**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. R117's face sheet documents she was admitted to the facility on [DATE] with multiple diagnoses including the presence of a stage 3 pressure ulcer to the left buttock, a stage 4 pressure ulcer to the left lower back, stage 3 pressure ulcer to the sacral region, and stage 3 pressure ulcers to the right upper back and left lower back. On 6/4/25 at 10:25 AM, R117 was lying in her bed with an air mattress, and she was positioned onto her right side with pillows. The skin evaluation forms were requested and reviewed and show the first pressure ulcer assessments were completed on 5/8/25. On 6/5/25 at 9:24 AM, V10 RN, said when a resident is admitted with pressure injuries it is the responsibility of the admitting nurse to perform wound assessments and document them in the wound sheets. She said this should be done on the day of admission. After the initial assessment the resident is placed on wound rounds and will be seen by the wound physician and V6. She said the initial assessment should include the measurements of each wound, and the wound bed description. Based on observation, interview, and record review the facility failed to identify pressure injuries for a resident at risk for pressure ulcers, failed to identify pressure wounds prior to becoming advanced stages, failed to perform an initial wound assessment for a resident with a new pressure ulcer, failed to perform weekly assessments on pressure wounds, and failed to implement treatments upon identification of pressure wounds for 4 of 11 residents (R28, R3, R86, and R117) reviewed for pressure ulcers in the sample of 59. This failure resulted in R28's pressure wound not being treated for 26 days after it was identified and deteriorated to a stage 4 and resulted in R3's pressure wounds not being identified until they progressed to stage 3 and stage 4, and this failure also resulted in R86's sacral pressure wound not being assessed between December 2024 and March 2025 at which time it had progressed to a stage 4. The findings include: 1. R28's face sheet showed he was admitted to the facility 9/21/22 with diagnoses to include anemia, hypertension, atrial fibrillation, primary osteoarthritis of left knee, primary osteoarthritis of left hip, and pressure ulcer of right ankle. R28's care plan initiated 10/3/22 showed, Risk for impaired skin integrity due to incontinence and decreased functional mobility . Approaches: . Daily skin inspection; report any changes in skin or signs of possible skin breakdown or redness . Nutritional support based on assessment and MD (physician) orders . R28's care plan initiated 5/21/25 showed, Pressure Ulcers/Skin Prevention . [R28] has a stage 4 pressure wound to sacrum. Factor complicating wound healing include impaired mobility and occasional incontinence . R28's Dietary Note entered 3/27/25 by V4 (Registered Dietitian) showed, Patient with pressure wound to coccyx . To promote skin health, additionally this writer recommends Active Liquid Protein 60ml/daily. This will provide 200 calories and 30 grams of protein . R28's medical record showed no evidence of R28 receiving the Active Liquid Protein supplement. R28's Wound Assessment Report dated 2/15/25 showed, Date wound identified: 2/15/25 . Wound Location: sacrum; tunneling wound . Present Upon admission: No . Measurements: Length 0.5 cm, Width 0.6 cm, Depth 1.0 cm . Physician Notified: Yes Treatments: Pending treatment orders . This assessment showed no classification of R28's sacral wound. R28's medical record showed no evidence of wound assessments completed for his sacral wound between 2/15/25 and 3/13/25. R28's February 2025 eTAR (electronic Treatment Administration Record) showed no treatments for R28's wound. R28's March eTAR showed an order initiated on 3/13/25 for Hydrocolloid Dressing to Coccyx . for Open wound . (26 days after the wound was identified). R28's Skin Evaluation Form for his coccyx wound dated 3/13/25 showed, . Origin Date: 3/13/25 . Treatment: Hydrocolloid patch to coccyx . Tunneling wound to coccyx . Length 2.0 cm, Width 0.1 cm Depth 1.0 cm . Smooth undermining Sinus Tract: 1 cm . Resident noted to have reopened wound to his coccyx Area cleaned and covered with a hydrocolloid dressing until wound physician can assess. R28's Wound Physician Initial Wound Evaluation dated 3/25/25 showed, . Stage 4 Pressure Wound, Sacrum, Full Thickness . Duration: greater than 60 days . Wound size 2.0 x 0.4 x 0.9 . On 6/05/25 at 12:13 PM, V6 (Wound Care Nurse) said R28's coccyx wound was changed to a sacral wound after it was reassessed. V6 said the floor nurses do the initial wound assessments when the wound is identified on a skin evaluation form. V6 said the wound started out as MASD (moisture associated skin damage) and was real wet and nasty. V6 said the wound opened up then into pressure. V6 said she has a skin assessment for R28 dated 2/26/25 showing no existing skin