**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to identify an area of pressure before becoming a stage 3, failed to have a wound evaluated by a wound care professional and failed to assess and document an area of skin breakdown. This applies to one of three residents (R1) reviewed for pressure in the sample of three. This failure resulted in R1 sustaining a stage 3 pressure ulcer with 90% slough and necrotic tissue to her sacrum. The findings include: The facility face sheet for R1 shows she was admitted to the facility on [DATE] with diagnoses to include spinal stenosis, Type 2 Diabetes Mellitus, abnormalities of gait and mobility and urge incontinence. The facility assessment dated [DATE] shows R1 to have severe cognitive impairment and requires maximal assistance with her activities of daily living. The same assessment shows R1 was admitted to the facility with a risk of developing a pressure injury but did not currently have any. The facility's electronic health record census tabs shows R1 was discharged to another facility on 12/3/24. On 1/15/25 at 11:00 AM, V4, R1's Power of Attorney (POA) said her mother was at the facility for rehab after back surgery and then she was to be transferred to another facility for long term care. V4 said she was told by the facility staff that R1 had a stage 2 pressure injury to her sacrum. V4 said she was aware of the pressure injury and had asked for R1 to be seen by a wound care professional, but that had never happened. V4 said when R1 arrived at the new facility, that facility's wound care provider happened to be in the building, and saw R1 that day. V4 said the provider said there was no way the pressure injury was a stage 2 due to all the slough (devitalized tissue) that was present. V4 said the provider debrided the wound and it was determined to be a stage 4 pressure injury with a small amount of bone being visualized. On 1/15/25 at 9:45 AM, V1 Administrator and V2 Director of Nursing said V2 was in charge of wound care when R1 was a resident in the facility. V2 said when a resident gets a new wound it is assessed by her and a treatment is ordered for the care. A wound care professional is contracted by the facility to see all wounds, but the day R1's wound was discovered, she was also diagnosed with COVID-19 and was placed on isolation. V2 said the wound care professional would not see her while she was on isolation for COVID-19. V2 then said that after R1 was off of isolation, it was the Thanksgiving holiday and the wound care professional was not working. V2 said she continued with treatment of the wound and did not feel the wound was getting worse and was improving. V2 said the wound was a stage 3 pressure injury when it was found. The wound was filled with slough. V2 said she tried to get R1 seen by the local wound care clinic but no appointments were available. V1 and V2 said R1's Physician was aware of the wound and had signed orders for the care of the wound. On 1/15/25 at 10:09 AM, V3 Registered Nurse said R1 was being treated for a wound to her sacrum with daily dressing changes. V3 said R1 had some sort of wound to her sacrum area before but she could not recall what the issue was. V3 said when R1 was transferred to another facility the wound care orders were sent with her. V3 said R1 was not seen by the wound care professionals at the facility due to her having been diagnosed with COVID-19 and was on isolation for 10 days. V3 said the wound to the sacrum of R1 had a lot of slough present with a black center found. V3 said you could not see the bottom of the wound. V3 said at one point the daughter asked that her mother be placed back on a medication to help with overactive bladder due to large amounts of incontinence and her mothers bottom was getting very red and sore. V3 said she reached out to the Physician and an order was obtained for the medication. V3 said that was on 11/6/24 that she reached out to the Physician telling him R1 was having large amounts of urine incontinence and her sacrum was having breakdown. On 1/15/25 at 12:25 PM, V5 Nurse Practitioner (NP) said she saw R1 one time while she was at the facility and she was not aware R1 had a pressure injury to her sacrum. On 1/15/25 at 2:20 PM, V6 Medical Doctor (MD) said he does not recall R1 having a pressure injury to her sacrum and does not recall giving any orders for it. V6 said when he is notified of a new pressure injury he usually goes with the nurse to look at the wound. V6 said he does not have any notes showing he did this with R1. V6 said he expects the staff to assess the skin frequently and report to him any skin issues. V6 said debridement of the wound would help with allowing