**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A. Based on observation, interview and record review the facility failed to provide assistance in a manner to prevent falls for 2 (R5 and R10) of 6 residents reviewed for falls in a sample of 16. This failure resulted in R10 sustaining a large intracranial hematoma, left eyebrow laceration and a left periorbital hematoma and R5 sustaining a skin tear to right shin and right shoulder along with a forehead laceration requiring 4 sutures. Findings include: 1. R10's admission Record documents an admission date of 12/02/2019 with diagnoses including: acute cystitis without hematuria, unspecified Escherichia coli as the cause of diseases classified elsewhere, encephalopathy, hemiplegia affecting left non-dominant side, history of transient ischemic attack and cerebral infarction without residual deficits, osteoarthritis right shoulder, cerebral infarction, other abnormalities of gait and mobility, other lack of coordination, blepharoconjunctivitis of the left eye, third nerve palsy of left eye, history of covid-19, anxiety disorder, schizophrenia, aphasia following cerebral infarction, other symptoms and signs involving cognitive functions following other cerebrovascular disease, dysarthria following other cerebrovascular disease, muscle weakness, repeated falls, other symptoms and signs involving the nervous system, disorientation, altered mental status, restlessness and agitation, weakness, history of malignant neoplasm of the brain, and epilepsy. R10's Minimum data Set (MDS) quarterly review dated 07/02/24 documents a Brief Interview of Mental Status (BIMS) of 14 indicating R10 is cognitively intact. R10's eating assistance is documented as: setup or clean-up assistance, oral hygiene as: supervision or touching assistance, upper body dressing as: substantial/maximal assistance and roll to right or left as: dependent. R10's Fall risk data collection form dated 9/24/24 documents a score of 29 indicating R10 was a high risk for falls. R10's hospital's discharge summary with an admission date of 09/10/24 and a discharge date of 09/24/24 documents: Hospital Course: Patient (R10) is [AGE] year-old with past medical history of brain tumor, seizure disorder, dementia, hyperlipidemia and hypothyroidism. She had a recent episode of nonresponsiveness at a SNF (Skilled Nursing Facility) unit and was sent in for altered mental status. Patient's (R10) baseline is that she is unable to ambulate and is wheelchair-bound. ER (emergency room) evaluation included CT (computed tomography) of the brain and CT brain perfusion with no evidence of ischemia chest x-ray no acute process CTA (computed tomography angiography) head neck indicated acute ischemia to the left anterior cerebral artery distribution could not be excluded. Her blood glucose was initially 60 (milligrams/deciliter) and she was given D10 (dextrose 10%) patient was admitted to the hospitalist service and neurology was consulted. She was also found to have a UTI (urinary tract infection) and antibiotics were started. MRI (magnetic resonance imaging) of the brain recommended by neurology showed no acute abnormalities, EEG (electroencephalography) showed generalized slowing, echo indicated normal LV (left ventricular) size with an EF (ejection fraction) of 55-60 (%). Neurology felt patient was suffering from encephalopathy related to covid infection. Feeding tube was placed due to continual failure of swallowing eval. She is to have a video swallow eval today. Patient had trouble with hyponatremia but that has improved with fluid restriction and urea sodium after hypertonic NICU (neonatal intensive care unit). She was transition to p.o. (per oral) Cortef . Pts (patient's) sodium is normalized. Video swallow evaluation revealed no aspiration. Diet recommendations in dc (discharge) summary. Pt will transition back to snf. R10's MDS significant change review dated 09/29/24 documents a BIMS of 05 indicating severely impaired. R10's eating assistance is documented as: dependent, oral hygiene as: dependent, upper body dressing as: dependent and roll to right or left as: dependent. R10's Care Plan documents a focus area of: R10 is at risk for falls with a date initiated of 04/03/2021. Interventions included: dated 07/24/2024 of anti-slip mat in seat of wheelchair and dated 07/08/24 of do not leave resident alone when sitting on the side of the bed. R10's care plan documents a focus area of: R10 has a history of CVA (cardiovascular accident) with a date initiated of 04/12/2021 and interventions including: monitor/document communication skills, document baseline if resident is presenting problems with cognitive function and communication, obtain order for speech therapy consult to evaluate and treat dated 03/23/2022, monitor/document residents abilities for ADLs (activities of daily living) and assist resident as needed. Encourage resident to do what he/she is capable of doing for self dated 04/12/2021, and monitor/document/report to MD (medical doctor) PRN (as needed)) for neurological deficits: level of consciousness, visual function changes, aphasia, dizziness, weakness, and restlessness dated 04/12/2021. R10's care plan documents a focus area of: R10 has left hemiplegia/hemiparesis related to stroke with an initiated date of 07/29/2022 and interventions of: give medications as ordered, monitor/document for side effects and effectiveness dated 07/29/2022, obtain and monitor lab/diagnostic work as ordered, report results to MD and follow up as indicated dated 07/29/2022, pain management as needed, see MD order, provide alterative comfort measures PRN dated 07/29/2022, and PT, (physical therapy) OT (occupational therapy), ST (speech therapy) evaluate and treat as ordered dated 07/29/2022. New interventions added 10/7/24 include, resident is working with therapy in tilt/reclining chair with anti-skid mat in place, dated 10/07/24 of will reassess for safety upon resident's return from the hospital, and dated 10/08/24 of: keep resident's tilt/recline chair in reclined position until staff is ready to assist with meals. Interventions also included: dated 07/24/2024 of anti-slip mat in seat of wheelchair and dated 07/08/24 of do not leave resident alone when sitting on the side of the bed. R10's final investigation report submitted to IDPH (Illinois Department of Public Health) dated 10/10/24 documents: (R10) age [AGE] with diagnoses of Cerebral infarction, hemiplegia affecting left side, encephalopathy, personal history of TIA (transient ischemic attack), osteoarthritis of right shoulder, epilepsy, major depressive disorder, aphasia, schizophrenia, and personal history of malignant neoplasm of the brain. On 10/7/24 R10 sustained a fall when she sat forward in her tilt/recline chair and fell to the floor. Licensed staff initiated a head-to-toe assessment. The resident voiced complaints of pain to her face and head. Logged rolled to her back to monitor airway. Laceration noted to forehead. First aid administered. No loss of consciousness. Resident left in position d/t (due to) potential for FX (fracture). V31 (Medical Director) notified and an order received to send to ER for evaluation. POA (power of attorney) notified of occurrence and pending transfer. Resident transferred per ambulance to ER for evaluation and treatment. Resident admitted to hospital with DX (diagnosis) of intracranial hematoma without loss of consciousness. Returned to facility on 10/9/24 with hospice referral. Laceration above left eyebrow closed with steri -strips. Care plan reviewed and updated On 11/27/24 at 8:24 AM, V22 (Certified Nurse Aide) stated, R10 could sit up, she had head and neck control, she would also scoot herself forward in her chair. V22 stated, on the day R10 fell out of her wheelchair (10/07/24) everyone was in the dining room. V22 stated she pushed R10 up to the table and positioned her up so that she could eat without choking. V22 stated she was up at the kitchen window getting R10's food so she could assist her and she heard R10 fall. V22 stated, she thought R10 fell sideways out of her chair because she didn't hit the table and the way she was laying on the floor. V22 stated, there were other CNAs in the dining room, but no one right next to R10. V22 stated, when R10 came back after, she believes she had a stroke, she was not as good, she was more confused, her speech was more slurred, she would fall asleep when they were assisting her to eat and she was switched to a thickened liquid and puree diet. V22 stated, she was educated after R10 fell to have her food in front of her before she puts her in the upright position. On 11/26/24 at 4:05 PM, V6 (Physical Therapy) stated she would expect someone to be there when R10's chair was in the fully inclined position. V6 stated R10 returned to the facility after her last stroke on 09/24/24 with multiple declines, she had low motivation to bend forward also. On 11/27/24 at 9:56 AM, V4 (Director of Rehabilitation) stated prior to 10/07/24 when R10 had her last fall, speech language was working with R10 due to her decline after her last stroke. R10 was lethargic and they changed her diet to honey thick liquids and puree food. R10 