**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement interventions to prevent and treat a pressure injury per facility policy. This failure resulted in the development of a DTI (Deep Tissue Injury) for a resident at moderate risk for the development of pressure injuries. This applies to 1 of 4 residents (R59) reviewed for pressure injuries in the sample of 18. The findings include: Face sheet, dated April 9, 2025, shows R59 was admitted to the facility on [DATE], and her diagnoses included pulmonary embolism, malignant neoplasm of bronchus or lung, weakness, diabetes, protein-calorie malnutrition, vascular dementia, congestive heart failure, chronic kidney disease, and need for assistance with personal care. MDS (Minimum Data Set), dated January 15, 2025, shows R59's cognition was severely compromised and R59 required substantial / maximal assistance from staff for rolling left and right. Skin Observation Weekly, dated October 10, 2024, shows R59's skin was normal with no open areas. Braden scale, dated October 9, 2024, shows R59 was at high risk for pressure injuries because she was completely immobile, was bedfast, and did not make even slight changes in body or extremity position without assistance. Braden scale, dated February 6, 2025, shows R59 was assessed to only be at moderate risk for pressure injuries, was chairfast, had very limited mobility and made occasional slight changes in body or extremity position but was unable to make frequent or significant changes independently. The assessment also shows R59 had very limited sensory perception. On April 8, 2025, at 12:33 PM, V10 (Licensed Practical Nurse) stated she was unaware of any pressure ulcer related to R59. On April 8, 2025, at 12:37 PM V12 (Wound Nurse) stated R59 had a facility-acquired pressure injury that was assessed as an unstageable right plantar DTI. V12 stated R59 had the pressure injury for months which was caused by her sitting position in her chair. V12 stated R59 was being treated with betadine and a gauze island twice a week. On April 8, 2025, at 12:39 PM, V12 (Wound Nurse) walked into R59's room and pulled back the sheets to observe R59's feet. V12 stated, that's not quite offloaded. R59 had black socks on both feet, both feet were resting on a pillow and R59's lateral plantar side of right foot touching pillow. R59's green pressure-relieving boots were on the counter across from her bed and not on her feet. V12 stated R59's pillow under her lower extremities should be placed back under her calves to give her a boost and so her feet were not touching anything. V12 stated R59's pillow should not have been placed under her feet. On April 8, 2025, at 2:07 PM, R59 was lying in bed with offload boots and V13 (CNA/Certified Nursing Assistant) took off the sock on the right foot. There was a dressing present. At 2:10 PM, V12 took off the dressing and R59 had a blackened area with raised edges on her right sole. This area was approximately 2.5 cm (centimeters) in diameter with redness in the surrounding area. V12 was asked to describe the area, and she said it was a deep tissue injury, which was unstageable due to necrotic tissue. Initial Wound Evaluation & Management Summary, dated February 25, 2025, shows R59 was identified to have a wound on her right plantar foot. The assessment shows R59 had a pressure ulcer identified as an unstageable DTI with intact skin greater than 7 days in duration measuring 2 centimeters (cm) by 2.5 cm and the depth was not measurable. The skin was assessed as intact with purple/maroon discoloration. The evaluation's dressing recommendations included betadine and silicone foam with border twice a week and as needed. The evaluation's intervention recommendations include offloading the wound, use of a pressure off-loading boot, and repositioning R59 per facility protocol. Care plan, initiated October 11, 2024, and reviewed April 8, 2025, showed R59 had the potential for impairment to skin integrity related to incontinence, the diagnosis of diabetes, and impaired mobility. R59's intervention, dated October 11, 2024, included providing a pressure reducing mattress on bed. The care plan fails to show any pressure relieving interventions implemented to prevent the development of a pressure injury on her lower extremities while sitting in her chair. The care plan also failed to show interventions for her diagnosed pressure injury, or the implementation of enhanced barrier precautions related to her wound. POS (Physician Order Sheet), dated January 1, 2025, to April 30, 2025, shows R59's physician orders included: - Offload boots to be worn while in chair and during bedtime three times a day for DTI (ordered February 26, 2025) - Bottom lateral foot: Monitor and cleanse wound with NSS (Normal Saline Solution), apply betadine and cover with dry dressing two times a week one time a day every Tues, Fri for wound care (ordered February 18, 2025, and revised February 26, 2025) - Right plantar foot: Cleanse wound with NSS, apply betadine and cover with dry dressing two times a week. One time a day every Tuesday, Friday for wound care (ordered February 26, 2025, and revised April 5, 2025) - Infection precautions enhanced barrier secondary to wounds (ordered March 27, 2025) On April 9, 2025, at 1:08 PM, V22 (Physician) stated usually on admission at the facility the wound care team assesses and recommends pressure injury prevention interventions for residents at risk for pressure injuries. V22 stated usually the interventions including repositioning, floating heels and use of pressure relieving boots is part of the resident's care plan as preventative measures the facility should be doing if a resident was identified as someone that requires those measures. V22 stated it was certainly possible that the lack of interventions could have caused R59's DTI. V22 stated the facility either did not conduct a proper assessment or if they were providing the interventions they did not document them. On April 9, 2025, at 12:25 PM, V38 (Physician) stated R59 should have interventions in place based on the facility protocol. V38 stated R59's pillow should be behind her heel and R59 should have both offloading boots on when in bed. Wound Evaluation and Management Summary, dated April 1, 2025, shows R59 had a pressure injury that was described as an unstageable DTI for greater than 40 days measuring 1.8 cm by 2 cm with a depth unmeasurable. The assessment was no exudate, and the skin was intact with purple/maroon discoloration. The treatment plan shows apply betadine twice a week and as needed for 22 days in addition to a gauze island with boarder to be applied twice a week and as needed for 22 days. The plan of care (reviewed and addressed) shows R59's wounds were to be off-loaded and R59 was to be repositioned per facility protocol. Wound Evaluation & Management Summary, dated April 8, 2025, shows R59's pressure ulcer measured 1.8 cm by 2 cm and the depth was not measurable. The wound was described as an unstageable DTI with intact skin with no exudate. The plan of care recommendations show R59's wound was to be off-loaded. Pressure Injury Prevention and Management Policy, undated, shows, The intent of this organization is to develop and maintain systems and pr\processes to ensure that the resident does not develop pressure ulcers/injuries (PU/PI) unless clinically unavoidable and that the facility provides care and services consistent with professional standards of practice to: Promote the prevention of pressure ulcer/injury development; Promote the healing of existing pressure ulcers/injuries (including prevention of infection to the extent possible); and Prevent development of additional pressure ulcer/injury Avoidable means that the resident developed a pressure ulcer/injury and that one or more of the following was not completed Evaluation of the resident's clinical condition and risk factors; Definition or implementation of interventions that are consistent with resident needs, resident goals, and professional standards of practice; Monitoring or evaluation of the impact of the interventions or Revision of the interventions as appropriate Risk Assessments 4. Findings from the pressure ulcer/injury risk assessment will be incorporated into the resident's plan of care Preventive Measures 1. Preventive interventions will be implemented based on the pressure ulcer/injury risk assessment, other related factors, and resident preferences. Such interventions may include: .c. Use of pressure reducing/relieving support surfaces or devices that assist with pressure redistribution and tissue load Care Plans: 1. A resident centered care plan will be developed and implemented to address the resident's risk for development of a pressure ulcer/injury and to promote healing if the resident has a pressure ulcer/injury

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure safe wheelchair transport for a cognitively impaired resident (R34) that required staff assistance. As a