**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to turn and reposition 1 (R14) of 8 residents investigated for pressure ulcers in the sample of 38. This failure resulted in R14 having re-opened pressure ulcers and new in house acquired pressure ulcers. Findings include: R14's Facesheet documents an admission date of 6/23/2024. Diagnosis include Syringomyelia and Syringobulbia, Ulcerative Colitis, Chronic Embolism, Crohn's Disease, Dorsalgia. R14's Minimum Data Set, MDS, dated [DATE] documents R14 has no cognitive deficits. R14 is dependent for mobility and transfers. R14's care plan with a revision date of 2/10/2025 documents R14 SKIN: R14 has developed a stage III pressure wound to his right back. Interventions include Assist and encourage resident to turn and reposition every one to two hours and PRN. Ensure proper body alignment. R14's admission Nursing assessment dated [DATE] documents R14's skin intact. No wounds documented. R14's progress notes dated 11/7/2024 at 1:08PM documents V19 (Wound Care Nurse Practitioner) present to assess right buttock with area having a stage II pressure wound with new order of cleanse right buttock with wound cleanser then apply collagen hydrogel mixed with collagen particles to wound bed and cover with calcium alginate then cover with dry dressing daily. R14's progress notes dated 2/10/2025 at 11:53AM Writer summoned to R14's room by CNA. Upon assessment, observed that R14 has developed an unstageable wound to his right back and an abrasion to his right buttock. Call placed to V19 with new orders of cleanse areas with wound cleanser then apply medi-honey to wound bed cover with calcium alginate and silicone bordered super absorbent dressing daily. R14 notified. R14's progress notes dated 4/2/2025 at 8:10AM documents V14 (Registered Nurse) was present to assess wound with no new orders yet did observe a re-opened stage III pressure wound to right buttock with new order of cleanse right buttock wound with wound cleanser then apply collagen hydrogel mixed with collagen particles then apply to wound bed cover with silicone boarded super absorbent dressing daily. R14 notified. R14's progress notes dated 5/6/2025 at 2:52PM documents V19 present to assess wound with new order of SSD cream to treatment. R14 notified. R14's Skin and Wound Evaluation dated 11/29/2024 documents pressure wound to right gluteal, unstageable, in house acquired. Exact date of discovery 11/7/2024. Slow to heal. R14's Skin and Wound Evaluation dated 3/6/2025 documents new stage 3 pressure ulcer to right gluteal. In house acquired. Exact date of discovery 2/10/2025. R14's Skin and Wound Evaluation dated 4/17/2025 documents new stage 3 pressure ulcer to right gluteal. In house acquired. Exact date of discovery 4/1/2025. R14's Skin and Wound Evaluation dated 5/13/2025 documents stage 3 pressure ulcer right lower back. In house acquired. Exact date of discovery 2/10/2025. On 5/14/2025 at 11:00AM R14 stated I am never turned or pulled up. I have been like this all morning. My care is poor. I haven't been up in a chair in months. I am afraid to get up because I am afraid, they will not put me back to bed and I will be stuck there in pain. My sore on my back was bleeding a lot last night. On 5/14/2025 at 1:55PM V9, Wound Nurse, provided wound care to R14 with assist of V21, Licensed Practical Nurse, LPN. R14's wound draining dark brown fluid and bright red fluid on bandage and on gauze used to clean wound. R14 in same position he was in at 11:00AM and was incontinent at this time. V9 stated R14 refuses a pressure reducing mattress. He can turn himself a little. His wound is healing slowly. The staff try to get him to turn. Facility policy with a revision date of 9/2023 states To prevent or reduce the incident of pressure injuries, standards of practice should be implemented. A pressure injury may be defined as any lesions cause by unrelieved pressure that results in damage to the underlying tissue. Although friction and shear are not primary causes of pressure injuries friction and shear are important contributing factors to the development of pressure injuries.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to follow and implement progressive interventions and perform appropriate supervision to prevent falls for 1 (R24) of 6 residents in the sample of 38. This failure resulted R24 falling and R24 sustaining a fracture. Findings include: R24's Face sheet documents an admission date of 2/7/2024. Diagnosis include Metabolic Encephalopathy, Adult Hypertrophic Pyloric Stenosis, Hypertension, Radiculopathy. R24's Minimum Data Set, MDS, dated [DATE] documents R24 is severely cognitively impaired. R24 requires partial to moderate assist with mobility and transfers. R24's mode of transportation is walker and/or wheelchair. R24's care plan updated 3/28/2025 documents Fall: R24 is at risk for falls Cognitive deficits, Functional Deficits, History of Falls, Poor Balance. Interventions include: 1/10/25 prompt or assist for change in position, toileting, offer fluids, and ensure R24 is warm and dry. Encourage staff to anticipate needs. 6/28/24 Educate R24 to use the call light and wait for staff assist to walk to the bathroom. Fall risk assessment quarterly and as needed. R24's admission fall risk assessments dated 6/28/2024 documents R24 is at high risk for falls. R24's progress notes dated 6/28/2024 at 8:02PM document R24 was found in R24's bathroom on the floor at 7:11pm. This nurse and night nurse with CNA helped R24 up from floor to toilet. R24 had bowel movement. R24 stated I need to go to the bathroom this nurse asked what is hurting, R24 pointed to left side of head. R24 noted with red water left eye. this nurse contacted V28 (Physician) over telehealth, V28 recommended this nurse to ask family if they want R24 to be monitored. Contacted V27 (Family). V27 requested for bed alarms and for R24 to be closer to nurse's station. This nurse voiced concerns to V2 (Director of Nursing). Neuros started. R24's fall investigation dated 6/28/2024 at 7:38PM stated Interdisciplinary meeting to discuss fall from 6/28/2024. R24 alert and oriented x2-3. Brief Interview for Mental Status, BIMS, 00. R24 requires 1-2-person physical assist with ADLs and transfers. R24 is incontinent of bowel and bladder at times. RCA, root cause analysis: Attempted to self transfer to toilet and fell onto floor. All previous fall interventions in place adding reeducating R24 to call and await assistance. All parties agree with plan of care. Care Plan reviewed and updated. R24's progress notes dated 1/10/2025 at 6:22AM documents CNA came to this nurse stating that R24 was on the floor when she walked into R24's room to give R24 care and get R24 up for the day. This nurse assessed R24 and noted no open areas or any bleeding and R24 stated she was not in any pain. This nurse and CNA carefully got R24 up on the bed and after talking to R24 she stated she would like to get dressed and get into her chair. This nurse told CNA that R24 was able to get dressed and get into her chair. R24's family (V27), V1 (Administrator), V2, V3 (Assistant Director of Nursing), and V28 were notified. R24's progress notes dated 1/11/2025 at 9:48AM documents Continue monitoring related to fall. R24 x-ray of left hip came back new fracture of left inferior pubis ramus. Contacted V28. New order for outpatient ortho appointment related to fracture. Notified V27, V1, V2, V3. R24's 1/10/25's fall investigation dated 1/11/2025 at 6:22AM documents Root Cause Analysis, R24 got up to use the bathroom and R24 thought she should get up and get ready also. New inventions: Frequent rounding and prompt or assist R24 in position change, toileting, offer fluids and ensure R24 is warm or dry. Obtain labs to rule out acute change in condition. Neurology consults to monitor disease progression. Care plan updated as appropriate. R24's radiology report dated 1/10/2025 documents Fracture of the left inferior pubic ramus. On 5/14/2025 at 10:00AM R24 sitting at nurse's station. R24's room at end of the hall away from nurse's station. On 5/14/2025 at 2:00PM V20, Certified Nursing Assistant, CNA, assisted R24 from wheelchair to bed. R24 was not toileted prior to going to bed. R24 stated I wasn't working in January when R24 fell and hurt herself. She can stand but that's it. We try to have her at the nurse's desk during the day. She is in her room right now because she is ready for a nap. Facility policy with a revision date of 7/2024 states This facility is committed to maximizing each resident's physical, mental, and psychosocial wellbeing. While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventative strategies, and facilitate as safe an environment as possible. All residents' falls shall be reviewed, and the resident's existing plan of care shall be evaluated and modified as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to administer a seizure medication for 1 of 8 residents (R7) reviewed for significant medication errors in the sample of 9. This failure resulted in R7 having multiple seizures, requiring hospitalization. Findings include: On 1/28/25 at 1:20 PM, R7 stated she didn't get her seizure medication for two days, had four seizures and was admitted to the hospital. R7 stated this happens often but she has and is getting her medication now. R7's Face Sheet, undated, documents R1 has a diagnosis of Epilepsy. R7's MDS (Minimum Data Set), dated 12/2/24, documents R1 has a BIMS (Brief Interview for Mental Status) score of 15, indicating R1 is cognitively intact. R7's Care Plan, dated 9/23/19, documents R7 requires healthcare monitoring related to a diagnosis of a seizure disorder. She is at risk for injury due to uncontrolled seizure activity. She is at risk for aspiration of respiratory secretions or vomiting during seizure and suffocation. She receives antispasmodic medication per physician orders. Intervention is to administer medications as ordered. R7's POS (Physicians Order Sheet) documents the following orders: 6/8/23 - Vimpat Oral Tablet 50 MG (Milligrams), Give 1 tablet by mouth two times a day for Epilepsy, Give with 200 mg to equal 250 mg two times a day. 7/19/22 - Vimpat Tablet 200 MG, Give 1 tablet by mouth two times a day related to Epilepsy. R7's Progress Notes, document the following: -11/18/2024 at 11:26 AM - This writer made aware that res stated she just had small seizure in room while sitting in wheelchair. Stated it only lasted a few seconds, no falls or injuries. Vitals 105/58, 69, 97.6, 98%. NP (Nurse Practitioner), admin (Administrator), and DON made aware. Resident also stated that she had a fall last night, assessed that left middle finger is swollen. Pain level 6 PRN (as needed) Norco given. Will continue to monitor. -1/1/2025 at 3:45 PM - Patient was noted to have seizure activity for 30 seconds, in her wheelchair, patient came out of the seizure. Patient v/s (vital signs) was taken 122/80, 81, 98.2, 18, 98%. Patient took all her meds after the episode, resident family, DON made aware, MD was made aware of the incident. Res Keppra (seizure medication) level reordered for tomorrow. Resident in a pleasant mood and cooperative to cares. -1/20/2025 10:45 PM - Medication Administration Note - Vimpat Oral Tablet 50 MG, Give 1 tablet by mouth two times a day for Epilepsy Give with 200 mg to equal 250 mg two times a day, Need a script. -1/20/2025 at 6:16 PM - Resident noted to have a seizure lasting approximately 1 minute NP made aware new order for labs resident and family aware. -1/21/2025 7:36 PM - This resident had a 2 minute witnessed seizure, resident was seizing in her chair and was sliding downward this nurse caught her in time and let her seizure take its course before assisting her correctly in her seat. This resident was a bit lethargic and confused once coming out of seizure after a few minutes this nurse asked her name, birthday, and place and she answered correctly. BP 142/69, P 63, R 18, T 97.9. This res was out of Vimpat, there wasn't any in the Cubic to pull from. Script was sent over around noon and when this nurse called for an update the pharmacy stated they never received it. This nurse resent the script and they stated it would be sent out tonight and that they are unable to send it to our backup pharmacy because they would want a separate script. (On-call MD) notified, POA (Power of Attorney) called n/a (not available) at this time, & DON notified. The doctor on call was also made aware that pharmacy was called and stated that meds will be sent out tonight she stated to monitor this resident until her medications arrive. Resident is now in her bed watching TV (television) at this time. Call light is in place. -1/21/2025 8:20 PM - This nurse called and spoke with (on call MD) about sending a stat script for this resident's Vimpat, she stated it has been sent over to our backup pharmacy and it should cover tonight's and tomorrow morning med pass. DON and Admin notified. -1/21/2025 at 10:46 PM - Medication Administration Note, Vimpat Tablet 200 MG, Give 1 tablet by mouth two times a day related to Epilepsy, Medication not available. -1/22/2025 6:03 PM - This resident had a seizure that lasted 59 seconds while lying down in her bed. Resident stating, she didn't feel well and said she felt like she was going to seize, this nurse stated to her that it is best she lie down instead of sitting in chair, so she does not fall, and she agreed, moments later resident started seizing and this nurse was a witness and turned her to her side and counted it to 59 seconds. Res VS are: b/p 120/64, P 63, T 97.3, O2 97, R 20, PAIN 0. Pupils are equal and reactive, POA has been notified and stated to this nurse Thanks and that she appreciates the call. DON & ADMIN notified, & (on call MD) notified to just keep an eye out on res throughout the night. There are NNO (No new orders) at this time. -1/22/2025 9:10 PM - This resident started having seizures back to back, M.D. stated to send this resident out. Resident has been sent to the hospital for observation. POA, Admin and DON notified. -1/23/2025 6:29 AM - Resident admitted to the hospital, room [ROOM NUMBER] with a Dx (diagnosis) of Seizures. -1/24/2025 at 2:35 PM - Resident arrived back at facility in wheelchair, assisted by 2 (facility) employees with NNO. R7's Medication Administration Record (MAR), dated 1/20/25, documents R7's Vimpat was not given as ordered on 1/19/25, 1/20/25, and 1/21/25. R7's Hospital Records, dated 1/22/25, R7 was admitted to the hospital with a diagnosis of Seizures. On 1/28/25 at 11:05 AM, V11, Family Nurse Practitioner, stated R7 not being given the Vimpat on 1/19/25, 1/20/25, 1/21/25, and 1/22/25, did contribute to R7 having seizures and subsequently being admitted to the hospital. V11 stated that medications are a big issue at this facility, there is no initiative from the nurses to make sure residents have prescriptions for their medications. V11 stated it is left on the DON (Director of Nurses) and ADON (Assistant Director of Nurses) to ensure this is happening. V11 stated he will check with the DON/ADON to see if any prescriptions are needed, if so, he will take care of it, give it to the DON/ADON to send to the pharmacy. V11 stated it's also a pharmacy issue because once they have sent a copy of the prescription to them and have confirmation that it was received, the facility still has to call them to get confirmation that they received it and find out when the medication is going to be arriving at the facility. V11 stated a lot of times, pharmacy will say that they didn't receive the prescription even though the facility has fax confirmation that it was sent. On 1/28/25 at 1:23 PM, V16, LPN (Licensed Practical Nurse), stated she sent R7 to the hospital for seizures. V16 stated R7 went for a couple of days without her Vimpat (seizure medication), and she can't go without it for one day and she has seizures. V16 stated normally they could get the medication from the emergency kit, but the Vimpat was not available. V16 stated pharmacy wouldn't send it and told the facility that they didn't receive the prescription for it, so they sent it again and finally received it. On 1/29/25 at 6:45 AM, V1, Administrator, stated they were unable to get R7's Vimpat due to the insurance not paying for the medication until 1/24/25, so when the DON was notified, unsure of the date, that R7 was out of the medication and pharmacy would not send it until 1/24/25, the medication order was sent to the local pharmacy and the facility paid for it and picked it up on 1/22/25. The Medication Administration Policy, dated 6/2015, documents if a medication is not given as ordered, document the reason on the MAR and notify the Health Care Provider if required. If a medication is ordered but not present, check to see if it was misplaced and then call the pharmacy to obtain the medication. If available, obtain from the contingency or convenience box. If the Physician's order cannot be followed for any reason, the physician should be notified in a timely manner (depending on the situation), and a note should reflect the situation in the resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the Facility failed to assess, monitor, and perform vital signs for 1 of 3 residents (R2) reviewed for change of condition in the sample of 6. This failure resulted in R2's low oxygen saturation level, hospitalization, and being put on a ventilator, unable to return to the facility. Findings include: On 10/4/2024 at 1:22 PM, V1, Administrator stated, (R2) was recently sent to the hospital for a change of condition, and when she got to the hospital, she tested positive for COVID, and they admitted her for COVID and pneumonia. (R2) had to go on a ventilator. We do not take any residents with ventilators (vents) so she was going to be sent to another facility that takes vents and will not be returning to us. R2's Physician Order Sheet (POS) for October 2024 documents a diagnosis of amyotrophic lateral sclerosis, acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, morbid obesity, hypertension, depression, chronic pain, and encounter for screening for COVID-19. R2's Minimum Data Set (MDS) dated [DATE] documents R2 was cognitively intact for decision making of activities of daily living. She has impairments on both sides of her upper and lower extremities, uses a wheelchair and was dependent on most activities of daily living. R2's Care Plan: Respiratory: (R2) has potential for difficulty in breathing related COPD acute respiratory, date initiated 11/15/2023. Interventions: Assess respiratory status