**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy review and interview, the facility failed to provide timely and necessary care/treatment for Resident #100 and Resident #102 following identified changes in condition. Actual Harm occurred beginning on 10/09/24 when Resident #100, who was severely cognitively impaired was noted by direct care staff (Certified Nursing Assistant 3249) to be favoring her right side, had bruising noted and wasn't right without evidence a licensed nurse assessed the resident or provided necessary intervention. On 10/11/24 licensed staff documented Resident #100 was sitting awkwardly in her chair and guarding her upper right side thigh area. Between 10/11/24 and 10/14/24 the resident exhibited signs of increased pain (facial grimacing and guarding of the leg) with an inability to obtain an x-ray of the area (due to positioning issues). On 10/14/24 (five days after the initial change was identified) the resident was transferred to the hospital and diagnosed with a right hip fracture which required surgery. The resident did not return to the facility after being transported to the hospital. Actual Harm occurred on 09/21/24 when Resident #102, who was severely cognitively impaired sustained a witnessed fall that resulted in a fracture. However, at the time of the incident the resident was not comprehensively assessed for injury or need for additional medical treatment nor was there documentation of the incident at the time it occurred. On 09/24/24 (three days after the fall occurred), Resident #102 was transported to the hospital with bilateral hip pain and diagnosed with a pelvic fracture. The resident did not return to the facility after being transported to the hospital. This affected two residents (#100 and #102) of three residents reviewed for change in condition. Findings include: 1. Review of the closed medical record for Resident #100 revealed an admission date of 07/08/23 with diagnoses including Alzheimer's disease, anxiety disorder, disorder of bone density and structure, osteoarthritis, subsequent encounter for closed fracture of left femur, hypercholesterolemia, hypertension, muscle weakness, dysphagia, and difficulty walking. Resident #100 was discharged to the hospital on [DATE]. Review of the fall assessment completed on 04/15/24 revealed Resident #100 was at risk for falls. Review of next fall assessment, still showing in progress, dated 09/24/24 revealed Resident #100 was not at risk for falls. Review of the care plan dated 07/18/24 revealed Resident #100 was at risk for falls. Interventions included two-person transfer assist for transfers, educate resident and family to call for assistance before transferring, maintain food/fluids/ and needed items within reach, implement preventative fall interventions/devices, maintain call light within reach and educate resident to use call light, and monitor for changes in mobility. Review of the care plan dated 07/18/24 revealed Resident #100 had potential for pain. Interventions included administer medications per physician orders and monitor for side effects and effectiveness, notify physician if current pain medication is ineffective, determine what the resident's optimal pain level is for day-to-day function and quality of life, encourage resident to request pain medication before the pain becomes too intense or prior to activities, monitor for any change sin usual activities, monitor for changes in behavior such as screaming, refusals, monitor for changes in mood that may be indicators of pain, monitor for changes in sleep, monitor for verbal and non-verbal signs and symptoms relating to pain: grimacing, guarding, moaning, crying, increased anxiety, and offer non-pharmacological interventions to relieve pain and monitor for effectiveness. Review of the quarterly Minimum Data Set (MDS) Assessment, dated 10/01/24, revealed Resident #100 had severely impaired cognition, utilized a wheelchair for mobility, and required substantial or maximum assistance for all activities of daily living (ADLs). Review of a progress note dated 10/11/24 at 4:44 P.M. revealed Resident #100 was sitting awkwardly in her chair and guarding her upper right side thigh area. Resident #100 was transferred to bed and Registered Nurse (RN) 334 noted two bruises approximately three inches in length on the dorsal aspect of the right thigh. Resident #100 was actively guarding and fighting against the assessment of the