**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and implement pressure relieving interventions to prevent pressure ulcer development, conduct a pressure ulcer risk assessment once a week for four weeks after admission and then quarterly thereafter, update pressure ulcer care plans with pressure relieving interventions, and failed to provide a treatment as ordered by the physician for three of three residents (R1, R2, and R3) reviewed for facility acquired pressure ulcers in the sample of four. These failures resulted in R1 developing a stage four full thickness pressure ulcer to the medial heel that required surgical debridement, R2 developing an infected, painful stage four pressure ulcer to the left lateral ankle that required surgical debridement, and R2 developing a painful stage four pressure ulcer to the right lateral heel that required surgical debridement. Findings include: The facility's Pressure Injury/Pressure Ulcer Prevention and Treatment Protocol dated 10-24-22 documents Objective and Purpose: To ensure that measures are taken to prevent skin breakdown and to provide guidelines for treatment of any pressure injury or pressure ulcer that might develop. Pressure Ulcer/Injury refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. A pressure injury will present as intact skin and may be painful. A pressure injury will present as an open ulcer. The appearance of which will vary depending on the stage and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. Soft tissue damage related to pressure and shear may also be affected by skin temperature and moisture, nutrition, perfusion, co-morbidities, and condition of the soft tissue. Principles: 1. A skin assessment (Braden Scale Pressure Ulcer Risk Assessment) is completed on all residents upon admission and weekly for the first four weeks after admission, quarterly, and whenever there is a change in the resident's condition. 2. An individualized plan of care will be developed for the resident following the guidelines of the assessment. 3. All high and moderate risk residents will be assessed for the needs of the items below. If the intervention is initiated, it will be added to the care plan. A. Special mattress and wheelchair cushions. B. PROMS (Passive Range of Motions). C. Protein and/or Nutritional Supplements. D. Turning and positioning schedule. E. Skin Checks. F. Elbow/heel protectors/bridging of heels. 6. When a resident is admitted to the facility or develops a pressure injury in the facility, the following will occur: A. Assess the pressure injury for location, size, wound bed, drainage, odor, tunneling, undermining or sinus tract, wound edges/surrounding tissues, and pain at site. B. Determine the injury's current stage of development: Stage One Pressure Injury: Non-blanchable erythema of intact skin. Stage Two Pressure Ulcer: Partial thickness skin loss with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink, or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not viable. Granulation (new tissue) tissue, slough (dead tissue in wounds), and eschar (black or brown hardened layer of dead tissue that forms over a wound) are not present. Stage Three Pressure Ulcer: Full thickness loss of skin, in which subcutaneous fat is visible in the ulcer and granulation tissues are epibole (rolled wound edges) are often present. Slough and or/eschar may be visible but does not obscure the depth of tissue loss. If slough or eschar obscures the wound bed, it is an unstageable pressure ulcer/pressure injury. Unstageable Pressure Ulcer: Full-thickness skin and tissue loss in which the extent of tissue damage with the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. Stable eschar (dry, adherent, intact without erythema or fluctuance) should only be removed after careful consideration and consultation with the resident's physician, or nurse practitioner, physician assistant, or clinical nurse specialist. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon, or purple discoloration due to damage of underlying soft tissue, this area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue, This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. C. Notify the physician of the above assessment and obtain orders for treatment of pressure ulcer/injury. If pressure ulcer/injury is showing no improvement, Physician will be notified so change of treatment may be obtained, E. Care plan will be established for treatment of existing pressure ulcers/injuries. G. For pressure ulcer with drainage the physician will be notified, and culture obtained if ordered. Pressure Injury and Treatment Protocol: H. Weekly measurements will be conducted and entered in the chart under wound management. J. Turning and repositioning assistance will be given to those residents that are unable to reposition themselves. K. Special devices will be used to relieve pressure, L. All treatment and charting of pressure ulcers/injuries will be done by licensed staff. 