healthy tissue to grow and will prevent infections and other complications. V6 said he was not surprised R1 developed a pressure injury due to her age, recent back surgery, immobility, incontinence and having uncontrolled diabetes. On 1/15/25 at 2:45 PM, V2 said she was not aware R1 had orders for wound care between 9/27/24 and 10/20/24 and feels it must have been for preventative measures for R1. V2 said she expects an area of pressure to be identified prior to it becoming a stage 3. The facility pressure ulcer weekly wound evaluation form dated 11/11/24 shows R1 had a stage 2 facility acquired pressure ulcer to her sacrum with slough present and a moderate amount of drainage. The skin around the wound was labeled as macerated (skin softens and breaks down due to moisture). The date acquired was shown as 11/11/24. No measurements are recorded on this document. The weekly pressure ulcer report dated 11/11/24 shows R1 had a stage 3 pressure ulcer first identified that day and measured 3.0 by 2.5 centimeters with an unknown depth to her sacrum. The wound was 90% slough filled. The note shows to refer to wound care professional once off isolation. The weekly pressure ulcer report dated 11/18/24 shows the wound was measured at 2.9 by 2.5 centimeters and an unknown depth with 90% slough present. The report dated 11/25/24 shows R1's wound was measured at 2.9 by 2.5 centimeters with a depth of 0.2 centimeters with slough still at 90%. The report dated 12/2/24 the day before R1's discharge, shows the wound still had 90% slough and measured 2.8 by 2.0 centimeters. The Physician Order Sheet (POS) shows an order dated 9/26/24 to cleanse the open area to sacral area with wound care cleanser, pat dry, apply medi honey to wound bed, cover with bordered foam dressing daily and as needed. The order shows it was entered by V2 DON. The weekly pressure ulcer report dated 9/3024 does not show any open areas for R1. The facility electronic health record for R1 does not show any evidence of an open area to R1's sacrum being measured or monitored from 9/27/24 to 10/20/24. The facility Treatment Administration Record (TAR) dated 9/2024 and 10/2024 shows a dressing change was completed on R1 between 9/27/24 to 10/19/24. The TAR dated November 2024 shows R1 was on droplet precautions from 11/11/24 to 11/22/24 for a COVID-19 infection. A Physician communication form dated 11/6/24 shows R1 was having large amounts of urine incontinence and had breakdown to her sacral area. The office clinic notes dated 11/29/24 signed by V5 NP does not show any wounds for R1. The progress note dated 11/27/24 signed by V6 MD does not show any skin issues for R1. The facility policy with a revision date of 3/2021 for wound assessment shows it is the policy of the facility to assess each wound at the time the wound is identified. Each would will be assessed weekly thereafter or with any significant change in the wound. The wound policy also shows if the wound base is obscured by slough it is classified as an unstageable wound and the once the slough is removed a stage 3 or 4 ulcer will be revealed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to prevent pressure injuries for residents at risk for pressure, failed to initiate treatment orders when pressure injury was found, failed to monitor a pressure injury for signs and symptoms of infection for 2 of 4 residents (R1, R3) for pressure in the sample of 4. This failure resulted in R1 developing a Stage 3 pressure injury to her right heel that became infected and R3 developing two Stage 2 pressure injuries to his sacrum. The findings include: 1. R1's Nursing admission data collection dated 10/3/24 shows R1 was admitted on [DATE] due to hysterectomy with bladder sling, no impaired skin integrity, abdominal area has 3 small incision sites. On 11/23/24 at 8:47 AM, R1 was sitting up in a wheelchair at the dining room table eating breakfast. R1 had heel protective boots on both feet and a mechanical lift sling underneath her. R1 said she was doing ok and had the boots on because her foot hurt her. On 11/23/24 at 9:20 AM, V3 Registered Nurse was in R1's room, just finishing wrapping R1's heel with a gauze dressing. V3 said R1 has an unstageable pressure wound to her right heel. V3 said the wound started off as a deep tissue injury and then the area turned black and fell off. V3 said it got infected and R1 was put on antibiotics. V3 said now it is a large area on her heel with white and yellow slough and R1 is seeing the wound doctor now. V3 said when R1 was admitted she was able to stand and pivot and now R1 is transferred with a mechanical lift because she is unable to bear weight on the right foot. V3 said R1 is alert and