Review of the undated staff education titled, Proper Storage of Equipment, revealed housekeeping, State Tested Nurse Aides (STNAs) and nurses were educated. Interview on 09/24/24 at 4:51 P.M. with Registered Nurse (RN) #182 revealed she worked 09/05/24 and was the nurse for Resident #23 when he returned from the hospital with stitches on 09/05/24 at approximately 6:40 A.M. RN #182 stated Resident #23 began to eat breakfast in the dining room, then had a seizure. After the seizure resolved, the staff assisted Resident #23 to his room to rest. RN #182 stated she was familiar with his seizure activity and was not concerned it was related to his head injury. Further interview revealed the staff began to change Resident #23's clothes before lunch and found his left arm swollen. RN #182 contacted the physician who ordered an x-ray, but the mobile x-ray service was unable to get a good view of Resident #23's arm, so Resident #23 was sent back to the ED. Interview on 09/25/24 at 2:39 P.M. with the Director of Nursing (DON) and concurrent review of the facility's fall investigation into Resident #23's fall on 09/05/24 revealed Resident #22 did not require assistance while walking, and was accompanied by staff while walking down the hall to get a soda. Concurrent observation occurred when the DON and surveyor entered the secured unit where the DON demonstrated the physical condition of the fall. The DON stated a mechanical lift was backed against the wall along the 600 hall across from the MDS Coordinator's office. A floor heater was also noted to be along the wall opposite the office. The DON stated the legs were sticking into the walkway. Interview on 09/26/24 at 11:37 A.M. with the DON confirmed the staff education was not dated. The DON stated she did not review a policy; she explained to staff where to store mechanical lifts, such as in the beauty shop or near the shower when the shower was not in use. The DON stated she did not have any formal audits to ensure equipment was stored properly. The DON did not provide a date the education was provided before the conclusion of the survey. Observation and interview on 09/26/24 at approximately 4:00 P.M. with Maintenance Director #104 revealed the 600 hall where the DON indicated the mechanical lift was placed was 93.5 wide. Further observation revealed the mechanical lift base, at floor level, from back wheel to front wheel was 42.5 while the part of the mechanical lift at eye level was more narrow than the legs. The usable width of the hallway floorspace was reduced to approximately 51 (four feet, 3 inches) for Resident #23 and the STNA to walk together down the hall. Review of the policy Fall Risk Assessment, dated 2001, revealed the staff will seek to identify environmental factors that may contribute to falling, such as lighting and room layout. 2. Review of the medical record for Resident #22 revealed an admission date of 07/09/24 with diagnoses of hemiplegia and hemiparesis, and need for assistance with personal care. Review of the comprehensive admission MDS assessment dated [DATE] revealed Resident #22 had impaired cognition, mobilized with a wheelchair, was dependent for shower/bathing, chair to bed transfers, and tub/shower transfers. Review of the Fall Risk Evaluation dated 07/16/24 revealed Resident #22 was at risk for falls. Review of the current care plan revealed Resident #22 was at risk for falls related to hemiplegia, hemiparesis and weakness. Interventions included keeping a fall mat at bedside (added 09/17/24), encouraging call light use, and keeping the bed in the lowest position. Review of a nursing progress note dated 08/18/24 at 4:25 A.M. revealed Resident #22 was found sitting on the floor in front of her bed with legs outstretched in front of her. Resident #22 was assessed and found to have no injuries. Review of the fall investigation dated 08/20/24 revealed Resident #22 was found on 08/18/24 at 4:20 A.M. sitting on the floor in front of her bed with her legs outstretched. Resident #22 was assessed and no injuries were found. Review of the Interdisciplinary Team's (IDT) review revealed no root cause related to the fall and determined the appropriate intervention was a mat to the floor at the outside of the bed and the other side of the bed placed against to the wall to ensure adequate floor space in the room for mobility equipment. Review of a nursing progress note dated 09/14/24 at 5:56 A.M. revealed Resident #22 was found on the floor. Resident #22 was assessed and found to have no injuries. Review of the fall investigation dated 09/14/24 revealed Resident #22 was found on the floor on 09/14/24 at 5:50 A.M. next to her bed. Resident #22 stated she was reaching for a television remote. A nursing assessment was completed and no injuries were identified. The IDT review revealed the root cause was Resident #22 reaching