could support her head and trunk to a degree. On 11/27/24 at 10:10 AM, V25 (Therapy) stated she had evaluated R10 on 09/25/24. R10 would ebb and flow and sometimes she could be lethargic and obstinate during mealtime. She would expect her to have her food and then be put in the upright position in her wheelchair. They were currently working on core strength and reaching abilities with her. V25 stated R10 had recently been hospitalized just prior to her fall and she had more limited abilities. R10 was out for over 10 days, her wheelchair was changed to a wheelchair that looks like a recliner on wheels that the feet platform does not raise, her swallow function changed, she was no longer the same after the hospital stay. After the hospital stay she was deconditioned, she was very different than she was prior to her hospital stay from the stroke. R10's therapy note dated 09/26/24 documents: patient (R10) demonstrates L (left) lateral lean, sacral sitting, occasional anterior leaning forward in w/c (wheelchair) increasing fall risk. R10 presents with decreased alertness and does not respond to verbal cures for adjusting self in w/c, therapist can readjust and as day progresses R10 will have to have multiple repositioning in standard w/c. Provided R10 with tilt in space w/c and feature of recline back. R10 has foot board to provide support for BLE (both lower extremities) in neutral position. Staff education provided on patient to be tilted back when not in line of sight, when R10 is at mealtime, or in line of sight, may be placed in a neutral position. Provided nonskid mat under bottom in order to prevent sliding forward with chair having an anti thrust cushion feature in chair. Response to session interventions: presented with decreased alertness, not following verbal cues or tactile cues. R10's progress note dated 10/07/24 at 5:20 PM documents: staff heard a loud crash and found resident laying on the floor face down. Chair had been reclined back in main dining room awaiting meal but when staff turned around chair was straight up. R10's progress note dated 10/07/24 at 5:30 PM documents: EMS (emergency medical services) here to transport resident to ER for evaluation and treatment for fall. R10's progress note dated 10/08/24 at 12:38 AM documents: called ER and spoke with nurse on update of resident. ER nurse reports resident is being admitted to the unit due to a brain bleed. R10's progress note dated 10/08/24 at 6:29 AM documents: spoke with ICU (intensive care unit) nurse. Resident admitted with intracranial hematoma without loss of consciousness. R10's hospital daily progress note dated 10/08/24 documents: subjective: has had some headaches but no new neurologic deficits from her baseline. Summary: [AGE] year old female with remote history of right temporal lobe tumor resection, previous stroke with residual speech and cognitive deficit, residual left-sided weakness, seizure disorder, dysphagia on modified diet, recently hospitalized with encephalophy in setting of covid infection, hyponatremia, UTI (urinary tract infection) found to have adrenal insufficiency, presenting back from nursing facility after sustaining a traumatic fall with noted large intracranial hematoma, along with left eyebrow laceration, and a left periorbital hematoma, Laceration repair in ED (emergency department). (R10's) aspirin and Plavix was stopped. (R10) was given platelets and DDAVP (desmopressin) following initial presentation. Neurosurgery consulted. Monitored further with serial neuro (neurological) checks. Follow-up CT (computed tomography) head appeared stable. R10's neurosurgery consultation dated, 10/08/24 at 7:21 AM documents: the patient (R10) is a 55 y.o. (year old) female who presented to the ED (emergency department) on 10/2024 after she fell out of a chair in her nursing home striking her head. She has a neurosurgical history that is significant for prior brain tumor resection, though no records are available and no family is at bedside to provide further information and she is a very poor historian. She apparently resides in a nursing home due to chronic left hemiparesis and cognitive difficulty. She fell from a chair to the floor at her facility, striking her head and sustaining a laceration. She was brought to the ED where a CT revealed intracranial hemorrhage, prompting neurosurgical consultation. She has been observed overnight in the ED due to a lack of beds in the ICU. She currently endorses headaches, however she has delayed speech and difficulty expressing herself at baseline. She will follow commands in all extremities with baseline left-sided weakness. Records from the nursing home state she takes ASA (acetylsalicylic acid (aspirin)) and Plavix, though the reasons are unclear. She was given Platelets and DDAVP in the ED. R10's progress note dated 10/09/2024 at 5:41 PM documents, Res (resident) back from hospital and nonverbal. EMS said res had not said a word the whole transport. Res v/s (vital signs) wnl (within normal limits). Left eyebrow laceration dried blood noted and bruised face and eye with left eye swollen shut. Res to have hospice consult and DNR. Noted DNR signed by her sister and not her POA. Res made comfortable in bed. R10's progress note dated 10/13/24 documents: EMS here to transport resident to hospice center. On 11/27/24 at 2:08 PM, V27 (Family) stated, R10 was diagnosed with Covid and a UTI and they had got her back to the facility and she fell in the dining room. They (the family) decided to send her to hospice in another state due to brain bleed causing seizures. On 11/27/24 at 3:06 PM, V1 (Administrator) stated when R10 fell in the dining room on 10/07/24 she was put in the upright position for eating and then the staff went to get her food from the window and she fell. V1 stated, she would have expected them to get her food, come back, and then put her in the upright position. R10's Death Certificate documents R10 died on [DATE] with the cause of death listed as intracranial hemorrhage. Other significant condtions contributing to death include: temporal lobe tumor, cerebrovascular accident with sided residual weakness and seizer disorder. The manner of death is marked as natural. On 12/04/24 at 11:38 PM, V30 (Nurse Practitioner) stated, her and V31 (Medical Director) had looked at R10's diagnoses and medical history extensively prior to taking R10 on as a patient. R10 has had a couple brain bleeds prior to the fall on 10/07/24. R10 had CVA residual affects from how the body heals and reroutes, therefore it was likely that she would have another CVA. R10 had CVA's prior. V30 stated, no she does not believe the fall on 10/07/24 hastened or exacerbated R10's death. R10 had a personal history of brain cancer, CVA's, and schizophrenia and that would probably lead R10 to have another cerebral infarction. Another CVA would cause her to fall. After her last hospital visit her and V31 were going to discuss with R10's family hospice care for R10. There is no way she would say the fall hastened or caused her death. R10's brain neoplasm was affecting her ocular nerve. Based on her history and disease process there is no way she can say that fall caused her death. Due to her past diagnoses with her current prognoses and the recent encephalopathy due to covid they can not say what all that would cause and would affect. There are many different variables with covid and how it has affected systems and exacerbated disease processes. V30 stated based on R10's history, disease processes and recent diagnoses there is no way she can say that event (the fall) caused her death her diagnoses and disease process was an affecting factor. 2. R5's admission Record documents an admission date of 09/11/2024 with diagnoses including: dementia, xerosis cutis, other atrophic disorders of skin, muscle weakness, acute kidney failure, full incontinence of feces, lack of coordination, urinary incontinence, altered mental status, and cognitive communication deficit. R5's MDS dated [DATE] documents a BIMS score of 00 indicating severe impairment. R5's care plan documents a focus area of: R5 has an ADL self care performance dated 09/12/2024 with interventions to include: Bed Mobility: the resident requires 1 staff participation to reposition and turn in bed with date initiated of 9/12/24, Transfer: The resident requires 1 staff participation with transfers with date initiated 9/12/24. A new intervention dated 10/18/24 included Side rails: quarter rails up as per V31's order for safety during care provision, to assist with bed mobility. Observe for injury or entrapment related to side rail use. Reposition PRN to avoid injury. R5's care plan documents a focus area of R5 is at risk for falls and has had an actual fall d/t generalized weakness, poor nutritional status, incontinence, history of falls with a date initiated of 09/12/2024 and an intervention of: place quarter rails to bed that can be placed in upright position during cares to prevent falls from air mattress. Until bedrails placed two CNAs at a time when giving incontinence care with a date of 10/17/2024. R5's Care plan also lists a focus are, (R5) has limited physical mobility date initiated 