1. R1's Face Sheet documents R1 is an [AGE] year-old admitted to the facility on [DATE] with the diagnoses Muscle Weakness, Lack of Coordination, Cognitive Communication Deficit, and Vascular Dementia. R1's MDS (Minimum Data Set) assessment dated [DATE] documents R1 is severely cognitively impaired, requires moderate assistance with personal hygiene and rolling left to right, is at risk for developing pressure ulcers, has one stage four facility acquired pressure ulcer, and is not on a turning and repositioning program. R1's current Physician's Order Sheets dated 5/26/25 through 6/26/25 document, Start Date: 6/17/25 Stage four pressure wound of right lateral ankle cleanse with wound cleanser, pat dry, apply hydrogel to would bed, cover with abdominal pad and kerlix (rolled gauze). Change dressing daily and as needed for impaired dressing integrity. R1's Braden Scale for Predicting Pressure Sore Risk assessment dated [DATE] documents a score of 16 indicating R1 was at risk of development of pressure ulcers. This same Braden Scale documents R1 was chairfast, was slightly limited in mobility, and required minimum staff assistance in moving to prevent friction and shearing. R1's Medical Record dated 6/27/24 through 6/27/25 does not include any quarterly Braden Scale Pressure Risk Assessments except for the one completed on 12/26/24. R1's Wound Evaluation and Management Summary dated 3/12/24 and signed by V14 (Wound Physician) documents, Stage four pressure wound of the right medial heel full thickness. Etiology: Pressure. Stage four. Duration: Less than 62 days. Wound Size: 5.0 cm (centimeters) by 5.3 cm by not measurable depth. Exudate: Moderate serosanguinous (pinkish drainage). Slough: 40 % (percent). Granulation tissue: 60 %. General Recommendations: Off-load wound, reposition per facility protocol, float heels in bed, and prevalon (heel floating cushioned) boots. Surgical Excisional Debridement procedure to remove necrotic tissue and establish the margins of viable tissue. R1's current Pressure Ulcer Care Plan does not include the interventions to ensure R1 is wearing heel pressure relieving boots and did not include pressure relieving interventions to prevent pressure to the heels prior to the development of R1's right medial heel pressure ulcer. On 6/26/25 from 11:00 AM through 11:45 AM R1 was sitting up in her wheelchair. R1 did not have heel protecting boots on, or a dressing covering the right outer heel wound. On 6/26/25 at 1:00 PM V16 (Wound Nurse) stated, I do not know why (R1) did not have a dressing on her right heel. On 6/27/25 at 9:35 AM R1 was lying on a low air-loss mattress. R1's heels were lying directly on the bed. R1 did not have pressure relieving heel boots on, or her heels off-loaded as ordered by the physician. R1's right foot was facing outward, putting pressure directly on the right ankle pressure wound. During this time, V17 (CNA/Certified Nursing Assistant) verified he did not know R1 was supposed to wear heel protector boots. On 6/27/25 at 9:30 AM V2 (DON/Director of Nursing) performed the wound treatment to R1's right outer heel. R1's right outer heel was covered in 40 percent slough and was approximately five cm round. On 6/27/25 at 12:00 PM V2 (DON) stated, (R1) has only had one Braden Scale Pressure Risk Assessment done within the last year. (R1) should have had Braden Scale Pressure Risk Assessments done quarterly. (R1's) pressure relieving heel boots are not on the care plan and (R1) did not have any pressure relieving interventions to the heels prior to the development of the pressure ulcer to the right heel. (R1's) wound to the right medial heel was caused by pressure. (V17/CNA) is new to taking care of (R1) and is probably not aware that (R1) needs a heel boot on. 2. R2's Face Sheet documents R2 is a [AGE] year-old admitted to the facility on [DATE] with the diagnoses of Fracture of the Right Humerus, Osteoarthritis, Chronic Diastolic Congestive Heart Failure, Reduced Mobility, Stiffness of the Left Ankle, Left Knee and Right Ankle, Chronic Kidney Disease Stage Three, and Hypertension. R2's MDS assessment dated [DATE] documents R2 is cognitively intact, is dependent on staff