oriented to self, place, but has some developmental delays so it takes a little bit for her to make her needs known. On 11/23/24 at 10:06 AM, V2 Director of Nursing said she is the acting wound nurse right now. V2 said R1 was sent to see a wound doctor at the local hospital when her wound started getting worse and was looking visibly bigger. V2 said not all residents with pressure injuries see the wound doctor only those whose wounds that the medical doctor think needs more care. V2 could not recall if R1's wound became infected. On 11/23/24 at 11:30 AM, R1 was in bed with heel boots in place. R1 said her foot hurt a little right now, but not like it did at first. R1 said she doesn't like to have a sore foot. On 11/23/24 at 12:34 PM, V2 said a Certified Nursing Assistant mentioned to her that R1 had something on her heel and the nurse on duty did a change in condition report (SBAR). V2 said when she first assessed R1's wound on 10/19/24 (during the weekly pressure ulcer assessments), it was a dark brown/purple area to the right heel and was not open at the time. V2 said she notified the doctor and got orders for treatment. V2 said she was not aware of any changes to R3's wound until 11/11/24. V2 said when she assessed R1's wound on 11/11/24 she noticed the wound was worse, and had opened up at one end with yellow slough and clear yellow drainage. V2 said she did not notice an odor. V2 said she saw R1's wound before V6 Nurse Practitioner (NP) saw R1 on 11/11/24. V2 said V6 saw R1 and ordered antibiotics for the wound and to see the wound doctor. V2 said R1 was seen by the wound doctor at the local hospital on [DATE]. On 11/23/24 at 1:40 PM, this surveyor with V2 observed R1's wound. R1 had a large irregular open wound with depth. R1's wound was almost R1's entire heal approximately 2 x 4 centimeter and had depth. R1's wound contained yellow slough and this surveyor could smell a foul odor through a surgical mask. V2 completed wound care and applied the treatment to R1's wound. R1 said several times that her foot hurts a little bit. R1's SBAR dated 10/19/24 at 2:35 PM shows open area to right outer aspect of heel. This form does not contain measurements or a description of the wound. The facility's Weekly Pressure Ulcer Report for R1 dated 10/21/24 shows first observation, facility acquired stage 1, right heel, 1.5 x 1.5 x 0.0 centimeters, with treatment orders betadine and foam dressing daily 10/22/23. This document does not contain a description of the wound. R1's Physician Orders shows treatment orders for R1's right inner heel were ordered on 10/22/24 (3 days after wound was found). The facility's Weekly Pressure Ulcer Report for R1 dated 10/28/24 and 11/4/24 shows no change in status, with no description of wound. R1's Skin Check Weekly report dated 10/17/24 shows no new changes this week. with no description of the wound. R1's Physician Communication Form dated 11/10/24 shows Nurse to Provider Communication: Please look at right heel- it is getting worse, foul odor, moderate amount of drainage; and NP/Doctor Response/Orders/Follow Up: 11/11/24- Get R1 into hospital wound care please (re :heel wound-right), Bactrim Ds twice daily for 7 days (heel wound), until seen by wound doctor , cleanse right heel wound with wound cleanser-gently scrub to remove drainage-apply an antibiotic/collagen product and cover with foam dressing. Change dressing every 3 days or if dressing comes off. Foam dressing needs to be securely taped around wound, Keep bilateral heels off bed or any pressure. The facility's Weekly Pressure Ulcer Report for R1 dated 11/11/24 shows Status-Worsened, right heel unstageable, 1.8 x 4.2 x 0.2 centimeters, moderate exudate, no odor. The facility's Weekly Pressure Ulcer Report for R1 dated 11/18/24 shows Status-Worsened, right heel unstageable, 2.0 x 4.0 x 0.3 centimeters, moderate exudate, mild odor. R1's NP Progress Note dated 11/11/24 shows right heel pressure ulcer with foul odor and moderate amount of drainage. Will get her into local Hospital Wound Care as she does need debridement. She does have bilateral heel pads on however she still needs these heels offloaded. Discussed plan of care with nursing staff, they verbalized understanding. R1's Hospital Wound Care Visit Report dated 11/18/24 shows new patient presents to the clinic today after developing a pressure wound after having surgery and being in a nursing care facility. Patient is currently at local nursing care facility, developed a wound a little over a week ago on the posterior aspect of the right heel. Right heel wound is a chronic stage 3 pressure injury. Initial wound encounter measurements are 3.19 x 3.76 x 0.1 cm depth. Necrotic adipose