**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who developed facility-acquired pressure ulcers were assessed by the wound care physician/NP-Nurse Practitioner; failed to ensure the residents received nutritional interventions to promote wound healing; failed to put interventions in place to prevent pressure ulcers from deteriorating; failed to provide wound care treatments as ordered by the physician; and failed to follow their policy to do a root cause analysis for residents with facility-acquired pressure ulcers. This failures resulted in R1's facility-acquired pressure ulcer increasing in size, and R1's DTI (Deep Tissue Injury) progressing to an unstageable pressure ulcer. This applies to 3 of 3 residents (R1, R2, R3) reviewed for facility-acquired pressure ulcers in the sample of 3. The findings include: 1. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE] with multiple diagnoses including nondisplaced fracture of the right great toe, COPD (Chronic Obstructive Pulmonary Disease), OSA (Obstructive Sleep Apnea), Type 2 diabetes, cataract, hypertension, lymphedema, history of breast cancer, heart failure, morbid obesity, altered mental status, major depressive disorder, insomnia, muscle weakness, difficulty walking, lack of coordination, need for assistance with personal care, shortness of breath, and dementia. R1's MDS (Minimum Data Set) dated October 17, 2024 shows R1 has moderate cognitive impairment, requires setup assistance with eating, supervision with oral and personal hygiene, bed mobility, and transfers between surfaces, and substantial/maximal assistance with toilet hygiene, showering, and lower body dressing. R1 is occasionally incontinent of urine, and frequently incontinent of stool. The MDS continues to show R1 was at risk of developing pressure ulcers and did not have pressure ulcers at the time of her admission to the facility. On November 25, 2024 at 10:26 PM, V11 (Nurse) documented, Writer made aware of open area to heel left foot. Upon further assessment, writer observed open area on left heel. Writer cleaned area with normal saline, dried with sterile gauze and applied 4x4 to area. Provider and family is aware. Wound care is aware. New orders for protein and to keep foot elevated and Podiatry consult. Staff to continue to follow up. On November 26, 2024 at 9:40 AM, V3 (WCN/RN) documented, Was notified that a wound was found on [R1's] left heel. Upon assessment, she has a Stage 3 pressure ulcer there. She was also found to have a small DTI (Deep Tissue Injury) on her right heel. She spends little time in bed, but she may have pressure from the back of her shoes. Her daughter and MD were notified. On November 25, 2024 at 1:40 PM, V1 (Administrator) documented, I saw [R1] at lunch time propelling herself to the dining room using her heels. I asked [R1] if she wanted help, she stated no she was fine. On December 4, 2024 at 9:15 AM, R1 was lying in bed in her room, sleeping. R1 was not covered by a sheet or blanket and her legs were visible. R1's heels were resting on the mattress. R1 was not wearing foam heel boots. No pillows were present in R1's bed to offload her heels from the mattress. R1 did not have a low air loss mattress. On December 4, 2024 at 9:28 AM, V10 (CNA-Certified Nursing Assistant) entered R1's room and said, I had to wake her up this morning. She likes to sleep late. R1 attempted to make position changes in her bed but found it difficult to change positions in bed without the assistance of V10. V10 was unable to find foam heel boots or other pillows in R1's room to elevate R1's heels off the bed. R1 was wearing a nightgown and short socks in bed. V10 removed R1's socks. R1 had a dressing over the back of her left heel. The dressing had peeled away from R1's skin and was bunched up over the back of her ankle. The wound on R1's heel was exposed. The wound on R1's heel appeared approximately 1 inch in diameter. The wound appeared crater-like, dry, and with some redness in the center of the wound. R1 also had a dressing over her right heel, and the wound was not visible. V10 assisted R1 with dressing herself and placed R1's shoes on her feet. On December 4, 2024 at 9:40 AM, V3 (WCN-Wound Care Nurse/RN-Registered Nurse) said she believes R1's pressure ulcers were caused by R1's shoes. V3 said, [R1] uses her feet to propel herself around in her wheelchair. She has a Stage 3 pressure ulcer on her left heel and a DTI (Deep Tissue Injury) on her right