Based on observation, interview and record review the facility failed to provide ordered interventions to prevent the development of deep tissue injuries and worsening of a pressure injury and failed to provide weekly measurements and assessments for pressure injuries for four of five residents (R10, R47, R39 and R53) reviewed for pressure injuries from a total sample list of 33. These failures resulted in R10 and R47 developing deep tissue injuries and R47's unstageable pressure injury worsening. Findings include: The facility provided Prevention of Pressure Ulcers Policy dated August 2008 documents that the purpose of this procedure is to provide information regarding identification of pressure ulcer risk factors and intervention for specific risk factors. When in bed, every attempt should be made to float heels by placing a pillow from knee to ankle or with other devices as recommended by the physician. Additional factors that increase risk of pressure injuries include a healed ulcer. 1.) R10's care plan dated 4/20/22 documents that R10 is at risk for pressure ulcer development due to decreased strength and mobility and that the facility is to ensure that R10 wears heel boots to decrease the potential for pressure injury. The facility weekly pressure ulcer wound report dated April 26, 2024 documents an unstageable, left heel wound resolved for R10. On 6/11/24 at 1:15PM, R10 was observed laying in bed, without heel protectors or any type mechanism to float R10's heels. On 6/11/24 at 1:17PM, V2 Director of Nursing said that R10's right heel is boggy, and is developing a new deep tissue injury. On 6/12/24 at 8:30AM, V2 Director of Nursing said that R10 was supposed to have heel protectors on while in bed because she had a history of deep tissue injuries. On 6/12/24 at 8:45AM, V39 Licensed Practical Nurse said that the likely reason for R10's deep tissue wound is because her heels aren't being protected. I've seen her in bed a couple of times without her heel protectors on. On 6/12/24 at 8:50AM, V15 Certified Nursing Assistant stated, Yesterday (R10) didn't have her heel protectors on and she should have had them on. 2.) R47's physician orders dated 4/24/24 document an unstageable left heel pressure injury. R47's physician orders dated 9/30/23 document to ensure that heel protector boots are on while in bed. On 6/11/24 at 2:00PM, R47 was laying in bed without wearing protective heel coverings. On 6/12/24 at 8:30AM, R47 was sitting in her chair wearing non-slip socks, resting on the floor. R47's left foot had a scab on it and R47's right heel was turning light purple and was boggy, as with a deep tissue injury. The Weekly Wound Report dated 5/20/24 documents R47's left heel unstageable injury measures 0.2 centimeters (cm) x 0.7 cm x 0.4 cm. The Weekly Wound Report dated 5/27/24 documents R47's left heel unstageable injury measures 0.5cm x 1 cm x 0.7 cm and declining. The Weekly Wound Report dated 6/3/24 documents R47's left heel unstageable injury is measured at 0.7cm. No other measurements were taken, nor evaluation of the wound made. On 6/12/24 at 9:00AM, V2 Director of Nursing said that he was unaware of a new deep tissue injury on R47's right foot and that as his wound nurse had left the facility, he was trying to fill in as best that he could. On 6/12/24 at 8:45AM, V39 Licensed Practical Nurse said that the likely reason for R47's deep tissue wound is because her heels aren't being protected. I've seen her in bed a couple of times without her heel protectors on. On 6/12/24 at 12:22PM, V24 Nurse Practitioner said that if the interventions aren't put into place such as the heel protectors, the wounds will continue to worsen and I would expect both (R10 and R47) to be wearing (heel protectors) in bed as well as being monitored weekly. 3.) R53's electronic medical record documents diagnoses including Congestive Heart Failure, Acute and Chronic Respiratory Failure. R53's Physician's Orders dated 6/12/24 document orders for a Stage 3 pressure to the Sacrum, cleanse with wound cleanser, pat dry, apply a hydrocolloid wound dressing and cover with a bordered foam dressing. R53's Skin and Wound Evaluation dated 4/22/24 documents a new area to the Sacrum measuring 2.9 cm (centimeters) x (by) 3.5 cm x 1.3 cm and is documented as MASD (Moisture Associated Skin Damage) due to Incontinence Associated Dermatitis. R53's medical record has no further measurements or assessments of the area to the Sacrum until 5/2/24. R53's Skin and Wound Evaluation dated 5/2/24 documents a Stage 3 pressure wound to the Sacrum with no measurements of the area. The next Skin and Wound Evaluation is dated 5/17/24, 15 days later, and the area is documented as an Unstageable pressure wound to the Sacrum measuring 1.8 cm x 4.9 cm x 2.9 cm. R53's medical