**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, interview, and facility policy review, the facility failed to provide appropriate assistance and follow care planned interventions for Resident #48 to prevent a fall with an injury. The facility failed to complete a fall investigation and neurological checks as ordered for Resident #29 and failed to ensure appropriate interventions were in place to prevent Resident #37 from leaving the secured unit. Actual harm occurred on 04/03/24 when Resident #48, who was severely cognitively impaired sustained a fall and fractured left hip when ambulating wearing inappropriate footwear and without her walker. At the time of the incident, staff told the resident to go put shoes on but failed to provide any additional intervention or assistance to prevent the fall with injury. This affected three residents (#29, #37, and #48) of seven residents reviewed for accidents. The facility census was 69. Findings include: 1.Review of the medical record for Resident #48 revealed an admission date of 09/08/21 with diagnoses including dementia, depression, hypertension, disorientation, dysphagia, osteoporosis, and fracture of unspecified part of neck of left femur acquired 04/04/24. Review of Resident #48 ' s quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had severely impaired cognition. The assessment revealed Resident #48 required supervision or touching assistance with putting on her shoes and supervision or touching assistance with sit to stand transfers. Resident #48 used a walker for ambulation. Review of Resident #48 ' s first meeting (care conference) minutes dated 01/23/24 revealed she was at high risk for falls. This was due to her age being greater than 80 years (of age), incontinence with urgency and frequency, receiving two or more high fall risk drugs, requiring assistance or supervision for mobility, transfer, or ambulation, and a lack of understanding of physical and cognitive limitations. Review of Resident #48 ' s physical therapy progress report dated 03/01/24 revealed the resident required supervision or touching assistance for picking up an object and needed a walker for ambulation and transfers. Review of Resident #48 ' s progress note dated 04/03/24 revealed around 4:35 A.M. that morning Former Assistant Director of Health Services (ADHS) #210 was passing medications when Certified Resident Care Associate (CRCA) #211 informed her that there was a fall on the secured unit. The nurse found Resident #48 lying on her back on the floor between her table and the foot of her bed. Upon assessment, the resident ' s left leg was noticeably shorter in length and externally rotated outward. Resident #48 was holding her left hip and leg and stated that was the only area that hurt. Vital signs were assessed with no concerns and the resident denied hitting her head. Emergency services were contacted and arrived around 4:45 A.M., they evaluated the resident, requested a splint for her leg, and initiated intravenous pain medication. The resident was transferred to the hospital at approximately 5:45 A.M. Statement from CRCA #141 revealed she was in the hallway talking to another resident when Resident #48 came to her doorway wearing only socks. CRCA #141 reminded the resident to go back to her room and put her shoes on. Within minutes, CRCA #141 heard a scream and went to Resident #48 ' s room to find her on the floor. Intervention was for therapy evaluation and neon tape to the walker. Review of Resident #48 ' s fall event dated 04/03/24 and closed on 04/08/24 revealed prior to the fall the resident was ambulating with improper or ill-fitting footwear (socks). She experienced 10 out of 10 pain and injury was noted to her left hip and leg. The resident had a cognitive or memory impairment that affected safety and judgement and required use of an assistive device and often forgets to use the device. Review of Resident #48 ' s x-ray dated 04/03/24 revealed an x-ray of the pelvis and left hip were completed. There was an angulated comminuted (producing multiple bone splinters) intertrochanteric fracture of the left hip. No osteoporosis to the area was noted. Review of Resident #48 ' s interdisciplinary team note revealed the team met to discuss Resident #48 ' s 04/03/24 fall. They indicated Resident #48 was attempting to sit in a chair to put her shoes on, she did not get the chair pulled out all the way, and it appeared as though she missed the chair when she went to sit down. The resident was transferred to the emergency room and the intervention upon return was a therapy referral and visual cue to use the walker. Review of Resident #48 ' s plan of care as of 04/04/24 revealed she required staff assistance to complete activity of daily living (ADL) tasks completely and safely. She ambulated without an assistance device and was able to feed herself with set up. It was noted that her ADL ' s may fluctuate with cognitive loss and dementia progression. Interventions included allowing sufficient time to complete all or parts of tasks, encouraging her to do as much as safely possible for self, observing for deterioration ADL abilities, and providing adequate rest periods between activities. The care plan did not address Resident #48 ' s assistance needs for dressing, applying footwear, or transfers from sit to stand. Review of Resident #48 ' s plan of care as of 04/04/24 revealed she was at risk for falling related to syncope and collapse, dementia, and poor safety awareness. Interventions included encouraging the resident to assume standing position slowly, ensuring the floor is free of liquids and foreign objects, keeping personal items and frequently used items within reach, staff to assist with transfers as needed, and providing non-skid footwear. Review of Resident #48 ' s profile care guide as of 04/04/24 revealed she needed supervision assistance with transfers. The profile care guide did not address Resident #48 ' s assistance needs for applying footwear. Interview on 06/24/24 at 12:21 P.M. with CRCA #141 revealed she had been sitting at the desk in the common area talking to another resident when she saw Resident #48 begin to come out of her room. Resident #48 did not have a walker and did not have shoes on, Resident #48 was wearing regular socks. CRCA #141 reported she did not want Resident #48 to fall so she told her to go put her shoes on. She reported a couple minutes later she heard the resident scream; she believed the resident was bending over to get her shoes when she fell. CRCA #141 called the nurse who assessed the resident and sent her out. Interview on 06/24/24 at 3:43 P.M. with the Executive Director (ED) verified that the therapy notes indicated Resident #48 required supervision or touching assistance for picking up an object and a walker for ambulation and transfers. She additionally verified the care plan did not thoroughly address Resident #48 ' s activity of daily living assistance needs. The ED verified Resident #48 ' s plan of care indicated she was at fall risk and required non-skid footwear to prevent falls. Review of the facility policy, Fall Management Program Guidelines, dated 12/31/23, revealed the policy stated, should the resident experience a fall the attending nurse shall complete the Fall Event. This includes an investigation of the circumstances surrounding the fall to determine the cause of the episode, a reassessment to identify possible contributing factors, interventions to reduce risk of repeat episode and a review by the Interdisciplinary Team (IDT) to evaluate thoroughness of the investigation and appropriateness of the interventions. Any orders received from the physician should be noted and carried out. Care plan interventions should be implemented that address the resident ' s risk factors. 