for personal items; therefore, the intervention was to keep personal items within reach. Review of a nursing progress note dated 09/17/24 at 4:25 A.M. revealed Resident #22 was observed lying on her right side on the floor beside her bed. Resident #22 was assessed and found to have no injuries. Review of the fall investigation dated 09/17/24 revealed Resident #22 was found lying on her right side on the floor next to her bed on 09/17/24 at 4:25 A.M The IDT review revealed the cause of the fall was confusion and attempting to ambulate when not capable of ambulating independently. The IDT developed an intervention of putting a fall mat next to the bed. Review of a nursing progress note dated 09/19/24 at 6:42 P.M. revealed Resident #22 was on the floor next to the dresser. Resident #22 stated she hit her head. Further review of the medical record revealed no evidence neurological checks were completed after Resident #22's unwitnessed falls on 08/18/24, 09/14/24, and 09/19/24. Interview and observation on 09/24/24 at 7:30 A.M. with STNA #162 confirmed Resident #22 was lying in bed with her knees hanging over the edge of the bed and no fall mat was in place. STNA #162 further confirmed, upon review of the electronic medical record, Resident #22's care plan indicated she should have a fall mat beside the bed while in bed. STNA #162 stated Resident #22 often tried to get out of bed. Subsequent interview with STNA #162 and LPN #174 on 09/24/24 at approximately 7:35 A.M. revealed neither staff were aware Resident #22 should have a fall mat. Interview on 09/25/24 at 2:46 P.M. with concurrent review of the facility's fall investigations for Resident #22 revealed the facility reviewed the falls for Resident #22 and determined the trend for her falling in the early morning hours was attributed to her having a urinary tract infection (UTI). However, the fall on 08/18/24 was prior to Resident #22's diagnosis with a UTI on 09/14/24. Additionally, the DON stated the IDT team decided not to implement the fall mat on 08/18/24 and instead decided to only do one intervention at a time, selecting the intervention to move the bed against the wall. The DON confirmed Resident #22 was found on the floor next to her bed after the falls on 09/14/24 and 09/17/24. Interview on 09/26/24 at 11:33 A.M. with the DON confirmed she could not provide neurological assessments for Resident #22's unwitnessed falls on 08/18/24, 09/14/24, and 09/19/24. Further interview with the DON revealed the reason Resident #22's fall mat was not in place during the observation on 09/24/24 was because housekeeping was washing it. The DON stated the fall mats get dirty and need to be washed. Review of the policy Falls and Fall Risk, Managing, dated 2001, revealed the staff will identify and implement relevant interventions to try to minimize serious consequences of falling. 3. Review of the medical record for Resident #63 revealed an admission date of 04/17/23 with diagnoses of encephalopathy, repeated falls and unsteadiness on feet. Review of the quarterly MDS assessment dated [DATE] revealed Resident #63 had impaired cognition, mobilized with a walker, required supervision or touching assistance for chair to bed transfer, substantial/maximal assistance for tub/shower transfer, and for shower/bathing self. Further review revealed she had one fall without injury since the previous assessment. Review of the Fall Risk Evaluation dated 12/14/23 revealed a score of zero. Review of the current care plan for Resident #63 revealed she was at risk for falls related to dementia. Interventions included assisting in positioning and comfort as needed and observe daily and report any observed unsafe conditions. Review of the facility's incident report dated 03/10/24 revealed a State Tested Nurse Aide (STNA) called the nurse to assist with Resident #23 off the floor in the shower. STNA stated Resident #63 slipped out of the shower chair. Review of an IDT progress note dated 03/11/24 revealed Resident #63 was in the shower and slipped out of the chair stating she had soap in her eyes. Resident #63's fall was witnessed by staff. No injuries were noted. Review of the facility's incident report dated 06/08/24 revealed the nurse was notified by the STNA that Resident #23 slipped out of the shower chair to the floor landing on her behind. Review of an IDT progress note dated 06/11/24 revealed Resident #63 was in the shower and slid off the chair onto the floor. STNA was present during the shower. Resident #63 was assessed and no injuries were noted. A floor mat was on the floor. Interview on 09/25/24 at 2:46 P.M. with the DON revealed she did not attempt to interview with STNA who was present during Resident #63's fall on 03/10/24. Further interview revealed the DON attempted to call the agency STNA who was present during the fall on 06/08/24 but did not receive a return call. The DON confirmed no intervention was implemented after Resident #63's first fall from the shower chair on 03/10/24. Additionally, the DON stated the intervention after Resident #63's second fall from the shower chair was to add a larger fall mat to the floor in the shower; however, the DON stated the larger mat did not fit. Further interview with the DON regarding a fall intervention for Resident #63 revealed staff were expected to stand closer to prevent Resident #63 from sliding from the shower chair again. Review of the policy Falls and Fall Risk, Managing, dated 2001, revealed the staff will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. 