**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that staff administer prescribed PRN (as needed) blood pressure medication for a resident; failed to assess and document vital signs for a resident with a change in condition; and failed to monitor and document a resident's blood sugar as ordered. This failure affected one (R2) of three residents reviewed for nursing care and resulted in R2 becoming unresponsive while at the facility and required hospitalization and treatment that included intubation and being admitted to the intensive care unit (ICU) for treatment of septic shock and healthcare associated pneumonia. Findings include: R2 is [AGE] years old and was originally admitted to the facility on [DATE], face sheet listed the following medical diagnosis among others: Dysphagia following cerebral infarction, type 2 diabetes, hypertensive heart and chronic heart disease, essential primary hypertension, systemic lupus erythematous, acquired absence of right leg, unspecified viral hepatitis C, etc. Hospital record dated 3/6/2025 states in part, patient brought in ALS per Emergency Medical Service (EMS). EMS called uncontrolled blood pressure, upon arrival at nursing home EMS states unresponsive and diaphoretic with shallow respirations. The same hospital record documented in part, [AGE] year-old male with past medical history of diabetes, CKD, hypertension .presents to the emergency department from nursing home via EMS for evaluation after he became unresponsive. Reportedly, his blood pressure was uncontrolled earlier, (unclear if it was low or high) and then he became unresponsive and diaphoretic with shallow respirations. Patient was intubated on 3/6/2025 at 6:01am, lab revealed positive RSV, chest x-ray with possible pneumonia, clinical impression septic shock and health care associated pneumonia. Review of physician orders showed the following: clonidine HCl Tablet 0.1 MG Give 1 tablet by mouth three times a day for antihypertensive. Hydralazine HCl Tablet 10 MG Give 10 milligram by mouth every 6 hours as needed for Elevated blood pressure. Give for SBP over 160 and DBP over 100. Blood Glucose Fingerstick Monitoring BID at breakfast & dinner. Call MD if BS is under 70___ or over _250__. two times a day for diabetic monitoring. Order date 10/25/2024. Medication administration record for the month of March 2025 showed that R2 received only one dose of the ordered PRN (as needed) hydralazine on 3/6/2025 at 0100. Last vital [NAME] documented for R2 was on 2/25/2025 prior to the one documented by V8 on 3/5/2025. Last blood sugar documented was on 2/25/2025 prior to the 3/6/2025. Per record review, R2 was observed with poor appetite for breakfast and lunch and diminished lung sounds with rumbling upon auscultation as documented in progress note dated 3/3/2025at 15:08. Medical doctor was notified and an order for respiratory panel and chest x-ray was obtained. 3/32025 at 15:10, respiratory panel was collected and placed in the soiled utility refrigerator. Laboratory result dated 3/4/32025 stated that R2's lab was canceled due to an unlabeled specimen. There was no follow up documentation to the collected sample, no assessment or vital signs documented for the resident the rest of 3/3/2024 and all three shifts on 3/4/2025. Laboratory result dated 3/4/32025 stated that R2's lab was canceled due to an unlabeled sample. Repeat lab result dated 3/5/2025, reported at 20:18 showed that R2 tested positive for RSV. 3/5/2025 at 13:04, V9 (LPN) documented the following: During med pass writer heard congestion during breathing in the resident, writer contacted Primary doctor to alert of s/s, order for Geri-tussin DM 10ML three times a day for 10 days PO (by mouth), cont. to monitor. V9 did not document any assessment or vital signs for R2 after she made this observation. On 4/2/2025 at 11:41AM, V9 (LPN) said that said that she assessed R2 and noted that he was having a respiratory issue and coughing, there was an outbreak of RSV in the facility, so she called the doctor and received an order for cough syrup. V9 said that R2 should have gone out the same day but she followed the order. Care plan initiated 12/25/2022 states that R2 have altered cardiovascular status r/t CHF, Hypertension, and heart disease. Interventions include assess for shortness of breath and cyanosis every shift as needed, monitor vital signs, notify MD of significant abnormalities, monitor/document/report PRN any changes in lung sounds on auscultation (i.e. crackles), edema and changes in weight, monitor/document/report PRN any s/sx of CAD: chest pain or pressure especially with activity, heartburn, nausea and vomiting, shortness of breath, excessive sweating, dependent edema, changes in cap refill, color/warmth of extremities. On 3/5/2025 19:07:20, V8 (RN) documented the following Writer observed that the resident refused to communicate with him when asked a question, he looks confused, refuses to take his medication and dinner. V/S (vital signs) BP.166/85. P.98. T.97.8. SPO2 87. writer assists with 2 liters of oxygen, will continue to monitor. On 4/1/2025 at 4:05PM, V8 (RN) said that he is familiar with R2, when he came to work on 3/5/2025, the outgoing nurse told him to monitor resident's respiration; V8 continued passing medications and decided to check his lab results. V8 called the doctor to report a positive RSV result for R2 but the doctor did not answer, V8 faxed the result to the doctor. V8 called the DON (Director of Nursing) to let her know and she advised him to follow up with the doctor. Night shift nurse came and V8 handed over to her, he is not sure what the blood pressure was at that time. Vital sign documented by V8 at 23:57 is as follows: B/P 166/98, Pulse 127, T-97.8 02 sat 94%, no respiratory rate charted. V8 was asked if he gave R2 any PRN (as needed) blood pressure medicine and he said, I did not know that the resident have such medication, I don't really know the resident because I hardly work that set, it was the night nurse that informed me that resident have a PRN hydralazine and I even went with her to pull it. On 3/6/2025 at 03:16, V5 documented the following: Writer observed resident sweating, lethargic, not verbally responsive with labored breathing. Vitals 160/89, Temp.99.0 Pulse 84 on oxygen, BS 90. CO -nurse called EMS. EMS arrived at the facility @ 0301. On 4/1/2025 at 1:08PM, V5 (RN) said that she is familiar with R2 and was the person that sent him to the hospital 3/6/2025. V5 came to work at 11:00PM and was notified by the outgoing nurse that R2 was not feeling well. V5 assessed the resident with the outgoing nurse and noted that his blood pressure was elevated, the outgoing nurse made some calls while V5 stayed with the resident. V5 rechecked resident's vitals and his blood pressure got higher, she medicated resident with a PRN blood pressure medicine and Tylenol for elevated temperature. V5 said that resident's blood pressure and temperature came down a little after the medication, but the respiration remains shallow, and resident was unresponsive. V5 said that the physician did not call back until early morning and she informed him that resident was sent to the hospital. V5 added that resident is usually responsive but not that night. Medication administration record for the month of March 2025 showed that R2 received only one dose of the ordered PRN hydralazine on 3/6/2025 at 0100. Last vital [NAME] documented for R2 was on 2/25/2025 prior to the one documented by V8 on 3/5/2025. Last blood sugar documented was on 2/25/2025 prior to the 3/6/2025. On 4/2/2025 at 11:22AM, V10 (Primary Physician) said that R2 was sent to the hospital immediately and his test came back positive for RSV; he was treated and he came back to the facility. Surveyor informed V10 that R2 did not return to the facility and presented the documentation by the nurse that they called with the positive RSV result and V10 did not call back until the morning after the resident has been sent out. V10 then said that he must have mistaken this admission with resident's previous hospital visit, V10 added that he keeps his phone with him all the time and always calls the facility back. If the nurse thinks that something is wrong with a patient and the doctor does not answer then they can call the DON and make the decision to send out the resident; they don't have to wait for the doctor to take an action. On 4/12025 at 3:12PM, V2 (DON) said that nurses are supposed to check blood sugar and vital signs as ordered and it should be documented in the MAR (Medication Administration Record) or in the vitals section of the medical record. On 4/2/2025 at 10:30AM, V2 (DON) said that the protocol to follow when staff cannot reach the physician is to call the medical director, all the nurses are aware of this, if they cannot reach the physician they should continue trying and inform the DON of what is going on. V2 added that the rule of thumb is to reach for the nurse practitioner first, then the attending physician and the medical director if needed. Job description for registered nurse and licensed practical nurse document (undated) states in part: The basic functions: under the direction of the physician is responsible for total nursing care to all residents on assigned unit during the assigned shift including responsibility for delegation of duties, resident nursing care, staff performance and adherence by staff members to facility policies and procedures. Essential duties: 3. Administer prescribed medications and treatments according to policy and procedure, evaluate treatment effectiveness on a continuing basis. 9. Recognize significant changes in the condition of residents and take necessary action. 10.Document nursing care rendered, resident response, and all other pertinent and necessary data as outlined in facility's policies and procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to supervise one resident (R2) who was diagnosed with Dementia, cognitively impaired with a history of falls and identified as high fall risk from sustaining three falls within forty-five days. This affected one of three residents (R2) reviewed for falls. This failure resulted in R2 sustaining an unwitnessed fall with a laceration to the back of the head injury requiring suture and staple repair and sustaining another fall with a laceration to the back of the head requiring staples. Findings include: R2 was admitted to the facility on [DATE]with a diagnosis of type II diabetes, dementia, psychosis, Alzheimer's disease, anemia, encephalopathy, and history of falling. R2's Minimum Data Set, dated [DATE] documents brief interview for mental status score a 3/15 which indicate severe cognitive impairment. R2's fall risk dated 8/26/24 documents R2 at risk for falls. R2's psycho therapy progress note dated 8/15/24 documents: chief complaint: follow up on restlessness and dementia. Info gathered from staff: staff report patient is less anxious, less restless, confused, tries to get up at times with no assistance, requires close monitoring. Patient seen sitting on wheelchair by the nurses' station, appears comfortable, pleasantly confused. Denies anxiety or depression. denies sleep and appetite concerns. Patient is being continuously monitored by staff for safety due to unsteady gait and trying to get up with no help. R2's incident report dated 8/17/24 documents: Resident noted face down on the side of her bed. Resident was assessed head to toe. No injury noted. R2 assisted back to wheelchair. Under mental status: disoriented but within normal limits for this resident, oriented to person. Under predisposing physiological factor: impaired memory; Under predisposing situation factors- ambulating without assistance. On 10/3/24 at 12:32PM, V11 (Restorative nurse) R2 is confused due to diagnosis of dementia and she can be restless. V11 said R2's fall on 8/17/24 was due to R2 unaware of safety needs. V11 said R2 has dementia and may do things that are unsafe. Interventions placed were x-rays, toileting before and after meals, and floormats were added. R2 is in the busy bee program during the day and should be monitored by staff. R2 needs to be in a high visual area when out of bed. R2 will sometimes be at the nursing station after activities so staff are present. R2 has a behavior of standing up from her wheelchair. R2's incident report dated 9/1/24 documents: Writer was informed by another staff that resident was on the floor. Writer observed laceration to the back of head and resident was bleeding. Under mental status: disoriented but within normal limits for this resident, oriented to person. Under predisposing situation factors documents restless. Facility reportable dated 9/1/24 documents: R2 had an unwitnessed fall on 9/1/24 around 6:26PM at the nurse's station. Resident was unable to state what occurred. Full body assessment noted bleeding from the head. Md notified and order to the hospital for evaluation. Resident retuned with a diagnosis of laceration to the head and four staples to the area. Under Final: Based off the facility investigation, it can be determined that the resident had a fall event due to standing from her wheelchair, causing it to tilt backwards. As a precaution, antitippers were added to R2' wheelchair while remaining in visible sight of staff during wake hours. Under summary of investigation: V5 (laundry aide) was interviewed. V5 said he was pulling linen on C/D wing when R2 suddenly stood up form her wheelchair and fell backwards. V21 (nurse) said she was administrating medication on her assigned wing when she heard V5 call for help.V9 (Nurse) said she was administrating medication on her assigned wing when she was notified by peer that resident had fallen. On 10/1/24 at 2:52PM, V5 (laundry aide) said he was going to pull the soiled linen near nursing station and observed R2 sitting behind the nursing station at the desk. V5 said there were no other staff present. The nurses were in the hallways passing medication. V5 said he saw R2 start to stand up and heard another resident telling for R2 to sit down. V5 said he heard a noise and when he looked he did not see R2 anymore. V5 said he went closer and observed R2 on the floor next to her wheelchair. V5 said the wheelchair was flipped back. R2 hit her head on the floor. On 10/3/24 at 3:23PM, V10(CNA)said he was familiar with R2's care. R2 likes to stand up from her wheelchair and try to walk. R2 requires frequent checks and staff will take turns sitting with her because of her impulsive behaviors. R2 will usually sit by the nursing station so someone is with her because she is a high fall risk. On 9/1/24, V10 said he was R2's assigned aide. V10 said R2 was sitting behind the nursing desk with staff. V10 said he told staff he was going on break and when he returned he received report that R2 had fallen and was sent to the hospital. On 10/3/24 at 3:48PM, V9 (Nurse) said she was familiar with R2 care needs. V9 said R2 is agitated and restless and staff will keep her at the nurses station for close monitoring. R2 is always trying to stand up from her wheelchair to go to the store or home. V9 was one of nurses working on 9/1/24 when R2' fall occurred. V9 said she was not at nursing station when R2 fell and unsure what staff was there. R2's fall was unwitnessed and she was found behind the nursing desk on the floor with head injury. V9 said someone should have been at the nursing station watching the residents. On 10/3/24 at 12:32PM, V11(Restorative nurse) said the fall on 9/1/24 root cause was impulse, and anti-tippers added to wheelchair and therapy screen. On 10/4/24 at 10:31AM, V20 (ADON) said they do not currently have any residents on one to one monitoring. Some residents maybe on close monitoring which indicates staff are making frequent rounds and watching the residents closely. Some at risk residents are placed near the nursing station when activities are not being done for close monitoring. The nurse's station is not left unattended, and staff are always near the area. The nurses or aides are responsible for monitoring the residents. R2's fall IDT (interdisciplinary team) note dated 9/2/24 documents: Summary of incident: The writer was notified by the other nurse that the resident is on the floor. The writer assesses the resident and observes that the resident is bleeding from her head, the writer stabilizes the resident until the ambulance arrives at about 6:31pm. Root cause of fall determined by IDT: nothing documented. New interventions and/or changes suggested by the IDT at this time: Bed mat in place , call light within reach and bed in lowest position. R2's hospital record dated 9/1/24 documents under notes: R2 is alert and oriented x1 which is her baseline. R2 states she does not recall how the fall happened as it occurred very quickly. Per nurse who spoke to nursing home staff, fall was unwitnessed, but they suspect R2 fell out of her wheelchair. Under physical exam: 2 centimeters by 3 centimeter laceration in the shape of a cross with central gaping revealing skull. Under laceration repair for occipital scalp length 3 centimeters x 4 milmeters depth. Sutures and staples used. Two sutures used for gaping center and 4 staples applied to the edges. R2's therapy notes dated 9/5/24 documents under precautions: fall risk, confusion with decreased safety awareness, 1:1 supervision for safety. R2's facility state reportable dated 9/28/24 documents: R2 had witnessed fall on 9/28/24 around 11:30PM at the nurse's station. Full body assessment noted bleeding from the head. MD notified and order to send the hospital for evaluation. R2 returned with