2. Review of the medical record for Resident #37 revealed an admission date of 11/08/23 with diagnoses including dementia, depression, diverticulosis, age-related osteoporosis without pathological fracture, repeated falls, mixed-receptive-expressive language. Review of Resident #37's admission assessment dated [DATE] revealed when reviewing her exit seeking or elopement it was noted she had a history of exit seeking, exhibited periods of pacing, agitation or wandering toward the exit, had eloped within the last three and six months, and demonstrated confusion and had the ability to exit campus. Review of Resident #37's physician order dated 11/08/23 revealed an order for a secured or locked unit. Review of Resident #37's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had a severe cognitive impairment. She had wandering that placed her at significant risk of getting to a potentially dangerous place. Review of Resident #37's progress note dated 11/11/23 revealed the nurse was notified that an emergency exit alarm was sounding on the locked unit. Resident #37 was noted standing a few feet from the emergency exit in front of the facility on the sidewalk. The aide reported it took her and three additional aides to get the resident back into the building as she was hitting, kicking, and punching staff. She was escorted back to the day room in the locked unit but continued to attempt to exit. There was no exit seeking event (incident investigation) for this incident. Review of Resident #37's progress note dated 11/12/23 revealed the aide reported the resident was attempting to get out of the facility through the fire emergency door. She was agitated and tearful regarding her late husband, she was able to be redirected back to her room and calmed down. Review of Resident #37's plan of care dated 11/27/23 revealed they demonstrated exit-seeking behaviors and wandering. Interventions included monitoring for wandering triggers such as need for toileting inactivity, and time of day, encouraging regular family contact or visits with others, provide structured routine to resident's day, resides on legacy lane for safe wandering, assess need for wander guard and apply as appropriate, offer diversional activities as needed, and re-direct resident away from doors/exits as needed. Review of Resident #37's progress note dated 02/01/24 revealed she was having behaviors and exit seeking. She was aware of the code to the main door and was able to unlock it and try to exit the unit. The resident was redirected back to the common area, the resident was to be on continuous watch until the door code was changed. Review of Resident #37 ' s quarterly observation and data collection dated 05/08/24 revealed the resident wandered. There was no exit seeking event for this incident. Review of Resident #37 ' s exit seeking event dated 02/12/24 revealed the resident came out of her room and said she was leaving and her bags were packed. She headed towards the door and was redirected by staff. No wandering alert device was in place and the intervention was to monitor the residents ' patterns. Review of Resident #37's quarterly MDS 3.0 assessment dated [DATE] revealed Resident #37 had intact cognition. Review of Resident #37's progress note dated 05/16/24 revealed she was found to have placed the code into the memory care door and walked out of the unit. Staff caught up with the resident as she was exiting the exterior doors. Resident #37 stated she was going to go home just over the hill. Staff were able to redirect her back to the secured unit. Review of Resident #37 ' s exit seeking event dated 05/16/24 revealed the resident was seen exiting the building but remained on the property. The resident did not have a wandering alert device in place. She had a cognitive memory impairment that affected safety and judgement but had the ability to learn door codes. The immediate measure taken included placement in the secured unit and changing the door codes. Review of the staff education on 05/16/24 revealed the ED sent a message to all employes indicating the code to the memory care unit had been changed. Staff were to ensure residents did not watch them enter the code and they were to remind families of this as well. Attached to the message was a list of staff indicating whether the message was received or not. 28 employees did not acknowledge they received the message and had no read time for the message. Review of Resident #37's interdisciplinary team note dated 05/17/24 revealed they reviewed the incident on 06/12/24 and noted that the exit door codes were changed to ensure resident's safety. Review of Resident #37's plan of care dated 06/12/24 revealed they demonstrated exit-seeking behaviors and wandering. Interventions included monitoring for wandering triggers such as need for toileting inactivity, and time of day, encouraging regular family contact or visits with others, provide structured routine to resident's day, resides on legacy lane for safe wandering, assess need for wander guard and apply as appropriate, offer diversional activities as needed, and re-direct resident away from doors/exits as needed. Observation on 06/17/24 through 06/20/24 revealed the code to the memory care unit was the same as listed on the 05/16/24 staff education. The keypad inside the memory care unit had no cover obscuring the numbers. Review of an e-mail on 06/18/24 at 6:16 P.M. from the ED verified the only exit seeking events for Resident #37 were completed on 02/12/24 and 05/16/24. Interview on 06/18/24 at 2:44 P.M. with CRCA #104 verified Resident #37 was able to learn and memorize the code to the memory care unit. Reported the memory care unit code was changed last time and for a while they were not telling family members, but some of the families did know the code. CRMA #104 reported due to Resident #37 ' s elopements she did not say the memory care code out loud