tissue is exposed. There is a large amount of serosanguineous drainage noted which has a mild odor. The patient reports a pain level of 5/10. The wound margin in irregular, wound bed has no-granulation, yes-slough. Advised patient to off-load foot ulcer. Expected duration of skilled wound care therapy 1-3 months. On 11/23/24 at 1:00 PM, V6 NP was called and a message left. There was no return call. 2. On 11/23/24 at 9:35 AM, V4 Certified Nursing Assistant had just finished providing incontinence care for R3. V4 said R3 has a pressure injury on his left hip and a patch on his shoulder but she didn't think he had any other wounds. V4 said R3's bottom was red but there was no open areas that she had seen during care. V4 rolled R3 to his side, and lowered his brief. R3's sacral area was visibly red and there were two small openings on his sacrum area. V4 said R3 should be turned and repositioned every 2 hours and she had not reported R3's redness to his bottom or applied any cream. V4 said she was not sure how long R3's bottom had been red. V5 LPN came into the room and assisted to hold R3. V3 LPN came in and assessed and measured the openings. V4 said both wounds are Stage 2 pressure injuries since the wounds are open. V4 said the lower opening on R3's sacrum measured 1 x 0.4 cm and the upper wound measured 0.5 x 0.2 cm. V4 cleaned both wounds and applied a dressing. V5 said she would notify the doctor and get treatment orders. On 11/23/24 at 12:34 PM, V2 said R3 openings on his sacrum are new, he had nothing there previously. V2 said R3 is at risk for pressure and has pressure reducing interventions of low air loss mattress and wheelchair cushion, float heels, and turn and reposition every 2 hours to reduce pressure. V2 said if R3 had redness to his bottom, cream should be applied. V2 said she was aware that R3 had been having some loose stools which could cause breakdown. V2 said the doctor was notified of R3's wounds and treatment orders were obtained. R3's Progress Note dated 11/23/24 at 10:10 AM, shows resident was noted to have open areas to sacrum. MD notified of new areas. R3's Care Plan shows R3 has actual skin impairment to skin integrity related to decreased mobility, incontinence/moisture, friction and shearing, nutrition and disease process. R3 was admitted with wound to left hip. Interventions: apply moisture barrier with each incontinence episode, and resident needs assistance to turn/reposition frequently and as required. R3's Wound Physician Visit Summary Report dated 11/20/24 shows R3 has a stage 3 full thickness pressure injury to left lateral thigh. Discussed importance of offloading, pressure relief and frequent turning and repositioning changes. Staff present for all education and verbalized understanding. The facility's Pressure Ulcer/Pressure Injury Prevention Policy dated 3/2022 shows An individual plan of prevention will be developed to meet the needs of the resident. It will include the consideration of mechanical support surfaces, nutrition, hydration, positioning, mobility, continence, skin condition, and overall clinical condition of the resident as well as the risk factors as they apply to each individual. The goal is for the resident to be free of preventable pressure ulcer/pressure injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure pressure ulcers were assessed, prescribed treatment orders were transcribed and provided, and treatment dressings were in place for residents with pressure ulcers. These failures apply to 4 of 5 (R179, R6, R66, R55) residents reviewed for pressure ulcers in the sample of 18. The findings include: 1. R179's face sheet shows she is a [AGE] year old female admitted to the facility on [DATE], from another facility. Her diagnoses include COPD, unspecified dementia without behavioral disturbance, type 2 diabetes, multiple sclerosis, gastrostomy status, unspecified cerebral infarction. On 10/21/24 at 9:24 AM, V7 (Licensed Practical Nurse/LPN) provided wound care to R179. V7 removed the soiled dressing from her coccyx. A round open area to her coccyx was observed. V7 cleansed the wound, applied calcium alginate and foam dressing but did not apply the medicated cream to the wound bed. V7 said R179's treatment order was santyl and calcium alginate. R179's Wound Assessment form dated 10/2/24 documents a stage 3 coccyx pressure ulcer measuring 3.8 cm (centimeters) x 5.8 cm x 0.9 cm. R179's Treatment Medication Administration Record shows orders to cleanse the wound with normal saline, to irrigate and scrub the wound bed, the apply collagenase santyl, nickel thick (2 millimeters) topically to entire wound bed, edge to edge. Apply calcium alginate to wound bed, cover with foam dressing. R179's Nursing Admission/readmission Data Collection report dated 10/9/24 documents an open area to her coccyx but it does not include measurements of the wound. R179's EHR (electronic health record) does not show an assessment of R179's wound after 10/9/24. On 10/22/24 at 1:17 PM, V2 (Director of Nursing/DON) said she is the DON and the wound nurse. She has been doing both positions since November 2023. Wounds should be assessed on admission and weekly. The physician prescribes the wound treatment and staff should follow the treatments orders. 