Based on interviews and record reviews, the facility failed to provide effective supervision to prevent an avoidable fall for one resident (R1) exhibiting increased confusion/agitation/wandering due to dementia. This affected one of three residents (R1) reviewed for fall prevention. This failure resulted in R1 being involved in a fall incident sustaining a right femur fracture. Findings include: R1's medical record notes R1 with diagnoses including, but not limited to, diabetes, unsteadiness on feet, abnormalities of gait and mobility, lack of coordination, and weakness. R1's MDS (minimum data set), dated 3/14/24, notes R1's BIMS (brief interview of mental status) score was 5 out of 15. R1 required partial assistance with bed mobility. R1 required substantial assistance with toileting, transfers, and bathing. Per CMS (Centers for Medicare and Medicaid Services) a BIMS score 0-7 notes severe cognitive impairment. R1's care plan, initiated 3/8/24, notes R1 is at risk for falls related to gangrene left toes, unsteadiness on feet, abnormalities of gait and mobility, lack of coordination, weakness, and reduced mobility. R1's physical therapy evaluation, dated 3/8/24, notes R1 presents with balance deficits, body awareness deficits, decreased static/dynamic balance, and strength impairments. On 5/15/24 at 2:05 PM, V5 (Rehabilitation Director) stated R1 was receiving physical therapy from 3/8/24 - 4/9/24. V5 stated R1 was able to walk with a front wheeled walker and contact guard assistance. V5 stated R1 was not able to walk without a walker. V5 stated R1 needed verbal cues for hand placement on walker with ambulation. On 5/15/24 at 2:30 PM, V4 CNA (certified nurse aide) stated V4 was working on the other wing of the nursing unit. V4 stated V4 went onto the wing R1 resides on and was looking for the lift device. V4 stated V4 observed the lift device halfway down the hall near R1's room and retrieved it. V4 stated V4 heard something as he was pushing the lift device near the nurses' station. V4 stated when he looked back, he saw R1 on the floor by a resident's door. V4 stated he was not sure if was R1's room or not. V4 stated he was not paying attention to the surroundings prior to R1's fall. V4 denied seeing a walker near R1. On 5/15/24 at 2:45 PM, V3 RN (registered nurse) stated on 4/10 about 8:00 PM, V3 heard a commotion and saw V4 CNA with R1. V3 stated R1 was laying on the floor halfway in another resident's room and halfway in hall. V3 stated V3 did not know R1 walked, R1 was usually in bed or wheelchair when V3 works. V3 stated on day R1 was more confused than usual. V3 stated R1 was looking for her brother. V3 stated prior to 4/10, R1 was alert and oriented x 1-2. V3 stated V3 was not informed by off-going nurse of R1's increased confusion. V3 stated prior to the fall, R1 was sitting in wheelchair in her room. V3 denied seeing a walker in R1's room or near R1 at time of fall. On 5/16/24 at 1:30 PM, V8 NP (nurse practitioner) stated residents have dementia and are experiencing hypoglycemia might not be able to tell staff how they are feeling. V8 stated with these residents must rely more on what resident exhibits. V8 stated these residents will exhibit agitation and increased confusion. V8 stated R1's blood sugar was low on 4/10, it was 37. V8 stated she held R1's insulin to see if R1's agitation and confusion would improve. V8 stated residents with dementia may also exhibit sundowning (increased confusion and restlessness) in the evenings. V8 stated R1's dementia, hypoglycemia, and sundowning contributed to R1's fall. On 5/16/24 at 2:40 PM, V7 CNA stated V7 worked 3:00 PM -11:00 PM shift on 4/10/24. V7 stated R1 was having more that confusion day. V7 stated earlier in shift, R1 was wandering on the nursing unit looking for her brother. V7 stated R1 was able to self-propel in wheelchair. V7 stated before dinner V3 RN instructed V7 to bring R1 to her room. When questioned if R1 preferred to eat meals in her room rather than in the dining room, V7 responded, No, it is just the routine. V7 denied R1 exhibiting any wandering behaviors prior to day. V7 stated V7 was just finishing his dinner break when another CNA got him and informed him R1 fell. V7 stated R1 stated she was looking for her son, R1 heard his voice and thought he was in the other room. V7 stated after V3 assessed R1, V3 instructed V7 to put R1 in bed. V7 denied seeing a walker in R1's room or near R1 at time of fall. R1's hospital medical record, Hospital record, dated 4/10/24-4/13/24, notes x-ray of R1's right hip shows an acute valgus (deformity in which an anatomical part is turned outward to an abnormal degree) impacted fracture of the right femoral neck. No evidence of dislocation. Mild degenerative changes in the hips. On 4/11/24, R1 was taken to surgery for repair of fracture. R1's medical record, dated 4/10/24 at 2:36pm, V6 LPN (licensed practical nurse) noted R1 has been confused and agitated since yesterday (4/9/24). R1's medical record, dated 4/10/24 at 2:45pm, V8 NP (nurse practitioner) notified by V6 LPN R1 has been confused and agitated since yesterday evening. R1 seen in dining room. Confused. Believes her sister/family members are in the room and need help. Needs frequent orientation as she is trying to get up. Glucose 37 (normal range is 70-99) on laboratory results this morning; point of care glucose 75 at 6:00 AM. Confusion likely related to hypoglycemia; will consider urinalysis if there is no improvement. R1's medical record, dated 4/10/24 at 7:40 PM, V3 RN noted V3 was about to pass bedtime medications when V3 found out from another CNA, V4, R1 was on the floor. Found out R1 was lying on her back in another resident's room. Both upper and lower extremities extended. R1's wheelchair was in R1's room and R1 walked alone going to the other resident's room. R1 was asked if she hit her head and she said yes but it's not painful. No injuries noted except for a small scratch on R1's elbow. Range of motion of both upper and lower extremities adequate. Physician was notified and ordered to send R1 to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide safe transfer with a full (mechanical) lift per care plan; failed to inform doctor of refusal in using the (mechanical) lift and failed to reassess for safe transfers for 1 (R1) of three residents (R1, R2, R3) reviewed for falls. This failure resulted to R1 sliding on the floor sustaining a fracture of the tibia/fibula. Findings include: R1's Facesheet indicates that R1 was admitted to the facility on [DATE] with diagnosis including but not limited to: Chronic Obstructive Pulmonary Disease, Emphysema, Chronic Respiratory Failure with Hypoxia and Hypercapnia, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Nondisplaced Oblique Fracture of the Shaft of Right Tibia, Venous Thrombosis and Embolism, Disorder of the Autonomic Nervous System, Irritable Bowel Syndrome, Pulmonary Blastomycosis, Urinary Tract Infection, Neurological Dysfunction of Bladder, Anxiety Disorder, Major Depressive Disorder, Agoraphobia with Panic Disorder, Other Cord Compression, Paraplegia, Essential Hypertension, Obesity, Obstructive Sleep Apnea, Gastroesophageal Reflux Disease without Esophagitis, Visual Hallucinations, Paranoid Disorder, and Age Related Osteoporosis without Pathologic Fracture. R1's Minimum Data Set with Assessment reference date of 12/31/2023 under Section C: Brief Interview for Mental Status (BIMS) documents a score of 13. (The BIMS assessment uses a points system that ranges from 0 to 15 points: 0 to 7 points suggests severe cognitive impairment. 8 to 12 points suggests moderate cognitive impairment. 