Every finding on record at Citadel of Northbrook, The

Based on interview and record review, the facility failed to meet a resident's need to have two staff assist while being provided incontinence care per the resident's assessed needs. This failure applied to one (R38) of three residents reviewed for falls and resulted in R38 sustaining a fall while being provided incontinence care that resulted in fractures to the right fourth and fifth ribs and a 6.5-centimeter infrapatellar subcutaneous hematoma to the right knee.Findings include:R38 is a [AGE] year-old female admitted to the facility on [DATE] with the diagnoses including but not limited to obesity, heart failure, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, chronic obstructive pulmonary disease, and seizures.On the (MDS) Minimal Data Set assessment of 11/06/2025, section C, the BIMS (Brief Interviewed Mental Status) score was 15/15, indicating cognitive intact. On MDS of 10/03/2025, GG section R38 is dependent for toileting hygiene. The helper does all the effort. The resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity. Section GG for Roll left and right: The ability to roll from lying on the back to the left and right side and return to lying on the back on the bed. R38 is Substantial/maximal assistance - Helper does more than half the effort. The helper lifts or holds the trunk or limbs and provides more than half the effort.On 12/10/2025 at 09:13 AM, R38 said, I fell on [DATE], and V14(Certified Nursing assistant) was helping me change my brief because I was dirty, V14 first cleaned my front and turned me to my left side towards the door, and V14 stayed on my right side and rolled me. I had my left hand holding the headboard to help with the turning, and I felt my fingers sliding out. I tried to hold myself, but I fell face forward. They called 911 and sent me to the hospital, and I had rib fractures and a badly injured right knee. My right side was really bruised up. I hit my head on the nightstand, and I still have bruises on my face and forehead. V14 was changing me by herself and did not get any assistance. I cannot use my right arm at all because of the stroke, and I requested a side rail for my bed, but I only received it after I had a fall.On 12/09/2025 at 2:00 PM, V14 (Certified Nursing assistant) said, I was providing care to R38 and turned her towards the door to change her brief. I was trying to wipe her and she tried to reach for something and fell facing down. I was changing her brief by myself and she fell face forward. I was not able to hold her to prevent the fall. I did not call anyone to assist me with her care.On 12/09/2025 at 3:00 PM, V15 (Registered Nurse) said that when V14 called her to the room, R38 was already on the floor and she called 911 and sent her to the hospital. R38 was alert but had a hematoma on her head and complained of pain to her chest and right knee. R38 is dependent on care and V14 was helping her to get changed when R38 fell.On 12/10/2025 at 9:32 AM, V13 (Restorative Nurse/Fall Coordinator) said, I usually review falls, update the care plan, and complete the root cause analysis. R38 is dependent on her toileting needs and substantial/maximum assistance for left-to-right turn mobility and requires two staff assists during care. During the fall, only one certified assistant was providing care. R38 requires two assists during the care.On 12/10/2025 9:25 AM, V3 (Director of Nursing) said, R38 went to the hospital after a fall and had a rib injury and the facility has a restorative/fall coordinator. We meet with the Interdisciplinary team to discuss falls daily and I updated the care plan.Hospital records dated 10/24/2025 reviewed and computerized tomography of the chest noted with Possible right fourth and right fifth ribs and computerized tomography of the right knee showed a 6.5-centimeter infrapatellar subcutaneous hematoma to the right knee. Per hospital V20(Physician)'s notes, R38 has a nondisplaced fracture of the right fourth and fifth lateral/anterolateral ribs.On 12/10/2025 10:23 AM, V2 (Assistant Administrator) provided facility policy titled: Fall, Fall Risks and Managing, Revised March 2018. Which includes: Based on previous evaluation or current data, the staff will identify interventions related to the resident's specific risk and causes to try to prevent the resident from falling and try to minimize complications from falling.Fall Risks factors2. Residents conditions that may contribute to the risks of falls:Functional impairmentResident-Centered Approach to manage falls and Fall RisksIf a system evaluation of a resident's fall identifies several possible interventions, the staff may choose to prioritize interventions.

Based on observation, interview, and record review, the facility failed to ensure that Permethrin External Cream 5% was administered with adequate indication for use for five (R28, R35, R77, R87, and R107) of five residents reviewed for medication administration.Findings include:R28 is an [AGE] year-old male who originally admitted to the facility on [DATE] and continues to reside in the facility. R28 has multiple diagnoses including but not limited to the following: dementia, anxiety, glaucoma, CAD, HTN, and osteoarthritis.R35 is an [AGE] year-old female who originally admitted to the facility on [DATE] and continues to reside in the facility. R35 has multiple diagnoses including but not limited to the following: osteoarthritis, psychosis, anxiety, HTN, and dementia.R77 is a [AGE] year-old female who originally admitted to the facility on [DATE] and continues to reside in the facility. R77 has multiple diagnoses including but not limited to the following: dementia, HTN, abnormalities of gait, depression, Alzheimer's disease, and anxiety.R87 is a [AGE] year-old female who originally admitted to the facility on [DATE] and continues to reside in the facility. R78 has multiple diagnoses including but not limited to the following: COPD, type II DM, CHF, hypoxic ischemic encephalopathy, depression, dementia, and HTN.R107 is a [AGE] year-old male who originally admitted to the facility on [DATE] and continues to reside in the facility. R107 has multiple diagnoses including but not limited to the following: quadriplegia, psychosis, osteoarthritis, dementia, depression, and HTN.Per physician orders dated 12/7/2025, R28, R35, R77, R87, and R104 were all treated with Elimite External Cream 5% (Permethrin) with directions to apply to neck to toes topically one time only for prophylactically.Permethrin Cream description shows it is a topical scabicidal agent for the treatment of infestation of scabies. It is to be noted that R28, R35, R77, R87, and R104 were never diagnosed or had a confirmed case of scabies.On 12/8/2025 at 2:49PM, V7 (Nurse Practitioner) said on 12/7/2025 the staff had mentioned to me that multiple residents had a generalized rash. I recommended Permethrin for all of these residents, but I do not suspect scabies.On 12/9/2025 at 11:30AM, V10 (Pharmacist) said Permethin 5% Cream is only indicated for a positive case of scabies.At 2:40PM, V8 (Nurse Practitioner) said when a resident has a generalized rash like this, I typically treat it with hydrocortisone cream, loratadine, or maybe even a topical steroid. If a resident had a scabies rash would be able to see tunneling, tracking, or burrowing especially on the hands and lumps under the skin.At 3:10PM, this surveyor and V8 observed R77's skin. V8 said this does not look like scabies. It looks like dermatitis or possibly a reaction to something such as soap or laundry detergent. I will most like prescribe loratadine to help with the itching.At 3:10PM, this surveyor and V8 spoke with R87. R87 said I do not have a rash at all, they just prescribed me Permethrin because I came in contact with other residents with a rash.V7's progress notes for R28, R35, R77, R87, and R104 dated 12/7/2025 all state in part but not limited to the following: Noted with generalized rash, no track marks. No concern of transmission such as scabies; however rash is generalized and will try to see if rash responds. Skin is dry, rash is flat.

Based on observation, interview, and record review the facility failed to provide dignity to resident while feeding. This deficiency affects one (R105) of three residents in the sample of 26 reviewed for Dignity Findings include: On 02/18/25 at 11:54 AM, R105 observed in dining room. On 02/18/25 at 11:56 AM, V16 (Certified Nurse Aide) observed feeding R105 while standing over resident. V16 said that he is aware that he needs to be sitting down to feed R105, said he had no chair available. On 2/18/25 at 11:59 AM, V15 (Unit Manager) said that all staff feeding residents should be sitting next to resident and not stand over the residents, chairs are available in dinning room. On 02/19/25 at 1:36 PM, V2 (Director of Nursing) said that staff should provide feeding assistance to resident while sitting next to resident to be at eye level and provide dignity to resident. Hand hygiene to performed before and after. Facility's policy on Assistance with Meals revised July 2017 Policy: Resident shall receive assistance with meals in a manner that meets the individual needs of each resident. Procedure: Dining Room Residents: 3. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: a. Not standing over residents while assisting with meals Facility's Policy on Residents Rights revised December 2016 Facility Statement: Employees shall treat all residents with kindness, respect and dignity. Policy Interpretation and Implementation 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident right to: a. a dignified experience. b. be treated with respect, kindness and dignity.

Based on observation, interview, and record review the facility failed to implement its policy on resident self-administration by failure to perform an assessment conducted by IDT (Interdisciplinary Team) to determine safe self-medication administration of resident. The facility failed to obtained physician order for resident self-medication administration. The facility failed to ensure storage of medication in locked box in the resident room. The facility also failed to document, and care planned of resident self-administration of medication. This deficiency affects one (R36) of three residents in the sample of 26 reviewed for Resident Self-medication administration. Findings include: On 2/18/25 at 11:46AM, Observed R36 on semi-sitting position in bed with V13 RN (Registered Nurse). R36 is alert and oriented x 3 and can verbalize needs to staff. Observed eye drop medication unlabeled at bedside tray table. She said that it is her eye medication- Refresh eye drops, that she uses every 5 minutes due to severe eye dryness. She said that she has eye problems such as glaucoma and macular degeneration. She has been taking her own medication since last month. She said that nurses are aware that she uses her own eye medications at bedside. V13 RN said that she is aware, but she didn't document the eye medication that R36 is taking at bedside. V13 RN said that resident can do self-medication administration if there is an order from her primary care physician. On 2/18/25 at 11:49AM, Reviewed R36's medication administration record and active physician order sheet with V13 RN. No order of refresh eye medication found in chart and no order of resident self-medication administration. No self medication administration assessment done. Informed V4 Unit Manager/ ADON (Assistant Director of Nursing) of concerns identified and requested for Resident self-administration policy. On 2/18/25 at 12:17PM, V3 DON said that the resident can self-administered medication if he/she is alert and oriented and can self-administered. There should be also a physician order and resident self-medication assessment done by IDT (Interdisciplinary Team). Facility's policy on Self-Administration of Medications revised [DATE] indicated: Policy: Resident have the right to self-administer if the IDT has determined that it is clinically appropriate and safe for the resident to do so. Procedure: 1. As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. 2. In addition to general evaluation of decision-making capacity, the staff and practitioner will perform a more specific skills assessment, including but not limited to the resident's: a). Ability to read and understand medication labels b). Comprehension of the purpose and proper dosage and administration time for his or her medications d). Ability to recognize risks and major adverse consequences of his or her medications 6. For self- administering residents, the nursing staff will determine who will be responsible for documenting that medications were taken. 8. Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents. 9. Staff shall identify and give to the charge nurse any medications found at bedside that are not authorized for self-administration, for return to the family of responsible party.

Based on observation, interview, and record review the facility failed to ensure not to use multilayers of linen over the low air loss mattress as manufacturer recommendation to resident with Stage 4 pressure ulcers. This deficiency affects one (R30) of three residents in the sample of 26 reviewed for Wound care management. Findings include: On 2/19/25 at 9:57AM, Observed R30 lying on bed with Low air loss mattress. V19 said R30 has pressure ulcers, and the Wound care nurse does her wound dressings. V19 RN checked the linens over the LAL (Low air loss) mattress. Observed flat sheet and a folded linen in quarters over the mattress. R30 is wearing disposable brief. V19 said that R30 should only be on flat sheet over the LAL mattress. On 2/19/25 at 11:07AM, Informed V3 DON (Director of Nursing) of above observation. She said that resident on LAL mattress should only have flat sheet over the mattress. On 2/20/25 at 10:59AM, Observed R30 has flat sheet and folded linen over the LAL mattress. R30 wears disposable brief. Showed V10 Wound Care Nurse of observation made and informed her that V3 DON said that R30 should only have flat sheet over the LAL mattress. Observed V10 WCN and V5 Restorative Aide performed wound dressing to R30. V10 said R30 has stage 3 pressure ulcer on right upper back. It has minimal wound serosanguinous drainage clean pink 100% granulation. V10 said that R30 has stage 4 pressure ulcer on sacrum it has 60% slough formation and 40% pink granulation. R30 is admitted on [DATE] with diagnosis listed in part but not limited to Stage 3 Pressure ulcer on right upper back, Stage 4 pressure ulcer on sacral region. Active physician order sheet indicates right upper back - cleanse with NS (normal saline), pat and dry, apply Medi-honey, apply silver alginate and foam dressing daily and as needed. Sacrum- cleanse with wound cleanser, apply hydrogel, alginate and cover with foam dressing daily and every 8 hours as needed. Wound assessment report dated 2/17/25 indicated: Sacrum- facility acquired stage 4 pressure ulcer identified on 5/28/24, measures 6 x 9.5 x 1.20cm, 90% red/pink tissue, 10% loosely adherent slough, heavy serosanguinous drainage. Right upper back-facility acquired stage 3 pressure ulcer identified on 9/20/24, measures 2 x 2 x 0.70cm, 100% pink/red tissue, heavy serous drainage, present undermining-9 o'clock to 11 o'clock/3.00cm. Intervention: pressure redistribution mattress per facility policy/protocol. Facility did not provide policy on low air loss mattress. Facility's policy on Support Surface Guidelines revised September 2013 indicates: Purpose: to provide guidelines for the assessment of appropriate pressure reducing and relieving devices for residents at risk for skin breakdown Steps in the procedure: 1. Any individual at risk for developing pressure ulcers should be placed on a redistribution support surface, such as foam, gel, static air, alternating air or air loss or gel when lying in bed.

Based on observation, interview and record review, the facility failed to ensure that an ongoing assessment is rendered to identify change in limitation of a resident's left-hand range of motion. This deficiency affects one (R52) of three in a sample of 26 reviewed for Restorative nursing program. Findings include: On 2/18/2025 at 12:30 PM, observed with V5 (Restorative CNA) that R52 has a left-hand flexion contraction with no hand splint applied. V5 said that R52 should have a hand splint applied. On 2/20/2025 at 10:53 AM, V5 said that R52 is in bed mobility program, but she first observed R52's left-hand flexion contraction with the surveyor. V5 said that she notified V14 (LPN) and V9 (Restorative Nurse). On 2/18/2025 at 12:40 PM, showed observation made to V14 (LPN) that R52 has a left-hand flexion contraction. V14 said that R52 should have a splint applied to her left hand. On 2/20/2025 at 10:00 AM, V9 (Restorative Nurse), said that when V9 assessed R52 on 1/17/2025, V9 did not observed any limitation on range of motion (ROM) on R52 left hand. V9 said that decrease in R52's left-hand range of motion was reported to her after the surveyor's observation. V9 said that she assessed R52 and noted the decrease ROM and referred to occupational therapy for further evaluation. On 2/21/2025 at 10:11 AM, V2 (Director of Nursing) said that her expectation is that when the restorative staff are providing restorative program to report any changes in range of motion to the nurse, their chain of command so that the resident will be referred for appropriate treatment. On 02/21/2025 at 10:50 AM, V23 (OTR/L) said that he evaluated R52 on 2/19/2025 based on referral due to decreased ROM. R52's Occupational Therapy OT Evaluation & Plan of Treatment Certification Period: 2/19/2025 - 3/20/2025 R52 have a diagnosis but not limited to spinal stenosis, site unspecified, and other lack of coordination. Musculoskeletal System Assessment: UE ROM - LUE ROM = Impaired. LUE ROM - Shoulder = Impaired; Elbow/Forearm = Impaired; Hand = Impaired; Thumb = Impaired. Finger = Impaired; Middle Finger = Impaired; Ring Finger = Impaired; Little Finger = Impaired. RUE Strength = Impaired . LUE Strength = Impaired. RUE Strength Shoulder = Impaired; Elbow/Forearm = Impaired; Wrist = Impaired. LUE Strength Shoulder = Impaired; Elbow/Forearm = Impaired; Wrist = Impaired Facility Policy Functional Impairment - Clinical Protocol Assessment and Recognition 3. The staff and physician will identify individuals with potential for significant improvement in function or significant decline in function, including the ability to perform activities of daily living (ADLs).