result, R34 sustained pain and significant bruising to the right side of the face, forehead and orbital area to the right eye. This applies to 1 of 1 resident (R34) reviewed for fall-related accidents in the sample of 18. The findings include: The EMR (Electronic Medical Record) shows that R34, is a [AGE] year-old with diagnoses of dementia, psychosis, anxiety disorder, major depressive disorder, age related physical debility, repeated falls, unsteadiness of feet, difficulty walking, need of assistance with care, hyperlipidemia, Vitamin D deficiency, hypothyroidism, and chronic kidney disease. R1 was admitted to the facility on [DATE]. The MDS (Minimum Data Set) assessment dated [DATE], showed that R34's cognition was severely impaired with a BIMS (Brief Interview Mental Status) score of 0/15. The MDS documents that R34 required substantial to maximum assistance from staff during wheelchair transport in the corridor or similar places. On April 7, 2025, at 10:30 A.M., R34 was seated in her wheelchair in the corridor. R34 was observed with a dark blue bruise on the forehead, entire right side of her face and lower orbital area of the right eye. R34 was not interviewable and not able to verbalize how she acquired the bruise. R34 was noted to be anxious and was pacing back and forth from the outside and inside her room. V10 (LPN/Licensed Practical Nurse) was present during this time. V24 said that R34 sustained the bruise from a fall incident that occurred on March 15, 2025, while being transported by CNA using wheelchair without the use of wheelchair leg rests. V24 also said that R34 was anxious and must not be feeling comfortable from the facial bruise. The facility's incident report dated March 15, 2025, showed: CNA (Certified Nurse Assistant) was transporting (R34) to the dining room, for lunch when (R34's) foot got caught underneath the wheelchair, (R34) slid out of the wheelchair and landed on her side hitting her head .911 called . hematoma forehead. The nurse's progress notes March 15, 2025, at 1:19 P.M., showed CNA was transporting (R34) to the dining room for lunch when (R34) foot got caught underneath the wheelchair, (R34) slid out the wheelchair and landed on her right side hitting her head.BP 102/58 HR 103 R 18 T 96.9. NOD (Nurse on Duty) help CNA assist (R34) back to wheelchair and to her room. 911 called and .transport (R34) to .hospital for evaluation. On April 9, 2025, at 12:10 P.M., V17 (LPN/Nurse Supervisor on March 15,2025) said that R34 had fell forward while seated in her wheelchair and being transported and propelled by (V16/CNA). V17 said that R34's feet were caught underneath the wheelchair that caused the fall. V17 also said that the fall could have been prevented if leg rests were used. V17 added that during the fall incident on March 15, 2025, R34's leg rest were not used during transport and assisted by V16. On April 9,2025 at 12:17 P.M., V19 (CNA) said that R34 did not have the leg rests attached to the wheelchair when transported by V16 and R34 legs were caught and caused the fall. V19 said she saw V16 (CNA) propel R34 in a wheelchair and R34 fell forward. Multiple attempts made for an interview with V16 (CNA) during survey but to no avail. On April 9, 2025, at 12:19 P.M., V18 (LPN, on duty on March 15, 2025, Day shift) said that (V16) had propelled and assisted (R34) to dining room for lunch, (R34) fell forward, there were no leg rests used, (R34's legs/feet) were caught under the wheelchair. On April 9, 2025, at 11:42 AM, V2 (Acting Director of Nursing) said that V16 was supposed to use leg rests when assisting and transporting R34 to ensure safe transport. On April 9, 2025, at 12:06 P.M., V11 (Director of Skilled Rehabilitation/ Physical Therapist) stated that leg rests must be used to ensure safe transport using a wheelchair and being propelled by staff. V11 added this would prevent legs/feet being caught under the wheelchair during transport and would prevent fall accident. On April 9, 2025, at 12:40 P.M. V20 (CNA), said yes, (R34) has pain due to the bruise, she might not be able to say it but with the bruise that big, she must be in pain. On April 9,2025 at 12:42 P.M., V21 (RN) said that R34 has facial pain due to the large bruise. On April 9, 2025, at 11:00 A.M., V14 (Regional Nurse Consultant) said the facility must implement safe transport via wheelchair. V14 also said that facility has no policy for safe transport, but skilled therapy department practice was to be implemented to ensure safe transport for resident while being transported using a wheelchair.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide safe transfer assistance. This failure resulted in R1 sustaining left and right femoral fractures. This applies to 1 of 3 residents (R1) reviewed for safe transfers. Findings include: R1's Medical diagnosis from the electronic record documents R1 as a [AGE] year old with diagnoses to include a right and left periprosthetic fracture around both artificial knee joints, dementia and physical disability. On 05/02/2024 at 11:18 AM, V13 Hospital staff stated Before these fractures, (R1) could not bear weight, she was contracted and unable to stand up on her own. She was bedbound. On 04/30/2024 at 02:17 PM, V9 Certified Nursing Assistant (CNA) stated That morning I got (R1) up out of bed like I always do. I put my arms under her armpits and did the pivot transfer. I felt her become dead weight then. Her knee seemed like it was swelling. I told the nurse (V6 Licensed Practical Nurse [LPN]). Then I took her down to the shower room and gave her a shower. The other knee was starting to swell up then, so I made sure the nurse knew what was going on. On 04/30/2024 at 11:00 AM V6 LPN stated (R1) is a one person assist for transfer. She's a pivot transfer. We don't always use a gait belt; it seems to cause (R1) pain when we do. We just put our hands under her arm pits and transfer. The Final Report to Illinois Department of Public Health dated 04/22/2024 documents under Summary CNA stated 'When I got to the room to get the resident up to the shower room, the resident was transferred by placing both arms under the patient's armpits to pivot and transfer.' The CNA stated she felt patient dead weight and sat the resident down in wheelchair. The CNA noticed when putting the gown on the resident, there was swelling observed to the left knee and the resident stated that there was pain to the left knee also. Under Summary of the Investigation, it documents All the staff from the day before (04/21/2024) stated they did not notice any swelling to the left or right knee. Xray's bilateral legs were ordered. The results stated there were fractures to both legs. The Radiology Results Report for R1 dated 04/22/2024 at 01:00 and 01:13 PM document under Findings: Right knee- There is an acute versus subacute comminuted fracture of the distal femur, immediately proximal to the distal femoral prosthesis with angulation. Left knee- There is an acute distal femoral shaft fracture, located immediately adjacent to the prosthetic femoral component of total knee replacement, which remains in anatomic alignment. The care plan for R1 dated 09/02/2023 and reviewed 03/05/2024 documents Transfer : The resident requires (SPECIFY what assistance) by (X) staff to move between surfaces (SPECIFY FREQ) and as necessary. Date Initiated: 09/02/2023 Revision on: 10/07/2023; which was incomplete and did not specify R1's individualized transfer needs. On 05/02/2024 at 10:45 AM, V2 Director of Nursing stated Transfer status is determined by the physical therapist. We monitor the residents everyday. The staff will notify nursing if a resident has a change in ability so the resident's transfer status can be reassessed. That information is then used in the care plans. The care plan for (R1) isn't updated. That is why there is no direction for transfers. On 05/01/2024 at 02:30 PM, V5 Physical Therapist stated The gait belt should always be used for every transfer. Anything else is not a safe transfer. On 05/01/2024 at 11:25 AM, V4 Medical Director stated (R1) has a lot of medical issues and has declined recently. She is very contracted on both legs. The injury may be the result of a forceful transfer. The undated Activities of Daily Living policy documents under Mobility (transfer and ambulation, including walking) i. Residents will be assisted with transfer and mobility as ordered by the physician/practitioner and/or as instructed in the resident's care plan