13 to 15 points suggests that cognition is intact). On 1/26/2024 at 11:04 AM, R1 was observed in bed watching television. When asked what happened on 12/18/23, R1 stated, I had a fall. It happened after lunch, I wanted to get my hair cut. I haven't been out of bed for about 6 months, V5, the aide was helping to get up. V5 had me sitting at the edge of the bed and was standing to pivot when my legs buckled, and I ended up sitting on the floor. My right leg was under my body and my foot was flat and I heard the crack. I pulled out my foot slowly. V5 then called another CNA, V6. V6 picked me up and put me in the chair. From that point forward my leg was numb. In a case like that when I haven't been up for long time, we should have used the sit to stand. But I did get my hair cut that day. I fractured my shin. I gotta (sic) take responsibility for my stupidity, I should have known better but I wanted to get my hair cut. There's no one to blame for it. On 1/26/2024 at 1:22 PM, V5, Certified Nursing Assistant (CNA) stated, On 12/28/23, R1 had a hair appointment. She needs a (mechanical) lift for transfers but R1 refused to use the (mechanical) lift and she said she wanted to get up for the beauty shop. So, I got R1 ready, got R1 dressed and had R1 sit by the edge of the bed while I called another CNA for assistance. The R1 said she is dizzy and then she started sliding onto the floor. I held on to R1's gait belt and then she slid down on the floor. I informed V3, R1's nurse, that R1 refused to use the (mechanical) lift and V3 said that it's okay to transfer R1 with 2 person assist since she was refusing. When asked if V3 talked to R1 about dangers of not using the (mechanical) lift, V5 stated, V3 did not talk to R1 about it. V6, CNA, and V3 assisted R1 back to bed, with 3 person assist, we did not use the (mechanical) lift. On 1/26/2024 at 1:24 PM, R1 was interviewed again. R1 stated she did not refuse to use the (mechanical) lift and the (mechanical) lift was not offered for her to use. R1 stated, I have never used the (mechanical) lift. V5 did not have the Sit-to-Stand or (mechanical) Lift on 12/18/2023. We just didn't think to use it. I heard a crack on my bones when I fell on the floor. V5 and V6 assisted me to get up when I fell and put me back to the bed without using the (mechanical) lift. Progress Noted dated 12/18/2023 by V3, Registered Nurse documents in part: CNA (Certified Nursing Assistant) called NOD (Nurse on Duty) to informed (sic) that pt. (patient) slid to the floor during transfer (sic) resident to the wheelchair. NOD came to the resident room noted resident siting position on the floor next to the bed. Interview with V3, Registered Nurse, on 1/26/2023 at 1:20 pm was conducted. V3 stated, I was the nurse in charge of R1 on 12/18/2023. V5, Certified Nursing Assistant called me and informed me that R1 slid on the floor. V5 stated that she was getting R1 ready and had R1 sitting at the edge of the bed and R1 started slipping on the floor. I was then called to R1's room and observed R1 on the floor. I did a head-to-toe assessment, R1 said she was not in pain. V3 informed me then that (mechanical) lift was not used because R1 refused to sue the (mechanical) lift. When asked why her documentation on R1's progress notes stating that R1 refused to use the (mechanical) lift had a created date of 12/20/23, which was 2 days after the fall, V3 did not respond. R1's Care Plan with a revision date of 12/20/23 affirm that R1 requires (mechanical) lift with (X2) staff assistance for all transfers. The said Care Plan does not address that R1 was refusing to use the (mechanical) lift. On 1/26/2024 at 1:30 PM, V2, Director of Nursing stated, When somebody refuses the (mechanical) lift, the staff needs to inform us so we can do an evaluation to assess for proper transfer. R1 sustained fracture of the tibia. When I called V7, Physician, V7 said the fracture was pathological, we didn't report it. I talked to V7 the following day, he said it's due to her co-morbidities, R1 has severe osteopenia. If it's pathological in nature, we don't send a report to the state reporting agency. V2 affirmed that tibial fracture is considered a serious injury. V2 stated there was no report submitted to the state surveying agency about this serious injury. Review of R1's medical records excludes documentation regarding any condition that would place R1 at risk for pathological fractures. On 1/26/2024 at 1:55 PM, V7, Physician, stated, For R1, we discussed the fall, and the discussion was that R1 was sitting on the side of the bed and was being assisted and slipped and did not really have any per se trauma. We reviewed R1's X-ray and showed severe Osteopenia and that certainly can contribute to a pathological fracture, in the absence of trauma. R1's severe osteopenia could have caused the fracture because I was informed that there was really no trauma to the extremity. I have been informed from time to time that R1 was refusing to use the body lift, but for this particular incident, I don't recall them informing me that she refused to use the (mechanical) lift on 12/18/23. On 1/26/2024 at 3:12 PM, V6, Certified Nursing Assistant (CNA) stated, I was in the room with V5. When I got there, R1 was already on the floor. V5 prepared R1 for the transfer, and V5 said R1 slid on the floor. Then nurse checked R1, and R1 said she has no pain. So, the nurse, V6 and myself (sic) put her back to the bed, all 3 of us without using the (mechanical) lift. R1 said she wanted to go to the beauty shop, so all 3 of us transferred her to the wheelchair this time without using the (mechanical) lift so that she can go to the beauty shop. Review of R1's medical records excludes any documentation that R1 was reassessed for proper transfer techniques since R1 was allegedly refusing to use the (mechanical) lift. Review of medical records also exclude documentation that R1 was educated on the dangers of refusing to use the (mechanical) lift. V3, Registered Nurse, affirm that she was informed that R1 refused to use the (mechanical) lift after R1 slid on the floor. V3 documented on the progress notes with a created date of 12/20/2023, which is 2 days after the incident, that R1 refused to use the (mechanical) lift. R1's hospital records document under Xray Ankle Complete Minimum 3 Views, (Right) and Xray Tibia/Fibula, 2 Views (Right): Final Result, IMPRESSION: A minimally displaced oblique fracture involving distal tibia is noted with nondisplaced distal fibular diaphyseal fracture. Facility Policy titled Safe Lifting and Movement of Residents with a review date of July 2022 documents in part: In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. POLICY INTERPRETATION and IMPLEMENTATION: 3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include: a. Resident's preferences for assistance; b. Resident's mobility (degree of dependency); c. Resident's size; d. Weight-bearing ability; e. Cognitive status; f. Whether the resident is usually cooperative with staff;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent or identify the origin of how a resident sustained a right hip fracture. This affected one of three residents (R1) reviewed for injury of unknown origin. This failure resulted in R1 complaining of pain to the right leg. R1 was assessed, sent to the local hospital, and diagnosed and treated for complex comminuted periprosthetic fracture. Findings include: R1 face sheet shows R1 is [AGE] year-old female, R1 has diagnoses of presence of right artificial hip joint, history of falling, unspecified dementia, lack of coordination. R1 plan of care denotes R1 has difficulty hearing and visual deficits. R1 incident report to the department dated 8/6/2023 denotes in part, location of incident shower room, resident complained of pain on right leg upon assessment, noted right hip swelling and shortening of right leg no bruising or redness noted. NP (Nurse Practitioner) notify and assess resident in order to send resident to hospital for evaluation, resident had no fault or incident noted, grandson notified about resident transfer to hospital, 911 paramedics call for resident transport to hospital. Resident transferred to hospital, admitted to hospital with diagnosis of periprosthetic fracture of proximal femur. Investigation initiated and to follow final report investigation completed after staff interview and medical record review, resident had no recent fall nor incident, no outward injuries nor bruising noted. Resident [AGE] year-old, frail elderly, medically complex resident with diagnosis of diabetes hypertension acute renal injury anemia hyperkalemia and had history of right hip hemiarthroplasty and into so fight at the greater trochanter care plan will be updated when resident returned to facility. Type of injury fracture. R1 incident report titled other, dated 8/6/23, denotes in-part, at around 2:45 pm, CNA called this writer's attention that patient was complaining of right leg pain when CNA was trying to move it in the shower room. Immediately went there, patient was wearing jogger pants, said it was hurting. We transferred her to patient's room into her bed to take a closer look without her pants. Noted to have pain and swelling on right hip, with shortening of right leg. NP (Nurse Practitioner) informed. NP saw patient and ordered for stat right hip to include right femur bone. PRN (as needed) Tylenol given for pain. All stat called could not provide an ETA (expected time arrival). Supervisor on duty informed. SNOD (Supervisor Nurse on Duty) informed DON (Director of Nursing). Decision was to send patient out to ER for further eval. Supervisor on duty informed that we will send via 911. VS taken. 