Based on observation, interview, and record review the facility failed to use appropriate infection control practices during feeding assistance and perform hand hygiene. This deficiency affects two (R30, R67) of three residents in the sample of 26 reviewed for Infection control protocol. Findings include: On 02/18/25 at 12:00 PM, R67 observed in dining area. On 2/18/25 at 12:00 PM, V17 (Registered Nurse) observed feeding R67 and then observed feeding another resident at the same table and no hand hygiene performed in between. V17 said that she knows she has to feed one patient at a time and said that she did not perform hand hygiene after feeding one resident and going to another. On 02/18/25 at 12:09 PM, V15 (Unit Manager) said all staff should perform hand hygiene before and after assisting with feeding resident. Hand sanitizer is available in unit and sink available to wash hands in dinning area for hand hygiene. On 02/19/25 at 1:36 PM, V2 (Director of Nursing) said expectation of staff when feeding resident is to perform hand hygiene before and after feeding resident and when touching surfaces, staff should be sitting down when feeding resident to be at eye level of resident. Facility's policy on Hand hygiene revised August 2015 Policy: This facility considers hand hygiene means to prevent the spread of infections. Procedure: 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help the spread of infections to other personnel, residents, and visitors. 6. Use an alcohol-based and rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: p. Before and after assisting a resident with meals. 39781 On 2/18/25 at 12:39PM, Observed R30 on semi- sitting position in bed, while V18 CNA (Certified Nurse Assistant) standing on the right side of bed, feeding R30. V18 only wears gloves, and her clothes touches the side rails of the bed. R30 is on enhanced barrier precaution (EBP). V18 said that it's okay for her just to wear gloves since she is only feeding. V13 RN (Registered Nurse) said that V18 CNA should wear additional PPE (Personal Protective Equipment) such as gown and mask because she has direct contact with resident when feeding. On 2/18/25 at 1:30PM, V3 DON (Director of Nursing) said that the infection preventionist is on vacation and she is responsible while she is out. V3 said that V18 CNA should wear appropriate PPE when feeding resident on EBP such as mask, gloves, and gown. Facility's policy on Enhanced Barrier Precaution (EBP) revised March 2023 indicates: EBP may be indicated for resident with the following: *Indwelling medical devices *Wound requiring a dressing Definition used in EBP implementation: * High contact resident care activities What are EBP? * EBP expands the use of PPE beyond situations in which exposure to blood and body fluids is anticipated *EBP falls between standard precaution and contact precaution on the continuum of care *EBP requires use of gown and gloves when performing high- contact resident care activities What PPE is required? *Gown and gloves every time with high contact activities *PPE is required when performing high contact resident care activities 40001 On 2/18/2025 at 11:58am this writer observed V22 (Certified Nursing Assistant-CNA) in the second floor dining room distributing out lunch trays to residents, moving wheelchairs into the dining room, placing bibs on resident's and feeding resident's with out using hand sanitizer or hand washing. On 2/18/2025 at 12:15pm V22 said it is other staff members in the dining room also they will be here soon. On 2/18/2025 V2(Director of Nursing-DON) said their should be a nurse, a CNA and a restorative aid in the dining room at all times during meals, and I expect all employees to wash their hands, between touching residents, sanitize between passing trays, when touching wheelchairs and assisting with meals. On 2/20/2025 at 9:30am V22 said I should have washed my hands when touching other residents and wheelchairs and use hand sanitizer between distributing out meal trays and assisting with meals.

Based on observation, interview, and record review the facility failed to post [NAME] program information that is in an accessible and visible location to the resident in the facility. This deficiency affects 77 residents eligible for [NAME] Program. Findings include: On 2/18/25 at 10:39AM, V1 Administrator said that they have 3 residents enrolled in the [NAME] Program. V1 said that [NAME] program information is posted in all 3 units. V1 said that social services are responsible for the [NAME] program, but she is responsible to ensuring that [NAME] program information are posted in all units, visible to all residents. Rounds made with V1 to look for [NAME] Program posting. No posting found in the front desk/front lobby. No posting was found in the Medbridge and Arcadia unit (first floor). Posting was found by the nursing station of Brookview unit (2nd floor). On 2/19/25 at 10:00AM, V1 Administrator said that there are 77 residents out of 132 residents in the facility that are eligible for [NAME] program. Facility's policy on Discharge planning, protocol and procedure indicates: Services available in [NAME] County under the [NAME] Council Decree: The facility shall provide educational materials and information to newly admitted [NAME] Class members within the designated time frames, notifying them of their rights and services under the [NAME] Consent Decree. The facility shall conspicuously display in a public and accessible location, a Department provided poster informing residents of their right to explore or decline community transition, and their right to be free from retaliation, regardless of their decision on transition.

Based on interviews and record reviews, the facility failed to provide effective supervision to prevent an avoidable fall for one resident (R1) exhibiting increased confusion/agitation/wandering due to dementia and low blood sugar levels. This affected one of three residents (R1) reviewed for fall prevention. This failure resulted in R1 being involved in a fall incident sustaining a right femur fracture. Findings include: R1's medical record notes R1 with diagnoses including, but not limited to, diabetes, unsteadiness on feet, abnormalities of gait and mobility, lack of coordination, and weakness. R1's MDS (minimum data set), dated 3/14/24, notes R1's BIMS (brief interview of mental status) score was 5 out of 15. R1 required partial assistance with bed mobility. R1 required substantial assistance with toileting, transfers, and bathing. Per CMS (Centers for Medicare and Medicaid Services) a BIMS score 0-7 notes severe cognitive impairment. R1's care plan, initiated 3/8/24, notes R1 is at risk for falls related to gangrene left toes, unsteadiness on feet, abnormalities of gait and mobility, lack of coordination, weakness, and reduced mobility. R1's physical therapy evaluation, dated 3/8/24, notes R1 presents with balance deficits, body awareness deficits, decreased static/dynamic balance, and strength impairments. On 5/15/24 at 2:05 PM, V5 (Rehabilitation Director) stated R1 was receiving physical therapy from 3/8/24 - 4/9/24. V5 stated R1 was able to walk with a front wheeled walker and contact guard assistance. V5 stated R1 was not able to walk without a walker. V5 stated R1 needed verbal cues for hand placement on walker with ambulation. On 5/15/24 at 2:30 PM, V4 CNA (certified nurse aide) stated V4 was working on the other wing of the nursing unit. V4 stated V4 went onto the wing R1 resides on and was looking for the lift device. V4 stated V4 observed the lift device halfway down the hall near R1's room and retrieved it. V4 stated V4 heard something as he was pushing the lift device near the nurses' station. V4 stated when he looked back, he saw R1 on the floor by a resident's door. V4 stated he was not sure if was R1's room or not. V4 stated he was not paying attention to the surroundings prior to R1's fall. V4 denied seeing a walker near R1. On 5/15/24 at 2:45 PM, V3 RN (registered nurse) stated on 4/10 about 8:00 PM, V3 heard a commotion and saw V4 CNA with R1. V3 stated R1 was laying on the floor halfway in another resident's room and halfway in hall. V3 stated V3 did not know R1 walked, R1 was usually in bed or wheelchair when V3 works. V3 stated on day R1 was more confused than usual. V3 stated R1 was looking for her brother. V3 stated prior to 4/10, R1 was alert and oriented x 1-2. V3 stated V3 was not informed by off-going nurse of R1's increased confusion. V3 stated prior to the fall, R1 was sitting in wheelchair in her room. V3 denied seeing a walker in R1's room or near R1 at time of fall. On 5/16/24 at 1:30 PM, V8 NP (nurse practitioner) stated residents have dementia and are experiencing hypoglycemia might not be able to tell staff how they are feeling. V8 stated with these residents must rely more on what resident exhibits. V8 stated these residents will exhibit agitation and increased confusion. V8 stated R1's blood sugar was low on 4/10, it was 37. V8 stated she held R1's insulin to see if R1's agitation and confusion would improve. V8 stated residents with dementia may also exhibit sundowning (increased confusion and restlessness) in the evenings. V8 stated R1's dementia, hypoglycemia, and sundowning contributed to R1's fall. On 5/16/24 at 2:40 PM, V7 CNA stated V7 worked 3:00 PM -11:00 PM shift on 4/10/24. V7 stated R1 was having more that confusion day. V7 stated earlier in shift, R1 was wandering on the nursing unit looking for her brother. V7 stated R1 was able to self-propel in wheelchair. V7 stated before dinner V3 RN instructed V7 to bring R1 to her room. When questioned if R1 preferred to eat meals in her room rather than in the dining room, V7 responded, No, it is just the routine. V7 denied R1 exhibiting any wandering behaviors prior to day. V7 stated V7 was just finishing his dinner break when another CNA got him and informed him R1 fell . V7 stated R1 stated she was looking for her son, R1 heard his voice and thought he was in the other room. V7 stated after V3 assessed R1, V3 instructed V7 to put R1 in bed. V7 denied seeing a walker in R1's room or near R1 at time of fall. R1's hospital medical record, Hospital record, dated 4/10/24-4/13/24, notes x-ray of R1's right hip shows an acute valgus (deformity in which an anatomical part is turned outward to an abnormal degree) impacted fracture of the right femoral neck. No evidence of dislocation. Mild degenerative changes in the hips. On 4/11/24, R1 was taken to surgery for repair of fracture. R1's medical record, dated 4/10/24 at 2:36pm, V6 LPN (licensed practical nurse) noted R1 has been confused and agitated since yesterday (4/9/24). R1's medical record, dated 4/10/24 at 2:45pm, V8 NP (nurse practitioner) notified by V6 LPN R1 has been confused and agitated since yesterday evening. R1 seen in dining room. Confused. Believes her sister/family members are in the room and need help. Needs frequent orientation as she is trying to get up. Glucose 37 (normal range is 70-99) on laboratory results this morning; point of care glucose 75 at 6:00 AM. Confusion likely related to hypoglycemia; will consider urinalysis if there is no improvement. R1's medical record, dated 4/10/24 at 7:40 PM, V3 RN noted V3 was about to pass bedtime medications when V3 found out from another CNA, V4, R1 was on the floor. Found out R1 was lying on her back in another resident's room. Both upper and lower extremities extended. R1's wheelchair was in R1's room and R1 walked alone going to the other resident's room. R1 was asked if she hit her head and she said yes but it's not painful. No injuries noted except for a small scratch on R1's elbow. Range of motion of both upper and lower extremities adequate. Physician was notified and ordered to send R1 to the hospital.

Based on observation, interview and record review, the facility failed to follow physician's orders and failed to administer medication in accordance with acceptable clinical practice for 9 (R1, R5, R7, R31, R43, R54, R78, R95, R99) of 9 residents reviewed for medication administration. Findings include: On 4/9/24 at 9:54AM V11 LPN (Licensed Practical Nurse) was observed completing 9:00AM medication administration. After holding one tablet metoprolol 25mg (milligrams) from R45, V11 returned to the medication cart, and placed the tablet back in the medication blister pack with unclean hands. V11 said, it was okay to return the medication because it did not fall on the floor. Surveyor observed V11 touch the medication with V11's bare hands and brought into the resident's room. The medication fell out of the medication cup and onto the tray. At the conclusion of the observation V11 said, although they had passed medications to all their residents, they did not sign out all the medications as given on the MAR (Medication Administration Record). Surveyor observed on the Electronic Health Record, that several resident cards were red indicating overdue administration/documentation. V11 said, all medications for the morning shift needed to be signed out for the following residents: R95, R78, R31, R43, R1, R5, R7, R99 and R54. V11 said, sometimes they sign out the medications as they give them, but most of the time, they finish the mediation pass and sign out the medications while sitting at the nurse's station and usually the nurse completes documentation by 9:50AM before turning red. On 4/9/24 at 3:00PM V2 (Director of Nursing) said, it is the expectation and according to policy that medications are documented and signed out as soon as they are given to the resident. Once medications are removed from packaging, they should be discarded if not administered. Facility Policy titled Medication Administration (Pharmacy) revised 10/2014 states in part: B. Administration 2.) Medications are administered in accordance with written orders of the prescriber. 18.) The resident is always observed after administration to ensure that the dose was completely ingested. If only a partial dose is ingested, this is noted on the MAR, an action is taken as appropriate. D. Documentation (including electronic) 1.) The individual who administers the mediation dose records the administration on the resident's MAR directly after the mediation is given. At the enc of each mediation ass, the person administering the medications reviews the MAR to ensure necessary doses were administered and documented. In no case should the individual who administered the medication report off-duty without first recording the administration of any medication. 6.) If a dose of regularly scheduled medication is withheld, refused, not available, or given at a time other than the scheduled time, the space provided on the front of the MAR for that dosage administration is [initialed and circled]. An explanatory note is entered on the reverse side of the record. If [consecutive doses] of a vital medication are withheld, refused, or not available the physician is notified. Nursing documents the notification and physician response. If an electronic MAR system is used, specific procedures required for resident identification, identifying medications due at specific times, and documentation of administration, refusal, holding of doses, and dosing parameters such as vital signs and lab values are described in the system's user manual. These procedures should be followed and may differ slightly from the procedures for using paper MARs. 40920 On 04/09/24 at 11:40AM, R99 was observed in her room, awake and alert. R99 stated she had a headache, she does not get her medication on time, and she has noticed small flies in her room for a while now. Surveyor observed a medication cup with 4 large white pills, one oval and the other three round on resident's bedside table. R99 said she does not know what the medications are, not sure how long it has been there, but she does not think that it is from this morning, it might be from the previous day. On 04/08/24 at 11:50AM, V3 (Unit Manager) was called to the room and shown the medications in the cup. V3 said she does not think the medications are from this morning, but probably from yesterday, because she did not pass morning medication for the resident today, another nurse did but she went home for an emergency. V3 identified the medications as Sul Carafate 1gm three times a day, Magnesium 1 tablet daily, and 2 tablets of Simethicone every 8 hours. V3 was asked if it is their normal practice to leave medication at the bedside. V3 said, No, nurses are not supposed to leave medications at the bedside.