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents identified as being at risk for pressure ulcers were provided interventions to prevent the development of facility-acquired pressure ulcers. The facility also failed to follow their policy for documentation and assessment of the facility-acquired pressure ulcers and implement new interventions to promote healing and prevent the further development of additional pressure ulcers. This failure resulted in R2 developing a facility-acquired Stage 2 pressure ulcer to the left outer ankle. This applies to 2 of 3 residents (R1, R2) reviewed for pressure ulcers in the sample of 7. The findings include: 1. The EMR shows R2 was admitted to the facility on [DATE]. R2 has multiple diagnoses including, COPD (Chronic Obstructive Pulmonary Disease), hypertension, muscle weakness, weakness, protein-calorie malnutrition, heart failure, chronic kidney disease, and glaucoma. R2's MDS dated [DATE] shows R2 has moderate cognitive impairment, requires supervision with eating, extensive assistance with bed mobility, dressing, and personal hygiene, and is totally dependent on facility staff for toilet use and bathing. R2 is always incontinent of bowel and bladder. R2's MDS continues to show R2 is at risk of developing a pressure ulcer and did not have a pressure ulcer at the time of the MDS assessment. R2's care plan, initiated July 30, 2022 shows R2 has the potential for impaired skin integrity related to impaired mobility, incontinence, prefers to stay in bed. As of April 17, 2023, R2's care plan was not updated to show interventions for R2's left lateral foot pressure ulcer and buttocks pressure ulcer. The EMR shows a physician order dated December 7, 2022 for CNA (Certified Nursing Assistant) to assist resident up in the wheelchair between 0700 (7:00 AM) - 930 (9:30 AM) every day. Nurse to document if patient refuses. The order is not shown on the MAR (Medication Administration Record) or TAR (Treatment Administration Order) to ensure facility nursing staff have a place to document acknowledgement of the order or R2's refusal. The facility does not have documentation to show R2 was assisted to the wheelchair daily or that the resident refused to get up to the wheelchair. On April 17, 2023 at 9:45 AM, R2 was sitting up in bed. R2's bilateral feet were resting on the bed, with his bilateral heels and the left lateral side of his foot resting on the mattress. A pair of foam boots were noted to be on the wheelchair near R2's bed. On April 17, 2023, at 11:30 AM, R2 was sitting up in bed with his heels and lateral side of his left foot resting on the mattress. V11 (RN) said R2 prefers to stay in bed and always stays in the same position in his bed. R2's foam boots were noted to be on R2's wheelchair across the room. On April 17, 2023 at 2:45 PM, R2 was sitting up in bed with his bilateral heels and lateral side of his left foot resting on the mattress. On April 18, 2023 at 10:52 AM, R2 was sitting up in his bed. V16 (CNA-Certified Nursing Assistant) and V17 (CNA) provided incontinence care to R2. R2's incontinence brief was soaked with urine. V16 and V17 said the folded sheet under R2's buttocks and the bed sheet were soaked with urine, approximately 6 to 8 inches from R2's left side. A strong urine odor was present, and the sheets had a dark brown dried ring around the urine-soaked area. A dressing covered a wound on R2's buttocks. On March 10, 2023 at 3:59 PM, V11 (RN) documented, .Writer also noted a wound on his left mid, lateral foot. Wound nurse and MD made aware. The facility does not have documentation to show R2 was seen by the wound care physician for the left lateral wound until April 18, 2023. The EMR shows an order dated March 10, 2023 to paint betadine to left medial lateral heel daily and as needed. The facility does not have documentation to show the wound care was administered on March 14 and 19, 2023. The order was discontinued on March 22, 2023. The EMR shows an order dated March 22, 2023 to paint left medial lateral (no site specified) daily and as needed every day shift for wound. The facility does not have documentation to show the wound treatment was administered on March 23, 27, 28, 29, 2023 and April 1, 6, and 9, 2023. On April 18, 2023 at 11:03 AM, V18 (Agency RN) was asked if she provided wound care to R2's left lateral foot. V18 said, I am from agency. I didn't even look at the TAR. That's up to the wound nurse. On April 18, 2023 at 11:10 AM, V15 (Wound Care Physician) and V3 (Wound Care Nurse) provided wound care to R2. V3 lifted R2's left leg from the bed to visualize R2's left lateral foot (outer foot) pressure ulcer. A second wound was visible on R2's left outer ankle. V3 and V15 did not acknowledge the presence of the ankle wound and did not assess the ankle wound. V3 set R2's leg down on the bed. This surveyor asked V3 if she was aware of a wound on R2's left ankle and V3 said no. This surveyor asked V3 and V15 to re-examine R2's left lateral leg. V3 lifted R2's left leg from the bed a second time, and V15 identified a Stage 2 pressure ulcer on R2's left outer ankle. V15 said the wound on R2's ankle is a Stage 2 pressure ulcer. V3 (Wound Care Nurse) said the wound on R2's left ankle is a newly developed, facility-acquired pressure ulcer as of April 18, 2023 and she was not aware of the pressure ulcer. R2 was turned to his left side. A pressure ulcer was visualized on R2's buttocks. V3 (Wound Care Nurse) continued to say the pressure ulcers on R2's buttocks and left lateral foot are facility-acquired pressure ulcers. V15 said, The wound on R2's left ankle is a Stage 2 pressure ulcer. The wound on his buttocks is a DTI (Deep Tissue Injury). They need to get a low air loss mattress for this resident. Pressure is the cause of his wounds, and if he is not being moved from that position or wearing the foam boots, then floating his feet with a pillow is the best option for him, especially if he refuses the boots. They need to change his position. V15 continued to say R2 was not referred to him to be seen for the pressure ulcer identified on R2's left lateral foot on March 10, 2023, and this was his first assessment of R2's current pressure ulcers. V15 said, If they do not put the residents on a referral list for me to see, then I do not know about the wounds and I do not see the residents. V15's (Wound Care Physician) progress note dated April 18, 2023 shows the following wound documentation: Site #1: Unstageable DTI of the left buttock partial thickness, Etiology: Pressure. Wound size: 2 x 2 x not measureable cm. Recommendations: Off-load wound, turn side to side in bed every 1-2 hours if able; low air loss mattress. Site #2: Stage 2 pressure wound of the left, lateral ankle partial thickness. Etiology: Pressure. Wound size: 0.8 x 0.8 x not measurable cm. Recommendations: Off-load wound, pressure off-loading boot, float heels in bed. Site #3: Stage 2 pressure wound of the left lateral foot, partial thickness. Etiology: Pressure. Wound size: 1.0 x 0.8 x not measurable cm. Recommendations: Off-load wound, pressure off-loading boot, float heels in bed. On April 18, 2023 at 1:26 PM, R2 was sitting up in bed eating lunch. R2's bilateral heels and the lateral side of his left foot were resting on the mattress. R2's heels were not off-loaded and R2 was not wearing foam boots. 2. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE] with multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting his right dominant side, dementia, paroxysmal tachycardia, polyneuropathy, seizures, major depressive disorder, anxiety, repeated falls, peripheral vascular disease, chronic atrial fibrillation, right eye blepharitis, anemia, right shoulder pain, insomnia, anxiety, spinal stenosis, and sciatica. R1's MDS (Minimum Data Set) dated March 17, 2023 shows R1 has severe cognitive impairment, is able to eat with supervision, requires limited assistance with bed mobility, and extensive assistance with all other ADLs (Activities of Daily Living). R1 is frequently incontinent of bowel and bladder. R1's MDS continues to show R1 is at risk of developing pressure ulcers and did not have pressure ulcers at the time of the MDS assessment. On April 14, 2023 at 10:02 AM, V11 (RN-Registered Nurse) documented R1 had a right toe open blister measuring 1 cm (centimeter) by 1 cm. The documentation does not show which of R1's right toes had the open blister, or the location of the blister on R1's toe, the stage of the wound, type of tissue, the surrounding tissue description and presence/absence of pain with the pressure ulcer. On April 17, 2023 at 9:45 AM, R1 was sitting up in a wheelchair in his room. R1's wheelchair did not have foot/leg rests in place and R1's bilateral feet were resting on the floor of his room. R1 had bilateral elastic wraps extending from below his knees to each foot. R1 was wearing non-skid socks over the tops of his feet. The non-skid socks did not cover R1's heels, and his bare heels were resting on the floor. R1's bilateral legs appeared swollen from above his knees to his feet. R1 said, I have a sore on my butt and on my toe and it really hurts. R1 continued to say he has felt panicky lately when lying in bed and has spent the last three weeks sitting up in his wheelchair at night. On April 17, 2023 at 9:58 AM, V11 (RN) said R1 should have his legs elevated off of the floor while sitting in the wheelchair. V11 continued to say R1 has preferred to sit up in his wheelchair over the last three weeks