heel. Both wounds were found on November 26, 2024. We have two wound NPs (Nurse Practitioners) who come to the facility weekly. [R1] has not been seen by either wound care NP. I don't think we have a protocol for when the residents should be seen by the wound care NP. I don't think we have a protocol for when residents should be put on a low air loss mattress. Usually, we only use a low air loss mattress when the resident is immobile and has a Stage 2 or higher pressure ulcer. V3 entered R1's room at 9:45 AM. R1 was sitting up in her wheelchair fully dressed, including wearing her shoes. V3 told R1 she was surprised to see R1 wearing her shoes. V3 removed the dressing on R1's left heel. V3 noted the dressing was not covering R1's pressure ulcer. V3 said the dressing should be covering R1's pressure ulcer. V3 said, On November 26, 2024, R1's left heel wound measurements were 1.2 cm. (centimeters) long by 0.8 cm. wide, by 0.3 cm. deep. Today the measurements are 1.5 cm. long by 1.8 cm. wide, by 0.2 cm. deep. The wound is getting wider/bigger. V3 removed the dressing on R1's right heel and said, The DTI area has now turned to a scab. I am going to discontinue putting any dressing on this and leave it open to air. During the wound care treatment, R1 stated she has very little feeling in her feet due to her diabetes. R1 said she can feel something is there but could not say exactly what she was feeling. On December 4, 2024 at 11:26 AM, V8 (WCN/LPN-Licensed Practical Nurse) said, I am responsible for arranging all wound care visits between our wound care providers and the residents. The other wound care nurses notify me who needs to be seen and I arrange it. The wound care physician and NPs come to the facility on Mondays and Tuesdays, and I round with them. We were never notified [R1] needed to be seen by the wound care physician or NP, so we did not see that resident. It could have happened right away if [V3] (WCN/RN) would have made the referral and added [R1] to the list. V8 continued to say when a resident has a DTI and the DTI develops a scab over the area, the pressure ulcer would be considered an unstageable pressure ulcer. As of December 5, 2024 at 4:00 PM, the facility did not have documentation to show R1 was assessed by the wound care physician or NP since the development of her pressure ulcer on November 25, 2024. The facility does not have documentation to show R1 was encouraged not to wear her shoes or to stop using her heels to self-propel her wheelchair. The facility does not have documentation to show R1 was educated regarding her pressure ulcers. The facility does not have documentation to show R1 was assessed by the dietitian following the development of her pressure ulcers until December 4, 2024. V5 (Dietitian) documented R1 has Increased protein needs related to increased demand for healing as evidenced by skin impairments. The facility does not have documentation to show orders for protein supplements were ordered until December 4, 2024. R1's care plan for potential for pressure ulcer development/impaired skin integrity was created on September 24, 2024 by V12 (MDS Nurse). R1's care plan does not show R1's care plan interventions were updated after the development of her left heel Stage 3 pressure ulcer, or her right heel DTI. On December 4, 2024 at 3:24 PM, V12 (MDS Nurse) said, I was aware [R1] developed pressure ulcers. I did not update the care plan interventions. [R1's] care plan interventions were not updated after she developed pressure ulcers. The facility does not have documentation to show a root cause analysis was completed after R1 developed pressure ulcers at the facility, as shown in the facility's policy for facility-acquired pressure ulcers. On December 4, 2024 at 3:24 PM, V9 (NP) said, I was aware [R1] developed pressure ulcers. I believe they automatically have the wound NP look at the resident. I usually just have the wound care nurse address it unless it gets worse. Then we must take more invasive steps. I was not notified that [R1's] wound was larger as of today. The wound nurse told me the shoes were rubbing on her heel. It would be my expectation that they put interventions in place to prevent the wound from getting worse. On December 4, 2024 at 4:17 PM, V13 (Primary Care Physician) said, The last time I saw [R1] was October 22, 2024. I was called and told [R1] had a pressure ulcer last week. They told me it was because of the shoes she was wearing. Of course, I would expect them to stop putting those shoes on her if that is what caused the pressure ulcers. I would have expected them to have her seen by the wound care doctor or nurse practitioner, and make sure she was evaluated by the dietitian. If she had a DTI and it now has a scab on it, that wound is considered an unstageable pressure ulcer, so that wound is worse. If the Stage 3 pressure ulcer measurements are bigger, then that wound got worse also. Of course, they should put new interventions in place once they find someone has a pressure ulcer. I would say her pressure ulcers got worse because they did not do anything to prevent that from happening. 