Every finding on record at The Citadel at Saint Anne Place

Based on interview and record review the facility failed to ensure a dependent resident was provided with incontinence care for 2 of 3 residents (R1, R2) reviewed for incontinence care in the sample of 6. The findings include:1. R1's face sheet showed she was admitted to the facility 6/3/26 with diagnoses to include acute respiratory failure with hypercapnia, spondylopathy in lumbar region, depression, chronic congestive heart failure, lupus erythematosus, and rheumatoid arthritis. R1's facility assessment dated [DATE] showed she has no cognitive impairment. R1's 6/20/26 Daily Skilled Nursing Note showed, . Resident Orientation: Person, Place, Time, Situation, Makes Self Understood without concern. Resident is incontinent of urine. Resident is incontinent of bowel.On 6/23/26 at 9:14 AM, R1 was sitting in her wheelchair. R1 said the first week she was at the facility she woke up at 4:45 AM and was soaked with urine through her nightgown, sheets, and bedding. R1 said her call light had fallen on the floor so she couldn't use it to call for help. R1 said she was screaming nurse, nurse but no one would come in. R1 said it took three and a half hours for someone to come in and help her. R1 said it was finally around 8:00 AM when someone came into her room to deliver her breakfast tray that they figured out she needed changed. R1 said they told her that she was too quiet, and they forgot to check on her. R1 said they told her she should have clipped her call light on her gown so it couldn't fall but R1 said she has arthritis and is unable to do that for herself. R1 said she was crying and wanting her phone to call her son because she wanted to go home. R1 said her son is her caregiver at home and never leaves her wet like that.On 6/23/26 at 3:52 PM, V10 CNA (Certified Nursing Assistant) said, [R1] was very upset. She was soaked through, sheets and all. Her call light had fallen on the floor and she couldn't reach it. She was just really upset, she was crying. I don't think there is a time limit on rounds, I guess I just kind of go around and check everyone out make sure everyone is good. 2. R2's face sheet showed she was admitted to the facility 6/9/26 with diagnoses to include polyneuropathy, chronic obstructive pulmonary disease, cellulitis of buttock, pressure ulcer of sacral region (stage 3), overactive bladder, and rheumatoid arthritis. R2's facility assessment dated [DATE] showed she has no cognitive impairment and requires staff assistance for all cares.R2's care plan initiated 6/1/26, [R2] is incontinent of urine related to overactive bladder, polyneuropathy, and impaired mobility. She is at risk for skin breakdown, urinary tract infection, and impaired dignity related to urinary incontinence. Provide prompt incontinence care after each episode of urinary incontinence. R2's 6/20/26 Daily Skilled Nursing Note showed, .Resident Orientation: Person, Place, Time, Situation, Makes Self Understood without concern. Resident is incontinent of urine. Resident is incontinent of bowel. Resident with pressure wound, stage 3 coccyx.On 6/23/26 at 9:00 AM, R2 said she is often left to sit in soiled incontinence briefs for an hour or longer. R2 said she uses her call light to let them know when she is wet but it often takes an hour to be answered. On 6/23/26 at 1:45 PM, V3 CNA said they should be rounds every 2 hours for incontinent residents. V3 said it is important to provide timely incontinence care to prevent infection and skin conditions. The facility's undated procedure provided by the facility 6/23/26 showed, Perineal Care; Purpose: The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infection and skin irritation, and to observe the resident's skin condition.

Based on interview and record review the facility failed to protect a resident's rights to receive unopened personal package to 1 of 3 residents (R1) reviewed for resident's rights in the sample of 3.The findings include:R1 facility assessment dated [DATE] shows R1 has a no cognitive impairment.On 4/21/26 at 9 AM, R1 said her packages have been delivered to her already open without her consent. R1 said this had caused her concern and discomfort. R1 said she did not want her packages opened by anyone but herself. R1 said she had been told it was V2 (Director of Nursing-DON) that had been opening her package before delivery. On 4/21/26 at 12:32 PM V9 (Receptionist Staff) said all mail (letters and packages) were delivered to the reception area at different times. The mail and packages were sorted according to residents' room number, then they were to be picked up by Life enrichment staff to be delivered to the resident's room unopened. If mail comes during off hours (when working PMs) mail will be delivered the next day. However, R1's packages must be held so V2 (Director of Nursing-DON) can go through the contents to make sure the items are permitted in the facility. V2 (DON) would open R1's package in the reception area or be brought to the DON's office for her to go through the items. Once the items are checked, V2 brings them to R1's room or she leaves R1's opened package in the reception area to be delivered by the Life enrichment staff.On 4/21/26 at 11:53 AM, V6 (Life Enrichment Staff) said R1's packages are opened and inspected by the DON (V2) before delivery. If the contents are approved, the package is given to R1. If not, it will not be delivered. On 4/21/26 at 12:08 PM, V8 (Life Enrichment Staff) said they were the ones delivering mail to the residents. V8 said she had picked up R1's package already opened in the reception area. R1 had also asked why her package was opened when it got delivered to her. Staff explained that V2 (DON) had to go through her items first before delivery.On 4/21/26 at 10:35 AM, V1 (Administrator) said staff should not open any resident's mail or package. If the package needs to be opened to make sure items are safe, then it should be opened in front of the resident and with the resident's consent.On 4/21/26 at 2:30 PM, V1 (Administrator) and V2 (DON) both said they had no contract signed by R1 that she was giving permission for her packages to be opened by staff prior to delivery to R1. The Facility Policy entitled Resident Rights for people in Long Term Care Facilities under, Your Rights to Privacy and Confidentiality: Your facility must deliver and send your mail promptly; your facility may not open your mail without your permission.

Based on observation, interview, and record review the facility failed to administer and accurately document administering a lidocaine patch. This applies to 1 of 3 residents (R1) reviewed for medication administration in the sample of 5. The findings include: R1's Order Summary Report dated 4/14/26 shows R1 has an active order for lidocaine external patch 4 % (percent) (Lidocaine) with instructions to apply to the lower back topically one time per day for low back pain. R1's Medication Administration Record (MAR) for March 2026 shows R1's lidocaine patch was administered every day for March except for 3/10/26 and 3/27/26 when R1 refused. R1's MAR for April 2026 shows R1's lidocaine patch was administered every day from 4/2/26 to 4/14/26 and refused the patch on 4/1/26. R1's April and March MAR show R1's pain was well managed. R1's Minimum Data Set, dated [DATE] shows R1 is cognitively intact. On 4/14/26 at 12:15 PM, R1 was lying in bed with her needs met and no noticeable pain. R1 said she cannot recall the exact timeframe, but approximately between the end of March and beginning of April, R1 was not administered R1's lidocaine patch for between four days and one week. When R1 told staff that R1 had not been administered R1's lidocaine patch, R1 said staff told R1 well, why didn't you tell us? R1 could not recall who told R1 this information. On 4/14/26 at 3:12 PM, V4 (Registered Nurse- RN) said V4 cares for R1 9 out of 14 days every two weeks. V4 said a few weeks ago, there were some days that R1 had refused to accept the administration of R1's lidocaine patch. V4 also said there were at least two days during that time where V4 had not realized R1 got out of bed and was not administered R1's lidocaine patch. The specific dates were not known, but V4 was pretty confident there were a few days that R1's patches were not administered at all. V4 said if the patch was not administered, it should not have been signed on the MAR as having been administered. On 4/14/26 at 2:26 PM, V2 (Director of Nursing) said when R1 would refuse the lidocaine patch, staff would not reattempt applying R1's lidocaine patch.Facility Medication Administration policy dated 10/25/14 states, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so.

Based on interview and record review the facility failed to transfer a resident in a safe manner for 1 of 3 residents (R1) reviewed for falls in the sample of 3.The findings include:R1's electronic face sheet shows R1 has diagnoses of right lower leg wound, dementia, stroke and history of transient ischemic attack.R1's care plan dated 12/2/25 stated (R1) has an ADL self-care performance deficit r/t Dementia and weakness, TOILET USE: R1 is dependent with 2 staff for toileting.A progress notes dated 12/10/25 documents: 1445-CNA came out to patients' room to let this nurse know that patient was on the floor in her bathroom CNA and another nurse went to assist patient, and patient was put back in her wheelchair.On 12/16/25 at 10:53 AM V8 (License Practical Nurse-LPN) said she was R1's Nurse working last 12/10/25 when she saw V7 (Certified Nursing Assistant-CNA) coming from R1's room. R1 was on the floor. V8 said by the time she got to R1's room, R1 was already back in her wheelchair.On 12/16/25 at 11:05 AM, V7 said she was the CNA working when the incident happened. V7 said she placed R1 to the bathroom with another staff (cannot recall who the staff was.) When R1 was done using the bathroom, there was no staff available, V7 said she decided to transfer R1 by herself and without using a gait belt. V7 said she instructed for R1 to grab the bar in the bathroom. V7 said as she pulled R1 up, R1's legs gave out, and R1 fell to the floor. V7 said because she did not use a gait belt there was no way she can hold unto R1. V7 said she went out and asked for help. 2 Nurses came to help get R1 up from the floor. V7 said the DON (V2) fired her due to the incident.On 12/16/25 at 2:30 PM, V10 (LPN) said she was one of the Nurses working on 12/10/25 when R1 fell. V10 said she heard a commotion coming from R1's room. V10 said she ran to R1's room. R1 was in the bathroom holding unto the grab bar, R1 was already kneeling on the floor, R1 was crying in pain, her legs were trapped between the toilet seat and the grab bar. The CNA (V7) was by R1, no gait belt was noted in R1's waist. Due to the small space, the mechanical lift cannot fit in the bathroom. V10 said she went to get another staff to help with R1-(V11) LPN came to help and R1 was safely assisted back to her chair with 3 staff. V10 said R1 had no noted injury but had a small skin tear to her left arm.On 12/16/25 at 9AM, V11 (LPN) said she was one of the Nurses who assisted R1 back to her wheelchair. R1 was a 2 staff assist for toileting. The CNA (V7) transferred R1 to the bathroom by herself without using a gait belt. R1 was a 2 staff assist for all transfers. R1 was found on the bathroom floor. R1 did not have the strength to stand up. It took 3 staff to move R1 to her wheelchair safely. On 12/16/25 at 11:30 AM, V2 (Director of Nursing) said V7 knew R1 was a two staff transfer. V7 also did not use a gait belt. The facility has zero tolerance for unsafe transfers. V7 was no longer employed at the facility. V2 said R1 had a small skin tear treated at the facility. The facility policy on Safe Lifting and Movement of Residents dated 2017 documents, to protect the safety and wellbeing of staff and residents, and promote quality care, this facility uses appropriate techniques and devices to lift and move residents.

Based on interview and record review the facility failed ensure a thorough assessment was performed for a resident sustaining a fall and failed to identify an acute fracture prior to sustaining a second fall. This failure resulted in R3 sustaining a fall with x-ray results showing a right hip impacted subcapital fracture of right femoral neck without staff identifying and reporting her injury and sustaining a 2nd fall approximately two days later delaying emergency care and services. This applies to 1 of 3 residents (R3) reviewed for quality of care in the sample size 18. The findings include: R3's face sheet shows diagnoses including Alzheimer's, unspecified intracapsular fracture of right femur, subsequent encounter for closed fracture with routine healing, unspecified fracture of left pubis, palliative care, anxiety, muscle weakness, unsteadiness on feet, repeated falls and hypertension. R3's Fall Risk assessment dated [DATE] shows she is high risk for falls. R3's Final Incident Report dated 10/10/25 shows on 10/5/25 approximately 12:45 PM, (R3) was observed laying on right side in the dining room. Assessment revealed limited range of motion (ROM) to her right lower extremity.(R3) sent out to the local hospital x-rays shows a right femur fracture. (R3's report does not include her first fall on 10/3/25 and the x-ray results on 10/4/25 showing a right hip fracture). R3's hospital records dated 10/5/25 shows (R3) had multiple ER visits for recurrent falls who presented after a fall unwitnessed fall from her wheelchair. Nurse that assessed her noticed she was crying when moving her lower extremities.reported another fall on 10/2 or 10/3.decreased ROM to right hip about 10 degrees flexion limited by pain.right lower extremity appears shorter and externally rotated.right x-ray shows subcapital femoral neck fracture with varus angulation. R3's X-Ray report dated 10/4/25 shows right hip impacted subcapital fracture of right femoral neck with varus deformity. On 11/24/25 at 10:05 AM, V14 (Registered Nurse/RN) said on 10/3/25, she was R3's nurse when she fell from her bed. After the fall R3 was rubbing her right hip and wincing in pain and could not verbally communicate. R3 said she was working with V21 (Agency RN) who did the fall follow up documentation. V21 had a lighter assignment and has lots of nursing home experience and we were working together as a team. V14 said V21 has a lot more nursing home experience than her and V21 was helping her assess R3. V14 said she was R3's primary nurse and did not document the fall in the medical record at that time because V21 said she would document R3's fall. V14 said she was asked to put in a nursing note by the facility because there was no documentation regarding her fall on 10/3/25. V14 said she put in note on 10/13/25 (ten days later) because she was told to by management. She could recall R3 having pain to her right hip but does not recall any changes to her right lower extremity. On 11/24/25 at 9:09 AM, V21 (Agency RN) said on 10/3/25, she offered to help V14 (RN) because she was behind and really struggling. V21 said she put in some orders and notified the provider of the fall. V21 said she did not assess R3 following her fall and was not R3's nurse. When a resident falls, nursing should assess the resident including vitals, pain, check range of motion, notify the family, and physician. On 11/25/25 at 7:00 AM, V13 (RN) said she was R3's nurse on third shift after she fell on the previous shift. V13 said when she arrived, R3 was sitting at the nurse's station, she was having obvious pain to her right hip. R3 was guarding her right hip. When x-ray arrived R3 was transferred to her bed. V13 said she assisted R3 into bed, I don't remember how R3 was transferred back to bed but said she had a change in her transfer status but could not recall the details. V13 said she does not remember assessing R3's right leg and she received the x-ray results by fax and remembers there was no evidence of a fracture. My memory of the night is not good. V13 said after a resident sustains a fall, post fall monitoring includes checking rom (range of motion), pain, and monitoring for any changes. V13 said she should have done an assessment on R3 and documented her findings in the medical record. V14's nurses note late entry date 10/13/25 (10 days later) documents on 10/3/25 .(R3) at foot of bed right hip in contact with floor. Assisted back to bed with CNA.(R3) indicating via gesture that hip is painful.V21's nurses note dated 10/3/25 at 8:14 PM, documents order received for x-ray of right hip and leg related to fall in resident bedroom.V13's nurses note dated 10/4/25 at 6:33 AM, documents (R3) continue to have guarding leg and hip. STAT (urgently) X-ray performed, and report shows no recent fracture or dislocation. X-ray results placed in V19's (Nurse Practitioner) folder for review. The next nurses note dated 10/5/25 at 1:39 PM, shows (R3) had an unwitnessed fall in the dining room.(R3) observed laying on her right side.has limited ROM (range of motion) bilateral lower extremities, crying out when bilateral lower extremities are moved.sent to the local hospital. R3's electronic medical record shows from 10/3/25 to 10/5/25 there was no assessment of her right lower extremity until her 2nd fall on 10/5/25. R3's Pain Assessment Record dated 10/3/25 to 10/5/25 shows pain score of 4 to 8 recorded. R3's hospital records dated 10/5/25 shows (R3) had multiple ER visits for recurrent falls who presented after a fall unwitnessed fall from her wheelchair. Nurse that assessed her noticed she was crying when moving her lower extremities.reported another fall on 10/2 or 10/3.decreased ROM to right hip about 10 degrees flexion limited by pain.right lower extremity appears shorter and externally rotated.right x-ray shows subcapital femoral neck fracture with varus angulation. On 11/24/25 at 2:25 PM, V19 (NP) said she was not aware of R3's hip fracture on 10/4/25. She would expect staff to notify her of the x-rays results and assess residents after a fall to monitor for injuries. On 11/24/25 at 11:13 AM, V16 (Nurse Manager) said she is the fall coordinator, when a resident falls nursing should assess the resident and document in the progress notes. Post fall monitoring should occur every shift for 72 hours to monitor for changes and document their assessment. R3 was a high risk for falls with frequent falls. R3 had a fall on 10/3/25 in her room, she is not sure what happened with her fall because the nurse did not document the fall at the time. V2 (DON/Director of Nurses) spoke to the nurse about her assessment and her lack of documentation and follows up on the falls with injury. V16 said R3 had a 2nd fall two days later 10/5/25 with an injury. Staff should send out a resident to the ER right away if the x-ray results show a fracture and report it the physician. Imaging usually calls the facility to report fractures. She is not sure why R3 was not sent after her x-ray results showed a right femur fracture on 10/4/25. On 11/24/25 at 12:47 PM, V2 (DON) said she was not aware of R3's right femur fracture on 10/4/25 until she started printing out the documents today. V2 confirmed R3's x-ray dated 10/4/25 shows a right femur fracture and V13 documented there was no fracture. When she pulled the hospital report she assumed the fracture was from the 2nd fall. V2 said she was aware of R3's fall on 10/3/25 and was made aware V14 did not document R3's fall assessment. V2 said staff should document and assess a resident after falling, with post fall monitoring for 72 hours, monitor for changes and notify the x-ray reports. We have a problem with nursing not assessing, monitoring or reporting x-results. The facility's Fall Clinical Protocol Policy dated 2008 states, Assessment and Recognition as part of the initial assessment, the physician will help identify individuals with a history of falls and risk factors for subsequent falling.in addition, the nurse shall assess and document/report the following: vitals, recent injury especially fracture or head injury, musculoskeletal function, observing for changes in normal range of motion, weight bearing., etc., pain.monitoring and follow up.the staff with the physicians guidance, will follow up any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved. The facilities Notification of Change Guidance Policy dated 2024 states, It is the practice of this facility that changes in a resident condition or treatment are immediately shared with the resident and/or the resident representative.and are reported to and consulted with the attending physician.an accident involving the resident, which results in injury and has the potential for requiring physician intervention.

Based on interview and record review the facility failed to ensure residents were treated with dignity by answering call lights in a timely manner. This applies to 4 of 4 residents (R15, R16, R17, R18) reviewed for dignity in the sample of 18. The findings include: On 11/25/25 at 11:30 AM R15 stated, It takes a long time, but I do not know how long because I do not have a clock. It feels like at least 20 - 30 minutes most of the time. It is worse during shift change or when they are on their breaks. I lay in wet diapers quite a while- all the time. They often come in and turn the light off and say they will be back and sometimes they come back and sometimes they don't. It is not good. Some are very nice and others are not. Some do not want to listen to what I want them to do. One girl yesterday threatened to leave the room and not come back.On 11/25/25 at 11:40AM R16 stated, Sometimes an hour- usually a little less. Sometimes I wet my pants because I have to wait so long. Makes me feel helpless. Nighttime I think is the worst. Some of the staff are nice, some are very rude. They are really good at turning off the call lights. I tell them as many times as they turn them off; I will turn it back on.On 11/25/25 at 11:45AM R17 stated, I have waited anywhere from 15 minutes to 2 hours to have my call light answered. This IV has been beeping for 30 minutes now. The nurse said she was going to set a timer on her watch so she could come and turn it off. (continued to beep until Surveyor reported to nurse at 12:15PM). I have a catheter and a stoma, so I have that going for me but when I put my call light on, I usually need a pain pill, or I need to be repositioned in the bed. When they don't come it makes me feel like I have no value, like my concerns and my needs are immaterial. They said that whenever a CNA (Certified Nurse Assistant) walks past the room and my call light is on, they should be checking to see what I need. That never happens. My doctor is currently looking for another place for me to live.On 11/25/25 at 12:00PM R18 stated, Sometimes the call light doesn't get answered at all and I try to make it to the bathroom on my own. It is either that or wet the bed. Plenty of time I have dribbled in my Depends because I can't get there in time. What does that sign say? (Sign on the bathroom door reads- Wait for the nurse, don't get up alone. Well sometimes that is not possible. I always tell them they are going to have a bigger mess to clean up if they don't come in time. I have fallen a couple of times, and I am afraid it will happen again. But I have to go to the bathroom. If they just take me in there then I will find my way back. Sometimes that light in there (bathroom) is still going off 15-20 minutes after I have gotten myself back in the bed.The facility Residents' Rights for People in Long-term Care Facilities Pamphlet given to residents on admission to the facility stated, Your facility must provide services to keep your physical and mental health, and sense of satisfaction.

Based on observation, interview and record review the facility failed to ensure sterile catheter dressing changes were performed for a resident with a PICC (Peripherally Inserted Central Catheter) this applies to 1 of 3 residents (R2) reviewed for central lines in the sample of 18. The findings include: On 11/21/25 at 8:28 AM, R2 was in her room lying in bed. R2 said she had a PICC in her left upper arm placed on 9/16/25, because she had infection in her knee, and she was getting IV antibiotics. The staff were not changing the dressing weekly. She told the staff it needed to be changed weekly, and they said they did not know how to do change the dressing because they were not RN's (Registered Nurse's). R2 said her PICC line was removed because it got clogged.On 11/21/25 at 9:40 AM, V11 (RN) said PICC line dressings should be changed once a week. Only RN's can change the dressing on PICC lines and there should be an order when to change the dressing. On 11/21/25 at 3:05 PM, V2 (Director of Nursing-DON) said R2 had a PICC line for IV antibiotics. V2 said residents with PICC lines should have weekly dressing changes. V2 said nursing should put in the order to change the PICC lines to ensure the dressing is done. V2 confirmed R2 did not have orders entered to change her PICC line dressing weekly and R2's dressings were not done. R2's Vascular Access Order/Consent is dated 9/16/25 for insertion of her PICC line. R2's Physician Order Sheets dated October 2025 shows there is no order to change her PICC line dressing. R2's Medication Administration Record (M.A.R.) shows on 10/21/25 orders to discontinue PICC line and IV antibiotics for treatment of a wound infection. The facility's Central Venous Catheter Dressing Changes Policy revised 2016 states, Central venous catheter dressings will be changed at specific intervals, or when needed, to prevent catheter-related infections.dressings must stay clean, dry and intact.change transparent semi-permeable membrane dressings at least every 5-7 days and PRN (as needed when wet, soiled or not intact). equipment and supplies to replace sterile dressing.sterile central venous catheter dressing kit. The following information should be recorded in the residents medical record: date and time the dressing was changed, location and objective of insertion site .signature and title of the person recording the data.

Based on interview and record review the facility failed to administer medications as ordered by the resident's physician. This applies to 1 of 3 residents (R1) reviewed for medication administration in the sample of 13.The findings include: On 11/21/25 at 9:45 AM R1 stated, It took 11 hours for me to finally get my Depakote. It was on September 20th. I talked to the night shift and then the day shift and then the swing shift and no one had time to give me my medication. Finally, it was given to me after Bingo (after 2PM). I should get it twice a day at 8AMand 8PM.On 11/21/25 at 3:15 PM V8 (Ombudsman) stated, I know she was really upset when she went the whole day without getting her medications.On 11/21/25 R1's Medication Administration Record for September was reviewed and shows no initials for the administration of Depakote (Anticonvulsant) 125 milligram (mg) at 8:00 AM or 8:00 PM on September 20, 2025. This same form also shows no initials for the administration of R1's Bupropion XL (Antidepressant) 300mg at 8:00 AM or her Abilify (Antipsychotic) 2mg at 8:00 PM. On 11/21/25 V2 (Director of Nursing) confirmed that V7 (Agency Nurse) was the nurse assigned to administer R1's medications on September 20, 2025. On 11/21/25 Surveyor called V7 and left a message with a request to return the call. No return call was received prior to survey exit on 11/25/25.