for personal hygiene, rolling side to side, and transfers, is at risk of developing pressure ulcers, has one facility acquired stage three pressure ulcer, has one stage four facility acquired pressure ulcer, and is not on a turning/repositioning program. R2's current Physician's Order Sheets dated 5/26/25 through 6/26/25 document, Start Date: 5/6/25 Stage four pressure ulcer wound of left lateral ankle cleanse with wound cleanser, pat dry, apply xeroform (petroleum gauze) to wound bed, cover with abdominal pad, and [NAME] with kerlix once daily. Start Date: 6/14/25 Stage three pressure wound of right lateral heel cleanse with wound cleanser, pat dry, apply xeroform, cover with abdominal pad, wrap with kerlix and secure with tape daily and as needed. R2's Treatment Administration Record dated 6/1/25 through 6/27/25 documents R2's treatments to the right lateral heel pressure ulcer and left lateral ankle were not performed on 6/20/25. R2's Braden Scale for Predicting Pressure Sore Risk assessment dated [DATE] documents a score of 14 indicating R2 is at moderate risk of development of pressure ulcers. This same Braden Scale documents R2 is chairfast, is very limited in mobility, and requires moderate to maximum assistance in moving to prevent friction and shearing. R2's Medical Record dated 5/28/24 through 6/27/25 does not include any Braden Scale Pressure Risk Assessments weekly times four weeks after admission, or quarterly except for the one assessment dated [DATE]. R2's Wound Evaluation and Management Summary dated 4/22/25 and signed by V14 (Wound Physician) documents, Stage four pressure wound of the left lateral ankle full thickness. Etiology: Pressure. Stage four. Duration: Less than one day. Wound Size: 0.9 cm by 1.5 cm by non-measurable cm. Exudate: Moderate serosanguinous. Slough: 80%. Granulation tissue: 20%. Dressing Treatment Plan: Xeroform gauze apply once daily as needed if saturated, soiled, or dislodged. Surgical excisional debridement procedure to remove necrotic tissue and establish the margins of viable tissue. General Recommendations: Off-load wound, reposition per facility protocol, turn side-to-side in bed, elevate legs, and float heels in bed. Specific to visit recommendations: Pressure off-loading boot-prevalon. R2's Wound Evaluation and Management Summary dated 5/6/25 and signed by V14 (Wound Physician) documents, Stage four pressure wound of the left lateral ankle full thickness. Etiology: Pressure. Stage four. Duration: Less than 15 days. Wound Size: 1.3 cm by 1.3 cm by non-measurable cm. Exudate: Moderate sero-sanguinous. Slough: 80%. Granulation tissue: 20%. Dressing Treatment Plan: Xeroform gauze apply once daily as needed if saturated, soiled, or dislodged. Deep swab technique of stage four pressure wound of left lateral ankle demonstrates MRSA (Methicillin-Resistant Staphylococcus Aureus) and Proteus Mirabilis on 5/6/25. Start Bactrim DS (Double Strength) BID (twice daily) for 14 days. Probiotics daily for 30 days. Surgical excisional debridement procedure to remove necrotic tissue and establish the margins of viable tissue. Stage three pressure wound of the right lateral heel full thickness. Etiology: Pressure. Stage: Three. Duration: Less than one day. Wound Size: 2.0 cm by 1.5 cm by 0.4 cm. Exudate: Light serosanguinous. Dressing Treatment Plan: Xeroform gauze apply once daily as needed if saturated, soiled, or dislodged. Secondary dressing abdominal pad once daily and as needed. General Recommendations: Off-load wound, reposition per facility protocol, turn side-to-side in bed, elevate legs, and float heels in bed. Specific to visit recommendations: Pressure off-loading boot-prevalon. R2's Wound Evaluation and Management Summary dated 6/26/25 and signed by V14 (Wound Physician) documents, Stage four pressure wound of the left lateral ankle full thickness. Etiology: Pressure. Stage four. Duration: Less than 66 days. Wound Size: 0.8 cm by 0.5 cm by 0.3 cm. Exudate: Moderate sero-sanguinous. Slough: 30%. Granulation tissue: 70%. Dressing Treatment Plan: Xeroform gauze apply once daily as needed if saturated, soiled, or dislodged. Sharp selective debridement procedure to remove biofilm and remove devitalized epidermis and/or dermis. Stage four pressure wound of the right lateral heel full thickness. Etiology: Pressure. Stage: four. Duration: Less than 52 days. Wound Size: 1.2 cm by 0.8 cm by non-measurable depth cm. Exudate: Moderate Serous. Slough: 100%. Dressing Treatment Plan: Xeroform gauze apply once daily as needed if saturated, soiled, or dislodged. Secondary dressing