rate, depth, pattern, skin color. Monitor O2 (oxygen) Sats (saturation). Monitor every shift for shallow respiration, diaphoresis, dyspnea, monitor vital signs and lung sounds, observe for change in breathing pattern. All of the interventions listed were documented with the date initiated of 11/15/2023. R2's Progress Notes dated 9/25/2024 at 11:35 AM, document Patient states she is not feeling good today and is very worried for her health situation. She reports her health concerns of being short of breath and unable to cough. Therapist notified nursing staff of patient concerns and nursing staff assessed patient. R2' s Progress Notes dated 9/25/2024 at 6:56 PM, Resident sent to (ED) (emergency department) via EMS (Emergency Medical Services) with c/o (complaint of) SOB (shortness of breath). O2 sats 79% during MD (Medical Doctor) consultation. MD instructed this nurse to raise O2 concentration to 5 L (liters), O2 sats improved to 91% but LOC remained unaffected. MD (Medical Doctor) instructed this nurse to send resident out due to change of condition. MD stated she would call report into (Hospital). On 10/8/2024 at 9:44 PM, V13, Physical Therapist stated he was familiar with (R2), and he remembered she was a total assist, and her ALS (Amyotrophic Lateral Sclerosis) was progressing. The last time she had any therapy was on 8/30/2024 and she received speech therapy. (R2) did not have any therapy treatment, speech, or physical therapy on 9/25/2024. I am not sure what you are referring to. I have checked our records, and (R2) did not see any therapist on 9/25/2024. On 10/8/2024 at 10:07 AM, V6, Licensed Practical Nurse (LPN), stated, I am fairly new in the facility. I am the Wound Nurse. Earlier in the day some staff told me (R2) was having some discomfort and I took (R2's) O2 (oxygen) sats and she was at 96%. I called the Telehealth doctor and sent her out later in the day. I recorded her vital signs in the progress notes and on the (electronic medical charting) under vitals. When I first checked on (R2) she was not in respiratory distress. I remember at that time COVID was in the building and I know I did not test her for COVID but did send her out. I did not write the entry for (R2) on 9/25/2024 at 11:35 AM. Someone did come and get me; I believe it was someone from therapy and let me know she was having breathing issues. On 10/8/2024 at 10:34 AM, V1, Administrator stated, The only way anyone could write a note for a nurse's note is if they have a password. Once they make a note, they have to enter their password again in order for the note to go through. More than likely, (V6) just forgot she had written the note. I find it hard to believe anyone else has her code. She is fairly new and learning so much stuff. R2's Electronic vital signs do not document any vital signs were being performed on R2. Oxygen, temperature, and pulse were not documented on her chart, everything was blank after 9/19/2024. No vital signs were documented for 9/25/2024 except for the oxygen levels on 9/25/2024 at 6:56 PM, no other O2 levels were documented when R2 stated she was having shortness of breath on 9/25/2024 at 11:35 AM. On 10/8/2024 at 1:57 PM, V18, Certified Nursing Assistant (CNA) stated, I remember (R2), her breathing was very rapid, and you could tell she was off. I immediately went and got the nurse, this was right before lunch, and let her know she was having issues with her breathing and said she did not feel good. If I charted anything, like her vitals it would be in PCC. I can't remember if I charted anything, but I did go and get (V6) and let her know what was going on. Then later that night (R2) was sent out to the hospital. The nurse was (V6, LPN). We can chart and/or the nurse can chart vitals. If we chart anything it will be in the (electronic charting system) On 10/8/2024 at 1:50 PM, V2, Corporate Nurse/Director of Nursing stated, I would expect all change of conditions to be charted in the charts and all vitals to either be in the Progress Notes and or (electronic charting system). On 10/8/2024 at 2:03 PM, V19, CNA stated, I remember the day (R2) went out to the hospital because she was not looking good. She could talk and she said she was having issues breathing. This was right before lunch. I remember telling the nurse and then later she was sent out to the hospital. The nurse was (V6), I believe. R2's Progress Notes dated 9/26/2024 4:18 AM, documents, Note Text: Resident was sent to (Hospital) for low 02 sats. I called (hospital) and they stated that (R2) is intubated at this time. On 10/9/2024 at 2:00 PM, V22, Nurse Practitioner stated, If a resident has a history of ALS and they tell staff they are not feeling well, and they were having issues with breathing I would expect to be notified. If a resident was complaining of SOB, then I would expect to be notified. I would expect the O2 stats to be monitored at least every shift but without knowing the vitals it makes it difficult because if (R2's) vitals were not within normal limits then I would expect to be contacted immediately and sent out. I would expect all vitals to be charted and documented in the patient's chart. If (R2's) oxygen situations were below 90 and I felt she was in distress I would have sent out her sooner to the hospital. R2's Hospital Notes dated 9/25/2024 documents, 7:00 PM, (R2) is a 58 y.o. (year old) female presenting to the ED (emergency department) c/o (complaint of) respiratory distress, EMS (Emergency Medical Services) reports they found the patient in significant respiratory distress. They immediate placed her on a non-rebreather with minor improvement. Impression: 9/26/2024 Patient presented to ED via EMS with respiratory distress, Patient intubated in ED. Plan includes respiratory, infection disease and medical management, isolation, ventilator, IV antibiotics, remdesivir and steroids. The Facility Change in Resident Condition Policy with a review date of September 2024 documents, It is the policy of the facility, except in a medical emergency, to alert the resident, resident's physician, and resident's responsible party of a change on condition. Once the physician has been notified and a plan developed, the nursing or social service staff will alert the resident and the family of the issues and any physician order. The communication with the resident and their responsible party as well as the physician will be documented in the resident medical record, or other appropriate documents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assess, monitor, and transfer a resident to the hospital in a timely manner for 1 of 3 residents (R2) reviewed for change in condition and complete treatments as ordered for 6 of 6 residents (R1, R2, R3, R4, R5, and R6) reviewed for wounds in a sample of 6. This failure resulted in R2 being admitted to the hospital with the diagnoses of sepsis (a life-threatening complication of an infection) and acute respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions). Findings include: 1. R2's admission Record, with a print date of 08/27/24, documented R2 has diagnoses of but not limited to chronic respiratory failure with hypoxia, chronic pulmonary embolism, and non-pressure chronic ulcer of right calf limited to breakdown of skin. R2's Minimum Data Set (MDS), dated [DATE], documented R2 was moderately cognitively impaired with a Brief Interview of Mental Status (BIMS) of 10 out of 15 and she required partial/moderate assistance with upper body dressing, some of bed mobility, substantial/maximal assistance with toileting hygiene, shower/bathe, lower body dressing, personal hygiene, lying to sitting position, transfers, and she was always incontinent of bowel and bladder. R2's MDS, M section dated 05/01/24 documented she did not have any skin issues at that time including no venous/arterial ulcers. R2's Care Plan, with an admission date of 12/29/2022, documented R2 is at risk for respiratory infections related to (r/t) COVID-19, chronic respiratory failure, and chronic pulmonary embolism. Interventions are but not limited to monitor for lower respiratory infection (LRI) and temperature. The Care Plan documented SKIN: R2 has developed what is presenting as a venous wound to her right lateral front lower leg. Interventions include but not limited to assess and document of progress of areas weekly, monitor area for signs and symptoms (s/s) of infection: odor, drainage, color, size, notify physician (MD) of abnormal findings, observe, and assess regularly, skin assessment weekly, and treatment as ordered to right lateral front lower leg. R2's Physician's Orders, dated 08/12/23 at 2:56 PM, documented weekly skin screen (complete skin form if new alteration is present) every day shift every Saturday for prophylaxis. R2's weekly skin screens for May 2024 were reviewed and documented R2 did not get her weekly skin screen on 05/25/24. R2's weekly skin screens for June 2024 were reviewed and documented R2 did not get her weekly skin screen on 06/22/24 and 06/29/24. R2's Wound Care Note, dated 06/18/2024 at 11:47 AM, documented writer notified by Certified Nursing Assistant (CNA) patient (Pt) had an open area to the right lower extremity (RLE) upon assessment it was observed the Pt had what was presenting as a ruptured blister wound. Wound bed had 100% granulation with no undermining or tunneling. The wound had moderate serous drainage, edges attached, peri wound was intact, no odor or pain, and RLE cool to touch and discolored. V8, Nurse Practitioner was called, and new orders received, and call placed to set up appointment for a doppler. R2's Skin & Wound Evaluation, dated 06/18/24, documented R2 had a new skin area (blister) to her front right (Rt.) lateral lower leg measuring area: 0.4 square centimeters (cm2), length: 0.9 centimeters (cm), and width: 0.7cm. R2's Physician's Orders, dated 06/20/24 at 8:25 AM, documented Cleanse right lateral calf with wound cleanser then apply collagen particles to wound bed then apply xeroform and cover with dry dressing daily. R2's Skin & Wound Evaluation, dated 06/25/24, documented R2's venous wound to her front Rt. Lateral lower leg was deteriorating and now measuring area 12.5cm2, length: 3.0cm, and width: 5.2cm. R2's Physician's Orders, 06/28/24 at 1:10 PM, documented R2's treatment was changed to the following: Triamcinolone (TMC) Acetonide External Cream 0.1 % (Triamcinolone Acetonide (Topical)) Apply to Right anterior calf topically every day shift to Promote Wound Healing Cleanse right anterior calf wound with wound cleanser then apply TMC mixed with A&D ointment and collagen particles to wound bed cover with calcium alginate then apply abdominal (ABD) pad and Kling daily. R2's Treatment Administration Record (TAR) for the month of June 2024 was reviewed and had no documentation R2 received her daily wound treatments on 06/20/24, 06/23/24, 06/28/24, 06/29/24, and 06/30/24. R2's Skin & Wound Evaluation, dated 07/03/24, documented R2's venous wound to her front Rt. Lateral lower leg was stable and measuring area: 15.2cm2, length: 3.6cm, and width: 6.5cm. It also documents under evidence of infection there is increased drainage, increased pain, and warmth. R2's Skin & Wound Evaluation, dated 07/11/24, documented R2's venous wound to her front Rt. Lateral lower leg was improving and now measuring area: 19.7cm2, length: 5.7cm, and width: 4.9cm. R2's Skin & Wound Evaluation, dated 07/19/24, documented R2's venous wound to her front Rt. Lateral lower leg improving and measuring area: 15.6cm2, length: 3.4cm, and width: 6.5cm. R2's TAR for the month of July 2024 was reviewed and had no documentation R2 received her daily wound treatment on 07/02/24, 07/14/24, 07/18/24, 07/19/24, 07/20/24, 07/22/24, 07/24/24, 07/25/24, and 07/27/24. R2's Skin and Wound Note, dated 07/25/24, documented evaluation for venous wound to Right Lower Extremity (RLE) increased edema with erythema, warmth and pain, 2+ edema to RLE toes up to knee, 1+ edema to Left Lower Extremity (LLE). Wound assessment size 6 cm x 8.5 cm x 0.1 cm. Peri wound: fragile, edema, erythema, venous, denuded. Exudate: Heavy amount of serosanguineous drainage. Recommend STAT venous doppler to RLE to rule out deep vein thrombosis (DVT), if unable to obtain today then send to emergency room (ER) for evaluation. R2's Physician's Orders, dated 07/26/24, documented Keflex oral capsule 500mg (Cephalexin) give 1 capsule by mouth four times a day for skin redness for 7 days cellulitis to bilateral lower extremities. R2's Progress Notes, dated 07/27/2024 at 08:04 AM, documented Nurse's Notes Resident is shaking and very warm to touch. Resident is short of breath, oxygen (O2) saturation (sat) on room air is 85%. Place oxygen to 1 liter (L) and O2 sat is 90%. Place oxygen to 2 Liters (L) and O2 sat is 92%. Resident complains of shortness of breath. Emergency Medical Services (EMS) called at this time. Estimated Time of Arrival (ETA) is at 08:45. R2's Physician's Order, dated 10/02/23, documented Oxygen at 2L via nasal cannula at bedtime (HS) for sleep apnea. R2's Electronic Medical Record (EMR)/Vital Signs (v/s) were reviewed and documented on 07/27/24 at 8:11 AM, R2's blood pressure (B/P) was 130/48, temperature (T.) was 98.7, Respirations (resp) were 20, and R2's O2 saturation was 85%. There were no other v/s documented for 07/27/24. R2's Progress Notes, dated 07/27/2024 at 2:45 PM, documented Nurses Notes resident (Res) transported to the local hospital via ambulance at 2:15 PM. R2's Progress Notes, dated 07/27/2024 at 9:11 PM, documented Res admitted to local hospital for sepsis and hypoxia. R2's Electronic Medical Record (EMR) was reviewed and no documentation regarding continued monitoring of R2's condition including R2's oxygen saturation (SpO2). On 8/27/24 at 2:00 PM, V14, Licensed Practical Nurse (LPN) was contacted on the phone for an interview. V14 stated she had arrived at the facility at 5:38 AM and was working that morning to cover a few hours until the day nurse arrived. V14 said she was performing a check on her residents and a Certified Nursing Assistant (CNA) had told her R2 was acting different. V14 said she went into the room, and R2 was shaking, and her face was red. V14 stated she obtained R2's vital signs, her (R2) oxygen saturation was low so V14 obtained an oxygen tank and applied oxygen. V14 said she called the local ambulance with the number located on the sign at the nurse's station. She said the ambulance service told her they were on their way and about ten minutes later, the ambulance service called back and said they would be arriving about 8:45 AM. V14 said she let the oncoming nurse know she had called the ambulance and the estimated time of arrival. V14 then left as her partial shift was completed. On 08/27/24 at 2:45 PM, V15, LPN was called and asked if she could relay the events on 07/27/24, regarding her care of R2. V15 stated that she called the facility to let them know that she would be running a little late that day and they got the night nurse to stay over until she arrived. V15 stated V14, LPN had given her (V15) report and told her she had called the ambulance and was sending R2 out because she had the shakes. V15 said she looked in R2's room and staff were getting her dressed and preparing her for ambulance transfer. When V15 checked in the room later, she noted that R2 was eating her breakfast. V15 stated that it was time for the afternoon medications, and she called the ambulance service because they had not yet arrived. The ambulance service told her it would be another hour, so she cancelled the transport and said that if she assessed R2 and she needed to go out to the hospital, V15 would call herself. V15 said later on she assessed R2 and felt that R2 was behaving differently. V15 said she noted a change in R2's condition, and R2 hadn't eat lunch, so she called the emergency ambulance transport and they said they would arrive in five minutes. The ambulance arrived at 2:15 PM to transfer R2 to the hospital. V15 stated that she couldn't find the earlier transfer paperwork that had been prepared, she tried to reprint the paperwork, and had difficulty only receiving one or two of the papers. V15 said the hospital called back asking for the paperwork and once again she had difficulty, and she had the wrong fax number. V15 also stated the hospital staff asked her why she had waited so long to send R2 out. V15 was asked about any additional vital signs for R2 which she stated were not done because her assessment of change in condition did not occur until right before she called the ambulance. V15 stated her charting was in the progress notes regarding transfer by local ambulance at 2:15 PM. V15 stated that her charting again was done later when she charted the hospital admitting diagnosis of hypoxia and sepsis. On 09/05/24 at 12:16 PM, V20, CNA stated she was at the facility on the day R2 was being sent out to the hospital. V20 said when she first arrives at the facility, she will walk down her hallway and check on everyone and the night shift had told her something was wrong with R2 and R2 hadn't been acting right. V20 said R2 didn't eat breakfast that morning, she wouldn't get up out of bed, and that isn't like her at all. V20 stated night shift usually gets R2 up, but she was still in bed when she got to the facility that morning. V20 stated when she checked on R2 that morning she seen R2 was on oxygen, so she asked the nurse why and the nurse told her she was getting ready to send R2 out to the hospital. V20 stated she knew they were sending R2 out, so she kept a close eye on her throughout the day. V20 stated at 11:00 AM she noticed R2 wasn't looking good, so she went and talked with the nurse and asked her about R2 being sent out. On 09/05/24 at 12:29 PM, V15, LPN was contacted for a follow up interview regarding R2. V15 said she got to the facility about 8:00 to 8:15 AM on 07/27/24 and was told by the nurse covering for her she (V14) was sending R2 out to the hospital. V15 said V14, LPN told her she called the non-emergency ambulance number, and they would be here by 8:45 AM to pick up R2. V15 stated she went down to check on R2, but the CNAs were getting R2 cleaned up and changed so she could go out the hospital and she also seen her breakfast in her room. V15 stated she didn't do any vital signs at this time and R2 did not have any oxygen on, but she said R2 takes it off all the time. V15, said she didn't go down and check on R2 again until a couple of hours later around lunch time after she talked with a CNA. V15 said when she went down to R2's room to check