2. R6's face sheet shows he is a [AGE] year old male with diagnoses including dysphagia, CHF, atrial fibrillation, acquired absence right leg below knee amputee, type 2 diabetes, depression, and adult t-cell lymphoma/leukemia in remission. On 10/21/24 at 10:38 AM, R6 was lying in his bed. He said he has a wound on his bottom with no dressing on. On 10/21/24 at 1:58 PM, V6 (Registered Nurse/RN) and V8 (CNA-Certified Nursing Assistant) entered R6's room to provide wound care. V7 rolled R6 on his side, there was no treatment dressing to his open wound on his right buttock. Bloody drainage was noted on the incontinent pad. At 2:08 PM, V6 said she was not sure why R6 did not have dressing on, she thinks because R6 had a bed bath earlier but was not sure. On 10/22/24 at 1:17 PM, V2 (DON) said R6 has a stage 2 on his buttock, he should have a treatment dressing in place. R6's Minimum Data Set assessment dated [DATE] shows he has stage 2 pressure ulcer. R6's Wound Progress note dated 10/9/24 documents his right buttock wound measuring 6.8 cm x 0.2 cm x 5 cm with treatment orders including to cleanse wound with hydrochlorous, apply calcium alginate to wound bed and apply foam dressing daily. 3. R66's face sheet shows he is a [AGE] year old male with diagnoses including muscle wasting, encounter for orthopedic aftercare following surgical amputation, acquired absence of left leg below the knee, type 2 diabetes, peripheral vascular disease, and non-pressure chronic leg ulcer of right lower extremity. On 10/21/24 at 1:45 PM, V6 (RN) said R66 was admitted with a pressure wound to his sacrum and left below knee amputation. R66 was lying in bed. To his right lower extremity, an ace wrap was in place and left below knee amputee. V8 (CNA) assisted him on side. Two foam dressings were in place to the right and left sacrum. V6 removed the old dressing, cleansed the wound and applied medi-honey, calcium alginate and foam dressing. On 10/21/24 at 2:08 PM, V6(RN) said the floor nurses do the treatment orders on wounds, but she was not sure who is measuring wounds and wounds should be measured weekly. R66's Wound Weekly Report dated 9/5/24 documents left sacrum wound measuring 4.5 cm x 6.0 cm and right sacrum measuring 2.0 cm x 3.5 cm. R66's Pressure Ulcer Weekly Wound Evaluation report dated 10/14/24 documents stage 2 sacrum pressure measuring 2.3 cm x 1.7 cm x 0.1 cm signed by V2 (DON) on 10/22/24. The same report does not include the two open areas to his sacrum. R66's EHR does not show documentation of the sacral wounds after 9/5/24 to 10/22/24 approximately six weeks. On 10/22/24 at 1:17 PM, V2 (DON) said she has been the wound nurse and DON since November of last year. Wounds should be assessed weekly to ensure wounds are not getting worse. She got behind on things and did not measure R66's wound until today. 4. On 10/21/24 at 10:01 AM, R55 was observed sitting in her wheelchair, she said she has wound on her bottom with a dressing in place. R55's Physician Wound Assessment report dated 10/9/24 documents a stage 3 sacrum pressure ulcer measuring 4.5 cm x 3 cm x 0.2 cm. Treatment orders include cleanse wound with hypochlorous acid, apply skin prep to wound, apply calcium alginate to wound bed, and cover with bordered foam daily. R55's Treatment Administration Record (T.A.R.) shows orders to cleanse sacral wound with wound cleanser, apply medihoney, calcium alginate and bordered gauze daily and as needed. The T.A.R did not show orders were changed until 10/22/24 (13 days later) with orders to cleanse wound with hypochlorous acid, apply skin prep to wound and apply calcium alginate to wound bed, cover with bordered foam daily. On 10/22/24 at 1:17 PM, V2 (DON) said the wound physician comes weekly, she receives the wound report that day or the day after, and she changes the orders if needed. She confirmed R55's treatment orders were not changed until today and she was not receiving the prescribed treatment. The facility's Pressure/Wound List provided on 10/22/24 does not include R179, R6, R66 and R55's pressure ulcers. The facility's Pressure Ulcer/Pressure Injury Prevention Policy dated 2022 states, A facility must identify whether the resident is at risk for developing or has a pressure ulcer upon admission and thereafter, evaluate resident specific risk factors and changes to the resident condition that may impact the development and;/or healing of pressure ulcer, implement, monitor and modify interventions .provide treatment .