abdominal pad once daily and as needed. Surgical excisional debridement procedure to remove necrotic tissue and establish the margins of viable tissue. General Recommendations: Off-load wound, reposition per facility protocol, turn side-to-side in bed, elevate legs, and float heels in bed. Specific to visit recommendations: Pressure off-loading boot-prevalon. Low air-loss mattress. R2's current Pressure Ulcer Care Plan does not include the interventions to ensure R2's low air-loss bed and did not include pressure relieving interventions to prevent pressure to the heels/ankles prior to the development of R2's right lateral heel and left lateral ankle pressure ulcers. On 6/27/25 at 9:48 AM V2 (DON) performed wound treatments to R2's left lateral ankle and R2's right lateral heel. R2's left lateral ankle wound was approximately 1.3 cm round and covered in 80 percent slough. R2's right lateral heel was approximately 2.0 cm by 1.5 cm with a slight depth and red in color. On 6/27/25 at 12:15 PM V2 (DON) stated, (R2) did not get the Braden Pressure Ulcer Risk Assessments done weekly for four weeks after admission or quarterly. The only Braden Pressure Ulcer Risk Assessment (R2) had done was on 6/24/25. (R2's) treatments to the left lateral ankle and right lateral heel were not done as ordered on 6/20/25. (R2's) wounds to the left lateral ankle and right later heel were caused by pressure. (R2) did not have pressure relieving interventions to the heels or ankles prior to developing the pressure ulcers. (R2's) care plan does not include (R2's) low air-loss mattress. 3. R3's Face Sheet documents R3 is a [AGE] year-old admitted to the facility on [DATE] with the diagnoses of a Fracture to the Right Femur, Dementia, Psychotic Disturbance, Mood Disturbance, Anxiety, Major Depressive Disorder, Chronic Pain, Hypertension, Cognitive Communicative Deficit, and Hearing Loss. R3's admission Braden Scale for Predicting Pressure Sore Risk assessment dated [DATE] documents a score of 16 indicating R3 was at risk of development of pressure ulcers. This same Braden Scale documents R3 was chairfast, had no limitations in mobility, 3 and required moderate to maximum assistance in moving to prevent friction and shearing. R3's admission MDS assessment dated [DATE] documents R3 was significantly cognitively impaired, was dependent on staff for turning left to right, personal hygiene, and transferring to the chair. This same MDS documents R3 was at risk for developing pressure ulcers, had no pressure ulcers upon admission, and was not on a turning/repositioning program. R3's Significant Change MDS assessment dated [DATE] documents R3 is severely cognitively impaired, is dependent on staff for turning left to right, personal hygiene, and transferring to the chair. This same MDS documents R3 was at risk of developing pressures, had no pressure ulcers as of 4/25/25, and was not on a turning/repositioning program as of 4/25/25. R3's Medical Record dated 3/25/25 through 6/27/25 does not include any Braden Scale Pressure Risk Assessments weekly times four weeks after admission, or after a change in condition except for the one assessment dated [DATE]. R3's Progress Notes dated 6/14/25 at 4:59 AM and signed by V15 (LPN/Licensed Practical Nurse) document, Two cm open area noted to right ischium. Area cleansed and hydrocolloid applied. R3's current Physician's Order Sheets dated 5/26/25 through 6/26/25 document, Start Date: 6/14/25 apply hydrocolloid to right ischium every three days and as needed. R3's Treatment Administration Records dated 6/14/25 through 6/26/25 document R3 did not get a treatment performed as scheduled to the right ischium on 6/20/25. R3's Initial Wound Evaluation and Management Summary dated 6/19/25 and signed by V14 (Wound Physician) documents, Stage two pressure wound of the right ischium partial thickness. Etiology: Pressure. Stage two. Duration: Less than one day. Wound Size: 1.0 cm by 0.7 cm by 0.1 cm. General Recommendations: Off-load wound, reposition per facility protocol, turn side-to-side in bed, and float heels in bed. Low air loss mattress. Dressing Treatment Plan: Hydrocolloid three times per week and as needed if saturated, soiled, or dislodged. R3's Wound Evaluation and Management Summary dated 6/26/25 and signed by V14 (Wound Physician) documents, Stage two pressure wound of the right ischium partial thickness. Etiology: Pressure. Stage two. Duration: Less than eight days. Wound Size: 1.0 cm by 0.7 cm by 0.1 cm. General Recommendations: Off-load wound, reposition per facility protocol, turn side-to-side