9/12/24. Interventions included, Mobility: the resident requires 1 staff participation for mobility with date initiated 9/12/24. R5's final report to IDPH dated 10/22/24 documents: On October 16th approximately 1850 (6:50 PM) the C.N.A was assisting the resident with incontinence care, the resident scooted to the side of the bed and rolled off and hit her head. The C.N.A called for the nurse. The resident was noted with a cut to her right forehead, skin tear to right shin and right shoulder. The resident denied any other pain or discomfort, ROM (range of motion) assessed and was WNL (within normal limits). MD/POA informed. Orders to have resident evaluated in ER. The resident returned from ER with four sutures to her forehead. Orders to remove sutures in 5-7 days. Follow up with left ovarian mass. Investigation: The resident was seen in ER as stated above and returned to facility. During ER visit a CT scan of head, spine and pelvis was completed and was negative for any acute intercranial abnormality. CT of spine was negative for any acute cervical fracture. CT scan of pelvis incidentally showed an ovarian mass and constipation. Orders received to remove sutures in 5-7 days, order placed to remove on 10/25/24. The resident has had a pain level of 1-2 and denied need for any PRN (as needed) medications. Bruising is noted to forehead and beneath eye fading in color. The resident did have a BM (bowel movement) on 10/17/24. The resident has resumed her normal activities. The resident prefers to stay in bed and receive her meals and care in her room. The DON (Director of Nursing) had a discussion with the POA regarding the air mattress and changing her mother to a regular pressure reduction mattress, POA did not want to change mattress due to age and weight to prevent any skin issues. The DON offered quartered side rails up during provision of care. POA/daughter agreeable to quarter side rails. Bed kept in low position and call light in reach. Care plan updated with interventions. On 11/22/24 at 1:57 PM, V8 (Certified Nurse Aide/CNA) stated, she was providing care for R5 when she fell out of bed. V8 stated, R5 was in the middle of the bed and she rolled R5 onto her side, she is little and has never moved when providing care for R5 until she got these sores on her bottom. Previously when she would wipe her she would twitch or grunt but never move much. The day when she fell she was wiping her bottom because she had a bowel movement and she jerked and moved and rolled off of the bed. She would never roll before when providing care. R5 had always been a one person assist when providing care. After R5 fell, a second person would always go in to assist when providing care until she got her siderails. R5 can hold on to the side rails fine while providing care. R5's sores on her bottom have healed a lot so she does not jerk or twitch while providing care anymore. R5's bed is raised higher than the 18 inches or so off the floor when providing care, she would guess the bed would be approximately 2.5 feet off the ground. On 11/22/24 at 2:20 PM, V8 demonstrated to this surveyor the height of the bed when care would be provided, which was approximately 2.5 feet off the ground. On 11/22/24 at 2:20 PM, R5 was laying in the center of her bed she had approximately seven inches from her shoulders to the edge of the bed. On 11/22/24 at 4:25 PM, V9 (CNA) stated she had provided care for R5 before, and she had never moved before while providing care but she would swat at you on occasion. R5 did not have any sores when she had provided care for her. R5's progress note dated 10/16/24 at 6:50 PM documents: resident (R5) had rolled off the bed while CNA providing incont (incontinence) care, resident has laceration to R (right) forehead, skin tear to R shin, and skin tear to R shoulder. R5's hospital note dated 10/16/24 at 10:36 PM documents: CT of the head was negative for any acute intracranial abnormality. CT of the chest was negative for anything acute. CT of the cervical spine was negative for any acute cervical spine fracture. CT of the abdomen pelvis did show a left ovarian mass and constipation as well. Laceration to the right forehead was repaired. Patient will be discharged back to the nursing home. Sutures should be removed in 5 to 7 days. Will advise nursing home staff of constipation and left ovarian mass as well. Patient will be discharged shortly in stable condition. R5's hospital note dated 10/17/24 at 1:45 AM documents: subjective: history of present illness: [AGE] year old patient who presents to the emergency department status post fall. The patient is unable to give any history. It is reported that the patient fell from bed. She was lying in bed at (the facility) and fell approximately 2 feet onto the floor. No LOC (loss of consciousness) reported. The patient has a bandage on her head. R5's progress note dated 10/17/24 at 1:25 AM documents: resident (R5) returned to facility with orders to remove sutures in 5 -7 days. Follow up with left ovarian mass. R5's progress note dated 10/22/2024 at 3:33 PM documents: left message for (family) regarding the need to order side rails. Informed (her) that two CNAs will provide incontinence care for safety until quarter side rails placed. On 11/27/24 at 3:06 PM, V1 stated she was not at the facility when R5 fell from her bed, therefore she did not do the investigation. V1 stated she would not expect residents to fall out of bed during care. V1 stated, they put an intervention in of two CNAs to provide care for R5 until she was evaluated and received the siderails. The undated facility policy titled, Fall Prevention documents: the facility shall ensure that a fall management program will be maintained to reduce the incidence of falls and risk of injury to the resident and promote independence and safety A fall is the unintentional coming to rest on the ground, floor, or other lower level. If a resident loses balance and would have otherwise fallen if not for someone intervening is considered a fall, includes witnessed and unwitnessed falls, includes with or without injury. Serious injury includes but not limited to: fracture, laceration requiring sutures, any falls related to injury requiring an evaluation in the emergency room or admission to the hospital. B. Based on interview, observation, and record review the facility failed to provide adequate supervision to prevent elopement for 1 (R6) of 3 residents reviewed for elopement in a sample of 16. Findings include: R6's admission record documents an admission date of 09/28/21 with diagnoses including: dementia, cerebral ischemia, generalized anxiety disorder, muscle weakness, lack of coordination, difficulty in walking, and cognitive communication deficit. R6's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) score of 07 indicating cognition is severely impaired. R6's Care plan contains a focus area date initiated 7/8/24 documenting: R6 is an elopement risk/wanderer AEB (As Evidenced by) due to anger with placement within the facility. Interventions include distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: sitting in her room with her husband, also church activities dated 07/15/24 and wander alert device # model 4221-8698 dated 07/10/2023. A recent intervention includes: assist R6 to ambulate to her room or the common area in her hallway after meals in main dining room to prevent attempts of elopement dated 10/30/24. R6's elopement assessment dated [DATE] documents: section: 1. Elopement Risk: a. is the resident cognitively impaired and independently mobile (with or without a device)? with yes marked. 'History of Elopement': b1. Does the resident have; with 1. A history of elopement, 2. A desire to leave the facility, and 4. Wandering activity all marked. 'Elopement Risk Factors': b2. Does the resident 6. Have a diagnosis of Alzheimer's disease or dementia marked. C. documents 'yes' for is the resident at risk for elopement, d. documents: 1. Application of electronic monitoring bracelet 3. Picture in elopement book for: 'what interventions were put in place to prevent resident from eloping. The area 'Elopement Needs' area documents: focus: R6 is an elopement risk/wanderer AEB (As Evidenced by) due to anger with placement within the facility. The resident is an elopement risk/wanderer AEB with Goals marked as R6 will not leave facility unattended through the review date and R6's safety will be maintained through the review date, 'intervention' distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers sitting in her room with her husband, also church activities; intervention of wander alert and intervention of elopement/wandering risk, anger with placement within the facility. Intervention: 1. Offer to turn the tv to a station that R6 likes 2. Offer to sit and talk with R6 and see if you are able to calm her down 3. Call V26 (family) to talk with R6 to calm her down. R6's incident report dated 11/01/24 documents: The resident (R6) was last seen by staff approximately 1800-1810 ( 6:00 PM - 6:10 PM) in the main dining area. The resident did not mention leaving the facility to staff. The staff working with the resident were all interviewed, and statements obtained and reviewed. Unable to interview roommate as roommate has Alzheimer's diagnosis. Approximately 1800 -1810 on October 28th was the last time staff was able to state they saw the resident in the dining room. The temperature was approximately 72-75 degrees and clear with a breeze per weather service at 6pm on the 28th. The resident was wearing a short-sleeved t-shift, a wind breaker type jacket, pants, socks and her rainbow crocs. She was also carrying a blanket on her rollator walker. The resident was located by a staff members spouse less than 100 feet from the facility walking with her rollator near the adjacent business. The staff member's spouse called the staff member who was working at the facility at the time and notified her that he is with a resident from the facility, and he is next door. The staff member's spouse stayed with the resident until staff came out to assist her back to the facility. At approximately 1844 (6:44 PM), the staff went out to assist the resident back to the facility. The resident's wander guard went off when re-entering the facility. 