Based on Observation, Interview and Record Review, the facility failed to have a five percent (5%) or less medication error rate for one (R45) of one resident. There were 13 medication errors out of 34 medication opportunities, resulting in a 38.24% medication error rate. Findings include: On 04/09/24 at 09:14 AM V11 LPN (Licensed Practical Nurse) was observed administering 9:00AM medications to R45. When administering to R45, V11 said R45 takes medications whole, individually and in applesauce. R45 said R45 only wanted one pill prior to V11 administering, which V11 acknowledged. V11 administered medications by spoon and two pills were observed in the applesauce. R45 spit one small yellow pill out and nurse gathered with tissue, not questioning or re-offering. After observing administration, V11 was about to throw out the tissue when surveyor asked to identify the tablet. V11 said V11 didn't know what the tablet was, but then recognized it as digoxin against the medication card. V11 said this is a heart medication. Administered medications for R45 were reconciled against the current (April 2024) Medication Administration Records (MAR). Errors noted included: Not Given: Digoxin Oral Tablet 125 MCG (Digoxin) Give 0.5 tablet by mouth one time a day related to heart failure. Physician Order: Fish Oil Capsule 1200 MG (Omega-3 Fatty Acids) Give 1 capsule by mouth one time a day for supplement. Given: Fish Oil 1000mg (milligrams). Omitted Medications: Loratadine Tablet 10 MG Give 1 tablet by mouth one time a day for allergy (V11 did not offer or provide this medication). Fluticasone Propionate Suspension 50 MCG/ACT 1 spray in each nostril two times a day for Nasal congestion (V11 did not offer or provide this medication). Diclofenac Sodium External Gel 1% (Diclofenac Sodium (Topical)) Apply to Anterior ribs topically four times a day for pain apply 2 grams (V11 did not offer or provide this medication). On 04/09/24 at 9:36AM V11 was observed preparing and administering medications to R23. Errors included: Physician Order reads: Cholecalciferol (vitamin D3) Tablet 1000 UNIT Give 2 tablet by mouth one time a day for supplement. V11 gave vitamin B12 100mcg 1 tab. Physician Order reads: Docusate Sodium Oral Capsule 100 MG (Docusate Sodium) Give 1 capsule by mouth every 12 hours for Constipation; and Sennosides Oral Tablet 8.6 MG (Sennosides) Give 1 tablet by mouth two times a day for Constipation. V11 gave Senna Plus (Docusate 50mg, Senna 8.6mg) 1 tab. Physician Order reads: Metoprolol Tartrate Oral Tablet 25mg. Give 1 tablet by mouth two times a day for hypertension (no parameters noted). V11 held the medication without notifying the physician for a blood pressure of 113/69 and pulse of 91 beats per minute (as observed during vital signs taken at bedside). Omitted 9:00AM Medications: Lexapro Tablet 20 MG (Escitalopram Oxalate) Give 20 mg by mouth one time a day for depression/ anxiety. Spiriva HandiHaler Inhalation Capsule 18 MCG (Tiotropium Bromide Monohydrate) 1 capsule inhale orally one time a day for COPD/ 1 cap inhale once per day. Inhale the contents of 1 capsule daily. 2 puffs = 1 capsule. Artificial Tears Solution 1 % (Carboxymethylcellulose Sodium) Instill 1 drop in both eyes two times a day for 1 drop in both eyes BID. Keppra Oral Tablet 750 MG (Levetiracetam) Give 750 mg by mouth two times a day for Seizure disorder. NasoGel Nasal Gel (Saline) 1 application in both nostrils two times a day for dryness in nostrils Facility Policy titled Medication Administration (Pharmacy) revised 10/2014 states in part: A. 4). Five Rights- Right resident, right drug, right dose, right route ad right time, are applied for each medication being administered. A triple check of these 5 Rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dosed is prepared and the mediation put away. A. Check #1: Select the Medication-label, container and contents are checked for integrity, and compared against the mediation administration record (MAR) by reviewing the 5 Rights. B. Check #2: Prepare the dose-the dose is removed from the container and verified against the label and the MAR by reviewing the 5 Rights. C. Check #3: Complete the preparation of the dose and re-verify the label against the MAR by reviewing the 5 Rights. 5. Prior to administration, the mediation and dosage schedule on the resident's medication administration record (MAR) are compared with the mediation label. If the label and MAR are different and the container is not flagged indicating a change in directions or if there is any other reason to question the dosage or directions the physician's orders are checked for the correct dosage schedule. B. Administration 2. Medications are administered in accordance with written orders of the prescriber.

Based on observation, interview and record review, the facility failed to follow hand hygiene procedures during medication administration for two (R23 and R45) residents reviewed for infection control. Findings include: On 4/9/24 at 9:14AM, V11 LPN (Licensed Practical Nurse) was observed preparing and administering medications. During this observation, V11 did not perform hand hygiene at the beginning of the observation. Surveyor observed V11 remove tablets from medication blister cards popping the medications in V11's hand and placed them in a medication cups. As V11 moved across the cart, touching cards and common surfaces, V11 did not stop to perform hand hygiene. V11 continued this practice for two different residents R23 and R45. Facility Policy titled Medication Administration (Pharmacy) revised 10/2014 states in part: Preparation: 2. Handwashing and Hand Sanitization: The person administering medications adheres to good hand hygiene, which includes washing hands thoroughly before beginning a medication pass, prior to handling any medication, after coming into direct contact with a resident, and before and after administration of ophthalmic, topical, vaginal, rectal, and parenteral preparations and mediations given via enteral tubes. Examination gloves are worn when necessary. Hand sanitization is done with an approved sanitizer between handwashing, when returning to the medication cart or preparation area (assuming hands have not touched a resident or potentially contaminated surface). Sanitization can be done at regular intervals during the medication pass such as after each room, again assuming handwashing is not indicated. Sanitization is not a substitute for proper handwashing, and washing should be done if there is any question.

Based on interview and record review, the facility failed to provide safe transfer with a full (mechanical) lift per care plan; failed to inform doctor of refusal in using the (mechanical) lift and failed to reassess for safe transfers for 1 (R1) of three residents (R1, R2, R3) reviewed for falls. This failure resulted to R1 sliding on the floor sustaining a fracture of the tibia/fibula. Findings include: R1's Facesheet indicates that R1 was admitted to the facility on [DATE] with diagnosis including but not limited to: Chronic Obstructive Pulmonary Disease, Emphysema, Chronic Respiratory Failure with Hypoxia and Hypercapnia, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Nondisplaced Oblique Fracture of the Shaft of Right Tibia, Venous Thrombosis and Embolism, Disorder of the Autonomic Nervous System, Irritable Bowel Syndrome, Pulmonary Blastomycosis, Urinary Tract Infection, Neurological Dysfunction of Bladder, Anxiety Disorder, Major Depressive Disorder, Agoraphobia with Panic Disorder, Other Cord Compression, Paraplegia, Essential Hypertension, Obesity, Obstructive Sleep Apnea, Gastroesophageal Reflux Disease without Esophagitis, Visual Hallucinations, Paranoid Disorder, and Age Related Osteoporosis without Pathologic Fracture. R1's Minimum Data Set with Assessment reference date of 12/31/2023 under Section C: Brief Interview for Mental Status (BIMS) documents a score of 13. (The BIMS assessment uses a points system that ranges from 0 to 15 points: 0 to 7 points suggests severe cognitive impairment. 8 to 12 points suggests moderate cognitive impairment. 13 to 15 points suggests that cognition is intact). On 1/26/2024 at 11:04 AM, R1 was observed in bed watching television. When asked what happened on 12/18/23, R1 stated, I had a fall. It happened after lunch, I wanted to get my hair cut. I haven't been out of bed for about 6 months, V5, the aide was helping to get up. V5 had me sitting at the edge of the bed and was standing to pivot when my legs buckled, and I ended up sitting on the floor. My right leg was under my body and my foot was flat and I heard the crack. I pulled out my foot slowly. V5 then called another CNA, V6. V6 picked me up and put me in the chair. From that point forward my leg was numb. In a case like that when I haven't been up for long time, we should have used the sit to stand. But I did get my hair cut that day. I fractured my shin. I gotta (sic) take responsibility for my stupidity, I should have known better but I wanted to get my hair cut. There's no one to blame for it. On 1/26/2024 at 1:22 PM, V5, Certified Nursing Assistant (CNA) stated, On 12/28/23, R1 had a hair appointment. She needs a (mechanical) lift for transfers but R1 refused to use the (mechanical) lift and she said she wanted to get up for the beauty shop. So, I got R1 ready, got R1 dressed and had R1 sit by the edge of the bed while I called another CNA for assistance. The R1 said she is dizzy and then she started sliding onto the floor. I held on to R1's gait belt and then she slid down on the floor. I informed V3, R1's nurse, that R1 refused to use the (mechanical) lift and V3 said that it's okay to transfer R1 with 2 person assist since she was refusing. When asked if V3 talked to R1 about dangers of not using the (mechanical) lift, V5 stated, V3 did not talk to R1 about it. V6, CNA, and V3 assisted R1 back to bed, with 3 person assist, we did not use the (mechanical) lift. On 1/26/2024 at 1:24 PM, R1 was interviewed again. R1 stated she did not refuse to use the (mechanical) lift and the (mechanical) lift was not offered for her to use. R1 stated, I have never used the (mechanical) lift. V5 did not have the Sit-to-Stand or (mechanical) Lift on 12/18/2023. We just didn't think to use it. I heard a crack on my bones when I fell on the floor. V5 and V6 assisted me to get up when I fell and put me back to the bed without using the (mechanical) lift. Progress Noted dated 12/18/2023 by V3, Registered Nurse documents in part: CNA (Certified Nursing Assistant) called NOD (Nurse on Duty) to informed (sic) that pt. (patient) slid to the floor during transfer (sic) resident to the wheelchair. NOD came to the resident room noted resident siting position on the floor next to the bed. Interview with V3, Registered Nurse, on 1/26/2023 at 1:20 pm was conducted. V3 stated, I was the nurse in charge of R1 on 12/18/2023. V5, Certified Nursing Assistant called me and informed me that R1 slid on the floor. V5 stated that she was getting R1 ready and had R1 sitting at the edge of the bed and R1 started slipping on the floor. I was then called to R1's room and observed R1 on the floor. I did a head-to-toe assessment, R1 said she was not in pain. V3 informed me then that (mechanical) lift was not used because R1 refused to sue the (mechanical) lift. When asked why her documentation on R1's progress notes stating that R1 refused to use the (mechanical) lift had a created date of 12/20/23, which was 2 days after the fall, V3 did not respond. R1's Care Plan with a revision date of 12/20/23 affirm that R1 requires (mechanical) lift with (X2) staff assistance for all transfers. The said Care Plan does not address that R1 was refusing to use the (mechanical) lift. On 1/26/2024 at 1:30 PM, V2, Director of Nursing stated, When somebody refuses the (mechanical) lift, the staff needs to inform us so we can do an evaluation to assess for proper transfer. R1 sustained fracture of the tibia. When I called V7, Physician, V7 said the fracture was pathological, we didn't report it. I talked to V7 the following day, he said it's due to her co-morbidities, R1 has severe osteopenia. If it's pathological in nature, we don't send a report to the state reporting agency. V2 affirmed that tibial fracture is considered a serious injury. V2 stated there was no report submitted to the state surveying agency about this serious injury. Review of R1's medical records excludes documentation regarding any condition that would place R1 at risk for pathological fractures. On 1/26/2024 at 1:55 PM, V7, Physician, stated, For R1, we discussed the fall, and the discussion was that R1 was sitting on the side of the bed and was being assisted and slipped and did not really have any per se trauma. We reviewed R1's X-ray and showed severe Osteopenia and that certainly can contribute to a pathological fracture, in the absence of trauma. R1's severe osteopenia could have caused the fracture because I was informed that there was really no trauma to the extremity. I have been informed from time to time that R1 was refusing to use the body lift, but for this particular incident, I don't recall them informing me that she refused to use the (mechanical) lift on 12/18/23. On 1/26/2024 at 3:12 PM, V6, Certified Nursing Assistant (CNA) stated, I was in the room with V5. When I got there, R1 was already on the floor. V5 prepared R1 for the transfer, and V5 said R1 slid on the floor. Then nurse checked R1, and R1 said she has no pain. So, the nurse, V6 and myself (sic) put her back to the bed, all 3 of us without using the (mechanical) lift. R1 said she wanted to go to the beauty shop, so all 3 of us transferred her to the wheelchair this time without using the (mechanical) lift so that she can go to the beauty shop. Review of R1's medical records excludes any documentation that R1 was reassessed for proper transfer techniques since R1 was allegedly refusing to use the (mechanical) lift. Review of medical records also exclude documentation that R1 was educated on the dangers of refusing to use the (mechanical) lift. V3, Registered Nurse, affirm that she was informed that R1 refused to use the (mechanical) lift after R1 slid on the floor. V3 documented on the progress notes with a created date of 12/20/2023, which is 2 days after the incident, that R1 refused to use the (mechanical) lift. R1's hospital records document under Xray Ankle Complete Minimum 3 Views, (Right) and Xray Tibia/Fibula, 2 Views (Right): Final Result, IMPRESSION: A minimally displaced oblique fracture involving distal tibia is noted with nondisplaced distal fibular diaphyseal fracture. Facility Policy titled Safe Lifting and Movement of Residents with a review date of July 2022 documents in part: In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. POLICY INTERPRETATION and IMPLEMENTATION: 3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include: a. Resident's preferences for assistance; b. Resident's mobility (degree of dependency); c. Resident's size; d. Weight-bearing ability; e. Cognitive status; f. Whether the resident is usually cooperative with staff;