Based on interview and record review the facility failed to initially identify a pressure ulcer and put interventions in place to prevent the area from worsening for a resident at high risk for developing pressure ulcers. This applies to 1 of 3 residents (R5) reviewed for pressure ulcers in the sample of 18. The findings include: R5's EMR (Electronic Medical Record) shows that R5 was admitted to the facility on [DATE] with diagnoses including right femur fracture, second lumbar vertebrae fracture, right acetabular fracture, complicated by acute hypoxia, respiratory failure and hypokalemia following a motor vehicle accident. R5 was discharged back to the hospital on [DATE] due to hypokalemia and elevated white blood cell count. R5's Wound Assessment Details Report dated 11/11/25 shows that R5 has a left buttocks wound measuring 9.0 x 11.0 x 0.10cm (centimeters) with a scant amount of serosanguineous exudate. The wound is described as facility acquired MASD (moisture associated skin damage).The Wound Physician Assessment also dated 11/11/25 states, Patient presents for initial evaluation of left gluteal wound. Onset/Duration: ?1week, Initial etiology: pressure, Drainage: minimal, Odor: present. The affected area demonstrates moisture associated skin damage (MASD) with superficial epidermal erosion consistent with prolonged exposure to moisture and irritants. Appearance: Irregular partial-thickness skin breakdown with erythema, maceration and superficial denudement. No full thickness tissue loss is present.On 11/24/25 at 10:00AM V16 (RN/Registered Nurse- Nurse Manager) stated, (R5) was here after a bad Motor vehicle accident- here for wound care and therapy. He was moved after the first day because with his bariatric bed and the mechanical lift the room he was in was just too small. He had a bariatric bed with an air mattress from (DME company). The bed had some issues, and you had to hold the cord in a certain way to get it to go up and down and about 2-3 days before he left for the hospital the air mattress had kept inflating and deflating. So, on a Friday (11/7/25) night I know they moved him to a regular mattress so he would be comfortable to sleep. I don't know how long he was on the regular mattress, but I know the wound care nurse wanted him on the air mattress. He came in with a surgical wound to his right hip, a DTI (Deep tissue injury) to his right heel and then he acquired MASD to his left buttocks. He required turning and repositioning. He was alert and oriented and was getting therapy but was not too keen about getting out of bed. On 11/24/25 at 11:00AM V20 (Medical Records) stated, The bed was not going up and down, so I contacted (company). I don't have control over when they come - all the nurses know that. I put in the requests, but they come out when they can. I requested the bed to be repaired on 11/6/25 and they came on 11/6/25. I requested the mattress to be fixed on 11/11/25 and they came out but they brought the wrong size mattress, so they came the next day (11/12/25) with the right one.On 11/24/25 at 11:30AM V17 (LPN/Licensed Practical Nurse - Wound Care) stated, (V18) did the initial assessment for everyone. I did a skin assessment the day after (R5) got here - on 11/6/25. Then (V18) did the assessment and said it was MASD when (V18) said his butt was hurting so we looked at it. He wasn't moving much on his own- he was complete assist with movement- his wife would often say he was in too much pain and just leave him, but he also didn't make much effort. He was not eating much- I remember talking to him about his wounds and trying to get them to heal- he had been in the hospital a while and we wanted him to eat so he could get better. I would often see his breakfast tray, and he would say he wasn't hungry.On 11/24/25 at 12:40PM V2 (Director of Nursing) stated, (R5) was here following a motor vehicle accident. He was here for therapy. He was non weight bearing so the main focus was bed mobility. They notified me that the mattress was broken- it was over a weekend, and they put him on a regular mattress- they had a hard time getting him a new one and I called (DME company) and got him one within 45 minutes. The wound doctor (V18) was here, and (R5) had MASD on his buttocks and he debrided it. (V17) said he scraped it off. R5's Braden Scale for Predicting Pressure Sore Risk dated 11/5/25 shows that R5 was High Risk. The facility policy entitled Prevention of Pressure Wounds dated January 2017 states, Pressure injuries are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area and subsequent destruction of tissue.

Based on observation, interview, and record review the facility failed to assess, document, notify the provider, and monitor an injury of unknown origin for 1 of 3 residents (R1) reviewed for quality of care in the sample of 5. This failure resulted in R1 exhibiting signs of an injury (bruising, pain with movement of left arm) for three days before the facility notified the provider and obtained an order for an X-ray. R1's X-ray showed a non-displaced fracture of her left humerus (upper arm). The findings include: On 7/3/25 at 11:01 AM, R1 was seated in a padded, reclining wheelchair. R1 had a sling to her left arm. V5 (Unit Manager) explained to R1 that we needed to look at her arm. V5 unhooked R1's sling, removed her left arm from the sling, and exposed the skin to R1's upper arm. R1 had yellow bruising noted to her entire left upper arm, from her shoulder down to her elbow. R1 was unable to tell the surveyor what happened to her arm. The surveyor asked if R1's arm hurt and she replied, Only hurts when you move it. The facility's Final Report related to R1's injury of unknown origin showed R1 was found to have pain upon palpation of her left upper arm/shoulder area where results showed a fracture involving the head of the humerus with no displacement. This document showed that R1 had severe cognitive impairment and was unable to recall any falls or incidents. This document showed that R1's POA chose conservative treatment of this injury and she was treated at the facility. This document showed R1 does have non-verbal indicators of pain with movement. R1's Facesheet dated 7/3/25 showed diagnoses to include, but not limited to stroke with left sided weakness, diabetes, hypertension, dorsalgia, gastroparesis, osteoarthritis, macular degeneration, insomnia, anxiety disorder, vascular dementia, recurrent depressive disorder, and fracture of upper end of left humerus (6/20/25). R1's facility assessment dated [DATE] showed she had severe cognitive impairment and was dependent on staff for toilet hygiene, personal hygiene, bed mobility, and transfers. R1's Care Plan started 2/25/25 showed R1 needed assistance with daily ADL (Activities of Daily Living) care. This document showed R1 was a total mechanical lift with assistance of two staff for transfers and required total assistance of one staff for bed mobility. R1's Pain Care Plan initiated 6/20/25 showed R1 had a fracture to her left humerus (upper arm) which places her at risk for uncontrolled pain. R1's Progress Notes dated 6/20/25 showed, While CNA (Certified Nursing Assistant) was getting [R1] up and ready, she noticed that her skin on her left upper arm was yellow from shoulder to elbow. Writer noted that she had a small bruise on her left arm on the 18th. (there were no notes on 6/18/25 related to R1's bruise). NP (Nurse Practitioner) notified. 2 view X-ray ordered. Incident Report was complete . This note was modified on 6/21/25 at 12:45 PM (after the facility received R1's X-ray results showing a left humerus fracture). R1's progress notes did not contain any assessments or monitoring of R1's bruise to her left arm prior to 6/20/25 (Staff interviews showed R1's bruise was first reported 6/17/25). R1's Skin Evaluation Form dated 6/20/25 showed R1 had a 30 cm x 15 cm yellow/reddish bruise to left arm from shoulder to elbow. This was the first skin assessment completed on R1's left arm. R1's Radiology Report showed the date of service was 6/20/25 and the results were reported on 6/21/25 at 5:50 AM. This reported showed R1 had a recent proximal left humerus fracture with no displacement. The R1's facility Investigation Notes showed interviews with staff were documented on 6/23/25 and 6/24/25. These notes showed that V9 (LPN - Licensed Practical Nurse) was notified of R1's bruise on 6/17/25. These notes showed V12 (CNA) reported a big yellow bruise to V7 (LPN) on 6/17 or 6/18/25. These notes showed V7 was notified R1 had a bruise on 6/17/25 during report. These notes showed V8 (RN - Registered Nurse) said R1 had an 8 cm bruise (red), but had no idea how it happened. These notes showed V11 (CNA) returned from vacation on 6/18 and told V9 (LPN) she saw a bruise, but V9 said she already knew about it. These notes showed V5 (Unit Manager) was first made aware on 6/20/25 of a yellow bruise and red spot on top of R1's shoulder and lower upper arm and had the nurse call the NP for orders for an X-ray due to bruising and pain (three days later). R1's June 2025 MAR (Medication Administration Record) showed on 6/21/25 at 11:51 AM Tylenol 650 mg was administered for pain rated 4 on a 1 to 10 scale (10 being worst pain). R1's Provider Note dated 6/23/25 showed R1 was seen for a follow-up and newfound humerus fracture. R1 was noted with a bruise and yellowing discoloration of her shoulder therefore an X-ray was obtained. The nursing staff was unaware of an injury and there were no recent falls. The X-ray showed a fracture involving the neck of the humerus with no displacement, the shoulder joint was grossly intact. This note showed R1's fracture was likely pathological and conservative treatment measures were initiated. R1 had an order for a sling, pain management, and recheck an X-ray in 4-6 weeks. On 7/2/25 at 2:58 PM, V6 (LPN) said he usually works 2nd shift on R1's hall. V6 said he wasn't sure of R1's orientation status because she doesn't talk to him much. V6 said he gives her medications and that's about it. V6 said last week there was an issue with R1's being bruised. V6 said they did an X-ray and R1 had a fracture. V6 stated, We've all been racking our brains trying to figure out how that could have happened. V6 said whenever a resident has a new skin issue noted the nurse should immediately do an assessment on a Skin Assessment form and include a description of the wound and measurements. On 7/2/25 at 3:02 PM, V7 (LPN) said she floats all over the facility. V7 said when she has to take R1's blood pressure her arms seem very stiff. V7 said if a resident had a new bruise and was showing signs of pain then she would call the NP and notify them of the situation. V7 said she would follow the orders given by the NP. (The facility's Schedule showed V7 was R1's 3-11 PM nurse on 6/17/25 and 6/18/25. R1's EMR (Electronic Medical Record) did not contain documentation regarding R1's bruise prior to 6/20/25). V7 said she didn't recall when R1's bruising started and doesn't remember if she was in pain. On 7/3/25 at 8:57 AM, V9 (LPN) said she was assigned to R1's hall on 6/17/25. V9 said she was doing rounds when V10 (CNA) came and reported that R1's left arm was bruised and yellow when she got her up. V9 said she went in the room with V10. V9 said R1's whole deltoid was bruised and yellow. V9 stated, I thought well that's an old bruise. I asked [R1] are you in any pain,does it hurt. She said No. [V10] continued to get her up. My thinking was that it had already been addressed because it looked like an old bruise. When the oncoming nurse came in (V7-LPN), I did tell them in report. I told her [R1's] arm is bruised, it's old, it's yellow. I'm not on the same hall everyday, so 3 days later I was on that hall again. The X-ray report came off the copier and it showed [R1] had a fracture. I was stunned because it was an old bruise. I proceeded to notify [V4-NP]. I notified her daughter and it was decided to do conservative treatment. V9 said R1 had a stroke and her left side is week. V9 said she didn't do full ROM (Range of Motion) because that's R1's stroke side. I did move her arm up off her breast and lifted her arm. She didn't complain of pain at that time. I don't know what happened and [R1] wasn't able to tell me. She can make her needs known and she could tell me if she was having pain. V9 stated, That's all I know about it. I was gone on vacation. I saw it was an old bruise and wondered what the heck happened. That bruise should have been reported and addressed prior to me seeing it. It was yellow. On 7/3/25 at 10:36 AM, V8 (RN) said R1 knows herself, her daughter, and V8. V8 said R1 will say good morning to her and can answer yes or no questions, but her communication is limited at times. V8 said R1 had a stroke and she doesn't use her left arm. V8 said R1 can hold her left arm with her right when they use the total mechanical lift, but R1 is dependent on staff for most ADLs. V8 said she wished she remembers what the date was when she first saw R1's red bruise. V8 said R1 had an 8 cm, red bruise here (pointed to her left deltoid (upper arm area). V8 said she should have charted something, but she doesn't remember if she did or not. V8 said new skin concerns should be charted to keep track of the progress. V8 said a few days later R1's arm was yellow from her shoulder to her elbow. V8 stated, I know I charted the yellow discoloration on 6/20/25. V8 said on 6/20/25 R1's CNA reported the yellow bruise to me and came in with me to look at R1's arm. V8 stated, It was just a red bruise before and now it was all yellow from her shoulder to her elbow. It looked like the stage of bruise where it's starting to heal. V8 said V4 (NP) ordered a X-ray and R1's arm was fractured. V8 said she was not aware that R1 was in pain. On 7/3/25 at 10:51 AM, V5 (Unit Manager) said if a resident had a new bruise, then the staff should report it to her, especially if it is big. V5 said a 6-8 cm bruise in an unexpected location or appearing suspicious would be concerning. V5 said she would expect the nurse to call the Provider and the resident's family. V5 said the nurse should document an assessment in the progress notes or on a Skin Assessment. V5 said the nurse should document the assessment (size, appearance and location of the bruise), who they spoke with, the outcome, and any follow-up required. V5 said the purpose of documenting was to communicate with the care team and to track the progress of the wound. V5 said the nurse could review the notes to see if the Provider was aware of the bruise and what interventions or orders had been completed. V5 said she didn't see any notes regarding R1's bruise prior to 6/20/25. V5 said R1's first skin assessment was the one she completed. V5 said she would expect that R1's bruise was documented when it was found. V5 said she had no idea what happened to R1's arm. V5 said she wasn't notified of R1's bruise until 6/20/25. V5 said she had the nurse call the Provider and that was when the X-ray was ordered. V5 said bruises usually start a red or purple color then the colors and shape will change throughout the healing process. V5 said a yellow bruise means it's healing and happens later in the process. V5 said R1 was on blood thinners and she would expect that her bruise was documented when it was found and properly follow-up was completed. V5 said the CNAs should be observing the resident's skin during care and reporting any concerns to the nurse. On 7/3/25 at 11:14 AM, V10 (CNA) said she returned to work after some time off and saw R1's arm was a weird yellow color. V10 stated, I didn't know what it was and I reported it right away to the nurse. I went in with the nurse and she said, oh that's an old bruise. She said she was going to check the chart, but I never heard anything. She didn't seem too concerned, so I forgot about it. Days went by and I heard she (R1) broke her arm. It's so weird. V10 said R1 doesn't talk a lot, but she can answer yes or no. V10 said R1 needs total assistance with all care. V10 said night shift will usually get R1 cleaned up and dressed and the day shift will get her up in the chair for breakfast. On 7/3/25 at 1:09 PM, V12 (CNA) said she R1 will communicate with you if you make eye contact and give her time to answer. V12 said if you don't, then she will hold her head down and say nothing. V12 said R1 was total care because one side is paralyzed. V12 said she saw a bruise on R1 and reported it to V7 (LPN). V12 said R1's upper arm was yellow and darkish in color in the back of her arm. V12 said the discoloration when into her left shoulder. V12 said she asked R1 if she hurt her arm and she didn't answer. The nurse said they knew about it. She didn't do anything. V12 said when R1 is turned side to side for care, she will tense up her body. V12 said R1 usually gets up for breakfast and stays up until 1:30, then she lays down until dinner and goes back to bed around 6:30 PM. V7 said R1 can answer yes or no questions, but she isn't very conversational. V12 said a week after she reported the bruise to V7 she found out R1 had a broken arm. V12 said she showed V7 R1's shoulder and everything and she said they knew. She didn't seem concerned about it. On 7/3/25 at 1:22 PM, V11 (CNA) said R1 only speaks one or two words but could make her needs known. V11 said she might night be able to relay the full details, but you could figure out what she wanted. V11 said R1 was paralyzed on her left side, was total care, and required a lift to get out of bed. V11 said she was on vacation and returned to work on 6/18/25. V11 stated, I reported to the nurse and I was told it was something old. The nurse told me that [V10-CNA] had mentioned it a couple days before. There was no bruise before my vacation, but when I came back, I noticed it. I asked her what happen and she didn't say anything. When we turn her side to side she would say, Ow, my arm hurts or Ow my arm. The bruise was green, yellow, and purple when I saw it. It was her shoulder and upper arm, near her arm pit. I think the nurse was [V9 - LPN], but she said she knew and had reported it. I assumed she did whatever she needed to do. Then after that we started to put a sling on her arm. On 7/3/25 at 1:31 PM, V15 (CNA) said she worked R1's hall 6/14, 6/15, and 6/16 and she didn't see any bruising. V15 said the following Monday (6/16) or Tuesday (6/17) she was helping a CNA get R1 out of bed and she pointed out the bruise on R1's arm. V15 stated, I moved her (R1's) arm out just a touch to look at the bruising and she said, Ow. I stopped moving her arm. She'd never done that before. The CNA was [V11] and I let the nurse know. [V8] was the nurse. I left the room and the nurse went in. V15 said she just moved R1's arm to see how far the bruising went and she said, Ow. V15 said it looked like a big purple bruise on her bicep and it was yellow around it from her elbow to her shoulder. V15 said the CNAs look at the resident's skin during care and notify the nurse if they see anything unusual. V15 stated, I'll make sure the nurse comes before I finish what I'm doing. I'm not on the floor often so I make sure to report concerns so it can get documented and checked on. On 7/3/25 at 1:58 PM, V17 (Quality Director) said she wasn't directly involved in the investigation but V2 (DON - Director of Nursing) was not available for interview. V17 said the facility was unable to determine the cause of R1's fracture. The surveyor asked V17 when the facility because aware of R1's bruise. V17 replied, looking at the Investigation Notes it looks like around 6/17/25. The surveyor asked V17 what the nurse was expected to do if there was a new 8 cm red bruise on a dependent resident's upper arm. V17 replied the nurse should update the Provider, try to determine the potential cause, and document an assessment of the bruise. The documentation should include the location, size, and appearance. V17 said the documentation is a form of communication across the care team and is done to make sure the bruise is resolving and spreading further. V17 said newer bruises are generally darker in color, like a purple or red color, and as the bruise goes through the healing process it turns different colors. V17 said if R1 complained of pain when her arm was moved, then that should have been reported to the Provider immediately. V17 said the nurse may need to give pain medications and obtain orders for an X-ray, especially if the bruise was larger in size. V17 said there should have documentation of R1's bruise assessment, provider notifications, and potential interventions prior to 6/20/25. V17 said an undiagnosed fracture could pain surrounding the area, the fracture could worsen, and not heal properly. V17 said the Event printout showed R1's bruise was reported on 6/20/25, but the staff should have reported it sooner. On 7/3/24 at 2:13 PM, V4 (NP) said she was familiar with R1's care and sees her regularly. V4 said she saw R1 after her fracture. V4 said she was unsure of the exact date, but she was notified by nursing staff that R1 had discoloration of left arm into her armpit. V4 said the nursing staff reported there had been no incidents or falls. V4 said she gave orders for an X-ray the day she was notified (6/20/25). V4 said R1 had a history of a stroke and moves minimally. V4 said R1's movement was restricted on her left side. V4 said due to R1's increased weakness on the left side and her history of stroke R1 was at a high risk of developing a pathological fracture. The surveyor asked V4 if the facility notified her prior to 6/20 of R1's pain with movement of her left arm and the bruising that was first noted 6/17/25. V4 said she was not notified of R1 bruise and pain with movement prior to the day she ordered the X-ray (6/20/25 - 3 days later). V4 said she would have expected the facility to notify her. The facility's Skin Identification, Evaluation, and Monitoring Policy approved 5/2025 showed, The purpose of this policy is to outline a method of identification, evaluation, and monitoring for alterations in skin integrity . Procedure: Licensed nursing associate will evaluate the skin integrity through a physical skin evaluation and use of the Braden Skin at Risk tool. Upon admission, weekly for three weeks, quarterly, and when a significant change is identified. The nursing assistant will observe the resident's skin when assisting with activities of daily living and report changes to the nurse . The Licensed Nursing Associate: A. Complete a General Skin Check to evaluated for changes in skin integrity. B. Document in medical record the finding of general skin check . a. Document integumentary findings. i. Appearance of the wound, including measurements . 2. If new wound is identified . b. Notify health care provider of findings for further treatment orders. 3. Notification/Education of resident and resident representative of finding and physician orders. 4. Document evaluation in medical record . The Certified Nursing Assistant (CNA) should: A. Observe skin for changes when assisting with activities of daily living . D. Report skin integrity changes to the nurse . The facility's Change in Resident's Condition or Status Policy approved 1/2024 showed, Our community shall promptly notify the resident, his or her health care provider, and representative of changes in the resident's medical/mental condition and/or status . Policy Interpretation and Implementation. A. The nurse will notify the resident's health care provider or physician on call when there has been an: 1. Accident or incident involving the resident. 2. Discovery of injuries of unknown source . H. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status .