911 called. Paramedics came and picked up patient around 3:25 pm via stretcher. POA (Power of Attorney) and MD (Medical Doctor) informed. Endorsed to next NOD (Nurse on Duty). Injuries observed at time of incident suspected fracture right trochanter hip. Pain level 4. Mental status orientated to person orientated to place. Predisposing physiological factors fragile skin, incontinent, gait and balance, impaired memory. Predisposing situation factors loss of ability to walk. Notes 8/10/2023, root cause considering residents age medically complex condition history of right hip hemiarthroplasty lack of incidence resident may have hurt herself during act of physical mobility. R1 progress note dated 8/6/23 denotes at around 2:45 pm, CNA called this writer's attention that patient was complaining of Right leg pain when CNA was trying to move it in the shower room. Immediately went there, patient was wearing jogger pants, said it was hurting. We transferred her to patient's room into her bed to take a closer look without her pants. Noted to have pain and swelling on right hip, with shortening of right leg. NP informed. NP saw patient and ordered for stat right hip to include right femur bone. PRN Tylenol given for pain. Radiology company could not provide an ETA. Supervisor on duty informed. SNOD informed DON. Decision was to send patient out to ER for further eval. Supervisor on duty informed that we would send via 911. VS taken. 911 called. Paramedics came and picked up patient around 3:25 pm via stretcher. POA and MD informed. Endorsed to next NOD. R1 hospital record dated 8/7/23 denotes in-part chief complaint: right hip pain HPI: R1 is a [AGE] year-old female with PMH (past medical history) of HTN (hypertension), HLD, DM (diabetes mellitus), dementia who presents from SNF (skilled nursing facility) with right hip pain / swelling. It is unclear if she had fallen. Imaging in ER (emergency room) revealed a right hip peri-prosthetic fracture. Xray of pelvis -comminuted displaced impacted overlapped angulated periprosthetic fracture of the proximal femur. Distal tip of the stem of the prosthesis is directed anteriorly. No periosteal reaction. Trabecular pattern unremarkable. Joints: Head of prosthesis remains seated within the acetabular cup which is in stable position. Soft tissues: Unremarkable. Impression: Complex comminuted periprosthetic fracture. R1 MDS (Minimum Data Set) dated 5/17/23 denotes in-part section C, BIMS score 6 (cognitively impaired) section G transfers; extensive assistance two plus person physical assist. Bed mobility- extensive assist with two plus person physical assistance. Walk in a room extensive assist of 2 plus person physical assist. Locomotion on and off the unit, extensive assist of one-person physical assist. Dressing extensive assist of one-person physical assist. Eating supervision with one-person physical assist. Toilet use extensive assist of two plus person physical assist. Personal hygiene extensive assist of one-person physical assist. Balance during transition and walking; moving from seated to standing; not steady only able to stabilize with staff assist. Surface to surface transfer; not steady only able to stabilize with staff assist. R1 care plan for ADL self-care performance deficit due to decreased mobility pain related to right hip hemiarthroplasty, goal is one will maintain current level of function with ADL 's through the next review date, target date 8/22/23, interventions bed mobility program turn and reposition every room round assist with sideline position support backward pillow monitor for any intolerance monitor for presence of pain intolerance during bed mobility bare mobility the resident requires extensive assistance by 2 staff in turn and repositioning in bed every room round and as necessary transfer the resident require extensive assistance times 2 staff using sit to stand for all transfer. R1 care plan denotes R1 is high risk for falls due to decreased mobility, pain related to right hip hemiarthroplasty, diabetes mellitus and the use of narcotic medication, other medication side effects. Goal is will not sustain injury through the next review date, target date 8/22/2023. Interventions: anticipated and meet the resident needs be sure the resident call light is within reach and encourage the resident to use it for assistance as needed, the resident needs prompt response to all requests for assistance. Encourage the resident to participate in activity that promote exercise, physical activity for strengthening and improve mobility. Ensure the resident is wearing appropriate shoes non-skid socks when ambulating or mobilizing in wheelchair. Review medication that caused the fall. Scoop mattress. On 8/19/23 at 2:43pm, V3 (Administrator) said the investigation directed her and V6 (Director of Nursing/DON) to V5 (Certified Nursing Aide/CNA). V3 said V5 was asked to write a statement. V3 said V5 statement was reviewed, and there was not a lot of details, so V5 was asked to come into the facility for an interview. V3 (Administrator) said herself and V6 (DON) interviewed V5 on 8/10/23. V3 said during that interview V5 (CNA) said he got R1 up in the chair, V5 said he transferred R1 using the sit to stand mechanical lift. V3 said V5 said there was no falls, no incidents. V3 (Administrator) said V5 (CNA) stopped responding to the email communications and V5 stopped coming to work. V3 said V5 cannot be reached at the phone number they have on file. V3 said V5 (CNA) was terminated due to no call, no show to work. V5 said she is not aware of R1 having a fall. On 8/20/23, V5 said she did not review facility video surveillance. V5 said she does not know what happened to R1's hip. On 8/21/23 at 8:32am, V6 (DON) said she conducted the investigation for R1. V6 said she did not review video surveillance for her investigation for R1. V6 said she went back 3 days from the date R1 was observed with pain during her investigation. V6 said V5 (CNA) was the staff that worked with R1 prior to R1 being observed with pain and swelling on 8/6/23 in the hip. V6 said all the staff within those 3 days were asked to write a statement. V6 said when reviewing V5 written statement, there was not a lot of details. V6 said V5 was asked to come into the facility for an interview. V6 said V5 told her that he transferred R1 to the wheelchair using a gait belt on the morning of 8/6/23. V6 said V5 had R1 to sit at the bedside before transferring R1. V6 said V5 did not say he used the sit to stand to transfer R1. V6 said she only asked about transferring of R1, she did not inquire about bed mobility and dressing R1 that morning. V6 said V5 said he was getting R1 up for the day. V6 said V5 (CNA) statement consistently changed during the interview. V6 said R1 is on the get-up list, that's why V5 was getting her up that morning. V6 said if R1 had a fall outside of her room staff would have heard it or saw it. V6 said R1 cannot get up by herself after a fall, R1 needs assist to get up. V6 said there's no cameras in R1's room. V6 said she do not know what happened to R1 hip. V6 said she reviewed the hospital records and R1 has