issues. V6 then said she found a wound evaluation in the electronic record showing a wound assessment from 2/15/25 confirming the wound was present. V6 confirmed the assessment dated [DATE] was a wound assessment. V6 said no further assessments were documented until 3/13/25. V6 said she follows pressure wounds, vascular wounds, diabetic wounds, and arterial wounds but anything surgical, skin tears, MASD the floor nurses follow weekly. On 6/05/25 at 2:31 PM, V2 DON (Director of Nursing) said when the nurses think they see a pressure injury they are supposed to let the Wound Champion (V6) know. V6 would then go evaluate, put treatment orders in place and put him on the list to see V7. V2 said treatments should be initiated as soon as possible for the quickest possible healing for the resident. V2 said assessment of wounds is important to see if the wound has made progress, if the treatment is working, or if something needs to be changed. The nurses are supposed to be doing a skin assessment weekly and documenting the changes. On 6/05/25 at 8:50 AM, V7 (Wound Physician) said he has been seeing R28 for about a month now. V7 said he believes R28's wound was a stage 4 when he started following him. V7 said they should be discovering wounds when they are a stage 1 or 2.V7 said high protein supplements for wound healing and offloading are the two most important measures for pressure ulcer prevention and healing. 2. R3's face sheet showed she was admitted to the facility 10/10/24 with diagnoses to include muscle weakness, moderate protein calorie malnutrition, anemia, hypothyroidism, major depressive disorder, delusional disorder, anxiety disorder, and rheumatoid arthritis. R3's facility assessment dated [DATE] showed she has severe cognitive deficit and is dependent upon staff for all cares. R3's care plan initiated 5/23/25 showed, Pressure Ulcers/Skin Prevention . [R3] will maintain skin integrity without new skin related injuries over the next review period . Observe skin for redness and breakdown during routine care . Follow community skin care protocol . [R3] has impaired skin integrity, has a stage 4 pressure ulcer on sacrum, stage 3 pressure ulcer on left heel, stage 4 pressure ulcer on right heel, stage 4 pressure ulcer to right, upper, lateral shin .provide supplements to promote healing as ordered by physician . R3's medical record showed she was present in the facility from 10/10/24 through 2/23/25. R3's Wound Assessment Report dated 12/19/24 showed, . Date wound identified 12/19/24 . Wound Location: Right Heel; Left outer heel . Assessment Occasion: New Wound . Stage: Unstageable due to slough/eschar . Measurements Length 2.4 cm x Width 3.0 cm . Pain with wound/treatment: Yes . Pain Intensity: Moaning, grimacing . Wound Bed: Eschar 100%. R3's medical record showed she was present in the facility from 4/2/25 through 4/19/25. R3's Skin Evaluation Form dated 4/17/25 showed, . Origin Date: 4/17/25 . Category: Full Thickness Wound . Type: Pressure Injury . Description: Stage 3 Pressure Injury of Right Upper Lateral Shin . Cause: Pressure . Size: Length 1.5 cm x Width 0.3 cm x Depth 0.3 cm . R3's Wound Physician Evaluation dated 4/17/25 showed, . Stage 3 Pressure Wound of the Right, Upper, Lateral Shin, Full Thickness . 1.5 cm x 0.3 cm x 0.3 cm . Duration: greater than 2 days . On 6/05/25 at 12:26 PM, V6 (Wound Care Nurse) said a skin check is done on admission and they put all the same wounds in all over again. V6 said R3 had an immobilizer in place at one time to her right leg from some fractures. V6 said she is not sure where the pressure wound came from to R3's shin. V6 said it could have been the immobilizer but she couldn't say for sure. V6 said the wound was facility acquired on 4/17/25. V6 said she expects new areas to be brought to her through the wound module in addition to notification to the unit manager or herself. On 6/5/25 at 8:50 AM, V7 (Wound Physician) said R3's wound on her right shin was caused by her being in a cast or immobilizer after a fracture. V7 said when they took the immobilizer off there was that wound. V7 said if there was an immobilizer in place covering the leg he would not be looking under that during his rounds. The facility's policy and procedure with revision date of 07/2024 showed, Pressure Injury Assessment/Treatment . Purpose: The purpose of this procedure is to provide guidelines for a consistent method of identification of and for the initial care of identified pressure injuries, alterations in skin integrity, and the prevention of acquiring additional pressure injuries . General Guidelines . Skin risk and general skin assessment is to be completed upon admission and then weekly times 4 weeks. Basic skin assessment is to be completed on residents weekly and as needed . 