anymore. Interview on 06/20/24 at 12:55 P.M. and 3:07 P.M. with the ED verified there was no exit seeking event for the 02/01/24 exit seeking incident. She reported an interview with the prior ED (who was employed at the time of the incident) indicated the intervention for the incident was putting the resident on one on one until the code was changed. She reported the physician or nurse practitioner was not notified of this incident because it was considered baseline behavior for residents on a locked unit. The ED reported following the 05/16/24 incident she implemented changing the code monthly and provided communication to staff that they should not enter the code when the resident is around. The education also included asking staff to inform families to do the same. The ED verified that the staff education did not indicate that all staff read the education. The ED was unable to identify how changing the code monthly would prevent the resident from learning it in the time between the code changing. The ED acknowledged that the care plan called for assessing for a wander guard, however, she stated that it was facility policy to not put wander guards on memory care residents. Review of the policy ' Guideline for Elopement or Missing Residents ' dated 12/31/23, revealed when a resident deemed an elopement risk is observed exiting the campus door the provider and responsible party were to be notified and an exit-seeking event form was to be completed. 3. Review of the medical record for Resident #29 revealed an original admission date on 03/14/19 and a readmission date on 06/16/23. Medical diagnoses included Alzheimer's Disease with early onset, malignant neoplasm of prostate, epilepsy, mixed receptive-expressive language disorder, unsteadiness on feet, repeated falls, and need for assistance with personal care. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #29 had impaired cognition and scored an eight out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #29 used a walker and a manual wheelchair. The resident required substantial assistance from staff with toileting and bathing, moderate assistance from the staff for dressing, bed mobility, and transfers, and supervision or touch assistance with ambulation. There were not any falls reported on the assessment. Review of the progress notes dated from 04/01/24 to 06/21/24 revealed Resident #29 had a witnessed fall on 04/06/24 and hit his head, a witnessed fall on 04/11/24 and hit his head, and a witnessed fall on 04/25/24 and did not hit his head. Review of the Event Report dated 04/06/24 at 2:50 P.M. and completed by Licensed Practical Nurse (LPN) #178 revealed Resident #29 was standing on his bed when had a fall. Resident #29 reported he hit his head. The fall was unwitnessed and neurochecks were initiated. Review of the Event Report dated 04/11/24 at 4:55 P.M. and completed by Registered Nurse (RN) #182 revealed Resident #29 was standing and talking with another resident when he had a fall. The fall was witnessed, and it was reported that Resident #29 hit his head. Neurochecks were initiated. Review of the Event Report dated 04/25/24 at 10:53 A.M. and created by LPN #167 revealed Resident #29 had a fall while attempting to clean himself up in the bathroom and slipped on water he spilled on the floor. Resident #29 denied hitting his head and the resident's roommate denied seeing the resident hit his head. Resident #29 did have an abrasion to his right upper leg/gluteal area. There was no further information provided related to the investigation of the fall. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated April 2024 revealed Resident #29 had an order for to complete neurochecks every four hours for five hours dated 04/06/24. The neurochecks were not completed at 1:45 A.M. or 5:45 A.M. Resident #29 had an order to complete neurochecks every 15 minutes for one hour dated 04/11/24. There was not a neurocheck completed at 6:00 P.M. Resident #29 had an order to complete neurochecks every four hours times five dated 04/11/24. There were not any neurochecks completed at 4:00 A.M., 8:00 A.M., 12:00 P.M., or 4:00 P.M. Interview on 06/24/24 at 3:45 P.M. with the Director of Health Services (DHS) and ED confirmed there was no evidence of a fall investigation being completed in Resident #29's medical record. The DHS and ED also confirmed neurochecks were not completed as ordered as listed above. Review of the facility policy, Fall Management Program Guidelines, dated 12/31/23, revealed the policy stated, should the resident experience a fall the attending nurse shall complete the Fall Event. This includes an investigation of the circumstances surrounding the fall to determine the cause of the episode, a reassessment to identify possible contributing factors, interventions to reduce risk of repeat episode and a review by the Interdisciplinary Team (IDT) to evaluate thoroughness of the investigation and appropriateness of the interventions. Any orders received from the physician should be noted and carried out. Care plan interventions should be implemented that address the resident ' s risk factors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to prevent, assess, adequately monitor and treat pressure ulcers. This affected four residents (#49, #53, #61, and #66) of four residents reviewed for pressure ulcers. The facility census was 69. Actual harm occurred on 07/11/23 when Resident #66, who was cognitively impaired, required extensive assistance from staff for bed mobility, had a pressure ulcer to the gluteal fold and had a left leg contracture was found to have a Deep Tissue Injury (DTI) (intact or non-intact skin with localized area of persistent, non-blanchable, deep red, maroon, or purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister) to the left heel with increased pain and without evidence of effective pressure ulcer prevention interventions in place for the resident's heels. The resident's heels were observed directly on the mattress during observation. Findings include: 1.Record review revealed Resident #66 was admitted to the facility on [DATE] with diagnoses including unstageable pressure ulcer right buttocks, hemiplegia and hemiparesis affecting left non-dominated side, type two diabetes mellitus with diabetic neuropathy, heart failure, and neuromuscular dysfunction of bladder. Review of Resident #66's physician's orders and treatment administration records revealed on 01/31/23 an order was written to offload the resident's left foot/leg to relieve pressure. A plan of care, dated 03/10/23 for skin integrity revealed the resident was at risk for skin breakdown related to receiving antiplatelet and diuretic medication, left side hemiplegia, incontinence of bowel/bladder and risk for malnutrition. Interventions included treatment to coccyx as ordered, avoid shearing, conduct weekly