**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to obtain a physician's order, failed to obtain consent, and failed to perform an assessment for a resident using a seat belt in a motorized wheelchair for one of one resident (R44) reviewed for restraints in the sample of 14. The findings include: R44's Face Sheet shows she was admitted to the facility on [DATE] with diagnoses including muscle weakness, contractures to both knees, tracheostomy status, hemiplegia, malnutrition, anxiety disorder, and contracture to her left hand. On May 21, 2024 at 10:10 AM, R44 was in her room in her motorized wheel chair. R44 had a seat belt in place to her lower abdomen. R44 said she uses the seat belt because she slides out of the chair. The Self-Releasing Seat Belt Informed Consent for Use was signed by R44 on May 21, 2024. R44's Restraint Enabler was entered on May 21, 2024 at 3:41 PM. R44's Order Summary Report does not show any orders for a self-releasing seat belt prior to May 21, 2024. R44's Care Plan that showed R44 uses a seat belt was not initiated until May 21, 2024. R44's Care Plan shows document self-releasing seat belt and release and ensure valid consent is on the chart prior to use of the self-releasing seat belt. R44's Care Plan also shows the resident is able to release the seat belt by herself, assess at quarterly and as need, which was initiated on May 21, 2024. On May 22, 2024 at 9:50 AM, V2 (Director of Nursing) said R44 has used a seat belt since she came to the facility. V2 said that there should be a doctor's order, consent by the residents, and assessments should be done quarterly and as needed. The facility's Restraint Free Environment policy implemented on May 2, 2023 shows, Residents may use devices per request for positioning and safety purposes that they are able to freely remove on their own with a signed consent. The resident/resident's representative may request the use of a physical restraint; however the facility is responsible for evaluating the appropriateness of the request. The facility shall explain to the resident/resident's representative, the potential risks and benefits of using a restraint, not using a restraint, and alternatives to restraint use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R23's Face Sheet showed R23 had the diagnosis of weakness. A facility assessment done on 3/26/24 showed R23's cognition was intact. The same assessment showed R23 needed partial/moderate assistance to go from sitting to standing and to walk. R23's Witnessed Fall report dated 4/19/24 showed R23 was oriented to person, situation, time, and place. The same document showed R23 fell in her room during a transfer and a predisposing factor was gait imbalance. On 5/21/24 at 1:26 PM, R23 said she had a fall in her room while staff were assisting her to transfer to a scale. R23 said she stood up from her bed and had to take several steps to get to the scale. R23 said the scale was about 4 to 5 feet away. According to R23, her shoe caught the edge of the scale causing her to fall. R23 said staff were present during the fall and staff did not use a gait belt. R23 said staff did not lower her to the floor during the fall. R23 added sometimes staff used a gait belt to assist her to transfer. On 05/21/24 at 9:21 AM, V12 (CNA) said she was with R23 on 4/19/23 when R23 fell in her room. V12 said the day R23 fell she assessed R23 to stand up from bed by supporting R23 under her arm. V12 said when R23 stood and walked she needed help balancing. V12 said she helped R23 balance by holding onto R23's arm. According to V12, R23 took several steps and attempted to step onto the scale. V12 said as R23 stepped onto the scale V12 was not holding onto R23 and R23 fell. V12 said she did not use a gait belt while assisting R23 to transfer onto the scale. V12 said she only used a gait belt with R23 when walking outside of R23's room. On 05/21/24 at 11:39 AM, V2 (Director of Nursing) said a gait belt should be used when staff provide balance assistance during a transfer. On 05/21/24 at 12:43 PM, V13 (CNA) said gait belts are used to safely transfer residents. On 5/21/24 at 10:46 AM, V14 (R23's Physician) said given R23's comorbidities, she has weak bones putting her at risk for fractures. R23's Care Plan with an initiated date of 1/15/24 showed R23 had limited physical mobility related to weakness and at risk for falls related to noncompliance with assistance with transfers. The facility's Use of Gait Belt policy with a revised date of 5/21/24 showed it is the policy of this facility to use gait belts with residents that cannot independently ambulate or transfer for the purpose of safety. Based on observation, interview, and record review the facility failed to reassess a resident for safe swallowing after the resident had a choking episode in the facility. The facility failed to supervise a resident, with a history of falls, while the resident was seated on the toilet. The facility failed to ensure residents were transferred by staff in a safe manner. These