area. The note revealed there was no warmth, redness, or distinctive swelling identified. Resident #100 was unable to report if she was having pain. There was no knowledge of any falls. RN #334 notified Resident #100's nurse practitioner and new orders were received for x-rays of the right hip and thigh areas. RN #334 notified the unit manager and DON. Review of the pain assessment for October 2024 revealed Resident #100 had pain rated a three on a pain scale (scale of 1 the least pain to 10 the worse pain) on 10/11/24. Review of the progress note dated 10/11/24 at 5:48 P.M. revealed Resident #100's daughter was notified of the bruising and the orders for x-rays. Review of the undated photos (identified by family to be taken on 10/12/24) provided by Resident #100's family revealed four (4) photos of Resident #100. The first and second photo of Resident #100 showed her front right thigh with large bruising, left lower arm/hand with bruising, with CNA #207's body and badge visible in the photo. The third and fourth photo showed Resident #100's right posterior thigh area with large bruising. Review of Resident #100's progress note dated 10/12/24 at 7:06 P.M. revealed the x-ray technician was unable to obtain x-rays this shift and would attempt to obtain x-rays later this evening or the following morning. Review of the Medication Administration Records (MARS) and Treatment Administration Records (TARS) for October 2024 revealed Resident #100 received Tylenol on 10/13/24 at 2:00 P.M. for pain rated a level three. However, the medical record contained no information on where the resident's pain was, how the resident's pain was being monitored or treated further on this day. Review of Resident #100's progress note dated 10/13/24 at 07:35 A.M. revealed x-ray technician arrived to perform x-rays to right hip, pelvis, and femur. Resident #100 resisted positioning of x-rays. A call was placed to the resident's power of attorney (POA) per request for additional help with positioning. The resident's daughter did arrive and did attempt several times to assist with positioning. Resident #100 continued to resist assistance. A call placed to physician answering service and facility was awaiting call back. Review of Resident #100's progress note dated 10/13/24 at 09:17 A.M. revealed a call back was received from the on-call nurse practitioner with new orders for Flexeril (muscle relaxant) five milligrams (mg) one hour prior to x-rays being obtained on Monday 10/14/24 at 7:30 A.M. Resident #100's POA was notified. Review of Resident #100's progress note dated 10/13/24 at 11:05 A.M. revealed call placed to NP regarding signs and symptoms of pain observed during transferring and the facility was awaiting call back. Review of Resident #100's progress noted dated 10/13/24 at 12:02 P.M. revealed NP #345 returned call with new orders for Tylenol increased to 1000 milligrams (mg) every eight hours and as needed (PRN). Resident #100's POA was notified. Review of Resident #100's progress note dated 10/14/24 at 1:00 P.M., authored by the DON, identified a change of condition, but had no additional documentation completed to identify what the change in condition was or why the change in condition occurred. Review of a progress noted dated 10/14/24 at 2:00 P.M. revealed Resident #100 was transferred to hospital due to an inability to obtain an x-ray of resident's right hip. Resident #100's family was notified. The NP and DON were made aware of transfer. Review of the progress noted dated 10/14/24 at 9:00 P.M., authored by the DON, revealed Resident #100 transferred to a different hospital for trauma with right hip fracture. The resident's POA at bedside and notified at this time. Review of hospital orthopedic surgery operative note dated 10/15/24 revealed Resident #100 was seen in the emergency room and had presented as a patient who fell and injured their right hip which required surgery. X-rays were taken and revealed the resident sustained an intertrochanteric fracture with subtrochanteric extension of the right hip. Record review revealed the facility submitted a self-reported incident (SRI), tracking number 252914 to the State agency involving Resident #100. The SRI submitted by the DON revealed on 10/12/24 the receptionist notified the Administrator Resident #100's family was alleging the resident had an injury of unknown origin. Upon investigation, it was discovered a skin assessment was completed, and