Based on interview and record review, the facility failed to prevent or identify the origin of how a resident sustained a right hip fracture. This affected one of three residents (R1) reviewed for injury of unknown origin. This failure resulted in R1 complaining of pain to the right leg. R1 was assessed, sent to the local hospital, and diagnosed and treated for complex comminuted periprosthetic fracture. Findings include: R1 face sheet shows R1 is [AGE] year-old female, R1 has diagnoses of presence of right artificial hip joint, history of falling, unspecified dementia, lack of coordination. R1 plan of care denotes R1 has difficulty hearing and visual deficits. R1 incident report to the department dated 8/6/2023 denotes in part, location of incident shower room, resident complained of pain on right leg upon assessment, noted right hip swelling and shortening of right leg no bruising or redness noted. NP (Nurse Practitioner) notify and assess resident in order to send resident to hospital for evaluation, resident had no fault or incident noted, grandson notified about resident transfer to hospital, 911 paramedics call for resident transport to hospital. Resident transferred to hospital, admitted to hospital with diagnosis of periprosthetic fracture of proximal femur. Investigation initiated and to follow final report investigation completed after staff interview and medical record review, resident had no recent fall nor incident, no outward injuries nor bruising noted. Resident [AGE] year-old, frail elderly, medically complex resident with diagnosis of diabetes hypertension acute renal injury anemia hyperkalemia and had history of right hip hemiarthroplasty and into so fight at the greater trochanter care plan will be updated when resident returned to facility. Type of injury fracture. R1 incident report titled other, dated 8/6/23, denotes in-part, at around 2:45 pm, CNA called this writer's attention that patient was complaining of right leg pain when CNA was trying to move it in the shower room. Immediately went there, patient was wearing jogger pants, said it was hurting. We transferred her to patient's room into her bed to take a closer look without her pants. Noted to have pain and swelling on right hip, with shortening of right leg. NP (Nurse Practitioner) informed. NP saw patient and ordered for stat right hip to include right femur bone. PRN (as needed) Tylenol given for pain. All stat called could not provide an ETA (expected time arrival). Supervisor on duty informed. SNOD (Supervisor Nurse on Duty) informed DON (Director of Nursing). Decision was to send patient out to ER for further eval. Supervisor on duty informed that we will send via 911. VS taken. 911 called. Paramedics came and picked up patient around 3:25 pm via stretcher. POA (Power of Attorney) and MD (Medical Doctor) informed. Endorsed to next NOD (Nurse on Duty). Injuries observed at time of incident suspected fracture right trochanter hip. Pain level 4. Mental status orientated to person orientated to place. Predisposing physiological factors fragile skin, incontinent, gait and balance, impaired memory. Predisposing situation factors loss of ability to walk. Notes 8/10/2023, root cause considering residents age medically complex condition history of right hip hemiarthroplasty lack of incidence resident may have hurt herself during act of physical mobility. R1 progress note dated 8/6/23 denotes at around 2:45 pm, CNA called this writer's attention that patient was complaining of Right leg pain when CNA was trying to move it in the shower room. Immediately went there, patient was wearing jogger pants, said it was hurting. We transferred her to patient's room into her bed to take a closer look without her pants. Noted to have pain and swelling on right hip, with shortening of right leg. NP informed. NP saw patient and ordered for stat right hip to include right femur bone. PRN Tylenol given for pain. Radiology company could not provide an ETA. Supervisor on duty informed. SNOD informed DON. Decision was to send patient out to ER for further eval. Supervisor on duty informed that we would send via 911. VS taken. 911 called. Paramedics came and picked up patient around 3:25 pm via stretcher. POA and MD informed. Endorsed to next NOD. R1 hospital record dated 8/7/23 denotes in-part chief complaint: right hip pain HPI: R1 is a [AGE] year-old female with PMH (past medical history) of HTN (hypertension), HLD, DM (diabetes mellitus), dementia who presents from SNF (skilled nursing facility) with right hip pain / swelling. It is unclear if she had fallen. Imaging in ER (emergency room ) revealed a right hip peri-prosthetic fracture. Xray of pelvis -comminuted displaced impacted overlapped angulated periprosthetic fracture of the proximal femur. Distal tip of the stem of the prosthesis is directed anteriorly. No periosteal reaction. Trabecular pattern unremarkable. Joints: Head of prosthesis remains seated within the acetabular cup which is in stable position. Soft tissues: Unremarkable. Impression: Complex comminuted periprosthetic fracture. R1 MDS (Minimum Data Set) dated 5/17/23 denotes in-part section C, BIMS score 6 (cognitively impaired) section G transfers; extensive assistance two plus person physical assist. Bed mobility- extensive assist with two plus person physical assistance. Walk in a room extensive assist of 2 plus person physical assist. Locomotion on and off the unit, extensive assist of one-person physical assist. Dressing extensive assist of one-person physical assist. Eating supervision with one-person physical assist. Toilet use extensive assist of two plus person physical assist. Personal hygiene extensive assist of one-person physical assist. Balance during transition and walking; moving from seated to standing; not steady only able to stabilize with staff assist. Surface to surface transfer; not steady only able to stabilize with staff assist. R1 care plan for ADL self-care performance deficit due to decreased mobility pain related to right hip hemiarthroplasty, goal is one will maintain current level of function with ADL 's through the next review date, target date 8/22/23, interventions bed mobility program turn and reposition every room round assist with sideline position support backward pillow monitor for any intolerance monitor for presence of pain intolerance during bed mobility bare mobility the resident requires extensive assistance by 2 staff in turn and repositioning in bed every room round and as necessary transfer the resident require extensive assistance times 2 staff using sit to stand for all transfer. R1 care plan denotes R1 is high risk for falls due to decreased mobility, pain related to right hip hemiarthroplasty, diabetes mellitus and the use of narcotic medication, other medication side effects. Goal is will not sustain injury through the next review date, target date 8/22/2023. Interventions: anticipated and meet the resident needs be sure the resident call light is within reach and encourage the resident to use it for assistance as needed, the resident needs prompt response to all requests for assistance. Encourage the resident to participate in activity that promote exercise, physical activity for strengthening and improve mobility. Ensure the resident is wearing appropriate shoes non-skid socks when ambulating or mobilizing in wheelchair. Review medication that caused the fall. Scoop mattress. On 8/19/23 at 2:43pm, V3 (Administrator) said the investigation directed her and V6 (Director of Nursing/DON) to V5 (Certified Nursing Aide/CNA). V3 said V5 was asked to write a statement. V3 said V5 statement was reviewed, and there was not a lot of details, so V5 was asked to come into the facility for an interview. V3 (Administrator) said herself and V6 (DON) interviewed V5 on 8/10/23. V3 said during that interview V5 (CNA) said he got R1 up in the chair, V5 said he transferred R1 using the sit to stand mechanical lift. V3 said V5 said there was no falls, no incidents. V3 (Administrator) said V5 (CNA) stopped responding to the email communications and V5 stopped coming to work. V3 said V5 cannot be reached at the phone number they have on file. V3 said V5 (CNA) was terminated due to no call, no show to work. V5 said she is not aware of R1 having a fall. On 8/20/23, V5 said she did not review facility video surveillance. V5 said she does not know what happened to R1's hip. On 8/21/23 at 8:32am, V6 (DON) said she conducted the investigation for R1. V6 said she did not review video surveillance for her investigation for R1. V6 said she went back 3 days from the date R1 was observed with pain during her investigation. V6 said V5 (CNA) was the staff that worked with R1 prior to R1 being observed with pain and swelling on 8/6/23 in the hip. V6 said all the staff within those 3 days were asked to write a statement. V6 said when reviewing V5 written statement, there was not a lot of details. V6 said V5 was asked to come into the facility for an interview. V6 said V5 told her that he transferred R1 to the wheelchair using a gait belt on the morning of 8/6/23. V6 said V5 had R1 to sit at the bedside before transferring R1. V6 said V5 did not say he used the sit to stand to transfer R1. V6 said she only asked about transferring of R1, she did not inquire about bed mobility and dressing R1 that morning. V6 said V5 said he was getting R1 up for the day. V6 said V5 (CNA) statement consistently changed during the interview. V6 said R1 is on the get-up list, that's why V5 was getting her up that morning. V6 said if R1 had a fall outside of her room staff would have heard it or saw it. V6 said R1 cannot get up by herself after a fall, R1 needs assist to get up. V6 said there's no cameras in R1's room. V6 said she do not know what happened to R1 hip. V6 said she reviewed the hospital records and R1 has a bad fracture. V6 said R1 require 2 persons assist with the use of the sit-to-stand mechanical lift. V6 (DON) said V5 should use the sit-to-stand when transferring R1. V6 said it's for safety reason, to prevent injuries, especially in the elderly population. V6 said her root cause analysis was based on that no staff witness R1 falling. On 8/19/23 at 1:35pm, V1 (CNA- Certified Nursing Aide) said when she came on duty on 8/6/23 (morning) she saw R1 up in the wheelchair at the nurse station. V1 said she thought that was strange because R1 is not on the get-up list. V1 said multiple staff was shocked to see R1 up so early. V1 said R1 was escorted to the dining room to have breakfast. After breakfast, R1 had activities. After activities, it was soon time for lunch. V1 said after lunch, she went to toilet R1. V1 said she took R1 to the restroom, she went and got the sit to stand lift. V1 said she asked the Aide to assist her with R1. V1 said she lifted R1 leg to remove the leg rest, and R1 complain of pain. V1 said she went to get the nurse immediately so that the nurse can check R1. V1 said her and the nurse took R1 back to her room, put R1 in the bed. V1 said they took R1 joggers off and R1 had big swelling to the right hip. V1 said that was her first-time toileting R1 that day (after lunch). V1 said R1 was in pain. V1 said she checked R1 brief once or twice and R1 was dry. On 8/19/23 at 2:49pm, V2 (Nurse) said she was summons to the shower room when R1 had pain. V2 said she did not ask R1 what happened because R1 has dementia. V2 said she's not familiar with R1, she doesn't know if R1 would have been able to tell her what happened. V2 said R1 was taken to her room, placed on the bed for better observation. V2 said R1's right leg was noted with swelling. V2 said she gave R1 Tylenol for pain. V2 said she notified the NP and NP gave orders for Xray, but the Xray company did not give ETA, so R1 was sent to hospital for further evaluation. V2 said she did not get report that R1 had a fall from previous shift, she did not get report of incident from previous shift. On 8.19.23 at 12:20pm, V7 (Physician) said the facility notified him of R1's hip fracture, R1 was sent out to the hospital. V7 said the facility does not know what happened to R1's hip. V7 said the facility said no one reported any falls for R1. V7 made aware of allegation of R1 allegedly being dropped. V7 said that would makes sense if that's what happened but the facility doesn't know what happened. V7 said a fracture is a result of trauma. V7 said a fracture could develop spontaneously, but he has not seen that happen, it rare. V7 said R1 has a history of hemiarthroplasty. V7 made aware R1's diagnosis at the hospital of complex comminuted periprosthetic fracture. V7 said periprosthetic fracture is a fracture around the prosthesis. V7 said the surgeon would be better to ask if fracture is acute or chronic. R1 hospital record dated 8/7/23 denotes in-part chief complaint: right hip pain HPI: R1 is a [AGE] year-old female with PMH (past medical history) of HTN (hypertension), HLD, DM (diabetes mellitus), dementia who presents from SNF (skilled nursing facility) with right hip pain / swelling. It is unclear if she had fallen. Imaging in ER (emergency room ) revealed a right hip peri-prosthetic fracture. Xray of pelvis -comminuted displaced impacted overlapped angulated periprosthetic fracture of the proximal femur. Distal tip of the stem of the prosthesis is directed anteriorly. No periosteal reaction. Trabecular pattern unremarkable. Joints: Head of prosthesis remains seated within the acetabular cup which is in stable position. Soft tissues: Unremarkable. Impression: Complex comminuted periprosthetic fracture. First policy facility presented on 8/21/23, (3 pages) no date noted titled abuse prevention abuse denotes residents have a right to be free from abuse neglect exploitation misappropriation of property or mistreatment this includes but is not limited to corporal punishment involuntary seclusion and any physical or chemical restraint not required to treat the residence medical symptoms. The purpose of this policy and the abuse prevention program is to describe the process for identification, assessment, and protection of residents from abuse neglect misappropriation of property and exploitation this will be accomplished by conducting pre-employment screening orientating training employees, established environment for residents' sensitivity, resident security, and prevention of mistreatment. Immediately protecting residents involved in identifying reports of property possible abuse neglect exploitation misappropriation property. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means abuse is also the willful infliction of injury unreasonable confinement intimidation or punishment with resulting physical harm pain or mental anguish to a resident. Injury of unknown sources are injuries for which both the following conditions are met one the source of the injury was not observed any person the source of injury could not be explained by the resident and to the injury is suspicious because of the extent or location of the injury the number of injuries observed at one particular point in time or the incidence of injuries over time. Serious bodily injury is defined as an injury involving extreme physical pain substantial risk of death protracted loss or impairment of the function of organ or mental faculty or requiring medical intervention such as surgery hospitalization or physical rehabilitation. The second policy (3 pages) with last review date March 2019 denotes in-part abuse and neglect policy rather than have the right to be free from abuse neglect exploitation misappropriation of property or mistreatment this includes but is not limited to corporal punishment involuntary seclusion and any physical or chemical restraint not required to treat the residence medical symptoms. The facility third policy presented 8/21/23 title abuse and neglect (5 pages) with last revised date of July 2017 denotes in part the purpose of this policy and the abuse prevention program is to describe the process for identification assessment and protection of the residents from abuse neglect misappropriation of property and exploitation this would be accomplished by identify occurrences and patterns of potential mistreatment immediately protecting residents involved in identified reports of proper possible abuse neglect exploitation mistreatment and misappropriation of property implementing systems to promptly and aggressively investigate all reports and allegations of abuse neglect exploitation misappropriation of property and mistreatment and making all the necessary changes to prevent future occurrences. The residents' rights for people in the long-term care denote as a long-term care resident in Illinois, you are guaranteed certain rights, protection, and privileges according to state and federal laws.