diagnosis of laceration and four staples to the area. R2's incident report dated 9/29/24 documents: Resident was observed sitting in wheelchair across from the nurses station, she stood up and tried to sit back down and missed the chair and fell on her buttocks, hit her head against the wall, a small laceration with blood was noticed from the back of her head pressures was applied, 911 called. On 10/3/24 at 1:13PM, V12 (Nurse) said he was working the night R2 fell on 9/28/24. V12 said R2 has behaviors of trying to get out of bed and standing up from wheelchair. R2 has always had these behaviors and staff will take turns sitting with her during the shift to prevent her from falling. V12 said R2 was sitting across from the nursing station. V12 said R2 was attempting to get out of bed prior and that's why she was at the nursing station. V12 said they were doing change of shift report and V15(CNA) was assisting another resident with his shoes near R2. R2 stood up from her wheelchair and was instructed to sit back down but she must have moved and missed the wheelchair and fell to the ground. R2 hit her head on the floor or wall and did have an injury. R2 was sent out to the hospital. On 10/3/24 at 3:48PM, V9 (Nurse) said R2's fall on 9/29/24 was during change of shift. R2 was sitting in her wheelchair in front of the nursing station. R2 stood up from her wheelchair and staff instructed her to sit back down but she must have stepped to the side because when she sat back down she missed the wheelchair and fell hitting her head on the wall or other chair near her. There was an aide sitting near R2 who was helping another residents with his shoes but she could not see R2. Nurses were all busy doing change of shift and could not reach R2 in time. On 10/3/24 at 2:08PM, V15 (CNA) said she was familiar with R2's care needs and was present at time of fall on 9/28/24. V15 (CNA) said she was working on the unit and was near the station when another resident approached her to assist with his shoes. V15 said she took a chair that was near R2 and sat down with her back turned to R2. V15 said she assisted the resident with his shoes and during that time, R2 stood up and nursing staff was verbally instructing R2 to sit down. V15 said R2 will usually sit down when told and she was sitting but she moved and fell down to the floor by missing her wheelchair and hit her head possibly on the wall. V15 said she was not assigned to watch R2 at time of the fall. On 10/3/24 at 2:40PM, V11 (Restorative nurse) said The root cause of fall on 9/29/24 was impulse. V11 was asked where and what interventions were in place for R2's impulsive behaviors. V11 presented careplan for behavior problem manifested by attention seeking behaviors that include sitting or laying on the ground, making statements that are false. Interventions documented: administrate medications as ordered and anticipate the needs of the residents. R2's hospital record dated 9/29/24 documents under diagnosis fall, blunt head injury and scalp laceration. Under procedures laceration repair: occipital scalp 2 centimeter wound. Repaired with four staples. R2 plan of care documents: R2 is at risk for High risk falls related to impaired mobility, weakness, Diabetes, high risk medication use, impaired cognition, agitation, history of falling prior to admission Date Initiated: 06/17/2024 Revision on: 06/27/2024. Interventions: Anticipate and meet The resident's needs. Date Initiated: 06/17/2024. 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. Date Initiated: 06/17/2024 Dycem to bed added to wheelchair Date Initiated: 06/23/2024 Revision on: 07/05/2024 Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Date Initiated: 06/17/2024 Ensure that the resident is wearing appropriate footwear shoes, non-skid socks when mobile on unit Date Initiated: 06/17/2024 Revision on: 06/25/2024 Follow facility fall protocol. Date Initiated: 06/17/2024 Medication review Date Initiated: 09/30/2024 Revision on: 09/30/2024 Placed in busy bee Activities during the day Date Initiated: 06/17/2024 Pt evaluate and treat as ordered or PRN. Date Initiated: 06/17/2024 PT screen Date Initiated: 09/01/2024 Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers as to causes. Date Initiated: 06/17/2024 Tippers to wheel chair Date Initiated: 09/01/2024 Revision on: 09/09/2024 Toilet before meals after meals, and at bed time. Date Initiated: 08/17/2024 Xray to left hand and Left knee Date Initiated: 06/25/2024 Facility policy titled Fall prevention and management reviewed 1/24 documents: The facility is committed to maximizing each resident's physical, mental and psychosocial well -being. While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventative strategies, and facilitate as safe as an environment as possible. All residents fall shall be reviewed, and the residents existing plan of care shall be evaluated and modified as needed. Care plan to be updated with a new intervention based on root cause analysis after each fall occurrence.

Based on interviews and record reviews, the facility failed to follow its skin care prevention policy and implement effective interventions and monitoring to prevent one resident developing three facility acquired non-pressure wounds to the right foot and ankle. This affected one of three R1 residents reviewed for non-pressure wounds in a sample of 11. This failure resulted in R1 presenting to the hospital emergency room on 9/1/24 with sepsis secondary to a right heel wound that was infected and with acute osteomyelitis (bone infection). Findings include: On 9/5/24 at 1:40 PM, V11 (wound care nurse) stated that the staff nurses are responsible for monitoring residents' skin for any breakdown. V11 stated that V11 noted R1 with right heel bruising on 8/19/24 and obtained order for wound cleaning and the application of skin prep. V11 stated that the blister opened on 8/24/24 and V11 obtained an order for xeroform and dry dressing daily. V11 stated that the wound on the top of R1's foot was still a blister so V11 continued applying skin prep to this wound. V11 stated that V11 placed a pillow between R1's legs, because V11 was concerned that R1's left lower leg cast was putting pressure on R1's right leg and foot. V11 stated that R1 is unable to move self in bed, dependent on staff. V11 stated that R1's legs were contracted, crossed at knees, and V11 was concerned for pressure on right leg. V11 stated that R1's right foot wounds were trauma related because nothing was wrong with R1 prior to left foot fracture on 8/7/24. V11 stated that V11 performed wound care treatments six days a week and repositioned R1 during treatments. V11 stated that V11 checked to ensure she was able to insert two fingers under R1's rim of cast at toes and positive capillary refill. On 9/6/24 at 1:20 PM, V10 NP (nurse practitioner) stated that R1's legs were very contracted. V10 stated that R1 returned from the emergency room with a post mold to left tibia/fibula fractures on 8/8/24. V10 stated that V10 visited R1 on 8/12/24 and observed bruising to R1's right foot and left knee area. V10 stated that V10 would have V11 (wound care nurse) manage residents with bruising as well as open wounds. V10 stated that fractures, contractures, and poor nutrition puts R1 at risk for skin breakdown. V10 is unable to articulate how the bruising to R1's right foot and left knee could be from trauma on 8/7/24. V10 stated that if due to trauma would have been present at the time of injury on 8/7. V10 was able to review R1's current hospital record which notes right heel wound infection with osteomyelitis. V10 stated that once a wound is present, it can deteriorate very quickly to an infection. V10 stated that the mottling and increased respirations observed by nursing on 9/1 could be due to R1's body responding to the infection. On 9/6/24 at 4:26 PM, V14 (family member) stated that when she was visiting with R1 on 8/31/24, V14 noted R1's right foot wounds with a foul odor. V14 stated that V14 informed the nurse on duty of the foul odor. R1's weekly skin observation, dated 8/8/24, notes R1's skin warm, dry, within normal limits. Skin turgor is fair. Swelling observed to left foot. No skin concerns noted. There were no further weekly skin observations documented between 8/9/24 and when 9/1/24 when R1 was hospitalized . The CNAs (certified nurse aides) documentation, dated 8/8/24 -9/1/24, notes 8/8, 8/9, 8/14, and 8/21, the CNAs noted discoloration. On 8/11 and 8/18, the CNAs noted redness. On 8/21, the CNA charted skin tear. There is no documentation found in R1's medical record noting the nurse assessed R1 for these skin abnormalities. V10's NP progress note, dated 8/12/24, notes R1 with a soft cast on left leg. There are surrounding bruising and discoloration to R1's left knee and right foot. R1's wound assessment, dated 8/27/24, notes R1 was identified with a facility- acquired right dorsal foot hematoma (bruise) due to trauma on 8/27/24. It is a full thickness wound with 100% intact skin. Maceration (softening and breaking down of skin resulting from prolonged exposure to moisture) noted to periwound. Wound measured 11.10cm (centimeters) x 9.6cm. On 8/29/24, V11 initiated skin prep and gauze dressing treatment. R1's wound assessment, dated 8/27/24, notes R1 with a facility acquired right heel bruise due to trauma, identified on 8/20/24. It is a full thickness wound with 100% bright pink or red tissue. Wound measured 5.5cm x 4.5cm with serous (clear) drainage. On 8/26/24, V11 initiated xeroform and gauze dressing treatment. R1's wound assessment, dated 8/27/24, notes R1 with a facility-acquired right lower leg front bruise due to trauma, identified on 8/27/24. Wound with 100% pink or red non-granulating tissue. Wound measured 18.3cm x 3.1cm. On 8/27/24, V11 initiated application of skin prep treatment. R1's POS (physician order sheet), dated 8/20/2024, notes an order for right foot wound apply skin prep every day shift to prevent skin breakdown. There is an order, dated 8/24/24, for right ankle wound clean with wound cleaner pat dry, apply xeroform and rolled gauze every day shift for wound care. R1's TAR (treatment administration record), dated August 2024, notes R1 did not receive treatment to right ankle wound on 8/25 or 8/31. R1 also did not receive treatment to right foot blister on 8/25 or 8/31. R1's hospital record, dated 9/1/24, notes R1 presented to the emergency room at 11:07 AM. Condition is serious. R1's primary admitting diagnosis is osteomyelitis right foot. R1 with necrotic (dead tissue) right heel ulceration with foul-smelling drainage and right foot blister. R1's white blood cell count was 19.2 (normal range 4-11). X-ray of R1's right foot noted heel with soft tissue gas tracking superiorly along the achilles tendon. Impression: heel ulcer with evidence of infection by a gas-forming organism. R1 with sepsis secondary to necrotic infected right heel wound. Infectious disease physician consulted and noted severe sepsis, necrotic right heel ulcer with wet gangrene, and osteomyelitis. Along the medial ankle there appears to be tissue necrosis also. It is unlikely that the limb will be salvageable given the extensive necrosis of the heel. Antibiotics alone will not take care of the infection given the tissue damage. Very foul-smelling odor noted from the right foot. Wound dressings with small bugs noted. Podiatrist consulted and noted R1's right heel ulcer with achilles tendon exposed, limb not salvageable. Right heel wound measured 14.3cm x 12.2cm x 0.4cm. This facility's skin care prevention policy, reviewed 01/2024, notes dependent residents will be assessed during care for any changes in skin condition including redness and this will be reported to the nurse. The nurse is responsible for notifying the health care provider.

Based on interviews and record reviews, the facility failed to implement effective pressure relieving interventions to prevent one resident, who's lower extremities are severely contracted, at very high risk for skin breakdown, and dependent on staff for all ADLs (activities of daily living), from developing a facility acquired pressure ulcer on the left posterior distal thigh due to pressure from posterior mold splint on the left lower leg. This affected one of three residents R1 reviewed for pressure ulcers in a sample of 11. This failure resulted in R1 presenting to the hospital emergency room on 9/1/24 with a pressure wound to the left posterior distal thigh with hamstring tendon exposed. Findings include: On 9/5/24 at 1:40 PM, V11 (wound care nurse) stated that the staff nurses are responsible for monitoring residents' skin for any breakdown. V11 stated that R1 is unable to move self in bed, dependent on staff. V11 stated that R1's legs were contracted, crossed at knees. V11 stated that V11 checked to ensure she was able to insert two fingers under R1's rim of cast at toes and there was positive capillary refill. On 9/6/24 at 1:20 PM, V10 NP (nurse practitioner) stated that R1's legs were very contracted. V10 stated that R1 returned from the emergency room with a post mold to left tibia/fibula fractures on 8/8/24. V10 stated that V10 visited R1 on 8/12/24 and observed bruising to R1's right foot and left knee area. V10 stated that V10 would have V11 (wound care nurse) manage residents with bruising as well as open wounds. V10 stated that fractures, contractures, and poor nutrition puts R1 at risk for skin breakdown. R1's weekly skin observation, dated 8/8/24, notes R1's skin warm, dry, within normal limits. Skin turgor is fair. Swelling observed to left foot. No skin concerns noted. R1's left ankle down to the foot dark purple bruise, swollen and painful. Left elbow with dark purple bruising. The CNAs (certified nurse aides) documentation, dated 8/8/24 -9/1/24, notes 8/8, 8/9, 8/14, and 8/21, the CNAs noted discoloration. On 8/11 and 8/18, the CNAs noted redness. On 8/21, the CNA charted skin tear. There is no documentation found in R1's medical record noting the nurse assessed R1 for these skin abnormalities. R1's progress notes, dated 8/8/24 - 9/1/24, notes on three occasions, 8/27 at 1:18 AM, 8/28 at 00:17 AM, and 8/29 at 1:49 AM, documentation of positive capillary refill and two fingers can fit under the rim of the soft cast. There were no further weekly skin observations documented between 8/9/24 and when 9/1/24 when R1 was hospitalized . V10's NP progress note, dated 8/12/24, notes R1 with a soft cast on left leg. There are surrounding bruising and discoloration to R1's left knee. There is no documentation found in R1's medical record noting staff monitored the bruising and discoloration to R1's left knee or skin to left thigh area. R1's POS (physician order sheet), dated 8/11/2024, notes an order to monitor left lower extremity cast and surrounding areas for circulation, motion, and sensation, signs/symptoms of skin breakdown every shift, notify physician of abnormalities. R1's hospital record, dated 9/1/24, notes R1 presented to the emergency room at 11:07 AM. Condition is serious. Podiatrist consulted and noted R1's left distal thigh wound with hamstring tendon exposed related to pressure on leg from post mold splint on left lower leg. This facility's skin care prevention policy, reviewed 01/2024, notes dependent residents will be assessed during care for any changes in skin condition including redness and this will be reported to the nurse. The nurse is responsible for notifying the health care provider.