a bad fracture. V6 said R1 require 2 persons assist with the use of the sit-to-stand mechanical lift. V6 (DON) said V5 should use the sit-to-stand when transferring R1. V6 said it's for safety reason, to prevent injuries, especially in the elderly population. V6 said her root cause analysis was based on that no staff witness R1 falling. On 8/19/23 at 1:35pm, V1 (CNA- Certified Nursing Aide) said when she came on duty on 8/6/23 (morning) she saw R1 up in the wheelchair at the nurse station. V1 said she thought that was strange because R1 is not on the get-up list. V1 said multiple staff was shocked to see R1 up so early. V1 said R1 was escorted to the dining room to have breakfast. After breakfast, R1 had activities. After activities, it was soon time for lunch. V1 said after lunch, she went to toilet R1. V1 said she took R1 to the restroom, she went and got the sit to stand lift. V1 said she asked the Aide to assist her with R1. V1 said she lifted R1 leg to remove the leg rest, and R1 complain of pain. V1 said she went to get the nurse immediately so that the nurse can check R1. V1 said her and the nurse took R1 back to her room, put R1 in the bed. V1 said they took R1 joggers off and R1 had big swelling to the right hip. V1 said that was her first-time toileting R1 that day (after lunch). V1 said R1 was in pain. V1 said she checked R1 brief once or twice and R1 was dry. On 8/19/23 at 2:49pm, V2 (Nurse) said she was summons to the shower room when R1 had pain. V2 said she did not ask R1 what happened because R1 has dementia. V2 said she's not familiar with R1, she doesn't know if R1 would have been able to tell her what happened. V2 said R1 was taken to her room, placed on the bed for better observation. V2 said R1's right leg was noted with swelling. V2 said she gave R1 Tylenol for pain. V2 said she notified the NP and NP gave orders for Xray, but the Xray company did not give ETA, so R1 was sent to hospital for further evaluation. V2 said she did not get report that R1 had a fall from previous shift, she did not get report of incident from previous shift. On 8.19.23 at 12:20pm, V7 (Physician) said the facility notified him of R1's hip fracture, R1 was sent out to the hospital. V7 said the facility does not know what happened to R1's hip. V7 said the facility said no one reported any falls for R1. V7 made aware of allegation of R1 allegedly being dropped. V7 said that would makes sense if that's what happened but the facility doesn't know what happened. V7 said a fracture is a result of trauma. V7 said a fracture could develop spontaneously, but he has not seen that happen, it rare. V7 said R1 has a history of hemiarthroplasty. V7 made aware R1's diagnosis at the hospital of complex comminuted periprosthetic fracture. V7 said periprosthetic fracture is a fracture around the prosthesis. V7 said the surgeon would be better to ask if fracture is acute or chronic. R1 hospital record dated 8/7/23 denotes in-part chief complaint: right hip pain HPI: R1 is a [AGE] year-old female with PMH (past medical history) of HTN (hypertension), HLD, DM (diabetes mellitus), dementia who presents from SNF (skilled nursing facility) with right hip pain / swelling. It is unclear if she had fallen. Imaging in ER (emergency room) revealed a right hip peri-prosthetic fracture. Xray of pelvis -comminuted displaced impacted overlapped angulated periprosthetic fracture of the proximal femur. Distal tip of the stem of the prosthesis is directed anteriorly. No periosteal reaction. Trabecular pattern unremarkable. Joints: Head of prosthesis remains seated within the acetabular cup which is in stable position. Soft tissues: Unremarkable. Impression: Complex comminuted periprosthetic fracture. First policy facility presented on 8/21/23, (3 pages) no date noted titled abuse prevention abuse denotes residents have a right to be free from abuse neglect exploitation misappropriation of property or mistreatment this includes but is not limited to corporal punishment involuntary seclusion and any physical or chemical restraint not required to treat the residence medical symptoms. The purpose of this policy and the abuse prevention program is to describe the process for identification, assessment, and protection of residents from abuse neglect misappropriation of property and exploitation this will be accomplished by conducting pre-employment screening orientating training employees, established environment for residents' sensitivity, resident security, and prevention of mistreatment. Immediately protecting residents involved in identifying reports of property possible abuse neglect exploitation misappropriation property. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means abuse is also the willful infliction of injury unreasonable confinement intimidation or punishment with resulting physical harm pain or mental anguish to a resident. Injury of unknown sources are injuries for which both the following conditions are met one the source of the injury was not observed any person the source of injury could not be explained by the resident and to the injury is suspicious because of the extent or location of the injury the number of injuries observed at one particular point in time or the incidence of injuries over time. Serious bodily injury is defined as an injury involving extreme physical pain substantial risk of death protracted loss or impairment of the function of organ or mental faculty or requiring medical intervention such as surgery hospitalization or physical rehabilitation. The second policy (3 pages) with last review date March 2019 denotes in-part abuse and neglect policy rather than have the right to be free from abuse neglect exploitation misappropriation of property or mistreatment this includes but is not limited to corporal punishment involuntary seclusion and any physical or chemical restraint not required to treat the residence medical symptoms. The facility third policy presented 8/21/23 title abuse and neglect (5 pages) with last revised date of July 2017 denotes in part the purpose of this policy and the abuse prevention program is to describe the process for identification assessment and protection of the residents from abuse neglect misappropriation of property and exploitation this would be accomplished by identify occurrences and patterns of potential mistreatment immediately protecting residents involved in identified reports of proper possible abuse neglect exploitation mistreatment and misappropriation of property implementing systems to promptly and aggressively investigate all reports and allegations of abuse neglect exploitation misappropriation of property and mistreatment and making all the necessary changes to prevent future occurrences. The residents' rights for people in the long-term care denote as a long-term care resident in Illinois, you are guaranteed certain rights, protection, and privileges according to state and federal laws.