4. Record review for Resident #52 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #52 include encephalopathy, diabetes type two, malnutrition, traumatic amputation of bilateral legs below knees, heart disease, gangrene, altered mental status, and thrombosis with use of anticoagulants. Review of Resident #52's Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed the resident had intact cognition and was dependent on a wheelchair for ambulation. Review of Resident #52's care plans dated 04/09/24 revealed a focus for risk of falls. Interventions include Resident #52 will receive care and interventions necessary to ensure that his safety is maintained, ensure that the seatbelt is fastened when resident is up in wheelchair, observe Resident #52 in his daily activity and report unsafe conditions for interventions to assist with maintaining his safety. Review of Resident #52's progress notes dated 08/11/24 the resident was attempting to propel himself outside and fell out of the wheelchair and rolled into a hole in the concrete. Per the note the resident suffered no injuries and did not hit his head. Review of the facility's investigation dated 08/11/24 revealed the fall was witnessed. No injuries were noted on the investigation. Resident #52 reported his pain level at a 5 out of 10, in the comments stated resident denied pain at this time. Per the immediate action taken the nurse documented the resident will be educated to ask for assistance when going outside to ensure safety due to the deterioration of the driveway. Interview on 09/23/24 at 11:46 A.M. with Resident #52 revealed the resident stated he had a fall out of his wheelchair on 08/11/24 when he was coming back into the facility by the outside door on the 200-hall. Resident #52 showed the surveyor there are several broken pieces of concrete with bars sticking out near the door and the doorway itself has a raised cracked edge. Resident #52 stated he was attempting to get his motorized wheelchair over the cracked edge when the tires got stuck and his chair fell forward causing him to fall out of the wheelchair onto the ground. Resident #62 stated staff responded quickly to him and got him back into his wheelchair. Resident #52 stated he did not report any injuries to staff at the time of the fall. Interview on 09/23/24 at 3:00 P.M. with Resident #33 revealed the resident witnessed Resident #52's fall on 08/11/24. Per Resident #33, Resident #52 was going back into the facility when his wheelchair front wheels got 'caught in the hole at the doorway'. Resident #33 stated he saw Resident #52 fall forward out of his wheelchair and onto the ground. Resident #33 stated he ran to help but staff had already started to help Resident #52. Resident #33 stated he did not see the resident hit his head and heard the resident tell staff he didn't have any injuries. Interview on 09/24/24 at 3:33 P.M. with the DON verified Resident #62 was outside coming inside when the wheels of his wheelchair was stuck in the doorway threshold and the resident fell out of the wheelchair. The DON stated Resident #52 stated he had no injuries from the fall. Observation and interview on 09/25/24 at 4:00 P.M. with Social Worker (SW) #248 observing the area outside of the doorway into the facility on the 200-hall revealed the concrete was notably raised from the sidewalk to the concrete patio slab. A raised area of about 2-3 inches leaving a space from the sidewalk to the patio was observed. Per SW #248, during the fall investigation it was reported to her the resident was attempting to propel his motorized wheelchair back into the facility when the front wheels caught up on the raised portion of the sidewalk leading to the doorway. SW #248 verified the broken pieces of concrete with what appears to be bars sticking out and stated the facility had not completed any repairs to the sidewalk or patio concrete. Review of the facility policy titled, Fall Risk Assessment', dated 03/2018 revealed staff will seek out to identify environmental risk factors that may contribute to falls. Staff will collaborate to identify and address modifiable fall risk factors and interventions to minimize the risk