Based on observation, interview and record review the facility failed to ensure a plan of care was followed to review information on past falls, attempt to determine cause of falls, and anticipate and meet the resident's needs. The facility also failed to follow their fall protocol to ensure effective interventions for safety were in place to reduce the risk for falls for 1 of 3 resident's (R1) reviewed for safety. This failure resulted in R1 sustaining a left hip fracture of the femur head on 4/21/2024. Findings include: On 5/7/2024 at 10:30am R1 was observed at the nurse's station in his wheel-chair alert to name only. On 5/9/2024 at 12:30pm R1 was observed in his room sitting on the edge of the bed with a t-shirt, incontinent brief, no pants or socks on and with one foot half under the fall mat asking for pants. On 5/9/2024 at 12:35pm V5 (Nurse) observed with writer R1's condition and said he is a fall risk, he should be dressed and at the nurse's station for observation or in activities after breakfast. On 5/9/2024 at 12:36pm V6 (Certified Nurses Assistant - CNA) said R1 is a fall risk. I checked on him when I brought his breakfast tray in and he was in the bed. I was attending to my other residents. On 5/9/2024 at 2:30pm V8 (Certified Nursing Assistant - CNA) said on 4/19/2024 at about 8:30am upon doing morning care, R1 was very combative, guarding his leg and complained of pain. I immediately notified the nurse. On 5/9/2024 at 2:25pm V3 (Nurse) said on 4/19/2024 between 8am and 9am, V8 reported to her that R1 was guarding his left leg, complaining of pain and being combative with care. V3 said she called the physician for an x-ray and received it back on 4/21/2024 reporting that it was a fracture of the left femur. On 5/9/2024 at 12:50pm V2 (Director of Nursing - DON/Falls Coordinator) said I expect all the nursing staff to follow the safety protocol in place for each resident. R1 has a history of falls and is a fall risk. R1 is alert x1, ambulatory with a walker upon admission. R1 complained of pain on 4/19/2024, he was placed in a wheelchair and put on high risk for falls with interventions in place. R1 should have been up in his wheelchair for all meals, at the nurse's station or in activities. Never alone in his room. On 5/9/2024 at 3:00pm V1 (Administrator) said I thought R1 was dressed and in his wheelchair at the desk or activities. He's a fall risk because we do not know how R1 fractured his leg. We suspect a fall, but no one found him on the floor, so that is why we called it an injury of unknown origin. He was admitted with a history of falls. An admission record indicates R1 has an history of falls and unspecified dementia, severe with other behavioral disturbance. A care plan with a focus of a risk for falls related to impaired cognition, impaired mobility a history of prior falls prior to admission. An intervention of anticipate and meet the resident's needs, follow facility fall protocol and review information on past falls and attempt to determine cause of falls. An incident report dated 4/21/2024 of injury of unknown injury with a stat x-ray and possible fracture of left hip. A nurse's progress note dated 4/21/2024 at 14:16 indicating that R1 had a x-ray result of a positive fracture if the left femur heads. A diagnostic radiology report dated 4/21/2024 indicates that R1 had a acute fracture of the left femoral neck. Facility Policy: Fall Prevention and Management revision date 1/2024 General: This facility is committed to maximizing each resident's physical, mental and psychosocial well-being. While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventive strategies, and facilitate as safe an environment as possible. A resident fall shall be reviewed, and the resident's existing plan of care shall be evaluated and modified as needed. Guidelines: Upon admission: 1.A fall risk evaluation will be completed on admission, readmission, and quarterly significant change and after each fall.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to developed a resident specific care plan with interventions to address a residents drug use history. This failure resulted in R1 being found unresponsive, non-breathing and was pronounced dead at the hospital. This failure affected R1 out of 8 residents reviewed for comprehensive care plan. Findings include: R1 was [AGE] years old, was admitted to the facility on [DATE] with diagnosis of but not limited to: Anoxic brain damage, Poisoning by unspecified drugs and functional quadriplegia. R1's BIMS Score (Cognition test) was 14 meaning R1 was cognitively intact. R1's (10/22) admission paperwork from the hospital document in part: Anoxic brain damage secondary to drug overdose. R1's (10/10/2022 at 2:05 pm) progress note documents in part: Resident is a [AGE] year old, male, Caucasian newly admitted to the facility on [DATE]. Resident is alert x3 and he can make his needs known. Resident was diagnosed with anoxic brain injury due to drug overdose. Resident also has protein calorie malnutrition and dysphagia. R1's (12/4/23) death certificate documents cause of death: drug overdose, due to toxic effects of Fentanyl and Cocaine. R1's (12/4/2023 at 10:48 am) progress note documents: Upon rounding by staff, resident observed unresponsive and non-breathing. Resident a full code, code blue called, 911 emergency services contacted and CPR (cardio pulmonary resuscitation) initiated with crash cart present. Resident last observed alert and sleeping at approximately 7:50am. CPR continued until Emergency services arrived to facility and transferred resident to the hospital. Nurse Practitioner made aware. Family contacted and made aware. On 4/13/24 at 9:10 am V10 (Certified Nursing Assistant) said, she is on staff at the facility and has been here little over a year. She remembers R1, was keeping to himself, had an electric wheelchair and spoke to some residents. R1 needed help with putting on clothes, he was smoking cigarettes when it was time for smoke breaks, she did not have a clue or did not see signs of drug use, if she would suspect drug use she would let the nurse on duty and V2 (Director Of Nursing) and V1 (Administrator) know. V10 said, V16 was assigned to him but she was duty on that wing also. V10 asked V16 if if R1 wanted his breakfast tray, sometimes he didn't want anything. V10 said, V16 told her she just checked on him earlier and he was sleeping but if V10 could check on R1 because R1 didn't look right. V10 said, she went into R1's room and she went over by the window (R1's bed was by the window) and he didn't respond, he slept with pillow on his face usually, she got closer and noticed his fingertips were purple and it freaked her out because his eyes were open and she never seen anything like that. V10 said, she ran towards nurses station and she yelled called blue and everyone started running, even from different wings to help. On 4/13/24 at 9:28 am R8 said she was a friend of R1 and they were close. R8 said, she knew something of his history of drug use however she did not suspect R1 to do drugs. R8 said, she never saw R1 doing drugs or talk about drugs. R8 did not know R1 was struggling with drugs. R8 said, she never saw residents doing drugs. R8 said, he passed on Monday morning and the last time she saw him was Saturday evening and he was his normal self. R8 said, she was supposed to see R1 on Sunday but he never come over to her room. On 4/15/24 at 10:13 AM with V1 (Administrator), V2 (Director of Nursing) and V12 (Social Service Director) were present for the interview. V1 said, she was here at the facility, little after 9 am, code blue was called, she went there with V17 (ADON), as she was headed down there the nurse started CPR, 911 was called and staff continued CPR, paramedics were doing CPR also even as leaving the facility, Narcan was given but unsure if it was the paramedics or the facility that gave the Narcan. V15 (RN) was R1's assigned nurse. V1 said, she was not aware of R1 cause of death until she was informed by the surveyor. V12 (Social Service Director) said R1 had history of drug use. V2 said, one of R1's diagnosis were Poisoning by unspecified drugs and it could be drug are pharmaceutical and recreational. V12 was asked what facility had in place for R1 with known history of drug use, V12 said, R1 came with history of drugs and was in no condition to inject any drugs, he was not alert and oriented on admission, he became more oriented with time, R1 made improvements in functional abilities and was able to do more by himself, and he got physical therapy and got stronger. V12 said facility monitors residents and also does constant monitoring, for unusual behavior as needed. V12 said, he believes R1 was care planned for drug use (V12 was provided copy of R1's care plan and asked by surveyor to show where the care plan documents interventions for history of drug use). V12 said, he is not seeing R1 was care planned for drug use, and in hindsight R1 should have been care planned for drug use. V12 said, resident monitoring is based on observation and staff would document if something is observed and increased monitoring if required. V1 said, R1 never presented with active drug use and never facility found any drugs on him. V12 said, R1 had his own phone that he was using. V2 said, is someone comes in and they want to leave something for a resident, it goes first to social service and it is inspected and inventoried. V1 said, if (online food delivery platform system) is delivered or dropped off the facility does not inspect/open residents food, like staff will not open the actual wrapper but will look in the bag. V1 said, if packages come thru the mail they are inventoried so facility can keep track of resident belongings and social service inspects them first. R1's care plan does not document intervention in place for history of drug use. R1's (1/21/23) community assessment documents R1 does not appear to be capable of unsupervised outside pass privileges at this time. Facility's (11/22, rev.11/17) Comphrensive Care Plan policy documents in part: Facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident's rights, that includes measurable objectives and timeframes to meet a residents medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to follow their pressure ulcer prevention policy by not preventing a resident from developing a facility acquired Stage 3 pressure ulcer and failed to have effective interventions and physician orders in place for the treatment of the pressure ulcer once acquired. This failure applied to one (R3) of one resident reviewed for pressure ulcers and resulted in R3 not receiving the care and services required to aid in the healing and prevention of pressure ulcers. R3 developed a new stage 3 pressure ulcer to his left ischium. Findings include: R3 is [AGE] years old and have resided at the facility since 2/01/2023, with past medical history including, but not limited to Paraplegia, Type 2 diabetes without complication, colostomy status, acquired absence of left leg above knee, neuromuscular dysfunction of bladder, ataxia following other cerebrovascular disease, pain, major depressive disorder, hypertensive chronic kidney disease, Kidney failure, benign prostatic hyperplasia, etc. 11/27/2023 at 11:30AM, observed resident in his bed, awake and alert but said that he is tired, just came back from dialysis. Resident was noted to have a urinary catheter. R3 stated that it is supra pubic, and he also has a colostomy bag. 11/27/2023 at 1:40PM, resident was observed still lying on his back in the same position and stated that he is feeling a little better. Review of facility pressure ulcer log documented that R3 has a stage 3 pressure ulcer to left thigh back, facility acquired and identified on 9/22/2023. 11/28/2023 at 11:30AM, observed wound care for resident with V5 (Licensed Practical Nurse/LPN) and V7 (Wound Care Tech) noted a large area of excoriation on the residents back left tight with some whitish substance, resident's stoma site was noted with some brownish crusty substances and resident stated that the area is sore to touch. V5 wiped away the substances and stated that the wound doctor just changed the treatment to reduce the drainage. V5 proceeded to remove the old dressing, applied the new treatment. Neither V5 nor V7 repositioned the resident after the wound care or offered to reposition him. Surveyor presented this observation to V5 who stated that R3 refuses care and prefers to lie on his back and will not allow staff to reposition him. Surveyor pointed out that R3 was not offered an opportunity to be repositioned after the wound care treatment so how does he refuse if the care is not even offered and V5 did not have an answer to that question. 11/28/2023 at 2:30PM, R3 was observed in his room still lying in the same position since the wound care observation. Surveyor asked resident why he is still in the same position, and he said that he cannot turn, and that staff will not help him. R3 was asked if he refuses care from staff and he said no, he never refused any type of care from staff; they just don't help. Braden (pressure ulcer risk) score assessment dated [DATE] scored R3 as 11 indicating high risk for alteration in skin integrity. Minimum Data Set assessment (MDS) dated 10 /26/2023 section C (Cognition) scored R3 with a BIMs score of 14 (cognitively intact), section GG (functional abilities and goals) coded R3 as being dependent on staff for all ADL care. Care plan initiated 2/01/2023 states: I have a potential for impairment to skin integrity r/t need for assistance with mobility and HX of pressure injury, interventions include Avoid skin-to-skin contact, Encourage, and assist with turning and repositioning at regular intervals every shift as tolerated and when requested for comfort, Minimize pressure over boney prominences, etc. Pressure ulcer care plan initiated 2/01/2023 stated that resident has pressure ulcer related to immobility, LLE amputation and fragile skin. Interventions include Encourage and assist with turning and repositioning at regular intervals every shift as tolerated and when requested for comfort. Wound care note dated 10/16/2023 documented a stage 3 pressure ulcer to the left ischium measuring 2.6 X 2.0 X 0.1cm, surface area 7.54cm, >25 days duration, 70% granulation tissue and 30% skin. Recommendation: turn side to side in bed every 1-2 hours if able, offload wound, reposition per facility protocol. 11/27/2023 at 3:38PM, V5 (LPN/Wound Care) said that the doctor saw R3 today and put in an order for zinc oxide, he was previously getting treatment with zinc oxide before he went to the hospital. V5 does not have any treatment orders since the resident came back from the hospital, he does not get daily dressing change because he does not allow her to do the dressing change. V5 said, what good will it do to have an order when he will not let me change his dressing? V5 added that the previous order was for three times a week and she cannot recall when resident went to the hospital or how long he has been at the facility without a wound care order, resident has a stage 3 facility acquired pressure ulcer that was identified on 9/22/2023. 11/28/2023 at 2:05PM, V2 (Director of Nursing) said that if a resident is refusing care, everybody should be involved, the doctor, family, IDT, and they are supposed to provide education, document in the progress note and it should be care planned. V2 confirmed that V2 has never been notified by anyone that R3 refuses ADL and wound care. There was no care plan noted that addressed R3 refusing care. Pressure ulcer policy revised 1/15/2018 states its purpose as to prevent and treat pressure sores/pressure injury. Guidelines: 2. Inspect the skin several times daily during bathing, hygiene, and repositioning measures, may use lotion on dry skin. 5. Turn dependent resident approximately every two hours or as needed and position resident with pillow or pads protecting bony prominences as indicated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that proper precautions were in place during therapy session for a resident who was assessed as being at risk for falls. This failure affected one resident (R3) who had a witnessed fall during therapy, was transported to the hospital where she was diagnosed with a hip fracture, requiring a surgical intervention. Findings include: R3 is a [AGE] year-old female who was admitted to the facility on [DATE], with past medical history including, but not limited to encounter for other orthopedic aftercare, acquired absence of left leg below knee, type 2 diabetes mellitus with diabetic neuropathy, presence of left artificial hip, fracture of unspecified part of neck of femur, major depressive disorder, anxiety disorder, delusional disorder, etc. On 6/12/2023 at12:35PM, R3 was observed in her room, awake, alert and oriented and stated that she was having an occupational therapy session with a staff, she was required to pick up some socks that the staff dropped on the floor using a Reacher, R3 walked to the first clothing with a walker, wanted to pick up the socks and fell, R3 said she heard a pop and knew that she had broken something. This was her first time doing this exercise, she had a gait belt on her, but the staff did not hold on to the belt, she was just standing there. R3 said that she is used to a staff holding on to her gait belt and another staff following behind with her wheelchair when she is walking with her walker, she added that she is very upset because she was getting ready to go home before this happened, and this could have been avoided if the staff was holding on to her gait belt. Hospital record documented resident's diagnosis as hip fracture requiring operative repair. Facility reported incident dated 5/24/2023 documented in part, while resident was participating in her walking therapy, resident verbalized losing her balance and falling to the floor. She remained alert and oriented, was transferred to the hospital, admitted with the diagnosis of closed displaced fracture of the left femoral neck. Fall risk assessment dated [DATE] coded R3 with a score of 11 (at risk for falls). Minimum data set assessment (MDS) section G (functional) coded R3 as requiring supervision with one-person physical assist for transfer, bed mobility for bed mobility and transfers, and limited assistance with one-person physical assist for walk in room and walk in corridor. Care plan initiated 10/9/2022 stated that R3 have functional task performance deficit related to impaired mobility generalized weakness, left BKA, etc. Interventions include lying to sitting- supervision or touching assistance, sit to lying, supervision or touching assistance, sit to stand partial/moderate assistance, etc. Another care plan initiated 9/14/2021 states that R3is at risk for falls related to cognitive impairment, new BKA, generalized weakness, pain, impaired mobility, etc. Interventions include to encourage resident to participate in activities that promote exercise physical activity for strengthening and improved mobility, PT to evaluate and treat, therapy to screen. 