skin assessment, encourage to turn and reposition, float heels as needed and pressure reduction cushion in chair and mattress. A plan of care, dated 03/10/23 for activity of daily living (ADL) and resident's care guide revealed the resident required staff assistance to complete ADL tasks completely and safely due to left side hemiplegia, impaired cognition and poor safety awareness related to dementia and short term memory loss. The resident had bed rails for mobility, required a Hoyer (mechanical) lift for all transfers, and a wheelchair for transport. Review of Resident #66's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #66 had range of motion impairment to one side on the upper extremity and both sides of the lower extremity. The assessment revealed the resident required extensive assistance from two staff for bed mobility and was totally dependent on staff for transfers, dressing, locomotion, toilet use, personal hygiene, and bathing. The assessment reflected the resident had no pressure ulcers noted, however had pressure reducing device for her chair and bed, was receiving a nonsurgical dressing application, and application of ointment/medication to an area other than her feet. The resident was not receiving a treatment to her feet. Record review revealed a right heel assessment dated [DATE] which reflected Resident #66 had a scabbed area on the right heel measuring two centimeters in length by one centimeter (cm) width that was not present on admission. The nurse's description of the area noted it was pressure, statis, and a diabetic wound. An additional note indicated the area didn't have characteristics of a pressure sore; however, the aides reported the resident frequently had her foot in a position that could compromise the skin integrity. There was no evidence the resident was re-evaluated for additional pressure relieving interventions at this time. The next assessment, dated 06/22/23 revealed the resident had a right heel wound that measured three cm by two cm with 2.3 cm depth. The peri wound was described as being moist and macerated. The wound had a moderate amount of serosanguinous drainage, no odor present and the surrounding tissue was pink, and blanchable. Then there was second note, also dated 06/22/23 indicating the right heel was not a pressure ulcer but rather a scabbed area that was healed. Record review revealed no additional assessments or documentation of the resident's heel(s) after 06/22/23. On 07/10/23 at 4:15 P.M. observation of Resident #66's heels with Registered Nurse (RN) #107 revealed the resident's heels were not floated off the bed and there was dark purple non-blanchable area on the resident's left heel. The resident reported the area was very painful. The resident was noted to have her legs folded up under her in bed. The RN reported the resident left leg was contracted making it difficult to float her heels. Record review revealed no evidence this observed pressure ulcer was previously identified. The ulcer was discovered as a DTI. On 07/11/23 at 9:44 A.M. interview with the Director of Nursing (DON) revealed she was not previously aware of a pressure area to Resident #66's left heel but was told by staff the resident's heels were not floated off the bed during the surveyor's observation with RN #107. The DON verified the resident had a physician's order and plan of care with interventions to float the resident's heels. The DON reported the resident's left leg was contracted and it was hard for the resident to straighten out her left leg. The DON indicated possibly the nursing assessment completed on 06/16/23 was inaccurate and should have been for the left heel and not the right heel. The nurse had started an assessment on the right heel but the DON felt that was an error and should have possibly been for the left heel. The DON reported the resident had scabs originally on the left heel, however she did not feel scabs were pressure related. The DON provided no additional explanation as to what the areas of skin impairment would have been caused from if not pressure. The facility did not have a specific pressure ulcer prevention, identification or treatment policy and procedure. The DON only provided a copy of a book she had received during her training related to staging wounds. 2. Record review revealed Resident #66 was admitted to the facility on [DATE] with diagnoses including unstageable pressure ulcer right buttocks, hemiplegia and hemiparesis affecting left non-dominated side, type two diabetes mellitus with diabetic neuropathy, heart failure, and neuromuscular dysfunction of bladder. A plan of care, dated 03/10/23 for skin integrity revealed the resident was at risk for skin breakdown related to receiving antiplatelet and diuretic medication, left side hemiplegia, incontinence of bowel/bladder and risk for malnutrition. Interventions included treatment to coccyx as ordered, avoid shearing, conduct weekly skin assessment, encourage to turn and reposition, float heels as needed and pressure reduction cushion in chair and mattress. Review of the plan of care revealed it was not updated to reflect the development of any actual pressure ulcers for Resident #66. Review of Resident #66's medical record revealed the resident was being followed by an outside wound clinic for a pressure ulcer to the right gluteal fold. A visit note, dated 04/26/23 revealed Resident #66 had a Stage III (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss) pressure injury to the right gluteal fold that measured four-centimeter (cm) length by four cm width by four cm depth. The wound bed was full thickness, granulation, red and the peri-wound was excoriated and macerated. There was tunneling noted at the 7 o'clock position that was four cm. The wound had moderate amount of serosanguineous drainage. The wound clinic note revealed the ulcer had been present since 10/29/22. During this visit, a new dressing/treatment order was implemented to pack the wound with lightly moist Dakin's conform followed by gauze, abdominal dressing, and secure with tape daily and as needed if it becomes soiled was ordered. The resident was to return in three weeks on 05/15/23. The resident was seen by the physician assistant (PA) on 05/12/23. The PA reflected the resident had a Stage III pressure injury of buttock. New orders to follow-up with wound center as scheduled and obtain repeat wound culture of area due to history of pseudomonas. However, the wound culture was not collected until 05/18/23 (six days after being ordered by the PA). Review of Resident #66's wound clinic note dated 05/15/23 revealed the pressure ulcer to the right gluteal fold wound had deteriorated. The wound bed had bone exposure and slough. The peri wound was now non-blanchable, erythema, moist, and purple. The pressure ulcer measured 5.5 cm in length by 6.5 cm width