family and physician had been contacted on 10/11/24 with orders for an x-ray after a CNA reported the resident had a change in condition. Interview on 10/29/24 at 1:25 P.M. with Receptionist #260 revealed on Saturday, 10/12/24 Resident #100's daughter came to front desk, was upset, and showed pictures of bruises to Resident #100's inner thigh (couldn't remember which side). Receptionist #260 revealed she reported this immediately via telephone to the Administrator, the abuse coordinator. Receptionist #260 stated she saw the pictures on the phone and couldn't see how anyone else change/bathing the resident could not see the bruising. Interview on 10/30/24 at 9:15 A.M. with Resident #100's family revealed she was notified on 10/11/24 at 5:45 P.M. from someone at the facility that Resident #100 had slight bruising to right thigh and was favoring it. Resident #100's family reported she went to the facility on Saturday, 10/12/24 and found Resident #100 out in the lounge and asked CNA #207 to assist the resident to the bathroom and change her. Resident #100's family reported she saw large bruising on the resident's leg and took photos. Resident #100's family reported on 10/12/24 she showed the photos to Receptionist #260, who told her she was going to report this to the administrator. Interview on 10/31/24 at 2:24 P.M. with the DON revealed LPN #339 was terminated because she worked on 10/09/24 and it was reported to her by CNA #249 that Resident #100 was favoring her right side, bruising was noted, and something wasn't right with the resident. The DON reported LPN #339 failed to report the findings, there was no assessment or treatment of the resident, as the nurse did nothing. Interview on 11/04/24 at 8:24 A.M. via telephone with CNA #249 revealed on the morning of 10/09/24 while attempting to get Resident #100 up, she noticed she was holding onto her right leg like it was hurting when she attempted to straighten it, and the resident appeared to be in pain by making grimacing faces. CNA #249 revealed she notified LPN #339 Resident #100 was holding onto her right leg and grimacing, like she was in pain and LPN #339 stated okay. CNA #249 reported on 10/11/24 Resident #100 presented the same way, holding right leg in pain and grimacing. CNA #249 reported she notified LPN #318 of Resident #100's pain in her right leg and LPN #318 said okay. CNA #249 revealed on 10/11/24 in the morning while getting Resident #100 ready she was making noises like she was in pain, grimacing, and holding the right leg. CNA #249 stopped dressing her and immediately notified LPN #339 of the pain and stated something was wrong with the resident's right leg. LPN #339 informed CNA #249 Resident #100 was getting an x-ray. Interview on 11/04/24 at 12:31 P.M. via telephone with RN #334 revealed on 10/11/24 CNA #249 notified her Resident #100 was sitting in her chair funny and guarding her leg. RN #334 reported she assessed Resident #100 and found two bruises on the back lower thigh area of her right leg. RN #334 stated she notified the physician, unit manager, RN #258, the DON, and resident's family. RN #334 reported Resident #100 seemed in pain, and she was acting differently. RN #334 reported it was hard to tell due to her being non-verbal about what happened. RN #334 reported she didn't know how the resident got the bruising due to there being no reported falls. RN #334 revealed she was trying to figure out what happened. RN #334 confirmed she did not report to the Administrator, the abuse coordinator, because she didn't think to notify her and didn't know what was going on. Interview on 11/04/24 at 12:50 P.M. with CNA #206 revealed she was working on 10/11/24 and Resident #100 was not acting herself and noted her right leg was swollen. CNA #206 reported she notified RN #334 who assessed the resident and noted a bruise in her inner right thigh. CNA #206 reported Resident #100 was holding her right thigh, digging into it and didn't want anyone to touch it. Interview on 11/04/24 at 1:09 P.M. and on 11/05/24 at 9:38 A.M. with LPN #339 revealed on 10/09/24 CNA #249 notified her Resident #100 was guarding her right side and it was during change of shift, and LPN #339 had to go pick up her daughter. LPN #339 confirmed she did not do an assessment because it was during change of shift, and she had to go. LPN #339 reported on 10/09/24 she notified the oncoming nurse, LPN #270, Resident #100 needed assessed. LPN #339 