4. R117's face sheet documents she was admitted to the facility on [DATE] with multiple diagnoses including the presence of a stage 3 pressure ulcer to the left buttock, a stage 4 pressure ulcer to the left lower back, stage 3 pressure ulcer to the sacral region, and stage 3 pressure ulcers to the right upper back and left lower back. On 6/4/25 at 10:25 AM, R117 was lying in her bed with an air mattress, and she was positioned onto her right side with pillows. The skin evaluation forms were requested and reviewed and show the first pressure ulcer assessments were completed on 5/8/25. On 6/5/25 at 9:24 AM, V10 RN, said when a resident is admitted with pressure injuries it is the responsibility of the admitting nurse to perform wound assessments and document them in the wound sheets. She said this should be done on the day of admission. After the initial assessment the resident is placed on wound rounds and will be seen by the wound physician and V6. She said the initial assessment should include the measurements of each wound, and the wound bed description. Based on observation, interview, and record review the facility failed to identify pressure injuries for a resident at risk for pressure ulcers, failed to identify pressure wounds prior to becoming advanced stages, failed to perform an initial wound assessment for a resident with a new pressure ulcer, failed to perform weekly assessments on pressure wounds, and failed to implement treatments upon identification of pressure wounds for 4 of 11 residents (R28, R3, R86, and R117) reviewed for pressure ulcers in the sample of 59. This failure resulted in R28's pressure wound not being treated for 26 days after it was identified and deteriorated to a stage 4 and resulted in R3's pressure wounds not being identified until they progressed to stage 3 and stage 4, and this failure also resulted in R86's sacral pressure wound not being assessed between December 2024 and March 2025 at which time it had progressed to a stage 4. The findings include: 1. R28's face sheet showed he was admitted to the facility 9/21/22 with diagnoses to include anemia, hypertension, atrial fibrillation, primary osteoarthritis of left knee, primary osteoarthritis of left hip, and pressure ulcer of right ankle. R28's care plan initiated 10/3/22 showed, Risk for impaired skin integrity due to incontinence and decreased functional mobility . Approaches: . Daily skin inspection; report any changes in skin or signs of possible skin breakdown or redness . Nutritional support based on assessment and MD (physician) orders . R28's care plan initiated 5/21/25 showed, Pressure Ulcers/Skin Prevention . [R28] has a stage 4 pressure wound to sacrum. Factor complicating wound healing include impaired mobility and occasional incontinence . R28's Dietary Note entered 3/27/25 by V4 (Registered Dietitian) showed, Patient with pressure wound to coccyx . To promote skin health, additionally this writer recommends Active Liquid Protein 60ml/daily. This will provide 200 calories and 30 grams of protein . R28's medical record showed no evidence of R28 receiving the Active Liquid Protein supplement. R28's Wound Assessment Report dated 2/15/25 showed, Date wound identified: 2/15/25 . Wound Location: sacrum; tunneling wound . Present Upon admission: No . Measurements: Length 0.5 cm, Width 0.6 cm, Depth 1.0 cm . Physician Notified: Yes Treatments: Pending treatment orders . This assessment showed no classification of R28's sacral wound. R28's medical record showed no evidence of wound assessments completed for his sacral wound between 2/15/25 and 3/13/25. R28's February 2025 eTAR (electronic Treatment Administration Record) showed no treatments for R28's wound. R28's March eTAR showed an order initiated on 3/13/25 for Hydrocolloid Dressing to Coccyx . for Open wound . (26 days after the wound was identified). R28's Skin Evaluation Form for his coccyx wound dated 3/13/25 showed, . Origin Date: 3/13/25 . Treatment: Hydrocolloid patch to coccyx . Tunneling wound to coccyx . Length 2.0 cm, Width 0.1 cm Depth 1.0 cm . Smooth undermining Sinus Tract: 1 cm . Resident noted to have reopened wound to his coccyx Area cleaned and covered with a hydrocolloid dressing until wound physician can assess. R28's Wound Physician Initial Wound Evaluation dated 3/25/25 showed, . Stage 4 Pressure Wound, Sacrum, Full Thickness . Duration: greater than 60 days . Wound size 2.0 x 0.4 x 0.9 . On 6/05/25 at 12:13 PM, V6 (Wound Care Nurse) said R28's coccyx wound was changed to a sacral wound after it was reassessed. V6 said the floor nurses do the initial wound assessments when the wound is identified on a skin evaluation form. V6 said the wound started out as MASD (moisture associated skin damage) and was real wet and nasty. V6 said the wound opened up then into pressure. V6 said she has a skin assessment for R28 dated 2/26/25 showing no existing skin issues. V6 then said she found a wound evaluation in the electronic record showing a wound assessment from 2/15/25 confirming the wound was present. V6 confirmed the assessment dated [DATE] was a wound assessment. V6 said no further assessments were documented until 3/13/25. V6 said she follows pressure wounds, vascular wounds, diabetic wounds, and arterial wounds but anything surgical, skin tears, MASD the floor nurses follow weekly. On 6/05/25 at 2:31 PM, V2 DON (Director of Nursing) said when the nurses think they see a pressure injury they are supposed to let the Wound Champion (V6) know. V6 would then go evaluate, put treatment orders in place and put him on the list to see V7. V2 said treatments should be initiated as soon as possible for the quickest possible healing for the resident. V2 said assessment of wounds is important to see if the wound has made progress, if the treatment is working, or if something needs to be changed. The nurses are supposed to be doing a skin assessment weekly and documenting the changes. On 6/05/25 at 8:50 AM, V7 (Wound Physician) said he has been seeing R28 for about a month now. V7 said he believes R28's wound was a stage 4 when he started following him. V7 said they should be discovering wounds when they are a stage 1 or 2.V7 said high protein supplements for wound healing and offloading are the two most important measures for pressure ulcer prevention and healing. 2. R3's face sheet showed she was admitted to the facility 10/10/24 with diagnoses to include muscle weakness, moderate protein calorie malnutrition, anemia, hypothyroidism, major depressive disorder, delusional disorder, anxiety disorder, and rheumatoid arthritis. R3's facility assessment dated [DATE] showed she has severe cognitive deficit and is dependent upon staff for all cares. R3's care plan initiated 5/23/25 showed, Pressure Ulcers/Skin Prevention . [R3] will maintain skin integrity without new skin related injuries over the next review period . Observe skin for redness and breakdown during routine care . Follow community skin care protocol . [R3] has impaired skin integrity, has a stage 4 pressure ulcer on sacrum, stage 3 pressure ulcer on left heel, stage 4 pressure ulcer on right heel, stage 4 pressure ulcer to right, upper, lateral shin .provide supplements to promote healing as ordered by physician . R3's medical record showed she was present in the facility from 10/10/24 through 2/23/25. R3's Wound Assessment Report dated 12/19/24 showed, . Date wound identified 12/19/24 . Wound Location: Right Heel; Left outer heel . Assessment Occasion: New Wound . Stage: Unstageable due to slough/eschar . Measurements Length 2.4 cm x Width 3.0 cm . Pain with wound/treatment: Yes . Pain Intensity: Moaning, grimacing . Wound Bed: Eschar 100%. R3's medical record showed she was present in the facility from 4/2/25 through 4/19/25. R3's Skin Evaluation Form dated 4/17/25 showed, . Origin Date: 4/17/25 . Category: Full Thickness Wound . Type: Pressure Injury . Description: Stage 3 Pressure Injury of Right Upper Lateral Shin . Cause: Pressure . Size: Length 1.5 cm x Width 0.3 cm x Depth 0.3 cm . R3's Wound Physician Evaluation dated 4/17/25 showed, . Stage 3 Pressure Wound of the Right, Upper, Lateral Shin, Full Thickness . 1.5 cm x 0.3 cm x 0.3 cm . Duration: greater than 2 days . On 6/05/25 at 12:26 PM, V6 (Wound Care Nurse) said a skin check is done on admission and they put all the same wounds in all over again. V6 said R3 had an immobilizer in place at one time to her right leg from some fractures. V6 said she is not sure where the pressure wound came from to R3's shin. V6 said it could have been the immobilizer but she couldn't say for sure. V6 said the wound was facility acquired on 4/17/25. V6 said she expects new areas to be brought to her through the wound module in addition to notification to the unit manager or herself. On 6/5/25 at 8:50 AM, V7 (Wound Physician) said R3's wound on her right shin was caused by her being in a cast or immobilizer after a fracture. V7 said when they took the immobilizer off there was that wound. V7 said if there was an immobilizer in place covering the leg he would not be looking under that during his rounds. The facility's policy and procedure with revision date of 07/2024 showed, Pressure Injury Assessment/Treatment . Purpose: The purpose of this procedure is to provide guidelines for a consistent method of identification of and for the initial care of identified pressure injuries, alterations in skin integrity, and the prevention of acquiring additional pressure injuries . General Guidelines . Skin risk and general skin assessment is to be completed upon admission and then weekly times 4 weeks. Basic skin assessment is to be completed on residents weekly and as needed . 3. R86's electronic face sheet printed on 6/5/25 showed R86 has diagnoses including but not limited to congestive heart failure, severe protein-calorie malnutrition, pressure ulcer of sacral region, stage 4, and pressure ulcer of left lower back, stage 2. R86's facility assessment dated [DATE] showed R86 has no cognitive impairment and has a stage 2 and stage 3 wound and is at risk for pressure ulcers. R86's wound assessment dated [DATE] showed, Coccyx: irritation/excoriation 1x1x0.5cm(centimeters). Area assessed and is getting better . R86's wound physician assessment dated [DATE] showed, Stage 4 pressure wound of the sacrum, full thickness. Present greater than 30 days, 2.9x1.1x0.7cm, 2.9cm undermining, light serous exudate, 10% slough 70% granulation. Surgical excisional debridement procedure performed during this visit to remove necrotic tissue and establish margins of viable tissue . No wound assessments were present from 12/27/24-3/18/25 for R86's sacral wound. R86's care plan dated 3/19/25 (after initial wound physician visit) showed, (R86) has a stage 4 pressure injury to his sacrum related to noncompliance with repositioning in bed and refusing care. He is also incontinent of bowel. Due to his pressure injury, he is at risk for further deterioration, infection, fluid loss, and pain .float heels in bed, reposition side to side every 1-2 hours . (No pressure ulcer care plan was present for R86 prior to this date) A review of R86's treatment records dated January 2025-February 2025 showed R86's sacral wound treatment was not performed 8 days during the month of January and 4 days during the month of February. R86's skin assessment dated [DATE] showed no new areas of skin concern besides his sacral wound. On 6/4/25 at 8:39AM, R86 stated, I've been sitting like this since 4:30AM and my feet and butt are killing me. (foot of bed elevated and feet turned outward with ankles lying flat and rubbing on bed). I have sores on my butt, I came with one of them, one I think I got here; I'm waiting for them to change my dressings. (R86's right ankle was red and appeared to have a sore on it) They give me a bed bath every few days and wash my whole body because I don't to take a shower. I supposed if there were any sores on my ankles they would have seen them. I can't have my feet elevated because it hurts too much, I've tried everything, and I can't stand it. I wish I had some foam or something on my ankles. the nurse was supposed to put my dressings on my ankle at 4am and she brought the dressings and then left and hasn't been back. On 6/4/25 at 9:24AM, V3 (Registered Nurse) stated, (R86) doesn't have any orders for bandages to his ankles, he has nothing on them so there isn't a reason for a bandage. At 1:10PM (V3) stated, I did look at his ankles and he does have an open area on his right ankle now. That should have been noted during his bed bath or skin checks, but it wasn't. I put some padded dressings on to keep them covered until the wound nurse & doctor see him tomorrow. On 6/5/25 at 8:49AM, V7 (wound physician) stated, Facility acquired wounds should not be identified as stage 3 or 4, they should be identified at stage 1 or 2. (R86) has a new wound to his right ankle that is a stage 2. This should have been identified by staff during cares and his heels should have been elevated. It was resolved for a few weeks and now it is back. I am assuming because his heels are not being elevated. There are different strategies the facility could be using for pressure reduction. Some patients don't like the boots, so you need to be mindful of that, just using a heel protector is not enough, he has a special pillow, and I don't know why they aren't using it, the heels up device is the best for him but he is noncompliant with certain things. He must have something instead of the feet resting on the mattress, plain and simple. I didn't know he was refusing the heels up device otherwise I would have tried something different for him. He is a high risk for skin breakdown due to his noncompliance and lower weight because he doesn't have a lot of fat on him. They should be keeping a very close eye on him. You should not have identified his new wound, that should have been identified by the staff. On 6/5/25 at 2:47PM, V6 (wound champion) stated, I checked in our old charting system and there are not any assessments for (R86's) wound from 12/27/24-3/18/25. It is the responsibility of the floor nurse's to ensure these wound assessments and treatments are being done.

Based on observation, interview and record review the facility failed to assist a resident at risk for falls with reaching his urinal (R58), and safely transferring a resident with a mechanical lift (R23 and R2). This failure resulted in R58 falling and obtaining a fractured hip and wrist requiring surgery and hospital stay. The applies to three of eleven residents reviewed for safety in the sample of 59. The findings include: 1. The facility face sheet shows R58 was admitted to the facility with diagnoses to include adult failure to thrive, Type 2 Diabetes Mellitus, chronic kidney disease and low back pain. R58's facility assessment dated [DATE] shows he has no cognitive impairment and required maximum assist from staff for standing and toileting. On 6/04/25 at 2:18 PM, R58 said he was standing up at the foot of his bed reaching for his urinal. R58 said his legs gave out and he fell. R58 said he had his call light on because he could not reach his urinal. R58 said after half an hour he tried to do it himself and fell. R58 said he felt his hip break when he fell. R58 said he had to yell for help from the staff. R58 said because he is younger and has his wits about him the staff thinks he is independent. On 6/05/25 at 8:44 AM, V10 Registered Nurse (RN) said she was in the hall passing medications, when she heard someone yelling help me. V10 said she walked up and down the hall trying to find the source of the yelling and heard R58 yell out his room number. V10 said she found R58 on the floor at the foot of his bed near the bathroom door. V10 said she performed an assessment and felt due to the pain level, he probably had a fracture to his hip. V10 said R58's urinal was on the other side of the bed from where R58 had been sitting. V10 said she phoned 911 and R58 was sent to the hospital. On 6/5/25 at 11:22 AM, V9 Unit Manager said she investigates the falls for the facility, but if there is an injury, the Director of Nursing (DON) takes over the investigation. V9 said she did not talk to R58 about his fall, she just copied some papers for the DON. On 6/5/25 at 11:22 AM, V2 DON said during the facility investigation into the fall they determined R58 did not have his call light on. V2 said she believed R58 was in his wheelchair when the fall happened but wasn't sure. V2 said all falls are investigated to find the root cause of the fall so interventions can be put in place. The new interventions for R58 were to keep his personal items within his reach and provide R58 with a reacher/grabber tool. The facility investigation showed R58 was trying to grab something, stood up and fell. A reacher/grabber was to be given to R58 and all personal items needed to be within his reach. The nursing progress note dated 4/21/25 for R58 showed the nurse could hear someone yelling for help and she found R58 on the floor lying on his right side. The nurse (V10) wrote that R58 said he was moving around in his chair and slid out of the wheelchair. R58 said after the fall he rolled onto his other side. R58 said he broke his fall by putting down his left hand so he wouldn't hit his head. The note shows R58 was complaining of pain to his left hip. The fall risk assessment completed on admission dated 3/14/25 shows R58 was a moderate risk for falls. The hospital records dated 4/29/25 shows R58 arrived at the hospital on 4/21/25 with complaints of left hip pain after a fall at the facility. Diagnosis after x-rays showed an acute mildly displaced left hip fracture. Surgery to repair the hip was completed on 4/22/25. An x-ray of R58's left wrist was completed on 4/21/25 and a fracture to his left wrist was also found. The care plan for R58 dated 4/29/25 for falls shows the interventions to have personal items within his reach due to his risk for falls, repeated falls, weakness and malnutrition. The same care plan shows R58 required one staff assistance for toileting. 2. The facility face sheet for R2 shows she was admitted to the facility for diagnoses to include Type 2 Diabetes Mellitus, peripheral vascular disease, muscle weakness and stress incontinence. The facility assessment for R2 dated 5/24/25 shows R2 to be cognitively intact, requires a wheelchair for mobility. The same assessment shows R2 is dependent on staff for toileting. R2's care plan dated 2/25/25 shows a sit to stand mechanical lift is used for transfers. On 6/4/25 at 10:0 AM, R2 said she was being moved in the sit to stand lift from her bed to the bathroom one morning and she slipped out of the lift and fell on the floor. R2 said there were two staff in the room with her and she did not get hurt. R2 said her feet slid and now she is supposed to wear her tennis shoes when she gets up in the lift. R2 said she was wearing her house shoes when the fall happened. On 6/05/25 at 10:16 AM, V19 Certified Nursing Assistant (CNA) said she was pushing R2 in the sit to stand lift to the bathroom from her bed and R2 just slipped out. V19 said R2 was wearing house shoes and R2 never said anything to her before she fell, or after she fell. The written statement given by V19 after the fall shows R2 was strapped onto the lift and was being pushed into the bathroom, when R2 began telling the staff to bring the lift up higher. Then V19 wrote she began to see R2's weight begin to go to one side and R2 kept saying to raise the lift, but the lift was as high as it goes. (V19 denied this conversation with R2 when I spoke with her on the phone.) On 6/05/25 at 11:05 AM, V20 Licensed Practical Nurse (LPN) said she was called to R2's room after her fall. V20 saw R2 on the floor with her arms out of the stand slings and her feet over the leg of the lift. V20 said R2 told her she felt herself slipping and told the staff to raise her up. On 6/5/25 at 11:16 AM, V9 Unit Manager said R2 told her feet just slipped while she was being transported to the bathroom. V9 said R2 was wearing her house shoes. The nursing progress note dated 5/17/25 shows the CNA informed the nurse that R2 had fallen out of the sit to stand lift and was on the floor. The nurse (V20) wrote R2 was found on the floor with both legs in front of her body and on top the legs of the machine. R2 told the nurse she felt herself slipping. The care plan for R2 dated 5/14/25 for falls shows an intervention to ensure R2 has non-slip footwear at all times. A new intervention was added after the fall on 5/17/25 to ensure R2 has tennis shoes on before using the sit to stand lift. The fall risk assessment for R2 dated 2/16/25 shows a significant risk for falls. The facility fall investigation showed R2 felt herself slipping from the lift because her shoes did not have a good grip. The new intervention put in place was for R2 to wear tennis shoes when using the lift. 3. The facility face sheet shows R23 was admitted to the facility with diagnoses to include congestive heart failure, chronic obstructive pulmonary disease and cerebral infarction. The facility assessment dated [DATE] shows R23 to be cognitively intact and requires substantial assistance from staff for dressing and transfers. The care plan for R23 dated 5/15/25 shows he needs two assist with a gait belt for transfers. On 6/03/25 1:04 PM, R23 was observed with a black left eye. R23 said he hit by the lift when transferring out of bed. At 2:01 PM that same day, R23 said he was connected to the sit to stand lift and as he was being lifted up, he reached for a shirt that was hanging on the lift and as he was falling forward, he hit his head on the bar of the lift. On 6/5/25 at 11:08 AM, V20 LPN, said she was called to the room after being told R23 fell. V20 said she found R23 on his back with his legs crossed. V20 said the CNA told her he was not in the lift yet, but he fell when he reached forward to grab his shirt off the lift. V20 said the CNA said she left R23 sitting on the edge of the bed while she went to his closet to get him some clothes and she saw him lean forward and fall. V20 said R23 had a cut to his left eyebrow area that was beginning to swell, a scrape to his left knee and left ankle. On 6/5/25 at 11:19 AM, V2 DON said she had not interviewed R23 about his fall and was not aware R23 was saying he was already in the lift when he fell. V2 said she was told R23 was reaching for clothes while sitting on the edge of the bed and he fell forward off the bed. The facility investigation shows R23 was being assisted by staff with his morning routine, he reached for his shirt and fell to the floor. A written statement written by the CNA involved from the initial facility investigation shows R23 was sitting on the edge of the bed and the CNA V21 was at the closet getting clothes out, and the resident leaned forward and fell hitting his eye on the lift. The intervention added was to ensure the residents clothes are within his reach when sitting him up for AM care. The facility policy for fall prevention with a revision date of 7/2023 shows to provide an environment that is free from accident hazards, over which there is control, and provide supervision and intervention to residents to prevent avoidable accidents.

Based on observation, interview, and record review the facility failed to ensure accurate weights were obtained, failed to ensure significant weight loss was identified and reported to the dietitian, and failed to implement dietitian recommendations for 4 of 6 residents (R28, R3, R55, R41) reviewed for nutrition in the sample of 59. This failure resulted in R28 experiencing significant weight loss without the Registered Dietitian being notified. The findings include: 1. R28's face sheet showed he was admitted to the facility 9/21/22 with diagnoses to include anemia, hypertension, atrial fibrillation, primary osteoarthritis of left knee, primary osteoarthritis of left hip, and pressure ulcer of right ankle. R28's care plan initiated 10/3/22 showed, Risk for impaired skin integrity due to incontinence and decreased functional mobility . Approaches: . Nutritional support based on assessment and MD (physician) orders . R28's care plan initiated 9/28/22 showed, [R28] has increased potential for weight changes related to diuretic use . Goal and Target . Intakes to meet needs, Weight remain without significant changes . Medications per MD order . weigh resident per facility protocol. Record results and report any significant change to physician and dietitian . R28's weights were documented as follows: 5/22/25 - 226.4 lbs; 5/23/25 - 227.6 lbs; 5/24/25 - 226.7 lbs; 5/28/25 - 214.0 lbs; 5/29/25 - 214.0. These weight changes represented a significant 5.6 % weight loss from 5/22/25 through 5/28/25. R28's Nutrition Note entered 3/27/25 by V4 showed, Patient with pressure wound to coccyx . additionally, this writer recommends Active Liquid Protein 60 ml/daily. This will provide 200 kcal and 30 grams protein. On 6/05/25 at 9:56 AM, V4 RD (Registered Dietitian) said, They didn't notify me of that change, he is a monthly weight, so we obtain his weight the first shower of the month. I question the weights. It was as of yesterday that I was notified of his weight being 216. When I visibly look at him his chest and abdomen area does seem smaller. I think the readmission weight may have been incorrect because he was in the hospital . He comes out to the dining room to eat and when he first came back he wasn't wanting to eat. He used to eat 100% of his meals and he is telling me he isn't wanting to eat as much now. When they enter a weight, if it is significantly off I think it sends them a notification but I think there may be an issue with how it calculates the changes as 30 day, 60 day, 90 day changes. The nurses monitor the weights and let me know if there are changes. My hope would be after they enter the weight, it would be good practice to then look at their weight history to see if they have had a significant weight change . On 6/05/25 02:29 PM V2 DON (Director of Nursing) said the RD's dietary recommendations would be handed off to the unit manager or the nurse on the floor. The recommendations would be communicated to the Nurse Practitioner and they would give it as order. 2. R3's facesheet showed she was admitted to the facility 10/10/24 with diagnoses to include muscle weakness, moderate protein calorie malnutrition, anemia, hypothyroidism, major depressive disorder, delusional disorder, anxiety disorder, and rheumatoid arthritis. R3's facility assessment dated [DATE] showed she has severe cognitive deficit and is dependent upon staff for all cares. R3's care plan initiated 5/23/25 showed, Nutritional Status; [R3] has increased nutrient needs related to need for healing as evidenced by history of stage 4 pressure wound to sacrum. Also as increased potential for pressure wounds related to limited mobility. [R3] will have nutritional needs met and will not have an unplanned significant weight change over the next review period . R3's Nutrition Risk assessment dated [DATE] showed, . Current weight: 120 pounds . Nutrition: Increased nutrient needs related to need for healing as evidenced by presence of multiple pressure wounds . Interventions: Diet as ordered . Continued 1:1 assistance at meals. Goals: . weight remain stable. R3's medical record shows the last weight obtained for R3 was 120 pounds on 5/10/25. R3's medical record showed she was discharged to the acute care hospital 5/20/25 and returned as a readmission to the facility 5/23/25. R3's record contained no weights between her return to the facility 5/23/25 and 6/5/25. On 6/05/25 at 10:32 AM, V4 RD (Registered Dietitian) said R3 came back from the hospital 5/23/25 and no weights have been done since her readmission. V4 said R3's record showed a significant weight loss prior to her hospitalization but she feels that the weight that had been entered on 4/2/25 was not accurate. V4 said if a reweigh was done and a weight confirmed her record would show confirmed next to it. V4 said R3's 127 lb weight was not confirmed but R3 usually stays around 120 lbs. V4 said upon admission or readmission the facility policy is to get a weight every day for 3 days, then once weekly for 4 weeks, and if stable they would start doing monthly weights to monitor. V4 said she would have expected them to get readmission weights. V4 reviewed R3's record and said weekly weights were scheduled on the eMAR (electronic Medication Administration Record) but none of them were signed off. V4 said it is important to get readmission weights so she can assess R3 for significant loss. V4 said if she doesn't have those weights she has nothing to compare them to. On 6/05/25 at 2:21 PM, V2 DON (Director of Nursing) said weights are done with the first shower of the month, so they are all in the system by the 7th. V2 said the CNAs are getting the weights and entering them in the system and if they don't enter them sometimes the nurses do. V2 said if there was a significant change the system should flag it and it asks them if they really want to enter it. V2 said she does not know how the Registered Dietitian gets notified of significant weight changes. V2 said V4 (Registered Dietitian) should be looking at the weights at least every month. V2 said if there is anyone that has significant weight loss V4 would be documenting it and talking about it in their meetings. V2 said V4 should be able to print out all the residents weights every month. If there is a reweigh needed V4 will ask us for that. V2 said V4 is the expert with weight loss, she is the one who can give us the input on recommendations. V2 said it is V4's expertise the facility relies on for recommendations for getting supplements in place if needed. The facility's policy and procedure with approval date 06/2025 showed, Weight Monitoring . It is the policy of [the facility] that appropriate nutritional care shall be provided to residents who have a significant weight change. A significant weight change is identified as a weight loss or gain of 5.5% in 30 days, 7.5% in 60 days, or 10% in 180 days. Each resident should be weighed daily for the first three days of admission, weekly for the first four weeks, and monthly thereafter . Residents with a weight change of 5 lbs or greater should be reweighed to determine an accurate weight. The accurate weight should be entered in the resident's medical record . The RD should make recommendations for nutritional interventions based on the information obtained from the weekly Resident At Risk Review huddle meetings. RD recommendations should be reviewed and initiated by nursing associates . A nursing or nutrition associate should notify the health care provider of any significant weight change that is unexplainable or in which the RD has requested a nutritional intervention . 4. R55's Face Sheet showed she was admitted to the facility on [DATE] with diagnoses to include Alzheimer's (dementia), a Stage 4 pressure ulcer, and a hip fracture. R55's active order set showed an order for monthly weights, which was ordered on admission. R55's electronic health record (EHR) showed she weighed 154.6 pounds on 2/11/25; 142.8 pounds on 3/23/25; and 132.4 pounds on 4/4/25. R55's EHR showed this was a weight loss of 14.3 percent. R55's electronic health record showed no weight documented following the 4/4/25 weight as of 6/3/25 at 4:00 PM. R55's 5/21/25 progress note from 12:58 PM (Authored by V4, Registered Dietitian) showed: Late Entry for month of May. Resident weight for month of May not documented [in] EMR (electronic medical record). Will assess weight trend when June weight measurement received . On 6/04/25 at 1:44 PM, V15, Registered Nurse, stated monthly weights are done for all residents with the first shower of the month. V15 stated the CNAs (Certified Nursing Assistants) will notify her of the resident's weight, and she will enter the weight in the electronic health record. V15 stated the facility does not document weights in any other location other than the electronic health record. V15 stated R55 does not refuse care. On 6/04/25 at 1:59 PM, V16, Certified Nursing Assistant (CNA), stated CNAs measure residents' weights on their first shower of the month. V16 said the CNA will notify the nurse of the weight. V16 said CNAs can also enter weights into the EHR. V16 said she is R55's CNA, and R55 does not refuse care. On 6/04/25 at 2:21 PM, V4 stated R55 should have been weighed in May 2025 when she had her first shower of the month. V18 said she had noticed the missing weight in May, and per her normal practice, she would have sent a list of residents with either missing weights or weights that needed to be redone. V18 said monthly weights are important so she knows if her interventions are working and if they need to be adjusted to the unit manager. (The facility was requested to weigh R55.) On 6/04/25 at 03:42 PM, V2, Director of Nursing, stated R55's weight was 150 pounds. The facility's Weight Monitoring policy (last approved 6/2025) showed: Each resident should be weighed daily for the first three days of admission, weekly for the first four weeks, and monthly thereafter . 3. R41's electronic face sheet printed on 6/5/25 showed R41 has diagnoses including but not limited to epilepsy, acute kidney failure, Bipolar Disorder, Alzheimer's Disease, and type 2 diabetes. R41's facility assessment dated [DATE] showed R41 has experienced a weight loss and is not on a physician-prescribed weight-loss regimen. R41's care plan dated 2/25/25 showed, (R41) has increased potential for weight changes related to fluctuating intakes. Has a history of both significant weight gains and losses .(R41) is offered diet and oral nutritional supplement as prescribed, see physician order sheet. R41's Nutrition Risk assessment dated [DATE] showed, Comments/Recommendations: Interventions: Diet as ordered. Recommend Ensure 240ml once daily. This will provide 350kcal and 20g protein . R41's physician's orders for May 2025 and June 2025 showed no orders for R41 to receive a nutritional supplement. On 6/5/25 at 9:40AM, V4 (Registered Dietician) stated, The last time I reviewed (R41's) nutritional status was on May 12th and her weight had stabilized at that point since her previous significant weight loss. She is a picky eater, and I didn't want her weight to go down at all if possible, so I recommended a daily nutritional supplement for her. My recommendations go to the physician or nurse practitioner for each resident to approve. I put the recommendations in their box so they can sign off on it and then nursing enters the orders. I don't see the order for her supplement in her record though so I'm not sure what happened. If there isn't an order, then she won't receive it. The facility's policy titled, Weight Monitoring dated 01/2023 showed, It is the policy of (facility) that appropriate nutritional care shall be provided to residents who have a significant weight change .E. The RD (Registered Dietician) should make recommendations for nutritional interventions based on the information obtained from the weekly Resident at Risk Review huddle meetings. RD recommendations should be reviewed and initiated by nursing associates .