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure effective fall interventions were in place for resident's safety who is a high risk for falls and has a history of falls. This failure resulted in R45 falling out of bed and sustaining a left hip fracture needing surgical repair for 1 of 18 residents (R45) reviewed for safety in the sample of 18. The findings include: R45's Physician Order Sheet show R45 is [AGE] year old with diagnoses of vascular dementia, hypertension, weakness and left hip fracture R45's facility assessment dated [DATE] show R45 is severely cognitively impaired (BIMS of 1) R45's fall risk assessment dated [DATE] show R45 as a high risk for falls. On 10/21/24 at 9AM, R45 was in bed moaning I am sore. V19 (Registered Nurse) was with R45 at this time and said R45 has a hip fracture due to fall. On 10/21/24 at PM, V20 (R45's daughter) said she was very disappointed at the facility. My mom has had four (4) falls. All of these falls were her trying to go to the bathroom. Staff knew this is what she does so they needed to check on her often to see if she needed to use the bathroom. Staff should have made a schedule for her to go to the bathroom before she even tries to get up on her own. She (R45) had injuries due to these falls. She (R45) had large cut in her forehead when she fell late last year. She fell face forward while in the bathroom. This latest fall, last week, had resulted in her breaking her hip and had to have surgery to fix her broken hip. Again she was trying to go to the bathroom. V20 said [R45] has dementia and reminders for her not to get up by herself does not work, she won't remember that. R45 is weak and unsteady, she needs her device (walker) and a staff to bring her to the bathroom. Review of R45's fall incident reports show: 11/7/2023-(fall with injury) R45 self transferred from her bed into the bathroom .she lost her balance falling forward striking her head on the floor. Laceration to forehead, nose and right hand . Careplan documents intervention as follows: Do not leave resident in bathroom unattended. 1/31/24-resident audibly moaning, and door was shut . at 23:15 resident was on the floor in her bathroom .resident was sitting on the floor in front of her toilet, with her legs stretched out in front of her . Careplan documents intervention as follows: Call don't fall sign. Make sure R45's call light is within reach and encourage to use it for assistance as needed. (R45 has dementia) 9/8/24-This writer was notified by 200 hall nurse resident was in bathroom floor lying on her stomach with her head near the doorframe . Careplan documents intervention as follows: Encourage leaving bedroom door open for increased visualization and safety. R45's latest fall dated 10/16/24 (fall with injury) timed at 5:35 AM Residents roommate came out of the nurses station to say resident had fallen in her room. Resident was lying at the foot of the bed on her left side .complained of left hip pain .resident sent to ER. Hospital records dated 10/16/24 show, Fall at (nursing home), patient was getting to go to the bathroom when she fell and landed on her left side. Radiology report dated 10/16/24 show acute comminuted left intertrochanteric fracture. 10/17/24 [R45] had surgery for the left hip fracture. On 10/23/24 at 9 AM V1 (Administrator) and V2 (DON) said they completed R45's investigation and concluded that R45 was attempting to go to the bathroom again and not waiting for assistance. A Facility Reported incident sent to the state agency with date of incident 10/16/24 shows, Resident noted by roommate attempting to self-ambulate from bed. Roommate states she told resident to wait for help and use call light, resident continued to attempt self-transfer and subsequently fell. Resident noted to have her one slipper on and one off. Resident did not use her assistive device. Roommate notified nurse of fall. Injury: Closed intertrochanteric fracture of left hip. . Resident readmitted to facility (10/19/24) s/p surgical hip pinning for closed intertrochanteric fracture of left hip and new diagnosis of UTI. R45 is alert and oriented x 1. Upon investigation of fall, it was determined that resident did not use her call light or wait for assistance despite reminders to do. On 10/22/24 at 2:24 PM, V21 (CNA) said she was R45's CNA on 10/16/24. R45 gets up