2. The EMR shows R2 was admitted to the facility on [DATE]. R2 has multiple diagnoses including, right lower limb cellulitis, chronic lymphocytic leukemia, dementia, muscle weakness, difficulty walking, falls, idiopathic neuropathy, atrial fibrillation, acquired absence of right toe, and major depressive disorder. R2's MDS dated [DATE] shows R2 is cognitively intact, requires supervision with eating, partial/moderate assistance with oral hygiene, bed mobility, and transfers between surfaces, substantial/maximal assistance with personal hygiene, and is dependent on facility staff for toilet hygiene, showering, and dressing. R2 is frequently incontinent of bowel and bladder. R2's MDS continues to show R2 was at risk for developing pressure ulcers and did not have any pressure ulcers at the time of the MDS assessment. The facility's wound report dated December 4, 2024 at 10:22 AM shows R2 developed a facility acquired deep tissue pressure injury to his anterior left malleolus on November 20, 2024, and a facility-acquired unstageable pressure ulcer to his right heel. The facility does not have documentation to show a care plan was initiated after R2 developed a facility-acquired pressure ulcer. On December 4, 2024 at 3:40 PM, R2 was sitting up in his wheelchair in his room. R2 had a dressing on his right foot. R2 had difficulty answering questions about his wound due to his cognitive status at the time. On December 5, 2024 at 12:33 PM, R2 was sitting up in his wheelchair in his room. R2 was wearing non-skid socks. Two visitors were present in the room and R2 did not want to be disturbed at that time. On December 4, 2024 at 2:29 PM, V12 (MDS Nurse) said R2 does not have a care plan or interventions in place for his facility-acquired pressure ulcers. The facility does not have documentation to show a root cause analysis was completed to determine the cause of R2's facility-acquired pressure ulcers as shown in the facility's policy. The EMR shows the following order for R2 dated November 22, 2024: Right heel cleanse with house stock wound cleanser. Paint/swab with betadine and cover with dry dressing three times per week and as needed. The facility does not have documentation to show R2's wound treatments were administered as ordered on November 25, 27, and 29, 2024. The EMR shows the following order for R2 dated November 22, 2024: Left malleolus anterior, cleanse with house stock wound cleanser. Paint/swab with betadine and cover with dry dressing three times per week and as needed, every Monday, Wednesday, Friday. The facility does not have documentation to show R2's wound treatments were administered as ordered on November 25, 27, 29, 2024. On December 5, 2024 at 12:33 PM, V15 (Physician) said, [R2's] debility puts him at an increased risk for the pressure ulcers. It is standard protocol to initiate interventions to prevent pressure ulcers. It is my expectation that wound care treatments be administered as ordered. 3. The EMR shows R3 was admitted to the facility on [DATE] with multiple diagnoses including, idiopathic progressive neuropathy, Alzheimer's disease, major depressive disorder, personal history of cerebral infarction, history of breast cancer, and hypertension. R3's MDS dated [DATE] shows R3 has moderate cognitive impairment, requires supervision with eating and oral hygiene, substantial/maximal assistance with showering, personal hygiene, and bed mobility, and is dependent on facility staff for toilet hygiene, lower body dressing and transferring to and from the bed to the chair. R3 is always incontinent of bowel and bladder. R3's MDS continues to show R3 is at risk for developing pressure ulcers and did not have any pressure ulcers at the time of the MDS assessment. On October 9, 2024 at 1:54 PM, V3 (WCN/RN) documented R3 had a