3. R86's electronic face sheet printed on 6/5/25 showed R86 has diagnoses including but not limited to congestive heart failure, severe protein-calorie malnutrition, pressure ulcer of sacral region, stage 4, and pressure ulcer of left lower back, stage 2. R86's facility assessment dated [DATE] showed R86 has no cognitive impairment and has a stage 2 and stage 3 wound and is at risk for pressure ulcers. R86's wound assessment dated [DATE] showed, Coccyx: irritation/excoriation 1x1x0.5cm(centimeters). Area assessed and is getting better . R86's wound physician assessment dated [DATE] showed, Stage 4 pressure wound of the sacrum, full thickness. Present greater than 30 days, 2.9x1.1x0.7cm, 2.9cm undermining, light serous exudate, 10% slough 70% granulation. Surgical excisional debridement procedure performed during this visit to remove necrotic tissue and establish margins of viable tissue . No wound assessments were present from 12/27/24-3/18/25 for R86's sacral wound. R86's care plan dated 3/19/25 (after initial wound physician visit) showed, (R86) has a stage 4 pressure injury to his sacrum related to noncompliance with repositioning in bed and refusing care. He is also incontinent of bowel. Due to his pressure injury, he is at risk for further deterioration, infection, fluid loss, and pain .float heels in bed, reposition side to side every 1-2 hours . (No pressure ulcer care plan was present for R86 prior to this date) A review of R86's treatment records dated January 2025-February 2025 showed R86's sacral wound treatment was not performed 8 days during the month of January and 4 days during the month of February. R86's skin assessment dated [DATE] showed no new areas of skin concern besides his sacral wound. On 6/4/25 at 8:39AM, R86 stated, I've been sitting like this since 4:30AM and my feet and butt are killing me. (foot of bed elevated and feet turned outward with ankles lying flat and rubbing on bed). I have sores on my butt, I came with one of them, one I think I got here; I'm waiting for them to change my dressings. (R86's right ankle was red and appeared to have a sore on it) They give me a bed bath every few days and wash my whole body because I don't to take a shower. I supposed if there were any sores on my ankles they would have seen them. I can't have my feet elevated because it hurts too much, I've tried everything, and I can't stand it. I wish I had some foam or something on my ankles. the nurse was supposed to put my dressings on my ankle at 4am and she brought the dressings and then left and hasn't been back. On 6/4/25 at 9:24AM, V3 (Registered Nurse) stated, (R86) doesn't have any orders for bandages to his ankles, he has nothing on them so there isn't a reason for a bandage. At 1:10PM (V3) stated, I did look at his ankles and he does have an open area on his right ankle now. That should have been noted during his bed bath or skin checks, but it wasn't. I put some padded dressings on to keep them covered until the wound nurse & doctor see him tomorrow. On 6/5/25 at 8:49AM, V7 (wound physician) stated, Facility acquired wounds should not be identified as stage 3 or 4, they should be identified at stage 1 or 2. (R86) has a new wound to his right ankle that is a stage 2. This should have been identified by staff during cares and his heels should have been elevated. It was resolved for a few weeks and now it is back. I am assuming because his heels are not being elevated. There are different strategies the facility could be using for pressure reduction. Some patients don't like the boots, so you need to be mindful of that, just using a heel protector is not enough, he has a special pillow, and I don't know why they aren't using it, the heels up device is the best for him but he is noncompliant with certain things. He must have something instead of the feet resting on the mattress, plain and simple. I didn't know he was refusing the heels up device otherwise I would have tried something different for him. He is a high risk for skin breakdown due to his noncompliance and lower weight because he doesn't have a lot of fat on him. They should be keeping a very close eye on him. You should not have identified his new wound, that should have been identified by the staff. On 6/5/25 at 2:47PM, V6 (wound champion) stated, I checked in our old charting system and there are not any assessments for (R86's) wound from 12/27/24-3/18/25. It is the responsibility of the floor nurse's to ensure these wound assessments and treatments are being done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to assist a resident at risk for falls with reaching his urinal (R58), and safely transferring a resident with a mechanical lift (R23 and R2). This failure resulted in R58 falling and obtaining a fractured hip and wrist requiring surgery and hospital stay. The applies to three of eleven residents reviewed for safety in the sample of 59. The findings include: 1. The facility face sheet shows R58 was admitted to the facility with diagnoses to include adult failure to thrive, Type 2 Diabetes Mellitus, chronic kidney disease and low back pain. R58's