6/13/2023 at 12:10PM, V5 (OT Assistant and Director of Rehab) said that she has been discussing discharge plan with R3, they went to the room to do some exercise of her (V6) tossing some socks on the floor and the resident are supposed to pick them up with a Reacher while standing/walking. R3 had a gait belt on and came to the location in her wheelchair. When R3 stood up with a walker, V5 said that she would have taken the wheelchair for safety reasons, this was her first time doing this exercise with the resident, she has walked in the past but always with a walker. V5 said that when they were doing the exercise, R3 stood up from her wheelchair, her left hand was on her walker, and she was holding the Reacher in her right hand. Resident reached and picked up a sock, tried to put it in a container and lost her balance and fell to her left side. when the resident bent down, she can't recall holding on to the gait belt. R3 cannot ambulate independently only with a walker, V5 also said that for residents that are unsteady, staff is supposed to follow them with a wheelchair, she has seen restorative staff do that with R3. V5 was asked what she could have done differently to prevent the incident and she said, possibly holding on to the gait belt or with staff following her with a wheelchair, at that time, I did not think it was necessary. Occupational therapy treatment encounter notes dated 5/24/2023. Presented by V5 documented the precautions for R3 as fall risk. On 6/13/2023 at 12:39PM, V4 (LPN) said that the day R3 had a fall, she was on the phone when a therapy staff was yelling that R3 was on the floor, she ran to the area and saw the resident on the floor, the therapy staff was standing by the resident who was lying on her right side. V4 said she don't know if the staff used it or not, she has seen the restorative staff walking with R3, there are usually 2 staff, one staff will hold on to the gait belt and the other staff will be following them with a wheelchair. 6/15/2023 at 1:16PM, V27 (Restorative aide) said that she is familiar with R3, have worked with her since August of last year, when they do a restorative activity with R3, if she is already sitting in her wheelchair, staff will put a gait belt around her waist and position the walker in front of the resident. They will assist resident to a standing position to hold on to the walker, when the resident starts to walk, one staff will hold on to the gait belt, and the other will be following behind with resident's wheelchair. V27 said that the purpose of the gait belt is for safety, to enable the staff ease resident to her wheelchair if she gets weak and need to sit down. She added that she is aware that resident wears a prosthetics on her left leg, will consider her a fall risk. 6/15/2023 at 1:30PM, V28 (Restorative aide) said that she was at work the day R3 had a fall with injury but R3 was in therapy at that time. She has worked with R3 as a restorative aide with R27, it is usually 2 staff with the resident when she is walking with her walker, one holding on to her gait belt and the other following with her wheelchair. V28 said that the restorative people would not do an activity that requires resident to pick something from the floor while standing, she considers R3 to be slightly unsteady and would expect staff to hold on to her gait belt. V28 said that R3 has never been assessed as not needing chair follow and they always take that precaution with her. Facility falls prevention program revised 11/21/2017 presented by V2 (DON) states in part in its purpose; to assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk for falls to provide necessary supervision and assistive devices are utilized as necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and records reviewed the facility failed to follow the care plan interventions, failed to implement effective interventions, and conduct root cause analysis to prevent or reduce the risk of falling. This affected 3 of 4 residents (R1, R4, and R6) all reviewed for falls and fall prevention. This failure resulted in R1 falling while trying to retrieve a television remote sustaining a laceration to the right ear. This failure also resulted in R6 rolling out of bed and sustained Impression: 6.2mm oblique transverse fracture of posterior superior corner of this C4 vertebral body which appears acute, and acute appearing impacted fracture to the nasal bone. The findings include: On 3/23/23 at 11:50AM the surveyor toured the units with V19, MDS/Care Plan/ Restorative Nurse. V19 presented a binder with list of residents at risk for falls. V19 presented the list on each unit, an undated copy was presented to the surveyor. R1 is listed with interventions low bed is not indicated for R1. R4 has bilateral side rails listed as an intervention. A.R1 is [AGE] years old with diagnosis including but not limited to Muscle Wasting and Atrophy, Obstructive and Reflux Uropathy, Spina Bifidia, Protein Calorie Malnutrition, Dysphagia, retention of Urine, Functional Quadriplegia, Hyperlipidemia, Hypertension, Convulsions, History of Traumatic Brain Injury, and History of Falling (onset date 10/29/22). On 3/23/ at 9:58AM V12, Licensed Practical Nurse (LPN), said on 2/20/23 R1 had just returned from the hospital that shift and he fell. V12 said the CNA said R1 was pointing at the television and she had tried to turn it on for him, but it did not turn on. V12 said R1 was trying to get the remote, I told R1 I was going to get him the remote and left the room. V12 said before I got the remote he rolled out of the bed. V12 said I can't remember if a floor mat was in use. V12 said R1 had a cut on his head and the Director of Nursing told her to send R1 back to the hospital. R1 had a fall on 2/20/23 at 5:55PM. Incident report documents R1 observed face down on the floor next to the bed. R1's progress notes dated 2/21/23 document the cause of R1's fall is he rolled out of bed or attempted a self transfer. R1 has traumatic brain injury and has moments of impulsive behaviors. Intervention update stated R1 moved closer to the nurses' station, ensure personal items are within reach on bedside table. The care plan dated 2/20/23 keep all needed items in reach. Care plan intervention dated 10/31/22 states anticipate and meet resident needs. Intervention dated 2/13/23 states bedside matt. Hospital records obtained dated 2/20/23 documents R1 underwent a laceration repair to his right ear. Laceration documented to measure length 1.5 x depth 2. R1 received 4 sutures. On 3/22/23 at 3:10PM V5, LPN, said on 3/14/23 the CNA called for him and said the CNA had been changing R1 in bed. V5 said the CNA said she was dropping him (R1) to the floor mat. V5 said R1 was in the bed receiving care when he fell. V5 said there was only 1 CNA in the room when R5 fell. V5 said R1 is always restless. V5 said R1 was a fall risk. V5 said R1 is able to move side to side, but it is not purposeful movements, he needs staff assistance to roll for care. On 3/28/23 at 10:38AM V24, CNA, said on 3/14/23 she was replacing R1's linens with him in the bed. V24 said R1 rolled over to the side and he kept going and rolled off the bed. V24 said I have not seen a fall list or symbols to indicate who is a fall risk. R1 incident report dated 3/14/23 at 8:50PM documents the CNA said R1 rolled onto his floor mat while the CNA was changing him. R1's progress notes dated 3/16/23 document the cause of R1's fall is muscle weakness and lack of coordination. Intervention R1 will be a 2 person assist. R1's care plan for bed mobility initiated on 1/16/23 reads R1 requires assistance with bed mobility. Intervention dated 1/16/23 documents Provide assistance of 2 persons disciplines listed RN, LPN, CNA, and RN. ADL self care performance deficit care plan intervention dated 3/15/23 notes extensive assist by 2 persons. Fall intervention dated 3/14/23 documents change to 2 person assist with bed mobility tasks. (This intervention has been in place since 1/16/23.) On 3/24/23 at 11:01AM V17, LPN, said when R1 fell on 3/18/23 I was entering the room and saw R1 on the floor, on the right side of the bed. V17 said R1 had been in the bed when she saw him about 10 minutes earlier and he was moving some in the bed. V17 said his sheet was off his feet, I repositioned his sheet and spoke with him. V17 said R1 looked like he had rolled out of his bed, all of his body was on the floor mat. V17 said R1 was incontinent when he fell. V17 said R1 is not able to turn himself purposefully, he has control of his upper body more than his lower. V17 said R1 can't just turn himself. Incident report dated 3/18/23 at 3:15PM for R1 documents he was on floor mat on the right side of the bed. On 3/24/23 at 10:10AM V7, RN, said on 3/20/23 the CNA called my attention and I saw R1 on the side of the bed sitting, we asked him what happened. V7 said R1 said he said he wanted to get up. V7 said R1 said he fell from the bed. V7 said R1 does not roll he scoots. V7 said I had seen R1 around 2:00PM he got his medication. When I saw R1 he was ok, he was calm, he was not restless and he was not hot. V7 said R1 was a fall risk. V7 said we don't have a fall list or a fall binder. R1's progress notes dated 3/20/23 at 2:02AM document R1 observed on the floor beside his bed. On 3/20/23 at 2:38PM R1 was observed sitting on the floor by his bed. The root cause of one fall documented at 2:28PM is documented R1 restless in bed and was hot causing him to move about in bed and due to muscle weakness and lack of coordination R1 rolled self to floor. The root cause documented at 2:31PM states poor coordination with increase restlessness. On 3/24/23 at 11:20AM V18, CNA, said R1 is known for falling. V18 said I was on my 15 min break and I was told R1 had fallen. V18 said for R1 to turn in the bed he is an extensive assist. V18 said she has seen R1 put his foot on the ground or put his feet on the side of the bed. On 3/24/23 at 11:33AM V19, MDS/Care Plan Restorative Nurse, said on 3/14/23 I assessed R1 and he can move his arms and legs purposefully. V19 said R1 can turn side to side. V19 said last week R1 was having seizures and was more restless. V19 said when a fall occurs the nurse will inform the family, doctor, and add an immediate intervention. V19 said the Inter-disciplinary Team (IDT) will discuss the fall and develop appropriate interventions from the root cause. V19 said the root cause is the reason for the fall. V19 said identifying the contributing factors that caused a fall will lead to new interventions. V19 said R1 is weak with muscle atrophy and spinal bifida. V19 said diagnosis alone are not the root cause of a fall. V19 said more than a diagnosis is needed for a root cause. V19 said once the intervention is added the staff needs to follow the intervention listed on the care plan. V19 said every wing has fall list with interventions. On 3/24/23 at 12:33PM V21, Director of Rehab, said when she was working with R1 he was not able to roll in the bed independently. V21 said I have not seen R1 being restless or moving around in the bed. R1's Physical Therapy Discharge Summaries are dated 2/7/23 and 3/22/23. On 3/29/23 at 10:06 AM V19, MDS/Care Plan Restorative, said if a resident is having behavior, like restlessness, rolling, kicking, then I may not leave the resident in their bed. V19 said I may get them in a chair and take them to activities or nurses station to get them to supervision. V19 said if a resident is having behaviors during the shift the nurse should assess the resident to find out why they are having the behavior. V19 said after a fall the new intervention should be listed on the care plan. V19 said the intervention is added to the care plan during the interdisciplinary team meeting. V19 said the root cause of R1's fall on 2/20/21 was that R1 was trying to get up by himself. V19 said there was not charting about a remote related to R1's fall. V19 said bed mobility includes rolling from side to side. V19 said if the staff is changing R1's bed linens and he is in the bed, there should be 2 persons with him, one on each side of the bed. The surveyor asked V19 if R1's care plan before 3/14/23 stated 1 or 2 person assistance for bed mobility. While reviewing the care plan V19 said I am confused the care plan included both 1 and 2 person assist. V19 discussed the restorative care plan for bed mobility that states 2 person assist. V19 said all disciplines should use 2 person assistance for R1's bed mobility. While reviewing R1's care plan V19 said according to the care plan R1 should have 2 person assistance when rolling. V19 said on 3/18/23 R1 rolled out of bed because he was hot. V19 said the root cause of R1's fall on 3/19/23 was because he was restless. V19 discussed the root cause of R1's 2 falls on 3/20/23. V19 said a bedside floor mat was provided to R1 on 2/13/23. V19 said I can't prove the interventions are preventing the falls. On 3/29/23 at 12:45PM V33, Physician, said I have told the staff they need to bring R1 out to the nurses station, it could help prevent a fall. V33 said people need to pay attention to R1 so he does not fall. R1's Fall Risk assessment dated [DATE] notes he is at risk for falls with a score of 14. B.R6 is [AGE] years old with diagnosis including, but not limited to Ataxia, Lack of Coordination, Dementia, Adult Failure to thrive, Seizures, Syncope and Collapse, Protein Calorie Malnutrition, Hyperlipidemia, Bipolar Disorder, Intellectual Disabilities, Hypertension, Atherosclerotic heart Disease, and Dysphagia. On 3/28/23 during two interviews at 10:38AM and 11:05AM V24, CNA, said R6 had been in the bed when she did rounds. V24 said R6 was able to move himself in the bed. V24 said R6 was a 1 person assist with cares if he was not being combative. V24 said R1 was not having any behaviors before the fall, he was fine. V24 said if R6 had been combative or aggressive that shift she would have reported to her nurse. V24 said the nurse, V31, called her to the room and V24 saw R6 on the floor and he was bleeding from the nose. V24 said R6 became combative while she was assisting to get him off the floor. V24, CNA, said R6 was fine before the fall. V24 said if R6 was trying to be up and down or getting up on his own from the bed, I would have assisted him into a chair and probably brought him up to the nurses station for supervision. On 3/28/23 at 1:07PM V31, Registered Nurse, said I had been in R6's room giving his room mate medications. I then went out to the hallway to prepare R6's medications. V31 said I heard a bump, so I ran in, and called for help. V31 said R6's room mate said R6 was restless and fell. V31 said when I saw R6 he was on the floor in a sitting position trying to get up. V31 said R6 was sent to the hospital. V31 said when R6 came back to the facility he had a cervical collar a healing wound on his nose. V31 said R6 will get restless when he is incontinent and move from side to side. V31 said when R6 fell she had no eye vision of the room. V31 said before the fall R31 was in bed with is eyes closed, head of the bed was slightly elevated, about 30 degrees, and only the head pillow was in use. V31 said R31 had no rails in use, no floor mat, no alarm, and the call light was not on. V31 said V24 and V25, both CNAs, got R6 off the floor. V31 said before the fall, I was not told R5 was kicking. V31 said the CNAs will let me know when the patient is restless and I will check them. V31 said the CNAs will report when they are being hit or abused by residents. V31 said R6 was a fall risk before he fell. Transfer Form notes on 2/8/23 R6 was transferred to the hospital for a nose laceration. Progress Notes dated 2/2/23 note R6 has weakness and extensive assistance with bed mobility. Progress Notes dated 2/8/23 note R6 observed on floor by his bed after a fall. Laceration on nose with swelling. Progress Notes dated 2/9/23 documents R6 admitted to hospital with diagnosis of Neck Injury. Progress Notes dated 2/9/23 notes the root cause of the fall was R6 flailing and combative. R6's Functional Status assessment dated [DATE] notes he required extensive assist for bed mobility and transfer. Cognition on 2/7/23 is documented to be severely impaired. R6's fall risk assessment documents him at risk for fall with a score of 13. R6's hospital records dated collection on 2/8/23 CT Spine Cervical. Impression: 6.2mm oblique transverse fracture of posterior superior corner of this C4 vertebral body which appears acute. Spine surgical consultation is advised as the injury appears to involve least 2 columns and may be unstable. CT examination of the facial bones collected 2/8/23 impression: nasal septum is sharply angulated as the anterior aspects for acute fracture with deviation of the anterior portions of the left increased from previous exam suggestive of acute fracture with comminuted acute appearing impacted fracture of the distal aspect of the nasal bone. C.R4 is [AGE] years old with diagnosis including but not limited to Hemiplegia/Hemiparesis, History of Traumatic Brain Injury, Schizoaffect Disorder, Lack of Coordination, Fusion of Spine - Cervical Region, Seizures, Cerebrovascular Disease, Dysphagia, Abnormal Posture, Disorder of Brain. On 3/22/23 at 10:22AM R4 interviewed. R4 said when I fell the CNA was standing where you are, surveyor on side of bed at about R4's knee level. R4 said the CNA said she was going to change me. R4 said the CNA pulled on the sheet under me and then I just rolled and fell off the bed. R4 was alert to name, month, and situation when surveyor spoke with him. The surveyor observed R4 had one halo rail to the top side of his left bed and no standard style side rails. On 3/22/23 at 10:32AM R4 observed in his bed with a halo on the top left side of his bed, no siderails. On 3/22/23 at 1:45PM V3, LPN, said R4 is alert and oriented times 2 to 3 and is sometimes forgetful. V3 said R4 knows what is going on.V3 said R4 does not complain about anything. V3 said R4 fell off the bed one time. V3 said following the fall R4 requested side rails, he did not have them before the fall. V3 said when R4 fell, I was called to the room by the CNA, V2. V3 said V2 said R4 was on the floor, when I walked in R4 was on his back on the floor. V3 said R4 said