on R2 and she wasn't acting like her normal self. She said she hadn't eaten any of her lunch, she was drowsy, and she was lying off the side of the bed. V15 stated she did do v/s on R2 at that time. She said she checked her b/p and her pulse but didn't check her O2 saturation, then she went and called 911, and they (EMS) arrived at the facility in about 5 to 10 minutes after she called them. When questioned about where this surveyor would find the documentation and v/s V15 stated she didn't document the v/s, but she did inform the Emergency Medical Technicians (EMTs) what they were when they came to pick up R2. On 09/12/24 at 11:13 AM, V15, LPN said she did not ask the CNAs that day to take R2's v/s because she likes to take her own vitals. R2's Patient Care Report from the local ambulance service, dated 07/27/24 at 2:24 PM, documented R2's chief complaint was altered consciousness: lethargic, R2's v/s were as follows: B/P 134/96, Pulse 88, Respirations 16, SpO2 was 86% ambient air (room air). The Report documents at 2:27 PM it documented R2's v/s as follows: B/P 137/68, Pulse 94, Respirations 21, and SpO2 87%. At 2:38 PM it documented R2's v/s as follows: B/P 103/52, Pulse 90, Respirations 13, and SpO2 94%. R2's Hospital Report, dated 07/27/24, documented Clinical Indicators/Treatments 90 y/o (year old) female presents from her extended care facility with shortness of breath. O2 sat upon arrival 86% on room air. O2 2L (Liters) NC (nasal canula) initially applied up to 6L NC. Patient's respiratory status continued to worsen and BIPAP (bilevel positive airway pressure) was applied. Currently on NC 4L with O2 sats 94-95%. It further documents Reason for visit, visit diagnoses sepsis, due to unspecified organism, acute on chronic hypoxic respiratory failure, cellulitis of right lower extremity, and acute on chronic CHF (congestive heart failure). It also documented Critical care was necessary to treat or prevent imminent or life-threatening deterioration of the following condition(s): unstable vital signs and end of life care/management/discussion, acute congestive heart failure exacerbation (CHF), hypoxic respiratory failure, and sepsis. It also documented critical care was time spent by providing the following: Continuous telemetry, continuous pulse oximetry, interpretation of bedside monitors, imaging, and arterial/venous lab draws and several patient bedside exams, supplemental oxygen, and non-invasive positive pressure ventilator management. It also documented some of R2's labs were abnormal. R2's Complete Blood Count (CBC) was high at 19.8 with the normal range being 3.8-9.9. R2's Brain Natriuretic Peptide (BNP) was high at 2,045 with the normal range being <=450 picograms per milliliter (pg/ML). (BNP is a test that gives your provider information about how your heart is working. When your heart must work harder to pump blood, it makes more BNP. Higher levels of BNP can be a sign of heart failure. ClevelandClinic.org) R2's Hospital Report, dated 08/05/24 at 6:20 PM, documented R2's final diagnoses were but not limited to Sepsis, unspecified organism, Acute on chronic CHF, Acute respiratory failure with hypoxia, and cellulitis of right lower limb. On 08/27/24 at 09:18 AM, V3, R2's daughter said when she arrived to the hospital R2 was in severe pain and looked like H***. V3 said later in the evening the doctor came up to check on R2 and told her (V3) he was surprised R2 made it because he wasn't sure if she was going to. V3 said R2 was on oxygen and having issues with breathing. They gave R2 some morphine to help with the pain and after that she was kind of out of it for a couple of days. V3 said R2's leg was swollen and looked like it was going to rot off. She said she (V3) talked with the facility, and they told her they take good care of their residents. On 08/27/24 at 12:15 PM, V9, LPN said if she had a resident who had a change in condition, she would assess the resident, obtain vital signs, and if abnormal would notify the physician for further evaluation and orders. She would then notify the family and if needed she would then call an ambulance. On 08/27/24 at 12:30 PM, V13, LPN/Infection control nurse stated if she had a resident who had a change in condition and shortness of breath, she would assess the resident and then phone the physician. She said if the resident was critical, she would immediately call 911. On 08/27/24 at 1:30 PM, V1, Administrator stated if there was a resident who complained of shortness of breath and had a change in condition, she would expect the nurses to contact the physician, they should chart the situation, background, assessment, and recommendation (SBAR) in the progress notes, and if the situation is urgent the staff should call 911. She said the response time of an ambulance varies and if the call is made on the non-urgent phone number you never know when the ambulance will arrive. V1 stated six hours is too long to wait for an ambulance. On 08/27/24 at 1:45 PM, V2, Director of Nursing (DON) stated if her nurses had a resident who complained of shortness of breath and had a change in condition, she would expect the nurses to first put oxygen on the resident, then call 911, and this should be documented in the progress notes. V2 said six hours is too long to wait for an ambulance. On 08/27/24 at 12:12 PM, V8, Nurse Practitioner (NP) stated she was not working the day of R2's incident. She said the nurses here at the facility would call the exchange and speak with the on-call provider to get any orders. V8 said the nurses will document in the resident's progress notes that they contacted the on-call provider. V8 said if the nurses were to have a resident who was complaining of being short of breath and their oxygen saturation (SpO2) was 85% she would expect the nurses to assess the resident, place oxygen (O2) on the resident if they didn't already have it on, contact the provider, then send them out. She would also expect them to continue to monitor the resident especially if the resident had interventions in place and there was no change in the resident. V8 was asked if R2 having to wait from 8:04 AM until 2:15 PM to be sent out to the hospital was an appropriate amount of time to which V8 responded No that was not an appropriate amount of time for a patient to be in distress if she was still in distress. On 09/05/24 at 10:30 AM, V16, Wound Care, NP stated she makes weekly rounds on Thursdays, she assesses the wounds, documents on the wounds, takes pictures of the wounds, and makes treatment recommendations for the wound care. She said it is then run past the Primary Care Physician (PCP) and they will say yes or no to the recommendation, but they will generally agree with it. V16 stated the last day she saw R2 she (R2) was having increased edema and showing signs of cellulitis to her wound. V16 stated her recommendation on that day for R2 was to get a stat doppler and if they were unable to get the doppler that day to send R2 out to the ER for further treatment. She said she would expect the nurses to put the order in the day it was received and start the order that day or at least within 24 hours of getting the order. V16 stated if she makes a recommendation, and the facility has the supplies in the building she will do the dressing and apply the treatment that day. V16 stated from her understanding V4, Wound Nurse/LPN is to do the dressing changes Monday through Friday unless he is pulled to work the floor and then the floor nurses are to do their own dressing changes. V16 stated when the nurse is changing the dressing, she would expect the nurse to assess the wound. Look for drainage, look at the wound bed, watch for increased warmth, increased pain, and report any signs that are abnormal. V16 said with R2's type of wound (venous) and if there wasn't a clot present the dressing doesn't necessarily have to be changed daily all the time but because of her (R2's) drainage it should have been changed daily as ordered. V16 stated with the signs of cellulitis and the amount of drainage R2 had it could have been detrimental to the wound. She said it was a perfect breeding ground for bacteria. V16 stated if R2's wound was determined to be the source of R2's infection then yes it could have caused the sepsis. 2. R1's admission Record, print date of 08/27/24, documented R1 had diagnoses of but not limited to Type 2 diabetes, dysphagia, abnormalities of gait and mobility, end stage renal disease (ESRD), heart failure, dependence on renal dialysis, hypertension, chronic atrial fibrillation, and non-pressure chronic ulcer of heel. R1's MDS, dated [DATE], documented R1 was moderately cognitively impaired with a BIMS of 10 out of 15. It further documented she has impairment of both upper and lower extremities, treatment as ordered to left lateral mid foot and required use of a wheelchair. observe and assess regularly and protect heels. R1's Care Plan, last review date of 07/05/24, documented R1 is at risk for skin complications and has a problem listed as an arterial wound to her left lateral mid foot. The goal is that the area to her left lateral mid foot will remain stable/heal throughout the next review. Interventions include but not limited to assess and document progress of areas weekly, educate resident on MD orders for wound care, educate resident on the risks of infection and poor healing related to non-compliance, monitor area for signs and symptoms of infection, odor, drainage, color, and size, notify MD of abnormal findings, protect heals, skin assessment weekly and treatment as ordered to left lateral mid foot. R1's Physician's Orders, dated 07/04/2024, documented apply wound gel to left heel topically every day shift to promote wound healing. Cleanse left heel with wound cleanser then apply hydro gel mixed with collagen particles to wound bed then cover with calcium alginate then apply dry dressing daily. R1's TARs, for the month June 2024, shows no documentation that R1 received wound care on 06/13/24, 06/14/24, 06/22/24, 06/23/24, and 06/26/24. R1's TARs for the month of July 2024 shows no documentation for wound care on 07/02/24, 07/06/24, 07/18/24, 07/22/24, 07/27/24, and 70/29/24. R1's TARs for the month of August 2024 shows no documentation for wound care on 08/01/24, 08/02/24, 080/3/24, 08/09/24, 08/15/24, 08/17/24, 08/18/24, and 08/23/24. On 8/26/24 at 11:15 AM, R1 stated the floor nurses must change her dressing on the weekends because the wound nurse is off on the weekends. R1 stated that last Saturday (08/24/24) her wound care was performed while she was at in-house hemodialysis. During the same time V4, Wound Nurse was observed changing R1's dressing. The date on dressing was 8/24/24 (2 days prior to current observation date). V4 was asked what the date on the dressing was and he verified the date was 08/24/24. 3. R3's admission Record, print date of 08/27/24, documented R3 had diagnoses of but not limited to non-pressure chronic ulcer of other part of right lower leg, lymphedema, osteoarthritis, schizophrenia, and heart failure. R3's MDS, dated [DATE], documented R3 has a moderate cognitive impairment with a BIMS score of 10 out of 15 and requires use of a wheelchair and a walker, is incontinent of bowel and bladder, and is at risk for developing pressure ulcers. R3's Care Plan, last review date of 06/04/2024, documented R3 has a problem with a venous wound to his right lateral calf with the goal that the wound will remain stable/heal throughout the next review. Interventions include but are not limited to assess and document progress of areas weekly, educate resident on the risks of infection and poor healing related to non-compliance, monitor areas for signs and symptoms of infection, odor, drainage, color, and size, notify MD of abnormal findings, observe, and assess regularly, skin assessment weekly, and treatment as ordered to right lateral calf. R3's Physician's Orders, dated 04/09/24, documented remove ace wraps from lower legs every night shift. Also, to cleanse bilateral lower extremities (BLE) with soap and water and apply A&D ointment and then wrap with ace wraps every day shift for edema control. R3's Physician's Orders, dated 08/01/24, documented cleanse right medial calf with wound cleanser and then apply TMC mixed with A&D to wound bed, cover with calcium alginate, ABD pad and Kling daily for 7 days. R3's Physician's Orders, dated 08/09/24, documented clean left medial calf with wound cleanser and apply TMC mixed with A&D and cover with calcium alginate and dry dressing daily for 10 days. R3's TARs for the month of June 2024 had no documentation for wound care on the following dates: 06/13/24, 06/22/24, 06/23/24, and 06/29/24. There is no documentation of ace wrap removal on 06/06/24 and 06/12/24. R3's TARs for the month of July 2024 had no documentation for wound care on the following dates: 07/06/24, 07/18/24, 07/20/24, 07/21/24, 07/22/24, 07/27/24, 07/28/24 and 07/29/24. There is no documentation of ace wrap removal on 07/05/25, 07/10/24, and 07/14/24. R3's TAR for the month of August 2024 had no documentation on wound care for 8/1/24, 8/2/24, 8/3/24, 8/17/24, 8/18/24, and 8/19/24. Ace wrap removal at bedtime was not documented on 8/7/24, 8/13/24 and 8/22/24. 4. R4's admission Record, print date of 08/27/24, documented R4 had diagnoses of but not limited to multiple sclerosis, acute respiratory failure, metabolic encephalopathy, weakness, chronic pulmonary embolism, cellulitis, and dermatitis. R4's MDS, dated [DATE], documented R4 was moderately cognitively impaired with a BIMS of 12 out of 15, has impairment to both lower legs, is always incontinent of bowel and bladder, and is at risk for developing pressure ulcers. R4's Care Plan, last review date of 05/31/2024, documented R4 has a wound to his left great toe with the goal that the area to the left great toe will remain stable/heal throughout next review. Interventions include but not limited to assess and document the progress of areas weekly, educate resident on MD orders for wound care, educate resident on the risks of infection and poor healing related to non-compliance, monitor area for signs and symptoms of infection, odor, drainage, color, and size, notify MD of abnormal findings, skin assessment weekly and treatment as ordered to left great toe. R4's Physician's Orders, dated 05/20/24, documented apply Hydrocortisone (Topical) to buttocks and groin topically every day and night shift to Promote Wound Healing, Cleanse buttocks and groin with soap and water then apply Hydrocortisone, A&D ointment, Calamine lotion and nystatin twice daily. R4's Physician's Orders, dated 08/08/24 to 08/19/24, documented Triamcinolone Acetonide External Ointment 0.1% topical. Apply to left posterior calf topically every day shift to promote wound healing, cleanse left posterior calf wound with wound cleanser then apply TMC ointment mixed with A&D ointment to wound bed then cover with xeroform and cover with dry dressing daily. R4's Physician's Orders, dated 08/23/24, documented apply hydrogel to left lateral calf topically every day shift to promote wound healing. Cleanse left lateral calf wound with wound cleanser then apply Hydrogel mixed with collagen particles to wound bed cover with calcium alginate and dry dressing daily. R4's TARs for the month of June 2024 were reviewed and had no wound care documentation for the morning on 06/13/2024, 06/19/2024, 06/20/2024, 06/23/2024, 06/27/2024, and 06/30/2024 and in the evening on 06/18/2024 and 06/29/24. R4's TARs for the month of July 2024 had no wound care documentation on the mornings of 07/04/24, 07/16/24, 07/18/24, 07/19/24, 07/21/24, 07/22/24 and 07/28/24 and on the evenings of 07/12/24, 07/16/24, 07/17/24, 07/21/24 and 07/22/24. R4's TARs for the month of August 2024 were reviewed and had no wound care documentation for the mornings for 08/02/24, 08/15/24 and 08/22/24 and no evening documentation on 08/17/24. 5. R5's admission Record, print date of 08/27/24, documented R5 had diagnoses of but not limited to aphasia following cerebral infarction, brain stem stroke, human immunodeficiency virus, (HIV), diabetes, acute and chronic respiratory failure, dysphagia, end stage renal disease, (ESRD), stage 4 pressure ulcer of sacral region, and pressure ulcer of left heel. R5's MDS, dated [DATE], documented R5 has moderate cognitive impairment with a BIMS of 8 out of 15, impairment on bilateral upper and lower extremities, has an indwelling catheter, is always incontinent of bowel, and it also documents R5 is at risk of developing pressure ulcers, and he has a pressure ulcer. R5's Care Plan, last review date of 08/09/24, documented R5 has a pressure injury to his left heel and sacrum with the goal that the areas will remain stable/heal throughout the next review. Interventions include but not limited to assess and document progress of areas weekly, educate R5 on MD orders for wound care, educate resident on the risks of infection and poor healing related to non-compliance, monitor area for signs and symptoms of infection, odor, drainage, color, and size, notify MD of abnormal findings, skin assessment weekly and to provide treatment as ordered to the left heel and sacrum. R5's Physician's Orders, dated 06/03/24, documented apply betadine to left heel, then apply ABD pad and secure with Kling daily. R5's Physician's Orders, dated 06/07/24 through 06/15/24, documented cleanse sacrum wound with wound cleanser then reconstitute 3 capsules of compound of Streptomycin 80mg, Flucytosine 50mg, and Meropenem 150mg and 1 capsule of Levaquin 400mg and 1 packet of collagen particles with 12 pumps of [NAME]-gel then apply to wound bed, cover with, and lightly pack with calcium alginate and then cover with dry dressing daily. R5's Physician's Orders, with a start date of 06/21/24 and discontinued on 07/26/24, documented Cleanse Sacrum wound with wound cleanser then reconstitute 3 capsules of compound of Streptomycin 80mg, Flucytosine 50mg, and Meropenem 150mg and 1 capsule of Levaquin 400mg and 1 packet of collagen particles with 12 pumps of [NAME]-gel then apply to wound bed cover with and lightly pack with calcium alginate. R5's Physician's Orders, dated 07/09/24, documented apply hydrogel to left heel topically every day shift. Cleanse left heel with wound cleanser then apply hydrogel mixed with collagen particles to wound bed and cover with calcium alginate and cover with ABD and Kling daily. R5's Physician's Orders, dated 7/26/24, state to apply wound gel to sacrum topically every day shift for to promote wound healing. Cleanse sacral wound with wound cleanser then apply Hydrogel mixed with collagen particles to wound bed cover with calcium alginate then dry dressing daily. R5's TARs for the month of June 2024 were reviewed and had no documentation of the sacrum wound treatment being completed on 06/22/24, 06/23/24, 06/27/24, and 06/30/24. R5's TARs for the month of July 2024 were reviewed and had no documentation of the sacral wound treatment being done on 07/04/24, 07/18/24, 07/22/24, 07/23/24, 07/25/24 and 07/26/24. The August 2024 TAR showed no documentation on the sacral wound on 8/2/24, 8/7/24, 8/12/24, 8/21/24 and 8/22/24. R5's July 2024 TAR showed no documentation his wound care was completed on the left heel wound on 7/14/24, 7/18/24, 7/22/24, 7/23/24. R5's August 2024 TAR showed no documentation R5's wound care was completed on the left heel on 8/2/24, 8/7/24, 8/12/24, 8/21, and 8/22/24. 