100% head count was completed. All doors in the facility were checked by staff who verified that alarms were working. Elopement education was initiated immediately. The resident (R6) was unable to state which door she may have gone through to leave the facility. During investigation the resident's blanket was found on the picnic table just outside the breakroom door. A nurse leaving the facility at approximately 1838 noted the blanket on the table. The call to inform the facility of the resident outside was at approximately 1844 (6:44 PM). A 100% audit of all elopement assessments was completed and 100% of the residents were reassessed for elopement and care plans were updated as needed. The elopement books at each nurse station were reviewed for accuracy and a new picture of the resident placed in book. 100% of the wander guards were checked and verified for function. 100% of staff were in-serviced on the elopement policy, where the elopement binders are kept and how to react to an alarm sounding. A care plan was scheduled on 10/29 at 2pm with the POA but she was unable to make it to care plan meeting during this busy time of year. The medical director was updated regarding the investigation results. An elopement drill was completed on 10/31/2024. R6's progress note dated 10/28/24 at 6:40 PM documents: this nurse (V16, Licensed Practical Nurse) was notified by CNA (V15,Certified Nurse Aide) that (R6) was outside at storage facility next door. When I got outside (R6) was standing by the storage facility with 3 CNAs (V13, V14, V21) and 2 kitchen (Dietary) staff (V26 and V28). (R6) has been refusing to walk back to the facility with CNA's. I was able to talk R6 into coming back to facility. It was about 70 degrees outside still and resident was wearing a t-shirt, jacket, pants, slipper socks and shoes. She had a blanket at the picnic table and her walker with her. Once back in the building R6 went to bed. (R6's) wander device is on and working. A skin assessment was completed with no issues noted. On 11/26/24 at 11:05 AM the door R6 exited to the location where R6 was located was observed and was approximately 65 feet with no hazards observed. On 11/26/24 at 10:55 AM, V5 (Dietary) stated she received a call from V24 (Family of Employee) at 6:28 PM stating R6 was outside of the facility on the side of the storage units with him. V5 stated she asked V24 to stay with her and she would let staff know. On 11/26/24 at 10:58 AM, V24 (Family of Employee) stated he was over at the storage units on 10/28/24 at just after 6:00 PM when he came out of his unit at approximately 6:25 PM and saw R6. V24 then stated he called V5 at 6:28 PM to tell her R6 was with him and to let staff know. V24 stated he waited by the tree with R6 and staff came out minutes later to get R6 and convince her to go back inside. On 11/27/24 at 8:14 PM, V23 (CNA) stated she was working the day R6 eloped, she stated the last time she saw R6 was approximately between 6:15 and 6:30 PM she believes. One of the kitchen staff came out of the kitchen and said R6 was outside. R6 went out the double doors towards the breakroom is what she was told. V23 stated, she was in a room assisting another resident when R6 got out. They brought R6 back in the same way she went out and she thinks the alarm sounded, she does not specifically remember. V23 stated, usually there is a nurse by that nurse's station around that time. V23 stated she has been i[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide peritoneal dialysis treatments for 1 of 2 residents (R1) reviewed for dialysis in a sample of 7. This failure resulted in R1 presenting with a change in condition of confusion and being admitted to the hospital with lethargy and receivng hemodialysis during R1's hospital stay. Findings include: R1's admission Record documents R1's initial admission date to the facility as 03/25/24. The same document lists diagnoses for R1 including but not limited to: End Stage Renal Disease, Dependence on Renal Dialysis, Syncope and Collapse, Muscle Weakness (Generalized), Other Lack of Coordination, and Type 2 Diabetes Mellitus Without Complications. R1's current care plan, with an initiation and revision date of 4/16/24, documents a need of hemodialysis related to renal failure. There was no documentation of the need for peritoneal dialysis prior to this date upon request. R1's Minimum Data Set (MDS) dated [DATE] documents in section C, a Brief Interview for Mental Status (BIMS) score of 13, indicating that R1 is cognitively intact. The same MDS documented in section G, that R1 requires partial to moderate assistance, with rolling left to right, sitting to lying, lying to sitting on a bed, sit to stand, chair to bed transfer, indicating the helper would do less than half the effort. The same MDS documented in section O, Special Treatments, Programs and Procedures, that R1 receives dialysis upon admission and while a resident at the facility. R1's Discharge Planning Summary from the local hospital documents an entry on 3/22/2024 at 3:44 PM, that R1 was informed that this facility can meet her needs and that R1 wanted to talk to her family about her options. This same document has an entry dated 3/25/2024 at 10:22 AM that Patient (R1) was agreeable to rehab and referral sent to facility. An entry dated 3/25/2024 at 12:10 PM, documents (V3-admission Coordinator) accepted patient (R1) to facility with orders prior for peritoneal dialysis prior to (R1) transferring to ensure they can get the equipment prior to patient arrival. This same document dated 3/28/2024 at 9:01am has a late entry note on 3/25/2024 at 2:00pm stating that (R1) was agreeable to bringing her peritoneal dialysis equipment and 2 days' worth of fluids with her to facility while V9 (Family Member) was at bedside and V3 (admission Coordinator) agreeable to R1 going to the facility today. R1's Electronic Health Record (EHR) has no documentation of peritoneal dialysis orders received upon admission. R1's Nurse's Note dated 3/26/2024 at 6:05 PM, by V16 (Registered Nurse/RN), documents called and notified (V17 Nurse Practitioner/NP) that (R1) wouldn't be getting her peritoneal dialysis tonight due to not having all supplies available. Resident (R1) was supposed to bring 2 days supplies but forgot the fluids needed. Resident (R1) vital signs stable and will continue to monitor resident throughout the night. R1's Nurse's Note dated 3/27/2024 at 2:08 PM, documents V10 (Registered Nurse/RN) contacted V8 (Dialysis Registered Nurse) at R1's current dialysis provider regarding peritoneal dialysis orders. V8, states that resident is to use dialysis cycler to run 2 6-liter bags over 9-hour period every night. V10, notified R1 who can provide own dialysis treatment. R1's Nurse's Note dated 3/27/2024 at 8:18 PM documents, (R1) is experiencing a change in condition related to (R1) being confused and needing dialysis. R1's Nurse's Note dated 3/27/2024 at 8:46 PM documents, (V10 RN) notified (V17 Nurse Practitioner) that (R1) was having periods of confusion and unable to set up her peritoneal dialysis treatment. (V10) received orders from (V17) to send (R1) to (out of state) emergency room. (V10) attempted to notify family. On 5/03/2024 at 10:56 AM, V3 (Admissions Coordinator) stated she arranged admission to the facility with the discharging hospital and was aware R1 needed peritoneal dialysis. V3 stated it was understood by the discharging hospital that R1 would need to complete peritoneal dialysis independently while in the facility and would wait to be discharged to the facility until peritoneal dialysis supplies could be ordered and in the facility for R1. V3 stated the hospital case management arranged with R1 and R1's family to have a family member stop at R1's house to pick up the peritoneal dialysis machine with supplies and then bring the patient and supplies to the facility. V3 stated R1 arrived at the facility without her supplies and machine. V3 stated they have had a handful of patients receiving peritoneal dialysis over the years and could not confirm if staff were currently trained to assist