reported on 10/11/24 the nurse, (she didn't remember who), during report notified her she needed to order an x-ray for Resident #100. LPN #339 denied any CNA notified her of Resident #100 having pain in her leg. LPN #339 reported she got in trouble, was suspended on Saturday, 10/12/24 and then fired by phone on either 10/14/24 or 10/15/24, but couldn't remember for sure. Interview on 11/04/24 at 2:17 P.M. with LPN #250 revealed she worked on 10/12/24 and Resident #100 was exhibiting signs of pain around her hip area by wincing and pushing away staff. LPN #250 reported she was told by LPN #339 Resident #100 was awaiting x-rays and denied being told the resident needed assessed. Interview on 11/05/24 at 11:20 A.M. with CNA #207 revealed he worked on Saturday 10/12/24 and Resident #100's family requested he take the resident to the bathroom and change her. CNA #207 revealed the resident had bruises on her thigh, could not remember which thigh and stated the family took photos. Interview on 11/05/24 at 12:02 P.M. with the Administrator and Regional Nurse (RN) #338 revealed LPN #339 was suspended on 10/25/24 once they discovered Resident #100's change in condition and when they received statement from CNA #249 that the CNA notified LPN #339 regarding the concerns with Resident #100. Information obtained via email on 11/08/24 at 11:43 from Nurse Practitioner (NP) #345 revealed the on-call NP was notified of Resident #100's pain making it hard to get x-ray images on 10/13/24. NP #345 reported Resident #100 was known to be resistant to care. NP #345 reported the resident was ordered Tylenol and Flexeril to be given prior to getting the x-ray. NP #345 reported being notified later that day of Resident #100's pain to right lower extremity with repositioning and transfer. NP #345 gave an order to increase Tylenol to 1000 milligrams and change to three times a day. NP #345 reported on 10/14/23 the facility was still unable to get an x-ray, the pain was persistent and Resident #100 was sent to emergency department for evaluation. Review of the employee file for LPN #339 revealed she had a discipline for corrective action form dated 10/17/24 for performance/policy violation for incident/accident policy and not reporting a change in condition and was terminated via phone. Review of the facility policy, Resident Change In Condition, dated July 28, 2022 revealed the facility ensured staff provide timely and appropriate care and services when resident experienced a change in condition that has or was likely to cause serious life-threatening harm or injuries and/or adverse negative health outcomes. The facility would promptly notify resident, his/her attending physician, and responsible party of changes in the resident's condition and/or status. The licensed nurse would take immediate action to ensure timely and appropriate care and services are met when a resident change in condition was identified. 2. Review of the closed medical record for Resident #102 revealed an admission date of 04/14/24 and a discharge date of 09/24/24 with diagnoses including but not limited to acute chronic respiratory failure with hypoxia, congestive heart failure, encephalopathy, ventricular tachycardia, and history of malignant neoplasm of breast. Review of the quarterly Minimum Data Set (MDS) Assessment, dated 07/21/24, revealed Resident #102 had severely impaired cognition, utilized a wheelchair for mobility, and required substantial or maximum assistance for all activities of daily living (ADLs). Review of the most recent completed fall assessment dated [DATE] revealed Resident #102 was at risk for falls. Review of the care plan dated 04/15/24 revealed the resident was at risk for falls. Interventions included educate resident/family to call for assistance before transferring, implement preventative fall interventions/devices, maintain call light/food/fluids within reach, educate resident to use call light, and monitor for changes in mobility, Review of Resident #102's care plan dated 04/15/24 revealed resident had potential for pain. Interventions included administer medications per physician order and monitor for side effects, determine what the resident's optimal pain level is for day-to-day function and quality of life, encourage resident to request pain medication before pain becomes too intense, monitor any change sin usual activities, monitor for changes in behavior that may be indicators of pain such as