record documents two Skin and Wound Evaluations dated 5/23/24 for the pressure wound on the Sacrum. One assessment documents measurements of 5.7 cm x 4.5 cm x 1.8 cm and the other Skin and Wound Evaluation dated 5/23/24 documents measurements of the wound on the Sacrum as 2.0 cm x 2.7 cm x 1.1 cm. There is no explanation as to why there are two different assessments of the same area for R53 on 5/23/24. R53's Skin and Wound Evaluation dated 5/30/24 does not have any measurements of the pressure wound on the Sacrum. The next measurements for R53's pressure wound on the Sacrum are 14 days later on 6/6/24. R53's Skin and Wound Evaluation dated 6/6/24 documents measurements of the pressure wound on the Sacrum as 0.9 cm x 1.5 cm x 0.8 cm. On 6/12/24 at 11:25 AM, V2 Director of Nursing confirmed there were missing weekly assessments and could not explain why they were missing. V2 stated that their wound nurse is no longer with them. V2 stated that the wound logs that he has, document on 5/4/24 and on 5/30/24 that the nurse was unable to measure the wound but V2 stated there is no documented reason as to why they were not able to get measurements of the pressure wound on R53's Sacrum on those dates. On 6/12/24 at 11:55 AM, V29 Licensed Practical Nurse completed a wound treatment on R53's pressure wound to the Sacrum. The area was bright red and approximately 1 cm around. R53 was laying in bed on a low air loss mattress with a pillow under her right hip and the head of the bed elevated slightly. 4.) R39's Care Plan dated 4/23/24 documents diagnoses including Type 2 Diabetes Mellitus with Diabetic Neuropathy and Nutritional Deficiency. R39's Skin and Wound Evaluation dated 4/30/24 documents measurements of an unidentified wound as 0.3 cm x 0.9 cm x 0.5 cm. This wound assessment does not document what type of wound it is or where the wound is located or any other assessment of the wound. R39's Treatment Administration Record (TAR) dated 5/1/24 through 5/30/24 documents an order for a Stage 2 wound to the Coccyx and to cleanse with wound cleanser, pat dry, apply a hydrocolloid wound dressing and cover with a bordered foam dressing once a day every three days for wound management with a start date of 5/2/24. R39's medical record does not document any other wound assessments or measurements of the area on the Coccyx. On 6/10/24 at 10:02 AM, R39 was in her room in her recliner with her feet elevated. R39 stated that she has a wound on her bottom and has an extra cushion in her recliner. On 6/10/24 at 10:11 AM, V29 Licensed Practical Nurse stated that R39 has a pressure ulcer on her Coccyx. On 6/12/24 at 11:25 AM, V2 Director of Nursing confirmed there were no other measurements besides the ones on 4/30/24 for R39's wound on her Coccyx.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to prevent injuries from multiple mechanical lift transfers (R10) and failed to supervise a dementia resident to prevent an elopement (R56) for two of two of residents reviewed for accidents from a total sample list of 33 residents. Failing to safely transfer R10 using the mechanical lift resulted in R10 suffering skin tears to bilateral legs. Findings include: 1.) On 6/11/24 at 1:15PM, R10's bilateral shins have open areas, with dried, blood soaked dressings approximately the size of a knee cap covering the tears. The facility skin and wound evaluation dated 4/24/24 documents a new skin tear on R10's right front shin. No new interventions were documented in the medical record after this skin tear occurred. The facility risk evaluation dated 5/3/24 documents a new skin tear on R10's left shin caused by the mechanical lift hitting R10's legs. The facility weekly wound report-non pressure dated 5/27/24 documents a left shin skin tear and nothing about a right shin skin tear. On 6/12/24 at 8:20AM, V2 Director Of Nursing said that the cause of R10's skin tears on her shins was from the mechanical lift hitting her legs during transfer. We wrapped the mechanical lift to prevent it from happening again. 2.) R56's undated Face Sheet documents R56's medical diagnoses as Dementia, Cognitive Communication Deficit, Senile Degeneration of Brain and history of falls. R56's Minimum Data Set (MDS) dated [DATE] documents R56 as severely cognitively impaired. This same MDS documents R56 as requiring maximum assistance for bed mobility, transfers, toileting, bathing, dressing and transfers. R56's Initial Report to the State Agency dated 6/10/24 documents (R56) was witnessed by (V7) Medical Records sitting out the back door by (V20's) Visitor's car. (V20) had propped the back door open to unload a piece of furniture. On 6/10/24 at 3:21 PM R56 was sitting in a wheelchair in the loading area beyond the facility sidewalk next to V20's car. R56 had removed her own foot pedals