Based on observation, interview, and record review, the facility failed to handle food in a manner to prevent cross-contamination and failed to maintain food preparation equipment in a manner to prevent cross-contamination. This failure has the potential to affect all 131 residents residing in the facility. The findings include: On 6/3/25 at 11:46 AM, V14, Cook, began the lunch service from the steam table in the kitchen. All residents in the facility were served from this steam table. The lunch menu was battered fish with a lemon wedge, french fries, and peas. The lemon wedges did not have any utensils for handling. V14 placed a lemon wedge on each plate with her gloved hand. V14 also used her gloved hand to move the peas into a pile on the plate and organize the french fries on the plate. V14 also used her gloved hand to steady the fish as she moved the fish from the steam table to the residents' plates. On occasion, V14 also picked up the fish with her gloved hand and placed it on the plate. During the lunch service, V14 pulled down her shirt with her gloved hands, touched door handles, and she touched food carts; V14 did not change her gloves during the lunch service. On 6/3/25 at 9:22 AM, the facility's can opener showed caked-on debris. The debris was well-adhered, and it was on the sharp cutting tip. On 6/4/25 at 12:53 PM, the can opener tip was the same as observed on 6/3/25. On 6/4/25 at 12:53 PM, V13, Dietary Supervisor, stated the can opener had been used that day. V13 stated it had been cleaned. V13 said a new can opener had been ordered. V13 said the tip was dirty and there was a risk of cross-contamination using the dirty can opener. V13 also said food should not be touched with a potentially contaminated gloved hand. V13 said there was a risk of cross-contamination if staff handled food with a potentially contaminated hand. V13 said V14 should have used a utensil to handle the lemons and she should not have touched the residents' food on the plate unless she had clean gloves. The facility's Preventing Foodborne Illness-Food Handling policy (last approved 1/2023) showed, .All associates who handle, prepare or serve food shall be trained in the practices of safe food handling and preventing foodborne illness .All food service equipment and utensils shall be sanitized according to current guidelines and manufacturers' recommendations .

Based on interview and record review, the facility failed to correctly transcribe a physician's order for 2 residents (R60,R129), failed to ensure the correct dose of a medication was given for 1 resident (R90), failed to ensure the correct medications were given for 1 resident (R25). These failures apply to 4 of 4 residents outside of the sample reviewed for medication errors. The findings include: 1) R25's electronic face sheet printed on 6/5/25 showed R25 has diagnoses including but not limited to cerebral infarction, insomnia, dementia with behaviors, anxiety disorder, and major depressive disorder. The facility's document titled, Safety Event Entry dated 4/9/25 showed, (R25) given incorrect medications including cetirizine 10mg, gabapentin 100mg, quetiapine 50mg, and memantine 5mg. Error noted by another RN (Registered Nurse) as I was exiting the room. Nurse Practitioner notified and advised to monitor resident .resident has no change from baseline . 2) R60's electronic face sheet printed on 6/5/25 showed R60 has diagnoses including but not limited to liver cell carcinoma, multiple sclerosis, chronic kidney disease, chronic viral hepatitis C, and hypertension. The facility's document titled, Safety Event Entry dated 5/21/25 showed, Resident was admitted to the facility with antibiotic order for a total of 5 days and antibiotic continued to be administered for 7 more days .medication stop date was never entered by the nurse . 3) R90's electronic face sheet printed on 6/5/25 showed R90 has diagnoses including but not limited to weakness and repeated fall. R90's physician's orders from her original admission on [DATE] showed, Budesonide DR (Delayed Release)-ER (Extended Release) take 9mg by mouth every day. The facility's document titled, Safety Event Entry dated 5/14/25 showed, Resident has had diarrhea since admission. She has a history of chronic bowel disease and has been on Budesonide ER tab 9mg daily at home and also was ordered upon admission to (facility) .Gastroenterologist confirmed via fax that she should be on 9mg Budesonide daily. After further investigation, it was noted that the table dose from pharmacy was 3mg not 9mg . 4) R129's electronic face sheet printed on 6/5/25 showed R129 has diagnoses including but not limited to urinary tract infection, hypertension, carotid arterial disease, and chronic obstructive pulmonary disease. The facility's document titled, Safety Event Entry dated 4/9/25 showed, (R129) was given orders for a prednisone taper and the orders were not entered correctly with stop dates and the nurse continued to give the medication. It should have been stopped on 3/25/25 and was given until today when I discontinued the order on 4/9/25. On 6/5/25 at 2:20PM, V2 (Director of Nursing) stated, We have had several medication errors over the past 3 months. I think it has to do with agency staff not knowing the residents and not knowing our admission process. We now have our admission nurse's double checking the orders to ensure they are transcribed and entered correctly so hopefully that will help cut down on the errors. These errors never should have happened but thankfully there were no significant outcomes to these residents.

Based on observation, interview, and record review, the facility failed to puree peas to a smooth consistency. This applies to 6 of 6 residents (R7, R12, R35, R48, R103, R330) reviewed for altered diets in the sample of 59. The findings include: The 6/3/25 facility-provided list of residents receiving pureed diets showed that R7, R12, R35, R48, R103, and R330 were receiving pureed foods. On 6/3/25 at 11:05 AM, V14, Cook, began the puree process for the residents' peas. On 6/3/25 at 11:13 AM, V14 completed the puree process and placed the pureed peas into a metal steam table pan. There were visible chunks in the pureed peas. The peas were tested by this surveyor; the pureed peas had chunks, and it required chewing to comfortably swallow them. V14 stated the puree process was complete. V14 then covered the peas with plastic wrap and placed them in the steam oven. On 6/3/25 at 11:34 AM, V13, Dietary Supervisor, tested the pureed peas and stated, They have chunks. V13 stated there were also pieces of skin. V13 said the peas should be smooth, and she stated peas are difficult to puree. On 6/3/25 at 11:39 AM, V13 placed the pureed peas back into the food processor and blended them until they were smooth. On 6/4/25 at 12:53 PM, V13 stated the pureed peas were not a smooth consistency, and they should have been blended until they were smooth. On 6/4/25 at 1:08 PM, V4, Registered Dietitian, stated residents are generally placed on puree diets due to a diagnosis of difficulty swallowing. V4 said strokes can cause difficulty swallowing. V4 stated a resident ordered a puree diet could experience a choking episode if served food that is not smooth. V4 stated pureed foods should be smooth and not have chunks. R12's Face Sheet showed a diagnosis of difficulty swallowing. R7's Face Sheet showed a diagnosis of stroke. R48's Face Sheet showed a diagnosis of difficulty swallowing. R35's Face Sheet showed a diagnosis of difficulty swallowing. R103's Face Sheet showed a diagnosis of difficulty swallowing. R330's Face Sheet showed a diagnosis of difficulty swallowing. The facility's Dysphagia (Difficulty Swallowing) - Clinical Protocol policy (last approved 1/2024) showed: Treatment/Management .The physician will order an altered consistency diet when it is clinically relevant to manage significant risks of aspiration (choking) in individuals for whom other alternatives are unavailable .

Based on observation, interview and record review the facility failed to ensure residents dependant on staff for cares was treated in a dignified manner, and failed to care for a female resident with facial hair for 3 of 3 residents (R232, R332, R54) reviewed for dignity in sample of 59. The findings include: 1. R232's face sheet documents she was admitted to the facility on [DATE] with multiple diagnoses including a chronic non-pressure wound to her right lower leg. The treatment record shows a skin tear to the right hand with a dressing change three times a week, and a surgical incision to the left upper arm with a daily dressing change. All treatments are scheduled for the night shift. R232's admission assessment and care screening of 5/28/25 shows her to be cognitively intact. The same assessment shows she requires supervision or touch assistance with transfers to the toilet and sit to stand movements. On 6/05/25 at 11:48 AM, R232 said he biggest concerns was the nurses doing dressing changes in the middle of the night. She said her pain medication was scheduled every 8 hours around her therapy and it was given at 2-2:30 AM. But they do not just bring in the pain medication, they turn on the lights and do the bandage changes too. She said all she needs is the pain medication. The bandages should be changed at 9:30 - 10:00 PM, before going to sleep. She said it takes about 20 minutes to get the whole procedure done, then have to try and get back to sleep. R232 also said the waiting time for the call lights seems to be at least 30 minutes. They seem to be short staffed, but she needed help to get up to the bathroom. On 6/5/25 at 9:25 AM, V10 Registered Nurse (RN) said all of the dressing changes are scheduled on the night shift. But the staff should not be just going in to wake up residents just for a dressing change. She said it should be done closer to early morning. She said she tries not to wake anyone up for anything except a scheduled medication. On 6/05/25 at 9:05 AM, R232 said the call light times were not any better. She put on her call light at 5:00 AM today, and someone finally came in at 5:50 AM. When the aide came in, she stated she had 22 other rooms to try and cover. R232 said she had to use the bathroom so bad she started dribbling, and needed to get cleaned up. She reported having a care conference on 6/4/25 and she voiced her complaints with the call lights not being answered and the dressing changes getting done in the middle of the night. She said the issue was to be resolved, then at midnight last night the nurse came in and turned the lights on and changed the bandages. R232 was sitting up in her wheelchair visibly upset with her situation. On 6/5/25 at 10:53 AM, V8 Social Service Assistant said she attended R232's care plan meeting on 6/4/25, and recalls the concens with call lights and the timing of her dressing changes. She said those issues should have been addressed. The 11/2024 facility policy for resident rights documents 2. Residents are entitled to exercise their personal and legal rights and privileges to the fullest extent possible. 3. Our ministry will make every effort to assist the resident in exercising his/her rights and to assure that the resident is always treated with respect, kindness and dignity. 2. R332's face sheet showed she was admitted to the facility 5/29/25 with diagnoses to hyperkalemia, hyperlipidemia, sleep apnea, essential hypertension, and muscle weakness. R332's care plan initiated 5/29/25 showed, [R332] needs assistance with ADL (activities of daily living) care . [R332] will have daily care needs met . On 6/03/25 at 11:09 AM, R332 said she had made a complaint to a staff member. R332 said her main problem is that her call light is not answered timely and often takes an hour or more. R332 said one day she was in her room and had her call light for a long time. R332 said two aides walked past her room pushing someone in a wheelchair. R332 said she called out to the hall and told the aides my call light is on. R332 said the aides responded to her by saying Yeah, we can't help you and they walked away. R332 said she felt like a non-person because she depends on the aides. R332 said no one was checking on her. On 6/05/25 at 2:18 PM, V2 DON (Director of Nursing) said it is not appropriate to tell residents they can not help them. V2 said she would have at least expected the staff to see what she needed and communicate with her regarding when they will be back to assist her. The facility's policy and procedure with last approval date of 01/2024 showed, Quality of Life - Dignity . Policy Statement: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Policy Interpretation and Implementation Residents shall be treated with dignity and respect at all times . Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self worth . 3. R54's electronic face sheet printed on 6/5/25 showed R54 has diagnoses including but not limited to generalized anxiety disorder, depression, hypertensive chronic kidney disease, and urinary tract infection. R54's facility assessment showed R54 is dependent on staff for personal hygiene. On 6/3/25, R54 had 2 dime-sized patches of facial hair on her chin. The hair was dark and curling under her chin. R54 was unable to keep on task with questions regarding her facial hair during interview. On 6/4/25 at 11:28AM, V26 (R54's daughter) stated, My Mom would be mortified if she had all that chin hair. She always kept it shaved and definitely wouldn't want anyone seeing her with patches of chin hair. I don't know why she would even have that because she has an electric razor in her room that I bought her so all they have to do is give it to her and have her do it by herself. On 6/5/25 at 2:25PM, V2 (Director of Nursing) stated, No female resident should have long patches of chin hair on their face unless that is their preference. (R54) may not have had hers shaved because she refuses showers and that would be the time when staff deal with facial hair. They could do it in between the shower days though if they see that it needs to be addressed. I agree this is a dignity issue because if her daughter says she wouldn't like it then we need to be sure we are addressing it. The facility's policy titled, Quality of Life-Dignity dated 12/2021 showed, Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. A. Residents shall be treated with dignity and respect at all times. B. Treated with Dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth .

Based on observation, interview and record review the facility failed to answer the residents call light in a timely manner. This applies to three of three residents (R58, R99, R332) in the sample of 59 reviewed for call lights. The findings include: 1. The facility face sheet shows R58 was admitted to the facility with diagnoses to include adult failure to thrive, Type 2 Diabetes Mellitus, chronic kidney disease and low back pain. R58's facility assessment dated [DATE] shows he has no cognitive impairment and required maximum assist from staff for standing and toileting. On 6/04/25 at 2:18 PM, R58 said he was standing up at the foot of his bed reaching for his urinal. R58 said his legs gave out and he fell. R58 said he had his call light on because he could not reach his urinal. R58 said after half an hour he tried to do it himself and fell. R58 said he felt his hip break when he fell. R58 said he had to yell for help from the staff. R58 said because he is younger and has his wits about him the staff thinks he is independent. 2. The facility face sheet for R99 shows she was admitted to the facility with diagnoses to include Bell's Palsy, Atrial fibrillation and paralysis to her left side. The facility Brief Interview for Mental Status (BIMS) shows her to cognitively intact. On 6/04/25 at 1:44 PM, R99 said the call lights take a long time to be answered. R99 said it was an hour before she got changed this morning, and it takes a long time, almost all the time for the staff to answer her call light. 3. The facility face sheet for R332 shows she was admitted to the facility with diagnoses to include muscle weakness, chronic obstructive pulmonary disease and type 2 Diabetes Mellitus. The BIMS assessment dated [DATE] shows her to cognitively intact. On 6/03/25 at 11:09 AM, R332 said, getting the staff to answer her call light has been a big problem for her. R332 said, I can turn this on and wait for an hour. I generally walk myself to the bathroom but when I get in there, get the pull ups off and then I can't get a new one back on. One time 2 aides walked past pushing someone while I had my call light on, it had been on a long time, and they said oh yeah we can't help you. That made me feel like a nonperson, no one was checking on me, a lot of times its something simple I needed. On 6/05/25 at 2:18 PM, V2 DON (Director of Nursing) said, the facility has an old call light system and we don't have a way to monitor. I would have at least expected the staff to see what a resident needed, and communicate with them regarding when they will be back. No facility policy was provided by the facility regarding call lights.

Based on observation, interview, and record review the facility failed to ensure orders were in place for a resident with a CPAP (Continuous Positive Airway Pressure) and failed to properly clean and store CPAP equipment for 1 of residents (R108) reviewed for respiratory services in the sample of 59. The findings include: R108's face sheet showed he was admitted to the facility 5/15/25 with diagnoses to include pulmonary embolism, cough, obstructive sleep apnea, and muscle weakness. R108's Physician Order sheet for June 2025 which was printed 6/5/25 showed no orders for R108's CPAP machine. R108's June 2025 eTAR (electronic Treatment Administration Record) showed new treatments added 6/4/25 for CPAP - Place CPAP on at HS (hour of sleep) and remove in the AM (morning) for sleep apnea; Cleanse CPAP - Every day clean CPAP mask and tubing with soap and water and dry mask and tubing every morning. There was no evidence of R108's CPAP being cared for from 5/15/25 through 6/4/25. R108's care plan initiated 5/23/25 showed, Pulmonary . [R108] has potential for SOB (shortness of breath) and/or respiratory complications related to diagnosis of pulmonary embolism and obstructive sleep apnea . Oxygen/CPAP . Currently uses as need supplemental oxygen related to diagnosis of obstructive sleep apnea. Oxygen therapy puts him at risk for dry mouth, skin pressure points, poor stamina, lethargy, insufficient fluids, and anxiety . R108's complete care plan was reviewed and showed no CPAP settings or CPAP care. On 6/3/25 at 10:53 AM, R108's CPAP was on the bedside table. A sign was placed nearby that showed to put water in the CPAP machine. The CPAP mask was lying on the bedside table and was not bagged. On 6/04/25 at 1:39 PM, R108 said the staff help him with his putting his CPAP on at night. R108 said, They usually just leave it there on the table but I noticed yesterday, they put it in a bag and today too. On 6/05/25 at 2:16 PM, V2 DON (Director of Nursing) said if a resident has a CPAP machine, the orders should be entered upon admission. V2 said she would need to check their policy for her expectation for cleaning and storage of CPAP equipment but that she would expect the staff to follow the facility's policy and procedures. The facility's policy and procedure with last approved date of 09/2023 showed, . Procedure: CPAP/BiPAP Support . Purpose: A. To provide the spontaneously breathing resident with continuous positive airway pressure with or without supplemental oxygen . Preparation: . C. Review the physician's order to determine the oxygen concentration and flow, and the PEEP pressure (CPAP) for the machine . General Guidelines for Cleaning . D. Machine cleaning: Wipe machine with disinfecting wipes or wipe with warm, soapy water, and then rinse at least once a week and as needed F. Filter cleaning; 1. Rinse washable filter under running water once a week to remove dust and debris .G. Masks, nasal pillows and tubing: Clean daily by placing warm, soapy water and soaking/agitating for 5 minutes. Rinse with warm water and allow it to air dry between uses .

The facility failed to assess and obtain treatment orders for a resident (R86) with two skin tears. This applies to 1 of 2 residents reviewed for non-pressure skin conditions in the sample of 59. The findings include: R86's electronic face sheet printed on 6/5/25 showed R86 has diagnoses including but not limited to congestive heart failure, severe protein-calorie malnutrition, pressure ulcer of sacral region, stage 4, and pressure ulcer of left lower back, stage 2. R86's facility assessment dated [DATE] showed R86 has no cognitive impairment. R86's May 2025 and June 2025 physician's orders showed no orders for R86's skin tears to his left arm. On 6/4/25 at 8:39AM, R86 had 2 patches on his left arm, one on his lower arm and one on his upper arm. R86 stated, I have been waiting for them to change my dressings. I think it happened about a week ago when they were in here taking care of me. I don't really remember the exact scenario but there are 2 skin tears on my arm. On 6/5/25 at 1:17PM V3 (Registered Nurse) stated When a resident obtains a skin tear, we immediately clean the area, assess it, and typically we will put steri-strips on it and then notify the physician and obtain treatment orders. Once the orders are received, we enter them into the resident's orders, and it would go on their treatment record so we can be sure we treat the area until it is healed. (R86) has 2 dressings on his left arm where he has skin tears. I have no idea what's under those dressings or how they even look because he hasn't let us take them off. There are no orders in his chart for any treatment and there is no assessment that I can see so I'm not sure how big they are. On 6/5/25 at 1:22PM, V2 (Director of Nursing) stated, When a resident obtains a skin tear the nurse will clean and dress the wound, perform an assessment, and enter it into the computer system. Once that is completed, they will notify the resident's physician for treatment orders and enter it into the orders so that the nurses can continue treatment. There would be no reason not to do any of this because it is a skin alteration which is something we track until it is resolved. If (R86's) wounds are not treated, they could worsen or become infected. The facility's policy titled, Procedure: Skin Tears-Abrasions and Minor Breaks, Care of dated 01/2024 showed The purpose of this procedure is to guide the prevention and treatment of abrasions, skin tears, and minor breaks in the skin .A. Obtain a physician's order as needed. Document physician notification in medical record .D. Generate Non-Pressure form and complete .A .A skin tear is the disruption of epidermis resulting in lifting or friction of the skin .O. Assess the wound and surrounding skin for edema, redness, drainage, tissue healing progress, and wound stage .