failures apply to 3 of 14 residents (R14, R23, R42) reviewed for safety and supervision in the sample of 14. The findings include: 1. R14's admission Record showed R14 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease, dementia, and cognitive impairment. R14's Progress Note dated 5/19/24 showed, Resident found to be purple in color with airway obstruction. Performed Heimlich maneuver, after a few thrusts resident gasped for air. Resident sat in wheelchair and was tearful. The note showed R14 choked on her evening medications. R14 was not sent to the hospital for an evaluation after the incident. R14's physician was notified on 5/19/24. On 5/20/24 at 12:24 PM, R14 propelled herself in her wheelchair into her room. On R14's bedside table was a box of chocolates. R14 was asked about her choking incident. R14 stated, My nurse gave me my evening meds (medications). I take them whole, one by one. She watched me take them. The nurse walked out of my room. I took a sip of water and suddenly I couldn't breathe. I guess I let out a gasp or a noise. The nurse came in and hit me on my back. I am not sure what I coughed up. R14 stated, since her choking incident, R14 still takes her medications whole and there have been no changes in the type of diet she receives. R14 denied having any previous choking episodes in the facility. R14's physician orders dated 5/20/24 were reviewed. These orders showed no orders to crush R14's medications, no orders for R14 to be evaluated by speech therapy, and no changes in diet orders for R14. On 5/21/24 at 9:10 AM, V5 (Registered Nurse) stated, (R14) doesn't get her meds crushed. She just got her medications this morning. She takes them whole, one by one. On 5/21/24 at 10:27 AM, V6 (Speech Therapist/ST) stated, Parkinson's disease can put a resident at increased risk for swallowing problems. If a resident has a choking episode, on foods or meds, staff must notify the physician and refer the resident to me for an evaluation. Staff should immediately downgrade the resident's diet. Residents, that have swallowing problems or choke, are to be referred to me because I am the one that assesses the resident for safe swallowing or any swallowing problems. V6 stated she had never seen R14 and had not received an order to evaluate R14 as of 5/21/24 at 10:27 AM. On 5/21/24 at 10:39 AM, V2 (Director of Nursing/DON) stated, If a resident chokes in the facility, we notify the doctor, downgrade the resident's diet, and refer the resident to speech therapy for an evaluation. V2 stated, The night (R14) choked. The nurse has just given (R14) her pills. The nurse watched her take the pills. I am not sure how many pills (R14) took. The nurse walked out of (R14's) room and heard a strange noise coming from (R14). The nurse ran back into the room. She saw that (R14) was choking so she did the Heimlich on (R14). After a couple of thrusts, the nurse was able to get pill products out of (R14's) mouth. (R14) was upset but she could breathe. She was able to drink water. V2 stated, (R14) is still getting her meds whole. She hasn't been seen by or referred to speech therapy yet. She should have been. We got busy and didn't get these things done (crushing meds and referral to speech therapy). When V2 was asked how the facility could ensure that R14 could still safely swallow medications and foods since her choking incident, V2 stated, We don't know that she can. The facility's Foreign Body Airway Obstruction Management (Choking) policy dated 5/30/23 showed, Residents with impaired swallowing, neurological disorders or dental issues are at an increased risk for foreign body airway obstruction . Residents should be assessed to determine if they are at a higher risk for foreign body obstruction/choking episodes and care planned accordingly. Consult the speech language pathologist as needed . 2. R42's care plan current care plan showed R42 was at risk for falls due to his diagnoses of impaired cognition related to dementia, weakness, hypotension (low blood pressure), and anxiety. The care plan showed R42 had three unwitnessed falls in the facility, from 2/9/24-5/20/24, because of R42 trying to self-transfer. R42's resident assessment dated [DATE] showed R42 required partial to moderate assistance of staff for toileting and transfers. On 5/20/24 at 8:55 AM, R42 was seated on the toilet in his bathroom with no staff present in R42's room or bathroom. At 9:00 AM, V7 (Certified Nursing Assistant/CNA) entered R42's room to check on R42. From 9:00 AM-9:15 AM, V7 CNA stood outside the bathroom door as R42 remained on the toilet. At 9:20 AM, V7 transferred R42 from the toilet to his wheelchair by holding onto R42's arms. No gait belt was used. On 5/21/24 at 8:49 AM, V8 (CNA) stated R42 should not be left alone on the toilet because he is at risk for falls. V8 stated staff are use a gait belt on any resident that needs assistance from staff to transfer or ambulate. On 5/21/24 at 8:56 AM, V4 (Licensed Practical Nurse) stated, (R42) should not be left alone in the bathroom. He tends to wander and get up on his own.