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R6 is an [AGE] year-old female initially admitted to the facility 11/28/2017. R6's diagnosis includes but is not limited to, Parkinson's Disease, Unspecified Dementia, Functional Quadriplegia, Dysphagia, Gastrostomy, Fracture of Lower End of Femur. R6 was hospitalized from [DATE]-[DATE] for distal right femur fracture and readmitted with right lower extremity (RLE) hinge brace and an order for the brace to be worn at all times except for hygiene. Skin was intact upon readmission based on Nursing Admission/readmission Assessment completed on 11/26/22. R6's Braden Score for predicting pressure sore risk on 11/26/22 was assessed as being at high risk based on score of 10. R6 is NPO and receiving all nutrition from enteral feedings via gastrostomy tube. R6 developed four pressure injuries identified on 01/11/23 in the following locations: right Achilles, right lateral lower leg, right inner ankle, and right outer ankle. Per facility document titled, Wound Assessment Details Report dated 01/12/23 performed by V18 (Wound Care Coordinator) documents in part, right Achilles unstageable with wound measurements (2.3x2.5x0.1) 100% slough white fibrinous, right lateral lower leg unstageable with wound measurements (0.90x2.0x0.1) 100% slough white fibrinous, right inner ankle unstageable with wound measurements (1.4x2.0x0.1) 95% slough white fibrinous 5% bright beefy red, right outer ankle unstageable with wound measurements (4.5x1.3x0.1) 95% slough white fibrinous 5% bright beefy red. On 01/18/23 at 11:24 AM, V8 (Registered Nurse/RN) stated that before 01/03/23, R6 was wearing a right lower extremity leg brace all the time and that there were special instructions not to remove it. V8 stated that before 01/03/23, R6's leg brace was not being removed for any reason. V8 stated that the Certified Nursing Assistants notify the nurses if any skin alterations are identified. On 01/18/23 at 2:33 PM, surveyors observed V18 (Wound Care Coordinator) providing wound care treatment to R6. V18 stated that R6 had four unstageable pressure wounds that were caused by the friction from R6's right lower extremity leg brace. V18 stated that the hinge type of brace is known to cause friction which is a risk factor for developing a skin alteration. V18 stated that the unstageable pressure wounds were identified when R6's leg brace was taken off to give R6 a shower (01/11/23). V18 stated that the wound care doctor was at the facility on Monday (01/16/23) but did not see R6 or R6's pressure wounds. V18 stated that the wound care physician did not see R6 because V18 did not refer R6 to the wound care physician. V18 stated that V18 only refers residents with wounds to the wound care physician if the wounds are declining or infected or healing is not progressing. Surveyors observed right inner ankle, right outer ankle, and right Achilles covered with alginate dressing. When alginate dressing was removed surveyors observed the right inner ankle, right outer ankle, and right Achilles covered in slough with drainage. V18 stated that V18 used a different treatment dressing (alginate) other than what is ordered ({brand} enzymatic debriding wound agent, adaptic dressing) because V18 had observed an increase in drainage from these wounds yesterday during wound treatment. V18 stated, I haven't had a chance to change the treatment order yet. Surveyors observed V18 take measurements of wounds. V18 verbalized out loud the measurements obtained with the results as follows: right inner ankle (1.5x2.3x0.1), right outer ankle (4.5x1.4x0.1), right lateral leg (1.6x1.6x0.1). No measurement was provided for the wound to right Achilles. On 01/19/23 at 9:30 AM, V34 (Nurse Practitioner/NP) stated that V34 was not aware that R6 had developed pressure wounds and that the last time V34 had seen R6 was on 12/7/22. V34 stated, I remember them calling me about R6 needing a doppler study, but I was not notified about the four unstageable pressure wounds. It looks like they notified R6's primary physician. V34 stated that R6 is wearing a hinge brace which is known to cause friction which has the potential to lead to skin issues. V34 stated that if the staff was conducting daily skin checks they would observe any signs of skin deterioration on pressure point areas quickly. On 01/19/23 at 11:40 AM, V33 (Wound Care Physician) stated that V33 assesses and treats residents referred with all pressure ulcers, vascular ulcers, surgical ulcers, surgical wounds and all stages of non-healing wounds and infected skin areas. V33 stated that V33 works on a consult basis, and therefore the nurse needs to obtain an order from the primary physician for V33 to assess a resident. V33 stated V33 was consulted today to assess R6, and that it is the initial assessment for R6, so it is the first time V33 is doing measurements of R6's wounds. V33 attributes R6's unstageable pressure wounds to the leg brace worn by R6 and stated that the brace can cause friction which is a risk factor for developing pressure wound(s). V33 stated that the facility should be doing daily skin checks to identify skin changes. V33 stated that it is important for the wound treatment orders to be followed as prescribed and that the nurse should not be changing the order(s). On 01/19/23 at 12:00 PM, V18 (Wound Care Coordinator) provided to surveyor documents titled, Visit Report for R6 on 01/19/23 signed by V33 at 10:58:06 AM on 01/19/23 which documents in part that R6 has an unstageable pressure injury on right lateral lower log, right Achilles area, right lateral ankle and right medial ankle since 01/11/23, and the patient had a right leg brace for acute complex fracture of distal femoral metaphysis since 11/23/22, the patient is at increased risk for pressure injury due to the decreased mobility and the patient should be on a turning schedule. Measurements of the pressure injuries are documented as follows: right lateral leg (1.0x1.8x0.1) with small amount of serous drainage and large (67-100%) amount of necrotic tissue within the wound bed including Adherent Slough; right Achilles (2.2x2.5x0.1) with medium amount of serous drainage and large (67-100%) amount of necrotic tissue within the wound bed including Adherent Slough; right medial malleolus (right inner ankle) (1.0x2.0x0.1) with medium amount of serous drainage and large (67-100%) amount of necrotic tissue within the wound bed including Adherent Slough; right lateral malleolus (right outer ankle) (4.2x1.3x0.1) with medium amount of serous drainage and large (67-100%) amount of necrotic tissue within the wound bed including Adherent Slough. Note there is a discrepancy between the measurements provided on V33's documentation compared to the wound measurements taken by V18 and observed by surveyors on 01/18/23. On 01/19/23 at 12:09 PM, V2 (DON) stated that the overall goal is to keep resident's skin condition intact and not have any acquired pressure injuries. V2 stated that R6 was wearing a hinge leg brace which can cause friction and that the brace was the cause of pressure wounds R6 acquired. V2 stated that the interventions put in place when R6 returned from the hospital with the leg brace included checking the leg brace every shift and doing daily skin checks. V2 stated that the purpose of the daily skin check is to monitor the skin for any breakdown or issues with circulation. V2 stated that it is the nurse's responsibility is to do the daily skin checks. V2 stated that when a wound is identified the resident should be seen as soon as possible by the wound care physician. V2 stated that the skin treatment orders should be followed as prescribed and not changed because if the orders are changed it is not possible to know if the treatment was effective or not which could hinder the wound healing process. On 01/20/23 at 9:52 AM, V35 (Registered Dietitian) stated that R6 is receiving tube feeding formula and a commercial protein supplement via feeding tube for nutrition which is providing a total of 1320 calories, 77 gm protein. V35 estimated R6's nutritional needs as 1040-1300 calories, 62-73 grams protein. V35 stated R6 is receiving adequate nutrition from tube feedings with use of commercial protein supplement. R6's MDS (Minimum Data Set) dated 12/02/22 BIMS (Brief Interview for Mental Status) score is 0 indicating severe cognitive response (rarely/never understood) and section G (Functional Status) documents in part R6 requires total dependence for transfer and extensive assistance with bed mobility, dressing, toilet use and personal hygiene and limited range of motion on both upper and lower extremities. R6's Order Summary Report dated 01/18/23 documents in part check circulation, motion, sensation of right lower extremity every shift for brace right lower extremity (RLE) (12/06/22), check skin daily (12/06/22), and skin check daily under brace (RLE) every evening shift (12/14/22). R6's Treatment Administration Record dated 01/01/23-present documents in part, right lower leg: cleanse with normal saline, apply (Brand) enzymatic wound debriding agent to open areas, adaptic, dry dressing every day shift for RLE wounds dated 01/12/23. Facility policy titled, Prevention of Pressure Ulcers/Injuries dated July 2017 documents, in part assess the resident on admission for existing pressure ulcer/injury risk factors and repeat the risk