due to shortness of breath. V11 said R1 does not have foam boots to offload his feet while sitting in the wheelchair. On April 17, 2023 at 11:30 AM, R1 continued to sit up in his wheelchair with his feet resting on the floor. On April 17, 2023 at 12:17 PM, V2 (DON-Director of Nursing) said, We did not put in new care plan interventions to address [R1's] pressure ulcer. We were aware he was wanting to sit in the wheelchair and refusing to go to bed over the last three weeks. We did not put interventions in place to prevent a pressure ulcer while he continued to sit up in the wheelchair. On April 18, 2023 at 8:50 AM, R1 was sitting in a wheelchair in his room eating his breakfast. R1's bilateral feet were resting on the floor. A new recliner chair was present in R1's room. R1 said, I have not tried to the recliner yet. On April 18, 2023 at 11:28 AM, V3 (Wound Care Nurse) and V11 (RN) transferred R1 from the wheelchair to his bed to provide wound care. V3 removed the bilateral elastic wraps from R1's lower legs. R1's legs appeared swollen from above his knees to the tips of his toes. His bilateral lower legs were red, with the right lower leg appearing redder than the left lower leg. R1 complained of pain on his right heel. V15 (Wound Care Physician) provided wound care to R1's right great toe. V15 was able to obtain bilateral pulses in R1's feet using a doppler device. V15 said the wound on R1's toe is a Stage 3 pressure ulcer and the wound required debridement. V15 continued to say, The biggest issue for this resident is incontinence and pressure. Also, the fact that he wants to sit in his wheelchair. A recliner will definitely help him offload his feet, or if he would be able to lay in bed for a while and offload his feet. V3 (Wound Care Nurse) turned to V15 and asked if R1's wound treatment should be administered three times a week. V15 said, No. [R1's] pressure ulcer treatment to his right great toe should be administered daily. The EMR shows the following order entered by V3 (Wound Care Nurse) for R1, dated April 18, 2023 at 11:57 AM: Right big toe wound: Cleanse with NS (Normal Saline), pat dry and cover with leptospermum honey, calcium alginate and island dressing every day shift every Tuesday, Thursday, Saturday. On April 18, 2023, V15 documented the following regarding R1's pressure ulcer: Stage 3 pressure wound of the right, first toe, full thickness. Etiology: pressure. Wound size (Length x Width x Depth): 1 x 1.2 x 0.1 cm. Exudate: Moderate serous. Additional wound detail: Venous and arterial are cofactors. Dressing treatment plan: Leptospermum honey apply once daily for 30 days. Alginate calcium apply once daily for 30 days. Secondary dressing(s): Gauze island with border apply once daily for 30 days. Recommendations: Off-load wound, elevate leg(s). No shoes unless open-toed. Plan of care reviewed and addressed: The best medical estimate of the time required for this wound to heal with continued physician evaluation and intervention is 69 days. This estimate is made with an 80 percent degree of certainty. The facility's undated Pressure Injury Prevention and Management Policy shows: Policy: The intent of this organization is to develop and maintain systems and processes to ensure that the resident does not develop pressure ulcers/injuries (PU/PIs) unless clinically unavoidable and that the facility provides care and services consistent with professional standards of practice to: Promote the prevention of pressure ulcer/injury development; promote the healing of existing pressure ulcers/injuries (including prevention of infection to the extent possible); and prevent development of additional pressure ulcer/injury. Evaluation/Assessments: 1. Evaluation/assessment of pressure ulcer/injury will be completed weekly and with significant change in condition of the ulcer/injury by a licensed nurse and/or practitioner. 2. Documentation of the evaluations/assessment of the pressure ulcer/injury will be maintained in the resident's medical record. Documentation may include a. Location of ulcer/injury. b. Date that the ulcer/injury was acquired (when known). C. Description of the ulcer/injury to include stage, measurements (length, width, depth), presence/absence of any tunneling or undermining, type of tissue (epithelial, granulation, sough, necrosis, etc.), presence/absence and type of drainage, surrounding tissue description, and presence/absence of pain with the ulcer/injury. d. Treatment and interventions to promote healing. Treatment Protocols: 1. Treatments will be ordered by the physician/practitioner.5. Treatments, including preventive interventions, will be documented in the resident's medical record. 6. The physician/practitioner will be notified of the resident's refusal of prescribed treatments and/or interventions for prevention and care. Investigations: 1. If the resident develops a facility-acquired or worsening pressure ulcer/injury, the facility will conduct an investigation to causative factors. 2. Interventions to promote healing the acquired or worsening pressure ulcer/injury and to minimize recurrence of development will be incorporated into the resident's care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident who experienced an unwitnessed fall was assessed and provided treatment in a timely manner for 1 of 3 residents (R1) reviewed for quality of care in the sample of 6. This failure resulted in R1 remaining in the facility with multiple rib fractures, a swollen eye, and contusions to both his knees. The findings include: On 1/22/23 at 12:23 PM, V12 (R1's family member) said she arrived at the facility at 8:30 AM on 1/3/23. V12 stated, When I walked in, he was sleeping, but his room looked like a murder scene. I noticed both his knees were red and appeared bruised. There was a thick mattress on the floor beside his bed. His walker was broken and there was blood all over the room. There was drops of blood from the bed to the bathroom and a larger area of blood in the bathroom, by the toilet. It was so awful, I took pictures. Everything on his overbed table had been knocked off and was on the floor. I asked him what happened, and he told me that he turned on his call light around 3:50 AM to go to the bathroom. He said that the CNA (Certified Nursing Assistant) told him no, 'just go in your diaper.' He told me that he decided to go by himself but lost his footing on the mattress and fell onto his walker. He had to hit that walker hard because it was broken, and he ended up with several fractured ribs. I was in tears when he told me what happened to him. I asked the CNA and nurses what happened, but no one knew anything. I waited in the room for a long time. Finally, an agency nurse came in to give him his morning medication, but she wanted no part of it. She said she didn't know anything, and she didn't want to be involved. By then, more of our family members had arrived and we went to the DON's (Director of Nursing's) office, but she wasn't there. Eventually, V2 (DON) came to his (R1's) room, but she said she didn't know anything about him falling. V2 told me that she had been on vacation and hadn't read her emails yet. R1's Face Sheet dated 1/22/23 showed diagnoses to include, but no limited to: spinal stenosis, depression, generalized muscle weakness, repeated falls, osteoarthritis, overactive bladder, hypertension, dementia, prostate cancer, abdominal aortic aneurysm, difficulty walking, and unsteadiness on feet. R1's facility assessment dated [DATE] showed he had moderate cognitive impairment; required limited assistance of one person for bed mobility, transfers, and toilet use; and was always continent of bowel and bladder. R1's Admit-Readmit Screener dated 12/27/22 showed R1 was admitted from an acute care hospital for rehab. This document showed that he had dementia/cognitive impairment and a recent fractured hip. This document showed R1 was alert and oriented to person, time, and situation. R1's Progress Notes were reviewed from 12/27/22 (admission) to 1/3/23 (transfer to the emergency room). There was no documentation of R1's unwitnessed fall by the nursing staff before 1:23 PM. At 1:23 PM, V19 (Agency LPN - Licensed Practical Nurse) charted, Resident was picked up by local ambulance, went out to local hospital accompanied by family per MD orders for further evaluation due to unwitnessed fall. R1's MD Progress Note dated 1/3/23 at 9:17 PM, showed, . Patient see in follow-up today for a fall that was unwitnessed earlier this a.m. (morning). Patient with dementia cannot give history. Discussed with family had significant blood in the room as well as some swelling in the right periorbital (eye) area, has some right chest pain, and bilateral knee pain . General: chronically ill appearing, does not appear stated age . Pain to right rib area . Redness to bilateral knees . Alert, cooperative, confused, cognition deficits noted. Assessments & Plan: .Status post fall: Potential rib injury; patient with trauma unwitnessed