with 2.7 cm depth. The wound was assessed to have stool in it and large amount of serosanguineous drainage. New treatment orders included to stop the Dakin's due to maceration of the wound and to cleanse the wound daily (normal saline/soap and water), pack wound with conform followed by gauze, abdominal dressing, and secure with tape. The dressing was to be changed daily and as needed if it becomes soiled. The resident was to return on 05/29/23. Review of the wound clinic note and facility documentation revealed no evidence of an investigation or determination as to why the ulcer had deteriorated at this time. There was no evidence the resident's skin needs were re-assessed at this time to ensure adequate and effective interventions were in place to promote healing and to prevent additional decline. In addition, review of the administration records revealed no evidence the facility implemented this new wound care order following the wound clinic visit on 05/15/23. The administration records from 05/15/23 to 07/10/23 revealed staff continued to cleanse the wound with wound cleaner/normal saline, lightly pack with Dakin's moist gauze, and apply abdominal dressing once daily. Review of Resident #66's wound culture results, dated 05/25/23 revealed the aerobic culture was positive for pseudomonas aeruginosa. The organism was susceptible to the antibiotics listed except for Ticarcillin (which it was resistant to). Record review revealed no evidence the PA or physician were notified of the wound culture results or evidence the resident was assessed for the need for an antibiotic based on the wound culture results. Review of Resident #66's wound clinic note dated 05/31/23 revealed the pressure ulcer to the right gluteal fold measured four cm in length by three cm width with 2.3 cm depth and had moderate serosanguineous drainage. The wound bed assessment was not legible. The treatment orders were to cleanse the wound daily with soap and water, pack wound with conform followed by gauze, abdominal dressing, and secure with tape. Change the dressing daily and as needed if it becomes soiled. The resident was to return on 06/28/23. Review of Resident #66's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #66 had range of motion impairment to one side on the upper extremity and both sides of the lower extremity. The assessment revealed the resident required extensive assistance from two staff for bed mobility and was totally dependent on staff for transfers, dressing, locomotion, toilet use, personal hygiene, and bathing. The assessment, which was inaccurate based on wound clinic and PA documentation, reflected the resident had no pressure ulcers noted, however had pressure reducing device for her chair and bed, was receiving a nonsurgical dressing application, and application of ointment/medication to an area other than her feet. The resident was not receiving a treatment to her feet. Review of Resident #66's wound clinic note dated 06/28/23 revealed the pressure ulcer to the right gluteal fold measured two cm in length by four cm width by 2.5 cm depth. The wound bed had slough and peri-wound was noted to have erythematous and moisture. The wound was draining moderate amount of serosanguineous drainage. There was no change in wound orders. Although the resident was being following for wound care by the outside wound clinic (approximately monthly), review of the facility wound assessments/documentation revealed no evidence facility staff assessed (including a description or staging of the pressure ulcer) weekly on 04/26/23, 05/04/23, 05/11/23, 05/18/23, 05/25/23, 06/01/23, 06/08/23 or 06/22/23. Further review revealed an order dated from 02/15/23 to 07/10/23 for staff to cleanse right buttocks with wound with cleanser or normal saline, apply Medi-honey, and cover with a foam dressing as needed. However, review of the administration records revealed there was no evidence the Medi-honey was applied from 05/01/23 to 07/10/23. Review of Resident #66's care plans revealed no evidence of an actual pressure ulcer plan of care. On 07/10/23 at 4:15 P.M. observation of Resident #66's buttocks with Registered Nurse (RN) #107 revealed the resident had an undated dressing on the right gluteal fold. RN #107 reported the DON called the wound clinic yesterday to update the physician due to the not receiving the correct treatment that was ordered. The RN reported she could not assess or describe the wound to the surveyor because she was not properly trained nor had she taken a wound certification class. The wound was difficult to observe due to poor lighting and the location of the wound. The wound appeared deep and tunneled. There was no drainage noted on the old dressing or signs of infection noted. Interview on 07/10/23 at 12:20 P.M. with the DON revealed she was also the facility wound nurse and had just taken a class on wound care but felt she had not been provided proper training on wound assessment, staging, or appropriate treatments. On 07/11/23 at 9:44 A.M. interview with the DON revealed she had not been completing wound assessments for Resident #66's right gluteal fold wound because she had been told by the corporate nurse the area was not pressure due to the location of the wound not being on a pressure point area, even though the PA and wound clinic had indicated the wound was a Stage III pressure injury. The corporate nurse was no longer employed by the facility. The DON reported she had called the wound clinic to inform them the resident Dakin's was not discontinued on 05/15/23 per the wound clinics orders and the facility had still been administering the Dakin's soaks in error. The DON also indicated the order for the use of Medi-honey as needed should have been discontinued months ago when the order was changed to Dakins'. On 07/11/23 at 12:10 P.M. interview with the DON confirmed Resident #66's wound culture was ordered on 05/12/23 and not obtained until 05/18/23, which was not timely obtained. The DON reported she had no evidence the wound culture had been addressed (as of this date) and she had since called the ordering PA who reported she did not recall reviewing the wound culture results or ordering antibiotics to treat the organism the culture was positive for. The PA reported she would probably have forwarded the wound culture to the wound clinic to let them treat the organism but could not state for certain. The DON then indicated there was no evidence the wound culture had been sent to the wound clinic for review/follow up. 3. Record review revealed Resident #61 was admitted to the facility on [DATE] with diagnoses including pressure ulcer, chronic kidney disease, anemia, heart failure. Review of Resident #61's skin integrity plan of care dated 09/22/21 and revised 05/11/23 revealed the resident was at risk for skin breakdown and pressure ulcer development