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to perform peri care in a manner to prevent urinary tract infections for one of six residents (R1) reviewed for peri care in the sample of 14. The findings include: R1's admission Record shows she was admitted to the facility on [DATE] with diagnoses including dementia, influenza, pneumonia, psychotic disorder, muscle wasting, obesity, fluid overload, weakness, and history of falling. R1's Care Plan initiated November 29, 2023 shows the resident uses disposable briefs. Change every two hours and as needed. On May 20, 2024 at 12:57 PM, V9 and V10 (Certified Nursing Assistants/CNA) provided incontinence care for R1. R1's incontinence brief was saturated with urine and a large amount of stool. V10 CNA wiped a large amount of stool from R1's buttocks with a thin wet wipe. R1's stool was visible through the wet wipe. V10 folded the wet wipe in half and wiped R1's stool from her buttocks again. V10 folded the wet wipe a second time and wiped the stool from R1's buttocks with the same wipe a third time. R1 was turned onto her back. V9 wiped stool from R1's front peri area. V9 folded the wet wipe three times and wiped R1 four times with the same wet wipe prior to disposing of the wet wipe. On May 22, 2024 at 8:30 AM, V11 (CNA) said if stool is noted on a wet wipe, then it should be disposed of and a new wet wipe should be used. On May 21, 2024 at 10:17 AM, V2 (Director of Nursing) said wet wipes can be folded during incontinence care unless there is a large amount of stool. V2 said if there is a large amount of stool, then one wipe should be used and then thrown away and use a new wipe in order to prevent the spread of infection. The facility's Perineal Care policy reviewed May 20, 2024 shows, It is the practice of this facility to provide perineal care to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown. If perineum is grossly soiled, turn resident on side, remove any fecal material with toilet paper, then remove and discard. Cleanse buttocks and anus, front to back; vagina to anus in females, scrotum to anus in males, using a separate washcloth or wipes.

Based on observation, interview, and record review the facility failed to measure the external length of a peripherally inserted central catheter (PICC) for 1 of 2 residents (R52) reviewed for intravenous (IV) access in the sample of 14. The findings include: R52's Hospital Discharge Instructions dated 4/26/24 showed R52 had a PICC line placed to receive antibiotics for osteomyelitis (bone infection). On 05/20/24 at 12:30 PM, R52 had a PICC line to her right upper arm. R52 said she had a bone infection in her back and was getting IV antibiotics. R52 said the facility had been doing weekly dressing changes to her PICC line. However, R52 said she did not believe the facility was measuring the external length of the PICC. On 05/21/24 at 11:39 AM, V2 (Director of Nursing) said PICC measurements are done to see if the PICC has migrated. V2 added the measurements are documented in the Treatment Administration Record (TAR). R52's TAR showed the PICC dressing was changed 5/2/24, 5/9/24, and 5/16/24. There was no documented PICC measurements on the TAR. The facility's PICC/Midline/CVAD Dressing Change policy with a reviewed date of 5/20/24 showed measuring the external length of the PICC is done to ensure that it has not migrated and should be done with the weekly dressing changes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to perform hand hygiene and change their gloves in a manner to prevent cross contamination for one of 14 residents (R1) reviewed for infection control in the sample of 14. The findings include: R1's admission Record shows she was admitted to the facility on [DATE] with diagnoses including dementia, influenza, pneumonia, psychotic disorder, muscle wasting, obesity, fluid overload, weakness, and history of falling. R1's Care Plan initiated November 29, 2023 shows the resident uses disposable briefs. Change every two hours and as needed. On May 20, 2024 at 12:57 PM, V9 and V10 (Certified Nursing Assistants/CNA) provided incontinence care for R1. R1's incontinence brief was saturated with urine and a large amount of stool. R1 was laying on her back when V10 folded R1's incontinence brief in between her legs. There was stool noted to R1's front peri area. V10 then touched R1's body to help her to turn onto her right side. V10 did not change her gloves or perform hand hygiene prior to touching R1 body to help her turn. V10 then wiped the large amount of stool from R1's buttocks. V10 then helped R1 to turn onto her left side by touching her body. V10 did not change her gloves or perform hand hygiene prior to assisting R1 to turn. On May 22, 2024 at 8:30 AM, V11 (CNA) said glove should be changed after touching bodily fluids to prevent cross contamination. The facility's Hand Hygiene policy reviewed May 20, 2024 shows, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. The facility's Hand Hygiene Table shows either soap and water or alcohol-based hand rub should be used after handling contaminated objects.