assessment weekly, identify areas of impaired circulation due to pressure from positioning or medical devices and inspect the skin on daily basis, identify any signs of developing pressure injuries (i.e. non-blanchable erythema) and inspect pressure points. On 1/17/23 at 11:30 AM, observed R91's wound care completed by V18 (Wound Care Nurse). Observed R91's left buttock area with an open wound noted with small portion of the wound was bright red and the rest of the wound was filled with a white thick non removable appearance. R91 stated, This air mattress is too hard and makes my butt hurt. On 1/19/23 at 9:52 AM, V18 (Wound Care Nurse) stated, I am a Licensed Practical Nurse for 4-years. I received my wound care certification in April 2022. I have been the only full-time wound care nurse here for the last two years. I work Monday thru Friday, and the weekend supervisor will complete the wound care treatments. V33 (Wound Care Physician) comes in the facility on Mondays, at least once per week to assess residents on her (V33) list. V33 only assess wounds that are declining, infected, or change in condition. Typically, I manage the wounds unless I think the wound physician needs to get involved. If I feel the wound physician needs to assess a wound, I will call the resident's primary care physician for an order to allow V33 to assess the resident. I'm not sure what the PUSH acronym or the score located on the wound summary means. Once I enter the wound description the PUSH score is generated, the higher the number the worse the wound. However, in that square box underneath the title PUSH there is an arrow either pointing up or down. Arrow pointing up means the wound is worsening, and an arrow pointing down means the wound is improving. R91 was re-admitted to the facility on [DATE] with the Left buttock stage 3 pressure ulcer wound. On 1/10/23, I assessed R91's the left buttock wound, tissue was 100% bright beefy red, with scant serosanguineous drainage. R91's left buttock wound measures L[Length] 0.50cm x W [Width] 1.00cm x D[Depth] 0.10cm with the PUSH score of 5, no arrow was there because it was the first assessment completed. On 1/18/23 R91's left buttock wound was assessed as a stage 3 pressure ulcer wound, the tissue was 50% bright beefy red and 50% slough white fibrinous, with scant serosanguineous drainage. R91's left buttock wound measures L[Length] 2.00cm x W[Width] 0.50cm x D [Depth] 0.10cm with the PUSH score of 7 with the arrow pointing up, which indicated R91's wound has got worse. R91's wound interventions are an air mattress, encourage R91 to reposition, and heel boots while in bed. The air mattress is set per the resident's weight, he [ R91] weighs 134 pounds. I noticed during R91's wound care that his [ R91] air mattress was set at 300 pounds, which makes the mattress hard and firm. The air mattress is set at the wrong weight and can potentially cause the wound to worsen. R91 was not referred to V33, because I felt like I could handle the wound care alone. From 1/10/23 to 1/18/23, R91 wound did decline. On 1/19/23 at 11:30 AM, V33 (Wound Care Physician) stated, I worked in this facility for two years, assessing, and treating referred residents with all pressure ulcers, vascular ulcers, surgical wounds, all stage non-healing wounds and infected skin areas. Once I assess a resident my documentation is on an application, V2 (DON) and V18 has access to those assessments. I have not assessed R91's wound, because I have not received any referral from R91's physician or V18. If a resident has a stage 3 wound, I will think certainly, I should have been referred to assess that resident's wound. If a wound goes from 100% beefy red to 50% slough, and larger in size, the wound has worsened. The air mattress is an intervention of residents with pressure ulcers. The air mattress settings are based on the resident's weight. If the air mattress is set at a higher weight, it could potentially cause a wound and or an existing wound to worsen. On 1/19/23 at 12:10 PM, V2(DON) stated, V18 needs to refer a resident to V33 with a referral from the resident's physician. V33 is supposed to see all pressure ulcers as soon as possible. V18 should obtain an order for the wound care physician as soon as possible for all wounds. The air mattresses are set on the resident's weight for proper air distribution for residents with pressure ulcers. If the bed is set on a higher weight, it could potentially cause their wound to worsen. Reviewed R91's medical record documented in part: R91 was re-admitted on [DATE] with medical diagnoses of neuropathy, end stage renal disease, type 2 diabetes, liver transplant, kidney transplant, gastrostomy, gastritis, urinary tract infection, dysphasia, abnormal gait immobility, lack of coordination, hyperkalemia, heart failure, acute respiratory failure malnutrition, depressive disorder, seizures, chronic pain, cirrhosis of the liver, sepsis, and pneumonia. Physician order- dated 1/11/23, left buttock-cleanse with normal saline, apply (brand) non-adherent wound contact dressing , adaptic, and foam dressing every day shift on Tuesday, Thursday, Saturday, and Sunday. Face-sheet, medical diagnosis, physician order sheets, minimum data set [MDS], care plans, medication administration record, treatment administration record, and progress notes. Policy; Documents in part -Prevention of Pressure Ulcers/Injuries dated 7/2017 Support Surfaces and Pressure Redistribution' -Select appropriate support surfaces based on the resident's mobility, continence, skin moisture and perfusion, body size, weight, and overall risk factors Monitoring -Evaluate, report and document potential changes in the skin -Review the interventions and strategies for effectiveness on an ongoing basis Based on observation, interview and record review, the facility has the following failures for 3 out of 6 residents (R6, R25 and R91) for a total sample of 30 residents reviewed for pressure ulcers: Failed to follow their wound prevention and management policy to ensure residents does not develop pressure ulcers. Failed ensure that residents received wound treatments. Failed to follow manufacture's instruction for proper settings on the low air mattress. Failed to maintain correct dressing per physician's order. Failed to monitor skin status for prevention of pressure ulcers. Failed to refer residents with new and worsening pressure ulcers to wound care physician for assessment and treatment. These failures resulted in R6 sustaining 4 new facility acquired pressure ulcers on her right lower extremities. R25 sustaining 2 facility acquired pressure ulcers on the sacral pressure ulcer that further deteriorate with size, characteristic and appearance, and left heel pressure ulcer that was identified on its late stage (Stage 3). R91 sustaining left buttock pressure ulcer that worsened. Findings include: R25 was [AGE] years old, initially admitted on [DATE] with medical diagnoses of hemiplegia and hemiparesis. R25 brief interview of mental status 12/16/2022 has a score of 14 that means R25 cognitive status is intact. On 01/17/2023 at 11:22 AM. R25 stated that he cannot remember anyone did change his dressing today. R25 said that he has wound on his back and shook his head when asked if it gets any better. R25 was seen closing his eyes most of the time and fall asleep but responded short response during conversation. On 01/18/2023 at 10:16 AM, V18 (Wound Coordinator / Licensed Practical Nurse) stated that R25 has unstageable pressure ulcers on both his left heel and sacrum and that both wounds were acquired in the facility. And the most recent was V18's left heel pressure ulcer that was initially identified on 1/3/2023. When asked about the status of both sacral and left heel pressure ulcers. V18 said, It worsened, but there was a time that it was getting better. Both pressure ulcers are unstageable because of the presence of sloth. And when asked about the plan of care related to both pressure ulcers. V18 said, I do not do care plan. It is done by the MDS coordinator. It is part of my contract when I accepted the job as wound coordinator not to do care plan. V18 was