facility-acquired Stage 2 pressure ulcer of the sacrum. The pressure ulcer measurements were 1.70 cm. long by 1.20 cm. wide by 0.10 cm. deep. Wound status: active. On October 16, 2024 at 9:10 AM, V3 (WCN/RN) documented R3 had a Stage 2 pressure ulcer of the sacrum. The pressure ulcer measurements were 0.00 cm. long by 0.00 cm. wide by 0.00 cm. deep. Wound status: closed. V3's documentation continues to show, The wound to [R3's] sacrum has closed. She reports intermittent pain in the area relieved with position changes. Wound care provided, tolerated well. On October 24, 2024 at 10:07 AM, V3 (WCN/RN) documented R3 had a Stage 2 pressure ulcer of the sacrum. The pressure ulcer measurements were 0.00 cm. long by 0.00 cm. wide by 0.00 cm. deep. Wound status: closed. V3's documentation continues to show, [R3] continues with small open area noted to her sacrum. She reports intermittent pain in the area relieved with position changes. Wound care performed, tolerated well. V3's documentation does not show the measurements for R3's open wound. On November 4, 2024 at 9:59 AM, V3 (WCN/RN) documented R3 had a Stage 2 pressure ulcer of the sacrum. The pressure ulcer measurements were 0.00 cm. long by 0.00 cm. wide by 0.00 cm. deep. Wound status: closed. V3's documentation continues to show, [R3] continues with wound area noted to her sacrum. She reports intermittent pain in the area relieved with position changes. Wound care performed, tolerated well. V3's documentation does not show the measurements for R3's wound area. On November 13, 2024 at 10:54 AM, V3 (WCN/RN) documented R3 had a Stage 2 pressure ulcer of the sacrum. The pressure ulcer measurements were 0.00 cm. long by 0.00 cm. wide by 0.00 cm. deep. Wound status: closed. V3's documentation continues to show, [R3] continues with some redness to her sacrum . V3's documentation does not show the measurements for R3's reddened area. On November 21, 2024 at 9:22 AM, V3 (WCN/RN) documented R3 had a Stage 2 pressure ulcer of the sacrum. The pressure ulcer measurements were 1.80 cm. long by 1.00 cm. wide by 0.00 cm. deep. Wound status: active. V3's documentation continues to show, [R3] continues with open area noted to her sacrum. She reports intermittent pain in the area relieved with position changes. She is resistant to being on her side and spends much of her time on her back, not allowing this wound to improve much. She was left on her side after this visit. Wound care performed, tolerated well. R3's care plans were reviewed. As of December 4, 2024, the facility did not have documentation to show a care plan was initiated following the development of the facility-acquired pressure ulcer on October 9, 2024. The facility does not have documentation to show a root cause analysis was completed to determine the cause of R3's facility-acquired pressure ulcers as shown in the facility's policy. The EMR shows the following order for R3 dated October 18, 2024 and discontinued on November 13, 2024: Wound care to sacrum. Cleanse with normal saline, pat dry, apply triad to wound area and cover with dry dressing three times weekly and as needed if dressing becomes soiled, every Monday, Wednesday, Friday. The facility does not have documentation to show the wound treatment was administered as ordered on, October 18, 21, 23, 25, 28, 30, 2024, and November 1, 6, 8, 11, 13, 2024. The EMR shows the following order for R3 dated November 14, 2024: Wound care to sacrum. Cleanse with normal saline, pat dry and apply hydrocolloid dressing two times weekly and as needed if dressing becomes soiled or dislodged every Monday, Thursday. The facility does not have documentation to show the wound treatment was administered as ordered on November 28, 2024 or December 2, 2024. On December 4, 2024 at 9:15 AM, R3 was lying in bed. R3 refused to get out of bed and stated she had a sore butt. On December 5, 2024 at 2:13 PM, V2 (DON-Director of Nursing) said she was confused by V3's (WCN/RN) documentation of R3's wounds. V2 confirmed V3's documentation showed the wound was closed on October 24, 2024 but later in her documentation V3 documented the wound was open and no measurements were documented. V2 also confirmed on November 4, 2024, V3 documented R3's wound was closed but then documented a wound area was noted to R3's sacrum and no measurements were documented. V2 (DON) said, [V3's] (WCN/RN) documentation is inconsistent and does not make sense. [R3] had active orders for wound care