Based on observation, interview, and record review, the facility failed to assess and notify the wound care physician with changes in a pressure injury, and failed to implement pressure relieving intervention to prevent a pressure injury. This applies to 2 of 8 residents (R95 & R100) reviewed for pressure injuries in the sample of 23. These failures resulted in R100's pressure injury deteriorating to an unstageable pressure injury. The findings include: 1. R100's face sheet lists his diagnoses to include: nondisplaced intertrochanter fracture (hip fracture), type I diabetes mellitus, and coronary heart disease. R100's wound assessment report, dated 7/3/24 shows a newly identified stage 1 pressure ulcer was found on his right heel. The pressure ulcer measured 7.00 cm (centimeters) X 5.00 cm. R100's care plan, with problem onset of 7/10/24, shows, Problem/Need: Pressure ulcer stage 2 to right bottom heel. Approaches: Measure wound at least weekly. Record HxWxL (height x width x length), appearance, amount and odor of any drainage. Report any decline in would status to physician. R100's local hospital vascular surgery progress notes, dated 7/22/24 show, This is a [AGE] year-old gentleman who has a history of insulin dependent diabetes. Most recent A1C (blood check for insulin) from April of 2024 A1C 7.7. He has been following with podiatry for tissue loss. He unfortunately had a left hip fracture and was admitted to rehab From the standpoint of his lower extremity vasculature he has normal toe pressures bilaterally. On the left his ABI (ankle brachial index) is likely falsely elevated secondary to medical calcinosis with the waveform morphology demonstrates small T-wave phasic waveform. On physical exam he has clearly audible posterior tibial signal. From the standpoint of his lower extremity aterial perfusion I do believe with his toe pressure within normal limits he has enough perfusion to heal this superficial wound to the posterior heel We would recommend continued local wound care either with the podiatry clinic or with the wound care center. R100's wound assessment report dated 7/30/24 shows the same pressure ulcer was now a stage 2 measuring 3.00 cm X 3.00 cm with 5% slough and 95% granulation. Stage 2 pressure ulcer to bottom of right heel/foot assessed. Wound continues improving . On 8/7/24 at 9:05 AM, V4, Wound Care Nurse (WCN), stated R100 had a pressure ulcer on his heel that was healing. She sees him weekly to do assessments, otherwise, the floor nurses do the dressing changes daily. R100 had gone to a vascular appointment on 7/22/24 that was previously scheduled prior to admit to the facility. At that appointment, they did a doppler to check the pressures in his legs. They did not find anything significant and referred him to a wound care doctor to follow for his pressure ulcer. She stated he has not seen any wound care doctors yet and does not have any appointments set up. On 8/7/24 at 10:00 AM, R100 was lying in bed. He had a quarter size black soft circular wound to his right heel. He winced in pain when V4, WCN (Wound Care Nurse), removed the dressing and pressed in the middle of the wound. He stated the wound hurt and was painful. At 10:40 AM, V4, WCN, stated, The wound has deteriorated in one week since I last saw it. Now it has eschar (dead tissue). I would expect the floor nurses to notify me and the doctor of any changes in the wound. She had not heard anything about any changes in the wound. On 8/7/24 at 10:35 AM, V11, Wound Care Doctor, stated, If the wound is soft (boggy) as being described, I would call it an unstageable necrosis. I would expect the facility to manage a stage 1 or 2 pressure injury, but beyond that they should be consulting with someone with experience (him or an outside wound care clinic). The facility's Procedure: Pressure injury assessment/treatment, dated July 2024, shows, Purpose: The purpose of this procedure is to provide guidelines for a consistent method of identification of and for the initial care of identified pressure injuries, alterations in skin integrity, and the prevention of acquiring additional pressure injuries Definitions and descriptions: B. Pressure injury: A localized injury to the skin and/or underlying tissues as a result of pressure or pressure in combination with shear/friction. Pressure injuries usually occur over a bony prominence and are staged to classify the degree of damage. I. Eschar tissue: Dead or devitalized tissue that is hard or soft in texture; usually black, brown or tan in color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/edges of the wound Stage 2 Pressure injury: Partial-thickness loss of skin with exposed dermis. The wound bed is pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible, Granulation tissue, slough and eschar are not present Unstageable: Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough (yellow, tan, gray, green or brown) or eschar (tan, brown or black) in the wound bed. 40085 2. R95's Physician Orders Summary for August 2024 shows an order, with a start date of 1/23/24, for oxygen at 2-4 liters continuous, and an order with a start date of 2/24/24, for (ear protectors) applied to oxygen tubing at all times. R95's current Care Plan shows he has a self care deficit and requires extensive staff assistance for his Activities of Daily Living due to weakness. The Care Plan also shows on 7/17/24 he was found to have stage 2 pressure ulcer behind his right ear. A Wound Assessment Report completed on 7/17/24 shows R95 has a new facility acquired stage 2 pressure ulcer measuring .30 cm long, X .30 cm wide, X .20 cm deep with a scant (small) amount of serous (clear) drainage. A Braden Risk Assessment reported, completed 7/17/24, shows R95 is at high risk to develop a pressure injury. On 8/5/24, at 10:30 AM, R95 was lying in bed with his wife at his bedside. R95 had oxygen running via a nasal cannula tubing which was behind both ears. Behind and under his right ear were some gauze bandages, and behind his left ear wrapped around the tubing was a Styrofoam circular tube. On 8/6/24 at 11:42 AM, V7 (R95's spouse) said, He (R95) has been on oxygen continuously since he has been at the facility and he has a sore behind his ear from the oxygen tubing. The grips they use on the tubing are useless, they slide around all the time and fall off when staff reposition him. I come to the facility every day and sometimes the grips are just lying on his bedside table and not even on the tubing. On 8/6/24 at 1:02 PM, V4 (Wound nurse) said the oxygen tubing around R95's ear caused a stage 2 pressure injury. V4 said they use (ear protectors-- grips like a foam pool noodle) to try to prevent it, but they are not effective they don't stay in place and they pop off the tubing from him moving. On 8/7/24 at 9:16 AM, V6 (Regsitered Nurse/RN) said R95's tube grips fall off and slide around. He said he is unaware of any other interventions that were tried to prevent the pressure injury. V6 said the staff do not do daily checks behind the ears of residents on oxygen; they check when a resident is bathed, or once a week on skin check days and oxygen tubing change days. The facility provided Pressure Injury Assessment/Treatment policy, revised 7/2024, shows pressure relieving devices should be observed for effectiveness and interventions changed or implemented to prevent the development of pressure injuries.

Based on observation, interview, and record review, the facility failed to ensure a resident was supervised in preparation for a mechanical lift transfer resulting in a fall with injury, and failed to ensure nonslip material was in place in a wheelchair for 2 of 3 residents (R1, R3) reviewed for safety and supervision in the sample of 5. This failure resulted in R3 receiving an acute subdural hematoma along with 2 lacerations with 8 sutures to the left forehead and R1 receiving 14 sutures to the left forehead. The findings include: 1. R3's [DATE] fall risk assessment showed a moderate risk of falls. R3's [DATE] facility assessment showed severe cognitive impairment. R3's care plan showed he was alert but with memory deficits and impaired decision making. R3's activity of daily living (ADL) care plan showed he required staff assistance for all ADL's. R3's transfer care plan showed he was unable to transfer independently. R3's fall care plan showed he was severely cognitively impaired, was a high risk for falls, a total mechanical lift, 2 people assist for all transfers, and 2 persons for all care provided. R3's [DATE] fall incident report showed resident was found on the floor of his room bleeding. This report was completed by V14, nurse. R3's [DATE] local hospital summary showed a [AGE] year-old male with dementia, nonverbal presented due to a fall with head injury. The CT scan results showed an acute subdural hematoma. This note showed eight sutures were used to repair the forehead laceration. R3's [DATE] fax communication form showed a request for orders for a left eye laceration, left forehead abrasions, and right abrasion above the eye. R3's [DATE] wound notes showed a left cheek bruise, a left eye abrasion, a left eye laceration, and a right eye abrasion. On [DATE], R3 was in a common area with numerous other residents. R3's eyes were closed and he did not react to verbal stimuli. There was a television on in the room and no staff were providing uninterrupted supervision. On [DATE] at 11:18 AM, V2, Quality Director, said the root cause analysis of R3's fall showed he fell because his bed was elevated, and the fall mats were not next to the bed. At 12:21 PM, V16, Certified Nursing Assistant (CNA), said she takes total responsibility for R3's fall from bed on [DATE]. V16 said she was caring for R3 and readied him to transfer out of bed and left the room for about ,d+[DATE] minutes to find help to assist with the transfer. During this time, V16 was alerted that R3 was found on the floor. V16 said she had left R3 alone with the bed in a high position, and no fall mats in place when she exited his room. V16 said she should have never left him alone like that. At 12:23 PM, V3, Medical Director, said R3's fall should not have occurred. R3 lacked the understanding of the risk involved in self-transferring and had advanced dementia. V3 said if staff are preparing a resident for a transfer all staff and equipment needed should go into the room. A resident should not be left alone while staff retrieves help or equipment unless the resident was capable of understanding and had a good memory. A voicemail was left for V14 to contact this surveyor and no return call was received. This report showed R3's bed was in a high position and R3 was on the floor. 2. R1's face sheet showed a [AGE] year-old female admitted to the facility on [DATE]. R1's [DATE] facility assessment showed moderate cognitive impairment. R1's [DATE] nursing note showed resident's roommate notified staff R1 had fallen in the room. R1's [DATE] fall incident post actions showed resident to not be in wheelchair in her room by herself. R1's care plan showed she was alert with short term memory deficits. R3's [DATE] fall interventions showed to place nonslip material in wheelchair and do not leave in an unsupervised area. R1's [DATE] visit note authored by V3 Medical Director showed a history of Alzheimer's Dementia, poor insight and memory and R1 was not a reliable historian. V2's investigative notes showed R4 told her R1 was left unsupervised when staff went to get a lift and R1 fell . R1's [DATE] local hospital visit summary showed she was seen for a fall, had complex laceration of the forehead and laceration repair was performed X 2. R1's care card in her room showed to use nonslip material in the wheelchair and do not leave in an unsupervised area. R1's [DATE] fall incident report showed V12 CNA and V15 nurse were involved. At 9:16 AM, R1 was in the dining room in a wheelchair at a table. V6, Restorative CNA, brought R1 to her room and assisted by V5, Licensed Practical Nurse. R1 did not have any nonslip material underneath her in her wheelchair. V5 left R1's room. V6 then left R1 unattended in her room. On [DATE] at 9:00 AM, R4 (R1's roommate) said on [DATE], R1 was seated on the edge of her bed. A CNA dressed her, left the room for something, and R1 fell . At 11:18 AM, V2, Quality Director, said the root cause analysis of R1's [DATE] fall showed she fell because she attempted to self-transfer. V2 said a grab bar was put on R1's bed on [DATE]. At 12:23 PM, V3, Medical Director, said R1 was a high fall risk and if staff intend to transfer her, all staff and equipment should go in so as not to confuse the resident if you leave. Documents reviewed showed V12 was terminated on [DATE] due to not following proper procedure resulting in a patient's fall. V2 said R4 is a reliable historian, and V12 told her he left R1's room on [DATE] to get help or the lift or something. V2 said R4 told her V12 had left R1 unsupervised on ,d+[DATE] when she fell .

Based on interview and record review, the facility failed to provide a safe transfer for a resident. This failure resulted in R1 being transferred without a stand lift device and sustaining a spiral fracture to her right tibia and fibula. This applies to 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 8. The findings include: The Diagnosis/History Report, dated 11/14/23, showed diagnoses including iron deficiency anemia, hypothyroidism, atrial fibrillation, congestive heart disease, chronic obstructive pulmonary disease, cellulitis of left lower limb, neuralgia, neuritis, contusion of left lower leg, and transient ischemic attack. R1's Minimum Data Set, dated dated [DATE], showed she needs substantial/maximal assistance for transfers. R1's Care Plan Card, dated 6/28/23, showed she was to be transferred with a stand lift and two people. The Facility Reported Incident, dated 11/8/23, showed R1 was observed with swelling and tenderness to her right lower extremity on 11/7/23 at 12:30 PM. The physician was notified and orders were received to send R1 to the hospital. An X-ray was performed at the ER (emergency room ), which indicated an acute fracture of the right distal tibia and distal fibula. The resident returned to the facility at 4:04 AM on 11/8/23, at which point the facility became aware of the fracture diagnosis. Resident states her pain began after she was transferred into her bed at bedtime on 11/6/23. Investigation initiated immediately. The hospital emergency room Triage Note, dated 11/7/23, showed R1 went to the hospital with a chief complaint of lower right leg swelling. The After Visit Summary, dated 11/7/23, showed an X-ray was done of R1's right leg (tibia-fibula) for ankle pain with the twisting motion, generalized tenderness to palpation of the ankle and distal tibia and fibula. The findings showed an acute oblique fracture of the distal tibia. Acute nonocclusive fracture of the distal fibula. An X-ray was done of R1's right ankle and showed the resident stated her ankle was twisted when she was lifted from a chair. The findings showed and acute mildly displaced fracture of the distal fibula. An oblique nonocclusive fracture of the distal tibia extending through the medial malleolus. The facility's interview, dated 11/8/23, with V6, CNA (Certified Nursing Assistant), showed V6 stated she was assigned to R1 on 11/6/23. States R1 was to weak to use the stand lift. V6 stated that she pivot transferred the resident into bed. The facility's interview, dated 11/9/23 with V6, CNA, showed, V6 stated she was aware at the last meeting that staff was told to do a mechanical lift if the patient cannot stand with the stand lift. When asked why she pivot transferred the resident when she felt the resident could not safely complete a stand lift transfer? V6 stated she did not attempt to place the mechanical lift sling under the patient, as she did not feel the patient could safely stand, so she could place the sling. V6 stated she did not try to get help, as other staff were also busy with patient cares. On 11/14/23 at 9:37 AM, V1 (Administrator), V2, DON (Director of Nursing), and V5 (Quality Director) were present for an interview together regarding an injury that occurred to R1's right leg during a transfer on 11/6/23. V1 stated they started an investigation and identified V6, CNA (Certified Nursing Assistant), as the staff member that transferred R1, by standing and pivoting R,1 instead of using the stand lift. V1 stated V6 did not transfer R1 how she was supposed to, which lead to a fracture of R1's (right) leg. V5 stated therapy had evaluated R1 for weakness and had decided the safer transfer for R1 would be to use the stand lift. V1 stated on 11/6/23, R1 was being transferred to bed when this happened. R1 and the staff were interviewed. R1 did not complain of pain until 11/7/23 in the morning. Some pain for R1 is normal due to her history of cellulitis and nerve pain in her legs. On 11/14/23 at 10:06 AM, V5 (Quality Director) stated, (V6, CNA) said she attended the meeting on 10/4/23, that talked about transfers. Staff cannot upgrade transfers they can only downgrade. An example would be if a resident uses a sit to stand for a transfer, the CNA can use a mechanical lift and let the nurse know. The CNA cannot do a stand pivot transfer (upgrade in transfer) instead of the stand lift. V5 stated V6 attended the meeting and knew this. On 11/14/23 at 12:56 PM, V8, CNA, stated they know how to transfer a resident by looking at the care plan in the resident's closet. The care plan will say if the resident is a 1 assist, 2 assist, stand lift transfer etc. V8 stated all mechanical lifts are 2 assist. V8 stated she uses a gait belt for all stand pivot transfers. V8 stated she always transfers a resident by what is on the care plan for the resident's safety. On 11/14/23 at 2:25 PM, R1 stated an orderly broke her leg. R1 stated the orderly did not use the machine to transfer her. R1 stated she was told she could be moved without it. R1 stated she told the person she could not stand. R1 stated the person that transferred her did not use a transfer belt. The orderly picked her up, her leg twisted and it felt different. R1 stated she had pain when it happened, and the pain went away when she laid down. R1 stated she thinks she was in shock or something when this happened. R1 stated the next morning she had pain again. On 11/14/23 at 3:09 PM, V6, CNA, was contacted for an interview. A message was left, and V6 never returned the call. On 11/14/23 at 3:35 PM, V4, LPN (Licensed Practical Nurse), stated on 11/7/23, she was the nurse for R1 and another nurse came to her and stated V15 (R1's daughter) wanted R1 sent out to the hospital. V4 stated she went to R1's room, and V15 wanted her to look at R1's right leg; it was more swollen than the left leg. V4 stated she did not do any range of motion to R1's legs. R1 was sent to the hospital and had a fracture to her right leg. V4 stated she did not know about the transfer the night before until after this happened and they told her about it. On 11/15/23 at 9:41 AM, V14, PT (Physical Therapist), stated, They were using the stand lift for (R1's) transfers. Everyone knew they had to use the stand lift; it is on the care plan for (R1). If staff are unsure they will clarify the transfer with us during the day shift. It is important to follow the care plan for the residents safety. Some residents may not be safe to transfer any other way, anything can happen and someone could get hurt. The facility's Safe Lifting and Moving of Patients policy (1/2022) showed, in order to protect the safety and well being of associates and residents, and to promote quality of care, this community 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 safe lifting and moving of residents. Manual lifting of residents shall be eliminated when feasible. Nursing associates, in conjunction with rehabilitation associates, shall assess individual residents' needs for transfer assistance on an ongoing basis. Associates will document resident transferring and lifting needs in the care plan.

Based observation, interview, and record review, the facility failed to monitor a resident's weight who was experiencing weight loss, and failed to provide the ordered follow-up consults with the Dietician. This applies to one of one resident (R95) reviewed for weight loss in the sample of 23. These failures resulted in R95 experiencing a 15% weight loss. The findings include: The facility face sheet shows R95 was admitted to the facility on [DATE], with diagnoses to include congestive heart failure, repair of left hip fracture, and chronic kidney disease. The facility assessment, dated 5/25/23 for R95, shows her to cognitively intact and requires extensive staff assistance for bed mobility and transfers. The facility care plan for R95 shows on 5/25/23 a problem for weight loss/appetite was added to her care plan with a goal to maintain her current weight and her skin to remain free from pressure wounds. (R95 has a stage 3 pressure wound). Interventions include to weigh the resident as ordered and to record the results and report any significant change to the Physician and Dietician. The facility list of weights for R95 shows a weight of 116.8 pounds on 5/20/23, and on 7/12/23, R95 weighed 98.6 pounds. This is a 15 % weight loss for R95. The Physician Orders for R95 shows on 5/19/23 an order for daily weights. On 6/29/23 an order for weight to be checked every Monday, Wednesday and Friday. The facility weight list for R95 shows weights were not checked daily or three times a week. A gap from 6/17/23 to 7/9/23 shows no weights were obtained. The Physician orders for R95 shows on 6/22/23 an order was written for Dietary follow-up due to poor appetite and weight loss. On 6/25/23, another order was written for R95 to have a dietician consult related to a wound. R95's clinical record shows neither consult was completed. The nutrition risk assessment, dated 5/26/23 shows R95 to be at risk for malnutrition and interventions of daily weight was recommended. On 7/13/23 at 10:50 AM, V5, Dietician, said she was aware R95 was losing weight, and said she has been following up on it. V5 said she should have documented the interactions she has had with R95. V5 said she was not aware of the Physician order consult, and the computer had not alerted her to R95's recent weight loss. V5 said she would expect her weight to recorded daily as ordered, so her overall condition could be monitored. On 7/13/23 12:38 PM, V2, Director of Nursing/ DON, said, Weights should be monitored as ordered. It's important to monitor for weight loss or gain as they are an indication for underlying health issues. The facility policy, with a revision date of 1/2023, for weight monitoring shows appropriate nutritional care shall be provided to residents who have a significant weight change. A significant weight change is identified as a weight loss or gain of 5% in 30 days, 7.5% in 90 days or 10% in 180 days. C. a report should be generated from the electronic medical record system identifying all residents with a significant weight change F> A nursing or nutrition associate should notify the health care provider of any significant weight change .

Based on interview and record review, the facility failed to safely transfer a resident with a stand lift for one of three residents (R2) reviewed for safety in the sample of eight. This failure resulted in a probable hairline fracture to the right ankle. The findings include: R2's Physician Orders for January 2023 shows R2 was admitted to the facility on [DATE], with diagnoses including: Chronic atrial fibrillation, hypertension, bilateral primary osteoarthritis of knee, and history of falling. The facility's Serious Injury Incident Report, dated 1/27/23, shows R2 experience a fall with physical harm or injury on 1/24/23. The incident report shows R2 transfers with a mechanical lift and is interviewable. On 1/24/23, resident was assisted into be using (stand lift) but resident was not far enough back on the bed and began sliding and was assisted to the floor. Upon assessment by the nurse, right ankle was swollen and has a 5 centimeter bruising on the outer side and upon palpation, resident did complain of pain. Provider notified and ordered X-ray to right ankle and 1/26/23 X-ray came back with a probable hairline fracture to the right ankle. R2's Care Plan problem, dated 11/20/21, shows, (R2) has a history of falling related to pain and weakness as evidenced by right femur fracture. 1/25/23-CNA/Nurses to ensure bed is lowered to appropriate height (at the bed of the knee) for transfers with the (stand lift). Problem, dated 1/25/23, New pain as reported by (R2) following injury to right ankle. R2's Pain Evaluation, dated 1/25/23, shows R2 was experiencing pain to her right ankle when she moved it. Moving around R2's ankle increases her pain. The facility's Coaching Feedback shows V3, CNA (Certified Nursing Assistant), was educated on 1/27/23 in regards to safe transfers using (stand lift). Listening to patient/resident, being a patient advocate and ensuring bed is at the appropriate height during transfers to prevent falls/injuries were listed as the specific skill or behaviors to work on. On 2/21/23 at 10:15 AM, R2 said she had a fall from the lift. R2 said she told the CNA (Certified Nursing Assistant) her buttocks wasn't on the bed all the way. R2 said, She ignored me and moved the lift and my butt ended up on the floor. On 2/21/23 at 10:20 AM, V6, CNA (Certified Nursing Assistant), said the strap should be around the resident's legs when using a stand lift. The strap is used to keep the resident's legs on the pedestal and to support their legs. V6 said if the strap is not used, the resident legs could buckle. V6 also said it is important to make sure the resident is as far back on the bed as one can so the resident doesn't slip off. On 2/21/23 at 12:02 PM, V3, CNA, said (V3) was transferring R2 into her bed via the stand lift. V3 said when she was transferring R2 into bed, she didn't put R2 far enough onto the bed. V3 said she pulled the stand lift away from R2 and as she pulled the stand lift away, R2 slid to the floor. V3 said R2's buttocks was on the floor and her legs were bent to the side. V3 said V4, LPN (Licensed Practical Nurse), came in to assess R2 and V4 noticed a bump on R2's leg and R2 said the area was sore. V3 said when she transferred R2 via the stand lift, V3 put the sling around R2's waist and did not use the leg strap. V3 said she is supposed to use the leg strap. V3 said R2 did not let her know she was not on the bed all the way. On 2/21/23 at 1:58 PM, V4, LPN, said she was told R2 slid to the floor. V4 said she went into R2's room to assess her. V4 said when V4 touched R2's right outer ankle, R2 said it hurt. V4 said R2's legs were to the side and her buttocks were on the floor. V4 said she called the nurse practitioner, and the nurse practitioner ordered an x-ray. V4 said R2 was left in bed until after the X-ray. The facility's Safe Lifting and Moving of Patients policy revised 12/2019 shows, In order to protect the safety and well-being of associates and residents, and to promote quality care, this community uses appropriate techniques and devises to lift and move residents.