6. R6's admission Record, print date of 08/27/24, documented R6 had diagnoses of but not limited to type 2 diabetes, dependence on renal dialysis, congestive heart failure, (CHF), transient cerebral ischemic attack, (TIA), dependence on renal dialysis, essential [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents were free from abuse/neglect, failed to ensure residents felt safe, and failed to ensure residents needs were met in a dignified manner in the facility for 2 of 24 residents (R16, R99) in the sample of 44. This failure resulted in R16 feeling sexually assaulted and fearful to endure a similar situation from occurring again. Findings include: 1. On 5/14/2024 at 11:20 AM, V1, Administrator (ADM) stated, I am working on a reportable (incident) right now. I am going to term (terminate) her. It sounds like she was under the influence of something. Her set (assigned hall) was a mess. One resident made an allegation that is considered abuse. I also interviewed the other residents on the hall. Social Services took over. I had another resident (R99) with a complaint. She stated she did not feel abused but had an episode of incontinence, which she usually doesn't, and the CNA (Certified Nursing Assistant) slammed a diaper down and told her to clean herself up. She (R99) said she would just hate to see her do that to someone who couldn't speak for themselves. V1 continued to state, Another resident (R16) said she told the CNA she needed a pain pill. The CNA started rubbing on her all over and saying how she loved her. When I asked her (the resident) if she felt sexually harassed, she said, 'yes' and became tearful and stated she was uncomfortable. Her roommate (R16's) (R64) was in the bathroom, came out and told the CNA to leave. (R16) has had customer service complaints before but she is not someone who wouldn't be credible. On 5/14/24 at 12:05 PM, two police officers were observed in the building walking towards (R64's) room. At this time, (V1) told (R16) the officers were there to interview her about what had happened. This surveyor was present for the interview. R16 stated, I hit my button (call light) for pain med at 2:30 (AM)and nobody came. I did it again about a quarter til 3. The CNA said she thought it was my roommate who called (pressed the call light). I told her I was the one and she got all in my face. I told her if you get in my face, I'm gonna deck ya then, all the sudden she started rubbing all over my breasts. I'm sorry, I'm not like that. R16 then became visibly upset and anxious. R16 continued, I told her to stay away from me, don't touch me, stop! She just kept rubbing on me, my boobs. I am just a person, and I don't like that. (R64) got her off me and sent her down the hall. I finally got my medicine about 6 (AM). The nurse said no one had told her I needed it. I've been in 3 different places (facilities) and never had anything like this happen. At this time, (V21, Police Officer) asked R16 if it made her upset and uncomfortable and R64 stated, Yes, I'm going to always wonder if someone is going to do it to me again. If that's the case, I want out of here and to go somewhere else. V21 also asked R16, Was she rubbing with a flat hand or was she grabbing your breasts? R16 replied, I was protecting myself and had my hands over them (breasts). She was aiming to grab. She was saying, We're going to be the best of friends. R16 continued, I don't want to worry about when I need changed again if that will happen. You don't expect to be molested. On 5/14/2024 at 12:19 PM, R64, who was present in the room during R16's interview, R64 stated she concurs with everything R16 said about the incident and that R64 witnessed it. R16's Minimum Data Set, dated [DATE] documents R16 is cognitively intact. At 12:30, V21 stated the police report would take 5-7 days to be completed. On 5/14/2024 at 10:31 AM, V15, CNA stated, I witnessed the one (incident) with (R99). Nothing was done on the set (hall). The nurse said the CNA left at 6 (AM). (R16) told me she was soaking wet. I asked her why she didn't ask for help, and she told me she didn't want her (V24) touching her because she 'violated' her. She said (V24) started rubbing her across her chest and it made her uncomfortable. On 5/14/24 at 12:45 PM, R64 was heard asking an unknown staff member, Is that situation that happened in my room last night going to be taken care of? The Facility's Reported Incident Form dated 5/14/2024 documents the incident category is Resident Abuse, and the Resident/victim/perpetrators are R16 and V24. It further documents, (R16) reported that she put on her call light around 3:00 AM to ask for a pain pill. Staff member (V24, CNA) responded again and when she came in (V16) stated, 'You know there are two of us in this room and it was me who had the light on'. She said at that time (V24) was leaning over the bed rail and getting really close to her face asking her what she needed. She told her that she needed a pain pill. She also asked her to get out of her face, that she was getting too close to her. (V24) told her that it was too soon she couldn't have a pain pill. At that time, (V24) began to rub on her (R16's) chest on the outside of her gown and tell her that she would be ok, she was going to take care of her and loves her. (R16) felt uncomfortable and was telling (V24) to leave her alone. At that time, (R64), who is (R16)'s roommate, came out of the bathroom and got the aide out of the room. (R16) reported the incident to the nurse in the morning. It continues to document V24 was suspended. 2. On 5/13/2024 at 10:45 AM, R99 stated, There are two bad staff. I reported it to the guy nurse (V17, Licensed Practical Nurse). They sent her home. I asked one of them to move me up in bed. I've had a stroke and can't move. It's very difficult. She told me to do it myself. On 5/14/2024 at 9:00 AM, R99 stated, The CNA last night told me to change myself., threw a diaper on the table and left. I did the best I could cleaning myself up. (V15) helped me the rest of the way this morning and there were still about 3 streaks of poop left. The Administrator was just in here talking to me and said the CNA will be fired and the police will be here later for a report. On 5/14/2024 at 10:31 AM, V15, Certified Nursing Assistant (CNA) stated, I witnessed the one (incident) with (R99). The lady (unknown CNA) came in (to work) mad about her set (hall assignment). She was slamming doors. She was yelling at (R99) 'You better get up!'. I was so shocked by it, my mouth dropped. I made eye contact with (R99), and she was in tears. She (R99) was so distressed. I told the nurse and he (V17, LPN) called (V1). (V17) sent her home. The next night (R99) said she had the same thing from another CNA. The CNA said, 'That lady (R99) don't want to do anything for herself!'. Some of these CNAs are 'nasty' (ill mannered). The Facility-Reported Incident Form dated 5/9/2024 documents, Interview of Alleged Victim documents, Resident (R99) reported that the CNA (Certified Nursing Assistant) (V16) 'threw' her shirt at her and then she only assisted her with putting her arms in sleeves and not in pulling it over her head. It further documents, Interview of Witness-(V15) CNA states that she witnessed CNA (V16) yelling and demanding resident in (room) to do things and to get up and get herself ready and that the yelling was really intense. She also stated the aide (V16) walked out of the room cussing and saying, 'It's a shame when you don't want to shower or do anything for yourself'. The Facility's Abuse Policy and Prevention Program 2022 documents, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility id doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment of residents. It further documents this will be done by establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment. This Policy defines Sexual Abuse as sexual harassment, sexual coercion, or sexual assault including non-consensual consent to sexual activity. This Policy defines Mental Abuse as humiliation, harassment, threats of punishment or deprivation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed follow their Abuse Policy and Prevention Program by ensuring residents were free from abuse/neglect as well as felt safe and needs were met in a dignified manner in the facility for 2 of 24 residents (R16, R99) in the sample of 44. This failure resulted in R16 feeling sexually assaulted and fearful to endure a similar situation occurring again. Findings include: The Facility's Abuse Policy and Prevention Program 2022 documents, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment of residents. It further documents this will be done by establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment. This Policy defines Sexual Abuse as sexual harassment, sexual coercion, or sexual assault including non-consensual consent to sexual activity. This Policy defines Mental Abuse as humiliation, harassment, threats of punishment or deprivation. 1. On 5/14/2024 at 11:20 AM, V1, Administrator (ADM) stated, I am working on a reportable (incident) right now. I am going to term (terminate) her. It sounds like she was under the influence of something. Her set (assigned hall) was a mess. One resident made an allegation that is considered abuse. I also interviewed the other residents on the hall. Social Services took over. I had another resident (R99) with a complaint. She stated she did not feel abused but had an episode of incontinence, which she usually doesn't, and the CNA (Certified Nursing Assistant) slammed a diaper down and told her to clean herself up. She (R99) said she would just hate to see her do that to someone who couldn't speak for themselves. V1 continued to state, Another resident (R16) said she told the CNA she needed a pain pill. The CNA started rubbing on her all over and saying how she loved her. When I asked her (the resident) if she felt sexually harassed, she said, 'yes' and became tearful and stated she was uncomfortable. Her roommate (R16's) (R64) was in the bathroom, came out and told the CNA to leave. (R16) has had customer service complaints before but she is not someone who wouldn't be credible. On 5/14/24 at 12:05 PM two police officers were observed in the building walking towards (R64's) room. At this time, V1 told R16 the officers were there to interview her about what had happened. This surveyor was present for the interview. R16 stated, I hit my button (call light) for pain med at 2:30 (AM)and nobody came. I did it again about a quarter til 3. The CNA said she thought it was my roommate who called (pressed the call light). I told her I was the one and she got all in my face. I told her if you get in my face, I'm gonna deck ya then, all the sudden she started rubbing all over my breasts. I'm sorry, I'm not like that. R16 then became visibly upset and anxious. R16 continued, I told her to stay away from me, don't touch me, stop! She just kept rubbing on me, my boobs. I am just a person, and I don't like that. (R64) got her off me and sent her down the hall. I finally got my medicine about 6 (AM). The nurse said no one had told her I needed it. I've been in 3 different places (facilities) and never had anything like this happen. At this time, (V21, Police Officer) asked R16 if it made her upset and uncomfortable and R16 stated, Yes, I'm going to always wonder if someone is going to do it to me again. If that's the case, I want out of here and to go somewhere else. V21 also asked R16, Was she rubbing with a flat hand or was she grabbing your breasts? R16 replied, I was protecting myself and had my hands over them (breasts). She was aiming to grab. She was saying, We're doing to be the best of friends. R16 continued, I don't want to worry about when I need changed again if that will happen. You don't expect to be molested. On 5/14/2024 at 12:19 PM, R64, who was present in the room during R16's interview, R64 stated she concurs with everything R16 said about the incident and that R64 witnessed it. R16's Minimum Data Set, dated [DATE] documents R16 is cognitively intact. At 12:30, V21 stated the police report would take 5-7 days to be completed. On 5/14/2024 at 10:31 AM, V15, CNA stated, I witnessed the one (incident) with (R99). Nothing was done on the set (hall). The nurse said the CNA left at 6 (AM). (R16) told me she was soaking wet. I asked her why she didn't ask for help, and she told me she didn't want her (V24) touching her because she 'violated' her. She said (V24) started rubbing her across her chest and it made her uncomfortable. On 5/14/24 at 12:45 PM, R64 was heard asking an unknown staff member, Is that situation that happened in my room last night going to be taken care of? The Facility's Reported Incident Form dated 5/14/2024 documents the incident category is Resident Abuse, and the Resident/victim/perpetrators are R16 and V24. It further documents, (R16) reported that she put on her call light around 3:00 AM to ask for a pain pill. Staff member (V24, CNA) responded again and when she came in (R16) stated, 'You know there are two of us in this room and it was me who had the light on'. She said at that time (V24) was leaning over the bed rail and getting really close to her face asking her what she needed. She told her that she needed a pain pill. She also asked her to get out of her face, that she was getting too close to her. (V24) told her that it was too soon she couldn't have a pain pill. At that time, (V24) began to rub on her (R16's) chest on the outside of her gown and tell her that she would be ok, she was going to take care of her and loves her. (R16) felt uncomfortable and was telling (V24) to leave her alone. At that time, (R64), who is (R16)'s roommate, came out of the bathroom and got the aide out of the room. (V16) reported the incident to the nurse in the morning. It continues to document V24 was suspended. 2. On 5/13/2024 at 10:45 AM, R99 stated, There are two bad staff. I reported it to the guy nurse (V17, Licensed Practical Nurse). They sent her home. I asked one of them to move me up in bed. I've had a stroke and can't move. It's very difficult. She told me to do it myself. On 5/14/2024 at 9:00 AM, R99 stated, The CNA last night told me to change myself., threw a diaper on the table and left. I did the best I could cleaning myself up. (V15) helped me the rest of the way this morning and there were still about 3 streaks of poop left. The Administrator was just in here talking to me and said the CNA will be fired and the police will be here later for a report. On 5/14/2024 at 10:31 AM, V15, Certified Nursing Assistant (CNA) stated, I witnessed the one (incident) with (R99). The lady (unknown CNA) came in (to work) mad about her set (hall assignment). She was slamming doors. She was yelling at (R99) 'You better get up!'. I was so shocked by it, my mouth dropped. I made eye contact with (R99), and she was in tears. She (R99) was so distressed. I told the nurse and he (V17, LPN) called (V1). (V17) sent her home. The next night (R99) said she had the same thing from another CNA. The CNA said, 'That lady (R99) don't want to do anything for herself!'. Some of these CNAs are 'nasty' (ill mannered). The Facility-Reported Incident Form dated 5/9/2024 documents, Interview of Alleged Victim documents, Resident (R99) reported that the CNA (Certified Nursing Assistant) (V16) 'threw' her shirt at her and then she only assisted her with putting her arms in sleeves and not in pulling it over her head. It further documents, Interview of Witness-(V15) CNA states that she witnessed CNA (V16) yelling and demanding resident in (room) to do things and to get up and get herself ready and that the yelling was really intense. She also stated the aide (V16) walked out of the room cussing and saying, 'It's a shame when you don't want to shower or do anything for yourself'.