to orbital area; bilateral knee contusion; Because patient unable to give history and unwitnessed fall with significant mechanism evidenced by multiple injuries and blood sent here for evaluation. Further recommendation to follow. Discussed with family. Questions answered . The surveyor requested the facility's fall investigation and/or documentation of R1's unwitnessed fall. The facility was unable to provide the requested documentation. On 1/22/23 at 1:42 PM, V6 (RN - Registered Nurse) said after an unwitnessed fall, the nurse should perform a thorough assessment and observe for injuries. The nurse should provide first aid as needed. Then call the MD (Medical Doctor), family representative or POA, and the DON. V6 stated, If there was a lot of blood, a swollen eye, right rib pain, and bilateral knee contusions, then I would call 911. Those injuries would need immediate action. Especially if I didn't know what happened. V6 said the nurse should complete an Incident Report; document the resident assessment and interventions; and document any first aid provided. On 1/22/23 at 1:58 PM, V2 (DON) said after an unwitnessed fall the nurse should assess the resident and provide first aid. Then the nurse should call the MD for further orders; the family/POA should be notified; and the clinical person on call should be notified. The resident assessment and the information about the fall should be documented in the EMR (Electronic Medical Record). The nurse should complete an Incident Report; initiated Post-Fall Assessments; and enter a progress note. The documentation lets everyone know what happened. I don't know why there isn't any documentation of R1's fall. V2 stated, I went to talk to R1, and his family was very upset. The daughter told me there was blood on the floor and on his pillow. R1 told me that he got up, un-assisted, and went to the bathroom. He said he lost his footing on the fall mat and landed on his walker. He complained about pain in both his knees and his knees were red. He told me that he had bilateral knee replacements, so I started palpating areas. He complained of tenderness to his right rib area. I think he had a skin tear on his arm too. R1 denied hitting his head, but just to be safe I called V24 (MD), to get X-ray orders. V24 said he was on his way to the facility, and he would see R1 first. On 1/23/23 at 9:05 AM, V15 (RN) said she worked the night shift on 1/2/23 but was not assigned to R1's room. V15 said if there is an unwitnessed fall, then the nurse must do a head-to-toe assessment, initiate neuro checks according to facility protocol, and notify the MD right away. There should be documentation in the progress notes and an Incident Report completed. The nurse should describe what happened, how the resident looked, where the resident was found, and who was notified. V15 stated, It is very important for resident safety to treat the residents appropriately 24/7. The progress notes let the care team know what is happening with the resident, so we can follow-up and/or continue care. If a resident had an unwitnessed fall, increased pain with breathing or laughing, and soreness to the right ribs, then that would be alarming. The MD should have been notified immediately and the resident sent out for CT, X-rays, etc. I may give the resident pain medication while they wait for EMS to arrive, but they should be sent out for proper evaluation. On 1/27/23 at 11:28 AM, V2 (DON) said R1 reported that he fell during the night, but was unsure of the time. V2 stated, I spoke with the night shift staff and they said he didn't fall during their shift. They said he fell on the previous shift (2P-10P). The evening staff said they had no recollections of any falls and they had been in his room. I have no idea if V24 (MD) was notified of the fall before I called him. I'm not sure the exact time, just that it was before noon on 1/3/23. I should have been notified of R1's fall. They call or text me all hours of the day and night, but I didn't receive anything about this. The nurse should have called R1's POA and MD too. They did not follow the fall protocol and procedure. I didn't see anything charted about the fall or notifications that were made. V2 was asked what complications could arise from multiple rib fractures. V2 said R1 could have become short of breath and/or had a punctured lung. V2 said a thorough assessment showed that R1 needed to be sent to the hospital. On 1/27/23 at 3:13 PM, V24 (MD - medical doctor) said R1 was a recent admission. V24 stated, I don't remember all the specifics, but I think it was an unwitnessed fall. It was pretty bloody. Clinically I thought he was at his baseline. Because of the unknown mechanism of injury and the multiple injuries, I sent him out to the hospital to evaluated. He had rib pain. I wasn't sure if he hit his head. He was cleaned up by the time I got to the facility. I sent him to the emergency room, but he did not return to the facility. I'm not sure what time I was notified of R1's fall. It was in the morning of 1/3/23, but I would have to check my archives and I'm not sure if they go back that far. The surveyor requested V24 his phone/text archives and report the time he was notified. V24 did not call to provide the information. The facility's undated Assessing Falls and Their Causes Policy showed, The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall . After a Fall: 1. If a resident has just fallen or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine, and extremities. 2. Notify a licensed nurse to evaluate the resident for potential injury. 3. Obtain and record vital signs as soon as it is safe to do so. 4. If there is evidence of injury, provide appropriate first aid and/or obtain medical treatment immediately. 5. If an evaluation rules out significant injury, help the resident to a comfortable sitting, lying, or standing position, and document relevant details. 6. Notify the resident's attending physician/practitioner and family in an appropriate time frame. a. When a fall results in a significant injury or condition change, notify the practitioner immediately. b. Provide first aid/treatment as appropriate, notify EMS and/or arrange transport to the Emergency Department for further evaluation/treatment as needed and/or ordered . 8. Document the presence/absence of observed signs or symptoms of pain, swelling, bruising, deformity, and/or decreased mobility; and any changes in the level of responsiveness/consciousness and overall function. Note the presence or absence of significant findings. 9. If the resident hit their head or the fall was unwitnessed, complete and documented neurological checks per facility protocol and/or physician order. 10. Complete an incident report for resident after the fall occurs. The incident report form should be completed by the licensed nurse with input from other staff as appropriate and submitted to the Director of Nursing Services . The facility's undated Change in a Resident's Condition Policy showed, The facility will promptly notify the resident, his or her physician/practitioner, and representative of changes in the resident's medical/mental condition and/or status . Specific Procedures/Guidance: 1. The nurse will notify the resident's Attending Physician/practitioner or physician on call when there has been a (an): a. accident or incident involving the resident . g. need to transfer the resident to a hospital . 2. Prior to notifying the physician/practitioner, a nurse will notify the resident's representative when: a. The resident is involved in any accident that results in an injury including injuries of an unknown source . 