Based on observation, interview, and record review the facility failed to provide residents receiving puree diets with smooth consistency to 5 of 5 residents (R15, R6, R18, R20, R25) receiving pureed diets in the sample of 14. The findings include: The Facility provided a document entitled Diet Type Report, dated 5/20/24 show R15, R6, R18, R20, and R25 were receiving pureed textured diet. On 5/20/24 at 11:50 AM, the facility provided a test tray of puree diets that included pureed lasagna, pureed garlic bread, and pureed mixed vegetables. The pureed garlic bread was thick, chunky, and clumpy, and the pureed mixed vegetables was watery, and required chewing. V15 (Dietary Manager) who was with the surveyor during the test tray process also tasted the pureed test tray. After tasting, V15 pointed to the pureed garlic bread and stated, this is so thick, it needs more liquid to get the texture of a mashed potato. V15 said the pureed mixed vegetables can be thickened and needed to be smoother. Pureed foods should be smooth in consistency. On 5/20/2024 at 11:00 AM, V16 (Cook) said a puree texture should be similar to the mashed potato consistency. The facility policy entitled Puree Food Preparation dated 2/22/23 show It is the policy of this facility to provide puree food that has been prepared in a manner to conserve nutritive value, palatable flavor and attractive in appearance. Puree means that all food has been ground, pressed and/or strained to a consistency of a soft, smooth thick paste similar to a thick pudding. 2. Puree foods should be prepared in such a manner to prevent lumps or chunks, the goal is soft, smooth similar to a soft mashed potato.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a physician was notified of a change in condition for 1 of 3 residents (R25) reviewed for hospitalizations in the sample of 15. The findings include: R25's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include systolic congestive heart failure, acute eosinophilic pneumonia, personal history of COVID-19, paroxysmal atrial fibrillation, and hypertension. R25's facility assessment dated [DATE] showed she has severe cognitive impairment and extensive assist for most cares. On 7/13/23 at 9:59 AM, R25 was in common area sitting in her wheelchair, covered with a blanket, and resting with her head down. R25's acute care hospital documents dated 6/15/23 showed she was admitted to the hospital on [DATE] and discharged back to the facility on 6/15/23. The same documents showed, . presented to the hospital on 6/7 from nursing home with cough, chills, shortness of breath . Patient was subsequently admitted to the hospital for pneumonia . R25's 5/30/23 eMAR (electronic medication administration record) entered at 9:34 AM showed, Acetaminophen 500 mg given for complaint of lower back pain. R25's 5/30/23 eMAR note entered at 4:41 PM showed, Guaifenesin Liquid (Cough Syrup) 100 mg . resident requested for cough. R25's 6/3/23 eMAR note entered at 5:00 PM showed, Acetaminophen 500 mg . complains of headache and all over aches. R25's 6/4/23 eMAR note entered at 3:22 AM showed, Acetaminophen 500 mg . complains of aches all over. R25's 6/4/23 eMAR note entered at 10:30 AM showed, Guaifenesin Liquid (Cough Syrup) 100 mg . Resident has a nonproductive cough . R25's 6/4/23 eMAR note entered at 10:30 AM showed, Acetaminophen 500 mg . Resident requested for overall feeling of general discomfort . R25's 6/4/23 Health Status Note entered at 7:20 PM showed, Resident complains of overall general feeling of discomfort today. Overall general appearance lethargic, poor appetite. Has nonproductive cough . PRN (as needed) APAP (acetaminophen) given, and cough syrup given . will continue to monitor. R25's 6/5/23 eMAR note entered at 10:02 AM showed, Acetaminophen 500 mg Resident complains of overall general discomfort. 'I just don't feel good today.' R25's 6/5/23 eMAR note entered at 10:03 AM showed, Guaifenesin Liquid (Cough Syrup) 100 mg . Resident has nonproductive cough. R25's 6/6/23 eMAR note entered at 9:39 AM showed, Acetaminophen 500 mg . Resident requested for join pain. R25's 6/6/23 eMAR note entered at 9:55 AM showed, Guaifenesin Liquid (Cough Syrup) 100 mg . nonproductive cough. R25's 6/6/23 eMAR note entered at 5:20 PM showed, Guaifenesin Liquid (Cough Syrup) 100 mg . resident requested for cough. R25's 6/7/23 Health Status Note entered at 11:07 AM, Resident requesting to go to the ER (emergency room) as she is feeling weak, cough and SOB (shortness of breath). Resident requests I call daughter in law and ask what she thinks . ambulance called for transport to [acute care hospital] . R25's 6/7/23 progress note showed, Situation: . Shortness of breath . Nursing observations, evaluation, and recommendations are Resident is talking slowly due to her feeling SOB . nonproductive cough and sitting with eyes closed . On 7/13/23 at 10:01 AM, V3 (Registered Nurse/RN) said