and was holding them in her lap. R56 was sitting next to V20's back passenger car door. On 6/10/24 at 3:20 PM V20 (R14) visitor reported that R56 had followed him out of the facility and into the parking lot waiting for a ride home. V20 stated he had paused the alarm on the back sliding doors so that he could bring items in and out of facility for R14. V20 stated (R56) must have followed me out. She said she is waiting for a ride home. I don't think I am supposed to do that. I don't think (R56) should be loose. On 6/10/24 at 3:30 PM V1 Administrator stated V20 (R14's) visitor held the back sliding doors open which allowed R56 to wheel herself out of the facility unnoticed. V1 stated either way the staff should have been watching more closely. V1 stated R56 has little safety awareness and she should not be out of the facility unattended. V1 Administrator stated the facility policy on Elopements only covers what to do after someone is found to be missing. V1 stated the facility does not have a separate policy to instruct staff to monitor residents. V1 Administrator stated That is just standard of care. Our staff should know to supervise residents when a door is left open.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a safe transfer and implement a pressure relieving intervention to prevent pressure wounds for two (R29 and R23) of seven residents reviewed for pressure sores from a total sample list of 39. These failures resulted in R29 developing an unstageable pressure sore and R23 developing a deep tissue injury. Findings include: 1.) R29's undated diagnoses sheet documents diagnoses including pulmonary emboli, muscle contractures, Parkinson's Disease, hypertension, depression, hemiplegia and hemiparesis of the right side and Lewy Body dementia. R29's care plan identifies R29 as at risk for skin integrity due to fragile skin, incontinence, and poor mobility. The interventions listed include using caution during transfer and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. R29's Minimum Data Set, dated [DATE] documents R29 as totally dependent for transfers with lower extremity impairment bilaterally requiring a mechanical lift and the assistance of two persons. R29's Minimum Data Set, dated [DATE] documents R29 as moderately cognitively intact. On 5/15/23 at 10:30AM, R29 stated that his toes hurt, pointing to his left foot. The facility provided weekly pressure ulcer wound report dated 5/7/23 to 5/13/23 documents R23 acquired a 1.0 centimeter by 0.6-centimeter unstageable wound to his left great toe on 5/4/23. On 5/16/23 at 3:27PM, R29 was sitting up in a reclining, positioning chair wearing socks. Upon dressing change, the side of the left great toe was noted to have a scab that was black in color and dime sized. On 5/17/23 at 9:53AM, V9 (Certified Nursing Assistant/CNA) stated, R29 got his wound on his toe because they (staff) hit his toe on the (mechanical lift). You have to go slow with these people, or they get hurt. On 5/17/23 at 11:55AM, V15 (Nurse Practitioner/NP) said that when a (mechanical lift) hits the skin with force, it can obviously cause a wound. On 5/17/23 at 10:00AM, V2 (Director of Nursing/DON) stated, I'm not gonna lie, it could have been prevented. We need to do some education. 2.) R23's undated diagnosis sheet documents that R23 was admitted on [DATE] for skilled therapy following a hospitalization for repair of a right hip fracture with the following diagnoses: Right Hip Fracture, Dementia, Anemia, Anxiety, Depression, Arthritis, Coronary Artery Disease, Asthma, Hypothyroidism, Kidney disease, Overactive bladder, Obesity, and Vitamin D deficiency. R23 requires a mechanical lift and two assist for transfers. R23's skilled evaluation dated 10/31/22 documents R23 has lower extremity impairment bilaterally, for range of motion. The facility provided weekly pressure ulcer wound report dated 11/4/22 documents R23's deep tissue injury was identified on 10/19/22 on the right heel sized 17.1 centimeters by 4.3 centimeters by 5.2 centimeters with a treatment order to use liquid silicone barrier wipes on the heel. On 5/17/23 at 9:53AM, R23's heel was reddened with a scab running vertically with the foot. Iodine was also noted on the heel with a boggy appearance. On 5/17/23 at 9:54AM, V9 (CNA) said, R23's right heel was open but now it is just red. It wasn't being floated when she got the wound. On 5/17/23 at 10:05AM, V2 (DON) stated, R23 came to us with a broken right hip, and she couldn't really move. Her heels didn't get floated like they should have been. The (deep tissue injury) wound happened and then it opened and yes, it was preventable. On 5/17/23 at 11:48AM, V15 (NP) said that when a resident's heels are not floated and they rest on the bed, the likely result is preventable wounds.