factor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, observation, policy review and review of information from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to ensure monitoring of a pressure sore was completed to ensure appropriate care and treatment was provided to prevent deterioration of a pressure ulcer. This resulted in actual harm when Resident #50's pressure ulcer was not monitored on a weekly basis to ensure proper treatment and interventions were in place resulting in the pressure ulcer deteriorating from a stage two to an unstageable pressure ulcer. This affected one (#50) of two residents reviewed for pressure ulcers. The facility identified four residents currently residing in the facility with pressure ulcers greater than a stage one. Facility census was 76. Findings include: Review of Resident #50's medical record revealed an admission date of 11/21/14 with diagnoses including dysphagia, gastrostomy, malaise, generalized anxiety disorder, muscle weakness, major depression, hypertension, Alzheimer disease and unspecified symbolic dysfunction. Review Quarterly Minimum Data Set (MDS) dated [DATE] documented Resident #50 was assessed as severely cognitively impaired, was totally dependent on staff for all activities of daily living and was at risk for pressure ulcer development with no current pressure ulcers assessed with interventions in place to aide in prevention. Review of the comprehensive care plan documented Resident #50 was at risk for development of pressure ulcers related to impaired bed mobility, history of skin breakdown, impaired nutrition and incontinence. The interventions included air mattress to bed daily, pressure reducing seating present on tilt back chair, cleanse and dry after incontinence episodes and apply Calmoseptine, inspect skin every-day and report changes to the nurse, monitor nutritional status, nurse to perform weekly skin assessments and as needed, document and notify the physician of areas of concerns and turn and reposition every two hours. Review of the skin grid pressure sheet dated 03/04/19 documented Resident #50 was found to have a pressure ulcer to her right buttocks measuring 2.0 centimeters (cm) by 1.5 cm by 0.1 cm. The wound bed was described as pink-red with the peri wound white and fragile. There was no drainage noted, no foul odor, no tunneling and Calmoseptine was applied. The staging of the pressure ulcer was not assessed; however, it met the definition of a stage two pressure ulcer according to the facility assessment form and from information from the NPUAP. Review of a physician order dated 03/05/19 documented to cleanse the right buttock wound with normal saline, use honey alginate for wound bed, use skin preparation and foam with edges every-day for wound care. Review of the care plan dated 03/06/19 documented Resident #50 had alteration of skin integrity of the buttock. The interventions included up in chair for meals only, air mattress to bed every-day, provide treatment as ordered, turn and reposition every two hours and refer to wound clinic with follow up as ordered. Review of physician's order dated 03/20/19 documented a new treatment was order for normal saline, Santyl (nickel depth) with moistened two by two and foam daily and as needed. Review of weekly skin assessments completed on 03/06/19, 03/13/19, 03/20/19 and 03/27/19 mentioned the previously identified wound to the right buttock but lacked any documentation of the area being measured and assessed as required for pressure ulcers to ensure appropriate treatments and intervention were in place. Review of the advanced wound practitioners note dated 04/05/19 documented Resident #50 had an unstageable pressure injury to her right buttocks. The wound measures 1.2 cm by 2 cm by 0.1 cm. The wound bed was described as having 80 percent of soft black eschar with a small amount of serous drainage. Review of a physician order dated 04/04/19 documented a new treatment for the right buttocks, to cleanse with normal saline, apply honey gel and foam dressing daily, and as needed. Review of the advanced wound practitioner note dated 04/10/19 revealed Resident #50 had a right buttock wound that remained unstageable. The wound measured 1.5 cm by 1 cm by 0.5 cm. The wound bed was described with 50 percent yellow slough with a small amount of serous drainage. Review of the weekly skin assessment dated [DATE] documented open area remains on the right buttock. There lacked any documentation of the pressure ulcer being assessed as required. Review of the skin grid pressure sheet dated 05/01/19 documented the right buttock pressure area was unstageable. The wound measured 1.1 cm by 0.9 cm by 2.8 cm. The wound bed was covered with a large amount of moist yellow-brown drainage which had a foul odor. Further review of the assessment documented the physician was