Based on observation, interview and record review, the facility has the following failures for 3 out of 6 residents (R6, R25 and R91) for a total sample of 30 residents reviewed for pressure ulcers: Failed to follow their wound prevention and management policy to ensure residents does not develop pressure ulcers. Failed ensure that residents received wound treatments. Failed to follow manufacture's instruction for proper settings on the low air mattress. Failed to maintain correct dressing per physician's order. Failed to monitor skin status for prevention of pressure ulcers. Failed to refer residents with new and worsening pressure ulcers to wound care physician for assessment and treatment. These failures resulted in R6 sustaining 4 new facility acquired pressure ulcers on her right lower extremities. R25 sustaining 2 facility acquired pressure ulcers on the sacral pressure ulcer that further deteriorate with size, characteristic and appearance, and left heel pressure ulcer that was identified on its late stage (Stage 3). R91 sustaining left buttock pressure ulcer that worsened. Findings include: R25 was [AGE] years old, initially admitted on [DATE] with medical diagnoses of hemiplegia and hemiparesis. R25 brief interview of mental status 12/16/2022 has a score of 14 that means R25 cognitive status is intact. On 01/17/2023 at 11:22 AM. R25 stated that he cannot remember anyone did change his dressing today. R25 said that he has wound on his back and shook his head when asked if it gets any better. R25 was seen closing his eyes most of the time and fall asleep but responded short response during conversation. On 01/18/2023 at 10:16 AM, V18 (Wound Coordinator / Licensed Practical Nurse) stated that R25 has unstageable pressure ulcers on both his left heel and sacrum and that both wounds were acquired in the facility. And the most recent was V18's left heel pressure ulcer that was initially identified on 1/3/2023. When asked about the status of both sacral and left heel pressure ulcers. V18 said, It worsened, but there was a time that it was getting better. Both pressure ulcers are unstageable because of the presence of sloth. And when asked about the plan of care related to both pressure ulcers. V18 said, I do not do care plan. It is done by the MDS coordinator. It is part of my contract when I accepted the job as wound coordinator not to do care plan. V18 was asked if she was coordinating with the person doing the care plan since she was the staff that is doing direct care such as changing the dressing and alike. V18 said, If she (MDS Coordinator) asks me, I will give her information. But if you ask me what the interventions for R25's pressure ulcers right now. I don't have the information. I understand what you mean that it is supposed to be interdisciplinary coordination since I perform the care plan, there should be communication between me and the person doing the care plan to determine if interventions are effective. On 01/19/2023 at 09:08, V18 to perform treatment or pressure ulcer care of R25's sacral and left heel. Prior to dressing change V30 (Licensed Practical Nurse/LPN) stated that R25 had a lot of bowel movement earlier. And that she (V30) does not know what was ordered dressing for R25 sacral pressure ulcer. And that she (V30) and V10 (Certified Nursing Assistant/CNA) just cover it with dry dressing. Per physician order, the current and correct treatment is to cleanse sacral pressure ulcer with (Type) topical antiseptic solution pack inside cavity with moist gauze and cover with dressing. After V18 took off the covered dressing that V30 placed. The inside of the wound (pressure ulcer) was packed with gauze that was brownish in color and was soaked with drainage. V18 said, This is the gauze that I placed yesterday around 3:30 PM. After all the gauzed that was packed were taken out. Cavity of pressure ulcer became visible, and it was deep that it appears to be reaching the bones. Although a partial slough that cover portion of the bed of the pressure ulcer does not allow the bones to be seen. V18 stated, Yes, it is deep enough that it may reach the bone. During dressing change V18 measured both sacral and left heel pressure ulcers. Sacral wound measures in centimeters: 5.0 by 6.0 by 2.0 (length by width by depth) with 7 to 2 o'clock undermining. V18 said that there was undermining when she inserted the stick with cotton tip underneath R25's wound moving from 7 to 2 o'clock. Left heel measurement in centimeters: 2.3 by 2.4. Then V18 said, This is 100% slough. Pointing at R25's left heel pressure ulcers that the whole area was covered with slough. On 01/19/2023 at 10:06 AM, V18 (Wound Coordinator / Licensed Practical Nurse) was asked if nursing staff on the floor knows how to access wound treatment orders for them to place the correct dressing as ordered by physician in case dressing becomes soiled or wet. V18 said, Staff (nursing) staff on the floor can access treatment orders. And must know what dressing to place when needed. They have been informed and instruction were given to them. But I totally agree with you. Wound treatment must be performed correctly by both nursing staff on the floor and wound care staff. V18 was asked about the process to document treatment that was done in the treatment administration record (TAR). And was also asked if it should be sign on the same day the treatment was done. V18 said, I don't sign on the treatment administration record (TAR) after I performed the treatment. But I tried to sign it by the end of the day. And yes, sacral wound, you may say it worsen if the skin was intact with redness and later opens. V18 was asked, since there was a clear deterioration of R25's sacral pressure ulcer since 9/30/2022 until currently, why was the wound not seen by a wound doctor until 01/16/2023? V18 said, I tried to do the treatment on my own. I guess it would help but there are times that R25's wounds seem to be improving. V18 was also asked about R25's left heel since it was discovered already in stage 3, if nursing staff was monitoring R25's left heel should it be in an earlier stage when it was easy to manage? V18 said, I don't know. But when it was discovered, it was already stage 3. Per R25's notes dated 9/12/2022 in part reads that R25 skin on the sacral area was intact but with redness. Then foam dressing was applied. Per physician's order, foam dressing needs to be applied to R25's sacrum to start on 9/14/2022. Per R25's treatment administration record (TAR), for foam dressing was not signed as being perform on 9/14/2022 and from 9/20/2022 up to the end of the month no treatment was signed as being performed. On 9/30/2023, R25's sacrum pressure ulcer worsened from skin intact redness to open pressure ulcer measuring in centimeters as follows: 1.5 by 1.0 by 0.10 (length by width depth). Compared to sacral pressure ulcer assessment dated [DATE] measuring in centimeters as follows: 4.0 by 6.0 by 1.5 (length by width by depth). As to R25's left heel pressure ulcer, it was first identified on 1/3/2023 as stage 3 with measurement in centimeters as follows: 2.0 by 3.0 by 0.10 (length by width by depth). On 01/09/2023, left heel pressure ulcer was reclassified as to its stage from stage 3 to unstageable due to 100 % of the area of the pressure ulcer was covered with slough. On 01/19/2023 at 11:34 AM, V33 (Wound Doctor) said, I only see residents that was referred to me by the primary physician. And it was the first time R25 was referred to me, so I cannot make any determination or comparison as to the status of R25's pressure ulcers. But what is documented on her assessment dated [DATE] was the basis of the status of the wound. Yes, the presence of slough means wound deterioration and that a skin intact with redness that opened means worsening of the wound. It can be attributed to many factors including not performing of treatment. Per V33 documentations: R25 was only seen 1 time on 01/16/2023 although R25's sacral pressure ulcer was initially identified as having redness on 09/12/2022 and opened on 09/30/2022 that worsen overtime per facility Wound Round Assessments. And only saw R6's 4 pressure ulcers on resident's right lower extremities after facility was informed that R6's wounds are being reviewed. On 01/19/2023 at 12:12 PM, V2 (Director of Nursing/DON) said, All pressure ulcers besides stage 1 must be seen as soon as possible by Wound Doctor. The process for the primary care physician to give a referral for the wound doctor to see resident. R25's Health Records are as follows: Per R25's notes dated 09/12/2022, reads in part that R25 has blanchable pink noted to sacral area. Notes dated 01/11/2023 in part reads that R25 left heel and sacral wound declined. R25's treatment administration records (TAR) for the months of September, October, and November 2022 have multiple days that were not signed as treatment ordered by physician was being performed on the sacral pressure ulcer. Per facility Wound Rounds assessment R25's pressure ulcer was initially opened on 09/30/2022 and later deteriorates as to size, characteristic and appearance. From 1.5 by 1.0 by 0.10 centimeters (length by width by depth) on 09/30/2022 to 4.0 by 6.0 by 1.5 centimeters (length by width by depth). And even increased in size when seen on 01/19/2023 with the following measurements: 5.0 by 6.0 by 2.0 centimeters (length by width by depth) with 7 to 2 o'clock undermining. Per V33 wound assessment, it was the first time she saw R25 when sacral pressure ulcer had already worsened. Per facility assessment Wound Rounds left heel was initially assessed on its late stage (Stage 3) on 01/03/2023. Later left heel pressure ulcer on assessment dated [DATE] became unstageable due to slough white fibrinous covered 100% of the wound. Care plan for left heel was initiated on 01/08/2023, 5 days after pressure ulcer was identified. And later developed slough on 01/09/2023. Facility submitted Wound Care Pressure Ulcer Avoidability assessment dated [DATE] and signed by V33 (Wound Care Doctor) on 01/20/2023 although, V33 only saw R25 the first time on 01/16/2023. The same assessment was more than 3 months ago dated 09/30/2022 is still showing in progress today (01/20/2023). Dressings, Dry/Clean policy of the facility dated as revised 4/2022, in part reads: The purpose of this procedure is to provide guidelines for the application of dry, clean dressings. Under preparation: Verify that there is a physician's order for this procedure. Review the resident's care plan, current orders, and diagnoses to determine if there are special resident needs. Check treatment record. Under documentation, the following information should be recorded in the resident's medical record, treatment sheet or designated wound form: The date and time the dressing was changed. 45110 On 1/17/23 at 11:30 AM, observed R91's wound care completed by V18 (Wound Care Nurse). Observed R91's left buttock area with an open wound noted with small portion of the wound was bright red and the rest of the wound was filled with a white thick non removable appearance. R91 stated, This air mattress is too hard and makes my butt hurt. On 1/19/23 at 9:52 AM, V18 (Wound Care Nurse) stated, I am a Licensed Practical Nurse for 4-years. I received my wound care certification in April 2022. I have been the only full-time wound care nurse here for the last two years. I work Monday thru Friday, and the weekend supervisor will complete the wound care treatments. V33 (Wound Care Physician) comes in the facility on Mondays, at least once per week to assess residents on her (V33) list. V33 only assess wounds that are declining, infected, or change in condition. Typically, I manage the wounds unless I think the wound physician needs to get involved. If I feel the wound physician needs to assess a wound, I will call the resident's primary care physician for an order to allow V33 to assess the resident. I'm not sure what the PUSH acronym or the score located on the wound summary means. Once I enter the wound description the PUSH score is generated, the higher the number the worse the wound. However, in that square box underneath the title PUSH there is an arrow either pointing up or down. Arrow pointing up means the wound is worsening, and an arrow pointing down means the wound is improving. R91 was readmitted to the facility on [DATE] with the Left buttock stage 3 pressure ulcer wound. On 1/10/23, I assessed R91's the left buttock wound, tissue was 100% bright beefy red, with scant serosanguineous drainage. R91's left buttock wound measures L[Length] 0.50cm x W [Width] 1.00cm x D[Depth] 0.10cm with the PUSH score of 5, no arrow was there because it was the first assessment completed. On 1/18/23 R91's left buttock wound was assessed as a stage 3 pressure ulcer wound, the tissue was 50% bright beefy red and 50% slough white fibrinous, with scant serosanguineous drainage. R91's left buttock wound measures L[Length] 2.00cm x W[Width] 0.50cm x D [Depth] 0.10cm with the PUSH score of 7 with the arrow pointing up, which indicated R91's wound has got worse. R91's wound interventions are an air mattress, encourage R91 to reposition, and heel boots while in bed. The air mattress is set per the resident's weight, he [ R91] weighs 134 pounds. I noticed during R91's wound care that his [ R91] air mattress was set at 300 pounds, which makes the mattress hard and firm. The air mattress is set at the wrong weight and can potentially cause the wound to worsen. R91 was not referred to V33, because I felt like I could handle the wound care alone. From 1/10/23 to 1/18/23, R91 wound did decline. On 1/19/23 at 11:30 AM, V33 (Wound Care Physician) stated, I worked in this facility for two years, assessing, and treating referred residents with all pressure ulcers, vascular ulcers, surgical wounds, all stage non-healing wounds and infected skin areas. Once I assess a resident my documentation is on an application, V2 (DON) and V18 has access to those assessments. I have not assessed R91's wound, because I have not received any referral from R91's physician or V18. If a resident has a stage 3 wound, I will think certainly, I should have been referred to assess that resident's wound. If a wound goes from 100% beefy red to 50% slough, and larger in size, the wound has worsened. The air mattress is an intervention of residents with pressure ulcers. The air mattress settings are based on the resident's weight. If the air mattress is set at a higher weight, it could potentially cause a wound and or an existing wound to worsen. On 1/19/23 at 12:10 PM, V2(DON) stated, V18 needs to refer a resident to V33 with a referral from the resident's physician. V33 is supposed to see all pressure ulcers as soon as possible. V18 should obtain an order for the wound care physician as soon as possible for all wounds. The air mattresses are set on the resident's weight for proper air distribution for residents with pressure ulcers. If the bed is set on a higher weight, it could potentially cause their wound to worsen. Reviewed R91's medical record documented in part: R91 was readmitted on [DATE] with medical diagnoses of neuropathy, end stage renal disease, type 2 diabetes, liver transplant, kidney transplant, gastrostomy, gastritis, urinary tract infection, dysphasia, abnormal gait immobility, lack of coordination, hyperkalemia, heart failure, acute respiratory failure malnutrition, depressive disorder, seizures, chronic pain, cirrhosis of the liver, sepsis, and pneumonia. Physician order- dated 1/11/23, left buttock-cleanse with normal saline, apply (brand) non-adherent wound contact dressing , adaptic, and foam dressing every day shift on Tuesday, Thursday, Saturday, and Sunday. Face-sheet, medical diagnosis, physician order sheets, minimum data set [MDS], care plans, medication administration record, treatment administration record, and progress notes. Policy; Documents in part -Prevention of Pressure Ulcers/Injuries dated 7/2017 Support Surfaces and Pressure Redistribution' -Select appropriate support surfaces based on the resident's mobility, continence, skin moisture and perfusion, body size, weight, and overall risk factors Monitoring -Evaluate, report and document potential changes in the skin -Review the interventions and strategies for effectiveness on an ongoing basis 46342 R6 is an [AGE] year-old female initially admitted to the facility 11/28/2017. R6's diagnosis includes but is not limited to, Parkinson's Disease, Unspecified Dementia, Functional Quadriplegia, Dysphagia, Gastrostomy, Fracture of Lower End of Femur. R6 was hospitalized from 11/23/22-11/26/22 for distal right femur fracture and readmitted with right lower extremity (RLE) hinge brace and an order for the brace to be worn at all times except for hygiene. Skin was intact upon readmission based on Nursing Admission/Readmission Assessment completed on 11/26/22. R6's Braden Score for predicting pressure sore risk on 11/26/22 was assessed as being at high risk based on score of 10. R6 is NPO and receiving all nutrition from enteral feedings via gastrostomy tube. R6 developed four pressure injuries identified on 01/11/23 in the following locations: right Achilles, right lateral lower leg, right inner ankle, and right outer ankle. Per facility document titled, Wound Assessment Details Report dated 01/12/23 performed by V18 (Wound Care Coordinator) documents in part, right Achilles unstageable with wound measurements (2.3x2.5x0.1) 100% slough white fibrinous, right lateral lower leg unstageable with wound measurements (0.90x2.0x0.1) 100% slough white fibrinous, right inner ankle unstageable with wound measurements (1.4x2.0x0.1) 95% slough white fibrinous 5% bright beefy red, right outer ankle unstageable with wound measurements (4.5x1.3x0.1) 95% slough white fibrinous 5% bright beefy red. On 01/18/23 at 11:24 AM, V8 (Registered Nurse/RN) stated that before 01/03/23, R6 was wearing a right lower extremity leg brace all the time and that there were special instructions not to remove it. V8 stated that before 01/03/23, R6's leg brace was not being removed for any reason. V8 stated that the Certified Nursing Assistants notify the nurses if any skin alterations are identified. On 01/18/23 at 2:33 PM, surveyors observed V18 (Wound Care Coordinator) providing wound care treatment to R6. V18 stated that R6 had four unstageable pressure wounds that were caused by the friction from R6's right lower extremity leg brace. V18 stated that the hinge type of brace is known to cause friction which is a risk factor for developing a skin alteration. V18 stated that the unstageable pressure wounds were identified when R6's leg brace was taken off to give R6 a shower (01/11/23). V18 stated that the wound care doctor was at the facility on Monday (01/16/23) but did not see R6 or R6's pressure wounds. V18 stated that the wound care physician did not see R6 because V18 did not refer R6 to the wound care physician. V18 stated that V18 only refers residents with wounds to the wound care physician if the wounds are declining or infected or healing is not progressing. Surveyors observed right inner ankle, right outer ankle, and right Achilles covered with alginate dressing. When alginate dressing was removed surveyors observed the right inner ankle, right outer ankle, and right Achilles covered in slough with drainage. V18 stated that V18 used a different treatment dressing (alginate) other than what is ordered ({brand} enzymatic debriding wound agent, adaptic dressing) because V18 had observed an increase in drainage from these wounds yesterday during wound treatment. V18 stated, I haven't had a chance to change the treatment order yet. Surveyors observed V18 take measurements of wounds. V18 verbalized out loud the measurements obtained with the results as follows: right inner ankle (1.5x2.3x0.1), right outer ankle (4.5x1.4x0.1), right lateral leg (1.6x1.6x0.1). No measurement was provided for the wound to right Achilles. On 01/19/23 at 9:30 AM, V34 (Nurse Practitioner/NP) stated that V34 was not aware that R6 had developed pressure wounds and that the last time V34 had seen R6 was on 12/7/22. V34 stated, I remember them calling me about R6 needing a doppler study, but I was not notified about the four unstageable pressure wounds. It looks like they notified R6's primary physician. V34 stated that R6 is wearing a hinge brace which is known to cause friction which has the potential to lead to skin issues. V34 stated that if the staff was conducting daily skin checks they would observe any signs of skin deterioration on pressure point areas quickly. On 01/19/23 at 11:40 AM, V33 (Wound Care Physician) stated that V33 assesses and treats residents referred with all pressure ulcers, vascular ulcers, surgical ulcers, surgical wounds and all stages of non-healing wounds and infected skin areas. V33 stated that V33 works on a consult basis, and therefore the nurse needs to obtain an order from the primary physician for V33 to assess a resident. V33 stated V33 was consulted today to assess R6, and that it is the initial assessment for R6, so it is the first time V33 is doing measurements of R6's wounds. V33 attributes R6's unstageable pressure wounds to the leg brace worn by R6 and stated that the brace can cause friction which is a risk factor for developing pressure wound(s). V33 stated that the facility should be doing daily skin checks to identify skin changes. V33 stated that it is important for the wound treatment orders to be followed as prescribed and that the nurse should not be changing the order(s). On 01/19/23 at 12:00 PM, V18 (Wound Care Coordinator) provided to surveyor documents titled, Visit Report for R6 on 01/19/23 signed by V33 at 10:58:06 AM on 01/19/23 which documents in part that R6 has an unstageable pressure injury on right lateral lower log, right Achilles area, right lateral ankle and right medial ankle since 01/11/23, and the patient had a right leg brace for acute complex fracture of distal femoral metaphysis since 11/23/22, the patient is at increased risk for pressure injury due to the decreased mobility and the patient should be on a turning schedule. Measurements of the pressure injuries are documented as follows: right lateral leg (1.0x1.8x0.1) with small amount of serous drainage and large (67-100%) amount of necrotic tissue within the wound bed including Adherent Slough; right Achilles (2.2x2.5x0.1) with medium amount of serous drainage and large (67-100%) amount of necrotic tissue within the wound bed including Adherent Slough; right medial malleolus (right inner ankle) (1.0x2.0x0.1) with medium amount of serous drainage and large (67-100%) amount of necrotic tissue within the wound bed including Adherent Slough; right lateral malleolus (right outer ankle) (4.2x1.3x0.1) with medium amount of serous drainage and large (67-100%) amount of necrotic tissue within the wound bed including Adherent Slough. Note there is a discrepancy between the measurements provided on V33's documentation compared to the wound measurements taken by V18 and observed by surveyors on 01/18/23. On 01/19/23 at 12:09 PM, V2 (DON) stated that the overall goal is to keep resident's skin condition intact and not have any acquired pressure injuries. V2 stated that R6 was wearing a hinge leg brace which can cause friction and that the brace was the cause of pressure wounds R6 acquired. V2 stated that the interventions put in place when R6 returned from the hospital with the leg brace included checking the leg brace every shift and doing daily skin checks. V2 stated that the purpose of the daily skin check is to monitor the skin for any breakdown or issues with circulation. V2 stated that it is the nurse's responsibility is to do the daily skin checks. V2 stated that when a wound is identified the resident should be seen as soon as possible by the wound care physician. V2 stated that the skin treatment orders should be followed as prescribed and not changed because if the orders are changed it is not possible to know if the treatment was effective or not which could hinder the wound healing process. On 01/20/23 at 9:52 AM, V35 (Registered Dietitian) stated that R6 is receiving tube feeding formula and a commercial protein supplement via feeding tube for nutrition which is providing a total of 1320 calories, 77 gm protein. V35 estimated R6's nutritional needs as 1040-1300 calories, 62-73 grams protein. V35 stated R6 is receiving adequate nutrition from tube feedings with use of commercial protein supplement. R6's MDS (Minimum Data Set) dated 12/02/22 BIMS (Brief Interview for Mental Status) score is 0 indicating severe cognitive response (rarely/never understood) and section G (Functional Status) documents in part R6 requires total dependence for transfer and extensive assistance with bed mobility, dressing, toilet use and personal hygiene and limited range of motion on both upper and lower extremities. R6's Order Summary Report dated 01/18/23 documents in part check circulation, motion, sensation of right lower extremity every shift for brace right lower extremity (RLE) (12/06/22), check skin daily (12/06/22), and skin check daily under brace (RLE) every evening shift (12/14/22). R6's Treatment Administration Record dated 01/01/23-present documents in part, right lower leg: cleanse with normal saline, apply (Brand) enzymatic wound debriding agent to open areas, adaptic, dry dressing every day shift for RLE wounds dated 01/12/23. Facility policy titled, Prevention of Pressure Ulcers/Injuries dated July 2017 documents, in part assess the resident on admission for existing pressure ulcer/injury risk factors and repeat the risk assessment weekly, identify areas of impaired circulation due to pressure from positioning or medical devices and inspect the skin on daily basis, identify any signs of developing pressure injuries (i.e. non-blanchable erythema) and inspect pressure points.