to go to the bathroom and does not wait for assistance even when told repeatedly. R45 was toileted at 3:30 AM. V21 said at 5AM, she started to get up other residents. At around 5:30 AM, she heard R45 fell trying to get up unassisted. V21 said R45 might be trying to go to the bathroom at that time, that's also 2 hours after she was toileted earlier. V21 said R45 has dementia and forgets reminders. On 10/22/24 at 12:45 PM, V22 (LPN) said she was R45's nurse on 10/16/24. She last saw R45 around midnight and R45 was asleep. At around 5:30 AM, R18 (roommate) came to the nurses station and said R45 fell. R45 was at the foot of her bed lying in her left side. R45 got up from her bed unassisted. R45 was sent to the hospital due to left leg pain. She was found to have left hip fracture. V22 said R45 has been reminded to ask for assistance. V22 confirmed R45 has dementia and reminders for her to wait for staff do not work. R18 (R45's roommate) alert and oriented said she heard a loud sound. She saw R45 on the floor at the foot of R45's bed saying help me! R18 said she put her call light on and waited, then went to the desk and said. Please help she's on the floor! Two of them (staff) came and lifted her to bed then she left to go to the hospital. This surveyor clarified with V1 (Administrator) and V2 (DON) R45's fall interventions and their effectiveness. V2 confirmed that all of R45's four falls involved R45 trying to go to the bathroom unassisted. R45 has dementia (BIMS of 1). V2 (DON) said more frequent checks and toileting schedule would have been more appropriate interventions for R45 to prevent these falls. V1 (Administrator) said they recognized that residents interventions in the careplan were not specifics and resident centered. V1 said they have a started working with their Nurse Consultant regarding this matter. The facility's Fall Policy dated 9/17/19 shows, The purpose of the fall management program is to develop, implement, monitor and evaluate an interdisciplinary team fall prevention approach and manage strategies and intervention that foster residents independence and quality of life.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to accurately assess a residents weight loss and ensure nutritional interventions were implemented for a resident with significant weight loss. This failure resulted in R66's significant weight loss. This applies to 1 of 5 residents (R66) reviewed for weight loss in the sample of 18. The findings include: R66's face sheet shows he is a [AGE] year old male admitted to the facility on [DATE] with diagnoses including muscle wasting, encounter for orthopedic aftercare following surgical amputation, acquired absence of left leg below the knee, type 2 diabetes, peripheral vascular disease, and a non-pressure chronic leg ulcer of right lower extremity. R66's weight report provided on 10/22/24 documents: 8/27/24- 208.8 lb (pounds) 9/24/24- 184 lb 10/8/24- 186 lb 10/17/24- 182.2 lb R66's electronic health medical record documents Regular Diet, Regular Texture, Regular liquid Consistancy. Needs double portions of meat, eggs and milk at each meal for wound healing, start date: 8/26/24. R66's Dietary Note dated 10/10/24 documents he triggered significant weight loss of 6% in one month and 11% weight loss since admission. R66 had a left below knee prior to admission, was admitted with a cast to leg per DON (Director of Nursing). Currently has a stage II pressure ulcer to sacrum per DON. Diet regular, double meats, eggs and milk all meals .weight loss may be partially related to cast removal . will advise to increase liquid protein to 30 ml (milliliters) twice a day and continue to monitor weight. R66's weight report shows he lost 4 additional pounds since 10/10/24. On 10/21/24 at 12:02 PM, R66 was in his room eating in bed, using his right hand to feed himself. On 10/22/24 at 8:55 AM, R66 was in his room lying in bed. He said he noticed he has been losing weight but not sure why. An elastic bandage was wrapped to his right leg and left leg below knee amputee. He said he never had a cast on his leg and he has not been seen by V24 (Dietitian) recently. On 10/23/24 at 9:47 PM, V24 said nutrition assessments are done on admission, quarterly and if a resident triggers for weight loss. She monitors the weight report, if a resident triggers for weight loss the resident should be re-assessed with interventions implemented. She is at the facility twice a week but it could take up to two weeks or longer before she assesses the resident. R66 triggered for significant weight loss last month, he had double proteins in place and she recommended increasing his liquid protein from daily to twice a day. She said