notified of the decline in the wound. Review of the nursing note dated 05/01/19 documented the physician was notified of the status of the right buttock wound. According to the nurses note there were no new orders obtained at this time. Review of physician orders dated 05/01/19 lacked any documentation discontinuing or changing Resident #50's dressing change to her right buttock. Review of Treatment Administration Record from 05/01/19 through 05/15/19 lacked evidence of any treatment in place for Resident #50's pressure ulcer to her right buttock. Review of the skin grid pressure sheet dated 05/09/19 documented the right buttock pressure area was unstageable. The wound measured 1.2 cm by 1.0 cm by 2.8 cm. The wound was described as unable to see the wound bed due to brownish slough with a moderate amount of drainage and the wound was unchanged. Review of the skin grid pressure sheet dated 05/15/19 documented the right buttock pressure area was unstageable. The wound measured 1.3 cm by 1.0 cm by 3.0 cm. The wound bed was covered 100 percent with brownish-gray moist slough with a large amount of brown foul drainage. Further review documented the wound had declined and the physician was notified. Review of the physician order dated 05/15/19 documented for the right buttock wound to be irrigated with normal saline, gently pack with mesalt, and cover with a foam dressing twice a day and to make an appointment for a wound consult. Review of the physician order dated 05/21/19 documented a new treatment order for the right buttock wound which included cleanse the wound with peroxide, pack with iodiform and cover with foam dressing daily and as needed. Further review documented to follow-up with the wound specialist on 06/18/19 as scheduled. Review of the weekly skin assessments completed 05/22/19, 06/05/19 and 06/12/19 mentioned the previously identified pressure wound. The assessments lacked any documentation of the area being measured and assessed as required for pressure ulcers to ensure appropriate treatments and interventions were in place. Review of the wound specialist progress note dated 06/18/19 documented Resident #50's wound measured 0.7 cm by 1.5 cm by 2.8 cm and documented the wound was now a stage four pressure ulcer. On 07/02/19 at 11:08 A.M., interview with the Director of Nursing (DON) verified the facility does not have any pressure ulcer assessments completed for Resident #50 from 03/04/19 through 04/03/19 when the resident was seen by the wound practitioner and the residents wound was assessed as unstageable. She further verified there also lacked pressure ulcer assessments from 04/10/19 through 05/01/19. In addition, the DON verified there was no evidence of an appropriate treatment in place and/or verified the medical record lacked documentation of an ordered treatment being implemented for the unstageable pressure ulcer from 05/01/19 through 05/15/19. The DON verified she has no idea what happened and some kind of treatment had to have been done due to the assessments of the wound on 05/09/19 and 05/15/19 when a documented treatment was put into place. She also verified there was no assessment of the pressure ulcer as required from 05/15/19 to 06/18/19 when she was seen by the wound specialist. The DON further verified the pressure ulcer should have been monitored weekly with measurements and a description to ensure appropriate treatment and interventions were in place to prevent deterioration of the wound. On 07/02/19 at 1:25 P.M. an observation was made of Resident #50's pressure ulcer. At this time, the wound treatment was observed and completed by the Assistant Director of Nursing (ADON). The wound had a moderate amount of serous drainage with no odor. The area measured 0.8 cm by 0.8 cm with a depth of 2.2 cm. The ADON verified the wound was currently a stage four and healing. She also verified pressure ulcers are to be assessed on a weekly basis to ensure proper treatment and interventions are in place. Review of the facility undated policy and procedure for pressure ulcer/injury risk assessment purpose is to provide guidelines for structured assessments and identification of residents developing pressure ulcers/injuries. If a skin alteration is identified, initiate the appropriate assessment for the alteration in skin and document any changes needed in the care plan. Interventions must be based on current, recognized standards of practice. Review of information from the NPUAP revealed pressure ulcers should be assessed initially including measurements of the wound and there should be ongoing monitoring. According to the NPUAP the monitoring of a pressure ulcer should be ongoing to ensure healing of the wound. The NPUAP defined a stage two pressure ulcer as a partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Further review revealed an unstageable pressure