Based on observation, interview and record review, the facility failed to provide oral nutritional supplement as prescribed by physician. This failure resulted in a significant weight loss (>5% change over a span of 1 month and >10% change over a span of 6-month period) for 1 (R57) of 7 residents reviewed for nutrition in a total sample of 30. Findings include: On 01/17/23 at 12:16 PM, surveyor observed V10 (Certified Nursing Assistant/CNA) feeding R57 in the unit dining room, with R57 eating very slowly with eyes closed and overall poor intake less than 50% of lunch meal. No supplement observed on lunch tray. On 01/18/23 at 08:55 AM, surveyor observed V37 (Restorative Coordinator) feeding R57 in unit dining room. No commercial oral supplement observed on breakfast tray. No commercial oral supplement listed on R57's meal ticket. On 01/18/23 at 9:13 AM, V16 (Speech Language Pathologist) stated that R57 requires 1:1 feeding assistance. On 01/18/23 at 11:25 AM, V19 (Certified Nursing Assistant/CNA) re-weighed R57 upon request of the surveyor using the wheelchair scale on the unit. V19 stated that this is the scale used by staff to weight V19 every month. Surveyor observed R57 being weighed in R57's wheelchair with fleece lap blanket and sheet. This weight was 198.4 pounds. The weight reading was confirmed by V19 saying the weight scale reading out loud. After lunch at 2:08 PM, V19 transferred R57 to bed and R57's wheelchair was weighed without R57 sitting in it. R57's wheelchair plus the additional items of the fleece lap blanket and sheet was wheeled back onto the unit scale and the weight of was 80.4 pounds. The weight reading was confirmed by V19 saying the weight scale reading out loud. The difference between these two numbers makes the weight of R57 to be 118 pounds. On 01/18/23 at 12:21 PM, V8 (Registered Nurse/RN) stated that V8 did not give anyone on the unit Ensure supplement this morning as part of medication pass. V8 stated that there is not any Ensure supplement on the nursing unit or in the medication cart to give out. V8 stated that R57 did not receive (Brand) nutritional supplement this morning from nursing. On 01/19/23 at 9:40 AM, V34 (Nurse Practitioner/NP) stated that V34 has not seen R57 in person since 11/2022 but V34 did give a verbal order over the phone to approve R57 for labs, chest x-ray, speech evaluation and calorie counts. V34 stated that V34's expectation is that if R57 has an order for oral supplement then R57 should be receiving the supplement as ordered and that the purpose of the supplement is to provide R57 with additional calories to prevent weight loss. V34 stated that R57's weight loss is not desired or planned and is concerning since R57 is continuing to lose weight. On 1/19/23 at 9:45 AM, V26 (Dietary Manager) stated that when commercial oral supplements such as (Brand) are ordered with meals then the (Brand) oral nutritional supplement is provided by the kitchen and put on resident meal trays for that meal. V26 stated that if a resident has a physician order for (Brand) oral nutritional supplement, then that supplement will be listed on the resident's meal ticket, so the kitchen staff knows to add the supplement to the resident's meal tray. V26 stated that (Brand) oral nutritional supplement was in stock and available in the kitchen for use. V26 stated that a doctor or registered dietitian can order a supplement and that the staff notifies the kitchen when this occurs so that the kitchen can enter this information into the kitchen computer system which then generates the supplement on the meal ticket. V26 reviewed R57's menu profile in the kitchen computer system and stated that R57 does not have (Brand) nutritional supplement listed on R57's meals tickets and therefore is not receiving (Brand) nutritional supplement from the kitchen. On 01/19/23 at 10:00AM, V31 (Dietary Technician) stated that calorie counts were conducted last week but only given to V31 this morning to calculate. V31 stated that R57 is consuming an average intake of 732 calories per day based on the calorie count results and that R57 is not consuming enough calories to maintain R57's weight. V31 reviewed electronic medical record and stated, I do see the order for (Brand) oral nutritional supplement. V31 stated that R57 is not receiving (Brand) oral nutritional supplement from the kitchen at this time. V31 stated that if a resident had an order for a supplement but was not receiving the supplement the resident may not be able to maintain weight, and this could cause further weight loss because the purpose of the supplement is to provide extra calories. V31 stated that V31 was not aware of R57's weight loss and that a weight loss puts a resident into a high-risk category, which would require a referral to the registered dietitian for an assessment. On 01/19/23 at 10:47 AM, surveyor conducted interview with V35 (Registered Dietitian) over the phone. V35 stated that V35 worked remotely this week and that V35 had not been notified about R57's weight loss this month yet. V35 stated that current interventions in place include use of (Brand) oral nutritional supplement once per day at breakfast meal which would provide approximately 350 calories. V35 was not aware that the kitchen was not giving R57 the (Brand) oral nutritional supplement and stated, I am surprised that the kitchen has not been giving what is ordered. V35 stated that if a resident is not receiving a supplement as ordered, it has the potential risk for causing continued weight loss. V35 reviewed the diet technician's progress note documenting the calorie count results and stated that the calories R57 is consuming is not adequate and that without increasing R57's calorie intake, further weight loss is likely. R57 was admitted to the facility on [DATE] and has diagnoses which includes but not limited to: Unspecified Dementia, Hemiplegia and Hemiparesis Following Cerebrovascular Disease Affecting Right Dominant Side, Type 2 Diabetes Mellitus, Schizoaffective Disorder. R57's Order Summary Report dated 01/18/23 documents in part (Brand) oral nutritional supplement, one time a day for supplement at breakfast with order date from 11/08/22. R57's MDS (Minimum Data Set) from 11/15/22 BIMS (Brief Interview for Mental Status) was not calculated but indicated in section C0600 resident was unable to complete BIMS and indicated short and long-term memory problem. R57's MDS section G (Functional Status) dated 11/15/22 documents in part, limited assistance with eating and section GG (Functional Abilities and Goals) substantial/maximal assistance with eating. R57's care plan dated 11/09/22 documents in part, R57 is underweight, malnourished and to provide diet supplement as prescribed by physician. R57's Nutrition/Dietary progress note dated 01/19/23 completed by V35 at 11:15 AM documents in part, R57 has had a significant weight loss based on -9.7% change in 1 month, -10.5% change in 3 months, and -16% change in 6 months. V35 used the following weights to complete the progress note: (01/11/23) 122.4 pounds, (12/5/22) 135.5 pounds, (10/5/22) 136.8 pounds, (07/1/22) 146.2 pounds. V35 assessed R57's BMI (20.4) as being low for R57's age and that calorie count results show R57's average daily intake is 732 kcals which is not enough to maintain and/or gain weight. Facility document titled, Weights & Vitals dated 01/18/23 documents, in part, R57's weights as follows: (1/11/23) 122.6 pounds, (12/5/22) 135.5 pounds, (11/8/22) 135.5 pounds, (10/13/22) 136.8 pounds, (7/8/22) 146.4 pounds. Facility policy titled, Nutrition (Impaired)/Unplanned Weight loss - Clinical Protocol dated 09/2017 documents, in part, that the staff will report to the physician significant weight losses. Facility policy titled, Supplements undated documents in part that nutritional supplements will be provided as ordered to clients, nursing and dietary will distribute the nutritional supplement.

Based on observation, interview and record review, the facility failed to store and prepare food under sanitary conditions. This has the potential to affect all 141 residents that receive nutrition services from the kitchen. Findings include: On 01/17/2023 at 09:16 AM, surveyor conducted an initial tour of the kitchen with V26 (Dietary Manager). At 09:24 AM, surveyor inspected facility's walk-in refrigerator that also leads into the freezer. Surveyor observed a cart full of individual whoopie pies and puddings uncovered in the middle of the refrigerator. V26 stated kitchen staff prepared them in the morning and facility will serve them for lunch. In the freezer, surveyor observed ice build-up at the bottom of the freezer's left fan. There was a box of breakfast sausage underneath the fan. The box had a build-up of ice on the top left side. V26 stated the freezer is supposed to go through a weekly defrost cycle. On 01/18/2023 at 09:00 AM, surveyor conducted a follow-up kitchen tour. Surveyor observed the facility's knife holder that was fastened on the wall. Knife holder had dust and residue build-up on the top. V26 stated facility stored the clean knives in the knife holder. At 09:58 AM, surveyor observed V29 (Cook) prepare pureed meal. V26 stated facility has one blender. Blender was wet with clear liquid. V29 poured lima beans into blender. V29 completed pureeing the lima beans. Kitchen staff washed the blender. At 10:06 AM, surveyor observed the blender wet. Facility did not air dry the blender. V29 proceeded to puree ham. On 01/19/2023 at 12:40 PM, V2 (Director of Nursing/DON) stated facility should have at least two or three blenders for purees, but at the bare minimum, staff should let the blender dry in between uses. V2 also stated if facility is not storing and distributing food under sanitary conditions, there is potential for infection control concerns. Surveyor reviewed facility's Cleaning Procedure for Equipment and Utensils policy from the Food & Nutrition Services policy and procedure manual. Under the procedure for the blender, it documents in part: after rinsing and sanitizing the cannister, facility is to air-dry.

Based on observation, interview, and record review, the facility failed to ensure that residents' call light cords were within reach for 4 (R15, R82, R128, R239) out of a total sample of 30 residents. Findings include: On 01/17/2023 at 12:22 PM, surveyor entered R128's room for interview. R128 asked surveyor for more soup. Informed R128 of surveyor's roles. R128 stated [R128] doesn't know how to call staff. R128 began feeling around the bed. Surveyor noted R128's call light cord was on the floor near the head of the bed frame. R128 stated I can't reach it all the way back there. I want to call for more soup. I have nothing to call if I want something. R128 stated [R128] was feeling frustrated. At 12:33 PM, surveyor attempted to flag/call someone down the hallway. Could not reach staff. Surveyor went to nurses' station. V25 (Certified Nurse Aide/CNA) stated V25 was assigned to R128. V25 entered R128's room. V25 stated R128's call light cord was on the floor out of reach for R128. On 01/18/2023 at 03:10 PM, surveyor reviewed R128's comprehensive care plan. Focus created 1/17/2023 documents, which in part that R128 has altered respiratory function and uses oxygen via nasal cannula. Intervention initiated 1/17/2023 documents in part: Keep call light within reach at all times. R128's comprehensive care plan also documents in part a focus created on 12/15/2022 that R128 is at risk for falls. Intervention initiated 12/15/2022 documents in part: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. On 01/17/2023 at 02:09 PM, surveyor entered R239's room for interview. R239's call light cord was on top of a bedside drawer. R239 stated it is out of reach. On 01/18/2023 at 03:08 PM, surveyor reviewed R239's care plan. Focus initiated on 1/12/2023 documents in part that R239 is at risk for falls. Intervention initiated 1/12/2023 documents in part: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Facility's undated Call Lights policy documents in part: Place call light where resident can reach it at all times. 46342 On 01/17/23 at 11:35 AM, R15 observed lying in bed without the call light being within reach of R15. The call light observed to be on R15's side table which was located behind R15. R15 stated, I cannot reach that and it should be where I can reach it. R15 stated that R15 needs access to the call light to alert the staff when R15 needs help. R15 stated, when I cannot reach my call light, I try calling the staff using my telephone, but no one picks up the phone at the nursing station, so I have to call my family every time, and this makes my family mad. On 01/17/23 at 11:37 AM, V7 (Certified Nursing Assistant/CNA) observed R15's call light lying on top of R15's side table. V7 stated that R15's call light was not within reach of R15 and that the call light should be within R15's reach so R15 can alert the staff if R15 needs assistance. On 01/17/23 at 12:41 PM, surveyor observed R82 lying in bed with the call light tucked inside 2nd drawer of side table, which is located behind and out of reach of R82. R82 stated that R82 uses the call light to ask the nurses for help, but that it's never near me for me to use. R82 stated that if the call light was near me, I'd press the little red button to call the nurse. R82 stated, I don't know where the call light is right now. On 01/17/23 at 12:45 PM, V8 (Registered Nurse/RN) entered R82's room per surveyor's request and observed R82's call light tucked into R82's side table drawer. V8 quickly took the call light out of the drawer and placed it on R82's bed to put it within R82's reach. V8 stated that the call light should be near R82 so that R82 can always reach it. On 01/18/23 at 12:42 PM, V2 (Director of Nursing/DON) stated that all residents should have access to call lights and that the call lights should be within reach of the resident. V2 stated that there is risk if a resident does not have access to the call light because the resident could end up falling by trying to get up on their own. R15 has diagnoses which include but not limited to Multiple Sclerosis, Personal History of Traumatic Fracture, Unspecified Osteoarthritis. R15's MDS (Minimum Data Set) from 11/03/22 BIMS (Brief Interview for Mental Status) score is 07 indicating severely impaired cognition and section G (Functional Status) documents in part R15 requires extensive assistance for bed mobility, transfer, toilet use, locomotion on/off unit. R15's nursing care plan, dated 10/20/2021, documents in part that R15 is at risk for falls/injury and call light kept within reach. Care plan dated 04/14/2020, documents in part that R15 has an activity of daily living self-care performance deficit related to impaired mobility and intervention includes but not limited to encourage the resident to use bell to call for assistance. R15's care plan, dated 04/14/2020, documents in part that R15 is at high risk for fall due to impaired mobility related to multiple sclerosis and be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. R82 has diagnoses which includes but not limited to Unspecified Dementia, Muscle Weakness, Unsteadiness on Feet, Unsteadiness on Feet, Unspecified Fall, Multiple Fractures of Ribs, Unspecified Dislocation of Right Acromioclavicular Joint, Syncope & Collapse. R82's MDS (Minimum Data Set) from 11/16/22 BIMS (Brief Interview for Mental Status) score is 01 indicating severely impaired cognition and section G (Functional Status) documents in part R82 requires extensive assistance for bed mobility, transfer, toilet use, locomotion on/off unit, eating, dressing, personal hygiene. R82's nursing care plan dated 05/16/2022 documents in part that R82 is at high risk for falls related to history of falls, decreased mobility, and be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Facility document titled Morse Fall Scale dated 09/23/22 for R82 documents in part score 75, indicating high fall risk.