treatments. Those treatments were not documented as being administered as ordered. Every resident who has a pressure ulcer should be referred to the wound care doctor/NP. That did not happen for [R1] and [R3]. Every resident who develops a pressure ulcer in the facility should have a root cause analysis completed so we can individualize their care. That is our policy. That did not happen for [R1], [R2], and [R3]. All residents with pressure ulcers should have their nutrition assessed by the dietitian to see if they need protein supplements for wound healing. That did not happen either. We have three wound care nurses who work here and are exclusively assigned to wound care, seven days a week. Plus, we have two wound care doctors who visit this facility, twice a week. None of this should have happened. The facility's policy entitled Skin Management: Dressing Application, revised on 10/16 shows: General: Dressings are changed as ordered by the physician or NP. Guideline: .8. Dress wound as directed in the physician orders.11. Document on treatment sheet that dressing was completed, measure and describe wound weekly, and document any pertinent findings or communication with physician/nurse practitioner in the medical record. The facility's policy entitled Skin Management: Pressure ulcer, lower extremity ulcer evaluation and documentation, revised 7/14 shows: General: To report and gather data for the purpose of planning and implementing wound care treatment procedures. To evaluate outcomes in terms of wound management. Responsible Party: Wound Care Team. Guideline: .4. Pressure ulcers will be evaluated, a picture taken, and the following areas documented weekly: Location, Stage, Size: perpendicular measurement of the greatest extent of length and width of the ulcer using a disposable measuring device. Depth, presence and location.10. Wounds will be measured on a weekly basis The facility's policy entitled, Unavoidable Evaluation, reviewed 10/16 shows: Guideline: To provide a process for reviewing a pressure ulcer to determine the root cause. Responsible Party: Wound Care Team. Guideline: 1. When a resident develops an in house acquired pressure ulcer or the pressure ulcer deteriorates, the facility will do a root cause analysis to determine the reason.7. Once the evaluation is completed, the facility will consult with the physician and determine if the wound was unavoidable. If the resident's wound was unavoidable the physician will be asked to document such in the medical record.

Based on observation, interview, and record review, the facility failed to safely transfer a resident while using a mechanical lift. As a result of this failure, R1 sustained a laceration to the head and fracture of the thoracic 8 and 12 vertebral bodies after falling. R1 was transferred to the local hospital and received 2 staples to the back of R1's head. This applies to 2 of 6 residents (R1 and R7) reviewed for falls and accidents. The findings include: On 10/22/24 at 11:15 AM, R1 was observed in bed in her room. R1 said fall incident happened on a Thursday, which was her shower day. R1 said 2 Certified Nurse Aides (CNAs) transferred her using the mechanical lift from the bed to the shower chair and gave her a shower. R1 has a shower in her room. R1 said after the shower, the same CNAs were transferring her back to the bed using the mechanical lift. R1 said while they were attempting to put her back in bed, she fell to the floor on the bathroom side of her bed. R1 said she hit her head and there was some bleeding, and the staff called the ambulance, and she was sent to the hospital. R1 said had staples on her head and was at the hospital for 7 days. R1 said she is still experiencing pain on her middle and lower back from the fall. On 10/23/24 at 11:20 AM, R1 said she has not been out of bed since she returned from the hospital. R1 said she now requires a back brace when she is out of bed. R1 said she is not sure when she will get out of bed, adding being in the mechanical lift sling would cause her more pain and her body would be limp since there is no support with the sling. On 10/22/24 at 12:58 PM, V8 (CNA) said on the day of the incident, she assisted V11 (CNA) with giving R1 a shower. V8 said they transferred R1 using the mechanical lift and a shower sling. V8 said after R1's shower while transferring her to the bed, R1 slipped out of the shower sling and fell. V8 said the incident happened so quick, there was no