Based on observation, interview, and record review, the facility failed to supervise a resident at risk for falls and failed to follow the facility's policy and procedure for falls for 2 of 3 residents (R1, R3) reviewed for falls in the sample of 3. This failure resulted in R1 sustaining a fracture to his left hip which required a hospitalization and surgical intervention. The findings include: 1. R1's face sheet showed he was admitted to the facility on [DATE], with diagnoses to include traumatic subdural hematoma, pneumonia, chronic kidney disease, spinal stenosis, vascular dementia, and repeated falls. R1's facility assessment, dated 9/19/22, showed he had mild cognitive impairment and required extensive assistance of staff for transfers, uses a wheelchair, and a walker for ambulation. R1's medical record showed he was sent to the acute care hospital on 10/14/22, and returned to the facility on [DATE]. R1's admission assessment completed by the facility's nurse practitioner at his initial admission to the facility on [DATE] showed, . Chief Complaint: New admit - subdural hematoma . He presented to the [local acute care hospital] on 8/16/22 with fall several days prior Assessment . 5. Weakness/Debility.fall risk: facility fall precautions. Physical Therapy and Occupational Therapy, Monitor. 6. Subdural hematoma: acute on chronic, Continue plan of care, monitor, fall precautions . The facility's fall log for the previous 3 months showed R1 had an unwitnessed fall on 10/3/22 in his room, an unwitnessed fall on 10/13/22 in his room, and an unwitnessed fall on 10/14/22 in the dining room. R1's 10/12/22 Physical Therapy Progress Note showed R1 was ambulating 150 feet with a wheeled walker and contact guard assist of one staff. R1's 10/27/22 Physical Therapy Progress note ( after his fall with fracture) showed R1 required maximum assist to sit up in bed and was unable to ambulate due to pain and confusion. R1's facility fall risk assessment, dated 10/3/22, showed R1 was a high risk for falling. R1's record contained an Incident Witness Statement Form, dated 10/13/22 (the day before R1's fall with major injury), which showed an unwitnessed fall, . 10:30 AM, Left out a patient's room, walking down the hallway unit. Heard patient yelling for help. Went to patient room, saw patient on the floor sitting in upright position . R1's record contained a nursing note on 10/13/22 showing R1 was found sitting on the floor in his room in from of his wheelchair. There was no fall investigation provided upon request for R1's 10/13/22 fall. R1's fall risk care plan showed problem onset as 9/14/22, and an intervention added on 10/13/22 that showed, resident should not be left alone in room while in wheelchair . On 12/27/22 at 2:30 PM, V12 (R1's Spouse) said she and her son came into the facility on [DATE] to visit with R1. V12 said when she entered the facility, she went toward the public bathroom, and her son went to R1's room to take some things into the room. V12 said when she came out of the bathroom, she looked into the dining room as she passed by and saw a man laying on the floor. V12 said she went into the dining room and realized the man was R1 (her husband). V12 said R1 told her (while he was at the hospital) he got up because everyone else in the dining room had left, so he thought he should probably leave too. V12 said she got concerned when the fire department responded to the 911 call and was asking the staff if they saw how R1 fell , and the staff all said no. R1's Serious Injury Incident Report, dated 10/14/22, showed, On 10/14/22 around 12:45 PM, after lunch, dietary aide called for help as resident was noted to be on the floor . Resident is alert and verbalized 'I'm just walking to get out of the dining room.' . resident uses a wheelchair for mobility and stated he stood up and took a step . R1's nursing notek dated 10/14/22k showed, 10/14/22 at 12:00 PM - Writer was looking for resident to check his blood sugar before lunch and questioned CNA's (Certified Nursing Assistant) present on the unit. CNA's were unsure of where he went. Went to check residents room and he was not there. Writer requested [Another Nurse] to call the dining room to see if resident was brought down there to eat and CNA [V6] answered and stated he had brought him to the dining room. Writer stated not to leave resident alone. Writer proceeded down to the dining room to check BS (blood sugar). [V6] was sitting near resident and resident had just gotten food delivered to him. Writer told CNA not to leave resident along in the dining room as he is a fall risk. BS was 269. Writer went back to unit to get medications. While down on unit, writer was requested to give another resident pain medication and speak to a family member. While returning to the med cart writer was notified by [RN-Registered Nurse] that resident had fallen in the dining room. While getting the VS (vital signs) to go care for [R1], I see [V6, CNA on B hall]. I asked CNA what happened and he was unsure. CNA stated he was returning another resident to their room and left [R1] in the dining room for a moment. Upon entering the dining room resident was lying on his left side, legs stretched out . While assessing resident for injuries he complained of pain in left hip Resident stated he 'was just standing up to walk out of the dining room' .Attempted to roll resident into supine position to be hoyered into his wheelchair. Resident yelled out in pain and could not roll into supine position. Resident stated his pain was in the left knee to ankle at this time and denied hip pain. Resident's wife walked into the dining room at this time to visit with resident and saw him on the floor. Writer went back to the unit to find resident's son and walked him to the dining room per wife's request. The decision was made by the son and wife to send resident to [Local Acute Care Hospital] for evaluation . R1's acute care hospital emergency room documentation showed on 10/14/22 R1's xray of his left femur showed, . Impression: Acute comminuted intertrochanteric fracture left hip . On 12/27/22 at 12:00 PM, V3 (Certified Occupational Therapy Assistant/Therapy Manager) said R1 worked with both occupational and physical therapy from his admission on 9/14/22, through his discharge to the acute care hospital after his fall on 10/14/22. V3 said R1 returned to the facility on [DATE], and was evaluated by the therapy department on 10/21/22. R1 has not shown much progress since his readmission to the facility. On 12/27/22 at 11:48 AM, V5, RN (Registered Nurse), said R1 is alert with confusion. V5 said R1 transfers with a mechanical lift now. V5 said R1 came into the facility after a fall at home, and then went back to the hospital after a fall at the facility. V5 said R1 will try to transfer himself in his room or wherever he might be at the time. On 12/27/22 at 12:50 PM, V8 (Registered Dietitian) said she was in her office located off the main dining room when she heard a dietary aide yell for a CNA. V8 said she came out of the her office and saw R1 on the floor; she started to head down to the north hall to find a nurse. V8 said as she was going down north to find the nurse a CNA was coming from the south wing. V8 said, The CNAs are supposed to alternate taking residents back to their rooms so there is always a CNA in the dining room but on this day, unfortunately, when I came out of my office there was no CNAs in the dining room, just the dietary aide that found [R1] on the floor was in there. On 12/27/22 at 1:09 PM, V6, CNA, said, At the time the fall took place [R1] was in the main dining room. I was assigned to supervise the dining room. I was taking another resident back to their room and when I started heading back the nurse flagged me down and said [R1] had a fall . On 12/27/22 at 3:15 PM, V2, DON (Director of Nursing), said when a fall occurs the nursing staff should be entering a progress note in the resident's record showing a fall occurred and the details of the fall. V2 said she looked through R1's old chart and new chart and can not find documentation regarding his 10/13/22 fall. V2 said she was unable to find a fall investigation for R1's 10/13/22 fall. V2 said R1 had an unwitnessed fall again on 10/14/22 in the dining room. V2 said R1 should not have been left alone in the dining room, but unfortunately, it happened that way. V2 said R1 should have been supervised. On 12/28/22 at 11:03 AM, V13, NP (Nurse Practitioner), said R1 is very confused and he does try to do things on his own, which has resulted in falls since his admission. V13 said she is not sure if R1 is safe to be left alone in his wheelchair, and would have to see his chart to determine that. 2. R3's face sheet showed she was admitted to the facility on [DATE], with diagnoses to include Type 2 Diabetes, hypertension, atherosclerotic disease, hyperlipidemia, osteoarthritis, and chronic kidney disease. R3's facility assessment dated [DATE] showed she has mild cognitive impairment and requires limited assist of one staff member for all cares. The facility's fall log for the previous 3 months showed R3 had fallen on 10/3/22, 10/22/22, 12/3/22, and 12/23/22. R3's complete medical record was reviewed including agency staff documentation handwritten on paper and showed no progress notes entered in R3's record for there 10/3/22 or her 10/22/22 fall. The fall investigation into R3's 10/3/22 fall was requested and staff were unable to provide the investigation. On 12/27/22 at 3:15 PM, V2 said she was unable to find documentation of R3's falls on 10/3/22 and 10/22/22. V2 said she would expect to find a progress note in R3's record. V2 went on to say she was unable to locate a fall investigation into R3's fall on 10/3/22. V2 said she would expect a fall investigation to be initiated immediately after the fall because the fall investigation documents are kept at each nursing station. The facility's policy titled Falls Prevention, with last approved date of 03/2022, showed, Policy Statement, The intent of this policy is to provide an environment that is free from accident hazards, over which there is control, and provide supervision and intervention to residents to prevent avoidable accidents . The facility's policy titled Falls with last approved date of 01/2022 showed, Policy Statement/Overview, The purposes of this procedure is to provide guidelines for evaluation of a resident in the event a fall occurred and to assist associates in identification of potential causes of the fall . An incident report shall be completed for resident falls by a Licensed Nurse after the fall occurs.

Based on observation, interview, and record review, the facility failed to ensure safety interventions were in place while a resident was being weighed for 1 of 5 residents (R1) reviewed for falls in the sample of 5. This failure resulted in R1 falling, sustaining a nasal fracture, lacerations to his nose, and the resident being sent to the emergency room for treatment. The findings include: R1 was admitted to the facility on [DATE] with history of falls. The facility ' s Resident Incident Report shows R1 had a fall on 10/11/2022 in the shower room. Resident Incident Report shows R1 had swelling above his right eye, laceration to the bridge of his nose, lacerations to the tip of nose, abrasions to right hand and right knee. On 10/26/2022 at 8:54AM, R1 was observed lying in bed. R1 sat up in bed and sat on the edge of the bed to speak with this surveyor. R1 had a small scar on the bridge of his nose and his nose appeared crooked. On 10/26/2022 at 8:54AM, R1 was alert and oriented x3. R1 said he had a recent fall in the shower room and broke his nose. R1 said he was taken into the shower room by facility staff to get a weight check done. R1 said he tripped over the scale. R1 said he fell and hit his face on the floor. R1 said he had a bloody nose. R1 said he was sent to the hospital after the fall. R1 said his nose is crooked now following the fall and it wasn't like that before. R1 said he had a bump over his right eye from the fall. R1 said he feels the scale is unsafe. On 10/26/2022 at 10:36AM, V10, Certified Nursing Assistant (CNA), said Dietary had requested a weight check on R1 and she went to get R1's weight. V10 said she found R1 in the W dining room, where he prefers to eat lunch, and brought him into the W shower room. V10 said she opened the door for R1, and R1 walked towards the scale to get weighed. V10 said she moved to the far side or opposite side of the scale as R1 approached the scale. V10 said R1 lost his balance, stumbled, fell off to his right side, and hit his face on the ground. V10 said she was not able to catch R1, or stop his fall, because it happened too quickly. V10 said she did not have a gait belt on R1. V10 said V12, Laundry Attendant, was in the shower room at the time of the R1's fall. V10 said she called for help and went to R1's side. V10 said V11, Licensed Practical Nurse (LPN)/Restorative Nurse, came in to help. V10 said R1's face was bloody, and there was blood all over the floor. On 10/26/2022 at 10:49AM, V12 said on she was hanging up slings on the wall when V10 brought R1 in to get his weight. V12 said she turned around and was facing the scale, and saw R1 stumble and fall next to the scale. V12 said R1 hit his face on the shower room floor, and he was bleeding from his nose when he lifted his head up. V12 said she did not see R1 with a gait belt on. On 10/26/2022 at 11:08AM, V11 said she heard someone scream in the shower room. V11 said R1 was on the floor of the shower room with blood on the floor. V11 said she assessed R1. V11 said the Nurse Practitioner (NP) was notified, and the NP ordered the resident to be sent to the ER. R1 was seen at a [local area hospital] on 10/11/2022, and was seen in the Emergency Department (ED) for facial trauma with significant bleeding from cuts on nose according to hospital records. R1 was diagnosed with a nasal fracture and two lacerations were treated in the ED. A 1cm laceration to R1's nose was closed with glue according to hospital records. The second laceration was measured at 1cm and closed with a 6-0 prolene suture, requiring two sutures to close according to hospital records. R1 underwent a CT scan of facial bones wo contrast on 10/11/2022. Report findings: depressed right nasal bone fracture. On 10/26/2022 at 11:40AM, observations of the W shower room scale were made. The scale has two ramps on the shorter sides of the scale. The longer sides of the scale have a raised edge to it. There is no handle, support, or railing on the side of the scale that R1 fell near and injured his face. The only support found on the scale was on the side of the scale nearest to the wall with two narrow handles/grips, which is on the opposite side of the scale from where R1 fell . On 10/26/2022 at 11:40AM, R6 was observed entering the W shower room for a weight check. R6 was accompanied by facility staff V17, CNA. R6 walked up to the scale with his walker and stepped up on the scale. R6 said that's steep when he stepped onto the scale without his walker. On 10/26/2022, V2, Director of Nursing (DON,) said there were other types of scales available in the building that R1 could be weighed on. V2 said the facility has a standing scale and sitting scale available for use. V2 said the scale in the W shower room was not the best option to weigh R1. V2 said V10 should have stayed next to the resident while he was getting onto the scale. On 10/26/2022 at 10:06AM, V13, CNA, said CNAs should be using gait belts to obtain standing weights on residents because its safer. The facility provided the manufacturer's information for the scale in the W shower room. The manufacturer's information shows the scale is used as a scale for stretchers and wheelchairs and has a 2 inch high platform.

Based on interview and record review, the facility failed to provide the necessary care and services for a resident with unrelieved knee pain and swelling, which resulted in a delay in treatment of [REDACTED]. This applies to 1 of 3 residents (R1) reviewed for quality of care in the sample of 9. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on January 11, 2021 when R1 began complaining of right knee pain. The Immediate Jeopardy was identified on January 19, 2021. V1 (Administrator) was informed of the Immediate Jeopardy on January 25, 2021. This surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed on January 25, 2021, however, noncompliance remains at a Level 2 because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: R1's Resident Admission Assessment showed R1 was admitted to the facility on [DATE] with no deformity, swelling, bruising, or injury to her right knee or leg. R1's Care Plan, dated November 20, 2020, showed R1 was cognitively impaired related to her [DIAGNOSES REDACTED]. The care plan also showed R1 will need assist of one staff for ADL's, two staff if using a lift (transfer device) as needed. R1's Nursing Note, dated January 14, 2021, showed staff found R1 lying in bed, at 6:35 AM, holding her right knee with both hands. R1 was wincing and moaning with any movement of her right leg. Upon assessment of the staff nurse, R1's right lower extremity femur appears out of alignment with her right knee. The note showed an X-ray of R1's right knee was performed in the facility. Upon receiving R1's X-ray results, R1 was transferred to a local hospital for evaluation and treatment. R1's right knee CT scan (computed tomography) report dated January 14, 2021 showed, comminuted fracture through the distal right femoral shaft with 1 shaft with lateral displacement. On January 19, 2021 at 11:20 AM, V5, CNA, stated he cared for R1 on January 13, 2021, during the day shift. V5 stated, Around 10:30 AM that day, I provided (R1) with incontinence care and was going to get her dressed. I went to bend her right leg to get her pants on and she began screaming in pain. She grabbed her right knee with both of her hands and held it. I knew something was wrong at that time so I stopped what I was doing and went to get the nurse. V14 stated he reported R1's knee pain to V6, Registered Nurse (RN), and V11, RN, on January 13, 2021. On January 19, 2021 at 11:40 AM, V11, RN, stated, On January 13, 2021, (V5, CNA) reported to me that (R1) was having severe right leg pain. (R1) was not my patient that day so I told her nurse (V6, RN) that she was having right knee pain. I never assessed her that day. V11 also stated, I did not notify (R1's) physician of her knee pain. I should have assessed her immediately that day and called her physician. On January 19, 2021 at 11:46 AM, V14, Certified Nursing Assistant (CNA), stated she cared for R1 on January 11, 2021. V14 stated, I got her up out of bed that morning around 4:30 AM. I got her up by myself and used a gait belt. She didn't complain of any pain at that time. I put her in a wheelchair and took her to get weighed. I got her back into bed and she began rubbing her knees and complaining of pain. V14 stated she reported the R1's knee pain to the nurse on duty. On January 19, 2021 at 12:00 PM, V6, RN, stated, I was the nurse for (R1) on January 13, 2021. I was notified that she was having knee pain that day. Around 1:45 PM, I went in to look at her knee. When I palpated her right knee, she had severe pain. I didn't do any range of motion (ROM) exercises with her right leg so I don't know if her ROM was normal for her .I did not call (R1's) physician to notify him of (R1's) pain .There is no excuse. I should have called (R1's) physician immediately to inform him of her knee pain. On January 19, 2021 at 4:30 PM, V22, Licensed Practical Nurse (LPN), stated, On the morning of January 14, 2021, the CNA asked me to look at (R1's) right knee. When I walked into her room, (R1) was lying flat on her back in bed, holding her right knee. She kept repeating don't move my leg. (R11's) right knee was swollen and the bone above her knee was pushing the skin out over the knee. I didn't know if it was broken or dislocated. V22 stated he immediately ordered an X-ray of R1's knee and notified R1's physician. On January 20, 2021 at 9:20 AM, V23, CNA, stated she provided cares for R1 on January 14, 2021. V23 stated, I went into (R1's) room around 6:15 AM that morning to get her up. I pulled back her covers and she was lying on her right side with both of her hands holding her right knee. I didn't notice any deformity to her right knee at that time. I went to roll her on her back and she began screaming and hollering in pain. She was still holding onto her right knee. That is when I noticed her right knee did not look right. I went and got the nurse. On January 19, 2021 at 12:25 PM, V2, Director of Nursing, stated, We don't really know what happened to her (R1) because of her dementia and cognition. (R1's) injury could have happened when we rolled her (in bed) or got her up .This is a big deal. We had 3 staff members aware that (R1) had severe right knee pain and no one called her doctor. We failed to report her pain and that is significant. We should have called her doctor immediately when she began complaining of pain .The expectation is that if a resident is experiencing acute pain and/or a change in condition, the nurse immediately does a full assessment which includes checking range of motion, checking pulses in the extremity, and notifying the doctor immediately. On January 20, 2021 at 10:05 AM, V24, Hospital Nurse, stated, We (hospital staff) were very concerned about the severity of (R1's) injury when she arrived here. She couldn't tell us what happened due to her dementia and confusion. It takes a lot of force to break a femur bone even if the patient has [MEDICAL CONDITION]. When (R1) arrived to the hospital, her right femur bone was so deformed and sticking out. Her femur bone was literally causing tenting (stretching) to the skin above her right knee. On January 19, 2021 at 1:32 PM, R1's right knee X-ray report, dated January 14, 2021, was reviewed with V20, Nurse Practitioner (NP). V20 stated, There is no way a person can spontaneously break their femur (bone) even if they have [MEDICAL CONDITION]. It would take a tremendous amount of force to break the femur bone in a person's leg. This injury is usually caused by some sort of injury or trauma. On January 19, 2021 at 2:00 PM, V19, Nurse Practitioner, stated, Even with a [DIAGNOSES REDACTED]. These fractures are usually caused by a tremendous amount of force applied to the femur. On January 25, 2021 at 11:07 AM, V19, Nurse Practitioner, stated any resident change in condition, resident complaint of unrelieved pain, or complaint of new pain should be reported to a physician immediately after the nurse has assessed the resident. The facility's Change in Resident's Condition or Status Policy, dated July 2020, showed, Our community shall promptly notify the resident, his or her health care provider, and representative of change's in the resident's medical/mental condition and/or status .The nurse will notify the resident's Health care provider or physician on call when there has been a(an): .2. discovery of injuries of unknown source .4. significant change in the resident's physical/emotional/mental condition . The Immediate Jeopardy that began on January 11, 2021 was removed on January 25, 2021, when the facility took the following actions to remove the immediacy: Immediate Changes to Facility Systems 1. The facility immediately initiated an investigation to include interviews of the staff and other residents (1/14/2021). 2. The DON immediately began re-educating staff regarding identification of change of condition, notification of physician process and completion of required assessments on 1/19/2021. The remaining staff who have not completed education will be educated prior to their next scheduled shift. 3. The Interdisciplinary team has reviewed Resident Change in Condition policy and procedure and Physician Notification policy and procedure and it is in compliance with the CMS regulation F 684. 4. Residents identified as having a change in condition will be reviewed by the Interdisciplinary Team during the daily clinical meeting for review of completed assessment and required physician notification. If discrepancies are found immediate corrective action will be completed and one-on-one education provided to staff involved. 5. During weekly Resident at Risk meetings, the Interdisciplinary Team will review the clinical record of residents with noted change in conditions to have continued monitoring of compliance. The review will be documented in the resident's clinical record. 6. Starting 1/19/2021, DON and/or designee will complete routine random reviews of electronic medical records on identified residents with change in condition specific to completion of required assessments, timely physician notification, and completion of required documentation, three times per week for 8 weeks ending 3/19/2021. Quality Assurance 1. Routine review findings will be provided to QAPI committee for review.

Based on interview and record review, the facility neglected to notify a resident's physician of a resident's (R1) unrelieved knee pain and swelling and complete a medical evaluation on that resident. This resulted in a four day delay of treatment, from onset of symptoms, of a fractured femur for R1. This applies to 1 of 3 residents (R1) reviewed for abuse in the sample of 9. The findings include: R1's Resident Admission Assessment showed R1 was admitted to the facility on [DATE] with no deformity, swelling, bruising, or injury to her right knee or leg. R1's Care Plan, dated November 20, 2020, showed R1 was cognitively impaired related to her [DIAGNOSES REDACTED]. R1's Nursing Note, dated January 14, 2021, showed staff found R1 lying in bed, at 6:35 AM, holding her right knee with both hands. R1 was wincing and moaning with any movement of her right leg. Upon assessment of the staff nurse, R1's right lower extremity femur appears out of alignment with her right knee. R1's right knee CT scan (computed tomography) report, dated January 14, 2021, showed, comminuted fracture through the distal right femoral shaft with 1 shaft with lateral displacement. On January 19, 2021 at 11:20 AM, V5, CNA, stated he cared for R1 on January 13, 2021. V5 stated R1 began screaming in pain on January 13, 2021, when he bent her right leg to assist her in getting dressed. V14 stated he reported R1's knee pain to V6, Registered Nurse (RN), and V11, RN, on January 13, 2021. On January 19, 2021 at 11:40 AM, V11, RN, stated V5, CNA, reported to her, on January 13, 2021, that R1 was having severe right knee pain. V11, RN, stated she did not assess R1 or notify R1's physician of her knee pain that day because R1 was not her patient. V11 also stated, I should have assessed her immediately that day and called her physician. On January 19, 2021 at 11:46 AM, V14, Certified Nursing Assistant (CNA), stated R1 began complaining of knee pain and rubbing her knees after she was transferred out of bed on January 11, 2021. V14 stated she reported the R1's knee pain to the nurse on duty but could not remember which nurse. On January 19, 2021 at 12:00 PM, V6, RN, stated on January 13, 2021, she was notified of R1's severe right knee pain. V6 stated she did not do an assessment of R1's right knee pain and did not notify R1's physician of her knee pain on January 13, 2021. V6, RN, stated, I did not call (R1's) physician to notify him of (R1's) pain .There is no excuse. I should have called (R1's) physician immediately to inform him of her knee pain. On January 19, 2021 at 12:25 PM, V2, Director of Nursing, stated, We don't really know what happened to her (R1) because of her dementia and impaired cognition. (R1's) injury could have happened when we rolled her (in bed) or got her up .This is a big deal. We had 3 staff members aware that (R1) had severe right knee pain and no one called her doctor. We failed to report her pain and that is significant. We should have called her doctor immediately when she began complaining of pain .The expectation is that if a resident is experiencing acute pain and/or a change in condition, the nurse immediately does a full assessment which includes checking range of motion, checking pulses in the extremity, and notifying the doctor immediately. On January 19, 2021 at 4:30 PM, V22, Licensed Practical Nurse (LPN), stated, On the morning of January 14, 2021, (R1) was lying flat on her back in bed, holding her right knee. She kept repeating don't move my leg. (R1's) right knee was swollen and the bone above her knee was pushing the skin out over the knee. I didn't know if it was broken or dislocated. On January 20, 2021 at 9:20 AM, V23, CNA, stated she provided cares for R1 on January 14, 2021. V23 stated on January 14, 2021, when she rolled R1 over onto her back, she noticed R1's right knee didn't look right. (R1) was screaming in pain and holding her knee. On January 25, 2021 at 11:07 AM, V19, Nurse Practitioner, stated any resident change in condition, resident complaint of unrelieved pain, or complaint of new pain should be reported to a physician immediately after the nurse has assessed the resident. The facility's Abuse Prevention Policy, dated June 2020, showed, Neglect means the failure of the community, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.