R1 with her peritoneal dialysis. On 5/03/2024 at 12:10 AM, V5 (Director of Nursing/DON) stated that she has taken care of R1. V5 stated, her understanding was R1 missed one day of dialysis when she arrived at the facility because she did not have her supplies. V5 stated, R1's medical provider was notified of R1 not having her supplies and R1 was monitored through the night. V5 stated that V2 (Social Services Director) went the next day to meet family to pick up R1's supplies and dialysis machine. On 5/07/2024 at 11:08 am, V5 stated she was the educator for the peritoneal dialysis training for the facility. V5 stated that she used a power point to educate nursing staff. V5 stated she is not aware that a dialysis center staff came to the facility to train the staff and the staff did not have a peritoneal dialysis machine to demonstrate/practice on. On 5/03/2024 at 1:21pm, V2 (Social Services Director) stated he was asked to go meet R1's family at her home to get R1's peritoneal dialysis supplies and machine. V2 stated he did get the supplies and returned to the facility with them but cannot recall what day. V2 stated that R1 did review her dialysis orders with V10 (RN). On 5/03/2024 at 1:45 PM, V7 (Administrator of local Dialysis Company) and V8 (Nurse of local Dialysis Company) both stated, that R1 has been a peritoneal dialysis patient since April 2020 and was completing her treatments independently at home prior to her hospital admission at the end of March. V7 and V8 both stated, R1 would not be able to complete her treatments independently with R1 having a decrease in her physical abilities. On 5/07/2024 at 9:34am, V9 (Family Member) stated that she brought R1 to the facility after stopping at R1's house to retrieve her supplies to complete dialysis in the facility. V9 stated she was notified the next day that they forget the solution. V9 stated she was unable to get the solution to the facility until the next day. V9 stated that V2 did come to meet her at R1's house to pick up the solution on the third day of R1's admission. On 5/3/2024 at 9:39AM, V1 (Administrator) stated that R1 arrived at the facility without her peritoneal dialysis supplies. V1 stated that V3 (Admissions Coordinator) discussed with the hospital prior to discharging R1 to the facility that R1 would have to be able to complete the peritoneal dialysis, independently, and would need all supplies brought to the facility upon arrival. V1 stated that R1 arrived at the facility without her supplies. V1 stated that R1 was monitored through the night and then V2 (Social Services Director) went to meet R1's family at R1's home to get the peritoneal dialysis machine and supplies the next day. V1 stated that once the machine and supplies were brought to the facility, R1 could not complete the steps to start her dialysis. V1 stated R1's medical provider was notified and R1 was sent to the hospital for evaluation. V1 stated if they knew she was not bringing her supplies, they would not have accepted R1. V1 stated there was an issue with V9's (family member) car when she was notified the next day, they needed her to bring R1's solutions to the facility. On 5/07/2024 at 11:43 am, V10 (Registered Nurse/RN) stated she had direct patient care with R1. V10 stated she cared for R1 on day shift, 3/26/2024, after R1 arrived at the facility. V10 stated, that R1 arrived late the prior evening without her dialysis supplies and the facility was in contact with the family the next day to arrange getting the supplies. V10 stated on the third day, V10 and R1 set up the supplies and machine in R1's room. V10 stated she was under the impression that R1 was going to direct the staff on how to use the dialysis machine, however that evening when V16 (RN) went to help R1, R1 was not able to direct staff on how to assist. V10 stated, R1 was then sent out to the hospital since she had been without a dialysis treatment for 3 days. V10 stated that she did have peritoneal dialysis training a year ago by the facility staff, however, could not remember the exact date. V10 stated, she does not feel comfortable assisting with peritoneal dialysis and does not recall being trained by a dialysis facility faculty. On 5/08/2024 at 6:51 AM, V16 (RN) stated that she had direct patient care with R1. V16 stated she was the nurse that took care of R1 when she arrived at the facility her first night around 11:30 pm. V16 stated that R1 had a lot of bags with her dialysis equipment with her, however, R1 refused to set up the equipment and stated she did not need dialysis that evening. V16 stated she came in to work the next night and was told that R1's family was notified that R1 forgot her solution at home to complete her treatments and V9 (family member) was contacted to bring the solution to the facility. V16 stated that V9 notified the facility that her car was broken down and had no transportation to bring the solution to the facility however someone from the facility is welcome to go to her house and pick up the solution. V16 stated she notified V17 (Nurse Practitioner) of R1 missing her treatments because of no solution and was showing no signs of distress. V16 stated she received orders to monitor R1 for any signs of symptoms of distress. V16 stated when she arrived at the facility for the third night in a row, R1 had her supplies to complete her treatment. V16 stated that someone from the facility went to R1's home that day to get her solution. V16 stated R1 was physically unable to complete her dialysis treatment on her own and staff were supposed to assist by giving directions on what solutions to be used and buttons to be pushed on the machine. V16 stated R1's peritoneal dialysis order was received by the day shift nurse from the dialysis company on 3/27/2024 around 2:00pm. V16 stated the day shift nurse and R1 set up all supplies and her machine that day in R1's room. V16 stated around 7:00 pm, she went into R1's room to assist with dialysis and R1 was unable to give directions on how to set up and start treatments. V16 stated she notified the V17 (Nurse Practitioner) and sent R1 to the hospital. V16 stated she attended the peritoneal dialysis training instructed by V5 sometime in 2023. V16 stated she cannot recall if she was trained on a peritoneal dialysis machine during that training. V16 stated, she has not been trained on peritoneal dialysis by a certified dialysis staff member. V16 stated she feels comfortable assisting residents with peritoneal dialysis when they can give directions on their set up, solutions to use, etcetera. On 5/07/2024 at 1:27 pm, V11 (Physician) stated that R1 was his resident completing peritoneal dialysis treatments at home, independently. V11 stated he was notified after R1 was discharged from the hospital to this rehab facility. V11 stated he expects a nursing home facility to have supplies and proper training prior to accepting a peritoneal dialysis resident. V11 stated he would expect if R1 arrived at the facility without her supplies then the facility should have sent her back to the hospital to receive treatment or R1 to her home to get all her supplies to complete her treatment. On 5/08/2024 at 9:24 AM, V17 (Nurse Practitioner/NP) stated R1 arrived at the facility on 3/25/2024 without her dialysis supplies to complete her treatment. V17 stated she was notified the next evening when R1 still had not received her supplies at the facility. V17 stated when she was contacted by the nurse that R1 was unable to complete her treatments the next evening (day 3), she had R1 sent out to the emergency room for evaluation. V17 stated the understanding upon admission to the facility was that R1 was able to complete her dialysis treatments independently, however, R1 was unable to complete the steps or direct the staff on what was needed to initiate the peritoneal dialysis treatment. The facility's Inservice Education Signature Sheet for peritoneal training by V5 (Director of Nursing/DON) with Peritoneal Dialysis (Continuous Ambulatory) procedure was reviewed and had V10 (Registered Nurse/RN) and V16 (Registered Nurse/RN) signatures as having attended the training . R1's Hospital Discharge Summary from an out of state hospital dated 4/3/2024 documents that R1 was admitted to the hospital on [DATE] with a chief complaint of no dialysis in 2 days. The Cumulative Hospital Course and Treatment documents that R1 has End Stage Renal Disease (ESRD) and is on Peritoneal Dialysis (PD) and presented to the emergency room from the rehab center due to lethargy and R1 had not received peritoneal dialysis in at least 2 days. R1 was new to the rehab center, and they were not made aware of her peritoneal dialysis needs. R1 was admitted to the hospital with nephrology consult where a decision was made to change dialysis modality to hemodialysis (HD) and a permcatheter was placed. R1 completed a hemodialysis treatment on 4/03/2024 and was discharged in stable condition to the rehab facility. R1 was to continue hemodialysis treatments, 3 days a week. The same discharge summary documents under Discharge Problem List a principal problem of ESRD needing dialysis and active problems of Lives in a long-term custodial care facility, acute kidney injury, and acute post-hemorrhagic anemia.