time to catch R1. V8 said R1 landed on top of the legs of the mechanical lift. V8 stated R1 has a tendency of leaning towards her left side. V8 said she was guiding R1 during the transfer while V11 was maneuvering the mechanical lift. V8 said after the fall they notified the nurse, and the nurse assessed R1. V8 stated they called the ambulance and R1 was sent to the hospital. On 10/22/24 at 3:26 PM, V11 (CNA) said they used a mechanical lift to transfer R1. V11 said on the day of the incident after she and V8 had given R1 a shower, they were transferring her back to bed, and right before they got to R1's bed, R1 slipped out of the sling and fell. V11 said she was the one maneuvering the mechanical lift while V8 was guiding R1. V11 said the incident happened fast. V11 stated R1's body shifted left out of the sling and R1 landed on top of the legs of the mechanical lift. V11 said after the fall she called the nurse to assess R1 while V8 stayed with R1. V11 said R1 was taken to the hospital. On 10/23/24 at 10:02 AM, V12 (Licensed Practical Nurse/LPN) said she was informed by the CNA that R1 had a fall. V12 said when she got to R1's room, R1 was on the floor and had a laceration to her head. V12 stated she said she assessed R1 and R1 complained of pain in her back. On 10/22/24 at 2:50 PM, V3 (Director of Nursing/DON) said she was informed R1 slipped from the mechanical lift shower sling during a transfer after her shower. V3 said R1 was sent to the hospital after the fall, where she had 2 staples to her head, and the X-ray report showed there was a fracture to T8 and T12. V3 said when she investigated the incident, she found that the shower sling strap was giving way. V3 stated there was a small tear at the top blue part by the loops that is hooked onto the mechanical lift. On 10/23/24 at 2:14 PM, V1 (Administrator) said they do not have a time frame for replacing resident's mechanical lift slings; if it does not look good, they replace it. V1 said she purchased R1's shower sling and full body sling a year ago because R1 was complaining that her sling was missing. V1 said that it was R1's personal sling. R1's Fall Incident Report of 10/3/24 stated, On 10/3/24 during the morning care, the resident slipped with the presence of the staff inside the resident room. Analysis is maybe the blue strap starting to give away and the resident body shifted, slipped and fell. The sling used for R1's transfer had already been thrown away. R1's Face Sheet shows that the following diagnoses of wedge compression fracture of unspecified thoracic vertebra initial encounter for closed fracture, quadriplegia, disorder of bone and multiple sclerosis. R1's Restorative Evaluation of 10/14/24 shows that R1 is dependent on staff for transfers. R1's hospital records of 10/4/24 stated R1 was sent to the hospital following a fall; R1 was being bathed earlier in the morning, when resident was being placed back into the bed, the transfer device sling broke and she slipped to the ground. R1 hit back of head and dropped on her back. R1 had laceration repair to the scalp and was noted with thoracic vertebral fractures/closed fracture of thoracic vertebra. R1's CT (Computed Tomography) scan of 10/3/24 shows there are fractures of the T8 and T12 vertebral bodies which appear acute and subacute and there is minimal compression of the T9 vertebral body. The facility's Safe Lifting and Movement of Residents policy (revised July 2017) states that resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow the plan of care regarding the required number of staff assistance during bed mobility of a resident. This failure resulted in R1 sustaining an acute closed displaced supracondylar fracture of the distal end of the right femur after R1 fell off the bed during care on 11/4/2023. This applies to 1 of 3 residents (R1) reviewed for falls in the sample of 3. The findings include: The EMR (Electronic Medical Record) shows R1 as an [AGE] year-old resident, with diagnoses included multiple sclerosis, idiopathic gout, quadriplegia, atherosclerotic heart disease, chronic obstructive pulmonary disease, periprosthetic fracture around internal prosthetic right knee, vitamin D deficiency, vitamin B12 deficiency, anemia, polyneuropathy, anxiety disorder, major depression, insomnia, hyperlipidemia, osteoporosis, and osteoarthritis. The EMR also showed R1 had a history of right knee arthroplasty. The MDS (Minimum Data Set) 7/21/2023 showed R1 as cognitively