ulcer is a full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a stage three or Stage four pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of fall investigations, observations, resident and staff interview, and review of facility policy, the facility failed to ensure Resident #33's fall interventions were in place as indicated in Resident #33's care plan. The lack of implementing interventions resulted in actual harm when Resident #33 fell, hit her face on the floor and was subsequently hospitalized related to a closed head injury. This affected one (#33) of two residents sampled for falls. Additionally, the facility failed to ensure hazardous chemicals were kept secured. The facility identified two (#63 and #64) of 76 residents who were identified as cognitively impaired, independently mobile and that could potentially access these chemicals. The facility census was 76. Findings include: 1. Review of Resident #33's medical record revealed an admission date of 04/12/19. Diagnoses included chronic kidney disease, hypertension, heart disease, ventricular fibrillation, bradycardia, syncope and collapse, anemia, Alzheimer's disease, and Type II diabetes. Review of Resident #33's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of ten indicating Resident #33 was moderately cognitively impaired. Resident #33 required supervision with bed mobility, transfer, walking, locomotion, dressing, eating, toilet use, and personal hygiene. Resident #33 displayed no behaviors during the review period. Review of Resident #33's care plan revised 06/27/19 revealed supports and interventions for nutritional risk, risk for pain, risk for impaired skin integrity, mood concerns, Alzheimer's disease, and risk for falls. Resident #33's fall interventions included the following: on 04/13/19 an intervention was added to ensure the resident was wearing appropriate footwear when ambulating or mobilizing in the wheelchair, ensure call light was in reach and encourage use, decrease clutter with commonly used items in reach, report adverse medication effects to physician, and to encourage rest periods to avoid over tiring; on 04/19/19 an intervention was added for Physical Therapy (PT) to evaluate for a walker; on 04/23/19 there were added interventions to encourage resident to sit in bedside chair if resident wanted to sit up; on 04/27/19 an intervention was added for a low bed to floor with floor mat next to the bed; and on 06/27/19 an intervention was added to place non-skid strips on the floor in front of the chair and next to the bed. Review of Resident #33's fall risk assessment completed on 04/27/19 revealed Resident #33 was at moderate risk for falls. Review of Resident #33's physician orders revealed an order dated 06/05/19 for Apixaban (blood thinner) five mg (milligrams) two times a day and Aspirin, 81 mg one time a day. Review of Resident #33's fall investigations revealed Resident #33 had an unwitnessed fall on 04/18/19 with no injury. As a result of the fall, Resident #33's fall interventions were updated to include low bed to the floor with a floor mat next to the bed. Further review of the fall investigations revealed Resident #33 had an unwitnessed fall on 06/25/19 at approximately 11:30 P.M. Resident #33 was found on the floor sitting in front of her bed. Resident #33 was holding her covers to her nose and had a bump on the right side of her forehead. Resident #33 was mumbling and not able to say what happened. Resident #33 was assessed, vitals taken, physician was contacted and Resident #33 was sent to the hospital via paramedics. Resident #33's family was notified. Resident #33 returned to the facility on [DATE] with no new orders and a diagnosis of a hematoma to her face. Further review of Resident #33's medical record revealed the resident was sent to the emergency room on [DATE] per the family request. A Computed Tomography (CT) scan of the head was conducted and a closed fracture of a nasal bone with routine healing was identified and was documented as being treated for a closed head injury. Resident #33 returned to the facility on [DATE]. Observation on 06/30/19 at 1:28 P.M. of Resident #33 revealed Resident #33 propelling herself around her room in her wheelchair. Resident #33 had dark black bruises around both of her eyes and a raised purple/black bruise on the right side of her forehead. Interview on 06/30/19 at 1:30 P.M. with Resident #33 revealed she was alert and oriented. Resident #33 reported she fell when she was getting out of bed to go to the bathroom. Resident #33 stated she fell, hit her face on the floor, and broke her nose. Resident #33 stated the staff took care of her right away and she went out to the hospital. Resident #33 stated she stayed overnight and came back to the same room when she returned to the facility. Resident #33 stated her eyes and forehead