Based on interview and record review, the facility failed to follow assessed safety needs for a resident when using a mechanical lift device, by not having two persons to assist with the transfer. This failure resulted in R1 sliding out of the mechanical lift sling, landing on the floor, hitting his head and breaking his neck on [DATE]. R1 required hospitalization and subsequently expired. The Immediate Jeopardy began on [DATE], when R1 was transferred by one certified nursing assistant using a mechanical lift. During the transfer, R1 slid out of the mechanical lift sling, landed on the floor, hit his head on the mechanical lift, and broke his neck. R1 was transferred to the emergency department, and was diagnosed with [REDACTED]. R1's condition deteriorated and he died as a result of the neck fracture. On [DATE] E1 (Administrator) was informed of the immediate jeopardy. The Immediate Jeopardy was removed on [DATE]. While immediate actions were taken, the facility remains out of compliance at a severity level 2. Additional time is needed to monitor and evaluate the effectiveness of any new or revised policies, procedures, and training provided to staff. This applies to 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 6. The findings include: During this survey, R1 was unavailable for observation or interview, as R1 was discharged from the facility on [DATE], and died at the hospital on [DATE]. R1's undated Resident Care Guide was submitted by the Restorative Department as being his (R1's) current transfer plan. The document showed he requires a two assist with a mechanical lift. The Nurse's Note dated [DATE] for R1 showed at 6:30 AM, the nurse was at the nurse's station by the medication cart and heard a call for help. The nurse went into the resident's room with two other nurses to find the resident on the floor at the base of the mechanical lift. V11, Certified Nursing Assistant (CNA), had the resident's head with pressure applied to the back of the head. The nurse noted a gash approximately 1 inch long. R1 was alert and talking to staff. V11 stayed with resident. At 6:40 AM, a call was placed to the ambulance company for transport to the emergency room (ER). The facility's Final Report of Incident for R1 dated [DATE], showed R1 was alert with some confusion. R1 was dependent on staff for all activities of daily living, care, transfers, and used the full mechanical lift with assist of ,[DATE] for transfers. On [DATE], the CNA was assisting R1 out of bed to the chair with a full mechanical lift, and during the transfer R1 slid out of the sling to the floor. During the fall, he hit his head on the leg of the lift. R1 was sent to the ER and had a fracture of C4 & C5. The Neurosurgeon Consult Note dated [DATE] for R1 showed, Diagnostic data: Review of the computerized tomography scan of the cervical spine shows that he had a previous fusion at C,[DATE]. There is a fracture at the level of the C,[DATE] interspace with displacement posteriorly of 8 mm, this is a highly unstable injury. Impression: The patient suffered a C,[DATE] fracture at the fall. This is in the context of extensive ankylosis of his spine and fracture dislocation is highly unstable. The family does not wish to have any aggressive treatment as this would usually be a surgical stabilization situation. The patient does not want to have surgery and he appears to have at least enough insight to make this determination. We will palliatively treat him in a collar, understanding that this may not heal and he could suffer additional neurologic injury. The Trauma Surgeon's Summary of History and Hospital Course for R1 dated [DATE] showed, The patient was admitted after a fall at his nursing facility. He sustained unstable fractures of the neck and was seen by trauma service and was admitted . The patient did not pass a swallow evaluation, due to wearing the hard collar to protect him from his neck injury. Patent had difficulty swallowing his own saliva and was intubated due to significant buildup of secretions. This was done at the direction of the son, who was temporarily out of the country. After the son returned to the country and evaluated his father's condition, the choice was made to proceed to place the patient under comfort measures and perform [MEDICATION NAME] extubation. The extubation was performed and the patient was calmed (died )on [DATE] shortly after 5:00 PM. The patient's case was reviewed by the coroner, and the body released. On [DATE] at 9:00AM, V14 (Trauma Surgeon) stated, A hard collar was placed because of the C4-C5 fracture (neck fractures). The fractures to his neck were unstable at C4 & C5. The subsequent events like being unable to manage secretions, neck fractures and the collar led to him deteriorating and he needed to be intubated. V14 was asked if the fall lead to R1's death. V14 stated, Yes, the fall resulted in a C4-C5 fracture. His death at that time could have been prevented if he had not fallen and had neck fractures. From what I understand he was in a mechanical lift in the nursing home; they are supposed to have ample people performing the lift because this is what could happen. In theory if there were enough people monitoring the lift and the patient then he would not have fallen out of the lift. On [DATE] at 9:00AM, V2 (Director of Nursing - DON) stated, R1 expired at the hospital from fall related issues. R1 used a full mechanical lift. Our policy says to use a lift per manufacturer's guidelines. I understand why it is strange for him to fall out if everything is right. R1 moved slowly because he is so stiff that sometimes his movements would not be noticed. The CNA was V11. The sling was not the one that comes up between his (R1's) legs. It was the one that covered him from head to mid thighs. V2 stated she did not do R1's assessment, so she was unsure if 1 person was appropriate for the transfer with the mechanical lift. On [DATE] at 10:14AM, V4 (RN - Registered Nurse/Restorative Nurse) stated, I came here in August, (YEAR), and have been restorative certified since (YEAR). R1 was contracted at the hip joints, knees, elbows, and shoulders. R1 was a total assist of two people for transfers; it was more appropriate to do with 2 people because he was contracted and it is safer. They use a mechanical lift that uses slings with loops; a full mechanical lift sling. Two people are needed to transfer R1 safely. R1 was assessed for two people before I even came here. I do and update the resident care guide and it shows the residents functional status. R1's current care guide shows that he (R1) was a transfer of two people and using a mechanical lift. I don't know where it is (Resident Care Guide); it was here in the restorative book. V13 (Restorative Aide) will have a copy. I would never have changed him to a 1 person assist no matter what; he was a two person assist with a mechanical lift. The resident care guide in a resident's room is the final restorative assessment. It's hard to get a sling under someone that is contracted; you need two people to do it correctly. If a resident is placed in a mechanical lift correctly then the resident should not fall out. This is what happens if it is not done safely; he fell out and now he is dead. V4 stated there are some reasons a resident can fall out of a mechanical lift. V4 stated it can happen if a sling loop is not hooked securely, if the sling is not centered under the resident. The sling needs to be at least under the resident to their knees because the sling can scoot up; it should never be just to the thigh area. On [DATE] at 10:27AM, V13 (Restorative Aide) was asked by V4 (Restorative Nurse) if she had a copy of R1's Resident Care Guide. V13 stated, Yes, I took the one off his door in his room. V13 pulled out R1's care guide and showed it to the surveyor. A copy was made and given to the surveyor. V4 and V13 confirmed it was the resident care guide that was current and being used for R1 prior to his hospitalization . The resident care guide for R1 showed he was a 2 assist with a mechanical lift. On [DATE] at 2:34PM, V11 (CNA) stated, It was a busy morning. There is a care plan on the inside of his closet door; I don't know what the care card for R1 said. He has been there since I started and I just go off of what I was trained to do. I am not aware of R1 being a two person assist. I transferred him; I mechanically lifted him up, the chair was under him. He had a padded wheelchair. I lowered R1 and he slid out of the front of the sling. I tried to catch him; he hit his head on the lift. He is always stiff and always in pain with everything. R1 said he just had pain. I held his head and neck and yelled for help. On [DATE] at 12:58PM, V8 (CNA) stated, There is a resident care guide form posted in the resident's closet. It shows everything on the patient like how they ambulate, transfer, continence, diet, and repositioning. I look at it when I go into a resident's room. When I use a mechanical lift I usually have someone with me in case something happens. On [DATE] at 1:19PM, V9 (Licensed Practical Nurse - LPN/Nurse Manager) stated, Staff come in and are oriented to all of the mechanical lifts. We tell them where to find the information on the care for the resident which is the resident care guide. They also have assignment sheets for the residents they are taking care of. Everyone should have a resident care guide to show how to provide care. The facility's Mechanical Lift policy dated ,[DATE] showed, The use of mechanical equipment should be according to manufactures recommendations. The undated mechanical lift manufacturer recommendations showed, Make certain the patient you are about to lift has been assessed by the professional staff and approved to be lifted by the lift; Make sure you have sufficient staff to accomplish the procedure. Usually one person can perform the lift procedure with the lift. Certain patients; however, require the support of one or more additional staff members. This requirement must be recorded during the patient's assessment and communicated to the lifting staff. R1's MDS dated [DATE] showed extensive assist of 1 person for transfers; this assessment conflicted with the resident care guide the staff were currently using for instruction this residents care. R1's Care Plan dated [DATE], showed he was a full mechanical lift for transfers with the assist of ,[DATE] people; his care plan was changed on [DATE] and showed he should be a 2 assist for all transfers. On [DATE] at 8:22AM, V22 (Registered Nurse - RN/MDS Care Plan Coordinator) stated, A score for a resident under transfers that uses a mechanical lift should be a 4 - total dependence. The staff are being re-educated on completing the documentation and ensuring it is accurate. To do the care plan I look at the nurse's notes and minimum data set. I look at assessments by the restorative nurse and base the care plan on that and the MDS. I didn't look at R1's restorative assessment; I didn't know he was a 2 person assist. I didn't look at R1's care guide (restorative assessment) to see what the restorative nurse put in place. I didn't know the resident's care guide was part of the restorative assessment. On [DATE], V4 (RN/Restorative Nurse) stated, I did not have a quarterly restorative assessment for R1. I thought I had one but I can't find it. The resident care guide is what the CNA's follow and the resident care guide is a reflection of what the care plan should say. If activities of daily living don't capture the appropriate charting in a seven day look back period, you can't change the charting. The MDS is based on charting so it's not always an accurate reflection of the resident or for example of how they transfer. The accurate assessment of the resident is on the resident care guide; it's a reflection of my accurate assessment of the resident. I didn't update R1's care plan to show a 2 person assist. It said a ,[DATE] person assist on the care plan at the time this happened and it should have been a 2 person assist. I think the sling for him was too small. On (MONTH) 24, 2019, the surveyor confirmed through observation, interview, and record review, the facility took the following actions to remove the immediacy of the situation: 1. Resident(s) Identified: R1 was immediately assessed by nursing staff and transported to the hospital via ambulance for evaluation. R1 is no longer a resident at the facility. 2. Other Residents with Potential to be affected by the Immediate Jeopardy Incident: Like residents requiring a mechanical lift has the potential to be affected and have been reassessed to monitor appropriate mechanical lift use. 3. Staff Identified: a. The facility immediately initiated an investigation to include interviews of the staff involved in the incident on [DATE]. b. The facility immediately began re-education at least 90% of the nursing staff regarding proper lift techniques to include the proper sizing of slings beginning [DATE]. To date, [DATE], at least 90% of nursing staff have been re-educated and the remaining staff will not be scheduled to work until re-education is completed. 4. Immediate Changes Implemented: a. The Director of Nursing or designee has re-educated at least 90% nursing staff regarding proper mechanical lift techniques and proper sling sizing including return demonstration. The re-education continues to provide orientation for staff to include proper lift techniques and sling sizing that must be completed prior to providing direct care as of [DATE]. b. The mechanical lift in question was taken out of use immediately pending maintenance check as of [DATE]. c. Like residents requiring mechanical lifts have been re-assessed to verify that current transfer status is appropriate and documented as of [DATE]. d. A review of Minimum Data Set (MDS) coding for like residents requiring the use of mechanical lifts was completed on [DATE] to reflect the accuracy of assessments, care plans and care guides. e. Staff has been educated to the transfer procedure of using two person assist during mechanical lift transfers as of [DATE]. 5. Plan of Correction: a. The facility will schedule train the trainer with lift manufacturer for the Restorative Nurse. b. During the weekly Resident at Risk meeting the Interdisciplinary Team will monitor MDS, care plan and care guides for accuracy. 6. Quality Assurance: The Director of Nursing and/or designee will review transfer audit sheets to monitor for compliance for three months and present it to the QAPI committee for three months and then determine if further monitoring is indicated.

Based on interview and record review, the facility failed to send a resident for evaluation after the resident exhibited change in vital signs and level of consciousness. R2's condition continued to decline and the facility was unable to start IV fluids. R2 was not sent out for a period of about 4 hours after the directive to send her out was given. This failure contributed to a delay in treatment, and unecessary pain. R2 was admitted to the hospital with [REDACTED]. This applies to 1 of 6 residents (R2) reviewed for neglect in the sample of 6. The findings include: On (MONTH) 28, 2019, at 1:02PM, V19 OT (Occupational Therapist) entered a note into R2's chart which showed, took patient back to room and set patient up for a toilet transfer when she started reaching for things that were not there, therapist pulled the call light and nurse and CNA (Certified Nursing Assistant) arrived at that time patient's eyes rolled back but did not go completely unresponsive, assisted CNA to return patient to bed and left patient in care of nursing and CNA. On (MONTH) 29, 2019 at 3:55 PM, a nursing note by V5 LPN (Licensed Practical Nurse) showed at 8:00 AM, R2 was awakened to get a set of vital signs. R2's pulse was 108, and described as bounding, with a blood pressure of 90/50 . lethargic this a.m., appetite poor, unable to stay awake to take meds (medications), noted coarse crackles right upper lobe, unable to get patient to eat or drink. The note showed V17 NP (Nurse Practitioner) was contacted at 10:30 AM, and new orders were received to start intravenous fluids, and if they are not able to get IV access to call the NP back, and will probably send to ER (emergency room ). The same note showed at 11:00 AM an RN (Registered Nurse) tried three times to get the IV access it but was not successful . . Dtr (daughter) called nurse informed unable to get IV in. dtr (daughter) stated, send her out. Placed call to NP message left to call facility. At 12:30PM NP returned call stated, will be coming within the hour. ADON wanting to give pt (patient) more oral fluids and try to keep pt here and do what we can for her here (at the facility). At 14:30 (2:30 PM) patients daughter POA here requesting mother be sent out NP here patient going to (acute hospital ER) for evaluation and treatment. On (MONTH) 17, 2019 at 2:35 PM, V17 NP (Nurse Practitioner On-Call) stated she received only one call from the facility on (MONTH) 29, 2019 at approximately 11:00 AM. V17 said during that phone call, she gave new orders to start IV fluids and if they could not get the IV started they should send R2 to the emergency room for evaluation. V17 said when she arrived at the facility on (MONTH) 29, 2019 at approximately 3:00 PM to see another resident, she was very confused to hear R2 was still in the facility since they were unable to start the IV fluids. V17 said the facility was supposed to send R2 to the hospital if they were unable to start the IV. On (MONTH) 16, 2019 at 1:10 PM, V5 (LPN) stated she was working R2's hall on (MONTH) 29, 2019, and started her shift at 6:00 AM. V5 said R2 was kind of lethargic and couldn't stay awake. This was a change for her. V5 said she does not remember if she assessed the patient again after the initial assessment or if she took another set of vital signs after the first set at 8:00 AM. On (MONTH) 17, 2019, at 12:35 PM, V5 said she called the nurse practitioner on (MONTH) 29, 2019, because her assessment of R2 at 8:00 AM was concerning because of R2's bounding pulse and lethargy. V5 said she reported to V3 ADON (Assistant Director of Nursing) that they were unable to get the IV started, and V3 said to try and keep her in the facility. V5 said R2 had been having behaviors of playing possum during which she would say she was really tired and would slump her head forward and close her eyes like she was sleeping. V5 said on (MONTH) 28, 2019 (the day before she was sent to the hospital) during a therapy session, R2 had a behavior of closing her eyes and tipping her head back and then down, because she didn't want to do therapy and wanted to go to bed. V5 said it is possible that R2 was requesting to go to bed all the time and refusing therapy sessions because she was actually sick. R2's medical record showed no evidence of further assessments documented on R2 between the 8:00 AM assessment on (MONTH) 29, 2019 and R2's transfer to the hospital at 3:55 PM. On (MONTH) 16, 2019, at 11:00 AM, V3 ADON (Assistant Director of Nursing) said on (MONTH) 29, 2019, she was called down to R2's room because she was told R2 was lethargic, and unable to get out of bed. V3 said they were trying to start an IV when she arrived to the room but they could not get it started. V3 said, I thought (R2) was out of it, but she was able to communicate yes and no. V3 said the nurses had tried to start the IV twice so she told them to, maybe hydrate her first, give her water. V3 said after they tried the IV they wanted to send R2 to the hospital, but the nurse practitioner said to wait until she got there to send her out. V3 stated R2 should have been sent to the hospital when the change of condition was identified and the family requested. On (MONTH) 12, 2019, at 2:20 PM, V20 (R2's granddaughter) stated she had called the facility on (MONTH) 29, 2019, to get a prescription for a wheelchair for R2's discharge home, when the nurse told her R2 was unresponsive because R2 is just so tired. V20 said R2's daughter contacted the facility then, and requested R2 be sent to the acute care hospital for evaluation. V20 said the facility called back and said that R2 had come to, so they thought she was going to be ok, at which time V20 said they requested again for R2 to go to the hospital. V20 said at about 3:30 PM, R2's Power of Attorney went to the facility and found R2 had still not been sent to the hospital, and did not have an IV. V20 said R2's Power of Attorney demanded a transport to the hospital at that time. V20 said when R2 was sent to the hospital they were told R2's kidneys had shut down due [MEDICAL CONDITION]. R2's ambulance radio report dated (MONTH) 29, 2019 at 4:15 PM, showed R2's chief complaint as fever and lethargy and R2's heart rate as 130 beats per minute. R2's acute care progress note entered by V24 (Hospitalist) on (MONTH) 31, 2019, showed R2 was a skilled nursing home resident 6 weeks postoperative for a [MEDICAL CONDITION] admitted to the hospital with [REDACTED]. V24's assessment and plan with the same date of service of (MONTH) 31, 2019, showed R2's active problems: acute kidney injury (baseline creatinine 0.8 - R2's creatinine 4 on admission),[MEDICAL CONDITION] on admission due to Urinary Tract Infection, Metabolic acidosis due to acute kidney injury, lactic acidosis and diarrhea, acute [MEDICAL CONDITION] due to acute kidney injury, dehydration, and urinary tract infection. R2's therapy note dated (MONTH) 26, 2019 at 4:05 PM, entered by V19 (Occupational Therapist) showed, attempted patient x 3 and patient stated she was ill and was not getting out of bed, nursing aware. R2's therapy note dated (MONTH) 26, 2019 at 4:09 PM, entered by V21 PTA (Physical Therapy Assistant) showed, attempted to see patient x 3. Patient was in bed every time she was checked on. Patient would be whiny and state she was not going to therapy. R2's therapy note entered on (MONTH) 27, 2019 at 12:02PM entered by V19 showed, Patient needed frequent rest breaks due to fatigue. On (MONTH) 17, 2019 at 12:00 PM, V19 (Occupational Therapist) said R2 was initially doing pretty well in therapy, but then she started wanting to stay in bed. R2 said on (MONTH) 28, 2019 R2 had an episode during which her eyes rolled back and she appeared very dizzy. V19 said she knew that R2 was not feeling good for several days before the episode on (MONTH) 28, 2019, because she was very tired, would verbalize she was not feeling well, and was coughing a lot. R2's face sheet showed R2 was admitted on (MONTH) 22, 2019, with [DIAGNOSES REDACTED]. R2's physical therapy plan of care dated (MONTH) 22, 2019 showed under Prior Residence and Living Arrangement, R2 was independent with daily mobility and ADLS with no device and was driving. R2's daily skilled note dated (MONTH) 22, 2019, completed by V5 (LPN), showed R2 with frequent cough, fair appetite, and complaining of not feeling good today, wanting to go to bed. R2's daily skilled note dated (MONTH) 23, 2019, and completed by V5, showed R2 was alert, had noted rhonchi in all lobes that clears with cough, good skin color, and a fair appetite. V5's (MONTH) 23, 2019 note showed R2 complained of frequent urination. R2's daily skilled note dated (MONTH) 24, 2019, completed by V5, showed R2 on an antibiotic for upper respiratory infection, poor appetite, and resident with increased anxiety and confusion. R2's daily skilled note dated (MONTH) 26, 2019, and completed by V5, showed R2 alert and confused, wanting to get into bed all the time. R2's occupational therapist progress and updated plan of care dated (MONTH) 25, 2019 showed R2 was, making slow progress in skilled OT (occupational therapy) however appears to be getting sick again with cough and weakness . On (MONTH) 17, 2019 at 1:00 PM, V2 DON (Director of Nursing) said she would expect any resident with a change of condition would be closely monitored with repeat vital signs and assessment. V2 said she does not know why R2 was not sent out either time the family requested, or when the order said to send to the hospital if the IV could not be started. V2 said the (MONTH) 29, 2019 nursing note showed a concerning change of condition. V2 said after the 8:00 AM assessment of R2 there is no further assessments or vitals documented. V2 said when a resident has a change of condition, she would expect close monitoring, provider updates, and repeat vital signs. V2 said she would have expected to see further monitoring from the initial 8:00 AM assessment and the time that R2 was sent to the hospital at 3:55PM. V2 said she does not remember R2 having any behavioral concerns. On (MONTH) 17, 2019 at 10:18 AM, V16 RN (Registered Nurse) said when a resident experiences a change of condition, such as a change in vitals and change in level of mental status, we notify the nurse practitioner. V16 said they received an order to start an IV and were unable to get the IV started, he would call the provider back and see if they wanted the resident sent to the hospital. On (MONTH) 17, 2019 at 10:30 AM, V15 LPN (Licensed Practical Nurse) said a resident is considered to have a change of condition when they have a change to their level of consciousness, such as more confused or lethargic, or a change in a resident's vital signs. The facility's Change in a Resident's Condition or Status policy with reviewed date of (MONTH) (YEAR) showed the nurse will promptly notify the resident, his or her health care provider, and representative of changes in the resident's medical/mental condition and/or status. The same policy showed under the section Policy Interpretation and Implementation, A. The nurse will notify the residents' health care provider or physician on call when there has been a . 4. Significant change in the resident's physical/emotional/mental condition notify the residents' health care provider or physician on call when there has been a significant change in the resident's physical/emotional/mental condition . 7. the need to transfer the resident to the hospital/treatment center . B. A significant change of condition is a major decline or improvement in the resident's status that: 1. Will not normally resolve itself without intervention by associate or by implementing standard disease-related clinical interventions .