kicking, screaming, refusals, monitor for changes in mood, monitor for changes sleep pattern, monitor for verbal and non-verbal signs and symptoms relating to pain: grimacing, guarding, crying, moaning, and increased anxiety, offer non-pharmacological interventions to relieve pain, provide rest periods, therapy screen/eval as needed (PRN), and refer to ancillary services PRN. Review of Resident #102's medical record revealed no progress notes were documented for the resident on 09/21/24. Review of a progress note dated 09/24/24 at 4:18 P.M., authored by LPN #342, revealed Resident #102 had a change in condition. However, no additional information about the resident's condition was noted at that time. Review of a hospital transfer form revealed Resident #102 was transferred to the hospital on [DATE] at 4:17 P.M. for a change in condition after falling and having bilateral hip pain. However, review of the resident's medical record revealed no additional information about a fall or bilateral hip pain prior to this documentation or evidence the resident had been assessed and/or monitored for pain following a fall. Review of a progress note dated 09/25/24 at 08:00 A.M., (as a late entry note), authored by the Director of Nursing (DON), revealed the DON called the hospital to follow up on Resident #102 who was sent to hospital with right hip pain. The hospital reported Resident #102 was admitted with a pelvic fracture. The resident did not return to the facility. Interview on 10/24/24 at 3:10 P.M. with the DON revealed the facility completed staff training on 09/25/24 related to reporting accidents/incidents because Resident #102 had sustained a fall (on 09/21/24) that was witnessed by LPN #342 and CNA #209, but the nurse did not report the incident, failed to document the fall occurred and failed to fill out an incident report. The DON reported she only found out about it because CNA #274 came forward and told the DON that the fall happened. Interview on 10/29/24 at 11:58 A.M. with Administrator and Regional Nurse (RN) 338 revealed it was discovered on 09/24/24 Resident #102 had a fall on 09/21/24 that wasn't reported, the resident was not assessed (until 09/24/24) and there was not an incident report completed. RN #338 reported after being made aware of the incident, she came to the facility to help with the investigation. RN #338 verified Resident #102 had a fall on 09/21/24 and CNA #274 and CNA #341 notified LPN #342. RN #338 confirmed LPN #342 never did an assessment, didn't report the incident, and no notifications (to the physician or family) were completed. RN #338 reported the DON found out about the fall on 09/24/24 when CNA #274 notified her. RN #338 reported LPN #342 was suspended pending investigation and then was terminated as a result of the incident. RN #338 reported CNA #209 found Resident #102 on the floor in her room. CNA #341 assisted and notified LPN #342 of the fall. CNA #274 was walking by the room, went to assist the resident, and notified LPN #342 of the fall. RN #338 reported all staff were educated and a plan of correction was put in place. Interview on 11/07/24 at 1:08 P.M. with CNA #209 revealed she was walking by Resident #102's room on 09/21/24 after breakfast when she heard her call out for help. CNA #209 reported she could see in the room the resident was on the floor, and she asked CNA #341 to notify the nurse of the fall. CNA #209 reported she immediately went into the room and found Resident #102 on the floor. CNA #341 returned to the room after she notified LPN #342 of the fall. CNA #209 reported CNA #274 came in to see if they needed help and if the nurse needed notification. CNA #209 informed CNA #274 LPN #342 was notified by CNA #341. Interview on 11/07/24 at 1:13 P.M. with CNA #274 revealed she was walking by Resident #102's room and saw her on the floor on 09/21/24 in the morning and CNAs #209 and #341 were assisting the resident. CNA #274 went into to see if they needed help. CNA #274 reported CNA #341 already notified LPN #342 of the fall. CNA #274 reported when she left the room, she notified LPN #342 of the fall. CNA #274 confirmed Resident #102 had a fall and LPN #342 was notified. CNA #274 revealed she was telling human resources how she hurt her back from the resident falling resulting in the DON discovering the resident has a fall. Attempts to interview LPN #342 on 11/07/24 1:25 P.M. and 11/12/24 at 9:15 A.M. were unsuccessful as the LPN was