related to weakness, requiring assist with her bed mobility, peripheral vascular disease, and incontinence of bowel and bladder. Intervention included to conduct weekly skin assessments. The care plan wasn't updated to reflect the resident's pressure ulcer to the sacrum. Review of Resident #61's quarterly MDS dated [DATE] revealed Resident #61 was at risk for developing pressure ulcers, totally dependent for bathing and required limited assist times one with eating, required extensive assist of two for bed mobility, transfers, and hygiene. Review of Resident #61's progress note dated 05/16/23 revealed the hospice aide informed the nurse about an open area on the resident's bottom. An area was noted in the mid/left upper coccyx. Hospice nurse gave orders to clean area with normal saline or wound cleanser, pat dry and cover with a dry clean dressing three times a week. Review of Resident #61's wound assessments revealed no evidence an initial comprehensive assessment of the pressure ulcer was completed on 05/16/23. Further review of Resident #61's wound progress notes dated 05/18/23 revealed the resident had a Stage II (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister) pressure ulcer to the sacrum that measured 2 cm by 2.5 cm by 0.2 cm. Hospice in agreement to cleanse area with wound cleanser, pat dry, then apply Medi- honey and cover with adhesive foam dressing and change every third day and as needed. Further review of Resident #61's wound management notes revealed on 05/30/23 the sacrum wound measured 1.0 cm by 1.5 cm by 0.01 cm and was a Stage II pressure ulcer. The wound bed was covered with 30% of slough. On 06/06/23 the wound remained a Stage II pressure ulcer that measured 1.0 cm by 1.3 cm by 0.1 cm with 10% of slough in the wound bed. On 07/06/23 the wound measured 1.0 cm by 1.0 cm and no depth was noted. Review of Resident #61's MAR/TAR revealed from 05/18/23 to 06/22/23 the order was to cleanse the sacrum wound with wound cleanser or normal saline, apply Medi-honey, and cover with foam dressing every three days and as needed. However, the frequency was entered every five days instead of every three days therefore during this time frame, the dressing was only changed every five days. On 06/22/23 the order was changed to cleanse the pressure ulcer with wound cleanser or normal saline, apply skin prep around the wound then apply bacitracin with zinc ointment, and cover with foam dressing every five days. Review of Resident #61's hospice notes dated 06/06/23 to 07/10/23 revealed hospice only measured the resident's sacrum pressure ulcer twice. On 06/27/23 the note indicated the resident had a Stage II sacrum pressure ulcer that measured 2.2 cm by 2.7 cm by 0.3. The wound bed was noted to have 20% slough. On 07/10/23 the wound measured 2.2 cm by 2.7 cm by 0.4 cm. Observation on 07/10/23 at 2:32 P.M., of Resident #61 with RN #107 and the DON revealed the resident had an open area the size of pea with depth on sacrum. The DON confirmed the wound had depth. Interview on 07/10/23 at 2:34 P.M., with the DON confirmed there was no comprehensive assessment completed on 05/16/23 when the area was discovered. The DON confirmed there were discrepancies in the depth of the wound due to sometimes she charted 0.1 and 0.01 or no depth. The DON confirmed the staging of the wound was inaccurate as well due to the wound had slough and according to staging recommendation a Stage II has no slough. The DON confirmed the dressing was not changed per orders because she had entered the frequency of Medi-honey as every five days, and it should have been changed every three days and the bacitracin should have been changed daily not every five days. The DON confirmed the care plan was not updated to reflect new sacrum pressure ulcer. 4. Record review revealed Resident #49 was admitted to the facility on [DATE] with diagnoses including Stage IV pressure ulcers, diabetes, heart failure, anemia, and necrotizing fasciitis. Review of Resident #49's wound clinic notes dated 05/24/23 revealed the resident was noted to have a Stage IV pressure ulcer on the sacrum that measured 1.5 cm by 1.5 cm by 4 cm that had moderate amount of foul-smelling serosanguineous drainage. Discharge instruction included to apply zinc to peri wound, lightly pack wound with aquacel rope followed by dry gauze and mepilex daily and as needed if it becomes soiled. Return in one week. Review of Resident #49's MAR/TAR dated May 2023 revealed no evidence treatment orders to apply zinc to the peri wound, lightly pack wound with aquacel rope followed by dry gauze and mepilex daily and as needed was completed. Review of Resident #49's wound clinic note dated 05/31/23 revealed the sacrum pressure ulcer measured 2.2 cm by 2.3 cm by 2.5 cm with undermining at 12 and 4 o'clock with a depth of 2.3 cm. The wound bed was red with slough and granulation. The resident required an Actigraft procedure. Discharge instruction included to leave mepitel and steri-strips in place for one week. Do not get wet. Change gauze and abdominal dressing. Review of Resident #49's progress note dated 06/01/23 revealed the wound center returned call at this time and stated the Actigraft was placed yesterday, and outer dressing is to be changed daily or as needed. Once dissolved continue to cover with dry clean dressing only until next appointment. Review of Resident #49's MAR/TAR dated June 2023 revealed no evidence the treatment order to leave mepitel and steri-strips in place for one week; do not get wet; change gauze and abdominal dressing was ordered was completed. Review of Resident #49's wound clinic note dated 06/13/23 revealed the sacrum pressure ulcer measured 2.4 cm by 2.0 cm by 3.5 cm with 3.0 cm undermining at 12 o'clock. Interview on 07/11/23 at 12:42 P.M., with the DON confirmed the wound clinic orders on 05/24/23 and 05/31/23 were not documented as being completed as ordered. 