the nurses should notify the provider if there is a change in the resident's treatment. V3 said they notify the physician through their electronic medical record unless they are notifying the physician of something urgent which they would call to the physician. On 7/13/23 at 10:10 AM, V6 (RN) said she sent R25 to the hospital when assessed her and heard fluid on her lungs. V6 said R25's general overall appearance was poor; she was pale and withdrawn. V6 said they call the physician if there is a significant change in a resident but for non-urgent notifications, they use the electronic record to notify. V6 said there was no documentation of notification to R25's physician between 5/11/23 and 6/7/23. On 7/13/23 at 10:49 AM, V2 (Director of Nursing) said if the nurse notes a change of condition, it is determined on a case-by-case situation if the physician is notified. If a resident starts to not feel well the nurse should do an assessment which would include vitals, lung sounds, all of it and then if they are depending upon the assessment, you will notify the physician or monitor the resident. V2 said if the resident's condition continues to get worse the nurse would notify the physician. V2 said the nurse should have started a notification to the physician to say the resident is using the Tylenol and cough syrup when she started taking them regularly. V2 said the 6/4/23 Health Status Note should have been a notification to the physician so the physician would be aware of the resident's complaints, the medications given, and the nurse's assessment. The facility's policy implemented 2/1/22 titled Notification of Changes showed, . the purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notified, consistent with his or her authority, the resident's representative when there is a change requiring notification . Compliance Guidelines: The facility must inform the resident, consult with the resident's physician, and/or notify the resident's facility member or legal representative when there is a change requiring notification. Circumstances requiring notification include . 2. Significant change in the resident's physical, mental or psychosocial condition such as a deterioration in health . 3. Circumstances that require a need to alter treatment. This may include. new treatment .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assess an area of pressure after one was identified for 2 of 4 residents (R20, R48) reviewed for pressure in the sample of 15. The findings include: The facility's 2/1/22 Pressure Injury Prevention and Management Policy showed the facility shall establish and utilize a systemic approach for pressure injury prevention and management, including prompt assessment. Assessments of pressure injuries will be performed by a licensed nurse and documented. 1. R48's face sheet showed an [AGE] year-old female with diagnosis of psychotic disorder, dementia, osteoarthritis, and muscle weakness. On 7/12/23 at 9:43 AM, V3 (Wound Nurse) performed wound care to R48's left heel wound. R48 complained of severe pain when the wound was cleaned and general pain aside from the wound itself. There was an oval shaped open area to the left lateral heel. The wound edges were very pale and well defined. Moderate serous drainage was noted from the wound. There was no odor and the wound measured approximately 1.5 centimeters X 1 centimeter with some depth. On 7/13/23 at 9:56 AM, V2 (Director of Nursing/DON) said R48's wound was found on 3/10/23 and a full wound assessment was not done. An initial wound assessment should include the location, color, shape, size, a description of the area around the wound, any odor, drainage, and if the skin is intact. A wound assessment should be done when it's found to establish a baseline to measure progression or improvement by. V2 said an assessment could be done by briefly visualizing the wound and noting any odor. The facility's 7/10/23 weekly wound report showed R48 had a Stage 3 (previous DTI-deep tissue injury) to the left outer heel that was facility acquired on 3/10/23. R48's 3/10/23 weekly skin assessment showed a small painful discolored area to the left outer heel. R48's first wound assessment dated [DATE] showed the wound was acquired 5/22/23 and was initially a suspected deep tissue injury and currently a Stage 2 pressure injury. This assessment showed it was the initial assessment and there was no previous assessment for reference. R48's 7/10/23 weekly wound assessment showed the left heel wound progressed to a Stage 4 pressure injury. R48's 6/6/23 facility assessment showed she was not cognitively intact and required extensive assistance of two plus persons physical assistance for bed mobility, transfers, toilet use, personal hygiene, and bathing. R48's care plan showed an alteration in skin integrity related to fragile skin as evidenced by a Stage 2 pressure injury to the coccyx on admission, a healed deep tissue injury to the sacrum that healed 5/29/23, and a Stage 3 pressure injury to the left outer heel (current). The National Institutes of Health website showed a wound assessment standard includes evaluation of the depth, length, and width of the wound. Evaluation of the wound bed for exposed bone, vessels, hardware, or subcutaneous fat. Survey for presence, type, and amount of exudate (drainage). Assess surrounding skin tissue for signs of injury. Check the wound margins. Evaluate for warmth, pain, odor, purulence, delayed healing, or other signs of infection. 