Based on interview and record review, the facility failed to notify the physician of a resident's change in condition. This failure contributed to R12's condition deteriorating and a delay in treatment. This applies to 1 of 3 residents (R12) reviewed for physician notification in the sample of 3. The findings include: R12's acute hospitalization discharge summary dated (MONTH) 6, 2019, shows [DIAGNOSES REDACTED]. R12's progress note dated (MONTH) 8, 2019, by V22 Nurse Practitioner shows there was a concern for aspiration and a feeding tube was placed on (MONTH) 5, 2019 (while in the hospital). R12's physician orders [REDACTED]. R12's Video Swallow Study report dated (MONTH) 25, 2019, shows it was recommended nothing be given by mouth due to aspiration and inability to eject material from the airway. Long term alternative means of nutrition was likely. R12's nursing note (authored by V14 LPN-Licensed Practical Nurse) dated (MONTH) 11, 2019, at 10:02 AM, shows resident lying in bed and coughing profusely. R12 had an emesis of a large amount of tube feeding, rattling in the throat and R12 was not able to productively cough up phlegm. This note shows the nurse suctioned 90 ml of phlegm and tube feeding from R12's throat and mouth. On (MONTH) 19, 2019, at 9:05 AM, V14 LPN (Licensed Practical Nurse) said she was walking by R12's room on (MONTH) 11, 2019, and heard her coughing. I disconnected her tube feeding for about an hour and a half and then turned it back on. I was concerned R12 would throw up again and couldn't clear it herself. R12 would have kept throwing up if I hadn't suctioned her. Residents should have the head of their bed elevated or seated upright if a tube feeding is in progress in case they cough or vomit, to keep aspiration from choking them. At 10:54 AM, V14 said I spoke to (V22 Nurse Practitioner) and got an order to suction R12. I did not notify V22 about R12's coughing, vomiting tube feeding or what was suctioned from R12's mouth. I did not notify V22 that I stopped R12's tube feeding for an hour and a half and then restarted it. R12's physician orders [REDACTED]. The facility's Enteral Nutrition Management Policy dated (MONTH) 5, 2019, shows to assess for signs\symptoms of feeding intolerance such as nausea and vomiting. This policy shows to prevent aspiration, and notify the provider if vomiting or signs and symptoms of aspiration (noisy respirations, persistent cough) occur. On (MONTH) 15, 2019, at 10:25 AM, V21 CNA said he worked a double shift (5:30 AM-7PM) on (MONTH) 11, 2019, and worked on R12's hall. V21 said R12 was gurgling all day. R12's breathing wasn't right all day. R12 threw up in the morning. The first time I saw her that morning I thought she was going to die, it was just a matter of when. That look was on her face. I didn't tell the nurse, I'm not a doctor and they saw her too. On (MONTH) 15, 2019, at 2:45 PM, V20 said that on (MONTH) 11, 2019, V21 asked him to help transferring R12. When I entered the room, R12 was coughing and breathing raspy. V20 defined raspy as congested and wet. We provided perineal care to R12 and she started coughing up phlegm, mucous. I told V21 get the head of her bed up quickly because R12's breathing was worsening. We had to rush through changing her so we could get her head up. I left the room and told V18 (LPN) R12 was breathing really badly, maybe she was aspirating and she needed to check on her. R12's physician order [REDACTED]. R12's nursing note dated (MONTH) 11, 2019, at 7:10 PM (authored by V18) shows a CNA summoned V18 to check R12 because R12 vomited and there was a loud rattle in her throat. On (MONTH) 15, 2019, at 2:20 PM, V18 said on (MONTH) 11, 2019, she was summoned to the room by R12's son and V20. When I entered R12's room, R12's tube feeding was going and she was gurgling and vomiting. I left the room and went to call V22. I did not check her vital signs, suction her or assess her lungs. She was dying. On (MONTH) 15, 2019, at 11:17 AM, V19 LPN said on (MONTH) 11, 2019, V18 was on the phone with the doctor, I believe and told me she didn't have a set of vital signs on R12 and asked me to get them. R12 wasn't looking too good. R12 was having periods of apnea (not breathing). Her oxygen saturation was 69%, pulse went from 80 to 60 and R12 did not have a blood pressure. R12 was having respiratory distress. I did not suction her. I left the room to see what the plan was and what code status was. V18 was still on the phone. When I returned to the room R12 was not breathing and did not have a pulse. On (MONTH) 19, 2019, at 10:25 AM, V2 Director of Nursing(DON), said it is abnormal to find tube feeding in a resident's mouth. It could mean they vomited and the provider should be notified. On (MONTH) 19, 2019, at 10:35 AM, V22 said she was never notified R12's tube feeding was turned off and did not give an order to restart it, you need an order. V22 said she was not notified of R12's profuse coughing, vomiting tube feeding, or of tube feeding liquid being suctioned from her throat and mouth. V22 said she was on call that day and would have sent R12 to the hospital that morning if she had been aware of this. V22 said she did not see R12 on (MONTH) 11, 2019, and did not hear any more until that evening when she was notified R12 coded. R12's local emergency room record dated (MONTH) 11, 2019, shows R12 was pronounced dead at 8:02 PM. The facility's Change in a Resident's Condition or Status Policy dated (MONTH) (YEAR) shows to notify the resident's health care provider of any changes in the resident's condition. The nurse will notify the president's health care provider when there has been an incident involving the resident, a significant change in the resident's condition and/or a need to alter the resident's medical treatment significantly. A significant change in condition is a major decline in the resident's status that will not normally resolve itself without intervention. The facility's Guidelines for Notifying Health Care Providers (Physicians) of Clinical Problems Policy dated (MONTH) (YEAR) shows the purpose is to ensure medical care problems are communicated to the health care provider in an efficient and effective manner.

Based on observation, interview, and record review the facility failed to accurately assess residents' skin and failed to implement preventive interventions and treatments. These failures resulted in R1 & R7 developing pressure ulcers on their heels that were not identified until the ulcers were unstageable with black eschar. This is for 5 of 7 residents (R1, 2, 4, 5, &7) reviewed for pressure ulcers in the sample of 15. The findings include: 1. R1's 2/25/13 Minimum Data Set Assessment (MDS) shows that R1was admitted on [DATE]. R1 needs extensive assistance of 2 persons for bed mobility and has total dependence on staff for transfers. R1 has severe cognitive impairment and a [DIAGNOSES REDACTED]. R1's 2/15/13 admission skin check shows that her feet were cool to touch and the skin on both heels was intact. On 5/15/13 at 1:40 PM, R1 was in bed with her heels resting directly on the mattress. E9 (Wound Care Registered Nurse) removed the dressing on R1's left heel to show hard black eschar (necrotic, dead, or devitalized tissue) on the posterior aspect. E9 took measurements of 1.5 x 1.7 centimeters (cm), cleaned the area with normal saline, painted the wound with [MEDICATION NAME], and then covered it with a foam dressing. E9 stated, "I couldn ' t tell you how she got the sore. When I was notified by the nurse there was already necrotic tissue on the heel." On 5/16/13 at 8:25 AM, R1 was sitting in a wheelchair in the bedroom. R1 had elastic stockings on both lower extremities. R1 was wearing shoes on both feet. At 10:50 AM, R1 remained in the wheelchair in the room with the elastic stockings and shoes on both feet. E9 said having shoes on does not relieve pressure from the heels. " I've told the nurses she shouldn ' t have the shoe on. " R1's February, March, April, and May 2013 Physician order [REDACTED]. R1's 4/1/13 Nursing Notes states, "Heels are intact, will continue to monitor." 4/4/13 Nursing Notes states, "Heels slightly boggy (underlying soft tissue damage) and intact, will continue to monitor." 4/8/13 Nursing Notes states, "Left heel noted with black discoloration that is intact, right heel is clear, will continue to monitor." 4/11/13 Nursing Notes states, "Left heel noted with black discoloration, [MEDICATION NAME] applied as ordered, convoluted boots in place, will continue to monitor." R1's Condition Report/Concern fax communication dated 4/10/13 states, "Resident has been noted with a pressure ulcer to the left heel area Stage VI, area noted to be black. Hospice is requesting for [MEDICATION NAME] to be painted at the heel daily." The response dated 4/11/13 states, "Agree." R1's April 2013 Treatment Administration Record (TAR) shows that no treatment was started until 4/11/13. R1's 4/17/13 POS shows an order to apply foam heel cup to left lower extremity ankle and change weekly. On 5/15/13 at 12:10 PM, E9 stated, "The floor nurses do skin checks twice a week, usually on evening and night shift. They (the floor nurses) email E10 (treatment nurse) and I with new concerns. The initial treatment is started by the floor nurses." Treatments are changed as needed after assessments are completed. R1's Wound Assessment Reports show the following: 4/9/13- 2.0 x 1.9 cm, wound bed has 100% eschar; 5/2/13- 1.9 x 1.7 cm, 100% eschar. Eschar is stable in nature at current time; 5/15/13- 1.5 x 1.7 cm, 100% eschar. R1's Wound Assessment Reports dated 4/8, 4/9, 4/17, 4/25, 5/2, 5/9, & 5/15/13 state, "Date Physician notified- 4/8/13." On 5/16/13 at 1:00 PM, E9 stated, "CNA ' s (Certified Nursing Assistant ' s) are to notify the floor nurse of any redness before the skin opens." On 5/16/13 at 2:05 PM, E8 (CNA) stated, "If I see a residents heels are red, I elevate the heels and notify the nurse." R1's Risk for Impaired Skin Integrity Care Plan initiated on admission (but dated 2/1/13) states, "Daily skin inspection; report any changes in skin or signs of possible skin breakdown or redness ... Turn at least every two hours when in bed ... Float heels off bed surface with pillows or specialty devices ..." R1's 4/8/13 unstageable pressure ulcer of the left lower extremity posterior heel Care Plan show approaches including: reposition every two hours; place pressure-reducing device on the wheelchair to decrease the pressure under bilateral ischial tuberosities (boney prominences on either side of the tailbone); encourage to shift weight while sitting up in the chair; develop turning/repositioning plan with R1's input; teach R1 the risk factors for development of pressure ulcers; weekly evaluation of wound healing; float heels on pillow; monitor for changes in skin status that may indicate worsening of pressure ulcer and notify the physician. The facility's 11/11/10 Pressure Ulcer Prevention policy states, "Individualized interventions will be implemented for at risk residents based on risk assessment findings ... Interventions will be documented in the resident care plan and revised based upon on-going assessment and evaluation." "The effectiveness of preventative interventions will be evaluated and changes to care plan made as appropriate ... The Care Plan will be updated to reflect discontinued interventions and the addition of new interventions based on this evaluation." The facility's 11/11/10 Pressure Ulcer Treatment policy states, "The attending physician is notified when a skin ulceration/wound is identified ... Orders for treatment of [REDACTED]." "Residents with pressure ulcers will have an individualized care plan developed ... The interventions are designed to decrease the magnitude of tissue loads and to provide levels of moisture and temperature that support tissue health and growth ... Avoid positioning residents on a pressure ulcer. Use positioning devices to raise a pressure ulcer off the support surface ... Use devices such as pillows and foam wedges that totally relieve pressure on the heels, most commonly by raising the heels off the bed." "Re-assessment of treatment plan, and residents overall clinical condition should be completed if no improvement in pressure ulcer is evident after 2 weeks of treatment based on PUSH Tool graphing. Re-evaluation of the treatment plan includes determining whether to continue or modify the current interventions. Documentation will include the rationale for continuing or changing the current treatment plan ... Communication with the physician related to wound progress will be documented at least every 2 weeks ..." 2. R7's 2/14/13 MDS Assessment shows R7 was admitted on [DATE]. R7 has total dependence on 2 persons for bed mobility and transfers. R7 has severe cognitive impairment. R7's 10/18/06 admission skin check shows callous areas by the right and left great toes. The right heel is noted to be pink, skin intact, and "not mushy" (underlying soft tissue damage). On 5/16/13 at 9:25 AM, E10 (Treatment Nurse) cleansed and treated R7's left heel. The open area was deep and pale pink. E10 stated, "Wounds need to be protected by making sure the heels are off loaded." R7's 2/4 & 2/7/13 Nursing Notes Skin checks show no new red or open areas. The 2/9/13 Nursing Note states, "Resident has 2 x 1.5 cm black area on left heel. Nurse Practitioner here and received the following orders: 1. Apply skin prep to area on left foot twice a day. 2. Apply (foam) cup to heel. Change (foam) cup every 7 days and as needed. Convoluted boot to left foot at all times." R7's 2/9/13 Wound Assessment Report shows R7 has a left heel pressure ulcer. The wound bed has 100% eschar and measures 2 x 1.5 x 0 cm. R7's 5/15/13 Wound Assessment Report shows R7 ' s left heel pressure ulcer has scant serous drainage. The wound bed is 80% granulation tissue and 20% slough. The wound measures 0.9 x 1 cm. The depth is not measured. The treatment is Hydrogel and foam dressing. R7's Risk for impaired skin integrity Care Plan is dated 2/1/13. R7's 2/13/13 Care Plan for an unstageable pressure ulcer to the left heel includes the following approaches: Reposition every 2 hours and as needed; Teach the risk factors for development of pressure ulcers; Weekly evaluation of wound healing; daily observation of skin with routine care; and float heels on a pillow. 3. R2's 9/7/12 MDS Assessment shows R2 was admitted [DATE]. R2 needs extensive assistance of 2 persons for bed mobility, transfers, and toilet use. R2 has cognitive impairment related to [MEDICAL CONDITION](Cardiovascular Accident). R2's 8/31/12 admission skin check shows R2 had a dark discoloration on the right great toe and a dark circle and callous on the right foot. Both right and left ankles were clear with skin intact. R2's Nurses Notes Skin Assessments show the following: 9/6/12- "Bilateral Lower Extremities (BLE) skin dry, intact. No discolorations. Heels firm, dry and intact" ; 9/12/12- "BLE are clear and intact. Feet clear with pedal pulses present" ; 9/15/12- "BLE skin dry, intact. No discolorations/bruises noted. Heels firm, dry and intact" ; 9/19/12- "BLE skin dry. Left lateral outer ankle with bruise and it opened. Site cleansed with normal saline and Calazyme applied with foam dressing. Wound nurse notified by email. Will continue to monitor. Heels soft, intact" . R2's 9/21/12 POS shows a physician order [REDACTED]. Wound specialist is to see patient. R2's September 2012 TAR shows a wound treatment was started on 9/21/12. R2's 9/26/12 Wound Care Specialist Initial Evaluation shows a pressure ulcer of the left, lateral ankle. The ulcer is unstageable due to necrosis. The wound size is 6 x 5 cm. The skin around the wound is macerated. The wound is draining light serous exudate. The wound is 50% thick adherent devitalized necrotic tissue and 50% granulation tissue. Recommendations are to apply Santyl and cover with foam dressing daily. Sponge cradle boot is to be worn in bed to off-load pressure to the wound. R2 had no Care Plan for the left lateral ankle pressure ulcer. R2's 9/7/12 at Risk for Pressure Ulcers Care Plan shows approaches including: reposition every hour and turn every 2 hours; encourage to shift weight while sitting up in the chair; teach risk factors for development of pressure ulcers; R2 needs assistance with repositioning to avoid skin friction/shearing; R2 needs 2 persons to assist with repositioning to avoid skin friction/shearing; daily observation of skin with routine care; float heels off the bed; use pillows or other supportive/protective devices to assist with positioning. On 5/6/13 at 2:00 PM, E8 (Certified Nursing Assistant- CNA) stated, "Resident skin is checked anytime care is given. Anything out of the normal, red or purple spots, anything that could be a problem is reported to the nurse for additional treatment." Residents are positioned off of the red spots. 4. R4's 5/3/13 MDS Assessment shows R4 was admitted on [DATE]. R4 needs limited assistance of 1 person for bed mobility, transfers, and toilet use. R4 has moderate cognitive impairment. R4's 4/26/13 admission skin check shows the coccyx/sacral area to be dark toned and skin intact. R4's Nursing Notes Skin Assessments show: 5/9/13- Buttock/peri area has no redness or open area noted; 5/13/13- Buttock/peri area has two small open areas. NP (Nurse Practitioner) notified. On 5/16/13 at 10:35 AM, E9 (Wound Nurse) removed the dressing from R4's sacral area to show one pale open area surrounded by reddened skin. E9 said that there is not much tissue covering the sacral area and that is why the staging progressed so rapidly. R4's 5/13/13 Wound Assessment Report shows a stage II pressure ulcer to the sacrum measuring 0.9 x 0.9 cm. R4 ' s 5/14/13 Report shows a stage III pressure ulcer to the sacrum measuring 1 x 0.8 cm with 100% granulation tissue. Treat with Hydrogel to wound bed and cover with foam dressing daily and as needed. Continue to monitor. The depth measurement was not done on either assessment. On 5/16/13 at 2:25 PM, E4 (Registered Nurse, Unit Manager of North Unit) stated, "I didn't know anything about (R4 ' s pressure ulcer) until E9 said something today." R4's 5/13/13 Stage III pressure ulcer to the sacrum Care Plan has approaches including: reposition every 2 hours and as needed; encourage to weight shift while sitting up in the chair; weekly evaluation of wound healing. On 5/16/13 at 2:10 PM, E7 (CNA) stated, "When getting the residents undressed for bed, I check the skin for any bruises, sores, redness, and skin tears. I look at the shoulders, buttocks, and heels. Any problems I tell the nurse and get the resident off the area. We use pillows for positioning." 5. R5's 4/16/13 MDS Assessment shows R5 was admitted on [DATE]. R5 needs extensive assistance of 2 people for bed mobility and has total dependence of 2 people for transfers. R5 has moderate cognitive impairment. R5's 4/9/11 admission skin check shows intact skin to right and left ankles and feet. There is mention of scabs on bilateral lower extremities, but no location specified. On 5/16/13 at 9:40 AM, E9 cleansed and treated R5's right outer ankle. R5's right outer ankle had an area of pale skin surrounded by darker skin. In the middle of the pale area was a pin point red area. R5's 4/9 & 4/16/13 Nursing Notes Weekly skin assessment state, "legs and heels are clear." R5 had no skin assessment for 4/23 & 4/30/13. On 5/17/13 at 9:00 AM, E3 (Assistant Director of Nursing) said the skin assessments are documented in the computer and had no further skin assessments to present. R5's 5/2/13 Hospice Nursing Visit Note states, "Facility CNA's returning patient to bed. Hospice CNA report states red area on right ankle bone outer side." Protective boots were put on. R5's Wound Assessment Reports for the right outer ankle pressure ulcer show the following: 5/2/13- stage I, 1.5 x 1.5 cm; 5/2/13- stage II, wound bed has 100% [MEDICATION NAME] tissue, 0.5 x 0.9 (no depth measurement), "Fax sent to (physician) to ask for an order as follows: Cleanse wound with normal saline, apply Hydrogel to wound area and cover with foam dressing daily and as needed." R5's 5/2/13 Condition Report/Concern Fax states, Resident has pressure area 1.5 cm to outer right ankle. May we have an order for [REDACTED]. The reply of " yes " to the fax was noted on 5/4/13. R5 ' s May 2013 TAR shows R5 ' s foam dressing treatment was started on 5/6/13. R5's 5/13/13 Wound Assessment Report shows the right outer ankle pressure ulcer is stage II measuring 0.5 x 0.5 cm (no depth is measured). The wound bed has 100% [MEDICATION NAME] tissue. R5 ' s 5/2/13 stage II pressure ulcer to the right outer ankle Care Plan has approaches including: Reposition every 2 hours and as needed; place pressure-reducing device in the wheelchair seat; encourage to weight shift while sitting up in chair; teach the risk factors for development of pressure ulcers; assist with repositioning to avoid skin friction/shearing; weekly evaluation of wound healing; On 5/16/13 at 1:00 PM, E9 stated, " I develop the care plans for the MDS Assessments for wounds. Wound documentation is in the computer. " There is no log to track residents with wounds. On 5/17/13 at 9:00 AM, E3 said there is no log of residents with wounds.

Based on observation, record review, and interview, the facility failed to ensure resident safety by not raising the side rail to prevent a resident from being rolled off the side of the bed. The facility failed to ensure that 2 persons were assisting a resident in bed mobility as required. These failures resulted in R2 sustaining a left shoulder injury and fractured metacarpals of the left hand, leaving R2 unable to feed herself. This applies to 1 of 3 residents (R2) reviewed for falls in the sample of 3. The findings include: R2's Minimum Data Set (MDS) Assessment documents that R2 requires extensive assistance of 2 or more persons for bed mobility, and toilet use. R2 required limited assistance of one person to eat. R2 has range of motion Impairement on one side affecting the upper extremity. R2's Active [DIAGNOSES REDACTED]. R2 had one fall since admission to the facility that resulted in injury. R2's height is 5 feet and her weight is 223 pounds. The Physician's Hospital Admission note of 3/2/12 documents that R2 had a fall that resulted in injury to her left should and left hand with metacarpal fractures of the left hand. R2 had generalized weakness and a previous fracture of the right humeral head. (Right shoulder area) The Hospital Physician's Consult note dated 3/2/12 documents that R2 had a fall out of bed earlier in the day. She has a prior fracture of the Right proximal humeral bone. On presentation, R2 has ecchymosis and bruising in and around the left hand with some pain around her fingers. She (R2) states that she thinks she broke her fingers as well. She has pain with any kind of motion to the left shoulder. The facility Incident Report of 3/2/12 documents that R2 and E11 (Certified Nursing Assistant) said that while R2 was getting cleaned up, R2 said that she was going to fall. E11 (CNA) said no you won't I have you and shortly after that R2 fell on the ground. R2 complained of left arm pain. The facility Record of Interview Report dated 3/2/12 shows that E11 was providing care to R2 when she (R2) was rolled off the side of the bed. R2's MDS assessment documents that R2 requires 2 persons for bed mobility. R2's Care Plan dated 3/5/12 documents that R2 required assistance with meals due to her Right arm fracture.(original condition on admission) Another Care Plan for fall risk (2/28/12) documents that R2 has pain and impaired mobility as risk factors. The goal is that R2 will not experience a fall with a serious injury. The care plan does not include how R2 should be turned/repositioned in bed with her fractured right arm. The care plan does not show how assistive devices such as side rails should be used to facilitate turning and repositioning R2. On 3/2/12 at 1:25 PM, R2 was observed in the TV lounge near the C unit. R2 was in her wheelchair. No foot rests were under R2's feet, her feet/legs were dangling and were visibly swollen. (lower legs were wrapped in ace bandages) R2 had an ace wrap and dressing to the left arm/ elbow to hand. R2's left hand fingers were discolored (ecchymotic) and very swollen. R2 was unable to use the left arm. (result from fall at facility) R2 stated she had fallen at home and then she fell here.(facility) E9 (Certified Occupational Therapy Assistant) was present and said she was going to work with R2 on feeding herself. E9 said that R2 had been to the Orthopedic Doctor for her Right arm and the sling was discontinued. R2 had notable edema of the right arm and hand. E9 said she was going to try and work with R2 to find a way she could feed herself. (both upper extremities are now injured) At 1:45 PM on 3/13/12, E10 (Licensed Practical Nurse) said that R2 had rolled out of bed when being turned by E11.(CNA) E2 (Assistant Director of Nursing) said on 3/13/12 at 2:05 PM that E11(CNA) must not have had the side rail up on the side of the bed that R2 rolled out of.