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to provide proper wound care, and to turn and reposition a resident, for 1 of 1 resident (R270) reviewed for treatments and care to prevent pressure ulcers in the sample of 44. Findings include: R270's Face Sheet, undated, documents R270 was originally admitted to the facility on [DATE] with Diagnosis of Hypoxic Ischemic Encephalopathy, Type 2 Diabetes Mellitus (DM), Osteomyelitis, Dysphagia, Obesity, Dysarthria/Anarthria, Anemia, Major depressive disorder, Neuromuscular dysfunction of bladder, Gastrostomy, Dependence on renal dialysis, Gangrene, Pressure Ulcer of sacral region-stage 4, Sepsis, PVD, Metabolic Syndrome, Atherosclerotic Heart Disease (ASHD). R270's Care Plan states, R270 is at risk for skin complications related to Unspecified Severe Protein-Calorie Malnutrition. Interventions: Assist and encourage resident to turn and reposition every one to two hours and PRN (as needed), elevate HOB (head of bed) no more then 30-degrees, ensure proper body alignment, skin assessment weekly. It continues R270 was admitted with a DTPI (deep tissue pressure injury) to his left heel. Interventions: Assess and document of progress of areas weekly, Assist and encourage resident to turn and reposition every one to two hours and PRN, Elevate HOB (head of bed) no more then 30-degrees, ensure proper body alignment, maximal remobilization, monitor area for s/s (signs/symptoms) of infection: odor, drainage, color, size, observe and assess regularly, protect heels, treatment as ordered to left heel. It continues R270 was admitted with a DTPI to his left lateral malleolus. Interventions: Assess and document of progress of areas weekly, assist and encourage resident to turn and reposition every one to two hours and PRN, elevate HOB no more then 30-degrees, ensure proper body alignment, maximal remobilization, observe and assess regularly, protect heels, treatment as ordered to left malleolus. It continues R270 was admitted with a stage-III pressure wound to his left Ischium. Interventions: Assess and document of progress of areas weekly, assist and encourage resident to turn and reposition every one to two hours and PRN, elevate HOB no more then 30-degrees, ensure proper body alignment, maximal remobilization, observe and assess regularly, skin assessment weekly, treatment as ordered to left Ischium, wound-vac to aid in healing. It continues R270 was admitted with an unstageable wound to his right gluteus. Interventions: Assess and document of progress of areas weekly, assist and encourage resident to turn and reposition every one to two hours and PRN, elevate HOB no more then 30-degrees, ensure proper body alignment, maximal remobilization, monitor area for s/s of infection: odor, drainage, color, size, observe and assess regularly, skin assessment weekly, treatment as ordered to right gluteus, wound-vac to aid in healing. It continues R270 was admitted with a stage-IV pressure wound to his sacrum. Interventions: Assess and document of progress of areas weekly, assist and encourage resident to turn and reposition every one to two hours and PRN, elevate HOB no more then 30-degrees, ensure proper body alignment, maximal remobilization, monitor area for s/s of infection: odor, drainage, color, size, observe and assess regularly, skin assessment weekly, wound-vac to aid in healing. R270's Minimum Data Set (MDS), dated [DATE], documents R270 has severe cognitive impairment and is dependent on staff for all Activities of Daily Living (ADLs). R270 has anuria and has a colostomy. On 5/13/24 at 10:45 AM, R270, was seen sitting in his recliner chair around the nurse's desk, right below knee amputation (RBKA), soft boot on left foot. R270 was just back from Dialysis. On 5/14/24 at 10:35 AM, V6, Licensed Practical Nurse (LPN)/Wound Care, stated that R270 has three stage-4 pressure ulcers and two unstageable ulcers. V6 stated that R270 came back from the hospital without the wound-vac and had no orders to continue it. V6 stated that he changes dressings and does wound care every day. On 5/14/24 at 10:20 AM, R270's wound-vac was seen in his closet in a plastic bag, along with its supplies. On 5/15/24 at 8:25 AM, R270 was seen sitting on his buttocks in his recliner in Dialysis. On 5/16/24 at 8:15 AM, R270 sitting in recliner on his buttocks during Dialysis. On 5/16/24 at 11:20 AM, R270 is still sitting in his recliner on his buttocks in Dialysis. On 5/15/24 at 12:45 PM, V6, LPN/Wound Nurse, stated All of (R270's) wounds are from the hospital. He was hospitalized for amputation of his leg and then sent here. He had all of these wounds when he arrived here. When (R270) pulled out his G-Tube, he was sent back to the hospital and for some reason, they kept him for 10 days. When he came back, he did not have his wound-vac in place and had no orders for it. I did not call the physician and ask about it but will check with the NP tomorrow when she comes to see him. I think that (R270) could benefit from having the wound-vac back on. On 5/15/24 at 12:50 PM, V6 began providing wound care to R270, Santyl spread on Xeroform and applied to wounds, then covered with occlusive dressing. Upon assessing R270, there were three new areas seen on R270 that V6 was not aware of. These seem to be blisters and was covered up by a band aid on one, and a small dressing on the other. Right upper/proximal flank 4 CM (centimeter) X 6.5 CM, Right mid-flank 0.9 CM X 0.9 CM, and Right distal flank - 1.5 CM X 1.5 CM. The proximal flank was still in a blister form, while the other two had blisters that popped and was oozing. V6 stated he was going to wipe them with betadine to dry them up and apply a dry dressing. V6 stated he knows what the physician will order, so he is going ahead and doing it before he calls, if the order is different, he will change it. On 5/15/24 at 1:15 PM, V6, LPN/Wound Nurse, continuing to work on R270's wounds. R270 rolled to his left side to assess his wounds on his sacrum/coccyx. R270 has three large open wounds/holes to his right ischium/sacral area. V6 stated that R270 came from hospital with them, and they were tunneled together but they are getting better. Wounds cleansed with wound cleanser and 4X4's, then packed with Santyl and Xeroform, then covered with large occlusive dressing. V6 stated that he changes R270's dressings every day and the days he is not working, it is the responsibility of the floor nurse to do. V6 took off R270's soft boot from his left foot to reveal an old dressing on his heel. The dressing was dated 5/8/24. V6 stated he is not sure why this dressing has not been changed since 5/8/24. On 5/15/24 at 1:30 PM, V6, LPN/Wound Nurse, stated (R270's) got a colostomy to help his wound heal because of his incontinence. (R270) sits in a recliner for most of the day. He gets up to his recliner early in the morning, eats a small breakfast, then I see him go by my office around 6:15 AM on his way to Dialysis. He is there for 3-4 hours and brought back to the floor in time for lunch. After lunch, which is usually around 1:00 to 2:00 PM, (R270) will be put into his bed and then I do his dressings. (R270) spends a lot of time sitting in his recliner and is not repositioned, which is making his wounds worse and hard to heal. I expected (R270) to come back from the hospital with his wound-vac in place and I am not sure why I didn't call and ask about it because he would probably benefit from having it. I think the new blisters he has is from sitting a long time in his recliner and it is rubbing on him somewhere. On 5/16/24 at 8:10 AM, V31, Nurse Practitioner (NP), stated that she sees R270, but does not take care of his wounds, that is a different NP. V31 stated that R270 definitely needs to get off his backside in order for his wounds to heal. On 5/16/24 at 8:15 AM, V32, Certified Hemodialysis Technician (CCHT), stated that R270 is scheduled for Dialysis every day from 7:00 AM until 10:00 to 10:30 AM, no later than 11:00 AM. V32 stated that the staff in Dialysis cannot turn and position the residents because they do not work for the facility. V32 stated they have to call the facility transport staff member to transfer R270 from their recliner to his recliner and then back to the floor. V32 stated she does not recall seeing any blisters on R270. On 5/16/24 at 11:00 AM, V1, Administrator, stated (R270) should not be sitting for those long periods of time. The facility's transporter is not that busy and could go and reposition (R270) as needed. I will consult OT/PT, and the care plan team for recommendations, and possibly have (R270) eat meals in bed rather than keep him sitting in his recliner. On 5/16/24 at 11:55 PM, V19, Wound Nurse Practitioner, stated that she saw R270 last on 4/16/24. V19 stated that R270 came back from the hospital without his wound-vac. V19 stated that R270 needs to be turned side to side every one to two hours in order for his wounds to heal and R270 sitting on his butt all day long are detrimental to his wounds. On 5/16/24 at 12:10 PM, V5, LPN, stated that R270 just came back from Dialysis because he had an adverse reaction to Vancomycin infusion and will be going to the hospital shortly. R270's Physician Order (PO), dated 4/9/24, documents Cleanse left ischium wound with wound cleanser then apply ABX (compound) mixed with Santyl to wound bed cover with Xeroform lightly pack with calcium alginate and 4x4s and cover with silicone boarded dressing daily. Everyday shift for To Promote Wound Healing. R270's PO, dated 4/9/24, documents Cleanse right ischium wound with wound cleanser then apply ABX (compound) mixed with Santyl to wound bed cover with Xeroform lightly pack with calcium alginate and 4x4s and cover with silicone boarded dressing daily. everyday shift for To Promote Wound Healing. R270's PO, dated 4/9/24, documents Cleanse sacral wound with wound cleanser then apply ABX (compound) mixed with Santyl to wound bed cover with Xeroform lightly pack with calcium alginate and 4x4s and cover with silicone boarded dressing daily. everyday shift for To Promote Wound Healing. R270's PO, dated 5/15/24, documents Apply betadine to right flank distal blister daily and cover with dry dressing daily. Everyday shift for To Promote Wound Healing. R270's PO, dated 5/15/24, documents Apply betadine to right flank medial blister and cover with dry dressing daily. everyday shift for To Promote Wound Healing. R270's PO, dated 5/15/24, documents Apply betadine to right flank proximal blister and cover with dry dressing daily. Everyday shift for To Promote Wound Healing. R270's PO, dated 5/14/24, documents Santyl External Ointment 250 UNIT/GM (Collagenase). Apply to Sacrum topically everyday shift for To Promote Wound Healing Cleanse sacrum with wound cleanser then apply Santyl to wound bed and cover with Xeroform and 4x4s and cover with silicone boarded dressing daily. R270's PO, dated 5/14/24, documents Santyl External Ointment 250 UNIT/GM (Collagenase). Apply to Left ischium topically everyday shift for To Promote Wound Healing Cleanse left ischium with wound cleanser then apply Santyl to wound bed and cover with Xeroform and 4x4s then apply silicone boarded dressing daily. R270's PO, dated 5/14/24, documents Apply betadine to left heel daily. Everyday shift for To Promote Wound Healing. R270's PO, dated 5/14/24, documents Apply betadine to left malleolus daily. Everyday shift for To Promote Wound Healing. R270's NP Note, dated 2/26/24, documents Patient being seen today for follow up care for pressure ulcer to sacral region, buttock and left gluteal fold, patient continues to be followed by wound care, patient examined while sitting in dialysis, patient expressed by nodding his head, continues to be followed by wound care, patient examined while sitting in dialysis, patient expressed by nodding his head his buttock is uncomfortable to sit on for long periods of time. R270's Skin Screen, dated 12/5/23, documents upon admission, Skin Evaluation: Sacrum: 5.1x5.4x3.0 with undermining from 11 to 4 o'clock. R270's admission Observation, dated 12/31/23, documents R270's reason for admission was sepsis, wound-vac to coccyx. Skin Condition: Site - Coccyx, wound-vac in place. R270's last Skin and Wound Assessment located in the electronic medical record, is dated 3/12/24. V6, Wound Nurse, stated that he is doing them and has no idea why they are not showing up in the medical record. The facility's Pressure Injury Policy, dated 9/2022, documents To prevent or reduce the incidence of pressure injuries, standards of practice should be implemented. The facility's Skin Care Prevention Policy, dated 1/2023, documents All residents will receive appropriate care to decrease the risk of skin breakdown. 1. The Nursing Department will review all new admissions/readmissions to put a plan in place for prevention based on the resident's activity level, comorbidities, mental status, risk assessment and other pertinent information. 2. Dependent residents will be assessed during care for any changes in skin condition including redness (non-blanching erythema), and this will be reported to the nurse. The nurse is responsible for alerting the Health Care Provider. 3. All residents will be evaluated for changes in their skin condition weekly. 5. All residents unable to reposition themselves will be repositioned as needed, based on a person-centered approach per the resident's plan of care. 6. Unless contraindicated, elevate heels off bed surface and avoid skin-to-skin contact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review the facility failed to provide adequate supervision and progressive interventions for 1 of 3 (R2) residents investigated for falls. This failure resulted in R2 having multiple falls and sustaining a Closed displaced fracture of medial malleolus of right tibia and closed avulsion fracture of lateral malleolus of right fibula. Findings include: R2's EMR, (Electronic Medical Records), undated documents, that the resident was admitted to the facility on [DATE]. R2's EMR dated 10/25/21, documents, a diagnosis of Cerebral Palsy, unspecified. R2's EMR dated 10/26/21, documents, a diagnosis of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R2's MDS, (Minimum Data Set), dated 09/05/23, documents, that resident has a BIMS, (Brief Interview for Mental Status), score of 14 out of 15. The MDS documents, that R2 is independent with setup help only for bed mobility, transfer, walk in room, walk in corridor, locomotion on unit, locomotion off unit, and toilet use. The MDS documents, that R2 requires supervision with setup help only for dressing and personal hygiene. The MDS documents, that R2 is not steady, but able to stabilize without staff assistance. R2's Fall Risk Evaluation dated 09/11/23, documents, a score of 15.0. Scoring a 10 or higher makes resident High Risk for falls. R2's Care Plan undated documents, Fall: (R2) is at high risk for falls cognitive deficits, functional deficits, history of falls, visual impairment r/t, (related to), weakness, recent falls, and decreased mobility. 10/07/23 fall with fracture, NWB, (Non-Weight Bearing), RLE, (right lower extremity). 10/20/23 ORIF, (Open Reduction and Internal Fixation), ankle. R2's Nurses Notes dated 01/16/23, at 5:20 PM documents, nurse was notified that res had fell to her knees in the hallway near 300-hall nurses' station, nurse came to assess res, (resident), and saw res just getting off the floor while holding on to walker, res stated, her legs buckled and gave out, she did not hit her head, nurse assessed res at this time, no injuries noted, res stated, she isn't in any pain at this time, nurse educated res on the importance of taking breaks when feeling tired, making sure to use wheelchair when can no longer walk, NP, (Nurse Practitioner) and POA, (Power of Attorney), has been made aware, no further concerns noted at this time, VS, (vital signs), 98.2 78 18 122/76 98 RA, (room air). Intervention dated 01/16/23 documents, encourage resident to use wheelchair. R2's Nurses Notes dated 02/06/23, at 11:25 AM documents, This nurse was notified by aid that res had a fall in the activity area. When I made it to the area res was up and sitting in a chair. Vitals was taken B/P (blood pressure):129/20, pulse:80, res (respirations) :18 temp, (temperature) :97.3, O2 97%RA, res stated, she tripped over the rug. ROM, (range of motion), was performed, and res complained of no pain and stated, she landed on her knees. Intervention dated 02/06/23 documents, Resident educated to be mindful of her environment and avoid tripping hazards. R2's Nurses Notes dated 02/28/23, at 2:56 PM documents, Resident fell backwards onto her bottom outside in the smoking area, resident's walker was in front of her when she fell. resident did not hit her head and the fall was visually seen by a staff member. Resident stated that she became dizzy and fell, Resident had no injuries noted at this time, no c/o, (Complaints of), pain or discomforts. Resident's BP was elevated 118/100, HR, (heart rate), was 95. This nurse had just administered morning medications 20 minutes prior to fall. NP notified of fall. Intervention dated 02/28/23, encourage resident to sit down in either w/c, (wheelchair), seat or on the seat on her rollator when she is smoking. R2's Nurses Notes dated 04/12/23, at 8:55 AM documents Res fell to her knees while ambulating in activity area. Res was able to get back up without assistance, denies pain and did not hit her head. VS are WNL, (within normal limits). no visible injuries noted. NP has been informed. NNO, (no new orders), have been given at this time. Intervention dated 04/12/23, documents, Monitor resident for tolerance and endurance. Schedule tasks accordingly. R2's Nurses Note dated 04/19/23, at 1:01 PM documents, Writer was informed that res had fallen in dining room and hit her head above her R, (right), eyebrow and has a skin tear to her L, (left), knee. VS are BP-194/86, P-73, R-20, T-97.3, o2- 98 on RA. Res is alert and able to move all extremities without complaints of pain/difficulty. Res was helped up from the floor by 2 staff members using a gait belt. She was able to walk from the dining room to her room without difficulty. Writer informed NP and was given order to send res to (local hospital) for further eval. Res guardian has been informed and has voiced no complaints or concerns. Intervention dated 04/19/23, documents, Therapy to evaluate for balancing and strengthening with recs for programming. R2's Nurses Notes dated 05/09/23, at 10:00 AM documents, Res fell during smoke break this am. Writer observed res sitting on her knees outside in the smoking area, with her wheeled walker in front of her. Res was assessed for pain and injury. Res denies pain, able to move both upper and lower extremities without difficulty. Res denies hitting her head. VS assessed, BP-78/56, P-103, R-18, T-97.9, o2-97% on RA. Res was helped from her knees onto and sat on the seat of her walker, then pushed to her room. Res is lying in bed, call light within reach, bed in the lowest position. Intervention dated 05/09/23, documents, Educated resident on taking her time while ambulating. R2's Nurses Notes dated 05/16/23, at 7:46 AM documents, Writer informed res was on the ground, Res was observed on her R knee, holding onto to wheeled walker while outside during smoke break. Res said she slipped in the rain. Res denies pain, denies hitting her head. Assessed for pain and injury, none noted. Res guardian has been informed and has voiced no complaints or concerns. VS BP-176/91, P-76, R-18, T-97.2, o2-98 on RA. Intervention dated 05/16/23, documents, encouraged (R2) to use wheelchair when going out to smoke, esp. in inclement weather. R2's Nurses Notes dated 05/24/23, at 9:56 AM documents, Writer alerted by staff to come to smoke break patio because there was a code blue. Writer observed res lying on the ground unresponsive, pulse faint and irregular. 