she did not physically see him, she was told he had a cast on his leg and contributed part of his weight loss to that. She said she sends the recommendations to V2 DON. R66's EHR (electronic health record) does not show documentation of a cast to his leg. R66's Physician Order Sheets dated October 2024 shows orders for liquid protein daily (not twice a day). The facility's Nutrition (Impaired)/Unplanned Weight Loss Policy states, The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a. 1 month -5% weight loss is significant, greater than 5% is severe .the staff and physician will identify pertinent interventions based on identified causes and overall resident condition, prognosis and treatment wishes .the staff will implement appropriate general or cause-specific interventions, as indicated .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents pain was managed after undergoing hip surgery. This failure resulted in R45 experiencing severe pain to 1 of 18 residents (R45) reviewed for pain management in the sample of 18. The findings include: R45 has diagnoses that include fractured left hip undergoing hip surgery, dementia, hypertension and weakness. R45 was readmitted to the facility on [DATE] after undergoing surgical repair to her left hip fracture caused by a fall. On 10/21/24 at 9AM, R45 was in bed moaning I am sore. V19 (Registered Nurse/RN) was with R45 at this time and said R45 has a hip fracture due to fall. On 10/21/24 at 12 PM, R45's room was closed but can hear audible moaning. This surveyor entered R45's room. R45 was in the bathroom sitting in the toilet seat. V18 (Certified Nursing Assistant) was with R45. R45 was crying in pain. It's sore!, it is so painful! I can't take this please, I can't, please help me, it hurt's so bad. V18 asked this surveyor to get the nurse. When V19 (RN) was in the room, she asked R45 what's wrong? R45 responded, this is so painful! pointing to her left hip. It is so sore, please help. V19 told R45 you had hip fracture! of course it will hurt!, do you want to go back to the hospital ? R45 answered I don't think that was necessary but my hip hurts so bad, I just want to go lay down!. V17 and V18 (both CNAs) tried to lift R45 up using using a gait belt to her wheelchair. R45 cannot bear weight and cried out I cannot move!, no please! this is sore touching her left hip again it is so painful! A walker was then placed in front of R45. R45 was directed to use the walker to get up. R45 said she cannot move, her legs hurts. V3 (Assistant Director of Nursing) came in the room. R45 said she cannot take the pain in her hip any longer. V3 informed R45 she understood R45 was experiencing severe pain and will try to put R45 to bed. V3 (ADON) was able to transfer R45 via sit to stand and R45 was placed in bed. R45 continued to moan. V19 (RN) then gave a pill to R45 and left the room. At 12:30 PM, This surveyor asked V19 (RN) what did she give R45. V19 said she gave R45 her pain medication. V19 said R45 has an old order of pain meds even before having surgery given four times a day 8AM, 12PM, 4PM, 8PM. Date of order 5/1/24. V19 said R45's pain is increased at this time due to hip surgery. R45's pain level was 6 (severe pain) At 2PM V3 ADON said R45 was definitely experiencing severe pain after this hip surgery At 2:48 PM, V18 (CNA) said R45 does this whimpering sound but earlier when R45 was toileted she had this excruciating pain in her hip that she cannot even move. R45's pain had definitely increased. R45's hospital discharge orders dated 10/19/24 after having hip surgery show a new pain med order of Norco 5/325 (Narcotic pain medication) 1 tab every four hours (approximately 3 days ago). Review of R45's Physician Order sheet dated 10/24 and R45's medication administration sheet (MAR) still has R45's old order (5/1/24) of Norco 1 tab four times a day. The new order of R45's Norco (every 4 hours) was not carried out. On 10/22/24 at 1:10 PM, V2 (DON) said when residents were readmitted , medications were reviewed to ensure all the ordered medications were carried out. R45's careplan with a revision date of 10/21/24 show R45 has pain whimpering .further risk for pain related to recent fall with left hip fracture. R45 does complain of pain during transfers. With intervention that include, monitor residents complaint of pain. Notify physician if intervention are unsuccessful or if current complaint is a significant change from residents past experience. On 10/23/24 at 9AM, V2 (DON) confirmed to this surveyor that R45's pain med from the hospital discharge orders had been corrected to reflect the correct order for R45's pain medications order last 10/19/24. (Norco 5/325 1 tab every 4 hours.)