I fell and he did not say any description of the fall. V3 said V2 was in R4's room, but she did not witness the fall. V3 said V2 said she was in the restroom in the room. V3 said V2 said R2 was trying to do patient care, but V2 said she did not witness him fall. On 3/22/23 at 2:03PM V2, CNA, said on 3/5/23 I was preparing to change R4. V2 said R4 was flat in the bed. V2 said I had not touched R4 and was in the bathroom getting the towels and bucket ready for bathing. V2 said I heard it (sound) and ran out and saw R4 on the floor. V2 said R4 had not asked for anything before the fall. V2 said R4's bed had not been raised for patient care. V2 said she did not see R4 roll out of bed. During a second interview on 3/24/23 at 1:19PM V2 said R4 had fallen sometime after breakfast and before lunch. V2 said she had done rounds at the start of her shift and he did not need any care at that time. V2 said she served R4 his breakfast in bed and had set him up to eat. V2 said R4 is alert and knows what is going on. V2 said R4 sometimes leans to the side. V2 said when she provided R4 his breakfast she had to reposition him in the bed. V2 said someone else helped me reposition R4 before breakfast, V2 said she did not know the name of the person who helped her reposition R4. V2 said she is not sure who collected R4's breakfast tray on 3/5/23. V2 said she later entered R4's room and stood at his bedside when letting him know she would give him a bath. V2 said she then went into the bathroom. V2 said when she initially into the room R4 was flat on the bed. V2 said I am not sure how the bed was when I saw him on the floor. V2 said R4 always has a lift sheet under him. On 3/24/23 at 11:50AM the surveyor observed, with V19, R4 with bilateral half side rails on his bed. R4 said they put the side rails on the bed the day before yesterday. On 3/24/23 at 12:23PM V20, MDS Coordinator, said with assistance R4 can roll and he can move a little with staff assistance. V20 said R4 can move slightly on his own in the bed, but not without staff assistance. V20 said R4 cannot roll without staff touching him if he is flat in the bed. V20 said R4 is alert and oriented and does not lie. V20 said when R4 tells you things it is probably accurately. V20 said they said he rolled out the bed on 3/6/23. V20 said R4 is not impulsive. At 12:55PM V20 said R4's side rails should have been put in place following his fall. On 3/24/23 at 12:33PM V21, Director of Rehab, said R4 was on therapy caseload. V21 said R4 was not able to turn unassisted in the bed. V21 said R4 has no function in his legs, he is not able to move his knees or hips. V21 said hip and knee movement is used for turning. V21 said in my opinion R4 can not roll out of bed unassisted. V21 said R4 is not impulsive and is alert and oriented, not confused or forgetful. On 3/24/23 at 1:48PM V4, Social Services, said R4's cognition is a 10 out of 15, he is moderately impaired. On 3/29/23 at 10:06AM V19, said the root cause of R4's fall on 3/5/23 is that he rolled out of bed. V19 said the root cause does not say why R4 rolled out of bed, it needs to say more. R4'sDocumentation Survey Report for March 2023 notes on 3/3/23; 3/4/23; and 3/5/23 R4 required extensive to total assistance from staff for bed mobility. R4's cognitive assessment dated [DATE] notes a score of 10, moderately impaired. Incident report dated 3/5/23 notes R4 noted on the floor next to his bed. R4 noted to be oriented to place, time, person, and situation. Progress Notes dated 3/6/23 notes R4's root cause of the fall rolled out of bed. R4's Occupational Evaluation and Plan of Treatment dated 2/28/23-3/14/23 notes R4's bed mobility assessment roll left and right = substantial/maximal assistance. R4's care plan for Activity of Daily Living assistance initiated on 8/28/19 identifies intervention bed mobility, extensive, 2 person. R4's fall care plan identifies on 3/8/23 half side rails added to the bed. On 3/24/23 at 10:10AM V7, RN, said if a fall risk resident with weakness is restless will tell staff to get them up, bring them out for us to keep an eye on them to prevent a fall. R6's fall risk assessment dated [DATE] notes he is at risk for falls with a score of 12. The facility policy Incident and Accidents review date 4/7/19 states all incident/accident reports are reviewed, signed, and investigated. The facility fall prevention program review date 11/21/17 states the program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Care plan incorporated interventions are changed with each fall, as appropriate. Preventative measures. Safety interventions will be implemented for each resident identified at risk. Fall safety interventions mentioned include, keeping resident belongings in reach, nursing personal will be informed of residents who are at risk of falling.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that staff were aware of care plan interventions for residents at risk for falls and failed to ensure that a resident who required staff assistance with ambulation was provided with assistance while ambulating in the hallway. This failure affected two (R3, R4) of four residents reviewed for falls and resulted in R3 having an unwitnessed fall in room and being admitted to local hospital with a diagnosis of subdural hematoma and resulted in R4 having a fall while ambulating without staff assistance, which resulted in an inter trochanteric fracture, requiring surgical intervention. Findings include: R3 is a [AGE] year-old male who was admitted to the facility on [DATE], with medical history including but not limited to: Traumatic subdural hemorrhage without loss of consciousness, unsteadiness on feet, dysphagia oropharyngeal phase, weakness, other lack of coordination, history of falling, muscle wasting and atrophy hemiplegia and hemiparesis following unspecified cerebrovascular disease, etc. R3 was not at the facility at the time of the investigation, per progress note dated 2/3/2023, resident had an unwitnessed fall and was taken to the hospital by 911. Facility reportable dated 2/8/2023 stated that resident was observed lying on the floor in his room beside his bed facing the wall, rolled out of bed, time of incident 23:18PM. Same document stated that follow-up report from the hospital documented that CT of the head was positive for subdural hematoma, no significant midline shift. Fall risk assessment dated [DATE] scored R3 as (12) at risk for falls, interim care plan dated 1/31/2023 stated that resident is at risk for fall, goal; I will not sustain any serious injury through the review date, the only intervention was to follow facility fall protocol. Minimum Data Set (MDS) assessment dated [DATE] section C (cognitive) scored R3 with a BIMs score of 2 (severe cognitive impairment), G (functional) coded R3 as requiring extensive assistance with 2-person physical assist for bed mobility, transfer, dressing, toilet use and personal hygiene, extensive assistance with one-person physical assist for eating, locomotion in room and off unit. Section H (bowel and bladder) of the same assessment documented that R3 is always incontinent of bowel and bladder. 2/21/2023 at 3:29PM, V6 (LPN) said that the day R3 fell was her first time working with the resident, he was okay during medication pass, maybe around 5:00PM, then she heard a yelling from resident's room, ran to the room and saw resident on the floor by the bed facing the wall. She got resident up with the help of other staff, assessed resident and noticed an old wound to his hip, there was no bleeding, but resident was grimacing to touch as if he is in pain, cannot tell if resident hit his head. V6 said that she does not know if resident is a fall risk, or if he has any fall interventions, she did not get any report from the outgoing nurse, resident is a new admit, they may have given report, but she cannot remember. V6 said she is not sure how resident takes his medication or the type of assistance he needed from staff, resident was alert but confused by the time he was sent to the hospital, his vitals were okay, and his neuro check seems to be normal. V6 does not remember who the C.N.A was and not sure the last time herself or the C.N.A saw resident before the fall. R4 is a [AGE] year-old male who was admitted to the facility on 5/4.2021, with history of Chronic obstructive pulmonary disease, dysphagia oropharyngeal phase, cellulitis left lower limb, unsteadiness on feet, essential primary hypertension, other lack of coordination, etc. R4 was no longer at the facility; was sent to the hospital on 2/4/2023 for coffee ground emesis as documented in medical record. Review of facility reportable showed that R4 had a fall on 1/17/2023 at approximately 10:30am while ambulating in the hallway with a cane. R4 was sent to the hospital was admitted and treated for a right hip fracture. Hospital record dated 1/17/2023 states, patient is from nursing home after a fall, states he was walking and lost his balance, fell, complained of right hip pain, denies dizziness. X-ray show displaced inter trochanteric fracture. Resident had a surgical procedure (right hip pinning-ORIF) on 1/18/2023. R4 also had a documented fall in his room on 10/2/2022 while walking in the room and complained of pain to his left elbow as stated in resident's progress note. Fall risk assessment dated [DATE] score resident as 12, at risk for falls. MDS assessment dated [DATE] section G (functional) coded R4 as requiring supervision (oversight, encouragement, or cueing) with one- person physical assist for walk in room and supervision with set up for walk in corridor. R4 was also coded as requiring supervision to limited assistance with one-person physical assist for all other ADL cares. Fall care plan initiated 10/9/2018 and revised 7/7/2022 states that R4 is at risk for falls related to impaired mobility. Interventions include call light within reach, ensure resident is wearing appropriate footwear when ambulating or mobilizing with wheelchair, bed in low position at night, even floors free from clutter and spills, etc. ADL care plan initiated 1/8/2019, revised 10/6/2022 states that resident requires assistance with ADLS due to weakness and debility, under locomotion on unit; it states supervision, one person. On 2/22/2023 at 10:28AM, V9 (LPN) said that the day R4 fell, she was at the nursing station, the C.N.A called her stating that resident fell, she saw the resident on the floor in the hallway, in front of the conference room. R4 was going to an appointment, he was ambulating with a cane, 3 staff members were already with the resident before V9 got there, V9 assessed resident and noted a blood spot on his head, she cleaned the area and placed resident on a wheelchair. V9 was asked what type of assistance resident needed from staff and she said that he will ask for water sometimes, he does not look like a fall risk and V9 is not sure if resident has any fall precautions. At 12:40PM, V11 (MDS/Care Plan) said that nurses do a fall risk assessment on residents upon admission and after every fall, based on the score, the MDS will develop a fall care plan which have to be updated after every fall. V11 said that R4 ambulates with a cane; all residents are to be supervised by staff. The day R4 fell, V11 was told that R4 was supposed to go to an appointment, something happened, and he was going back to his room when he fell. V11 added that she is not sure if someone was with the resident when he fell; she was not present at the time. At 2:06PM, V12 (ADON) said that she has worked at the facility for a few months. For resident care needs or those that are risk for falls, communication is done in stand up and during shift change, the precautions with interventions in place should be communicated to the C.N.A. As by the nurses. V12 also said that resident's needs are also documented in the task section of the medical record. Document presented by V1 (Administrator) titled, Fall Prevention Program (revision date 11/21/2017), states: Purpose .to assure safety of all residents in the facility when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary .Standards .the admitting nurse and assigned C.N.A are responsible for initiating safety precautions at the time of admission. All assigned nursing personnel are responsible for ensuring ongoing precautions are put in place and consistently maintained.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow their pressure ulcer prevention policy by failing to ensure that interventions were carried out, including turning and repositioning, in order to prevent residents from developing new pressure ulcers while in the facility. This failure applied to three (R3, R4, and R5) of three residents reviewed for pressure ulcers and resulted in (R3, R4, and R5) developing multiple stage 3 pressure ulcers while in the facility. Findings include: R3 is a [AGE] year old male who was admitted to the facility 9/3/21 with diagnoses that include Cerebral Infarction, Adult Failure to Thrive, Dementia and Dysphagia. According to R3's health record, MDS (Minimum Data Set) dated 1/9/23 notes R3 to have impaired cognition as with a BIMS (Brief Interview for Mental Status) score of 07. The MDS also indicated R3 required Extensive two person staff assist for bed mobility, toileting, and hygiene. On 1/23/23 at 12:36PM, R3 was observed sleeping in bed, presented with contractions of both legs and a urinary catheter hanging from the bed frame. Surveyor periodically observed R3 between 12:36PM and 3:15PM and R3 was noted to be in the same position as evidenced by position of head, body positioning wedge and urinary catheter bag which had not been emptied. Medical records indicate R3 is seen weekly by V19 Wound Care Physician and is being treated for a Stage 4 pressure wound on the right hip identified in the facility 11/15/22, Stage 3 pressure wound to the left hip identified in the facility 12/21/22 and Stage 3 pressure wound to the right lateral fifth toe identified in the facility 1/16/23. According to most recent Wound Care Physician assessment dated [DATE], left hip and right toe are healing and the right hip wound did not change in status. On 1/26/23 at 2:29PM, V19 Wound Care Physician said, some of the wounds I am currently treating for R3 are healing based on my notes so I wouldn't consider them to be unavoidable. On 1/24/23 at 2:07PM V8 CNA (Certified Nursing Assistant) said, I work with R3 regularly during the morning shift. He has wounds and should be repositioned every two hours because he has sores. When we are short staffed, it can be hard to turn and change every body within that time. R3's care plan for alterations in skin integrity initiated 10/9/22 and revised 1/19/23 include interventions that state: Follow facility policies/protocols for the prevention/treatment of skin breakdown; Assist and encourage turning and repositioning every two hours as tolerated every shift. R4 is a [AGE] year old male who was admitted to the facility 12/7/22 with diagnoses that include Multiple Sclerosis and paraplegia. According to R4's health record, MDS (Minimum Data Set) dated 1/3/23 indicates R4 has full cognition and requires extensive two person physical assistance with bed mobility, extensive one person assist with personal hygiene and is always incontinent of bowel and bladder function. According to wound care notes R4 arrived to the facility with multiple wounds and was initially assessed by V19 Wound Care Physician on 12/12/22. V19 weekly assessment dated [DATE] indicated all wounds present on admission were resolved. On 1/18/23 the facility identified two newly acquired wounds: a Stage 3 Pressure Ulcer to the left lateral lower leg, and Stage 3 pressure ulcer to the right medial knee. On 1/23/23 at 1:08PM, R4 was interviewed, and said, I developed new sores on my legs while in the facility. I can't turn on my own because I can't move my lower body. I need help from staff to turn and sometimes I'm in the same position for a while. Sometimes, I don't see a CNA regularly or every two hours in the evening or night. Care Plan for R4 initiated 12/14/22 revised 12/19/22 state R4 has potential for impairment to skin integrity related to impaired mobility and requires turning and repositioning frequently and as needed. R5 is an [AGE] year old male admitted to the facility 4/20/2012 with diagnoses that include cerebral infarction with hemiplegia and hemiparesis affecting left side, dysphagia, dementia and contracture of the left hand. According to R5's medical records, MDS dated [DATE] indicated R5 has mild cognitive deficits with a BIMS (Brief Interview for Mental Status) score of 09. R5 is incontinent of bowel and bladder and requires extensive two person assistance with bed mobility, transfers and hygiene. According to R5's wound care notes, the facility identified a Stage 3 pressure ulcer to the left lateral calf on 11/7/22. On 1/23/23 at 1:17PM R5 said, I have a pressure sore on my left leg that they change every day. I've had it for a while, and they say it is healing but I can't see it. I have occasional pain, and a while back the pain was too much for me about a month ago. It would sometimes prevent me from wanting to get up out of bed. The CNA's don't help me to change position and most of the time I lay in the same spot. R5 Care plan for Impaired Skin integrity initiated 7/21/22 and revised 7/28/22 include interventions that states, assist with turning and repositioning as needed. On 1/24/23 at 3:54PM V2 Assistant Director of Nursing said, CNAs should be turning and repositioning dependent residents every two hours and charting once per shift. The (electronic record) where they chart does not prompt every two hours, so it is unclear if the task is completed. I am not aware of any where else they would document this. I wouldn't know that turning and repositioning is happening if it isn't documented. Facility policy titled, Pressure Ulcer Prevention (revised 1/15/18) states in part: The purpose to prevent and treat pressure sores/pressure injury. 