911 call initiated, while this nurse stayed with res. Writer noticed res breathing was labored and res began to have uncontrollable body movements. EMT, (Emergency Medical Technician), arrived shortly after and res was transferred to stretcher and then to (local hospital). Guardian has been informed, no complaints or concerns have been voiced. No intervention noted for this fall. R2's Nurses Notes dated 05/25/23 at 1:46 PM documents, Writer informed by staff that res was on the floor in her room. Res assessed for injury and pain. No visible injury noted, res c/o pain to L hip when standing. VS assessed BP-167/93, P-71, R-18, T-97.1, o2-96 on RA. MD informed and gave order to DC Tegretol, order STAT, (Urgent or Rush), L hip XR (x-ray), CXR (chest x-ray), and labs CBC w/Diff (complete blood count with differential), UA (urinalysis) w/C&S (culture and sensitivity). Res and Guardian aware, no complaints or concerns voiced. Intervention dated 05/25/23, documents, Educated resident to rise slowly from her bed or wheelchair when she is feeling dizzy. R2's Nurses Notes dated 07/03/23, at 12:58 PM documents, Resident has been having unsteady ambulation this morning. This nurse provided pt education for ambulatory safety and referred a wheelchair, pt denied. Resident was witnessed going out the front lobby door and fell to her knees. Patient complained 5 out of 10 for pain in RLE. This nurse looked over pt no major signs of distress or discomfort. Resident is now using wheelchair and taking a rest from using walker. MD was notified but no answer. This nurse ordered 2 view X-ray on RLE, care ongoing. No intervention noted for this fall. R2's Nurses Notes dated 07/06/23, at 7:37 PM documents, resident at 6:54 reported to the CNA, (Certified Nursing Aide), that she broke her foot from a fall that happened in the shower at 2pm. this nurse asked resident what happened. Res stated, she fell in shower two time. resident complained of pain on the bottom of her right foot. small skin abrasion on right ankle. Vitals SPO2, (oxygen saturation), 96 RA, T 98.6, R 16, P 61, B/P 155/78. ROM was performed. V14 (Physician) notified, Guardian notified. resident is in bed with call light within reach. Intervention dated 07/06/23, documents, Encourage resident to use shower chair for safety. R2's Nurses Notes dated 07/08/23, at 10:41 AM documents, Writer informed by CNA that res fell in her room and got herself back up and into her bed. Res was assessed for visible injury, none noted. Res denies pain. VS BP-127/75, HR-58, o2-95% on RA, T-97.1, R-18. MD (V14) informed, gave order for orthostatic BP . Laying-BP-132/76, HR-63 Sitting-BP-170/110 HR-62 Standing-BP-191/116 HR-63. After reviewing results, MD gave order for res to have STAT CBC, CMP (complete metabolic panel, MAG, (magnesium), TSH, (thyroid stimulating hormone), and a UA. V15 (POA) has been informed, no complaints or concerns have been voiced. Intervention dated 07/08/23, documents, Ensure proper fitting footwear when up. R2's Nurses Notes dated 07/08/23, at 7:00 PM documents, Res came to the nurse station to report she had fallen in her bedroom while trying to go to the bathroom. She got herself up. She denied pain to writer, informed POA she was having pain and now could not walk. Writer left message with MD (V14); res being sent to (local hospital) for further eval. Intervention dated 07/08/23, documents, Encourage resident to ask for assistance when feeling weak. R2's Nurses Notes dated 07/14/23 at 11:00 AM documents, This nurse was standing at the nurse's station when (R2) literally came almost running up the hall towards the nurse's station. When (R2) got right up to the nurse's station she called for the nurse, while still almost running, and then abruptly stopped walking/running. When she stopped, she started to go forward, then went to turn and when she started to turn, she lost her balance, went down to left knee twisted herself around and sat on the floor. Advised (R2) to stay where she is while her nurse evaluated her. Able to move left and right legs straight out, pull her knees up to her chest and rotate her ankles without difficulty or c/o discomfort. Intervention dated 07/14/23, documents, Encourage (R2) to wear leg braces when getting up. R2's Nurses Notes dated 07/17/23, at 9:38 AM documents, resident found sitting on buttocks in front of wheelchair. Resident stated she was trying to pick up a towel off the floor. resident stated she did not hit her head. ROM performed x4 extremities without difficulty. Gait belt applied and resident assisted off floor back into wheelchair safely. This nurse escorted resident to her room and assisted her back to her bed safely. Nursing supervisor made aware. Intervention dated 07/17/23, documents, Encourage resident to lock wheelchair prior to leaning forward. R2's Nurses Notes dated 08/12/23 at 10:02 AM documents, Writer was informed that res had fallen out of bed and gotten herself up and laid back on the bed. Res said she tried to roll over and was on the edge of the bed, that caused her to fall and strike her back. She complains of pain to her back, a scratch is visible, the scratch is not bleeding. Writer ordered an XR to -cervical spine, dorsal spine, lumbar spine, sacrum and coccyx. Res POA has been informed. No complaints or concerns have been voiced. No intervention noted for fall on 08/12/23. R2's Nurses Notes dated 08/18/23 at 9:34 AM documents this nurse was informed by CNA that res was getting self-off the floor while CNA was entering the room, res stated that she thought she could make it to the restroom without her walker without falling, res stated that she did not use her walker because It was on the other side of the bed, res stated that she fell on her knees, res roommate witnessed the fall, res stated that she is ok and did not hurt herself, this nurse examined res, ROM WNL, res has bruising to the right knee that res stated it was old, res denies having any pain to legs at this time, will continue to monitor and update if condition changes. Res POA (V15) and sister-in-law made aware. Intervention dated 0818/23 documents Encourage resident to make sure she's using her wheeled walker when ambulating. R2's Nurses Notes dated 09/11/23 at 11:06 AM documents Aide reported to this nurse that resident had a fall. Resident stated she was throwing away a honey bun wrapper as she fell and hit her chin. Resident said she tried to get back into the bed but wasn't able to lift herself because of pain in Left knee. This nurse checked Vitals T 98.2 O2 97 RR 18 P 69 BP 137/110 and started neuro checks. Resident was provided a PRN (as needed) Narc for pain of chin and legs. Care ongoing. Intervention dated 09/11/23 documents Encourage resident not to bend forward when standing and to ask for assistance when the need is there. R2's Nurses Notes dated 10/07/23 at 11:32 AM documents Resident noted on floor in bedroom at 9:44am c/o pain 8.5/10 in right ankle. right ankle noted with bulges and swelling. right pedal pulse palpable. PRN hydrocodone administered. Vitals SPO2 95, T 99, P 94, B/P 120/62, R 22. notified NP and POA. sent resident to (local hospital) ER (emergency room) for eval. Intervention dated 10/07/23 documents Encourage resident to reach behind her to feel for surface before attempting to sit. R2's Nurses Notes dated 10/07/23 at 3:39 PM documents resident arrived at facility at 3:30pm. With diagnosis for Closed displaced fracture of medial malleolus of right tibia and closed avulsion fracture of lateral malleolus of right fibula. referral to Orthopedic Surgery @ (local hospital group) Orthopedics and Sports medicine 4700 Memorial drive Suite 300 [NAME]. Orders to make appointment on Monday for a F/U (follow up). R2's Fall investigation dated 10/07/23 documents Resident was found by staff on floor in room. This nurse went over to her and ask what happened. Resident stated that her right ankle gave out while she was walking in her room. Right ankle noted with swelling and bulges around right ankle. Vitals SpO2 95, T 99, B/P 120/62, R 22. Resident was in extreme pain 8.5/10. PRN hydrocodone given right pedal pulse present. Resident unable to give description. Resident was taken to the hospital for extreme pain and suspected fracture or dislocation of right ankle. IDT (Interdisciplinary Team) meeting to discuss fall from 10/07/23. Resident alert and oriented x4. BIMS 14. Resident requires no physical assist with ADLs (activities of daily living) and transfers. Resident is continent of bowel and bladder. RCA: Walked to bed and turned to sit and sit to close to edge of bed and slid off onto floor. All previous fall interventions in place adding encourage resident to reach back with hands and feel before sitting that she's close enough. All parties agree with plan of care. Care plan reviewed and updated. On 11/21/23 at 11:05 AM, R2 observed sitting in her wheelchair in room which is located at the opposite end of the hall from the nurses' station. On 11/22/23 at 10:00 AM, V5, Care Plan Coordinator stated that R2 has interventions for all of her falls except for the falls on 07/03/23 and 08/12/23. On 11/28/23 at 10:15 am, V2, DON (Director of Nursing) stated that she would expect a resident to have an intervention put in place after every fall. She stated that she would expect a resident that has had multiple falls to be supervised closer and moved closer to the nurses' station. Facility policy Fall Prevention and Management dated 09/2022 documents, This facility is committed to maximizing each resident's physical, mental and psychosocial well- being. While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventive strategies, and facilitate as safe an environment as possible. All resident falls shall be reviewed, and the resident's existing plan of care shall be evaluated and modified as needed. 4. Care plan to be updated with a new intervention based on root cause analysis after each fall occurrence.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to assure bed rails were securely attached to the bed frame to maintain resident safety for 3 of 5 residents (R4, R7, R8) reviewed for resident safety in the sample of 16. This failure resulted in R4's bed rail falling off and R4 sustaining a fall out of bed with multiple facial fractures and being hospitalized . Findings include: 1. R4's admission Record, undated, documents R4 was admitted to the facility on [DATE] and was discharged to the hospital on 6/29/23. R4's Electronic Medical Record documents R4's Diagnosis include Emphysema, Morbid Obesity, Type 2 Diabetes Mellitus, (DM), Chronic Respiratory Failure, Chronic Obstructive Pulmonary Disease, (COPD), Osteoarthritis, Intestinal obstruction, Cognitive Communication Deficit, Dysphagia, Major Depressive Disorder, End Stage Renal Disease (ESRD)/chronic kidney disease, (CKD), Renal Dialysis, Malignant Neoplasm of Rectum, Fibromyalgia, Mixed incontinence, Hypertension, (HTN), and Hyperlipidemia. R4's Baseline Care Plan, dated 6/28/23, documents, (R4) is at risk for falls. Interventions: call light within reach, provide clutter-free environment, encourage use of assistive device, provide proper, well-maintained footwear. R4's Care Plan, dated 6/30/23, documents, entered 7/7/23: (R4) is at risk for falls related to, impaired mobility, poor safety awareness and DX, (diagnosis): DM II, Osteoarthritis, and HTN. Interventions: 6/29/23 Facility side rail audit completed. Educate resident on using call light to ask for help, encourage appropriate use of assistive device, evaluate multiple falls to determine commonalities or patterns, fall risk assessment quarterly and as needed, keep frequently used items within reach, promote placement of call light within reach and assess resident's ability to use, provide proper, well-maintained footwear. R4's Minimum Data Set, (MDS), dated [DATE], documents, R4 was cognitively intact with a Basic Interview for Mental Status, (BIMS), of 14. R4 required extensive assistance of one staff person for bed mobility, toilet use, transfers, and locomotion. R4 was occasionally incontinent of urine and has a colostomy. R4's Fall Risk Evaluation, dated 6/27/23 at 4:54 PM, documents, R4 was a High Risk for falls with a score of 11. Scoring a 10 or higher makes resident High Risk for Falls. R4's Nurses Note, dated 6/29/23 at 5:24 AM, documents Staff completed rounds this nurse and CNA, (Certified Nursing Assistant), were in hallway and heard resident yelling for help. Upon entering room res, (resident), found lying face first on the floor on top of her right-side rail. Res stated, I tried to roll over in bed. Res complaining of bilat, (bilateral), hip pain and has small abrasion to middle of forehead. Res made comfortable until EMS, (Emergency Medical Service), arrived. Res assisted from floor to stretcher via, (full body mechanical lift). Call placed to responsible party (V12) -no answer, voicemail left to call facility at earliest convenience. Call placed to Dr., (doctor), (V16) - voicemail left. Nurse manager made aware. Res alert and oriented, able to make needs known, continues on 3 L, (liters), 02, (oxygen). Transferred to (Local Hospital), ER, (Emergency Room), for treatment and eval. VS, (vital signs), as follows 170/78-98-18-92%. R4's Nurses Note, dated 6/29/23 at 8:57 AM, documents, This nurse called for update on resident spoke with ER Nurse who is currently taking care of resident and was told resident has several fractures to whole face and currently awaiting results from CT, (cat scan), full body scan and will be transferred to, (Regional Hospital), for further evaluation and treatment. All parties notified. On 7/10/23 at 9:00 AM, R5 (R4's Roommate) stated, The nurse had just come in that night to check on us and shortly after she left, I heard a big bang and it sounded like the bedrail fell off, then I heard (R4) yelling for help. I couldn't see anything because of the wall between us. I heard the staff tell the ambulance guys that the bed rail fell off the bed. They were going to put another resident in that bed but, that resident wanted a warmer room, so they switched to a different room. I don't think they should use that bed until it is fixed. On 7/10/23 at 9:05 AM, room [ROOM NUMBER]-1, R4's bed, is currently empty. The bed appears to be an older bed with an air mattress on the bed frame. There is only one side rail on the left-side of the bed, (while lying in the bed), which is a metal rail with seven metal bars vertical on the rail. The bed rail is only secured by a black hand-turn knob that secures it to the bed by tightening it to the bedframe. The right-side bed rail is not on the bed. On 7/10/23 at 9:20 AM, V9, Maintenance Director, stated, If there is something that needs fixed in the facility, the staff can put it into the computer system and that will make a work order for me to do. I will usually send (V10, Maintenance Worker) to fix it. I don't recall any requests for bed rails to be fixed. We have a group text that sometimes, they use to put in a request for something to be fixed, but I don't see anything in the group text about bed rails. I did have a request on 6/21/23, to remove the bed from 110-1 to room [ROOM NUMBER], so that was done. I never know why; I just do what the work order says. We do inspections every week to all beds in the facility. We look at the power to the bed, the bed deflate/inflate as needed, and the bed rails to make sure they are secured. I don't really have a record of those inspections except for my last one on 6/29/23 after (R4) fell. On 7/10/23 at 9:25 AM, V10, Maintenance Worker, stated, There are a lot of times that the staff will catch me in the hallway and ask us to fix something and a work order isn't really done, we just go in and do it. I remember someone grabbed me one day and said that room [ROOM NUMBER]-1 needed a new bed rail for the resident to use as a support rail for turning. I made sure that the rails were secured to the bed before I left. I guess the only way a bed rail would fall off is if it wasn't put on properly or sometimes the resident uses it so much that it becomes loose. On 7/10/23 at 11:42 AM, V11, Social Worker at (Regional Hospital), stated, I'm the Social Worker helping (R4) and her husband at the hospital. They did not want to report it themselves because they felt they would have backlash. What they told me was that (R4) was admitted to the facility and immediately upon admission to her bed, she told the staff that her bed rail was loose and wiggly. They stated that they made it very clear to several staff members that it needed fixed, and no one did anything about it. (R4) stated, that while she was trying to reposition in bed, the bed rail fell off and she fell to the floor. (R4) is still in the ICU with multiple facial fractures and they are refusing to go back to that facility. On 7/10/23 at 11:49 AM, V12, R4's Husband, stated My wife (R4) got to the facility and upon putting her in her bed, she noticed that her bed rail was very loose and wiggly. She told and showed them how loose it was, and no one did anything to fix it. She was only there about a day or so, and I believe it was the nurse who called me around 4:00 AM and told me that my wife's bed rail fell off and she fell out of bed and was going to (Regional Hospital). They x-rayed just about everything, and it looks like she only has facial fractures. (R4) said it was the nurse who was working with her upon admission that she talked to about the bed rail. I went into the facility after she fell to collect all her belongings, and when I got to her room, they still had the same bed there with the rail sitting on the bed. I got down on the floor to look at how the rails are attached to the bed, and it is only attached by a hand knob that you hand tighten. All anyone had to do was to tighten the black knob and my wife would not be in this condition. Anyone could have done that. Their negligence is why my wife is like she is now. On 7/10/23 at 12:52 PM, V13, RN (Registered Nurse), stated, I was the one who admitted (R4). I am new to the facility and remember that I was very focused on the computer and my documentation. I vaguely remember someone in the room saying something about a bed rail, but without making something up or lying about it, that is about all I remember. When I came back to work, I heard that she fell out of bed. On 7/10/23 at 1:05 PM, room [ROOM NUMBER]-1's bed is empty, made up and ready for a new resident. The bed appears to have the same bed rails as R4's bed. Upon examination of the bed rails, both side rails have the same black hand turn knob that attaches it to the bed frame, and when examined, both knobs were loose and easily turned. On 7/12/23 at 10:45 AM, V20, CNA Supervisor, stated, I told the nurse the day before she fell that (R4) was leaning on that bed rail. The facility's Fall Investigation dated 6/29/23 at 4:45 AM, documents, Incident Description: Staff completed rounds at 4:45 AM, resident repositioned in bed and peri-care completed. This nurse and CNA, (Certified Nursing Assistant), were in hallway and