were a little swollen, but they were improving. Resident #33 stated she took herself to the bathroom and they kept reminding her to use her call light. Resident #33 was not aware of any other fall interventions. Interview on 07/02/19 at 4:57 P.M. with Licensed Practical Nurse (LPN) #86 revealed she was the nurse on duty on 06/25/19 when Resident #33 fell. LPN #86 reported she was called to Resident #33's room by State Tested Nursing Assistant (STNA) #2 because the resident had fallen. LPN #86 stated she was not aware what Resident #33 hit her head on but observed Resident #33 sitting by her bed with a bump on her head and blood on the bed and the floor. LPN #86 verified there was no mat on the floor at the time of the fall. LPN #86 reported Resident #33 was mumbling something about trying to get to the bathroom but was not acting like herself. LPN #86 reported Resident #33 was normally able to make her needs known, transfer herself, and take herself to the bathroom. However, Resident #33 also had trouble sleeping and could be very tired at times. The staff encouraged Resident #33 to use her call light when she was feeling weak but Resident #33 had not put her call light on. LPN #86 reported they assessed her, made notifications, called nine-one-one (911) and transferred Resident #33 immediately to the hospital by squad. Interview on 07/02/19 at 5:12 P.M. with STNA #2 revealed she was the aide on duty the night of 06/25/19 when Resident #33 fell. STNA #2 reported Resident #33 was mumbling something about trying to get out of bed when she was asked what happened. Resident #33 was bleeding from her nose, had a big knot on her head, and swelling had started around her eyes. STNA #2 reported she was the staff that cleaned up the blood and though it was an unwitnessed fall it was apparent from the location of the blood, Resident #33 had hit her face on the floor. STNA #2 stated Resident #33's bed was in the low position and verified there was no mat next to Resident #33's bed at the time of the fall. STNA #2 reported the nurse called 911 and Resident #33 was sent to the hospital. STNA #2 reported Resident #33 was a fall risk, was able to make her needs known, but had some confusion at times, and required just some supervision with her activities of daily living. STNA #33 reported they would keep a close eye on her because Resident #33 had trouble sleeping at night and wouldn't use her call light consistently when she was feeling tired and needed help. STNA #2 reported Resident #33 had not put her call light on the night of 06/25/19. Review of the facility policy titled, Assessing Falls and Their Causes revised January 2019 revealed resident's care plans were to be reviewed to assess for any special needs of the resident. Residents were to be assessed for falls at admission and regularly afterward for potential risk for falls. 2. Observation on 06/30/19 at 9:10 A.M. of the bathroom near the 300 hall nurses station found the bathroom door unlocked, opened, an aerosol can of air freshener marked with a warning label to avoid skin and eye contact. Two independently mobile residents were observed outside the open door of the bathroom. Interview on 06/30/19 at 9:15 A.M. with Housekeeping Staff (HS) #15 revealed the unmarked bathroom was considered the women's bathroom but anyone could use it. HS #15 reported the bathroom was kept unlocked. Observation on 06/30/19 at 10:09 A.M. of the women's bathroom near the 300 hall nurses station found the bathroom door unlocked, an aerosol can of air freshener marked with a warning label to avoid skin and eye contact. An independently mobile resident in a wheelchair was observed outside the opened door. Interview on 06/30/19 at 10:11 A.M. with Licensed Practical Nurse (LPN) #83 verified an aerosol can of air freshener with a warning label to avoid skin and eye contact and the product was left unattended on the sink. LPN #83 removed the chemical from the bathroom. Interview on 07/01/19 at 8:50 A.M. with the Administrator revealed two resident, Resident #63 and #64 had dementia/confusion and were independently mobile and that could potentially be affected by the unsecured chemicals. Review of the facility policy titled, Hazard Communication Policy and Procedure, dated 01/01/16 revealed staff were to be trained regarding hazards and identities of chemicals to ensure a safe living area for the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, staff and resident interviews, policy review and review of medication information from Medscape, the facility failed to ensure a resident's pain was properly managed. This resulted in actual harm when Resident #173 experienced uncontrolled severe pain and had difficulty sleeping. This affected one (#173) of one resident reviewed for pain management. The facility identified 42 residents on a pain management program. The