intact. The functional status regarding bed mobility showed R1 required extensive assistance of 2 plus staff members. The care plan dated 10/19/2023 showed two-person assistance was required for R1's bed mobility. The care plan also showed R1 requires the use of mechanical transfer lift device and two-person assistance for transfer. The progress notes dated 11/4/2023 showed, NOD (Nurse on Duty) called writer attention that (R1) fell on floor this morning during care by CNA (Certified Nurse Assistant) on duty and (R1) complain on right knee pain. Writer went immediately and noted (R1) in bed, alert and oriented, noted to complain of right knee pain also mentioned to writer she hit her head during the fall. Writer assessed head, no skin discoloration noted, very small bump noted. (R1) denies any pain or discomfort. R1 stated only her knee right is painful. On scale 0-10, R1 stated 8, offered pain medication. R1 stated NOD already give her pain medication before a few minutes. Informed MD .and updated. MD stated to send (R1) via 911 for evaluation. The progress notes also showed a follow up call was made to the hospital later the evening of 11/4/2023 and that R1 was admitted for right femur fracture. Hospital note dated 11/4/2023 showed, R1's x-ray result was closed displaced supracondylar fracture of distal end of right femur without intercondylar extension. Ortho on consult. Continue conservative management, pain control, DVT (deep vein thrombosis) prophylaxis, PT/OT (Physical/Occupational Therapy eval . will be back to skilled facility . R1 returned to the facility on [DATE]. The admission assessment dated [DATE] showed R1's diagnoses of right femur fracture. On 11/15/2023 at 11:00 A.M., R1 was lying in bed. R1's bed mattress was an air loss pressure reducing device. R1 said on 11/4/2023 around 9:00 A.M., V4 had given her a shower. R1 said there was no problem with shower, however, when she (R1) was put back to bed, V4 had turned her (R1) to the right side to dry her (R1's) back. R1 said during the turn, she (R1) landed on the floor. R1 said V4 was by herself when she (R1) was turned while in bed. R1 was observed with an ace wrapped around from right mid-thigh to mid-calf area. On 11/15/2023 at 1:52 P.M., V4 (CNA) said she had provided R1 a shower morning of 11/4/2023. V4 said R1 was put back to bed after the shower. V4 also said, (R1) was upset because she wanted a longer shower that last more than an hour and her shower lasted around 30 minutes. (R1) was very particular with care, demands a lot of things at the same time, and I try to please her by following her demands immediately. That morning, (R1) said to dry her back, so I turned her to her right side, then she rolled out of bed. I immediately called the nurse and she was sent out to the hospital. I felt bad what happened. All I want is to give her care at once so she would not get upset. On 11/15/2023 at 1:32 P.M., V9 (LPN/Licensed Practical Nurse) said sometime in the morning of 11/4/2023, she was called because R1 was on the floor. V9 said she immediately assessed R1. V9 said immediate care was provided to R1 and R1 was sent to the hospital via 911.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow plan of care regarding needed assistance for a resident requiring 2 plus person physical assist. The facility also failed to ensure that a bed rail was in functioning order when used as an enabler to ensure resident's safety. This applies to 1 of 3 residents (R2) reviewed for falls. These failures resulted in R2 sustaining a laceration to his head and left eyebrow requiring sutures and staples at the hospital. The findings include: The EMR (Electronic Medical Record) shows that R2, a [AGE] year-old with diagnoses that includes hemiplegia and hemiparesis due to effect of cerebral infarction, right above knee amputee, malignant neoplasm of left lung, tonsil, larynx, diabetes mellitus, peripheral autonomic neuropathy, PVD (peripheral vascular disease), COPD (coronary obstructive pulmonary disease), AHSD (atherosclerotic heart disease), atrial fibrillation, weakness and major depression. R2's original admission to the facility was on 8/1/2016 with most current reentry on 2/27/2023. On 3/13/2023 at 10:30 A.M., R2 was observed lying in bed. R2's bed mattress was an air loss pressure reducing device. R2's upper bed rails were on upward position. R2 was wearing a left-hand splint due to a hand contracture. R2 did not verbally response when