5. Record review revealed Resident #53 was admitted to the facility on [DATE] with diagnoses including pressure ulcer chronic kidney disease, heart failure, and left femur fracture. Review of Resident #53's hospital discharge orders dated 06/16/23 revealed to irrigate wound with Dakin's daily. The resident had a Stage IV pressure ulcer on the sacrum. Review of Resident #53's orders and TAR revealed to cleanse coccyx/sacrum pressure ulcer with wound cleanser or normal saline, soak gauze with Dakin's solution and lightly pack wound, cover with abdominal dressing, and change daily as needed. The resident's TAR for June 2023 and July 2023 revealed the wrong order was transcribed on the TAR and the resident's pressure ulcer was being treated by soaking gauze with Dakin's solution and lightly packing the wound instead of the correct order to irrigate the wound with Dakin's daily. Review of Resident #53's wound management report dated 06/22/23 to 07/06/23 revealed no evidence the stage of the sacrum pressure ulcer was assessed. Interview on 07/12/23 at 12:35 P.M., with the DON verified the wound orders were incorrectly transcribed on the TAR and the resident was not receiving the correct treatment to her sacrum pressure ulcer. The DON also confirmed the facility had not completed staging of the pressure ulcer. Observation on 07/12/23 at 12:42 P.M., with the DON revealed Resident #53 had dried and fresh drainage noted on a pillow placed under her feet while she was in bed. The DON reported the resident had an area on her right heel, but it had resolved. The surveyor asked to look at the resident's left heel. The resident had an open area noted on the left heel that was draining. The resident reported the area on the left heel had been there since the beginning of summer. The DON verified she was not aware of the pressure ulcer on the left heel. Review of Resident #53's medical record revealed no evidence of a pressure ulcer to the left heel. Review of the facility pressure ulcer staging guidelines (dated 2020) from the Wound Care Education Institute revealed a Stage II pressure ulcer was partial-thickness loss of skin with exposed dermis. Granulation tissue, slough, and eschar are not present. A Stage III pressure ulcer was full-thickness loss of skin in which fat is visible in the ulcer and granulation tissue and rolled wound edges are often present. Bone is not exposed. A Stage IV pressure ulcer was full thickness skin and tissue loss with exposed or directly palpable fascia, muscle tendon, ligament, cartilage, or bone in the ulcer. A deep tissue pressure injury was intact or non-intact skin with localized area of persistent, non-blanchable, deep red, maroon, or purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin color changes. This deficiency represents non-compliance investigated under Complaint Number OH00144145.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy and procedure review and interview the facility failed to develop and implement a comprehensive and individualized pain management program to provide adequate pain control for Resident #35. Actual harm occurred on 06/21/22 when Resident #35, who received Hospice services for terminal Parkinson's Disease, complained of continued, unrelieved pain despite scheduled and as needed narcotic pain medication doses, exhibited by verbal complaints of pain and moaning. The facility failed to comprehensively assess the resident's pain and notify Hospice services and/or the primary care physician regarding the resident's increased pain resulting in the resident being very restless and unable to get adequate rest due to increased pain despite additional dosages of as needed pain medication. This affected one resident (#35) of one resident reviewed for pain. The facility identified 12 residents receiving Hospice services and 50 residents on a pain management program. The census was 71. Findings include: Review of Resident #35's medical record revealed an admission date of 02/25/22 with diagnoses including metabolic encephalopathy, Parkinson's Disease, chronic kidney disease, kidney and ureter stones. The resident was also admitted with a pressure ulcer that was determined to be a [NAME] (terminal) ulcer by Hospice staff. Review of the admission Observation and Data Collection form, dated 02/25/22 revealed the resident did not report pain on admission to the facility. Review of the plan of care, dated 03/04/22 revealed the resident was at risk for pain related to acute pain, pressure ulcer and treatments, cervical disc degeneration and history of femur and pubis fracture. Interventions including notify physician of increased pain, observe for and record verbal and non-verbal signs of pain. Review of the Hospice team care plan (provided by the Hospice provider), dated 04/13/22 revealed the Hospice team was responsible for professional management of care in all settings as care related to the (resident's) terminal diagnosis and related conditions. The Hospice team was responsible for plan of care coordination with all contracted providers. Nursing, psych/social/pastoral care and volunteer visits as needed 24 hours per day for symptom management, emotional and spiritual support. Patient/caregiver informed of 24/7 access to all services and phone numbers provided. Review of the significant change Minimum Data Set (MDS) 3.0 assessment, dated 04/25/22 revealed the resident had moderate cognitive impairment and required extensive assistance of two staff to total dependence of one staff for activities of daily living. Further review revealed the resident occasionally had pain during the assessment and rated his pain an eight on a 1-10 pain scale, which indicated a moderate pain level and staff relied on non-verbal indicators such as protective body movements and vocal complaints of pain. The assessment revealed the resident received opiate pain medications seven days during the assessment period. Review of the physician's orders revealed the resident had an order, dated 04/13/22 for the pain medication, Oxycodone 7.5 milligrams (mg) every two hours as needed for pain and an order, dated 05/04/22 for Oxycodone 10 mg one tablet orally every four hours. The Oxycodone 10 mg was scheduled at 12:00 A.M., 4:00 A.M., 8:00 A.M., 12:00 P.M., 4:00 P.M. and 8:00 P.M. A plan of care, dated 05/09/22 revealed the resident was receiving Hospice services for terminal diagnosis of Parkinson's disease. Interventions included to administer drugs as needed for palliation per physician orders, administer pain medication as ordered and as needed, communicate with Hospice when any changes were indicated to the plan of care, coordinate care with the Hospice provider with the contact number and address of Hospice provided. On 06/21/22 at 5:15 P.M. interview with Resident #35's son revealed he wanted to ensure the resident's pain was controlled and he was comfortable. The son stated there were recent issues with the resident's pain control and the resident having extreme pain. Review of a progress note, authored by Registered Nurse (RN) #385, dated 06/21/22 at 10:03 P.M. revealed the resident was moaning out in pain. Scheduled pain medications given with negative results noted. As needed pain medications given twice with negative results noted. One on one and repositioning negative. The resident complained of pain in his kidneys, back and all over. The resident refused dinner, offered and accepted fluids. The note indicated this nurse would continue to monitor. Review of a progress note, authored by RN #385, dated 06/22/22 at 12:00 A.M. revealed the resident continued to complain of pain. This nurse administered scheduled pain medications with an additional dose of as needed (PRN) pain medications after one on one, toileting and repositioning were ineffective. The resident