7. The nurse/designee will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide toilet assistance to prevent an unwitnessed fall; failed to follow the facility's fall protocol; and failed to assess a resident following an unwitnessed fall. These failures resulted in R1 sustaining multiple rib fractures, swelling to his right eye, and bilateral knee contusions. The facility failed to ensure fall interventions were in place for a resident with multiple falls (R3). This applies to 2 of 3 residents (R1, R3) reviewed for falls in the sample of 6. The findings include: 1. On 1/22/23 at 12:23 PM, V12 (R1's family member) said she arrived at the facility at 8:30 AM on 1/3/23. V12 stated, When I walked in, he was sleeping, but his room looked like a murder scene. I noticed both his knees were red and appeared bruised. There was a thick mattress on the floor beside his bed. His walker was broken and there was blood all over the room. There was drops of blood from the bed to the bathroom and a larger area of blood in the bathroom, by the toilet. It was so awful, I took pictures. Everything on his overbed table had been knocked off and was on the floor. I asked him what happened, and he told me that he turned on his call light around 3:50 AM to go to the bathroom. He said that the CNA (Certified Nursing Assistant) told him 'no, just go in your diaper.' He told me that he decided to go by himself, but lost his footing on the mattress and fell onto his walker. He had to hit that walker hard because it was broken, and he ended up with several fractured ribs. I was in tears when he told me what happened to him. I asked the CNA and nurses what happened, but no one knew anything. I waited in the room for a long time. Finally, an agency nurse came in to give him his morning medication, but she wanted no part of it. She said she didn't know anything, and she didn't want to be involved. By then, more of our family members had arrived and we went to the DON's (Director of Nursing's) office, but she wasn't there. Eventually, V2 (DON) came to his (R1's) room, but she said she didn't know anything about him falling. V2 told me that she had been on vacation and hadn't read her emails yet. R1's Face Sheet dated 1/22/23 showed diagnoses to include, but no limited to: spinal stenosis, depression, generalized muscle weakness, repeated falls, osteoarthritis, overactive bladder, hypertension, dementia, prostate cancer, abdominal aortic aneurysm, difficulty walking, and unsteadiness on feet. R1's facility assessment dated [DATE] showed he had moderate cognitive impairment; required limited assistance of one person for bed mobility, transfers, and toilet use; and was always continent of bowel and bladder. R1's Admit-Readmit Screener dated 12/27/22 showed R1 was admitted from an acute care hospital for rehab. This document showed that he had dementia/cognitive impairment and a recent fractured hip. This document showed R1 was alert and oriented to person, time, and situation. R1's Morse Fall Scale dated 12/27/22 showed R1 was at High Risk for Falling, with a score of 95. R1's Care Plan initiated 12/27/22 showed, R1 is at risk for falls r/t (related to) dementia and recent fall at home . fell on 1/3/23 and was sent to the hospital for an evaluation. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance . Follow facility fall protocol. R1's Progress Notes were reviewed from 12/27/22 (admission) to 1/3/23 (transfer to the emergency room). There was no documentation of R1's unwitnessed fall by the nursing staff before 1:23 PM. At 1:23 PM, V19 (Agency LPN - Licensed Practical Nurse) charted, Resident was picked up by local ambulance, went out to local hospital accompanied by family per MD orders for further evaluation due to unwitnessed fall. R1's MD Progress Note dated 1/3/23 at 9:17 PM, showed, . Patient see in follow-up today for a fall that was unwitnessed earlier this a.m. (morning). Patient with dementia cannot give history. Discussed with family had significant blood in the room as well as some swelling in the right periorbital (eye) area, has some right chest pain, and bilateral knee pain . General: chronically ill appearing, does not appear stated age . Pain to right rib area . Redness to bilateral knees . Alert, cooperative, confused, cognition deficits noted. Assessments & Plan: .Status post fall: Potential rib injury; patient with trauma unwitnessed to orbital area; bilateral knee contusion; Because patient unable to give history and unwitnessed fall with significant mechanism evidenced by multiple injuries and blood sent here for evaluation. Further recommendation to follow. Discussed with family. Questions answered . The surveyor requested the facility's fall investigation and/or documentation of R1's unwitnessed fall. The facility was unable to provide the requested documentation. On 1/22/23 at 1:58 PM, V2 (DON) said after an unwitnessed fall the nurse should assess the resident and provide first aid. Then the nurse should call the MD for further orders; the family/POA should be notified; and the clinical person on call should be notified. The resident assessment and the information about the fall should be documented in the EMR (Electronic Medical Record). The nurse should complete an Incident Report; initiated Post-Fall Assessments; and enter a progress note. The documentation lets everyone know what happened. I don't know why there isn't any documentation of R1's fall. V2 stated, I went to talk to R1, and his family was very upset. The daughter told me there was blood on the floor and on his pillow. R1 told me that he got up, un-assisted, and went to the bathroom. He said he lost his footing on the fall mat and landed on his walker. He complained about pain in both his knees and his knees were red. He told me that he had bilateral knee replacements, so I started palpating areas. He complained of tenderness to his right rib area. I think he had a skin tear on his arm too. R1 denied hitting his head, but just to be safe I called V24 (MD), to get X-ray orders. On 1/22/23 at 8:25 PM, V17 (CNA - Certified Nursing Assistant) said he works the overnight shift (10P-6A), and he was assigned to R1 that night. V17 stated, He didn't fall for me. I haven't had a fall on my watch for months. I think R1 fell right before I came in. I have the same routine. I come in, get report, and collect my supplies for rounds. When I walked past R1's room, he was in bed, so I didn't think anything of it. I was in R1's room around 10:30 PM and noticed all the blood. There were drops of blood on the floor from R1's bed to the bathroom. I turned on the bathroom light and there was a pool of blood near the bathroom. I was like, WTH (what the hell)! I told the nurses right away and they said he'd been falling all day. I took a towel a tried to sop up the blood. The nurses from the previous shift was still there and stated, Oh, he fell. I basically was sitter with him that night. That's how I know he didn't fall on my shift. We use a lot of agency staff, so I don't know most of their names. I told the nurse that she needed to check his elbow because it was cut, and he had a few scratches on his face. I'm not sure what she did when she went in the room. On 1/23/23 at 9:05 AM, V15 (RN) said she worked the night shift on 1/2/23 but was not assigned to R1's room. V15 said if there is an unwitnessed fall, then the nurse must do a head-to-toe assessment, initiate neuro checks according to facility protocol, and notify the MD right away. There should be documentation in the progress notes and an Incident Report completed. The nurse should describe what happened, how the resident looked, where the resident was found, and who was notified. V15 stated, It is very important for resident safety to treat the residents appropriately 24/7. The progress notes let the care team know what is happening with the resident, so we can follow-up and/or continue care. If a resident had an unwitnessed fall, increased pain with breathing or laughing, and soreness to the right ribs, then that would be alarming. V15 said she was not assigned to R1's room; V21 (RN) was R1's nurse that night shift. On 1/23/23 at 12:07 PM, V21 (RN) said she remembers R1, and he was a very nice man. R1 was in bed and slept most of the night. R1 did not tell me about the fall, but I know he didn't fall on my shift. V21 stated, If R1 had an unwitnessed fall, then the previous nurse should have done a head-to-toe assessment. I did not receive report of any inquiries. If I had known, then R1 would have been on neuro checks and more frequent assessments. I don't know the nurses name, she was agency. She should have been the one to complete the Incident Report and document R1's fall. On 1/23/23 at 3:44 PM, V22 (RN) said she was familiar with R1. V22 stated, I think he fell twice that same night. One of the agency nurses had R1 and she didn't do anything. V17 (CNA) came to me and said that there was blood on R1's floor and his elbow was bleeding. R1 wasn't assigned to me, but I went in to check on him. There was blood all over the room. There was blood over by the window, which was 15 - 20 feet across his room. I told the agency nurse about it, and she said that he was found on the floor mat, next to his bed earlier in the shift. I was in his room around 10:30 PM with V17 (CNA). The agency nurse came down but was overwhelmed. R1 had a skin tear to his elbow. I don't know if the agency nurse did anything. When I told her about the blood in R1's room, the agency nurse replied, 'I didn't know he fell again. I can't do 2 falls in 1 shift!' I asked her if he could get out of bed, and she said she didn't know. The agency staff doesn't know anything about these residents, and they don't seem to know how to use the EMR (Electronic Medical Record). I'm not surprised there isn't any documentation. The communication is poor, and care can be disconnected because we have so much agency staff right now. V17 (CNA) was the one that asked if we could put a dressing on R1's skin tear, but the agency nurse didn't want anything to do with it. They don't want to be responsible for anything. I placed the dressing on R1's arm and left. I had my own assignment to take care of. I wouldn't be surprised if the agency CNA told him to go in his diaper, either. On 1/23/23 at 2:23 PM, V20 (Agency CNA) said she had been taking an assignment regularly at the facility since September. V20 stated, I remember R1, he was big sweetie. He used a walker and had a wheelchair. R1 could go to the bathroom with a 1 person assist. Basically, we were just there to keep him steady. He did really well. R1 would turn on his call light when he needed to go to the bathroom. He was continent but needed help to get to the bathroom. He would only try to get up by himself if someone wouldn't help him. I came in at 6 AM that day (1/3/23). I get report then start my rounds. He usually likes to sleep in a little bit, so his daughter made it to the room before I did. She expressed that he had a skin tear on his arm, and it was bleeding. She said she wasn't too sure what happened. I told the nurse and went back to check on him. He told me that he turned on his call light, to go to the bathroom, around 4 AM. He said that the CNA wouldn't take him to the toilet and told him to go in his diaper. R1 said that he tried to go to the bathroom himself but fell. he said he broke his walker. I could see the broken walker and a sharp part that had blood on it, where he probably cut his arm. He said he crawled to the bathroom. R1 said he yelled for help in the bathroom, but no one came, so he crawled back to bed. I did notice that his knees were really red. He was complaining of some pain to his right abdominal area when he laughed, talked, and sat up. That was a new pain for him. I told the nurse. I believe V6 (RN) did an assessment and said R1's knees were really red. R1 told her that's because I was crawling on the floor. There were little droplets of blood on the floor and in the bathroom, probably from his arm. The blood had dried up, so I had to call housekeeping to come clean it up. The walker was up against the wall, and I could see that it was broken. There was a thick mattress next to his bed. I'm sure that was hard for him to walk on. He was able to tell me what happened, but he wasn't sure who the CNA was that told him to go in his diaper. The CNA probably knew he had a diaper on and that's why they just told him to go in it. I was so surprised because he is one of the easiest residents to transfer. On 1/27/23 at 11:17 AM, V16 (CNA) said she was working the day shift on 1/3/23. V16 stated, I remember R1 telling me that he fell. He said that someone refused to take him to the bathroom, so he went by himself. He looked frustrated and irritated. This was around 6:30 - 7 AM. R1 had a scratch on his elbow. I told the nurse about it, she was an agency nurse, I don't know her name. I believe she did go and check on him. I remember he was very upset and so was his family. The whole situation with R1 was just not okay. He is an easy transfer, that's why I'm so confused that this happened. No one should refuse to take a resident to the bathroom and tell them to go in their diaper. That's just awful. R1 was able to tell us when he needed to go to the bathroom and was rarely incontinent. On 1/27/23 at 12:07 PM, V19 (Agency LPN) said she only worked one day at the facility and that was enough. V19 stated, I don't remember R1 by name, but I remember the incident. Nobody told me anything about a fall in report. But the family said that R1 turned on his call light overnight and staff refused to take him to the toilet, so he took himself. He crawled to the bathroom and back to bed. His knees were red, and his elbow had a skin tear. I had no part of the fall, and I didn't want any part of it. R1 was part of my assignment that day (1/3/23), but I didn't want to get involved in that mess. The family was very upset, so I excused myself from that too. They were getting pretty loud. I gave R1 his medications and got out of there. I apologized to them because of the negligence of the previous shift. I won't ever go back there. On 1/27/23 at 11:28 AM, V2 (DON) said R1 reported that he fell during the night, but was unsure of the time. V2 stated, I spoke with the night shift staff and they said he didn't fall during their shift. They said he fell on the previous shift (2P-10P). The evening staff said they had no recollections of any falls and they had been in his room. I have no idea if V24 (MD) was notified of the fall before I called him. I'm not sure the exact time, just that it was before noon on 1/3/23. I should have been notified of R1's fall. They call or text me all hours of the day and night, but I didn't receive anything about this. The nurse should have called R1's POA and MD too. They did not follow the fall protocol and procedure. I didn't see anything charted about the fall or notifications that were made. On 1/27/23 at 3:13 PM, V24 (MD - medical doctor) said R1 was a recent admission. V24 stated, I don't remember all the specifics, but I think it was an unwitnessed fall. It was pretty bloody. Clinically I thought he was at his baseline. Because of the unknown mechanism of injury and the multiple injuries, I sent him out to the hospital to be evaluated. He had rib pain. I wasn't sure if he hit his head. He was cleaned up by the time I got to the facility. I sent him to the emergency room, but he did not return to the facility. I'm not sure what time I was notified of R1's fall. It was in the morning of 1/3/23, but I would have to check my archives and I'm not sure if they go back that far. The surveyor requested V24 his phone/text archives and report the time he was notified. V24 did not call to provide the information. The facility's undated Assessing Falls and Their Causes Policy showed, The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall . General Guidelines - 1. Falls are a leading cause of morbidity and mortality among the elderly in nursing homes . 4. Residents will be assessment upon admission and regularly afterward for potential risk of falls. Relevant risk factors must be addressed promptly . After a Fall: 1. If a resident has just fallen or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine, and extremities. 2. Notify a licensed nurse to evaluate the resident for potential injury. 3. Obtain and record vital signs as soon as it is safe to do so. 4. If there is evidence of injury, provide appropriate first aid and/or obtain medical treatment immediately. 5. If an evaluation rules out significant injury, help the resident to a comfortable sitting, lying, or standing position, and document relevant details. 6. Notify the resident's attending physician/practitioner and family in a appropriate time frame. a. When a fall results in a significant injury or condition change, notify the practitioner immediately. b. Provide first aid/treatment as appropriate, notify EMS and/or arrange transport to the Emergency Department for further evaluation/treatment as needed and/or ordered . 8. Document the presence/absence of observed signs or symptoms of pain, swelling, bruising, deformity, and/or decreased mobility; and any changes in the level of responsiveness/consciousness and overall function. Note the presence or absence of significant findings. 9. If the resident hit their head or the fall was unwitnessed, complete and documented neurological checks per facility protocol and/or physician order. 10. Complete an incident report for resident after the fall occurs. The incident report form should be completed by the licensed nurse with input from other staff as appropriate and submitted to the Director of Nursing Services. Defining Details of Falls: 1. After an observed or probably fall, clarify the details of the fall, such as when or where the fall occurred and what the individual was trying to do at the time the fall occurred. 2. After an unwitnessed fall, document observations of the resident's location, position, and possible environmental factors. 3. Observe to see if care plan interventions were in place at the time of the fall . Identifying Causes of a Fall or Fall Risk: 1. Immediately begin to try to identify possible or likely causes of the incident . 2. Evaluate possible chains of events (trends/patters) or circumstances preceding a recent fall, including: a. Time of day of the fall; b. Time of last meal; c. What the resident was doing; d. Whether the resident was standing, walking, reaching, or transferring from one position to another; e. Whether the resident was among other persons or alone; f. Whether the resident was trying to get to the toilet; g. Whether any environmental risk factors were involved . g. Whether there is a pattern of falls for this resident. 3. Continue to collect and evaluate information until the cause of falling is identified or it is determined that the cause cannot be found. 4. As indicated, the attending physician/practitioner may examine the resident or may initiate testing to try to identify causes. 5. Consult with the attending physician/practitioner or medical director to confirm specific causes from multiple possibilities. When possible, document the basis for identifying specific factors as the causes. 