facility assessment dated [DATE] shows he has no cognitive impairment and required maximum assist from staff for standing and toileting. On 6/04/25 at 2:18 PM, R58 said he was standing up at the foot of his bed reaching for his urinal. R58 said his legs gave out and he fell. R58 said he had his call light on because he could not reach his urinal. R58 said after half an hour he tried to do it himself and fell. R58 said he felt his hip break when he fell. R58 said he had to yell for help from the staff. R58 said because he is younger and has his wits about him the staff thinks he is independent. On 6/05/25 at 8:44 AM, V10 Registered Nurse (RN) said she was in the hall passing medications, when she heard someone yelling help me. V10 said she walked up and down the hall trying to find the source of the yelling and heard R58 yell out his room number. V10 said she found R58 on the floor at the foot of his bed near the bathroom door. V10 said she performed an assessment and felt due to the pain level, he probably had a fracture to his hip. V10 said R58's urinal was on the other side of the bed from where R58 had been sitting. V10 said she phoned 911 and R58 was sent to the hospital. On 6/5/25 at 11:22 AM, V9 Unit Manager said she investigates the falls for the facility, but if there is an injury, the Director of Nursing (DON) takes over the investigation. V9 said she did not talk to R58 about his fall, she just copied some papers for the DON. On 6/5/25 at 11:22 AM, V2 DON said during the facility investigation into the fall they determined R58 did not have his call light on. V2 said she believed R58 was in his wheelchair when the fall happened but wasn't sure. V2 said all falls are investigated to find the root cause of the fall so interventions can be put in place. The new interventions for R58 were to keep his personal items within his reach and provide R58 with a reacher/grabber tool. The facility investigation showed R58 was trying to grab something, stood up and fell. A reacher/grabber was to be given to R58 and all personal items needed to be within his reach. The nursing progress note dated 4/21/25 for R58 showed the nurse could hear someone yelling for help and she found R58 on the floor lying on his right side. The nurse (V10) wrote that R58 said he was moving around in his chair and slid out of the wheelchair. R58 said after the fall he rolled onto his other side. R58 said he broke his fall by putting down his left hand so he wouldn't hit his head. The note shows R58 was complaining of pain to his left hip. The fall risk assessment completed on admission dated 3/14/25 shows R58 was a moderate risk for falls. The hospital records dated 4/29/25 shows R58 arrived at the hospital on 4/21/25 with complaints of left hip pain after a fall at the facility. Diagnosis after x-rays showed an acute mildly displaced left hip fracture. Surgery to repair the hip was completed on 4/22/25. An x-ray of R58's left wrist was completed on 4/21/25 and a fracture to his left wrist was also found. The care plan for R58 dated 4/29/25 for falls shows the interventions to have personal items within his reach due to his risk for falls, repeated falls, weakness and malnutrition. The same care plan shows R58 required one staff assistance for toileting. 2. The facility face sheet for R2 shows she was admitted to the facility for diagnoses to include Type 2 Diabetes Mellitus, peripheral vascular disease, muscle weakness and stress incontinence. The facility assessment for R2 dated 5/24/25 shows R2 to be cognitively intact, requires a wheelchair for mobility. The same assessment shows R2 is dependent on staff for toileting. R2's care plan dated 2/25/25 shows a sit to stand mechanical lift is used for transfers. On 6/4/25 at 10:0 AM, R2 said she was being moved in the sit to stand lift from her bed to the bathroom one morning and she slipped out of the lift and fell on the floor. R2 said there were two staff in the room with her and she did not get hurt. R2 said her feet slid and now she is supposed to wear her tennis shoes when she gets up in the lift. R2 said she was wearing her house shoes when the fall happened. On 6/05/25 at 10:16 AM, V19 Certified Nursing Assistant (CNA) said she was pushing R2 in the sit to stand lift to the bathroom from her bed and R2 just slipped out. V19 said R2 was wearing house shoes and R2 never said anything to her before she fell, or after she fell. The written statement given by V19 after the fall shows R2 was strapped onto the lift and was being pushed into the bathroom, when R2 began telling the staff to bring the lift up higher. Then V19 wrote she began to see R2's weight begin to go to one side and R2 kept saying to raise the lift, but the lift was as high as it goes. (V19 denied this conversation with R2 when I spoke with her on the phone.) On 6/05/25 at 11:05 AM, V20 Licensed Practical Nurse (LPN) said she was called to R2's room after her fall. V20 saw R2 