conversation was initiated. R2 was connected to a gastrostomy feeding. R2 was also connected to an oxygen tubing. R2 was positioned in the middle of the bed. It was observed that there was approximately 4-6 inches width distance from R2's body to the edge of the bed. R2 was observed with multiple staples to the scalp between the middle and right side of the head. R2 also was noted with several small sutures to the left upper eyelid. V2, DON (Director of Nursing) was present during this time. V2 said that the staples and sutures were the lacerated wounds acquired by R2 from the fall of 2/22/2023. V2 said that R2 fell to the floor on 2/22/2023 during the provision of care by V5 (CNA). The incident report dated 2/22/2023 shows R2 fell to the floor from bed, during provision of care by V5. R2 was noted with bleeding on the face, head and was sent to the hospital. R2 was admitted with diagnoses of fall and hypoxia. R2 returned to facility on 2/27/2023 with staples on the middle of the head and sutures to left upper eyelid. On 3/13/2023 at 3:23 P.M., both V4 (Nurse) and V5 (CNA) were interviewed in the facility's conference room. V5 said R2 fell from bed to the floor on 2/22/2023 when he was providing care to R2. V5 said that it was only him and no other staff assistance when he turned R2 to the left side of the bed and R2 was holding unto the left side bedrail that was on upward position. V5 said he turned his back to get a bed sheet from R2's drawer, which was just next to R2's bed. V5 said the upper left bed rail went to the downward position, because the screws that attached to the bed were loose, and (R2) fell to the floor. V5 said V54 changed R2's incontinence brief and noted the bed sheet was soiled. V4 said she immediately went to R2's room when V5 called for help. V4 said she saw R2 lying on the floor, with bleeding from the head and left lower eyebrow. V4 said the left side of the upper bed rail was on downward position. V4 said, I assumed the screws that attached to the bed were loose because it did not hold to the intended and secured position, which was supposed to be upward. This was why maintenance had replaced the bed. (R2) is a big guy. When turning (R2) to the side while in bed and there was not enough bed space and (R2) lying on an air loss mattress, which can be slippery, it would be like a water wave. Gravity will pull him 9R2) down. This is what caused (R2) to end up on the floor. On 3/13/2023 at 3:45 P.M., V6 (Maintenance Director) said he inspected R2's bed the next day after the fall. V6 said that due to (R2) being a big guy. The screws from the bed rail that attached to the bed frame came loose and did not hold secured position. The bed rail went to downward position. R2's most recent MDS (Minimum Data Set) was 1/3/2023 which was the most recent assessment prior to R2's fall on 2/22/2023. The MDS indicated R2's functional assessment as follows: R2 with extensive assistance with 2 plus person physical assistance for bed mobility. The MDS described bed mobility as how resident moves to and from lying position, turns side to side, and positions while in bed. R2 was assessed as extensive assistance with 2 person plus physical assistance for toilet use. The MDS described toilet use as when a resident uses toilet, commode, bed pan, urinal, cleanses self after toilet use or elimination, including changing incontinence pad. Review further of R2's MDS assessment shows that R2 has mood disorder exhibited by low interest in activity, feeling empty, has trouble concentrating, feeling tired and low energy level. R2 also has limited range in motion on one side of upper extremity (left hand contracture) and one side of the lower extremity (right above knee amputee.). Review of R2's most recent care plan dated 1/3/2023, shows that there were no revised interventions to prevent further falls. The history of care plan shows that it was on 7/23/2020 that R2 was assessed for risk for fall; with intervention for education to staff for safety; 8/9/2020; staff education for safety; 3/26/2023 for dycem (non-skid seat cushion). R2 had histories of falls. R2 was sent out for CT (Computerized Tomography) of the head on 7/23/2020. The hospital admission record dated 2/23/2023 shows R1 was seen and treated for fall and hypoxia. The record also shows that due to the fall incident, R2 sustained a laceration to the left side of his scalp and a laceration below left eyebrow that were stapled and sutured.