6. If the cause is unknown but no additional evaluation is done, the physician/practitioner or nursing staff should note why . Documentation - When a resident falls, the following information should be recorded in the resident's medical record: 1. The condition in which the resident was found . 2. assessment dated , including vital signs and any obvious injuries. 3. Interventions, first aid, or treatment administered. 4. Notification of the physician and family, as indicated. 5. Completion of a falls risk assessment per facility protocol. 6. Appropriate interventions taken to prevent future falls. 7. The signature and title of the person reporting the data. Reporting - 1. Notify the following individuals when a resident falls: a. The resident's family; b. The Attending Physician/Practitioner (timing of notification may vary, depending on whether injury was involved); c. The Director of Nursing Services and/or licensed nurse. 2. Report other information in accordance with facility policy and professional standards of practice. 2. On 1/22/23 at 9:59 AM, the door to R3's room was open. The surveyor was standing next to V8 (LPN), at the medication cart, facing R3's room. R3 was lying on her right side in bed. R3 was fully clothed, lying on top of her bed linens. R3's was laying in a side-lying position with her knees and ankles bent. R3's legs were off the bed from her mid-thigh down. R3's knees were hanging down and her ankles were resting in the seat of her wheelchair. R3's wheelchair was parked parallel to her bed. There was a thick fall matt leaning against the wall, on the opposite side of R3's room. V8 did not intervene. R3's roommate had family visiting and they left the room, speaking to V8. R3 was sleeping on an air mattress. R3's Facesheet dated 1/22/23 showed diagnoses to include, but not limited to: diabetes, dementia, osteoarthritis, depression, peripheral vascular disease, polyarthritis, kyphosis, repeated falls, and abnormalities of gait and mobility. R3's facility assessment dated [DATE] showed R3 had severe cognitive impairment; required extensive assistance of one staff member for bed mobility, transfers, and toilet use; was not steady and required staff assistance to stabilize; was always incontinent of bowel and bladder. R3's Morse Fall Scale dated 1/6/23 showed she was a High Fall Risk, with a score of 75. R3's Care Plan revised 1/12/23 showed, R3 has impaired cognitive function/dementia or impaired thought processes AEB (as evidenced by) BIMS = 5 . Interventions: .Cue, reorient, and supervise as needed . R3's Care Plan revised 1/12/23 showed, R3 has a communication problem r/t (related to) dementia, impaired hearing and vision . Interventions: Ensure/provide a safe environment: Call light in reach. Adequate low glare light. Bed in lowest position and wheels locked . R3's Care Plan revised 1/17/23 showed, R3 has had an actual fall with no injury, at risk for falls d/t (due to) impaired cognition and safety awareness, impaired mobility, and dx (diagnosis of) dementia. Self reported fall on 11/2/22, claimed she rolled out of bed with no injury . Interventions: . When resident is in bed, fold up her w/c (wheelchair) and put it across the room (post fall 1/1/23). Provide assist with transfer and bed mobility, as necessary . The facility's Incident Report dated 10/22/22 to 1/22/23 showed R3 had 1 witnessed fall and 4 unwitnessed falls (in 3 months). On 1/22/23 at 1:49 PM, V8 (LPN) said R3 has dementia and is alert to self only. V8 stated, She had a history of falls at home. We try to keep her busy in activities during the day, but sometimes she wheels herself back to her room. If we see R3 in her room, we try to bring her back out unless the CNA has time to take her to the bathroom. R3 is only supposed to be in bed in the low position with the fall matt in place. She can transfer herself back to bed, but she's not supposed to. The fall mat should be next to the bed, whenever she's in bed. The surveyor described how R3 had her legs hanging off the bed, with her feet in the seat of the wheelchair. V8 stated, She shouldn't have been positioned like that. She could have slipped right off the bed. R3 has an increase of falling and a higher risk of injury (with the fall mat not in place). I'm not sure how that happened. On 1/23/22 at 1:58 PM, V2 (DON) said fall interventions should be in place. The interventions were put in place to prevent falls and/or prevent serious injury if the resident falls.

Based on interview and record review, the facility failed to monitor lab results and failed to provide physician treatments to a resident with an arterial wound. This applies to 1 of 3 residents (R1) reviewed for lab monitoring and wounds in a sample of 15. This failure resulted in a delay of treating R1 for a low hemoglobin level causing him to experience symptoms which would have improved with treatment. Findings include: 1. admission record dated 12/15/2022 documents R1 admitted to the facility 11/10/2022 with diagnoses to include post amputation, anemia, and kidney transplants. On 12/9/2022 at 11:20 AM V10 (R1's Daughter) stated the facility is not doing labs frequently enough and R1 was eventually sent for a blood transfusion but she feels the blood transfusion should have been done sooner. R1 confirmed he was more tired and didn't feel good prior to receiving the blood transfusion. R1's Laboratory Report dated 12/1/2022 documents a Complete Blood Count (CBC) dated 11/14/2022 with results showing a hemoglobin level of 8.2 grams/deciliter (gm/dL) and a normal range of 14-18 gm/dL. R1's Order Listing Report dated 11/10-12/13/2022 documents physician orders to complete a CBC on 11/25/2022. R1's Laboratory Report dated 12/1/2022 documents a CBC dated 11/25/2022 with results showing a hemoglobin level of 7.1 gm/dL (normal range of 14-18 gm/dL). R1's Order Listing Report dated 11/10-12/13/2022 documents physician orders to complete a Complete Blood Count (CBC) on 11/28/2022. R1's Laboratory Report dated 12/1/2022 does not show a CBC was completed 11/28/2022 and documents the next CBC on 12/1/2022 which shows R1's hemoglobin level as 6.2 gm/dL (normal range of 14-18 gm/dL). V5's (Physician Assistant) Progress Note dated 12/1/2022 documents R1 with a low hemoglobin and V10 reporting R1 being fatigued. V5 ordered to repeat a stat CBC and a plan to send R1 to the emergency room if the repeat hemoglobin is below 7 gm/dL. R1's Progress Notes dated 12/1/2022 at 10:11 PM documents R1's repeat CBC result with a hemoglobin of 6.2 and R1 complaining of being tired the entire shift. V5 was contacted and ordered R1 sent to the emergency room for evaluation. This note further documents R1 transferred at approximately 8:05 PM. On 12/13/2022 at 1:30 PM V5 stated R1's hemoglobin that was low on 11/25/2022 should have been repeated in 2-3 days. V5 stated once she became aware of R1's hemoglobin of 6.2 gm/dL on 12/1/2022 when a stat CBC was completed and R1 was sent out for a blood transfusion. V5 stated there was a glitch and the order was not relayed in the system correctly. V5 confirmed R1's low hemoglobin was likely the cause of his symptoms (tired and not feeling well) and if the lab was completed timely as ordered on 11/28/2022, R1 would likely have been sent for blood transfusion or an emergency room evaluation sooner. V5 stated R1's care was delayed causing him to suffer from symptoms which would be improved with treatment. 2. On 12/9/2022 at 11:20 AM R1 had a wrapped gauze dressing to his left hand. R1's 11/10-12/13/2022 Order Listing Report documents an order dated 11/19/2022 to cleanse R1's left second finger with normal saline and paint with betadine every 3 days and as needed. R1's Wound Report, completed by V14 (Wound Physician) dated 11/18/2022, documents an initial evaluation of R1's wounds which include an arterial wound to the left second and fourth fingers. V14 documents a treatment order for the left second finger to include leptospermum Honey three times per week and apply a dressing. R1's 11/10-12/13/2022 Order Listing Report and November-December 2022 Treatment Administration Record does not document R1's order being changed from betadine to leptospermum Honey and R1's left second finger wound was treated with betadine during this period. On 12/15/2022 at 2:50 PM V14 stated R1 was admitted with multiple different wounds and the betadine was supposed to be applied to the wound on the left fourth finger, not the second finger. V14 stated he expects the facility to follow and implement his orders. V14 further stated that the left second finger has a significant vascular issue and a vascular surgeon evaluation was recently ordered and pending. V14 stated that particular arm has a fistula that has issues and has obstructed blood flow. V14 confirmed R1's treatment should have been changed but stated he doubts any treatments will be effective until the vascular issue is addressed. The Brief Interview of Mental status date 11/16/2022 documents R1 as cognitively intact.