not available via telephone and did not return the surveyor's calls. Review of employee file for LPN #342 revealed a discipline on 09/24/24 of suspension for performance and safety/carelessness for failure to report an incident per policy and terminated. Review of facility policy, Fall Management, Revised December 2022, revealed that if a fall occurs, the licensed nurse would assess the resident for the injury from the fall immediately and initiate an investigation of the reason for the fall and implement an immediate intervention to attempt in preventing future falls. The licensed nurse would update the Fall Risk and Pain Assessment at the time of the fall. Physician and responsible party were notified promptly. Nurse would assess the resident for fall risk through the fall risk assessment upon admission, quarterly, and with significant change. This deficiency represents non-compliance investigated under Complaint Number OH00159351, Complaint Number OH00158985, and Complaint Number OH00158756.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of facility policy the facility failed to ensure one resident (Resident #54) did not develop an unstageable pressure ulcer of the sacrum. Actual Harm occurred when Resident #54 who was re-admitted to the facility on [DATE] for rehabilitation following surgery for a left hip fracture developed a sacral pressure ulcer that was not identified until it was unstageable. This affected one resident (Resident #54) out of three residents reviewed for pressure ulcers. The facility census was 57. Findings include: Review of Resident #54's medical record revealed an admission date of 03/16/18 and diagnoses included Alzheimer's disease, dementia, and urinary incontinence. Review of Resident #54's physician orders dated, 03/16/18, revealed turn and reposition frequently while in bed as tolerated every shift. Review of Resident #54's care plan dated 03/17/18, revealed Resident #54 had the potential for pressure ulcers, skin breakdown related to Alzheimer's disease, dementia, unsteadiness on feet, generalized muscle weakness, difficulty in walking, and fragile skin. The goal indicated Resident #54 would have intact skin, free of redness, blisters or discoloration through the review date. Interventions included to follow facility policies and protocols for prevention and treatment of skin breakdown; Braden skin assessment per facility protocol. Review of Resident #54's Braden Scale For Predicting Pressure Sore Risk dated, 01/04/22 and 03/31/22 revealed Resident #54 was at mild risk for developing a pressure ulcer or injury. Review of Resident #54's progress notes dated, 05/28/22, revealed Resident #54 had an unwitnessed fall and was sent via Emergency Medical Services (EMS) to the local hospital emergency room and was admitted with a hip fracture, possible head injury, and wrist pain. Review of Resident #54's progress notes dated, 06/02/22, included Resident #54 returned to the facility via ambulance from the hospital. Review of the admission assessment dated [DATE], included Resident #54 had a left hip fracture and a right wrist fracture. The admission Assessment also included Resident #54's coccyx had positional redness and was blanchable. Review of the Braden Scale For Predicting Pressure Sore Risk on 06/02/22 revealed Resident #54 was at a moderate risk for developing a pressure ulcer or injury. Review of Resident #54's progress notes from 06/02/22 through 06/21/22 did not reveal documentation Resident #54 refused to be turned and repositioned. Review of Resident #54's Medication Administration Record (MAR) revealed there was no documentation Resident #54 was turned and repositioned frequently on 06/06/22 and 06/07/22 from 6:00 P.M. through 6:00 A.M. Further review revealed there was no documentation Resident #54 was turned and repositioned frequently on 06/09/22 from 6:00 A.M. through 6:00 P.M. Review of Resident #54's Weekly Skin Checks dated, 06/08/22 and 06/16/22 revealed documentation of no new skin problems. Review of Resident #54's Weekly Skin Checks dated, 06/15/22, revealed Resident #54 had new skin problems but no details were documented why the new skin problem box was marked yes. Review of Resident #54's Quarterly Minimum Data Set (MDS) 3.0 assessment dated , 06/15/22, revealed Resident #54 had moderate cognitive impairment and required extensive assistance of two staff for bed mobility, transfers and toilet use. Resident #54 was frequently