facility census was 76. Findings included: Review of Resident #173's medical record revealed the resident was admitted to the facility on [DATE]. Medical diagnoses included malignant neoplasm of the colon. Review of admission observation dated 06/20/19 revealed she was cognitively intact. Functional status was independent for bed mobility, transfers, eating and toilet use. Review of a pain assessment dated [DATE] for Resident #173 revealed the document did not have a numeric rating or a verbal descriptor scale completed. The assessment further revealed the pain affected sleep, mood, socialization, activities of daily living, and physical activity. Review of the admission assessment dated [DATE] revealed per hospital records Resident #173 had an open sigmoid colectomy with a coloproctostomy and partial omentectomy. Review of physician orders revealed an order for Hydromorphone HCL (Dilaudid) tablet two milligram (mg) to give one tablet by mouth every six hours as needed for moderate to severe pain. Review of the Medication Administration Record (MAR) for Resident #173 dated 06/29/19 revealed no evidence of Hydromorphone being administered. The Hydromorphone was given on 06/30/19 at 2:06 P.M. Review of the care plan dated 06/20/19 for Resident #173 revealed the resident has pain related to a surgical wound status post colectomy and cancer. Intervention was to give Hydromorphone as ordered. Review of the progress notes dated 06/29/19 at 3:22 P.M. revealed the resident was unhappy and complained of pain a couple of times during the day. Further review of a progress note dated 06/30/19 at 1:30 A.M. revealed Resident #173 continued to complain about her pain and rated the pain a 10 out of 10. The note reported the resident's narcotics were still not in, the nurse called and spoke to the Nurse Practitioner (NP) about the resident's pain and the nurse was encouraged to give the maximum dose of an analgesic and offer an ice pack and if the pain continued, to send the resident to the hospital. Interview and observation of Resident #173 on 06/30/19 at 11:22 A.M. revealed she hadn't received her pain medication for a couple of days. She said Dilaudid was her medication and it was being used for her colon surgery due to cancer. She stated, I get really bad cramps. Resident #173 stated she had a cramp, she cried out in pain and said she couldn't do this and rated her pain as 10 out of 10. Resident #173 stated the pain was unbearable and she had difficulty sleeping. Resident #173 stated she told the facility if they can't control her pain, to send her back to the hospital. Resident #173 stated she was told on admission her pain would be controlled. Resident #173 stated the facility was supposed to be rushing her pain medications out today. A subsequent observation of Resident #173 on 06/30/19 at 12:52 P.M. revealed she grimaced with pain while holding her stomach. Interview with Licensed Practical Nurse (LPN) #49 on 06/30/19 at 11:40 A.M. revealed the pharmacy was waiting for the physician to approve Resident #173's narcotic pain medication. LPN #49 stated she got in report this morning the physician had been faxed, which was the only way the facility can contact him, and the physician did not get back with the facility. She stated she called the NP to see if she could approve the medication and she couldn't, but the NP tried to get in touch with the physician with no success. LPN #49 stated the facility didn't have the Hydromorphone and the emergency box didn't have it either. LPN #49 stated Resident #173 has been crying in pain today. LPN #49 stated finally the Director of Nursing (DON) came into the facility because of the annual survey and was able to get in touch with the physician directly and the approval was made for the facility to receive Resident #173's Hydromorphone. Review of policy entitled Administering Pain Medications (not dated) revealed the pain management program is based on a facility-wide commitment to resident comfort. Pain management was defined as the process of alleviating the resident's pain to a level that was acceptable to the resident and was based on his or her clinical condition and established treatment goals. Review of medication information from Medscape revealed Hydromorphone (Dilaudid) is an opioid analgesic used for moderate-to-severe pain. The medication should be taken as prescribed by the physician. Further review revealed precise and systematic pain assessment is required to make the correct diagnosis and determine the most efficacious treatment plan for patients presenting with pain. During a Pain Assessment the resident's pain is assessed on a zero to 10 scale with zero being no pain and 10 being the most severe pain. It was also indicated that pain medications work best if used at first signs of pain, if delay the medication may not work as well.