Based on observations, interview, and record review, the facility failed to meet professional standard in providing pharmaceutical services as to timely administering medication scheduled as per policy and procedure for residents (R105, R118, R93, R87, R77, R26, R82, R24, R44, R29, R67, R57, R112, R134, R56). And failed to follow professional standard for licensed staff permitted to administer medication by not following physician's order in giving the right dose of insulin for 1 resident (R118). These failures have the potential to affect 15 residents (R105, R118, R93, R87, R77, R26, R82, R24, R44, R29, R67, R57, R112, R134, R56) not receiving medications needed on time, and one resident (R118) not receiving correct dose of insulin. Findings include: On 01/17/2023 at 10:58 AM, V30 (Licensed Practical Nurse/LPN) was still passing medication for R105 and R118. After V30 prepared medications for R118, V30 said that R118 often refused medication. V30 tried to give R118 medication but refused to take all his (R118) medicines. V30 was asked what time schedule of medicine R118 and R105 was she giving? V30 stated These medicines are for 9:00 AM medication, but I still have a few left to give. Yes, it is supposed to be given an hour before and an hour after. Yes, between 8:00 AM to 10:00 AM. On 01/17/2023 at 12:06 PM, V30 was observed giving insulin (Lispro) medication via subcutaneous injection to R118. V30 said that she will give 1 unit to R118, then administered the medication by injecting it to R118's right upper arm. Review of R118 medication current physician orders, in part reads: Insulin Lispro Inject 12 unit subcutaneously every 6 hours for diabetes mellitus. And sliding scale when blood sugar results 150 and up. On 01/18/2023 at 2:08 PM, V30 was asked to clarify why she gave 1 unit of insulin for a standing order of 12 units. V30 said, R118 sugar was low. Then V30 checked R118's physician order and said, R118 blood sugar was 107. Yes, there is a standing order for 12 units. And sliding scale starts from 2 units. I don't know why I gave 1 unit. But I will notify the doctor so that insulin can be reviewed. On 01/18/2023 at 10:34 AM, V8 (Registered Nurse/RN) was observed still passing medications. When asked how many residents still did not receive their medications, Nurse stated that she still needs to administer medications of the following residents: R105, R118, R93, R87, R77, R26, R82, R24, R44, R29, R67, R57, R112, R134, R56. On 01/19/2023 at 12:12 PM, V2 (Director of Nursing/DON) stated, Facility follows 1 hour before and after the allotted time for medication administration as ordered by physician. And insulin must be given as ordered by the physician. If the order is for 12 units, then it must be given per physician's order. I heard that the Nurse Practitioner did not change the order for R118 insulin. Administering Medication policy dated as reviewed 12/17, in part reads: Medications shall be administered in safe and timely manner, and as prescribed. Only person licensed or permitted by this State to prepare, administer, and document the administration of medication may do so. Medications must be administered in accordance with the orders, including any required time frame. Medications must be administered within one (1) hour of their prescribed time frame. Per schedule of Routine Dose of Medication Administration not dated, it reads: Medications are administered 60 minutes prior to or after its scheduled time.

Based on observation, interview and record review, the facility failed to label and date oxygen tubing for 5 (R94, R111, R127, R128, R238) residents reviewed for oxygen therapy out of a total sample of 30. Findings include: On 01/17/2023 at 12:51 PM, surveyor was in R127's room for interview. Surveyor observed R127 on oxygen via nasal cannula. No label or date on the nasal cannula. On 01/18/2023 at 02:49 PM, surveyor reviewed R127's care plan. Focus created 12/06/2022 documents in part that R127 has altered respiratory function secondary to congestive heart failure, chronic obstructive pulmonary disease, and emphysema. Intervention created 12/06/2022 documents in part: Change oxygen bubbler and tubing weekly on Sunday and date and initial bubbler and tubing. On 01/17/2023 at 12:24 PM, surveyor was in R128's room for interview. Surveyor observed R128 on oxygen via nasal cannula. No label or date on the nasal cannula. On 01/18/2023 at 03:01 PM, surveyor reviewed R128's care plan. Focus created 01/17/2023 documents in part that R128 has altered respiratory function. Intervention created 01/17/2023 documents in part: Change oxygen bubbler and tubing weekly on Sunday and date and initial bubbler and tubing. On 01/17/2023 at 11:05 AM, surveyor was in R238's room for interview. Surveyor observed R238 on oxygen via nasal cannula. No label or date on the nasal cannula. On 01/18/2023 at 02:38 PM, surveyor reviewed R238's care plan. Focus created 01/18/2023 documents in part that R238 has altered respiratory function secondary to congestive heart failure. Intervention created 01/18/2023 documents in part: Change oxygen bubbler and tubing weekly on Sunday and date and initial bubbler and tubing. On 01/17/2023 at 12:51 PM, surveyor was in R127's room for interview. Surveyor observed R127 on oxygen via nasal cannula. No label or date on the nasal cannula. On 01/18/2023 at 02:49 PM, surveyor reviewed R127's care plan. Focus created 12/06/2022 documents in part that R127 has altered respiratory function secondary to congestive heart failure, chronic obstructive pulmonary disease, and emphysema. Intervention created 12/06/2022 documents in part: Change oxygen bubbler and tubing weekly on Sunday and date and initial bubbler and tubing. On 01/17/2023 at 12:24 PM, surveyor was in R128's room for interview. Surveyor observed R128 on oxygen via nasal cannula. No label or date on the nasal cannula. On 01/18/2023 at 03:01 PM, surveyor reviewed R128's care plan. Focus created 01/17/2023 documents in part that R128 has altered respiratory function. Intervention created 01/17/2023 documents in part: Change oxygen bubbler and tubing weekly on Sunday and date and initial bubbler and tubing. On 01/17/2023 at 11:05 AM, surveyor was in R238's room for interview. Surveyor observed R238 on oxygen via nasal cannula. No label or date on the nasal cannula. On 01/18/2023 at 02:38 PM, surveyor reviewed R238's care plan. Focus created 01/18/2023 documents in part that R238 has altered respiratory function secondary to congestive heart failure. Intervention created 01/18/2023 documents in part: Change oxygen bubbler and tubing weekly on Sunday and date and initial bubbler and tubing. 46342 On 01/17/23 at 10:50 AM, surveyor observed R94 wearing nasal cannula with oxygen infusing. The humidification bottle dated 01/16/23. The oxygen tubing was not dated. On 01/17/23 at 11:19 AM, surveyor observed R111 wearing nasal cannula with oxygen infusing. The humification bottle was labeled 01/17/23. The oxygen tubing was not dated. R111 stated that the respiratory staff did not change the tubing that morning. On 01/17/23 at 11:22 AM, V8 (Registered Nurse/RN) observed R111's oxygen tubing and stated, There is no date on this tubing. V8 stated that if the tubing is not dated, then there is no way for the staff to know when the tubing was last changed. On 01/17/23 at 11:50 AM, V9 (Respiratory Therapist/RT) stated that oxygen tubing is changed weekly. V9 stated, I don't date the tubing, only the water bottle, because it all comes together. V9 stated that R111's humification bottle and tubing was changed this morning. On 01/17/23 at 11:55 AM, when surveyor reentered R111's room, there was new tubing compared to when R111's tubing was observed at 11:19 AM based on the opaqueness of the tubing and the length of the new tubing. On 01/18/23 at 12:40 PM, V2 (Director of Nursing/DON) stated that oxygen tubing is changed weekly or as needed and that the tubing and the water container should both be labeled. V2 stated the tubing should be dated separately from the water container because the humidification bottle may need to be changed more often. V2 stated that dating the oxygen tubing is Important so that the nurses know when the tubing was changed because it is a potential infection control risk to the resident. R94 has diagnoses not limited to Chronic Obstructive Pulmonary Disease, Heart Failure, Chronic Kidney Muscle Weakness, Protein-Calorie Malnutrition, Hemiplegia/Hemiparesis following Cerebral Infarction. R94's MDS (Minimum Data Set) from 11/20/22 BIMS (Brief Interview for Mental Status) score is 06 indicating severely impaired cognition. R94's Order Summary dated 01/18/22 documents, in part oxygen 2L via NC as needed for hypoxia. R94's care plan dated 11/23/22 documents in part, change oxygen bubbler and tubing weekly on Sunday and date and initial bubbler and tubing. R111 has diagnoses not limited to Emphysema, Chronic Obstructive Pulmonary Disease, Nonspecific Abnormal Finding of Lung Field, Pneumonia. R111's MDS (Minimum Data Set) from 12/31/22 BIMS (Brief Interview for Mental Status) score is 14 indicating intact cognition. R111's Order Summary dated 01/18/22 documents, in part oxygen at 3L per minute via NC every shift for shortness of breath. R111's care plan dated 03/30/22 documents in part, change oxygen bubbler and tubing weekly on Sunday and date and initial bubbler and tubing.

Based on observation, interview, and record review, the facility failed to safely transfer a resident using a mechanical lift to prevent an avoidable accident for (R1) 1 of 3 residents reviewed for safe transfer. R1 hit her right hand on a metal clothes hook located on the bathroom door during a surface to surface transfer, R1 was subsequently sent to local hospital where she received 8 sutures to the right hand. Findings Include: R1 facility census shows R1 was in room 228 on 11/16/21. R1's plan of care shows R1 has diagnosis of weakness, hypertension, [CONDITION(S)], diabetes mellitus type 2, heart failure, chronic pain, [CONDITION(S)] disease, [CONDITION(S)] and [CONDITION(S)] following unspecified [CONDITION(S)] affecting the dominant left side, dementia without behavior disturbance, [CONDITION(S)], [CONDITION(S)], personal history of COVID-19. R1's MDS( Minimum data set) dated 10/26/2021 shows section G , functional status, shows R1 requires extensive assistance ( staff providing weight bearing support) with two plus person physical assist with transfer, and extensive assistance ( staff providing weight bearing support) with two plus person physical assist with transfers with toilet use. Facility incident report dated 11/16/21 shows in-part R1's name, time of incident 7:30am, location of incident: washroom, describe what happened, initial and final report-during toileting resident accidentally hit right hand on the towel rod and sustained laceration wound in between right small finger and ring finger. Wound cleansed and steri strips applied and covered with dry dressing. Physician notified of incident and ordered to send resident to hospital for evaluation, son notified of incident and transfer to hospital. Resident sent to hospital for evaluation. Resident back to facility with absorbable sutures intact on right hand and dressing dry and intact. Care plan updated. Son aware of plan of care. Type of injury- laceration, no fatal, family and doctor notified. R1's emergency room (ER) records dated 11/16/2021 shows in-part, received patient via ambulance from (nursing home) for laceration on right hand between 4th and 5th finger. Patient (R1) is alert A&ox2 (alert and orient x2) per norm. Patient stated, she injured her hand on back of bathroom door. Patient arrived with laceration covered with steri strips and bandaid, bleeding controlled. Patient able to move fingers CMS intact. Hx (history) of left side deficit to [CONDITION(S)], Parkinson, and dementia. Denies pain, numbness or tingling. Triage chief complaint: patient presents with hand laceration. R1 is an [AGE] year old female presenting with hand laceration to right hand. Procedure: laceration repair, 3 centimeter laceration to R (right) hand between 4th and 5th digit. Wound anesthetize with 1% [MEDICATION(S)]. Wound irrigated with copious normal saline. Wound explored for foreign body-base of wound visualized, no foreign body found. Wound closed with a total of 8 5-0 monocryl absorbable sutures. RN to place [MEDICATION(S)] and gauze. No complications. On 01/19/2022 at 9:38a.m, R1 was observed in her room sitting in a wheelchair watching television. R1 observed to be pleasant, calm and able to communicate verbally. When asked if R1 sustained an injury to the right hand R1 said, she does not remember, when asked if surveyor could look at her hand, R1 held her hand out and surveyor observed a healed vertical scar between the 4th and 5th finger extending toward the top of R1 hand. On 1/18/2022 at 12:33p.m, V4 Certified Nursing Aide (CNA) said she was assisting V5 Certified Nursing Aide (CNA) with transferring R1 to the bathroom with a sit to stand machine. V4 said, V5 was operating, and pushing the machine, and she was standing on the right side guiding the machine. V4 said, when they got away from the bed toward the door way, V5 closed the legs on the lift so the machine could fit through the doorway of the bathroom. V4 said, as she guided the machine to make the turn to go through the door way that's when R1's hand hit the metal hook on the door. V4 said, R1 did not swing her hands out and hit the metal hook, R1's hands was on the bars during the entire transfer. V4 said, the doorway was wide enough to fit the lift, V4 said, the door was wide open. On 01/18/2022 at 11:48a.m during observation of the door and hook in the room where R1 incident happened, the hook was observed to be removed, V3 (Maintenance Supervisor) said the hook was removed after R1 sustained the laceration to the hand. During observation of the sit to stand mechanical lift, the handle bars are observed to be horizontal. R1's plan of care shows R1 has an ADL (activity of daily living) self-care deficit d/t (due to) weakness, decreased mobility r/t ( related to) [CONDITION(S)] with left [CONDITION(S)], [CONDITION(S)], and dementia. Interventions are toilet use- the resident requires extensive assistance by (x2) staff with sit to stand toileting, Transfer- the resident requires sit to stand with two person transfer. Interview DON on what was root cause of laceration On 01/18/2022 at 1:28pm, V6 (Nurse) said, on 11/16/21 shortly after the start of the shift, he was summons to R1's room by V5, V5 was holding R1's hand and stated, R1 had sustained a skin tear. V6 said, he observed R1 sitting on the toilet, still attached to the mechanical stand. V6 said,vhe assessed R1's right hand and observed a deep laceration, with minimal bleeding, V6 said, he rendered first aide, he cleaned R1's hand, applied steri-strips, gauze, and wrapped R1's hand with a bandage. V6 said, he notified the physician and the physician gave orders to send R1 to local hospital for further evaluation. V6 said, R1 returned to the facility and had sutures to the right hand. V6 said, the metal hook was not positioned too high on the door and when the resident is on the sit to stand lift, in a standing position he could see how the accident could have occurred (V6 demonstrated that the hand would be the height of the hook on the door). V6 said, he was not there when the incident happened but there should be enough space between the resident and the door hook, when transferring a resident. V6 said, the resident hands should remain on the bars during a transfer, V6 said, the aides should check to make sure the resident hands remain on the bars. V6 said, it was an accident. At 12:45pm, patient (R1) back from ER visit and as per Nursing report patient had 8 sutures and they absorbable so no need to be removed. Please see discharge ER report. On 01/19/2022 at 9:24a.m, V5 said, she was the aide assigned to R1 on 11/16/2021 and V4 was assisting her with transferring R1 to the bathroom, V5 said, R1 was hooked up to the lift and when they pushed the lift in the bathroom R1's hand hit the metal hook and R1 sustained a cut, V5 said, R1's hand is better now, V5 said, it was a mistake. On 01/19/2022 at 11:20a.m, V7 (Restorative Nurse) said R1 requires two person assist with transfers, and when using the mechanical lift. V7 said, one person should operate the lift and the other person guide the lift. V7 said, it's for safety reasons. V7 said, the person guiding the lift are the eyes for the operator, meaning they have a better visual and they should ensure the path is clear and the machine has enough room to be maneuvered, they are making sure the balance is good, they should make sure the resident is holding the bars well. V7 said, the resident's body parts should not hit any surrounding objects, both CNA's should make sure the resident does not hit any surrounding objects. V7 said, it is possible to sustain an injury to the hand if the hand hits an object while on the lift during a transfer. On 01/19/2022 at 12:52p.m, V2 (Director of Nursing) DON said, she conducted the investigation for the incident that occurred on 11/16/21 with R1. V2 said, R1 hit her hand on the metal hook on the bathroom door, V2 said, V4 and V5 said it happened so fast. V2 said, the staff should make sure the resident hands are on the bars and that the resident hands does not hit the metal hooks on the door during a lift transfer. On 01/19/2022 at 1:00p.m V8 (Unit Manager) said, she was the unit manager on 11/16/21 when the incident with R1 occurred, V8 said, she interviewed V4 and V5. V8 said, initially V4 and V5 said, R1 hit her hand on the metal hook on the bathroom door. V8 said, during a return demonstration and further discussion with V4 and V5, V5 said, she was pushing the mechanical lift and V4 was guiding the lift, V5 said, V4 was looking down at the wheels, when guiding the lift and V5 said, she pushed the lift into the bathroom and that's when R1 sustained the cut to her hand. V8 said, V4 admitted to looking down at the wheels because there's something on the floor, and that's when she guided V5 to push the lift into the bathroom and R1 sustained the laceration to the right hand. V8 (Unit Manager) said, they both reported the injury to the nurse right away. When asked about V4 and V5 statement, V8 said, she wrote the statement and she made the mistake by not putting that V4 and V5 said V4 was looking down during the transfer. V8 said, the CNA's should make sure the path is clear and they have to make sure the resident hands does not hit anything as well. R1 progress notes dated 11/16/21 at 10:48am, shows in-part noted laceration on her pinky and ring finger on her right hand. As per 2 staff while patient on sit to stand during the transfer patient accidentally hit the towel holder in the bathroom door. Patient can't even remember what happened and she was laughing why we are all in her bathroom. Laceration cleansed with 09% (Normal Saline Solution)NSS applied with 4 sterile strips cover with gauze bandage and applied border gauze. Patient c/o pain during treatment, Tylenol was given. Notified Physician and ordered to send patient to ER for evaluation if she needed some stitches. Son notified and bed hold policy was discussed as well. On 01/19/2022 at 2:15p.m V4 and V5 was observed to transfer R1 using the sit to stand mechanical lift, V4 and V5 transferred R1 to the bed, R1 then informed V4 and V5 that she wanted to go to the restroom. V4 andV5 transferred R1 to the bathroom using the sit to stand lift. When attached to the lift, while raised in the lift for transferring, R1's hands was observed on the bars, R1's hand was observed to be at the height of the towel rack on the back of the bathroom door. In the attempt to clarify the interviews in the investigation, V2 said, V8 (Unit Manager) conducted the interviews for V4 and V5 because she can communicate with them better Facility policy Titled Lifting Machine, Using a Mechanical dated 07/2019 shows in-part the purpose of this procedure is to establish the general principles of safe lifting using a mechanical lift device. It is not a substitute for manufactures training or instructions. At least two people needed to safely move a resident with a mechanical lift, mechanical lifts may be used for tasks that require lifting a resident off the floor, transferring a resident from bed to chair, lateral transfer, lifting limbs, toileting or bathing, or repositioning. Types of lifts that may be available to the facility are sit to stand, floor based full body sling lifts and overhead full body sling lifts. Lift designs and operation vary across manufactures. Staff must be trained and demonstrate competency using the specifics machines or devices utilized in the facility. Steps in procedures shows in-part prepare the environment: clear an unobstructed path for the lift machine, ensure that there is enough room to pivot, position the lift near the receiving surface and place the lift at the correct height. Number 15., slowly lift the resident, only lift as high as necessary to complete the transfer, gently support the resident as he or she is moved, but do not support any weight. Facility policy Titled Safe Lifting and Moving of Residents dated 07/2019 shows in-part in order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents.