incontinent of urine and bowel. Review of Resident #54's Certified Nurse Practitioner (CNP) #909's Wound Care assessment and instructions dated, 06/15/22, included Resident #54 was admitted to the facility for rehabilitation. Resident #54 felt okay, there was no change in her current status, no fever, no change in activity level, no significant weight change. Resident #54 moaned with repositioning. Resident #54 was evaluated for a concerning area on her left heel which was present on admission to the facility. There was no documentation Resident #54 had a sacrum pressure ulcer. Review of Resident #54's Skin Pressure Ulcer Record dated, 06/21/22, revealed an unstageable sacrum pressure ulcer was first observed on 06/21/22 and measured a length of 3.0 centimeters (cm), width of 4.0 cm, and the depth was unable to be determined (UTD). The pressure ulcer had moderate serosanguinous (thin watery fluid that is pink in color) drainage, the wound bed had 80 percent granulation and 20 percent slough (dead tissue). Review of Resident #54's physician orders dated, 06/22/22, revealed cleanse coccyx area with normal saline or wound cleanser, apply calcium alginate then foam dressing, change every day and as needed every night shift and as needed for wound. Review of Resident #54's CNP #909's Wound Care assessment and instructions dated, 06/28/22, revealed Resident #54 had an unstageable pressure injury wound, located on the sacrum and was present on admission to the facility (see later note, the wound was not present on admission to the facility). The measurements were length 2.6 cm, width 3.1 cm, and depth was unable to be determined. The wound bed was composed of 80 percent granulation tissue and 20 percent slough. The wound had moderate serous drainage. This was an initial evaluation. Review of Resident #54's Medication Administration Record (MAR) and Treatment Administration Record (TAR) from 06/22/22 through 07/19/22 revealed cleanse coccyx area with normal saline or wound cleanser, apply calcium alginate then foam dressing, change every day and as needed every night shift and as needed for wound. Documentation revealed the dressing changes were completed daily, except on 07/17/22 there was no documentation the dressing change was completed. Review of Resident #54's Quarterly Minimum Data Set (MDS) 3.0 assessment dated , 09/11/22, revealed Resident #54 had moderate cognitive impairment and required extensive assistance of two staff for bed mobility and transfers. Resident #54 required extensive assistance of one staff for toilet use. Review of Resident #54's physician orders dated 10/10/22 revealed skin treatment sacrum, cleanse with normal saline, pat dry, apply nickel thick Santyl (enzymatic debrider) and calcium alginate, apply Triad paste to peri wound cover with absorbent dressing ( (abdominal pad [ABD]) daily every night shift and as needed. Change dressing if it becomes soiled or dislodged. No foam dressings. Review of Resident #54's progress notes from 10/16/22 through 10/20/22 did not reveal documentation Resident #54 refused to be turned and repositioned or was encouraged to turn and reposition. Review of facility document titled Skin Injury-Pressure Ulcers dated 10/17/22 revealed Resident #54 had an in-house acquired pressure ulcer. Review of Resident #54's CNP #909's Wound Care assessment and instructions dated, 10/17/22, revealed an addendum added on 10/19/22. The addendum stated CNP #909 had inadvertently documented the sacral pressure ulcer was present on admission. Further discussion with the staff and review of records showed that this was actually a wound that developed in-house (and appropriately documented in the facility records as such). Observation on 10/18/22 at 10:51 A.M. of Resident #54 revealed she was lying in bed on her right side and her television was on. Resident #54 made eye contact but did not respond when spoken to. During observation on 10/18/22 at 10:57 A.M. of State Tested Nursing Assistant (STNA) #891 providing incontinence care for Resident #54, STNA #891 stated she arrived at 7:00 A.M. for her shift and this was the first time today she checked, changed and repositioned Resident #54. STNA #891 stated this was because she just finished giving a resident shower and was busy making rounds on other residents. STNA #891 provided appropriate incontinence care and observation of the sacral dressing revealed it was dated 10/18/22 at 3:00 A.M. STNA #891 