in bed, and float heels in bed. Low air loss mattress. Dressing Treatment Plan: Hydrocolloid three times per week and as needed if saturated, soiled, or dislodged. R3's Care Plan dated 3/25/25 through 6/26/25 does not include the physician ordered pressure relieving interventions to provide a low air-loss mattress, off-load pressure to the wound, or float R3's heels while in bed. On 6/26/25 V2 (Director of Nursing) stated, (R3) has had no other Braden Scale Pressure Sore Risk Assessments since admission 3/25/25 and should have had a Braden Pressure Risk Assessment done weekly after admission and after a change of condition. On 6/26/25 from 11:35 AM through 2:00 PM and 6/27/25 at 9:15 AM R3 was lying in bed on her back, on a regular mattress (not low air-loss as ordered by the physician). R3's heels were lying directly on the bed. R3 did not have heel protection boots on, or her heels off-loaded as ordered by the physician. On 6/27/25 at 9:15 AM V2 (Director of Nursing/DON)) performed the wound treatment to R3's right ischium. When removing the hydrocolloid dressing, R3 was moaning and saying ouch. The right ischium wound was approximately 1 cm round pink with reddened skin surrounding the wound. During this time V2 stated, I do not know if (R3's) heels should be off-loaded or if (R3) is supposed to have a low air-loss mattress or heel boots. I will have to look at (R3's) orders. On 6/27/25 at 12:30 PM V16 (Wound Nurse) stated, I did not get (R3) a low air-loss mattress or pressure relieving boots. I do rounds with (V14) and have never looked at (V14's) recommendations. I will make sure I look now. (R3's) air-loss mattress and pressure relieving boots never got added to (R3's) care plan. The staff should always make sure (R3's) pressure is off (R3's) ischium wound and heels. On 6/27/25 at 10:30 AM V14 (Wound Physician) stated the facility should always off-load R3's heels to prevent pressure to the heels and the facility should have contacted hospice to order a low air-loss mattress and prevalon boots for the resident. R3's wound to the right ischium was caused from pressure. R1 and R3's wounds were caused from pressure according to my notes. V14 verified R1, R2, and R3 should have had pressure relieving interventions tried prior to development of pressure ulcers to prevent their (R1, R2, and R3's) pressure ulcers from developing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to ensure the floor was free and clear of trip hazards for one of three residents (R1) reviewed for falls with injury in a sample of four. On 01/05/25, R1 fell at the facility after a cord on the floor of the walkway entering her room became trapped in the wheel of her walker. R1 sustained a laceration to her forehead requiring placement of nine sutures, a skin tear and bruising to her right third finger, and fractures to C1 (first cervical vertebrae) and C2 (second cervical vertebrae), requiring R1 to wear a hard cervical collar at all times. Findings include: R1's Fall Investigation (dated 01/05/25) documents the following: On 01/05/25, at approximately 03:10 PM, RN (Registered Nurse) was notified by CNA (Certified Nursing Assistant) resident (R1) had a witnessed fall. Resident was walking with her walker and assist of one CNA with gait belt in place to the bathroom when resident's walker caught on the bed remote causing resident to lose her balance and fall to her right side. Nurse immediately went to assess the resident upon notification of fall. The resident was observed lying on the floor near the end of her bed with a CNA holding a washcloth to resident's forehead, shoes on with laces tied, walker near feet lying on its side, gait belt in place. RN completed assessment and noted laceration to center of forehead, skin tear to middle finger of right hand with bruising and vitals WNL (within normal limits). Nurse noted resident pain to be a 6 out of 10. CNA continued to apply pressure to forehead and keep resident's head secured until (local ambulance transport service) arrived. Resident is current with hospice care. Resident was transported to (local emergency department) for further evaluation/possible treatment. POA (Power of Attorney), MD (Physician), Hospice, and (V2, Director of Nursing) were notified. Staff interviews conducted post event were completed. CNA stated at approximately 03:10 PM, she was walking resident to the bathroom with resident's walker and a gait belt in place when resident's walker caught on the bed remote causing the resident to lose her balance and fall to her right side. Resident was evaluated