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to safely transport a resident in a wheelchair to prevent an accident for 1 of 3 residents (R1) reviewed for accidents in the sample of 6. This failure resulted in R1 receiving an 8 cm (centimeter) laceration over his right eye requiring 10 staples. The findings include: R1's face sheet documents R1 was admitted to the facility on [DATE] with diagnoses including neurocognitive disorder with Lewy bodies, Parkinson's Disease with dyskinesia, with fluctuations, and repeated falls. R1's Minimum Data Set (MDS) dated [DATE] documents in section C, Cognitive Patterns, a Brief Interview of Mental Status (BIMS) score of 01, indicating that R1 has severe cognitive impairment. Section GG, Functional Abilities and Goals, of the same MDS documents that R1 uses a wheelchair as a mobility device, R1 requires partial/moderate assistance (helper does less than half the effort) with sit to stand, walking 10 feet, and walking 50 feet with two turns. The same section documents that R1 requires supervision/touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance) with wheeling 50 feet in a wheelchair with 2 turns and requires partial/moderate assistance to wheel 150 feet in a wheelchair. R1's Fall Risk Data Collection dated 1/19/24 documents a score of 32 and documents high risk for the category. R1's Fall Incident Report in the Electronic Health Record dated 3/3/24 documents under Incident Description that at approx. (approximately) 1945 (7:45 PM) resident (R1) was being wheeled up the hall in wheelchair towards his room when the nurse witnessed resident lean forward and fall to floor hitting his head. Obvious laceration noted. Staff directed to not move resident. Under Immediate Action Taken it documents Obvious laceration to right side of head noted. New orders received to send to ER (Emergency Room) for eval and treat. The intervention documented is have leg rests on while being pushed in his w/c (wheelchair). R1's Patient Health Summary from the local hospital dated 3/3/24 documents a chief complaint of head laceration and stated complaint of .presents to the ER (Emergency Room) from local nursing home after he apparently fell forward out of his wheelchair striking his head on the ground resulting in a laceration over the right. The same document under Physical Exam stated laceration over the right eye. It is stellate on the medial side almost in a Y-shaped. The 2 arms are 1cm (centimeter) and then the rest of the laceration is 6cm. Extending through the subcutaneous tissue. No visible bone. Under Laceration/Wound Repair it documents the wound length is 8 cm and the wound was repaired with 10 staples. Physician Progress Note on the same document states that a CT (Computerized tomography) head, maxillofacial and cervical were all negative for acute fractures or findings. R1's Care Plan documents that R1 is at risk for falls and documents an intervention of Leg rests to be on the wheelchair when pushing residents with an initiation date of 3/3/24. On 3/7/24 at 2:15pm, V10 (CNA) said she was pushing R1 when he fell. V10 said she takes R1 with her in the wheelchair so she can watch him since he is always trying to get up. V10 said she parked R1 in his wheelchair outside of the room she had to go in. V10 said she was going to answer a call light and the nurse was at her medication cart. V10 said the nurse motioned to her that someone was trying to get up. V10 said she was about 6 doors down. V10 said she didn't pay attention and began pushing him. V10 said she didn't realize that R1 had scooted forward in his wheelchair and put his feet down causing R1 to fall face first on the floor. V10 said she did not have foot pedals on the wheelchair. V10 said they are using foot pedals now with R1 and he won't keep his feet on the pedals. On 3/7/24 at 3:00pm, V1 (Administrator) said she was aware of the foot rests not being on, but was not aware of R1 sitting at the edge of the wheelchair when being pushed. V1 said they implemented the intervention of ensuring the foot rests were on the wheelchair after he fell on 3/3/24. The facility policy titled Fall Policy (revision date 9/17/19) documents that the the facility shall ensure that a Fall management Program will be maintained to reduce the incidence of falls and risk of injury to the resident and promote independence and safety.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to apply a gait belt while transferring and ambulating 1 of 3 residents (R1) reviewed for falls in the sample of 3. This failure resulted in R1 falling to the floor which resulted in a fracture of the L2 vertebrae. Findings include: R1's admission Record in the medical record documents that R1 admitted to facility on 6/08/2022 with a diagnosis of cerebral infarction, unspecified. R1's Minimum Data Set (MDS) assessment dated [DATE] documents in Section C a Brief Interview for Mental Status (BIMS) score of 15, indicating that R1 is cognitively intact. Section G, Functional Status documents Limited assistance with one-person physical assist with bed mobility, transfers, ambulating, dressing, toilet use, and personal hygiene. R1's Care Plan documents under Focus that R1 is at risk for falls with an initiation date of 6/09/2022 and revision date of 12/13/2022. Under the section Goal it documents that R1 will be free from falls through the review date with an initiation date of 6/09/2022 and revision date of 12/20/2022 and target date of 5/08/2023. Interventions documented include: be sure the resident's call light is within reach and encourage the resident to use it for assistance with an initiation date of 6/09/2022 and revision date of 6/20/2022, ensure personal items are within reach with an initiation date of 6/09/2022, ensure that the resident is wearing appropriate footwear ambulating or mobilizing in wheelchair with an initiation date of 8/31/2022 and revision date of 9/19/2022. R1's Fall Risk Assessment dated 6/08/222 documents score: 9 (Low Risk). R1's Progress Notes dated 5/27/2023, documents It was reported to V4 (Licensed Practical Nurse) by (R1) that (R1) had experienced a fall last night, (R1) has a deep purple bruise on coccyx and (V4) noted (R1) is having problems transferring, (R1) stated It only hurts when they try and stand up. (R1) explained that she was using rollator (wheeled walker) with (V5-Certified Nurse Aide), (V5) went to pull blankets back for (R1) to get in bed, (R1) lost balance and landed on buttocks. (V9-Nurse Practitioner) notified and ordered (R1) to emergency room for evaluation. Family made aware. R1's Emergency Department Provider Notes dated 5/27/2023, documents in part .(R1) is a [AGE] year-old white female present to the emergency room with complain of low back pain .(R1) had a fall yesterday .person did not support her back and (R1) fell on the floor on her buttocks .(R1) has a bruise on her lower buttocks and low back .Final Impression, 1. Closed compression fracture of L2 lumbar vertebra, initial encounter. On 6/13/2023, at 9:00 a.m. V1 (Administrator) stated that it was reported that R1 experienced a fall on 5/26/2023 and V5 (CNA) was assisting R1 back from the bathroom and went to pull her bedding back and R1 lost her balance and landed on her buttocks. V1 stated that V5 was educated to follow R1's plan of care and to use a gait belt when transferring or ambulating a resident that requires assistance with transfers and ambulation. On 6/12/2023, at 11:25 a.m., V4 (Licensed Practical Nurse), stated that she was working on 5/27/2023 and was notified by the CNA that R1 was having difficulty transferring and she had noticed a bruise on her coccyx area. V4 stated she went in to assess R1 and observed a deep purple bruise to her coccyx and right buttock area. V4 stated that R1 told her she had fallen the night before. V4 stated she asked R1 if she was having pain and R1 told her she was having a little pain. V4 stated she offered R1 some pain medication at that time and notified the primary physician and made family aware. V4 stated the primary physician ordered for R1 to be sent out to the emergency department for an evaluation and treatment. V4 stated that R1 was sent out to the local hospital and returned with a fracture to her lower back. V4 stated that R1 normally transfers with assistance of one person with a gait belt and ambulates with a rollator walker. On 6/13/2023, at 10:00 a.m., V5 (Certified Nurse Aide) stated he was working the evening of 5/26/2023 and was helping R1 get ready for bed. V5 stated he helped R1 go to the bathroom and when R1 was coming out of the bathroom, he went over to her bed to pull down the bedding and when he turned around R1 had fallen to the floor on her buttocks. V5 stated R1 told him she was fine. V5 stated he notified V8 (Agency LPN), and she came in to look at R1. V5 stated that after V8 looked her over, he helped R1 get up and put her into bed. V5 stated that he did not have a gait belt on R1 when he was helping R1 to and from the bathroom. On 6/13/2023, at 10:15 a.m., V8 (Agency LPN) stated that she was working the evening of 5/26/2023 and was