positioned resident on her back and slightly propped up on the right side using a pillow. STNA #891 stated Resident #891 did not refuse to be turned and repositioned. Interview on 10/18/22 at 2:44 P.M. with CNP #909 revealed 06/15/22 was the first time she evaluated Resident #54's wounds. CNP #909 stated she was not told Resident #54 had a sacral pressure ulcer on 06/15/22 and only evaluated the left heel unstageable pressure ulcer. CNP #909 stated she did not go to the facility the following week and on 06/28/22 she evaluated the unstageable pressure ulcer on Resident #54's left heel and another unstageable pressure ulcer on Resident #54's sacrum. CNP #909 stated she was not told on 06/15/22 to evaluate Resident #54's sacral area. CNP #909 indicated she did not have a statement in her notes stating the sacral pressure ulcer was present on admission. Observations on 10/20/22 at 9:32 A.M., 10:38 A.M., and 11:19 A.M. of Resident #54 lying on her back and the head of the bed was elevated approximately 45 degrees. There were no observations of staff turning and repositiong Resident #54 or encouraging resident to turn and reposition. Observation on 10/20/22 at 12:27 P.M. of Resident #54 lying on her back with head of bed elevated and the lunch tray on the bedside table. Observation of the lunch tray revealed Resident #54 had not eaten any of it, she was slumped to the right and in an awkward position to eat the meal. Nurse #876 walked in the room, confirmed Resident #54 was in an awkward position for eating and positioned her on her back in an upright position so she could eat her food. Nurse #876 indicated she should have an STNA assist with positioning but there were no aides available at the moment and she had to do it herself. Interview on 10/20/22 at 1:00 P.M. with STNA #803 revealed she had not changed or repositioned Resident #54 since just after breakfast which was around 9:00 A.M. to 9:30 A.M. because she needed assistance and was waiting on STNA #812. STNA #803 stated she was taking a break now and would check and position Resident #54 after she was done with the break. Observations on 10/20/22 at 1:18 P.M. and 1:51 P.M. of Resident #54 revealed she was lying on her back with the head of bed elevated and was slumped to the right and sleeping. There was no observation of staff turning and repositioning Resident #54 or encouraging Resident #54 to turn and reposition. Observation on 10/20/22 at 2:26 P.M. of Wound Nurse/Licensed Practical Nurse (WN/LPN) #811 and Assistant Director of Nursing (ADON) #907 revealed they were preparing to change Resident #54's sacral pressure ulcer dressing. Observation of Resident #54 revealed she was lying on her back with a pillow slightly under her left hip. ADON #907 removed the wet incontinence brief, provided appropriate incontinence care and assisted WN/LPN #811 to roll Resident #54 onto her right side. Resident #54's sacral dressing was dated 10/20/22 at 5:30 A.M. and a small to moderate amount of brownish yellow drainage was noted on the dressing. WN/LPN #811 removed the soiled sacral dressing, washed her hands and cleansed the pressure ulcer wound with normal saline. The wound bed was pink, had whitish colored areas throughout and was approximately a two inch circle. WN/LPN #811 applied Santyl ointment to the sacral pressure ulcer, covered the Santyl with calcium alginate, applied Triad cream to the surrounding skin, and covered the calcium alginate with an ABD and tape. The edges of the wound were pink and raised and the surrounding skin had a two inch reddened area around the edges. Resident #54 flinched and nodded yes when asked if she was in pain and would like pain medication. WN/LPN #811 and ADON #907 positioned Resident #54 on her left side. Review of the facility policy titled Pressure Ulcer Prevention and Risk Identification revised, 10/2020, included licensed nurses would assess for redness, rashes, ecchymosis (bruising), shearing and open areas. The licensed nurse would pay close attention to surfaces of the skin that came in contact with the bed or chair, bony prominences, surfaces of the skin that came in contact with orthotic devices and skin folds. The physician and responsible party would be notified by the licensed nurse promptly of the newly identified skin area and a treatment would be initiated according to the physician order. This deficiency represents non-compliance investigated under Complaint Number OH00134790.