heard a loud noise, heard resident screaming for help. Upon entering room, resident was laying face first on the floor on top of side rail. Resident has small abrasion to forehead and complaining of bilat hip pain. Resident stated, I was trying to turn over in bed. Predisposing Environmental Factors: Safety Device. Predisposing Situation Factors: Side Rails Up. The Facility's Sentinel Call Worksheet dated 6/29/23 at 9:30 AM, documents, the date of incident: 6/29/23, the time of incident: 5:15 AM, the location: Resident's Room. What occurred: Resident Rolled out of bed and rail came off. How it Occurred: The Railing came off the bed. Staff training - immediate needs? The whole house side rail audit was done. The Facility's Post Fall Huddle, dated 6/29/23 at 5:15 AM, documents, What did the resident say he/she was trying to do just before the fall? Rolled over. What appears to be the initial root cause of the fall? Rolled out of bed. Side rail off. Conclusion: Resident rolled out of bed. The Facility's Follow-Up Investigation Report, dated 7/6/23, documents R4 has frontal sinus facial fracture, mildly compressed skull fx, (fracture), with possible subdural hematoma. Interview of alleged victim: Resident (R4) reported she rolled out of bed repositioning herself. Medical record review: Resident is alert and oriented X 3 and was able to make all needs known. Transfer status assist of X 2 for ADLs (Activities of Daily Living) and transfers. Resident is continent of bowel and bladder. Conclusion page: Unsubstantiated. Conclusion: Following a complete and thorough review including interviews and resident record, this occurrence was determined to be unavoidable. Root cause analysis: Resident attempted to turn and reposition without assistance and fell off the bed onto the floor. This allegation cannot be substantiated. (Completed by V2, Director of Nursing/DON) The Facility's Side Rail Audit, completed by V9, dated 6/29/23, documents room [ROOM NUMBER]-1 Bed 1 empty bed with BW, (black and white), rail regular, Bed 2 hospital bed. R4's (Local Hospital) emergency room record, dated 6/29/23, documents Pt., (patient), arrives in ED, (Emergency Department), via EMS from, (Facility), SNF, (Skilled Nursing Facility), c/o, (complaint of), bilateral hip pain s/p, (status post), fall. Pt. AO, (alert and oriented), X 4 and in NAD, (no added distress). Per EMS pt was being moved or turned at SNF and one of the bed rails gave way and she fell from the bed to the floor. A CT, (cat scan), of R4's Cervical Spine, Thoracic and Lumbar Spine, Abdomen/Pelvis, Facial Bones, and Head were completed with R4's CT Results: Mildly depressed fracture of the left frontal bone involving the left frontal sinus. Subtle increased density along the left anterior cranial fossa deep to the site of fracture. This is non-specific for a tiny subdural hemorrhage. R4 was transferred to, (Regional Hospital), Geriatric Trauma Team. R4's (Regional Hospital) emergency room record, dated 6/29/23, documents, Female transfer from, (Local Hospital), following fall. Per EMS, pt. was being turned by staff at facility when the side railing of her bed broke off and pt. fell out of bed flat onto her front side. OSH (outside hospital) imaging showed several facial fx, (fractures), as well as possible underlying SDH, (subdural hematoma/hemorrhage). 2. R7's admission Record, undated, documents R7 was admitted to the facility on [DATE]. R7's Electronic Medical Record, documents R7's Diagnosis include Cerebrovascular Accident, (CVA), Hemiplegia/Hemiparesis, Dysphagia, Morbid Obesity, DM, Visuospatial Deficit, Frontal lobe and Executive function deficit, Cognitive social or emotional deficit, Attention and concentration deficit, Anemia, ESRD/CKD, Dialysis, Anxiety disorder, HTN, Hyperlipidemia. R7's Care Plan, dated 6/6/23, documents, (R7) requires healthcare monitoring related to DX: CVA with Hemiparesis. She is at risk for impaired mobility and impaired communication related to effects of hemisphere damage on language or speech. It continues (R7) is at high risk for falls r/t, (related to), weakness d/t, (due to), hx, (history), /dx of CVA with hemiplegia, Dysphagia, Morbid Obesity, DM, CCD, (cognitive communication deficit), Osteomyelitis, Anxiety, HTN, Hyperlipidemia, ESRD and Anemia. Resident is an extensive assistance of two staff members for bed mobility. Resident is a total assistance of two staff members for toileting and transfers. Resident has weakness present. Resident utilizes Geri-chair. Interventions: 6/5/21 Bed moved against wall, fall mats placed by bed, fall risk assessment quarterly and as needed, promote placement of call light within reach and assess resident's ability to use. It continues (R7) has a self-care deficit in bed mobility r/t weakness and decreased mobility. Interventions: 2. Instruct and assist to cross leg over other towards the side turning to. 3.instruct to look towards the rail of the side turning to. 4.instuct to roll shoulders toward the side turning to. 5.Instruct to reach/grasp for rail of side turning to. 6. Instruct and assist to pull self toward side turning to. It continues (R7) requires assist with daily care needs r/t weakness d/t hx/dx of CVA with hemi, Dysphagia, Morbid Obesity, DM, CCD, Osteomyelitis, Anxiety, HTN, Hyperlipidemia, ESRD and Anemia. Resident is an extensive assistance of two staff members for bed mobility. Resident is a total assistance of two staff members for toileting and transfers. Resident has a (urinary catheter) and functional incontinence of bowel. Resident has a G (gastric)-tube present is NPO, (nothing by mouth). Resident is a total assistance of one staff member for meals. Resident has weakness present. Resident utilizes Geri-chair. She utilizes 1/2 side rails up X 2 to enhance mobility and transfer. Interventions: (full body mechanical lift), with two assists for transfers. R7's MDS, dated [DATE], documents, R7 has a moderate cognitive impairment with a BIMS of 12. R7 requires total dependence on two staff members for transfers, toilet use, and bathing. R7 requires extensive assistance from one to two staff members for all other ADLs. R7 is always incontinent of urine and frequently incontinent of bowel. R7's Physician Order, dated 7/10/23, documents, 1/2 Side rails up X 2 to enhance mobility and transfer. R7's Fall Risk Evaluation, dated 9/15/22, documents, R7 was a High Risk for falls with a score of 11. Scoring a 10 or higher makes resident High Risk for falls. On 7/10/23 at 1:38 PM, R7 was seen sitting in a recliner chair by her bed. R7 has the same bed rails as R4's bed had, and upon examination, the black hand turn knob on the right-side rail was loose and easily turned. The left side rail was against the wall and could not be examined. R7 stated that her rail is a little wobbly but has never fallen off. 3. R8's admission Record, undated, documents R8 was admitted to the facility on [DATE]. R8's Electronic Medical Record, documents, R8's diagnosis include: CVA, Hemiplegia/Hemiparesis, Acute/Chronic Respiratory Failure, Type 2 DM, Aphasia, Dysphagia, Anemia, ESRD/CKD, Gastrostomy, HTN, Deep Vein Thrombosis, (DVT), and Dependence on Renal Dialysis. R8's Care Plan, dated 4/18/23, documents (R8) is at risk for developing an impairment in functional joint mobility/ (R8) has impaired functional mobility/ (R8) has contractures noted to (specify), r/t: weakness/ discomfort when moving/ spasm of affected area/ poor motivation/ inactivity resulting from impaired cognition/ inactivity resulting from (specify)/ neurological deficit. R8's MDS, dated [DATE], documents, R8 has a severe cognitive impairment and requires total dependence for all his ADLs. R8 is always incontinent of both bowel and bladder. R8's Fall Risk Evaluation, dated 6/27/23, documents, R8 is a High Fall Risk with a score of 13. Scoring a 10 or higher makes resident High Risk for falls. On 7/10/23 at 1:35 PM, R8 was seen lying in his bed with the same bed rails as R4's bed. Upon examination of the rails, both side rails had the black hand turn knob which was loose and easily turned. The rails appeared to be wobbly. R8 was not able to communicate. On 7/11/23 at 12:00 PM, V17, Regional Director of Operations, stated, I went and looked at the rooms you mentioned that had loose bed rails and I only found one of them, in room [ROOM NUMBER]-2 (R8's bed), that was loose. Someone must have tightened the other two. I have our maintenance guys going room to room and tightening all the bed rails. On 7/13/23 at 8:55 AM, V1, Administrator, stated, Anytime a staff member is notified or sees something that is broke, or in need of repair, I would expect them to report it to maintenance immediately. I would expect maintenance to make the repair as soon as possible. The Facility's Use of Bed Rail Policy, dated 10/2022, documents, It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails. Appropriate alternative approaches are attempted prior to installing or using bed rails. If bed rails are used, the facility ensures correct installation, use, and maintenance of the rails. Bed Rails are adjustable metal or rigid plastic bars that attach to the bed. They are available in a variety of types, shapes, and sizes ranging from full to one-half, one-quarter, or one-eighth lengths. Also, some bed rails are not designed as part of the bed by the manufacturer and may be installed on or used along the side of a bed. Examples of bed rails include, but are not limited to side rails, bed side rails, safety rails, grab bars and assist bars. 6. The facility will assure the correct installation and maintenance of bed rails, prior to use. This includes a. Checking with the manufacturer(s) to make sure the bed rails, mattress, and bed frame are compatible. b. Ensuring that the bed's dimensions are appropriate for the resident by: i. Confirming that the bed rails are appropriate for the size and weight of the resident using the bed; ii. Installing bed rails using the manufacturer's instructions and specifications to ensure a proper fit; iii. Inspecting and regularly checking the mattress and bed rails for areas of possible entrapment; iv. Ensuring the bed frame, bed rail and mattress do not leave a gap wide enough to entrap a resident's head or body, regardless of mattress width, length, and/or depth. v. Checking bed rails regularly to make sure they are still installed correctly and have not shifted or loosened over time. c. Conducting routine preventative maintenance of beds and bed rails to ensure they meet current safety standards and are not in need of repair. 8. Responsibilities of ongoing monitoring and supervision are specified as follows: d. The maintenance director, or designee, is responsible for adhering to a routine maintenance and inspection schedule for all bed frames, mattresses, and bed rails. The Facility's Fall Prevention and Management Policy, dated 9/2022, documents, This facility is committed to maximizing each resident's physical, mental and psychosocial well- being. While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventive strategies, and facilitate as safe an environment as possible. All resident falls shall be reviewed, and the resident's existing plan of care shall be evaluated and modified as needed. 1. A fall risk evaluation will be completed on admission, readmission, and quarterly, significant change and after each fall. 2. Residents at risk for falls will have fall risk identified on the interim plan of care and the ISP with interventions implemented to minimize fall risk.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to assure bed rails were securely attached to the bed frame to maintain resident safety for 3 of 5 residents (R4, R7, R8) reviewed for residents' safe environment in the sample of 16. This failure resulted in R4's bed rail falling off, R4 sustaining a fall out of bed and requiring hospitalization with multiple facial fractures. Findings include: 1. R4's admission Record, undated, documents R4 was admitted to the facility on [DATE] and was discharged to the hospital on 6/29/23. R4's Electronic Medical Record documents R4's Diagnosis include Emphysema, Morbid Obesity, Type 2 Diabetes Mellitus, (DM), Chronic Respiratory Failure, Chronic Obstructive Pulmonary Disease, (COPD), Osteoarthritis, Intestinal obstruction, Cognitive Communication Deficit, Dysphagia, Major Depressive Disorder, End Stage Renal Disease (ESRD)/chronic kidney disease, (CKD), Renal Dialysis, Malignant Neoplasm of Rectum, Fibromyalgia, Mixed incontinence, Hypertension, (HTN), and Hyperlipidemia. R4's Baseline Care Plan, dated 6/28/23, documents (R4) is at risk for falls. Interventions: call light within reach, provide clutter-free environment, encourage use of assistive device, provide proper, well-maintained footwear. R4's Care Plan, dated 6/30/23, documents Entered 7/7/23: (R4) is at risk for falls related to impaired mobility, poor safety awareness and DX, (diagnosis): DM II, Osteoarthritis, and HTN. Interventions: 6/29/23 Facility side rail audit completed. Educate resident on using call light to ask for help, encourage appropriate use of assistive device, evaluate multiple falls to determine commonalities or patterns, fall risk assessment quarterly and as needed, keep frequently used items within reach, promote placement of call light within reach and assess resident's ability to use, provide proper, well-maintained footwear. R4's Minimum Data Set, (MDS), dated [DATE], documents R4 was cognitively intact with a Basic Interview for Mental Status, (BIMS), of 14. R4 required extensive assistance of one staff person for bed mobility, toilet use, transfers, and locomotion. R4 was occasionally incontinent of urine and has a colostomy. R4's Fall Risk Evaluation, dated 6/27/23 at 4:54 PM, documents, R4 was a High Risk for falls with a score of 11. Scoring a 10 or higher makes resident High Risk for Falls. R4's Nurses Note, dated 6/29/23 at 5:24 AM, documents Staff completed rounds this nurse and CNA, (Certified Nursing Assistant), were in hallway and heard resident yelling for help. Upon entering room res, (resident), found lying face first on the floor on top of her right-side rail. Res stated, I tried to roll over in bed. Res complaining of bilat (bilateral) hip pain and has small abrasion to middle of forehead. Res made comfortable until EMS, (Emergency Medical Service), arrived. Res assisted from floor to stretcher via (full body mechanical lift). Call placed to responsible party (V12) -no answer, voicemail left to call facility at earliest convenience. Call placed to Dr., (Doctor), (V16) - voicemail left. Nurse manager made aware. Res alert and oriented, able to make needs known, continues on 3 L, (liters), 02, (oxygen). Transferred to (Local Hospital), ER, (Emergency Room), for treatment and eval. VS, (vital signs), as follows 170/78-98-18-92%. R4's Nurses Note, dated 6/29/23 at 8:57 AM, documents, This nurse called for update on resident spoke with ER Nurse who is currently taking care of resident and was told resident has several fractures to whole face and currently awaiting results from CT, (cat scan), full body scan and will be transferred to (Regional Hospital), for further evaluation and treatment. All parties notified. On 7/10/23 at 9:00 AM, R5 (R4's Roommate) stated, The nurse had just come in that night to check on us and shortly after she left, I heard a big bang and it sounded like the bedrail fell off, then I heard (R4) yelling for help. I couldn't see anything because, of the wall between us. I heard the staff tell the ambulance guys that the bed rail fell off the bed. They were going to put another resident in that bed but, that resident wanted a warmer room, so they switched to a different room. I don't think they should use that bed until it is fixed. On 7/10/23 at 9:05 AM, room [ROOM NUMBER]-1, R4's bed, is currently empty. The bed appears to be an older bed with an air mattress on the bed frame. There is only one side rail on the left-side of the bed (while lying in the bed), which is a metal rail with seven metal bars vertical on the rail. The bed rail is only secured by a black hand-turn knob that secures it to the bed by tightening it to the bedframe. The right-side bed rail is not on the bed. On 7/10/23 at 9:20 AM, V9, Maintenance Director, stated, If there is something that needs fixed in the facility, the staff can put it into the computer system and that will make a work order for me to do. I will usually send (V10, Maintenance Worker) to fix it. I don't recall any requests for bed rails to be fixed. We have a group text that sometimes they use to put in a request for something to be fixed, but I don't see anything in the group text about bed rails. I did have a request on 6/21/23, to remove the bed from 110-1 to room [ROOM NUMBER], so that was done. I never know why; I just do what the work order says. We do inspections every week to all beds in the facility. We look at the power to the bed, the bed deflate/inflate as needed, and the bed rails to make sure they are secured. I don't really have a record of those inspections except for my last one on 6/29/23 after (R4) fell. On 7/10/23 at 9:25 AM, V10, Maintenance Worker, stated, There are a lot of times that the staff will catch me in the hallway and ask us to fix something and a work order isn't really done, we just go in and do it. I remember someone grabbed me one day and said that room [ROOM NUMBER]-1 needed a new bed rail for the resident to use as a support rail for turning. I made sure that the rails were secured to the bed before I left. I guess the only way a bed rail would fall off is if it wasn't put on properly or sometimes the resident uses it so much that it becomes loose. On 7/10/23 at 11:42 AM, V11, Social Worker at (Regional Hospital), stated I'm the Social Worker helping (R4) and her husband at the hospital. They did not want to report it themselves because they felt they would have backlash. What they told me was that (R4) was admitted to the facility and immediately upon admission to her bed, she told the staff that her bed rail was loose and wiggly. They stated that they made it very clear to several staff members that it needed fixed, and no one did anything about it. (R4) stated that while she was trying to reposition in bed, the bed rail fell off and she fell to the floor. (R4) is still in the ICU with multiple facial fractures and they are refusing to go back to that facility. On 7/10/23 at 11:49 AM, V12, R4's Husband, stated, My wife (R4) got to the facility and upon putting her in her bed, she noticed that her bed rail was very