notified by V5 (CNA) that R1 had fallen to the floor while coming back from the bathroom. V8 stated she went into R1's room and assessed R1. V8 stated that R1 did not have any complaints of pain or discomfort at that time and R1 was able to move her extremities with no problems and denied hitting her head. V8 stated that R1 was assisted up and put back to bed with no problems noted. On 6/12/2023, at 10:00 a.m., R1 stated she had a fall recently. R1 stated she was walking back from the bathroom with her walker and V5 (Certified Nurse Aide/CNA) was over at her bed pulling down the bedding on her bed to help assist her get ready for bed. R1 stated she lost her balance and fell into her closet and sat down to the floor. R1 stated that the nursing staff usually have a gait belt on her and walk with her when she is walking with her walker. R1 stated that V5 did not put a gait belt on her at that time. R1 stated she did not have any sudden pain until she got up the next morning and noticed her back was sore. R1 stated that she told the nurse she had back pain and had fallen the night before. R1 stated the nurse checked her out and noticed a bruise on her lower back/bottom. R1 stated she was sent out to the hospital and was told her lower back had a fracture in it. R1 stated she was brought back to the facility after her hospital visit. The facility's Final Report dated 5/27/2023 documents in parts . Staff were educated in the use of a gait belt, the proper way to complete the transfer and the task of preventing any incidents in the future .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure pressure ulcers were assessed, treated, and interventions were implemented timely for 1 of 3 (R66) residents reviewed for pressure ulcers in the sample of 36. This failure resulted in R66 developing a Stage 3 Pressure Ulcer to R66's coccyx which was up to 1 week old before it was assessed and treated. Findings Include: R66's facility admission Record with a print date of 5/24/23 documents R66 was admitted to the facility on [DATE] with diagnoses of fracture of femur, cirrhosis of liver, fracture of ribs, neurocognitive disorder, diabetes, and fracture of vertebra. R66's MDS (Minimum Data Set) dated 4/23/23 documents a BIMS (Brief Interview for Mental Status) score of 02, which indicates R66 has a severe cognitive deficit. This same MDS documents R66 is dependent on staff for bed mobility and toilet use and requires extensive assistance with transfers. This same MDS documents under Section M, R66 is at risk for developing pressure ulcers, has a Stage 2 pressure ulcer, and has the following interventions: pressure reducing device for chair, pressure reducing device for bed, nutrition/hydration intervention, and pressure ulcer/injury care. R66's Braden Scale for Predicting Pressure Sore Risk assessments document a score of 17 on 4/17/23 and a score of 15 on 4/24, 5/1, and 5/8/23. This indicates R66 is at risk for skin breakdown. On 05/24/23 at 9:25 AM, V4 (Registered Nurse/Wound Nurse) was observed administering treatments to the pressure ulcers located on R66's buttocks and coccyx. The area to R66's left buttock was red and opened with the surrounding tissue being red and inflamed. The area to R66's coccyx was covered with yellow slough with the surrounding tissue being red and inflamed. V4 stated R66 came to the facility with the small area on his left buttock and then developed the Stage 3 pressure ulcer to his coccyx after admission. V4 cleaned the areas with wound cleanser and applied calcium alginate to the pressure ulcer on R66's left buttock and applied Santyl, Adaptec, and silicone foam to the pressure area on R66's coccyx. V4 performed hand hygiene per current standards of practice. R66's weekly skin checks document on 4/24/23 there was a pressure ulcer to R66's left buttock with no assessments or measurements notes. R66's weekly skin check dated 5/8/23 documents a pressure ulcer to R66's coccyx and left buttock with no assessments or measurements notes. R66's weekly skin checks dated 5/1, 5/16, and 5/23/23 do not document assessments of pressure areas. R66's progress notes were reviewed from 4/17/23 to 5/24/23 and did not document assessments of pressure areas including measurements, classifications, and/or descriptions. R66's Skin and Wound Evaluation dated 4/18/23 documents a Stage 2 pressure ulcer to left buttock, present on admission to the facility. The assessment documents the pressure ulcer measures 3.1 cm x 2.3 cm x 0.1 cm with no undermining or tunneling. Under Notes the assessment documents, Stage 2 pressure ulcer to left buttock present on admission. Turn/reposition frequently. Arginaid to promote healing. R66's Skin and Wound Evaluation dated 5/8/23 documents the Stage 2 pressure ulcer to R66's left buttock that measures 2.9 cm x 1.1 cm x 0.1 cm. Under Notes the assessment documents, Stage 2 pressure area to buttock stable. Calcium Alginate continues to wound bed covered by silicone bordered foam daily. This indicates the pressure area to R66's left buttock was not assessed from 4/18/23 until 5/8/23. R66's Skin and Wound Evaluation dated 5/15/23 documents the Stage 2 pressure ulcer to R66's left buttock measures 1.2 cm x 0.6 cm x 0.1 cm with no undermining or tunneling. Under Notes the assessment documents, Stage 2 pressure area to left buttock has improved in size. Will continue calcium alginate to wound bed cover with silicone bordered foam daily. R66's Skin and Wound Evaluation dated 5/22/23 documents a Stage 2 pressure ulcer to left gluteus that was present on admission that measures 0.7 cm x 0.3 cm. x 0.1 cm. The assessment documents a light amount of exudate, no odor, attached edges, no pain, no swelling, and normal in color. Under Notes the assessment documents, Stage 2 pressure ulcer to left buttock continues to show improvement. Will continue calcium alginate to wound bed and cover with silicone bordered foam daily. Arginaid daily to promote wound healing. R66's Skin and Wound Evaluation dated 5/8/23 documents a Stage 3 pressure ulcer on R66's coccyx, acquired in house within the last week. The pressure ulcer is measured at 2.1 cm x 0.7 cm x 0.2 cm. Under Notes the assessment documents, Stage 3 pressure area noted to coccyx. 50% yellow slough. 50% granulation tissue noted to wound bed. New order for honey absorbing sheet to wound bed covered by silicone bordered foam daily. Arginaid added to promote wound healing. R66's Skin and Wound Evaluation dated 5/15/23 documents a Stage 3 pressure ulcer on R66's coccyx measured as 3.5 cm x 1.7 cm x 0.2 cm. Under Notes the assessment documents, Stage 3 pressure area to coccyx has deteriorated. Larger in size with 90% yellow slough noted to wound bed. 10% granulation tissue. Honey absorbing sheet to wound bed covered by silicone bordered foam daily. Arginaid daily to promote wound healing. R66's Skin and Wound Evaluation dated 5/22/23 documents a Stage 3 pressure ulcer to coccyx that was acquired in house, approximately one week ago. The assessment documents the area measures 3.0 cm x 1.0 cm x 0.2 cm with no undermining or tunneling. The assessment of the area is documented as no evidence of infection, moderate serous exudate, no odor, attached edges, no swelling, and normal peri-wound temperature. Additional care is documented as turning/repositioning program with no other interventions documented on this assessment. Under Notes the assessment documents, Stage 3 pressure area to coccyx stable. 90% yellow slough noted to wound bed. 10% granulation tissue. New order to apply Santyl ointment to wound bed covered with Adaptec and silicone bordered foam daily. Arginaid daily to promote wound healing. R66's Order Summary Report dated 5/24/23 includes the following physician orders Cleanse stage 2 pressure area to left buttock with wound cleanser. Pat dry. Apply calcium alginate to wound bed. Cover with silicone bordered foam dressing daily and prn (as needed) for soiling or dislodgement until healed. Every night shift for wound healing. Start date: 4/23/23, and Santyl External Ointment 250 unit/gm(gram) (Collagenase) Apply to stage 3 coccyx topically every night shift for wound care apply nickel thick layer Santyl to wound bed. Cover with Adaptec and silicone bordered foam daily. Start date: 5/22/23. This same Order Summary Report documents an order that was discontinued 5/22/23 to cleanse Stage 3 pressure ulcer to coccyx with wound cleanser, apply honey absorbing sheet to wound bed and cover with silicone bordered gauze daily with a start date of 5/8/23. This indicates there was no physician order for treatment of the Stage 2 pressure ulcer on R66's left buttock from 4/17/23 until 4/23/23. R66's Treatment Administration Record (TAR) dated 4/1/23 to 4/30/23 documents an order to Cleanse Stage 2 pressure area to left buttock with wound cleanser. Pat dry. Apply calcium alginate to wound bed. Cover with silicone bordered foam dressing daily and prn (as needed) for soiling or dislodgement until healed. Start date: 4/23/2023. The treatments are signed as being administered as ordered. R66's TAR dated 5/1/23 to 5/31/23 documents an order to Cleanse Stage 2 pressure area to left buttock with wound