Based on observation, interview, and record review, the facility failed to prevent a fall for one (R18) of five residents reviewed for accidents on the sample list of 39. This failure resulted in R18 sustaining a right hip fracture requiring surgical intervention. Findings include: R18's Fall Risk Care plan with an initiation date of 10/19/21 documents R18 is at risk for falls due to history of falls, confusion, gait, and balance problems, and R18 is unaware of safety needs. On 5/15/23 at 11:20 AM, R18 was sitting in a wheelchair in the doorway. When asked if R18 has fallen, R18 rubbed the top of her right leg and stated she has broken her leg. R18's Nurse's Notes dated 1/10/2023 at 9:09 PM document, Nurse was at desk and heard sounds of something falling. Then heard (R18) yell help. When entered room (R18) was sitting at foot of bed yelling my hip is broke my hip is broke. (R18's) right leg had external rotation. (R18) stated she heard the phone ring and had to get up and answer it. (R18) was holding her portable in her hand. This note also documents R18 was sent to the emergency room for evaluation. R18's Nurse's note dated 1/11/23 at 12:06 AM, documents R18 was admitted to the hospital with a Right Intertrochanteric fracture. R18's Radiology report dated 1/10/23 documents R18 had pain in right hip after a fall. This report documents R18 has an Intertrochanteric hip fracture. R18's Surgical report dated 1/13/23 documents R18's fracture was surgically repaired. R18's Post Fall Evaluation form dated 1/10/2023 at 8:15 PM documents R18's fall was not witnessed and occurred in the Resident's room. The form documents the activity at the time of fall was self-transferring. This form documents the reason for the fall as going to answer the phone. This form documents, a right hip injury resulted due to the fall. This form documents an intervention to place phone within reach. On 5/16/23 at 11:01 AM, V2 (Director of Nursing/DON) walked down to R18's room. V2 stated after R18's fall on 1/10/23 they moved R18's bedside table from the corner of the room to the side of R18's bed so that she could reach her phone. V2 stated her phone was on her nightstand in the corner of the room when she fell on 1/10/23. V2 stated the root cause of the fall was that she tried to get up out of bed to answer the phone and could not reach it and fell. At that time, R18's phone was sitting on the edge of R18's bedside table and was within reach. R18's bed was place near the middle of the room and the corner of the room was approximately five feet from the corner of the room.

Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to maintain a safe environment free of tripping and pooling water floor hazards in a resident room. This failure affects one of six residents (R162) reviewed falls/accident hazards on the sample list of 30. Findings include: R162's Diagnoses Sheet dated 6/3/22 documents the following diagnoses: Aftercare Following Joint Surgery, Major Joint Replacement, primary diagnosis on Presence of Left Artificial Knee Joint, Insomnia, Primary Osteoarthritis of Knee, and Acute Posthemorrhagic Anemia. R162's Physician Order Sheet dated as Last Order Review: 6/9/2022, documents the following: Monitor surgical incision to left lower extremity, up walking frequently, Clarification: Skilled Occupational Therapy five times a week, for four weeks including self-care, neurological reeducation, manual therapy, group therapy, therapeutic exercises, and therapeutic activities, (and) Clarification: Skilled Physical Therapy five times a week, for four weeks including therapeutic exercise, therapeutic activities, gait training, manual therapy, neuromuscular reeducation, and group therapy. R162 Minimum Data Set, dated [DATE] documents the following: R162's Brief Interview of Mental Status score of 15 out of possible 15, indicating no cognitive Impairment. R162's Care Plan documents: Problem; R162 is at risk for falls related to Left Total Knee Replacement, deconditioning, new environment, use of pain medications, balance deficits, multifocal Cerebrovascular Accident post-operatively and blood loss Anemia. Interventions include: Maintain a clear pathway in room, free of obstacles. On 06/14/22 at 12:20 pm, R162's bedroom floor had a three-feet long, by four feet wide puddle of water standing in front of R162's recliner chair, and next to R162's bed. There was a three gallon cooler sitting on the floor. The cooler was sitting in the puddle of water with a two inch tube attached to a cooler knee pad. The two-inch tubing extended from a knee pad laying on top of the cooler, down to the floor, and was coiled at the base of the cooler. The coiled tubing on the floor spanned eighteen inches, surrounded by the puddle of water. V10 (Registered Nurse/RN) stated That is a tripping hazard. The (cold therapy system) cooler comes from the hospital and fits on the knee. We need to figure out a safer way for her to use that (cold therapy system) without creating a mess on the floor she (R162) could slip in. On 06/14/22 at 12:25 pm, R162 ambulated with a front wheeled walker, out of the bathroom. R162 stopped walking one foot away from the puddle of water on the floor, in front of R162's recliner chair. R162 stated Oh that is scary. The last thing I (R162) want to do is fall. I (R162) have never fallen before. At my age I (R162) don't want to start now. I have told staff several times this cooler (cold therapy system) leaks. They tell me it is just condensation. I think a beach towel under the darn thing might help the condensation. Staff tell me to just put on my call light. I don't always see the puddles until I get up to walk somewhere. They (staff) should be watching. There are times I (R162) have said something and the nurses don't do anything about it. I (R162) just elected to have a knee replacement (shows left knee wound dressing) so I can continue to live an active life. I (R162) go to the (community fitness center), Bingo, and aerobic classes to stay fit. I think falling and breaking something would do me in at my age.