3. Turn dependent resident approximately every two hours or as needed and position resident with pillow or pads protecting bony prominences as indicated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview. and record review, the facility failed to ensure that staff provide timely incontinence care in a manner consistent hygiene standards of practice for residents dependent on staff for care. This failure applied to six (R1, R4, R5, R6, R7, and R8) of seven residents reviewed for incontinence care and resulted in R1 requiring interventions for newly acquired MASD (moisture associated dermatitis); R6 requiring current treatment for a facility acquired UTI (urinary tract infection); and R7 has experienced emotional distress as a result of having to wait for an extended amount of time to be provided with incontinence care. Findings include: R1 is a [AGE] year-old female who has resided at the facility since 2020, with past medical history of other specified arthritis, chronic obstructive pulmonary disease, abnormal posture, schizoaffective disorder bipolar type, other benign neoplasm of skin, morbid severe obesity due to excess calories, essential primary hypertension, iron deficiency anemia, etc. 1/23/2023 at 12:45PM, observed R1 in her room in bed, awake, alert and oriented x 3, stated she does not get changed very often; they will tell her that they are coming back but never do. R1 said that when she gets cleaned, staff do not clean inside vagina, they just clean around the area. R1 said that staff get upset when she has a bowel movement because it is loose and sticky; she even refuses her stool softener because she does not need them, though she takes Norco for pain, but she never gets constipated. R1 said that she has not been changed today, the last time she was changed was yesterday. Surveyor asked R1 if it is okay to observe her incontinence care and she said yes. At 1:58PM, observed incontinence care for R1 with V4 (CNA) and noted resident's incontinence brief visibly soaked with urine and brown in color, resident's bed sheet was also noted very wet with brown colored marks from dried urine all around the sheet. An open area was noted to the resident's sacral area actively bleeding. V4 (CNA) said that due to the number of people they need to care for, sometimes it takes a while before getting to some of the residents. V4 was observed wiping resident's front and vaginal area with a gloved hand using one wet towel, after removing the wet incontinence brief and sheets, then wiped resident's bottom area with another wet towel, removed the wet incontinence brief and sheets and proceeded to put clean sheets and a clean incontinence brief on the resident without changing her gloves or performing any hand hygiene. V4 also applied Vaseline and powder all over resident's body with the same pair of gloves. When V4 was about to put a clean brief on R1, R1 complained of itching in her vaginal area. V4 told R1 that she must go and get another towel. V4 covered R1 with a clean sheet, brought a clean towel and wiped resident's vaginal area and some dark/brownish substances that looked like bowel movement was noted on the towel. V4 said that this must have been left there from before because the resident does not have any bowel movement at this time. 1/24/2023 at 11:16AM, R1 was observed again in her room, awake and alert and states that she was not changed again last night, the staff did not change her because they said that she ran out of incontinence briefs. R1 stated that the facility provides the incontinence briefs but they keep a particular size for her in her drawer, but some staff will use them for her roommate. R1 said that she is wet right now and just had a bowel movement. 1/24/2023 at 12:25PM, observed staff providing incontinence care to R1, V8 (CNA) said that she is the assigned staff and had not yet changed R1 today. At this time, observed with V8 that R1 had a bowel movement and her brief was heavily soiled. V8 was not sure if R1 was changed last night. V8 asked R1 if she was changed last night and she said no. R1 was still noted with an open area in her bottom that was actively bleeding. At 12:30PM, V7 (Nurse Consultant) said that R1 (currently) has a laceration on her left buttocks due to moisture. V7 was asked what the cause of the moisture was and she said it might be urine. V7 added that she will apply some barrier cream to resident now and call the doctor for some orders. Review of physician orders for R1 shows an order to apply dermaseptin to gluteal folds q (every) shift and each incontinent care every shift for incontinent care and as needed, order date 1/24/2023. Care plan dated 7/11/2018 and revised 7/08/2022 states that R1 is incontinent of bowel and bladder. Interventions include to check resident frequently and as needed for incontinence, change incontinent brief frequently and as needed, etc. Facility MDS section C (cognitive pattern) coded R1 with a BIMS score of 13, section G (functional) coded R1 as requiring extensive assistance with two persons physical assist for dressing toilet use bed mobility and personal hygiene. Section H of the same MDS coded R1 as always incontinent for bowel and bladder. 1/23/2023 at 12:35PM R6 was observed in her room awake and alert, stated that she is doing okay, she was asked if she has been changed and she said no, the last time she was changed was yesterday. R6 said that this happens most of the time, she finishes eating lunch before being changed. At 12:50PM, observed incontinence care for R6 with V3 (CNA), resident was noted with an incontinence brief that is saturated with urine and brown in color with a very strong smell. R6 was noted to be lying on top of two draw sheets, which were wet. Staff wiped resident's frontal area with a wet cloth, and wiped the back area with a wet cloth, did not clean the labial area. V3 proceeded to put clean linens and a clean incontinence brief on resident without changing her gloves or performing any type of hand hygiene. V3 added that she still has some people to change, she is not sure how many. Review of R6's medical record shows a urine culture dated 1/22/2023 with a positive result for ESBL, physician orders for R6 shows that she is currently receiving Bactrim DS Tablet 800-160 MG (Sulfamethoxazole-Trimethoprim), give 1 tablet by mouth every 12 hours for UTI for 7 Days. Review of medical records showed the following care plan initiated 1/8/2020, I have had functional, bladder and bowel incontinence due to Impaired mobility, generalized weakness. Interventions include Brief use: resident uses, disposable briefs. Change frequently and prn. Check resident frequently and as needed for incontinence. Wash, rinse, and dry perineum. Change clothing PRN after incontinence episodes, etc. MDS assessment dated [DATE] coded R6 as requiring extensive assistance with 2 persons physical assist for dressing, toilet use and personal hygiene, section H coded resident as always incontinent of bowel and bladder. 1/23/2023 at 12:55PM, R7 was observed in the same room with R1, awake and alert and stated that she is waiting to get up, she was left in bed since Friday, she has not been changed either and is wet right now. At 1:30PM, observed incontinence care for R7 with V3 (CNA) and V4 (CNA) and noted resident with what looked like like two incontinence briefs, when surveyor asked if resident was wearing two briefs, V3 said that it is an inserted pad, both the pad and brief were visibly saturated with urine, brown in color and has a strong smell. R7 was asked the last time she was changed, and she said, Yesterday afternoon, the night shift staff here don't do sh**, they don't even come into the room. R7 added that she wears the insert in addition to her brief because she is a heavy wetter. V3 provided the incontinence care while V4 was assisting with holding the resident because resident is a two person assist. V3 removed the dirty brief and linen, wiped the resident with a wet cloth and proceeded to apply a clean brief, some powder and deodorant and clean linens to the bed without changing her gloves or performing any type of hand hygiene. Care plan dated 3/5/2021 and revised 5/28/2022 states that R7 is incontinent of bowel and bladder, interventions include check resident as required for incontinence, wash, rinse, and dry perineum after incontinence episode. Facility MDS assessment section G (functional status) coded R7 as requiring extensive assistance with two persons physical assist for bed mobility, dressing, toilet use and personal hygiene, section H coded R7 as always incontinent of bowel and bladder. 1/24/23 at 1:00PM while surveyor was interviewing V5 (CNA), R7 approached and asked V5 when she could be changed because she had been waiting for a while. V5 informed R7 that she was busy but would find another staff to assist when possible because R7 is a two person staff assist. R7 said to surveyor, I asked a little while before and I was told I couldn't get changed right away. At 2:17PM R7 approached another surveyor in the hall and said, I am not happy. I have a feeling that they'll make me wait until after 3'o clock when the next shift comes to be changed. It has happened before. I haven't been changed since 6am today when they got me up and put me in the chair. R7 began crying and said, I know I am a two person assist and she needs help but why is that my problem? Why should I have to suffer and wait? V5 came in and changed both of my roommates, what about me? When I have a bowel movement it goes up into my pubic hair and vagina because I'm sitting and can't get up because I'm paralyzed. It's gotten to the point where I want to go somewhere else. The nurses don't help either. I ask the nurses for help and they say they don't know where the CNA is. At 2:33PM V15 (LPN) informed surveyor that V5 (CNA) told her that she had been waiting to be changed 15 minutes prior and did not know she had been waiting long before that. V15 said, the nurses help when we have time, but right now, I have been running around like crazy because we are short a nurse and two CNA's and it's the end of the shift. At 2:34PM, V5 (CNA) was heard behind the nurse's station loudly saying to another CNA, I don't have no help! I shouldn't have to beg nobody to help me V5 and the other CNA were then observed telling R7 they would change her. R4 is a [AGE] year-old male who was admitted to the facility 12/7/22 with diagnoses that include Multiple Sclerosis and paraplegia. According to R4's health record, MDS (Minimum Data Set) dated 1/3/23 indicates R4 has full cognition and requires extensive 2-person physical assistance with bed mobility, extensive one person assist with personal hygiene and is always incontinent of bowel and bladder function. According to wound care notes R4 arrived to the facility with multiple wounds and was initially assessed by V19 Wound Care Physician on 12/12/22. V19 weekly assessment dated [DATE] indicated all wounds present on admission were resolved. On 1/18/23 the facility identified two newly acquired wounds: a Stage 3 Pressure Ulcer to the left lateral lower leg, and Stage 3 pressure ulcer to the right medial knee. On 1/23/23 at 12:52PM V5 and V9 CNAs (Certified Nursing Assistants) were observed providing incontinence care for R4. Before securing the incontinence brief, V5 placed an additional folded brief inside the front and said, I put an extra brief because sometimes R4 urinates so much it soaks the brief. No one told me to do this, this is just something that I do. On 1/23/23 at 1:08PM, R4 was observed alert and oriented in bed and said during an interview, I get changed at least once per shift. I urinate more than that but they come when they come. Sometimes I wait so long for them to come that I have to ask or pull my light which also takes a while for them to answer. R4's health record contained a care plan for incontinence initiated 12/9/22 and revised 12/14/22 which stated check R4 s required for incontinence; Wash, rinse, and dry perineum; Change clothing as needed after incontinence episodes. 1/24/2023 at 11:10AM, observed incontinence care for R8 with V9 (CNA) who tried to wash resident up in her bed. R8 was alert with confusion and continuously asking unrelated questions. V8 wiped resident's face with one end of a bath towel soaked in water, used the same towel to wipe resident's upper body and went down to wiping the vaginal area with the same towel. Surveyor asked V8 if she is using only one towel to wash and dry the entire body and she said yes. V9 was asked if that is the standard or that they do not have any towels and she said sometimes they don't have enough towels. Facility Minimum Data Set (MDS) assessment dated [DATE] coded R8 as requiring extensive assistance with one-person physical assist for transfer, bed mobility, dressing, toilet use and personal hygiene. Care plan for R8 dated 2/22/2022, revised on 10/11/2022 states that resident is incontinent of bowel and bladder related to moderate to severe cognitive impairment and impaired mobility. Interventions include but not limited to provide peri care after each incontinent episode, apply barrier cream after each incontinent episode, etc. R5 is an [AGE] year-old male admitted to the facility 4/20/2012 with diagnoses that include cerebral infarction with hemiplegia and hemiparesis affecting left side, dysphagia, dementia, and contracture of the left hand. According to R5's medical records, MDS dated [DATE] indicated R5 has mild cognitive deficits with a BIMS (Brief Interview for Mental Status) score of 09. R5 is incontinent of bowel and bladder and requires extensive 2-person assistance with bed mobility, transfers, and hygiene. On 1/23/23 at 1:17PM R5 was observed in bed alert and oriented. R5 said during an interview, I have to use the brief to relive myself. Sometimes I must wait an hour or more which is quite a time to sit in urine or feces. I like to be clean, and I just have to sit and wait. R5's health record contained a care plan for incontinence initiated 10/28/21 and revised 1/19/22 stating that R5 is incontinent f bowel and bladder and requires staff assistance with toileting task due to diagnoses of Parkinson's, Arthritis, Neuropathy and Hemiplegia. Care plan Interventions include checking R5 as required for incontinence; Wash, rinse, and dry perineum; Change clothing as needed after incontinence episodes. 1/24/2023 at 3:54PM, V2 (ADON) said that she has not provided any in-services on incontinence care since she started at the facility about six weeks ago. Her expectation from staff during incontinence care is for them to clean residents using proper cleaning solution, making sure they are cleaning from front to back. If providing a bath, they are supposed to use soap and water but for changing incontinent briefs, a wet wipe is okay. V2 said that staff should have at least two towels when providing ADL care, one for the face and the other for the body. When providing incontinence care for a female resident, staff are supposed to clean from front to back as well as the vaginal/labial area. Staff are supposed to perform hand hygiene before and after care and between soiled and clean surfaces. Residents should be checked and changed every two hours and as needed. A resident not having any incontinence briefs in the room should not be an excuse for not changing a resident, the facility provides the briefs, and they always have some in storage. V2 said that MASD (moisture associated dermatitis) on an incontinent resident is probably from being wet and soiled all the time. Incontinent care policy dated 11/28/2012 and revised 1/16/2018 provided by V1 (Administrator) stated its purpose as to prevent excoriation and skin breakdown, discomfort and maintain dignity. Under guidelines, the policy states that incontinent residents will be checked periodically I accordance with the assessed incontinent episodes or every two hours and provided perineal and genital care after each episode. Under procedure, the policy states in part; soap one cloth at a time to wash genitalia using a clean part of the cloth for each swipe, wash the labia firs, then groin areas, in the female resident, separate labia, wash with strokes .each side separately with a clean cloth or clean .keep labia separated with one hand. Clean/rinse inner/upper thigh areas to remove urine moisture, change gloves and perform hand hygiene, apply clean incontinence brief or incontinence pad, do not touch any clean surfaces while wearing soiled gloves, etc.