loose and wiggly. She told and showed them how loose it was, and no one did anything to fix it. She was only there about a day or so, and I believe it was the nurse who called me around 4:00 AM and told me that my wife's bed rail fell off and she fell out of bed and was going to (Regional Hospital). They x-rayed just about everything, and it looks like she only has facial fractures. (R4) said it was the nurse who was working with her upon admission that she talked to about the bed rail. I went into the facility after she fell to collect all her belongings, and when I got to her room, they still had the same bed there with the rail sitting on the bed. I got down on the floor to look at how the rails are attached to the bed, and it is only attached by a hand knob that you hand tighten. All anyone had to do was to tighten the black knob and my wife would not be in this condition. Anyone could have done that. Their negligence is why my wife is like she is now. On 7/10/23 at 12:52 PM, V13, RN, (Registered Nurse), stated, I was the one who admitted (R4). I am new to the facility and remember that I was very focused on the computer and my documentation. I vaguely remember someone in the room saying something about a bed rail, but without making something up or lying about it, that is about all I remember. When I came back to work, I heard that she fell out of bed. On 7/10/23 at 1:05 PM, room [ROOM NUMBER]-1's bed is empty, made up and ready for a new resident. The bed appears to have the same bed rails as R4's bed. Upon examination of the bed rails, both side rails have the same black hand turn knob that attaches it to the bed frame, and when examined, both knobs were loose and easily turned. On 7/12/23 at 10:45 AM, V20, CNA Supervisor, stated, I told the nurse the day before she fell that (R4) was leaning on that bed rail. The facility's Fall Investigation dated 6/29/23 at 4:45 AM, documents, Incident Description: Staff completed rounds at 4:45 AM, resident repositioned in bed and peri-care completed. This nurse and CNA, (Certified Nursing Assistant), were in hallway and heard a loud noise, heard resident screaming for help. Upon entering room, resident was laying face first on the floor on top of side rail. Resident has small abrasion to forehead and complaining of bilat hip pain. Resident stated, I was trying to turn over in bed. Predisposing Environmental Factors: Safety Device. Predisposing Situation Factors: Side Rails Up. The Facility's Sentinel Call Worksheet dated 6/29/23 at 9:30 AM, documents, the date of incident: 6/29/23, the time of incident: 5:15 AM, the location: Resident's Room. What occurred: Resident Rolled out of bed and rail came off. How it Occurred: The Railing came off the bed. Staff training - immediate needs? The whole house side rail audit was done. The Facility's Post Fall Huddle, dated 6/29/23 at 5:15 AM, documents What did the resident say he/she was trying to do just before the fall? Rolled over. What appears to be the initial root cause of the fall? Rolled out of bed. Side rail off. Conclusion: Resident rolled out of bed. The Facility's Follow-Up Investigation Report, dated 7/6/23, documents, R4 has frontal sinus facial fracture, mildly compressed skull fx, (fracture), with possible subdural hematoma. Interview of alleged victim: Resident (R4) reported she rolled out of bed repositioning herself. Medical record review: Resident is alert and oriented X 3 and was able to make all needs known. Transfer status assist of X 2 for ADLs, (Activities of Daily Living), and transfers. Resident is continent of bowel and bladder. Conclusion page: Unsubstantiated. Conclusion: Following a complete and thorough review including interviews and resident record, this occurrence was determined to be unavoidable. Root cause analysis: Resident attempted to turn and reposition without assistance and fell off the bed onto the floor. This allegation cannot be substantiated. (Completed by V2, Director of Nursing/DON) The Facility's Side Rail Audit, completed by V9, dated 6/29/23, documents room [ROOM NUMBER]-1, Bed 1 empty bed with BW, (black and white), rail regular, Bed 2 hospital bed. R4's (Local Hospital), emergency room record, dated 6/29/23, documents Pt. (patient) arrives in ED, (Emergency Department), via EMS from (Facility) SNF, (Skilled Nursing Facility), c/o, (complaint of), bilateral hip pain s/p, (status post), fall. Pt. AO, (alert and oriented), X 4 and in NAD, (no added distress). Per EMS pt was being moved or turned at SNF and one of the bed rails gave way and she fell from the bed to the floor. A CT, (cat scan), of R4's Cervical Spine, Thoracic and Lumbar Spine, Abdomen/Pelvis, Facial Bones, and Head were completed with R4's CT Results: Mildly depressed fracture of the left frontal bone involving the left frontal sinus. Subtle increased density along the left anterior cranial fossa deep to the site of fracture. This is non-specific for a tiny subdural hemorrhage. R4 was transferred to (Regional Hospital), Geriatric Trauma Team. R4's (Regional Hospital) emergency room record, dated 6/29/23, documents Female transfer from (Local Hospital), following fall. Per EMS, pt. was being turned by staff at facility when the side railing of her bed broke off and pt. fell out of bed flat onto her front side. OSH, (outside hospital), imaging showed several facial fx, (fractures), as well as possible underlying SDH, (subdural hematoma/hemorrhage). 2. R7's admission Record, undated, documents R7 was admitted to the facility on [DATE]. R7's Electronic Medical Record, documents R7's Diagnosis include: Cerebrovascular Accident, (CVA), Hemiplegia/Hemiparesis, Dysphagia, Morbid Obesity, DM, Visuospatial Deficit, Frontal lobe and Executive function deficit, Cognitive social or emotional deficit, Attention and concentration deficit, Anemia, ESRD/CKD, Dialysis, Anxiety disorder, HTN, Hyperlipidemia. R7's Care Plan, dated 6/6/23, documents (R7) requires healthcare monitoring related to DX: CVA with Hemiparesis. She is at risk for impaired mobility and impaired communication related to effects of hemisphere damage on language or speech. It continues (R7) is at high risk for falls r/t, (related to), weakness d/t, (due to), hx, (history), /dx of CVA with hemiplegia, Dysphagia, Morbid Obesity, DM, CCD, (cognitive communication deficit), Osteomyelitis, Anxiety, HTN, Hyperlipidemia, ESRD and Anemia. Resident is an extensive assistance of two staff members for bed mobility. Resident is a total assistance of two staff members for toileting and transfers. Resident has weakness present. Resident utilizes Geri-chair. Interventions: 6/5/21 Bed moved against wall, fall mats placed by bed, fall risk assessment quarterly and as needed, promote placement of call light within reach and assess resident's ability to use. It continues (R7) has a self-care deficit in bed mobility r/t weakness and decreased mobility. Interventions: 2. Instruct and assist to cross leg over other towards the side turning to. 3.instruct to look towards the rail of the side turning to. 4.instuct to roll shoulders toward the side turning to. 5.Instruct to reach/grasp for rail of side turning to.6. Instruct and assist to pull self toward side turning to. It continues (R7) requires assist with daily care needs r/t weakness d/t hx/dx of CVA with hemi, Dysphagia, Morbid Obesity, DM, CCD, Osteomyelitis, Anxiety, HTN, Hyperlipidemia, ESRD and Anemia. Resident is an extensive assistance of two staff members for bed mobility. Resident is a total assistance of two staff members for toileting and transfers. Resident has a (urinary catheter), and functional incontinence of bowel. Resident has a G, (gastric)-tube present is NPO, (nothing by mouth). Resident is a total assistance of one staff member for meals. Resident has weakness present. Resident utilizes Geri-chair. She utilizes 1/2 side rails up X 2 to enhance mobility and transfer. Interventions: (full body mechanical lift), with two assists for transfers. R7's MDS, dated [DATE], documents R7 has a moderate cognitive impairment with a BIMS of 12. R7 requires total dependence on two staff members for transfers, toilet use, and bathing. R7 requires extensive assistance from one to two staff members for all other ADLs. R7 is always incontinent of urine and frequently incontinent of bowel. R7's Physician Order, dated 7/10/23, documents 1/2 Side rails up X 2 to enhance mobility and transfer. R7's Fall Risk Evaluation, dated 9/15/22, documents R7 was a High Risk for falls with a score of 11. Scoring a 10 or higher makes resident High Risk for falls. On 7/10/23 at 1:38 PM, R7 was seen sitting in a recliner chair by her bed. R7 has the same bed rails as R4's bed had, and upon examination, the black hand turn knob on the right-side rail was loose and easily turned. The left side rail was against the wall and could not be examined. R7 stated that her rail is a little wobbly. 3. R8's admission Record, undated, documents R8 was admitted to the facility on [DATE]. R8's Electronic Medical Record, documents R8's diagnosis include: CVA, Hemiplegia/Hemiparesis, Acute/Chronic Respiratory Failure, Type 2 DM, Aphasia, Dysphagia, Anemia, ESRD/CKD, Gastrostomy, HTN, Deep Vein Thrombosis, (DVT), and Dependence on Renal Dialysis. R8's Care Plan, dated 4/18/23, documents (R8) is at risk for developing an impairment in functional joint mobility/ (R8) has impaired functional mobility/ (R8) has contractures noted to (specify) r/t: weakness/ discomfort when moving/ spasm of affected area/ poor motivation/ inactivity resulting from impaired cognition/ inactivity resulting from (specify)/ neurological deficit. R8's MDS, dated [DATE], documents R8 has a severe cognitive impairment and requires total dependence for all his ADLs. R8 is always incontinent of both bowel and bladder. R8's Fall Risk Evaluation, dated 6/27/23, documents R8 is a High Fall Risk with a score of 13. Scoring a 10 or higher makes resident High Risk for falls. On 7/10/23 at 1:35 PM, R8 was seen lying in his bed with the same bed rails as R4's bed. Upon examination of the rails, both side rails had the black hand turn knob which was loose and easily turned. The rails appeared to be wobbly. R8 was not able to communicate. On 7/11/23 at 12:00 PM, V17, Regional Director of Operations, stated I went and looked at the three rooms you mentioned that had loose bed rails and I only found one of them, in room [ROOM NUMBER]-2 (R8's bed), that was loose. Someone must have tightened the other two. I have our maintenance guys going room to room and tightening all the bed rails. On 7/13/23 at 8:55 AM, V1, Administrator, stated Anytime a staff member is notified or sees something that is broke or in need of repair, I would expect them to report it to maintenance immediately. I would expect maintenance to make the repair as soon as possible. The Facility's Use of Bed Rail Policy, dated 10/2022, documents It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails. Appropriate alternative approaches are attempted prior to installing or using bed rails. If bed rails are used, the facility ensures correct installation, use, and maintenance of the rails. Bed Rails are adjustable metal or rigid plastic bars that attach to the bed. They are available in a variety of types, shapes, and sizes ranging from full to one-half, one-quarter, or one-eighth lengths. Also, some bed rails are not designed as part of the bed by the manufacturer and may be installed on or used along the side of a bed. Examples of bed rails include, but are not limited to side rails, bed side rails, safety rails, grab bars and assist bars. 6. The facility will assure the correct installation and maintenance of bed rails, prior to use. This includes a. Checking with the manufacturer(s) to make sure the bed rails, mattress, and bed frame are compatible. b. Ensuring that the bed's dimensions are appropriate for the resident by: i. Confirming that the bed rails are appropriate for the size and weight of the resident using the bed; ii. Installing bed rails using the manufacturer's instructions and specifications to ensure a proper fit; iii. Inspecting and regularly checking the mattress and bed rails for areas of possible entrapment; iv. Ensuring the bed frame, bed rail and mattress do not leave a gap wide enough to entrap a resident's head or body, regardless of mattress width, length, and/or depth. v. Checking bed rails regularly to make sure they are still installed correctly and have not shifted or loosened over time. c. Conducting routine preventative maintenance of beds and bed rails to ensure they meet current safety standards and are not in need of repair. 8. Responsibilities of ongoing monitoring and supervision are specified as follows: d. The maintenance director, or designee, is responsible for adhering to a routine maintenance and inspection schedule for all bed frames, mattresses, and bed rails.

Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure adequate hydration for 1 of 4 residents (R3) reviewed for hydration in the sample of 10. This failure resulted in R3 being admitted to the hospital with severe dehydration. Findings include: R3's Face Sheet, undated, documents R3 was admitted to the facility on [DATE] with a diagnosis of Diabetes Mellitus, Gangrene, Kidney Disease, Non-Pressure Chronic Ulcer of the Left Lower Extremity, Right Below the Knee Amputation, Hypothyroidism and Other Symptoms Concerning Food and Fluid Intake. R3's Minimum Data Set (MDS), dated [DATE], documents R3 had moderate cognitive impairment and required supervision with eating. R3's Dehydration Risk Assessment, dated 9/28/22, documents R3 is at risk of dehydration. R3's Progress Notes, document the following: 1/11/2023 at 10:00 AM, Resident refused breakfast this am, writer offered to get resident something different from the kitchen, resident declined stating I just don't have an appetite. V10, R3's Sister has been informed, no complaints or concerns have been voiced. 1/11/2023 at 1:04 PM, Resident is alert and oriented times 3. Resident is able to verbally make her needs known. Resident does display symptoms of depression. Nursing staff noticed a decline in her health and inquired about hospice. Social Service Director (SSD) plans to reach out to family with updates. Lately the resident tends to self isolate, and she limits her socialization with others. It has been reported that resident refuses medications and food at times. 1/17/2023 at 11:19 AM, SSD discussed discharging with V10. V10 expressed she feels that R3 is on a decline and wants her out of the facility. V10 was informed that resident can be signed out against medical advice but strongly advised against it by medical staff. V10 reported wanting her to discharge back into the community but is concerned about the wound on her foot/toes. Nurse Practitioner and therapy were made aware, and both agree that it would not be a safe discharge. V10 states she agrees and understands that R3 will need 24 hour care if released. Resident remains in the facility; 1/19/2023 at 1:00 PM, Physician's Note: examined today, restless, anxious, confused: oxygen leave 74 on room air , heart rate 188, STAT (as soon as possible) nurse to start oxygen at 2-3 liters per nasal cannula with a goal of > 90 %, vital signs every shift and as needed. Stat urinalysis, Comprehensive Metabolic [NAME], Hemoglobin A1C, Complete Blood Count, Thyroid Stimulating Hormone, Chest X-ray, Electrocardiogram. Have Cardiology Nurse Practitioner consult with resident; 1/19/2023 at 6:04 PM, Resident taken off oxygen, saturation increased to 94% on room air. Resident is not showing signs of confusion at this time. Electrocardiogram resulted abnormal. Nurse Practitioner made aware, new order for cardiologist consult. Order entered. Vitals at this time are stable. Non stat eligible labs entered for routine draw on 1-20-22. Attempted to notify family, no answer, voice mail left; 1/19/2023 at 10:25 PM, Lab called in creatinine result of 16.5 (high) and blood urea nitrogen result of 291 (high). Called V16, R3's Physician and notified him of results, V16 instructed to send resident to the emergency room. 1/20/2023 at 4:17 AM, admitted to hospital with admitting diagnosis of Sepsis; 1/24/2023 at 10:48 AM, This nurse spoke with a nurse at the hospital intensive care unit. The nurse stated that resident has Cholecystitis and has plans to be taken to surgery for a splenectomy as well. There are no discharge plans at this time. R3's Hospital History and Physical, dated 1/19/23, documents R3 looks extremely dry, skin texture and turgor are markedly decreased, skin tense, oral mucosal membrane is extremely dry, tongue has an appearance of sandpaper. Skin texture and turgor are markedly decreased as noted, skin tense, lower extremities have pigmentation changes consistent with some previous, presumed, chronic venous stasis, toes and feet are almost withered, skin thickened, poor hygiene and long nails. Presents with very severe dehydration. R3's Blood Urea Nitrogen (BUN) was 306 (high) and her creatinine was 14.6 (high). On 3/29/23/ at 10:45 AM, V10, R3's Sister, stated R3 came to the facility for rehab after surgery. V10 stated she is not sure why R3 was there as long as she was because she had an apartment to go back to and was only here for rehab. V10 stated R3 was sent to the hospital because her vital signs were off and she didn't have any fluids in her. On 3/30/23 at 11:10 AM, V2, Administrator in Training, stated she would expect the nurses to put interventions in place for residents at risk for dehydration. On 3/31/23 at 9:15 AM, V16, Physician, stated if a resident is at risk for dehydration, she would expect the dietician to evaluate the patient, make recommendations and then the facility should consult with her for orders. V16 stated she would expect the facility to notify her of those recommendations and with any changes in a resident's condition. V16 stated a BUN/Creatinine of 306/14.6 is high, some patients can tolerate it that high but others cannot and it would be important to have them evaluated as soon as possible. V16 stated when those numbers (BUN/Creatinine) are elevated it means there is a problem with the kidneys and can be caused by kidney disease and dehydration, among other health conditions. The Hydration policy, dated 5/2015, documents this policy allows for each resident to be provided with sufficient fluid intake to maintain proper hydration and health. This is done through an evaluation to identify risk factors that may lead to dehydration, and, if present, a preventative care plan is developed.