asked if she was coordinating with the person doing the care plan since she was the staff that is doing direct care such as changing the dressing and alike. V18 said, If she (MDS Coordinator) asks me, I will give her information. But if you ask me what the interventions for R25's pressure ulcers right now. I don't have the information. I understand what you mean that it is supposed to be interdisciplinary coordination since I perform the care plan, there should be communication between me and the person doing the care plan to determine if interventions are effective. On 01/19/2023 at 09:08, V18 to perform treatment or pressure ulcer care of R25's sacral and left heel. Prior to dressing change V30 (Licensed Practical Nurse/LPN) stated that R25 had a lot of bowel movement earlier. And that she (V30) does not know what was ordered dressing for R25 sacral pressure ulcer. And that she (V30) and V10 (Certified Nursing Assistant/CNA) just cover it with dry dressing. Per physician order, the current and correct treatment is to cleanse sacral pressure ulcer with (Type) topical antiseptic solution pack inside cavity with moist gauze and cover with dressing. After V18 took off the covered dressing that V30 placed. The inside of the wound (pressure ulcer) was packed with gauze that was brownish in color and was soaked with drainage. V18 said, This is the gauze that I placed yesterday around 3:30 PM. After all the gauzed that was packed were taken out. Cavity of pressure ulcer became visible, and it was deep that it appears to be reaching the bones. Although a partial slough that cover portion of the bed of the pressure ulcer does not allow the bones to be seen. V18 stated, Yes, it is deep enough that it may reach the bone. During dressing change V18 measured both sacral and left heel pressure ulcers. Sacral wound measures in centimeters: 5.0 by 6.0 by 2.0 (length by width by depth) with 7 to 2 o'clock undermining. V18 said that there was undermining when she inserted the stick with cotton tip underneath R25's wound moving from 7 to 2 o'clock. Left heel measurement in centimeters: 2.3 by 2.4. Then V18 said, This is 100% slough. Pointing at R25's left heel pressure ulcers that the whole area was covered with slough. On 01/19/2023 at 10:06 AM, V18 (Wound Coordinator / Licensed Practical Nurse) was asked if nursing staff on the floor knows how to access wound treatment orders for them to place the correct dressing as ordered by physician in case dressing becomes soiled or wet. V18 said, Staff (nursing) staff on the floor can access treatment orders. And must know what dressing to place when needed. They have been informed and instruction were given to them. But I totally agree with you. Wound treatment must be performed correctly by both nursing staff on the floor and wound care staff. V18 was asked about the process to document treatment that was done in the treatment administration record (TAR). And was also asked if it should be sign on the same day the treatment was done. V18 said, I don't sign on the treatment administration record (TAR) after I performed the treatment. But I tried to sign it by the end of the day. And yes, sacral wound, you may say it worsen if the skin was intact with redness and later opens. V18 was asked, since there was a clear deterioration of R25's sacral pressure ulcer since 9/30/2022 until currently, why was the wound not seen by a wound doctor until 01/16/2023? V18 said, I tried to do the treatment on my own. I guess it would help but there are times that R25's wounds seem to be improving. V18 was also asked about R25's left heel since it was discovered already in stage 3, if nursing staff was monitoring R25's left heel should it be in an earlier stage when it was easy to manage? V18 said, I don't know. But when it was discovered, it was already stage 3. Per R25's notes dated 9/12/2022 in part reads that R25 skin on the sacral area was intact but with redness. Then foam dressing was applied. Per physician's order, foam dressing needs to be applied to R25's sacrum to start on 9/14/2022. Per R25's treatment administration record (TAR), for foam dressing was not signed as being perform on 9/14/2022 and from 9/20/2022 up to the end of the month no treatment was signed as being performed. On 9/30/2023, R25's sacrum pressure ulcer worsened from skin intact redness to open pressure ulcer measuring in centimeters as follows: 1.5 by 1.0 by 0.10 (length by width depth). Compared to sacral pressure ulcer assessment dated [DATE] measuring in centimeters as follows: 4.0 by 6.0 by 1.5 (length by width by depth). As to R25's left heel pressure ulcer, it was first identified on 1/3/2023 as stage 3 with measurement in centimeters as follows: 2.0 by 3.0 by 0.10 (length by width by depth). On 01/09/2023, left heel pressure ulcer was reclassified as to its stage from stage 3 to unstageable due to 100 % of the area of the pressure ulcer was covered with slough. On 01/19/2023 at 11:34 AM, V33 (Wound Doctor) said, I only see residents that was referred to me by the primary physician. And it was the first time R25 was referred to me, so I cannot make any determination or comparison as to the status of R25's pressure ulcers. But what is documented on her assessment dated [DATE] was the basis of the status of the wound. Yes, the presence of slough means wound deterioration and that a skin intact with redness that opened means worsening of the wound. It can be attributed to many factors including not performing of treatment. Per V33 documentations: R25 was only seen 1 time on 01/16/2023 although R25's sacral pressure ulcer was initially identified as having redness on 09/12/2022 and opened on 09/30/2022 that worsen overtime per facility Wound Round Assessments. And only saw R6's 4 pressure ulcers on resident's right lower extremities after facility was informed that R6's wounds are being reviewed. On 01/19/2023 at 12:12 PM, V2 (Director of Nursing/DON) said, All pressure ulcers besides stage 1 must be seen as soon as possible by Wound Doctor. The process for the primary care physician to give a referral for the wound doctor to see resident. R25's Health Records are as follows: Per R25's notes dated 09/12/2022, reads in part that R25 has blanchable pink noted to sacral area. Notes dated 01/11/2023 in part reads that R25 left heel and sacral wound declined. R25's treatment administration records (TAR) for the months of September, October, and November 2022 have multiple days that were not signed as treatment ordered by physician was being performed on the sacral pressure ulcer. Per facility Wound Rounds assessment R25's pressure ulcer was initially opened on 09/30/2022 and later deteriorates as to size, characteristic and appearance. From 1.5 by 1.0 by 0.10 centimeters (length by width by depth) on 09/30/2022 to 4.0 by 6.0 by 1.5 centimeters (length by width by depth). And even increased in size when seen on 01/19/2023 with the following measurements: 5.0 by 6.0 by 2.0 centimeters (length by width by depth) with 7 to 2 o'clock undermining. Per V33 wound assessment, it was the first time she saw R25 when sacral pressure ulcer had already worsened. Per facility assessment Wound Rounds left heel was initially assessed on its late stage (Stage 3) on 01/03/2023. Later left heel pressure ulcer on assessment dated [DATE] became unstageable due to slough white fibrinous covered 100% of the wound. Care plan for left heel was initiated on 01/08/2023, 5 days after pressure ulcer was identified. And later developed slough on 01/09/2023. Facility submitted Wound Care Pressure Ulcer Avoidability assessment dated [DATE] and signed by V33 (Wound Care Doctor) on 01/20/2023 although, V33 only saw R25 the first time on 01/16/2023. The same assessment was more than 3 months ago dated 09/30/2022 is still showing in progress today (01/20/2023). Dressings, Dry/Clean policy of the facility dated as revised 4/2022, in part reads: The purpose of this procedure is to provide guidelines for the application of dry, clean dressings. Under preparation: Verify that there is a physician's order for this procedure. Review the resident's care plan, current orders, and diagnoses to