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to have sufficient nursing coverage in order to provide adequate resident care and support. This failure effected 3 (R4, R5 and R7) out of 4 residents reviewed for lack of staff and has the potential to affect all 125 residents residing in the facility. Findings include: On 1/23/23 at 1:08PM, R4 said, CNA (Certified Nursing Assistant) staff can be low. It seems like they are sparse; like you don't see them as the day gets long. It usually takes two CNAs to change me because my legs are stiff. I get changed at least once per shift. I urinate more than that but they come when they come. Sometimes I wait so long for them to come that I have to ask or pull my light which also takes a while for them to answer. On 1/23/23 at 1:17PM R5 said, I have to use the brief to relive myself. Sometimes I have to wait an hour or more which is quite a time to sit in urine or feces. I like to be clean, and I just have to sit and wait. We usually don't have a problem in the morning but in the evening and night, it is more common that CNAs don't come in to check. They don't come and turn or reposition me regularly if they aren't even coming in the room. I don't put my light on or complain because I don't want to get anyone upset or retaliate against me. On 1/24/23 at 2:10PM V8 CNA said, I am having a hard time getting staff to help me change a resident (R7) that requires two staff assist to use the mechanical lift because we are short staffed. We are working with three CNA's today and we should have five. At 2:33PM V15 LPN said, when we are short CNAs; the nurses do help with care but today I am running and busy because we are also short a nurse. On 1/24/23 at 3:54PM V2 ADON (Assistant Director of Nursing) said I am currently responsible for the nursing schedule. A fully staffed shift is four to five nurses and 10 CNAs (Certified Nursing Assistant). The building is organized as A/B wing and C/D wing. A fully staffed day and evening shift has five CNAs for each wing and three CNAs for night shift. The A/B wing has three medication carts and can staff three nurses and the C/D wing is staffed with two nurses per shift. Staffing is challenging due to multiple call offs and because of that I am working the floor today. This is the second time that I have had to work the floor and I am a new employee to the facility. There is a registered nurse scheduled to work every shift and there is at least one working every day. On 1/25/23 at 12:10PM V1 Administrator said, the facility budget allows us to staff 13 nurses and 30 CNAs every day for direct patient care. We don't utilize any agency for staffing at this time. We hire some under contract but after the contract ends, often they don't stay. I think that the high turnover and the increased call ins are impacted by the fact that they really need a leader. We have had three DONs (Director of Nursing) in the past year and a new one just started today. When we don't have enough people to do what we need, we have to do the best we can. During the course of this survey, residents were observed to be soiled with feces and urine and in need of incontinence care for several hours. V1 was asked if lack of staff has contributed to delays in care and V1 stated, I can't answer that. We want them to be checked and changed and if that is not happening, we are looking at why. Nursing Assignment sheet dated for 1/23/23 and 1/24/23 were reviewed and included the following: 1/23/23 A/B wing: 7am to 3pm - 2 nurses, 3 CNAs - 3pm to 11pm, 3 nurses 2 CNAs C/D wing: 3pm to 11pm -2 nurses, 2 CNAs - 11pm to 7am, 2 nurses 2 CNA's 1/24/23 A/B wing: 7am to 3pm - 2 nurses 3 CNAs; 3pm to 11pm 2 nurses 2 CNAs; 11pm to 7am 1 nurse 3 CNAs C/D wing: 7am to 3pm - 2 nurses 3 CNAs; 3pm to 11pm 2 nurses 2 CNAs; 11pm to 7am 2 nurses 2 CNAs During the course of this survey, facility cited for concerns related to incontinence care not being provided (F690) and pressure ulcers (F686), with staffing as a contributing factor. Based on observation, interview, and record review, the facility failed to have sufficient staff to provide necessary care and services to residents required to meet their plan of care. This failure applied to six (R1, R4, R5, R6, R7, and R8) of seven residents reviewed for nursing care and resulted in R1 requiring interventions for newly acquired MASD (moisture associated dermatitis); R6 requiring current treatment for a facility acquired UTI (urinary tract infection); and R7 has experienced emotional distress as a result of having to wait for an extended amount of time to be provided with incontinence care. Findings include: R1 is a [AGE] year-old female who has resided at the facility since 2020, with past medical history of other specified arthritis, chronic obstructive pulmonary disease, abnormal posture, schizoaffective disorder bipolar type, other benign neoplasm of skin, morbid severe obesity due to excess calories, essential primary hypertension, iron deficiency anemia, etc. 1/23/2023 at 12:45PM, observed R1 in her room in bed, awake, alert and oriented x 3, stated she does not get changed very often; they will tell her that they are coming back but never do. R1 said that when she gets cleaned, staff do not clean inside vagina, they just clean around the area. R1 said that staff get upset when she has a bowel movement because it is loose and sticky; she even refuses her stool softener because she does not need them, though she takes Norco for pain, but she never gets constipated. R1 said that she has not been changed today, the last time she was changed was yesterday. Surveyor asked R1 if it is okay to observe her incontinence care and she said yes. At 1:58PM, observed incontinence care for R1 with V4 (CNA) and noted resident's incontinence brief visibly soaked with urine and brown in color, resident's bed sheet was also noted very wet with brown colored marks from dried urine all around the sheet. An open area was noted to the resident's sacral area actively bleeding. V4 (CNA) said that due to the number of people they need to care for, sometimes it takes a while before getting to some of the residents. V4 was observed wiping resident's front and vaginal area with a gloved hand using one wet towel, after removing the wet incontinence brief and sheets, then wiped resident's bottom area with another wet towel, removed the wet incontinence brief and sheets and proceeded to put clean sheets and a clean incontinence brief on the resident without changing her gloves or performing any hand hygiene. V4 also applied Vaseline and powder all over resident's body with the same pair of gloves. When V4 was about to put a clean brief on R1, R1 complained of itching in her vaginal area. V4 told R1 that she must go and get another towel. V4 covered R1 with a clean sheet, brought a clean towel and wiped resident's vaginal area and some dark/brownish substances that looked like bowel movement was noted on the towel. V4 said that this must have been left there from before because the resident does not have any bowel movement at this time. 1/24/2023 at 11:16AM, R1 was observed again in her room, awake and alert and states that she was not changed again last night, the staff did not change her because they said that she ran out of incontinence briefs. R1 stated that the facility provides the incontinence briefs but they keep a particular size for her in her drawer, but some staff will use them for her roommate. R1 said that she is wet right now and just had a bowel movement. 1/24/2023 at 12:25PM, observed staff providing incontinence care to R1, V8 (CNA) said that she is the assigned staff and had not yet changed R1 today. At this time, observed with V8 that R1 had a bowel movement and her brief was heavily soiled. V8 was not sure if R1 was changed last night. V8 asked R1 if she was changed last night and she said no. R1 was still noted with an open area in her bottom that was actively bleeding. At 12:30PM, V7 (Nurse Consultant) said that R1 (currently) has a laceration on her left buttocks due to moisture. V7 was asked what the cause of the moisture was and she said it might be urine. V7 added that she will apply some barrier cream to resident now and call the doctor for some orders. Review of physician orders for R1 shows an order to apply dermaseptin to gluteal folds q (every) shift and each incontinent care every shift for incontinent care and as needed, order date 1/24/2023. Care plan dated 7/11/2018 and revised 7/08/2022 states that R1 is incontinent of bowel and bladder. Interventions include to check resident frequently and as needed for incontinence, change incontinent brief frequently and as needed, etc. Facility MDS section C (cognitive pattern) coded R1 with a BIMS score of 13, section G (functional) coded R1 as requiring extensive assistance with two persons physical assist for dressing toilet use bed mobility and personal hygiene. Section H of the same MDS coded R1 as always incontinent for bowel and bladder. 1/23/2023 at 12:35PM R6 was observed in her room awake and alert, stated that she is doing okay, she was asked if she has been changed and she said no, the last time she was changed was yesterday. R6 said that this happens most of the time, she finishes eating lunch before being changed. At 12:50PM, observed incontinence care for R6 with V3 (CNA), resident was noted with an incontinence brief that is saturated with urine and brown in color with a very strong smell. R6 was noted to be lying on top of two draw sheets, which were wet. Staff wiped resident's frontal area with a wet cloth, and wiped the back area with a wet cloth, did not clean the labial area. V3 proceeded to put clean linens and a clean incontinence brief on resident without changing her gloves or performing any type of hand hygiene. V3 added that she still has some people to change, she is not sure how many. Review of R6's medical record shows a urine culture dated 1/22/2023 with a positive result for ESBL, physician orders for R6 shows that she is currently receiving Bactrim DS Tablet 800-160 MG (Sulfamethoxazole-Trimethoprim), give 1 tablet by mouth every 12 hours for UTI for 7 Days. Review of medical records showed the following care plan initiated 1/8/2020, I have had functional, bladder and bowel incontinence due to Impaired mobility, generalized weakness. Interventions include Brief use: resident uses, disposable briefs. Change frequently and prn. Check resident frequently and as needed for incontinence. Wash, rinse, and dry perineum. Change clothing PRN after incontinence episodes, etc. MDS assessment dated [DATE] coded R6 as requiring extensive assistance with 2 persons physical assist for dressing, toilet use and personal hygiene, section H coded resident as always incontinent of bowel and bladder. 1/23/2023 at 12:55PM, R7 was observed in the same room with R1, awake and alert and stated that she is waiting to get up, she was left in bed since Friday, she has not been changed either and is wet right now. At 1:30PM, observed incontinence care for R7 with V3 (CNA) and V4 (CNA) and noted resident with what looked like like two incontinence briefs, when surveyor asked if resident was wearing two briefs, V3 said that it is an inserted pad, both the pad and brief were visibly saturated with urine, brown in color and has a strong smell. R7 was asked the last time she was changed, and she said, Yesterday afternoon, the night shift staff here don't do sh**, they don't even come into the room. R7 added that she wears the insert in addition to her brief because she is a heavy wetter. V3 provided the incontinence care while V4 was assisting with holding the resident because resident is a two person assist. V3 removed the dirty brief and linen, wiped the resident with a wet cloth and proceeded to apply a clean brief, some powder and deodorant and clean linens to the bed without changing her gloves or performing any type of hand hygiene. Care plan dated 3/5/2021 and revised 5/28/2022 states that R7 is incontinent of bowel and bladder, interventions include check resident as required for incontinence, wash, rinse, and dry perineum after incontinence episode. Facility MDS assessment section G (functional status) coded R7 as requiring extensive assistance with two persons physical assist for bed mobility, dressing, toilet use and personal hygiene, section H coded R7 as always incontinent of bowel and bladder. 1/24/23 at 1:00PM while surveyor was interviewing V5 (CNA), R7 approached and asked V5 when she could be changed because she had been waiting for a while. V5 informed R7 that she was busy but would find another staff to assist when possible because R7 is a two person staff assist. R7 said to surveyor, I asked a little while before and I was told I couldn't get changed right away. At 2:17PM R7 approached another surveyor in the hall and said, I am not happy. I have a feeling that they'll make me wait until after 3'o clock when the next shift comes to be changed. It has happened before. I haven't been changed since 6am today when they got me up and put me in the chair. R7 began crying and said, I know I am a two person assist and she needs help but why is that my problem? Why should I have to suffer and wait? V5 came in and changed both of my roommates, what about me? When I have a bowel movement it goes up into my pubic hair and vagina because I'm sitting and can't get up because I'm paralyzed. It's gotten to the point where I want to go somewhere else. The nurses don't help either. I ask the nurses for help and they say they don't know where the CNA is. At 2:33PM V15 (LPN) informed surveyor that V5 (CNA) told her that she had been waiting to be changed 15 minutes prior and did not know she had been waiting long before that. V15 said, the nurses help when we have time, but right now, I have been running around like crazy because we are short a nurse and two CNA's and it's the end of the shift. At 2:34PM, V5 (CNA) was heard behind the nurse's station loudly saying to another CNA, I don't have no help! I shouldn't have to beg nobody to help me V5 and the other CNA were then observed telling R7 they would change her. R4 is a [AGE] year-old male who was admitted to the facility 12/7/22 with diagnoses that include Multiple Sclerosis and paraplegia. According to R4's health record, MDS (Minimum Data Set) dated 1/3/23 indicates R4 has full cognition and requires extensive 2-person physical assistance with bed mobility, extensive one person assist with personal hygiene and is always incontinent of bowel and bladder function. According to wound care notes R4 arrived to the facility with multiple wounds and was initially assessed by V19 Wound Care Physician on 12/12/22. V19 weekly assessment dated [DATE] indicated all wounds present on admission were resolved. On 1/18/23 the facility identified two newly acquired wounds: a Stage 3 Pressure Ulcer to the left lateral lower leg, and Stage 3 pressure ulcer to the right medial knee. On 1/23/23 at 12:52PM V5 and V9 CNAs (Certified Nursing Assistants) were observed providing incontinence care for R4. Before securing the incontinence brief, V5 placed an additional folded brief inside the front and said, I put an extra brief because sometimes R4 urinates so much it soaks the brief. No one told me to do this, this is just something that I do. On 1/23/23 at 1:08PM, R4 was observed alert and oriented in bed and said during an interview, I get changed at least once per shift. I urinate more than that but they come when they come. Sometimes I wait so long for them to come that I have to ask or pull my light which also takes a while for them to answer. R4's health record contained a care plan for incontinence initiated 12/9/22 and revised 12/14/22 which stated check R4 s required for incontinence; Wash, rinse, and dry perineum; Change clothing as needed after incontinence episodes. 1/24/2023 at 11:10AM, observed incontinence care for R8 with V9 (CNA) who tried to wash resident up in her bed. R8 was alert with confusion and continuously asking unrelated questions. V8 wiped resident's face with one end of a bath towel soaked in water, used the same towel to wipe resident's upper body and went down to wiping the vaginal area with the same towel. Surveyor asked V8 if she is using only one towel to wash and dry the entire body and she said yes. V9 was asked if that is the standard or that they do not have any towels and she said sometimes they don't have enough towels. Facility Minimum Data Set (MDS) assessment dated [DATE] coded R8 as requiring extensive assistance with one-person physical assist for transfer, bed mobility, dressing, toilet use and personal hygiene. Care plan for R8 dated 2/22/2022, revised on 10/11/2022 states that resident is incontinent of bowel and bladder related to moderate to severe cognitive impairment and impaired mobility. Interventions include but not limited to provide peri care after each incontinent episode, apply barrier cream after each incontinent episode, etc. R5 is an [AGE] year-old male admitted to the facility 4/20/2012 with diagnoses that include cerebral infarction with hemiplegia and hemiparesis affecting left side, dysphagia, dementia, and contracture of the left hand. According to R5's medical records, MDS dated [DATE] indicated R5 has mild cognitive deficits with a BIMS (Brief Interview for Mental Status) score of 09. R5 is incontinent of bowel and bladder and requires extensive 2-person assistance with bed mobility, transfers, and hygiene. On 1/23/23 at 1:17PM R5 was observed in bed alert and oriented. R5 said during an interview, I have to use the brief to relive myself. Sometimes I must wait an hour or more which is quite a time to sit in urine or feces. I like to be clean, and I just have to sit and wait. R5's health record contained a care plan for incontinence initiated 10/28/21 and revised 1/19/22 stating that R5 is incontinent f bowel and bladder and requires staff assistance with toileting task due to diagnoses of Parkinson's, Arthritis, Neuropathy and Hemiplegia. Care plan Interventions include checking R5 as required for incontinence; Wash, rinse, and dry perineum; Change clothing as needed after incontinence episodes. 