Based on interviews and record reviews, the facility failed to conduct a thorough assessment and monitoring of a resident after fall incident for one (R2) of three residents reviewed for accidents and supervision. This deficiency resulted in R2 sustaining a left [CONDITION(S)] which caused subsequent emergent transfer to the hospital where R2 required surgical intervention. Findings include: R2 is a [AGE] year old admitted in the facility on 07/21/21 with diagnoses of Dementia with Lewy Bodies; [CONDITION(S)] Disease; Pain in Left Hip and Displaced Intertrochanteric Fracture of Left Femur, Subsequent Encounter For Closed Fracture With Routine Healing. According to progress notes dated 09/18/21, R2 was observed sitting on the floor inside room Alert and verbally responsive but confused and forgetful. R2 denies hitting head, no change in level of consciousness and no complaints of pain. There were no injuries noted at the time of fall. On 10/19/21 at 11:40 AM, V4 (Registered Nurse, RN) was interviewed regarding R2's fall on 09/18/21. V4 verbalized, That time, V6 (Certified Nurse Assistant, CNA) did rounds and found (R2) sitting on the floor. When I went to room, I did a head to toe assessment and there were no injuries or pain at the time. (R2) was able to walk back to bed. I notified V5 (Physician) regarding the fall through voicemail, awaiting for a call back. He did not call back on my shift. The next day I was working, V8 (Nurse to the Practitioner, NP) was notified that she (R2) had a fall and complained of pain on the right leg. So I told him (V8) to do a STAT (immediately) X-ray of the right lower extremities. R2's X-ray report dated 09/18/21 documented the following results: Right Tibia and Fibula: Findings - there is no evidence of fracture or dislocation. Right Femur: Findings - There is no evidence of fracture or dislocation. According to V13 (RN) during interview on 10/19/21 at 12:50 PM, when she came back to work on 09/21/21, R2 was still complaining of pain , on left hip. Progress notes dated 09/21/21 indicated that in the morning at 9:00 AM, R2 complained of twitching and pain in the left leg, difficulty moving the left leg and tension in the left leg muscle; with shortening of the left leg. V5 was notified with order for R2 to be sent to the hospital for evaluation. V11 (Power of Attorney) was also notified but refused to bring R2 to hospital. Instead, (R2) has to be seen by therapy first for evaluation. However, after talking to V12 (NP), V11 agreed to take R2 to an outpatient orthopedic clinic the following day. Progress notes dated 09/22/21, time stamped 8:30 AM, documented that R2 left facility with V11 for an orthopedic appointment. Progress notes dated 09/22/21, time stamped 10:35 AM, V11 called facility to inform that R2 had a fracture on the left hip and will be admitted in the hospital for surgical intervention. R2's Hospital records dated 09/26/21 documented: Primary/Discharge diagnosis - Left [CONDITION(S)] Procedures or Surgeries done - Left hip ORIF (Open Reduction and Internal Fixation) On 10/19/21 at 2:35 PM, V8 was interviewed regarding R2's fall and X-ray order. V8 replied, On R2, I don't remember ordering for a right femur, fibula and tibia X-rays. I don't remember ordering that. V2 (Director of Nursing) was also asked regarding R2. V2 stated, She had a fall on 09/18/21. She was assessed, no injuries, no pain. V4 was the nurse on duty on 09/17/21 night shift and on 09/18/21 morning shift. There were no other complaints of pain from her (R2). At that time, I asked V4 why she ordered a right femur/tibia and fibula X-rays. She said that R2 complained of pain on the right side that morning and she notified V8 who did order for an X-ray on that right side. There was no fracture seen. Further review on R2's progress notes from 09/18/21 to 09/22/21 showed no documented assessment regarding R2 complaining of pain on her right side or leg post fall incident. According to neurological (neuro) evaluation sheet, R2 expressed pain on 09/18/21 at 10:40 AM but there was no specific location of pain indicated. Also, the neuro sheet documented that on 09/19/21, all observation on pain recorded as NO until 09/22/21 when R2 went for an orthopedic appointment, no notation to the fact that she (R2) complained of pain on 09/21/21 on her left leg. V2 (DON) was inquired of regarding follow-up assessment and monitoring conducted on R2 after the fall incident. V2 replied, There was no assessment documented regarding her (R2) complaining of pain on her right side. There was no 72 hours monitoring assessment post fall on her (R2). She (R2) is supposed to have been assessed for 72 hours post fall because you will never know if there is injury that you don't see right away. The 72 hours post monitoring charting should be in the progress notes but the only charting was resting comfortably in bed. Every incident should have 72 hours post fall monitoring charting. (R2) had a fall on 09/18/21 and should have been monitored until 09/21/21. But on 09/21/21, was already complaining of pain. V4 did not actually document that (R2) had pain on the right lower extremities, I don't know why. (R2) should have been assessed and it should be documented. R2 went to the orthopedic appointment, the clinic called stating R2 was [NAME] sent directly to the hospital with a left [CONDITION(S)]. X-ray orders are based on what nurse assessed on residents after a fall incident. Nurse has to do a full assessment and monitoring after fall incidents. All assessment documentation should be in the electronic medical chart. R2's neuro evaluation sheet is not a part of her electronic medical records. During interview with V5 (Physician) on 10/19/21 at 4:49 PM, he stated that he was the one who ordered the X-ray on the right hip. V5 stated, When (R2) had the fall last time, I was notified. They did not say that she had an injury. I was informed that it was just a fall and not complaining of any pain. I ordered an X-ray. I ordered a right hip X-ray. I based it on the side she had fallen. I was just notified that she had a fall on that right side. Since she has Dementia and a poor historian, I ordered a right hip X-ray. I ordered right only because I would not want her (R2) to be exposed to [CONDITION(S)] that much unless she is complaining of pain. She was apparently asymptomatic that is why I ordered X-ray on her right side where she fell off. Per facility's post fall huddle documentation worksheet, R2 was found sitting at the back of bedroom door during fall incident. V6 verbalized, On 09/18/21, around 4:00 AM, I did my rounds. Everybody in bed. Around 4:55 AM, I heard a noise, my instinct was to go with another resident who usually walks and walks. But she was on bed. Everybody was in bed on that hallway. I ran to the other hallway, I noticed that R2's door was closed and hard to open. I tried and put my head inside and that's when I saw R2 sitting on the floor behind the door. I called V4, we went inside together. She (V4) made an assessment on R2, no injuries. R2 said she had no pain, we walked from door to bed with the use of walker. R2 was able to walk at the time with no problem. Facility's incident report dated 09/22/21 also documented that R2 was observed sitting on the floor by the door in room and no injury noted at the time of incident. There was no documentation indicating that R2 fell on right side. Also, there were no follow-up documentation regarding post fall assessments charted within the 72 hours on R2's electronic medical records. The neurological evaluation sheet documented that on 09/08/21 at 4:55 AM until 09/19/21 at 1 PM, it was recorded that R2's left lower extremities can still be moved. On 09/19/21 at 4 PM, it was recorded that her (R2) left lower extremities as no movement until 9/22/21. There were no follow up reports regarding the assessment. On 10/20/21 at 10:15 AM, V12 (NP) was asked regarding fall monitoring on residents at risk. V12 stated, Staff need to do an immediate assessment, head to toe - looking for injuries; check neuro status, vital signs, notify me of incident, they have to do post fall assessments and monitoring regardless if it is in the facility policy or not, and have to notify me of any significant changes in the assessment. Initially, resident may not feel any pain due to adrenaline shock, so I need to know after the initial shock is resolved. There could be a possibility that injuries may present several days after fall. V5 was also asked regarding his expectations of staff regarding fall reports, stated, I expect them to call me immediately and tell me about the nature of the fall and the specific details of the incident, what side exactly resident fell on , how long they stayed on that position or if resident is complaining of pain. Facility's policy titled Falls date revised March 2018 documented in part but not limited to the following: After a fall: 6. Observe for delayed complications of a fall for approximately forty-eight (48) hours after an observed or suspected fall, and will document findings in the medical record. 7. Document any observed signs or symptoms of pain, swelling, bruising, deformity, and/or decreased mobility; and any changes in level of responsiveness/consciousness and overall function. Note the presence or absence of significant findings. Reporting 2. Report other information in accordance with facility policy and professional standards of practice.

Based on observation, interview, and record review, facility failed to identify and assess pressure wounds on a resident's left ankle and sacrum. This failure resulted in R3's pressure wounds deteriorating to unstageable wounds with slough and necrotic tissue before receiving treatment. This applies to 1 of 3 residents (R3) reviewed for pressure ulcers in a sample of 5. The findings include: The physician's orders [REDACTED]. R3's Braden Skin Risk assessment dated [DATE] shows that R3 scored a 15 (At risk) for skin breakdown. R3's initial Wound Assessment Detail Report dated 10/19/20 shows that R3 developed a facility acquired pressure ulcer on her left ankle. The wound is described as a deep tissue pressure injury, 70% deep maroon and 30 % bright beefy red. The wound edges are distinct and attached and there is moderate serous drainage. The wound measures 2 x 2 x 0.1 cm. The picture of the wound shows a dark, indurated wound bed with dry flaking skin surrounding the wound. This same document states, Seen by wound MD. New wound present on left ankle outer. New treatment order given. R3's Nurse's Notes date 10/19/20 state, Nurse -wound care report that resident has deep tissue 2 by 2 on left outer ankle. Continue to monitor the resident on her ankle. The Treatment Administration Record (TAR) dated 10/2020 show no new treatment orders for the left ankle until 10/21/20 (2 days after wound was found) R3's physician's orders [REDACTED]. The first Wound Physician Assessment is dated 11/2/20 and states, Wound is open. The wound is currently classified as an unstageable/unclassified wound with etiology of pressure ulcer and is located on the left lateral malleolus. The wound measure 1.3 x 1.5 x 0.1 cm. There is a medium amount of serous drainage noted. There is no granulation within the wound bed. There is a large amount of necrotic tissue within the wound bed including adherent slough . R3's initial Wound Assessment Detail Report dated 11/3/20 shows that R3 developed a facility acquired pressure wound to her left buttocks. The wound is described as unstageable, 30% bright pink or red and 70% slough white [MEDICATION NAME]. The wound edges are distinct and attached and there is moderate serous drainage. The wound measures 3 x 3.5 x 0.10 cm. The picture of the wound shows a dark dry wound bed with a lighter colored moist wound bed underneath. This same document states, Wound present on left buttock with black tissue. Wound cleansed and dressing applied . R3's Nurse's Notes dated 11/3/20 at 10:33AM state, CNA called this nurse to check on pt's left buttock. Noted an open area about a quarter size, without bleeding. Skin cleaned with NS then applied with medi honey and dry dressing until seen by Wound Nurse. Pt. denies pain. Repositioned to her right. side . R3's Nurse's Notes dated 11/3/20 at 1:18PM state, The writer was requested to check residents left buttock as she has a new wound. Assessment done. Noted an unstageable wound on left buttock measuring 3 x 3.5 x 0.1 cm with 30% granulation tissue and 70% slough. Wound edges well defined and attached. Moderate serous drainage noted. Peri wound noted with redness. Wound cleansed and dressing applied. Will upgrade the mattress . Will keep the head of bed at 30 degrees . On 11/20/20 at 11:20 AM V4 (Wound Care RN) stated, (R3) has a wound on her left ankle that has slough- we are using ([MEDICATION NAME] medication) on the wound. It started as a DTI- then it went to unstageable with slough. It needs debridement if it is ever going to heal. She goes to a wound clinic outside of the facility. I don't know how she got the wound. I just took over this position when the wound nurse had to be off. Her buttocks wound is not any bigger but it is not getting any better. We are using medi-honey and calcium alginate. Her son takes her to the wound clinic every week and they measure it but we measure it too. The wound clinic does not send us any reports. On 11/20/20 at 10:55AM, R3 was sitting up in her wheelchair in her room. R3 was sitting on a (pressure relieving) cushion. R3 appeared to be sliding slightly forward in her wheelchair. She appeared somewhat uncomfortable but denied pain. V3 (Registered Nurse) stated that R3's dressings were changed about one hour before by V4. On 11/20/20 at 2:30 PM, V2 (Director of Nursing) was asked about R3's wounds and the inaccuracy of the assessments. V1 stated the facility had recently done an in-service on the identification and assessment of wounds. R3's Current Care Plan states, Skin check every shift during care. Report immediately/ accordingly to wound RN/MD any new or deteriorating skin problem. Assess for possible causes to develop pressure ulcer such as pressure, friction, moisture, immobility and other contributing factors. The facility policy entitled Prevention of Pressure Ulcers/Injuries dated July 2017 states, Inspect the skin on a daily basis when performing or assisting with personal or ADLs. A. Identify any signs of developing pressure injuries (i.e. non-blanchable [DIAGNOSES REDACTED]), b. Inspect pressure points . This same policy states, Deep Tissue Pressure Injury is intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. and The Unstageable pressure ulcer appears as a full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar (devitalized tissue).