determine if there are special resident needs. Check treatment record. Under documentation, the following information should be recorded in the resident's medical record, treatment sheet or designated wound form: The date and time the dressing was changed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide oral nutritional supplement as prescribed by physician. This failure resulted in a significant weight loss (>5% change over a span of 1 month and >10% change over a span of 6-month period) for 1 (R57) of 7 residents reviewed for nutrition in a total sample of 30. Findings include: On 01/17/23 at 12:16 PM, surveyor observed V10 (Certified Nursing Assistant/CNA) feeding R57 in the unit dining room, with R57 eating very slowly with eyes closed and overall poor intake less than 50% of lunch meal. No supplement observed on lunch tray. On 01/18/23 at 08:55 AM, surveyor observed V37 (Restorative Coordinator) feeding R57 in unit dining room. No commercial oral supplement observed on breakfast tray. No commercial oral supplement listed on R57's meal ticket. On 01/18/23 at 9:13 AM, V16 (Speech Language Pathologist) stated that R57 requires 1:1 feeding assistance. On 01/18/23 at 11:25 AM, V19 (Certified Nursing Assistant/CNA) re-weighed R57 upon request of the surveyor using the wheelchair scale on the unit. V19 stated that this is the scale used by staff to weight V19 every month. Surveyor observed R57 being weighed in R57's wheelchair with fleece lap blanket and sheet. This weight was 198.4 pounds. The weight reading was confirmed by V19 saying the weight scale reading out loud. After lunch at 2:08 PM, V19 transferred R57 to bed and R57's wheelchair was weighed without R57 sitting in it. R57's wheelchair plus the additional items of the fleece lap blanket and sheet was wheeled back onto the unit scale and the weight of was 80.4 pounds. The weight reading was confirmed by V19 saying the weight scale reading out loud. The difference between these two numbers makes the weight of R57 to be 118 pounds. On 01/18/23 at 12:21 PM, V8 (Registered Nurse/RN) stated that V8 did not give anyone on the unit Ensure supplement this morning as part of medication pass. V8 stated that there is not any Ensure supplement on the nursing unit or in the medication cart to give out. V8 stated that R57 did not receive (Brand) nutritional supplement this morning from nursing. On 01/19/23 at 9:40 AM, V34 (Nurse Practitioner/NP) stated that V34 has not seen R57 in person since 11/2022 but V34 did give a verbal order over the phone to approve R57 for labs, chest x-ray, speech evaluation and calorie counts. V34 stated that V34's expectation is that if R57 has an order for oral supplement then R57 should be receiving the supplement as ordered and that the purpose of the supplement is to provide R57 with additional calories to prevent weight loss. V34 stated that R57's weight loss is not desired or planned and is concerning since R57 is continuing to lose weight. On 1/19/23 at 9:45 AM, V26 (Dietary Manager) stated that when commercial oral supplements such as (Brand) are ordered with meals then the (Brand) oral nutritional supplement is provided by the kitchen and put on resident meal trays for that meal. V26 stated that if a resident has a physician order for (Brand) oral nutritional supplement, then that supplement will be listed on the resident's meal ticket, so the kitchen staff knows to add the supplement to the resident's meal tray. V26 stated that (Brand) oral nutritional supplement was in stock and available in the kitchen for use. V26 stated that a doctor or registered dietitian can order a supplement and that the staff notifies the kitchen when this occurs so that the kitchen can enter this information into the kitchen computer system which then generates the supplement on the meal ticket. V26 reviewed R57's menu profile in the kitchen computer system and stated that R57 does not have (Brand) nutritional supplement listed on R57's meals tickets and therefore is not receiving (Brand) nutritional supplement from the kitchen. On 01/19/23 at 10:00AM, V31 (Dietary Technician) stated that calorie counts were conducted last week but only given to V31 this morning to calculate. V31 stated that R57 is consuming an average intake of 732 calories per day based on the calorie count results and that R57 is not consuming enough calories to maintain R57's weight. V31 reviewed electronic medical record and stated, I do see the order for (Brand) oral nutritional supplement. V31 stated that R57 is not receiving (Brand) oral nutritional supplement from the kitchen at this time. V31 stated that if a resident had an order for a supplement but was not receiving the supplement the resident may not be able to maintain weight, and this could cause further weight loss because the purpose of the supplement is to provide extra calories. V31 stated that V31 was not aware of R57's weight loss and that a weight loss puts a resident into a high-risk category, which would require a referral to the registered dietitian for an assessment. On 01/19/23 at 10:47 AM, surveyor conducted interview with V35 (Registered Dietitian) over the phone. V35 stated that V35 worked remotely this week and that V35 had not been notified about R57's weight loss this month yet. V35 stated that current interventions in place include use of (Brand) oral nutritional supplement once per day at breakfast meal which would provide approximately 350 calories. V35 was not aware that the kitchen was not giving R57 the (Brand) oral nutritional supplement and stated, I am surprised that the kitchen has not been giving what is ordered. V35 stated that if a resident is not receiving a supplement as ordered, it has the potential risk for causing continued weight loss. V35 reviewed the diet technician's progress note documenting the calorie count results and stated that the calories R57 is consuming is not adequate and that without increasing R57's calorie intake, further weight loss is likely. R57 was admitted to the facility on [DATE] and has diagnoses which includes but not limited to: Unspecified Dementia, Hemiplegia and Hemiparesis Following Cerebrovascular Disease Affecting Right Dominant Side, Type 2 Diabetes Mellitus, Schizoaffective Disorder. R57's Order Summary Report dated 01/18/23 documents in part (Brand) oral nutritional supplement, one time a day for supplement at breakfast with order date from 11/08/22. R57's MDS (Minimum Data Set) from 11/15/22 BIMS (Brief Interview for Mental Status) was not calculated but indicated in section C0600 resident was unable to complete BIMS and indicated short and long-term memory problem. R57's MDS section G (Functional Status) dated 11/15/22 documents in part, limited assistance with eating and section GG (Functional Abilities and Goals) substantial/maximal assistance with eating. R57's care plan dated 11/09/22 documents in part, R57 is underweight, malnourished and to provide diet supplement as prescribed by physician. R57's Nutrition/Dietary progress note dated 01/19/23 completed by V35 at 11:15 AM documents in part, R57 has had a significant weight loss based on -9.7% change in 1 month, -10.5% change in 3 months, and -16% change in 6 months. V35 used the following weights to complete the progress note: (01/11/23) 122.4 pounds, (12/5/22) 135.5 pounds, (10/5/22) 136.8 pounds, (07/1/22) 146.2 pounds. V35 assessed R57's BMI (20.4) as being low for R57's age and that calorie count results show R57's average daily intake is 732 kcals which is not enough to maintain and/or gain weight. Facility document titled, Weights & Vitals dated 01/18/23 documents, in part, R57's weights as follows: (1/11/23) 122.6 pounds, (12/5/22) 135.5 pounds, (11/8/22) 135.5 pounds, (10/13/22) 136.8 pounds, (7/8/22) 146.4 pounds. Facility policy titled, Nutrition (Impaired)/Unplanned Weight loss - Clinical Protocol dated 09/2017 documents, in part, that the staff will report to the physician significant weight losses. Facility policy titled, Supplements undated documents in part that nutritional supplements will be provided as ordered to clients, nursing and dietary will distribute the nutritional supplement.