cleanser. Pat dry. Apply calcium alginate to wound bed. Cover with silicone bordered foam dressing daily and prn for soiling or dislodgement until healed. Every night shift for wound healing. Start Date: 4/23/2023. This TAR documents signatures for all dates except 5/11, 5/14, and 5/20/23, which indicates treatments were administered as ordered on every day except 5/11, 5/14, and 5/20/23. R66's TAR dated 5/1/23 to 5/31/23 documents an order for Santyl External Ointment 250 unit/gm (Collagenase) Apply to Stage 3 coccyx topically every night shift for Wound Care. Apply nickel thick layer Santyl to wound bed. Cover with Adaptec and silicone bordered foam daily. Start Date: 5/22/23. This TAR documents signatures indicating treatments were administered as ordered. This same TAR documents an order to cleanse the Stage 3 pressure ulcer to coccyx with wound cleanser, apply honey absorbing sheet to wound wound bed and cover with silicone, with a start date of 5/8/23 and discontinue date of 5/22/23. This TAR documents signatures on each day indicating the treatments were administered as ordered except on 5/11, 5/14, and 5/20/23. R66 Care Plan dated prior to 5/24/23 did not contain an area related to potential skin breakdown or a pressure ulcer care area. On 05/24/23 at 10:12 AM, this surveyor reviewed R66's care plan with V4 (RN/Wound Nurse) and she confirmed R66 did not have a potential for skin breakdown or pressure ulcer care area on his current care plan. When asked how to tell what, if any interventions were in place to prevent skin breakdown V4 stated she didn't have a good answer for me at that time. R66's current Care Plan documents a Focus area of (R66) has potential/actual impairment to skin integrity r/t (related to) decreased mobility. Left Gluteus, Coccyx, Date Initiated: 5/24/23. The interventions documented for this care area dated 5/24/23 are, Administer medications as ordered. Monitor/document for side effects and effectiveness .Administer treatments as ordered and monitor for effectiveness Document location of wound, amt (amount) of drainage, peri-wound area, pain, edema, and circumference measurements .Encourage good nutrition and hydration in order to promote healthier skin .Evaluate wound for: Size, Depth, Margins, peri-wound skin, sinuses, undermining, exudates, edema, granulation, infection, necrosis, eschar, gangrene. Document progress in wound healing on an ongoing basis. Notify physician as indicated .Inform the resident/family/caregivers of any new area of skin breakdown .Monitor dressing when providing care to ensure it is intact and adhering. Report lose dressing to nurse .Monitor pressure areas for changes in color, sensation, temperature, and report any change to nurse .Pressure redistributing mattress on bed .The resident needs pressure redistributing cushion to protect the skin while up in chair. This indicates there was no care plan implemented related to skin breakdown from 4/24/23 when the Stage 2 pressure ulcer was identified until 5/24/23. On 05/24/23 at 3:22 PM, V9 (Certified Nursing Assistant/CNA) stated the facility staff rotate R66 every two hours and use pillows to keep him off his bottom. V9 stated they keep R66 clean and dry. V9 stated they have been implementing those interventions since R66 was admitted to the facility. On 05/24/23 at 3:24 PM, V15 (LPN/Licensed Practical Nurse) stated R66 didn't have a cushion in his wheelchair. V15 stated R66 was non-weight bearing when he was first admitted to the facility and wasn't up in his wheelchair. V15 stated they had to order a cushion to fit his wheelchair and it hasn't come in yet. V15 stated they keep R66 clean and dry, float his heels, and turn and reposition him every two hours and they implemented those interventions when R66 was admitted . V15 stated R66 had the pressure ulcer to his buttock when he was admitted and the one on his coccyx developed after admission. On 05/25/23 at 10:00 AM, V4 (RN/Wound Nurse) stated R66 should have had a skin breakdown/pressure ulcer care plan in place. V4 stated if the care plan wasn't present the staff would just use standard nursing practice for interventions such as turn and reposition, intake, hydration. V4 stated there is no documented assessment of the Stage 2 pressure ulcer to R66's left buttock until 5/8/23. On 05/25/23 at 10:25 AM, V2 (Director of Nurses) stated she put the physician order for the treatment to the pressure ulcer on R66's buttock in on 4/23/23 and the pressure ulcer was documented on the 4/24/23 weekly skin check. V2 stated she didn't have measurements, or an assessment of the area documented until 5/8/23. V2 stated the pressure ulcer should have been assessed weekly and she knows it was measured but she failed to document the measurements. V2 stated there was no care plan documented and the interventions to prevent the pressure ulcer from worsening was to turn and position at least every two hours, observe the area with treatments, and if it was worsening to put new interventions in place. This surveyor reviewed R66's TAR and asked her why there were some days with no signatures, V2 stated she believes the nurses did the treatments but just failed to document them. When asked how they monitored the pressure ulcer on R66's left buttock to ensure it wasn't worsening, V2 stated they did it with the dressing changes. V2 stated she didn't administer every treatment and the same nurse did not administer every treatment. When asked if she had different nurses doing the treatments with no assessments of the area documented, then how would the nurse know if the area worsened or improved, V2 stated, They can only go off what they have seen prior. When asked if there were any new interventions implemented after R66 developed a Stage 3 pressure ulcer on his coccyx, V2 stated there were dietary interventions implemented to promote healing. V2 stated a cushion was also placed in R66's chair. This surveyor reviewed with V2, R66 didn't have cushion in his chair and V2 stated, Ok. When asked if she had a resident who had a Stage 2 and developed a Stage 3 pressure ulcer if she would expect new interventions to be implemented other than dietary changes, V2 stated, Yes. On 05/25/23 at 2:15 PM, V1 (Administrator) stated she would expect staff to assess, obtain treatment orders, and implement new interventions for residents with pressure ulcers. V1 stated she couldn't find an order to treat the Stage 2 pressure ulcer to R66's left buttock prior to 4/23/23. On 05/25/23 at 2:23 PM, V17 (Nurse Practitioner/NP) stated he wasn't aware R66 had pressure ulcers. V17 stated with R66's condition he doesn't think the pressure ulcers would be avoidable. V17 stated he would expect the facility staff to assess and document assessments so they could monitor if the areas are improving or declining. V17 stated if the facility had notified him of the areas, he would have given the order to refer R66 to wound care. V17 stated he hasn't seen the pressure areas but has seen R66 three times since he was admitted to the facility. V17 stated every time he had seen him, R66 has been up in his wheelchair except when R66 was in isolation. V17 stated he has no documentation he was notified of the areas and/or gave orders to treat the areas. On 5/25/23 at 2:35 PM, V4 (RN/Wound Nurse) stated she thinks V17 (NP) gave her the orders for the treatments to R66's pressure ulcers. The facility Pressure Ulcer/Pressure Injury Prevention (PUP) policy dated 4/2018 documents, Prevention of Pressure Ulcers/Injuries; A pressure ulcer/injury (PU/PI) can occur wherever pressure has impaired circulation to the tissue. A facility must: Identify whether the resident is at risk for developing or has a PU/PI upon admission and thereafter; Evaluate resident specific risk factors and changes in the resident's condition that may impact the development and/or healing of a PU/PI; Implement, monitor, and modify interventions to attempt to stabilize, reduce, or remove underlying risk factors; and If a PU/PI is present, provide treatment to heal it and prevent the development of additional PU/PI's 1. Assessment: A standardized pressure ulcer/pressure injury risk assessment (Braden Scale) will be used to identify residents who are at risk for the development of pressure ulcer/pressure injury 2. Planning: An individual plan of prevention will be developed to meet the needs of the resident. It will include the consideration of mechanical support surfaces, nutrition, hydration, positioning, mobility, continence, skin condition and overall clinical condition of the resident as well as the risk factors as they apply to each individual .3. Implementation: Interventions for the prevention of pressure ulcer/pressure injury will be individualized to meet the specific needs of the resident 4. Evaluation and Reassessment: The facility's Care Management System committee will review program components to evaluate the effectiveness of the prevention program and facility systems. Findings and recommendations will be reviewed with the QA Clinical Committee. Based on evaluation, the need for reassessment and further changes to the individual resident's plan of care will be determined and acted upon.