2. R20's face sheet showed a [AGE] year-old female with diagnosis of dementia, acquired absence of left toe, osteomyelitis of the left foot and ankle, heart attack, dementia, and chronic kidney disease Stage 3. On 7/12/23 at 9:17 AM, V3 (Wound Nurse) performed a dressing change to R20's left medial ankle. The open area was circular, pale, and approximately 1 centimeter in diameter with some depth. There was a moderate amount of serous drainage which caused the dressing to come off in her stocking. There was no foul odor, and the wound edges were well defined. R20 tolerated the procedure without complaints of pain. On 7/13/23 at 9:56 AM, V2 (DON) said R20's pressure injury started out as a teeny tiny scab. I found it on 6/16/23 at 4:00 PM. It was on her left inner ankle. I had the wound nurse do full wound assessment on Monday morning (6/19/23). A full wound assessment should be done when a wound is identified. R20's 5/12/22 admission assessment does not show any impairment of skin integrity. R20's 5/20/22 pressure injury risk assessment showed she was at risk for developing pressure injuries. The facility's 7/10/23 weekly wound report showed R20 had a Stage 2 pressure injury to the left medial ankle that was facility acquired on 6/19/23 (wound was identified 6/16/23). R20's 6/16/23 weekly skin assessment authored by V2 (DON) showed an old scab to the left inner ankle. There was no wound assessment documented. R20's 6/19/23 weekly wound assessment showed a left medial ankle wound assessment was not completed until 3 days after identification. This assessment showed the pressure injury was a Stage 2. R20's 7/10/23 weekly wound observation showed the left medial ankle wound had progressed to a Stage 3. R20's care plan showed she was at risk for impaired skin integrity and had a Stage 2 pressure injury to the left ankle and a healed Stage 3 pressure injury to the left heel. R20's 5/21/23 facility assessment showed she was not cognitively intact and required extensive assistance of two plus persons physical assistance for bed mobility, transfer, toilet use, and personal hygiene. This assessment showed R20 was at risk for developing pressure injuries and did not have any unhealed pressure injuries.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure fall prevention interventions were in place for a resident at risk for falls for 1 of 4 residents (R54) reviewed for falls in the sample of 15. The findings include: R54's face sheet showed a [AGE] year-old female admitted to the facility on [DATE]. R54's diagnosis included a history of falling, dementia, physical debility, and polyosteoarthritis. On 7/13/23 at 09:49 AM, R54 was sitting in a high back reclining chair in the hall area outside her room. No staff were present. R54 was leaning and reaching forward. V9 (Certified Nursing Assistant/CNA) came down hall and saw R54 leaning for and reaching forward while in the chair. R54's chair pad alarm was disconnected thus inoperable. The wire was not connected to the transmittal box. On 7/13/23 at 9:49 AM, V9 said if the cord isn't plugged into the transmitter, it won't work. It won't alarm if she (R54) tries to get up. On 7/13/23 at 9:56 AM, V2 (Director of Nursing/DON) said it's important that fall interventions are in place and working to prevent falls, injury, and harm to the residents. R54 was in a wheelchair when she fell (forward out of the chair) in the chapel. Since R54's admission on [DATE], there were 4 fall incidents documented. R54's 5/17/23 fall incident showed she was found in her room, lying on her back in front of a recliner. R54's 5/23/23 fall incident showed she was in the chapel with other residents and a volunteer. All four resident witness statements showed R54 fell forward out of the chair and on to the floor. This report showed R54 complained of pain to the right shoulder and right elbow. R54 had a skin tear to the right elbow and a lump to the right shoulder. R54 was sent to the emergency room. Xray records showed a fracture to the right upper extremity and right pubis ramus. R54's 6/20/23 fall incident showed she was found in her room laying on the floor on her back in front of a recliner. R54's 7/7/23 fall incident showed R54 was found sitting on the floor next to the wheelchair in the hallway where her room was located. R54's care plan showed she was at risk for falls and to utilize a bed/chair alarm. R54's 5/15/23 facility assessment showed she was not cognitively intact. The facility's 9/2/22 Fall Prevention Policy showed the nurse will initiate interventions on the care plan.