in (local emergency department). Resident returned to (facility) 01/05/25 for continued long term care. Diagnosis: Cervical Fracture of C1 & C2 (with Cervical Collar in place) and laceration to forehead with nine stitches. Resident POA (Power of Attorney) chose no surgical intervention at this time and to remain of hospice care keeping resident comfortable. Hospice adjusted pain medication to help ensure resident comfort. Family to provide more frequent monitoring. New interventions put into place, staff educated and care plan updated. POA and MD (Physician) notified and are in agreement with plan of care. R1's 01/05/25 Fall Investigation also documents the following: Evaluation Notes: (R1) is alert with confusion at baseline (Brief Interview of Mental Status score of 3, indicating severe cognitive impairment), (R1) had a witnessed fall in her bedroom while ambulating with CNA (V6, Certified Nursing Assistant), resident's walker got wrapped in the bed remote cord, this is believed to be the root cause of the incident. (R1) obtained C1 and C2 fracture, laceration and bruising as result from this incident. Care Plan reviewed, new intervention: bed remote control fixed to bed. On 02/05/25 at 01:25 PM, V5 (Certified Nursing Assistant) verified her written statement included in R1's 01/05/25 fall investigation and stated the following: I was right across the hall when (R1) fell. (V6, Certified Nursing Assistant) was walking (R1) into her room, and (V6) called out for help after the fall. The right front wheel of (R1's) walker ran over the loose cord that was on the ground in the walkway near the footboard of (R4's, R1's roommate) bed. The cord was hanging from (R4's) bed and it caused (R1) to fall after it got stuck in her walker's wheel. The cord connects to the bed remote, which (R4) cannot utilize due to her Dementia. The cord was still stuck around the right front wheel of (R1's) walker when I entered the room. (R4) had just moved back into that room a day or two before (R1's) fall. The bed remote cord must have become unsecured when (R4's) bed was moved. I went and got (V12, Registered Nurse), who responded to R1's room right away. On 02/05/25 at 03:50 PM, V6 (Certified Nursing Assistant) stated she was the staff member assisting R1 when she fell. V6 stated, The cord from the bed remote of (R4's) bed had came loose. It was dangling from the underneath of (R4's) bed and was sitting on the floor. I was walking with (R1) to the bathroom. She uses a walker when she walks, and I had a gait belt on her. She must have ran over the remote cord hanging from (R4's) bed while we were walking into the room. While we were walking, I felt (R1) suddenly jolt backwards. I'm guessing this is when the cord that was tangled in the wheel of her walker became taut, and this caused her to lose her balance and fall. I tried to stop her, but she just went down so quick. After she had fallen, you could see the cord from (R4's) bed was tangled in the right front wheel of (R1's) walker. She had a big cut in the middle of her forehead, and a skin tear on her right middle finger. (V5, Certified Nursing Assistant) was right across the hall in another resident's room, and I called her to come in the room for help. She came into R1's room, I explained what had just happened, and she immediately went and got (V12, Registered Nurse), who came in right away. On 02/05/25 at 02:30 PM, V9 (Certified Nursing Assistant) stated she was working when R1 fell on [DATE]. V9 stated, I last saw (R1) when she was in the day room. (V6, Certified Nursing Assistant) was walking with her when she fell. The cord from a bed remote got stuck in the wheel of her walker. I saw the cord stuck in the wheel when I entered the room after (R1) fell. On 02/10/25 at 08:30 AM, V12 (Registered Nurse) stated she was the nurse that responded after R1's 01/05/25 fall. V12 verified her written statement form R1's fall investigation, which documents the following: This nurse was called to (R1's) room by (V5, Certified Nursing Assistant) due to resident being on the floor. Resident observed on floor with another CNA (V6, Certified Nursing Assistant) holding wash cloth to resident's forehead, shoes on with laces tied, walker near feet lying on its side, gait belt in place. Upon inspection, resident observed to have a laceration to center of forehead, skin tear to middle finger of right hand with bruising and knot present. Fall witnessed by (V6, Certified Nursing Assistant). Pressure applied to forehead and sent to ER (Emergency Room) for further evaluation. Hospice, MD (Physician), POA (Power of Attorney) and (V2, Director of Nursing) notified. V12 stated due to R1's extensive confusion, she estimated R1's pain to be a 6 out of 10 based on the Wong-Baker Faces Pain Scale (visual analog pain scale used to assess pain in children and adults). On 02/05/25 at 01:45 PM, R1 was reclined in a recliner with a blanket covering her lap near the nurse's station. R1's eyes were closed, and a hard cervical collar was in place around R1's neck. R1 appeared confused, did not open her eyes or respond to verbal stimuli, and was moaning incomprehensible phrases. A moon-shaped scar with well-approximated edges was present in the middle of R1's forehead. A small scabbed area with faint bruising was present on R1's right third digit. R1's (local hospital) emergency department medical record (dated 01/05/25) documents the following: HPI (History of present illness): Patient is a [AGE] year-old female who presents to the emergency department today for evaluation of injuries sustained from a ground level fall. She has a history of advanced dementia and resides at a nursing facility. She is currently enrolled in hospice but due to the size of lacerations involved she was sent here for evaluation and repair of the lacerations. It is reported that she fell forward. Sustained a large laceration to her forehead and a laceration to her right middle finger. (R1) Has also been complaining of some neck pain since the fall occurred. She is not on any form of blood thinners. She did not lose consciousness. She has not had any vomiting since injury occurred. This same medical record also documents, Skin: Positive for wound (large forehead laceration); Comments: 10 centimeter laceration to forehead with visualized portion of skull; Neck: Diffuse posterior neck tenderness; Musculoskeletal: 1.5 centimeter laceration to dorsal aspect of right middle finger. R1's same (local hospital) medical record documents the following: CT (computed tomography) Cervical Spine without Contrast: Cervical: There is an acute, obliquely oriented, complete type II fracture of the base of the dens (second cervical vertebrae). There is no displacement at the fracture site at this time. An acute, nondisplaced fracture of the right-sided posterior arch of C1 (first cervical vertebrae) is also present. R1's (local hospital) emergency department medical record also documents the following: Medical Decision Making: CT (computed tomography) of the head showed no acute fractures or bleeds. Unfortunately, CT of the cervical spine did show a nondisplaced type II dens fracture with a non-displaced posterior arch fracture of C1 on the right side. I did discuss patient's case with (V15, local Neurosurgeon) who was on on-call for Neurosurgery. He notes that this would usually require surgical repair. However, patient is a hospice patient with advanced dementia. Family is very reluctant to have her undergo surgery. (V15) notes if this is the case the only other alternative would be to place patient in (hard cervical collar). Patient's power of attorney had extensive discussion with other family members. It was decided by family and power of attorney that they would forego extensive trauma workup or surgical intervention. They would like patient to be kept as comfortable as possible. They do understand that if patient moves her neck in certain way could lead to neurological defects or death. They would like to respect her wishes and allow her to be discharged back to the nursing facility on hospice. We will provide her with a small amount of Lortab (pain medication) elixir. She tolerated suture procedure of her forehead very well. Dissolvable sutures were placed so she would not have to undergo suture removal. Well, the laceration on her finger could benefit from some sutures. The edges are well-approximated and attempting to repair it has caused her distress. Family is okay with just bandaging the finger for now and letting it heal. On 02/05/25 at 03:20 PM, V1 (Administrator) verified R1 fell as a result of her wheeled walker contacting a cord that was hanging from the foot of R4's bed. V1 verified that R1 has to ambulate past R4's bed to enter her bathroom. V1 verified that R1 returned to the facility after her evaluation in the local emergency department with a C1 and C2 fracture sustained during her fall on 01/05/25, requiring R1 to wear a hard cervical collar. V1 also verified R1 had 9 sutures placed to a large laceration in her forehead, and had a dressing in place on the skin tear sustained to her right third digit after her 01/05/25 fall.