1/24/2023 at 3:54PM, V2 (ADON) said that she has not provided any in-services on incontinence care since she started at the facility about six weeks ago. Her expectation from staff during incontinence care is for them to clean residents using proper cleaning solution, making sure they are cleaning from front to back. If providing a bath, they are supposed to use soap and water but for changing incontinent briefs, a wet wipe is okay. V2 said that staff should have at least two towels when providing ADL care, one for the face and the other for the body. When providing incontinence care for a female resident, staff are supposed to clean from front to back as well as the vaginal/labial area. Staff are supposed to perform hand hygiene before and after care and between soiled and clean surfaces. Residents should be checked and changed every two hours and as needed. A resident not having any incontinence briefs in the room should not be an excuse for not changing a resident, the facility provides the briefs, and they always have some in storage. V2 said that MASD (moisture associated dermatitis) on an incontinent resident is probably from being wet and soiled all the time. Incontinent care policy dated 11/28/2012 and revised 1/16/2018 provided by V1 (Administrator) stated its purpose as to prevent excoriation and skin breakdown, discomfort and maintain dignity. Under guidelines, the policy states that incontinent residents will be checked periodically I accordance with the assessed incontinent episodes or every two hours and provided perineal and genital care after each episode. Under procedure, the policy states in part; soap one cloth at a time to wash genitalia using a clean part of the cloth for each swipe, wash the labia firs, then groin areas, in the female resident, separate labia, wash with strokes .each side separately with a clean cloth or clean .keep labia separated with one hand. Clean/rinse inner/upper thigh areas to remove urine moisture, change gloves and perform hand hygiene, apply clean incontinence brief or incontinence pad, do not touch any clean surfaces while wearing soiled gloves, etc.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records reviewed the facility failed to ensure that one resident (R5) of 4 residents reviewed was free from abuse from a CNA in a total sample of 21. This failure resulted in R5 being screamed at and threatened to be hit with a cane by a CNA and R5 feeling afraid and unsafe at the facility. Findings include: The facility's final Incident reported dated 10/17/2022 documents the following: R5 stated on Monday 10/17/2022 that a C.N.A. on the night shift the night before threatened to hit him with a cane. He described her as a young lady with a nice physique who was African American with blonde curly hair. No one with that description worked on that day. R14 was the roommate of R5 and is alert and oriented. R14 states that he does not know why, but a C.N.A came in the room and waved the cane at R5 and said she was going to hit him with it. Report also documents 2 staff members being interviewed: V29 (nurse) and V22 (CNA) Review of R5's face sheet documents a [AGE] year old male with history of the following diagnoses: Encounter for Surgical aftercare following surgery on the digestive system, Encounter for attention to colostomy, Type 2 Diabetes Mellitus Without complications, Obesity, hypertension, Benign Prostatic Hyperplasia, personal history of Transient Ischemic Attack and Cerebral Infarction Without Residual Deficits, Colostomy status, long term (current) use of anticoagulants. R5's Minimum Data Sheet (MDS) dated [DATE] section C documents R5's mental status was intact as noted in the Brief Interview for Mental Status (BIMS) score of 14 out of 15. R5's admission observation dated 9/28/2022 documents R5 Alert and oriented to person, place, time and situation. On 10/3/2022 V34 (FNP) document R5 to be alert and oriented. On 12/29/22 at 12:55 PM V1 (Administrator) states that she is the abuse coordinator. V1 states that on 10/17/2022 R5 asked to see her and family called and said go see him because he had a concern. V1 states that R5 said the CNA threatened to hit him with a cane the previous night. V1 states, R5 said it was an African American with light curly hair. V1 states we had no one with that description. V1 states then someone told her that V22 (CNA) wears a light colored wig. V1 states on the video she saw she could see the room and did not see a CNA go into his room. V1 states that on 10/15/2022 she saw that V22 was on the unit and saw her wearing light colored hair on 10/15/2022. V1 states she never saw V22 go into R5's room. Surveyor asked for clock-ins for V22 for that week. V22's time clock in report documents she did not work on 10/15/2022. After pointing that out to V1 that V22 did not work 10/15/2022, V1 states she doesn't remember the day she saw V22 in the light colored wig on video and she no longer has the video. V1 states V22 was suspended pending investigation. We had figured out it was V22 that R5 was talking about. V1 states R5's Roommate, R14 added info that helped her figure it out. V1 states something wasn't sitting right with her about the allegation and R14 had corroborated it, so they suspended V22 on 10/20/22 pending the investigation. Incident reported on 10/17/22 documents that she was suspended on 10/20/22. V1 states she interviewed V22 on the 20th and suspended her on the same day. Then when surveyor states that V22 worked the night shift on 10/20/22 then V1 stated it was probably the 21st that we suspended her. V1 states V22 agreed she was assigned to R5 then we let V22 go. On 1/3/2023 at 10:33 AM V1 states that R5 said young lady who threatened him had blonde hair. V1 states she looked at the video from 10/16/2022 from 11pm to 7 am at the nurse's station only for who fit that description. V1 states, she did not look at who was going in and out of R5's room for that time period. V1 states she does not know if V22 went into R5's room because she did not look on the video by his room. V1 states several people working that unit that evening and she interviewed V29 (nurse) and the V22 (CNA) only. Video lasts only one week. V1 states she found video of V22, fitting the description that R5 gave on a different day, but she does not know what day that was. V1 states, when they figured out that it was V22 R5 was talking about they told V22 she was no longer employed. V1 states R5 had never had any allegations about any staff or residents before. On 12/28/2022 at 12:27 PM R14 states R14 that he remembers the situation with R5 and a CNA in October. R14 states the facility fired the CNA. R14 states that R5 was sitting up at the side of the bed and he had a colostomy bag. R14 states the CNA came into the room and she never said anything about emptying the bag or what she wanted to do. R14 states she just told R5 to lay down and R5 said no that he did not have to lay down. The CNA was then screaming lay down, lay down! she said if you don't I will hit you with this cane. V14 states, he saw her shadow and heard the commotion and he got up. R14 states the CNA was screaming lay down, lay down right now or I'll hit you with this cane, and she had the cane holding it up like she was going to hit him. R14 states he told the administrator what happened when she came and asked him about it. R14 states, I felt like it was wrong. R14 states R5 wasn't in the best of health, and R14 states he felt like the CNA was taking advantage of R5. R14 states he had back surgery but he got up to see what was going on. R14 states R5 was mad. The CNA had his cane in her hand and holding it up above his head like she was going to strike him. After that happened the CNA went to work on A&B for about a week and then I didn't see her again. The incident happened about midnight. I had my T.V on and the CNA was saying Lay down, I said lay down right now, If you don't lay down I'm going to hit you with this cane. R14 states, I thought she was going to hit him (R5) for real. On 12/28/2022 at 2:53 Pm V30 (family of R5) states that when she went to the facility on [DATE], they said they had started the investigation. V30 states V1 told her they would review the camera's because they didn't find anyone that fit the description R5 gave. V30 states that R5's roommate explained to them that the CNA wears different wigs and had a had a short wig that night. V30 states a few days later, V1 called and said I have good news, we found out who the CNA was and we terminated her on the spot. V30 put R5 on the phone and R5 assessed to be alert to person, place, event, and states in the middle of the night I was sitting on the side of the bed and the CNA came in and wanted me to lay back. R5 states the CNA didn't say why she wanted me to lay down. R5 states, she wanted me to lay down like a kid. She made it sound like I was a child. R5 states he told the CNA, You can't make me get in the bed. I'll get in the bed when I'm ready. R5 states, she took his cane and said I am going to hit you with this cane if you don't lay down. R5 states, I said please don't hit me. I felt like she was wrong. I was afraid. I was scared. I put my hands up so she wouldn't hit me in the head. The facility said no one fit the description with short hair. R5 states, I didn't feel safe after that, because I couldn't believe they would do that to me. I don't think they would fire her for nothing. R5 states he did not want to hit her, but was feeling like he would have to protect himself if she hit him. Review of staffing schedule and assignment sheet for 10/16/2022 documents V22 working the night of 10/16/2022 and was assigned to R5. Review of R5's clock in sheet document she worked the 3rd overnight shift (11PM to 7:30 AM) on 10/16/2022, 10/17, 2022, 10/18/2022, 10/19/2022 and 10/20/2022. Review of staffing schedule also documents V29 (nurse D wing), V35 (CNA), V36 (CNA), and V37 (CNA) working on C and D wings on 10/16/2022 . On 12/30/22 at 6:22 AM V29 (Nurse) states he has never heard of any situation with a resident and staff threatening with cane. V29 states he does not remember R5 and no one has interviewed him regarding R5. On 1/2/2023 at 11:45 PM V37 (CNA) states she doesn't remember R5. V37 states no staff has interviewed her regarding any situation or allegation of abuse with R5. The facility's Abuse Prevention and Reporting policy dated 10/24/2022 documents the following: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews, the facility failed to follow their practice and perform weekly skin assessments for one resident R6, out of 4 residents reviewed for pressure ulcer prevention in a sample of 21. This failure resulted in R6 developing an unstageable pressure ulcer to his coccyx, a deep tissue pressure injury to the left buttock and a left medial upper thigh full thickness wound. The facility also failed to properly assess one resident's (R8) wounds and order wound care treatments for 5 days after R8 was admitted with 3 wounds. This failure led to the worsening of R8's sacral wound. Findings Include: 1. R6 is a [AGE] year old admitted on [DATE] with a diagnosis not limited to major depressive disorder, unspecified hemiplegia and hemiparesis, essential (primary) hypertension, and multiple sclerosis. R6's admission skin assessment indicates that R6's skin was intact. MDS section G indicates that R6 needs extensive assistance, and is total dependence with activities of daily living. R6's Wound assessment dated [DATE] documents 3 new wounds identified on 10/27/2022: 1) Coccyx- unstageable, size 7.5 x2.5 x unknown, and 70% slough 2) Left buttock- deep tissue pressure injury. 6.00 x 5.00 x unknown, deep [NAME] 60% 3) Left medial upper thigh- full thickness On 12/30/22 at 2:24 PM V8 (MDS) states she looked for all assessments for R6 and was only able to find one assessment and handed surveyor an admission assessment dated [DATE]. Surveyor Reviewed R6's electronic records for wound assessments and there were no skin/wound assessments documented. Review of R6's Braden observation dated 6/2/2022 documents R6 as a moderate risk for development of pressure ulcers. On 10/07/2022, skin assessment documentation indicated wound observation on right knee (front), and sacrum. Review of R6's progress notes by the previous director of nursing documents the following: Resident observed with 3 new skin issues: unstageable wound to coccyx, DTI to left buttock, and skin tear/shearing to left inner thigh. 2. Review of R8's face sheet documents a [AGE] year old male with diagnoses including the following: Complete traumatic amputation at level between left hip and knee, sepsis, malignant neoplasm, diabetes mellitus, pressure ulcer of sacral region unstageable, and end stage renal disease. R8's Discharge wound care recommendations from the hospital dated 11/2/222 documents wound treatments for a Left Knee Amputation site, a Sacral Wound, and a Right Foot Wound. Review of R8's Braden observation dated 11/2/2022 documents R8 as at risk for development of pressure ulcers. Review of R8's admission skin integrity assessment is absent of any wounds and documents R8 to have potential for impairment to skin integrity. The admission skin assessment also documents R8 has a pressure ulcer, but does not specify a location of any wound or pressure ulcer or any measurements. Review of R8's wound assessment dated [DATE] documents a pressure ulceration that documents an unstageable sacral wound measuring 6.50 x 9.00 x unknown with 80% slough and no tunneling. The only other wound assessment is dated 11/15/2022, the day R8 was discharged and it documents the sacral wound with the same measurements and 100% slough and tunneling present. Review of R8's Physician orders documents he did not have any wound care orders for 5 days from admission [DATE] through 11/6/2022. The first wound care orders are dated 11/7/2022. Review of R6's care plan does not document his new 3 wounds or any new interventions. On 01/03/2023 at 10:15 am, V14 (Nurse) said that R6 had a wound on his sacrum and coccyx. V14 said that she started taking care of R6's wound after the wound care nurse left. V14 said that the facility wound care doctor does not see VA residents in the facility. V14 said R6 was never assigned to her because R6 resides on D-Wing, and she works on C-Wing. V14 said that weekly assessments are done when it pops up on the medication administration record or the treatment administration record. V14 said that weekly assessments are supposed to be done on all the residents and it could pop up to be done on different shifts. On 12/30/2022 at 1:03 pm, V32 (Previous Wound Nurse) said that she recalled taking care of R6. She said that R6 is 1 - 2 assist but she does not recall seeing any wounds. V32 said that if she notices any wounds on the residents, she tells the nurse and also document in the POC. On 12/30/2022 at 2:00 PM V18 (Nurse) said that she remembered that R6 had wounds but she cannot recall the location of the wounds. V18 said that R6 is not ambulatory, can only turn with assistance, and as such, is at high risk for developing a wound. V18 said that when she notices a wound on residents, she cleans the wound, covers it and notify the doctor for orders. V18 said that the wound care nurse is responsible for all wound care. V18 said that the nurses perform baseline skin assessment upon admission and on a weekly basis to ensure that the resident's skin integrity is intact or notify the doctor to initiate treatment for any skin breakdown in a timely manner. On 1/3/2023 at 09:58 AM, V18 said that she took care of R6 every day she worked. V18 said that the nurse does the skin assessment if it shows up on the medication administration record (MAR) or the treatment administration record (TAR). V18 said that she does not recall performing a skin assessment on R6, but if she did, it would be charted. On 1/3/2023 at 2:30 PM V2 (ADON) states upon admission all residents should have a skin assessment. V2 states, the admitting nurse documents the wounds and refers the resident to the wound care nurse. The nurse will then notify the doctor of wounds. V2 states, you want to document whatever skin condition is there on admission to have a baseline of where they are and that is standard practice. V2 states nursing staff should do skin assessments weekly. V2 states that nursing staff should be documenting skin or wounds on a skin assessment form or some nurses put it in the progress notes. V2 states, nurses should be documenting skin assessments weekly in the weekly skin assessment tool in the electronic medical record. Wound care team does the measurements of wounds. V2 states that within 72 hours the wound care team should see wounds and measure and assess the wounds. V2 states, orders for wound care should come with admission and immediately be put into the system. V2 states, she can't see any reason to wait 5 days to get wound care orders on a person with wounds and/or unstageable wounds. V2 states, If there are empty spaces on the Treatment Administration record (TAR) and it is not initialed, then it is not done. V2 states, the C.N.A.'s should be doing skin checks and documenting it when providing care to a resident. The facility's Pressure Injury and Skin Condition assessment dated [DATE] documents the following: 2) Residents identified will have a weekly skin assessment by a licensed nurse. 4) Each resident will be observed for skin breakdown daily during care and on the assigned bath day by the CNA. Changes shall be promptly reported to the charge nurse who will perform the detailed assessment. 10) Pressure injuries and other ulcers will be measured at least weekly and recorded in centimeters in the resident clinical record.