stated his hips felt like they were breaking through his skin. The resident stated he was miserable. The note revealed the nurse provided fluids to the resident. The resident continued to have no urine output at this time. Further review of the progress note, dated 06/22/22 at 4:07 A. M. revealed the resident continued to moan in discomfort while laying in bed. The resident continued to have zero urine output at this time. The nurse completed a bladder scan with results of greater than 400 milliliters of urine in the bladder. A urinary catheter was inserted per order due to urinary retention. The resident tolerated the procedure with greater than 400 milliliters of milky yellow urine obtained. The urine was noted to have a large amount of sediment upon return. The note revealed the nurse medicated the resident with scheduled pain medication as well as a dose of the PRN pain medication. The resident stated the pain was still terrible. The resident remained alert and able to make his needs known during the night. The resident was very restless and unable to get adequate rest due to increased pain despite additional dosages of PRN pain medication. On 06/22/22 at 5:25 A.M. Hospice was notified of the change in resident condition as well as increased pain. The nurse asked for a possible re-assessment for the need of Morphine pain medication. Awaiting a return call from the hospice nurse. Further review of the progress notes revealed no additional documentation regarding the Hospice notification or the resident's pain until 06/22/22 at 2:25 P.M. when RN #309 documented the Hospice nurse visited and a new order was received to change the resident's scheduled pain medication and increase the dosage of the PRN Oxycodone. Review of the PRN Oxycodone doses revealed staff documented the resident received additional Oxycodone on 06/21/22 at 5:31 P.M. (effective), 10:03 P.M. (effective); 06/22/22 1:14 A.M. (effective) and 3:35 A.M. (effective). However, the effectiveness documented on the PRN medication sheets were not reflective of the narrative nurse progress notes documented in the medical record. On 06/23/22 at 12:40 P.M. interview with Hospice Registered Nurse (RN) #401 revealed she visited Resident #35 from Hospice and revealed Hospice staff were unaware of the resident's continued complaints of unrelieved pain until 06/22/22 during the 5:00 A.M. hour when the Hospice triage nurse was notified. RN #401 verified Hospice was not updated on the intensity of the resident's pain or his inability to rest during the night and the message relayed was not as stated in the facility nurse's progress notes. RN #401 indicated had this been described to the triage nurse, Hospice would have visited the resident sooner for his pain management. RN #401 revealed the Hospice goal for Resident #35 was to achieve the best level of pain control for the resident as possible. RN #401 revealed the resident would never be pain free due to his chronic pain but Hospice wanted the resident as comfortable as possible. RN #401 revealed the resident received scheduled Oxycodone (narcotic pain medication) every four hours and Oxycodone every two hours as needed. RN #401 revealed the facility staff were told hospice could be called any time, day or night, if they need to report something or the resident needed anything and the expectation would be the same for uncontrolled pain. Further interview revealed, for a Hospice resident with uncontrolled pain, offering food and fluids would be an ineffective intervention to attempt and if he was having issues with pain control as indicated in the progress notes, a call should have been placed to the triage nurse to evaluate the resident and hopefully get new orders and something different for pain control started sooner. The RN also revealed there were always options for Hospice patients for pain control and if the resident was not achieving comfort, he should not have been left in that amount of pain for the night, affecting his ability for rest. Lastly, the RN stated residents with Hospice services needed to have the best pain control possible and verbalizations of unrelieved pain and/or moaning indicated the resident did not have the best pain control for him. RN #401 revealed the resident's pain management regimen was changed to longer acting medications and a higher dose of Oxycodone every two hours, as needed, to prevent additional issues with pain management. On 06/23/22 at 3:28 P.M. interview with the Assistant Director of Nursing verified the progress notes indicated the resident had uncontrolled pain and the nurse working should have contacted Hospice for the resident before the end of her shift to ensure the resident had effective pain management. The ADON revealed the nurse should have called the primary care physician if Hospice wasn't available but indicated Hospice was available with an on-call nurse after hours seven days a week. The ADON also verified there was no comprehensive pain assessment completed with the resident's uncontrolled pain on 06/21/22 into 06/22/22. The ADON verified the facility pain management policy required a comprehensive pain assessment be completed with changes in pain and the plan of care indicated the physician or hospice should be contacted with changes in pain. Lastly, the ADON verified the nursing progress notes indicated the resident had severe, uncontrolled pain affecting his quality of life and his ability to sleep and/or rest with a terminal diagnosis. The ADON also verified there was no evidence the primary care physician was notified. On 06/23/22 at 5:06 P.M. interview with RN #309 revealed she was the nurse who relieved night shift on 06/22/22. The night shift nurse reported the resident had excruciating pain throughout the night. The Hospice nurse came that day and ordered medication changes. The RN verified Resident #35's pain was usually controlled and it was unusual for him to have uncontrolled pain like he had during the shift. Attempts to reach RN #385 during the survey process were unsuccessful. Review of the Guidelines for Pain Observation and Management Policy, dated 05/11/16 and revised 05/23/17 revealed the purpose of the policy was to ensure each resident's pain including it's origin, location, severity, alleviating and exacerbating factors, current treatment and response to treatment was observed and documented according to the needs of each individual. If there was a change in pain indicators or verbalizations from resident, a pain event form would be completed to indicate changes and care plan update. Educate the resident/family/care givers on the pain management interventions and importance of notifying staff of changes in pain status. Implement the care plan approaches to assist with pain management. Evaluate the effectiveness of pain management interventions and modify as indicated.