on the floor with her arms out of the stand slings and her feet over the leg of the lift. V20 said R2 told her she felt herself slipping and told the staff to raise her up. On 6/5/25 at 11:16 AM, V9 Unit Manager said R2 told her feet just slipped while she was being transported to the bathroom. V9 said R2 was wearing her house shoes. The nursing progress note dated 5/17/25 shows the CNA informed the nurse that R2 had fallen out of the sit to stand lift and was on the floor. The nurse (V20) wrote R2 was found on the floor with both legs in front of her body and on top the legs of the machine. R2 told the nurse she felt herself slipping. The care plan for R2 dated 5/14/25 for falls shows an intervention to ensure R2 has non-slip footwear at all times. A new intervention was added after the fall on 5/17/25 to ensure R2 has tennis shoes on before using the sit to stand lift. The fall risk assessment for R2 dated 2/16/25 shows a significant risk for falls. The facility fall investigation showed R2 felt herself slipping from the lift because her shoes did not have a good grip. The new intervention put in place was for R2 to wear tennis shoes when using the lift. 3. The facility face sheet shows R23 was admitted to the facility with diagnoses to include congestive heart failure, chronic obstructive pulmonary disease and cerebral infarction. The facility assessment dated [DATE] shows R23 to be cognitively intact and requires substantial assistance from staff for dressing and transfers. The care plan for R23 dated 5/15/25 shows he needs two assist with a gait belt for transfers. On 6/03/25 1:04 PM, R23 was observed with a black left eye. R23 said he hit by the lift when transferring out of bed. At 2:01 PM that same day, R23 said he was connected to the sit to stand lift and as he was being lifted up, he reached for a shirt that was hanging on the lift and as he was falling forward, he hit his head on the bar of the lift. On 6/5/25 at 11:08 AM, V20 LPN, said she was called to the room after being told R23 fell. V20 said she found R23 on his back with his legs crossed. V20 said the CNA told her he was not in the lift yet, but he fell when he reached forward to grab his shirt off the lift. V20 said the CNA said she left R23 sitting on the edge of the bed while she went to his closet to get him some clothes and she saw him lean forward and fall. V20 said R23 had a cut to his left eyebrow area that was beginning to swell, a scrape to his left knee and left ankle. On 6/5/25 at 11:19 AM, V2 DON said she had not interviewed R23 about his fall and was not aware R23 was saying he was already in the lift when he fell. V2 said she was told R23 was reaching for clothes while sitting on the edge of the bed and he fell forward off the bed. The facility investigation shows R23 was being assisted by staff with his morning routine, he reached for his shirt and fell to the floor. A written statement written by the CNA involved from the initial facility investigation shows R23 was sitting on the edge of the bed and the CNA V21 was at the closet getting clothes out, and the resident leaned forward and fell hitting his eye on the lift. The intervention added was to ensure the residents clothes are within his reach when sitting him up for AM care. The facility policy for fall prevention with a revision date of 7/2023 shows to provide an environment that is free from accident hazards, over which there is control, and provide supervision and intervention to residents to prevent avoidable accidents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure accurate weights were obtained, failed to ensure significant weight loss was identified and reported to the dietitian, and failed to implement dietitian recommendations for 4 of 6 residents (R28, R3, R55, R41) reviewed for nutrition in the sample of 59. This failure resulted in R28 experiencing significant weight loss without the Registered Dietitian being notified. The findings include: 1. R28's face sheet showed he was admitted to the facility 9/21/22 with diagnoses to include anemia, hypertension, atrial fibrillation, primary osteoarthritis of left knee, primary osteoarthritis of left hip, and pressure ulcer of right ankle. R28's care plan initiated 10/3/22 showed, Risk for impaired skin integrity due to incontinence and decreased functional mobility . Approaches: . Nutritional support based on assessment and MD (physician) orders . R28's care plan initiated 9/28/22 showed, [R28] has increased potential for weight changes related to diuretic use . Goal and Target . Intakes to meet needs, Weight remain without significant changes . Medications per MD order . weigh resident per facility protocol. Record results and report any significant change to physician and dietitian . R28's weights were documented as follows: 5/22/25 - 226.4 lbs; 5/23/25 - 227.6 lbs; 5/24/25 - 226.7 lbs; 5/28/25 - 214.0 lbs; 5/29/25 - 214.0. These weight changes represented a significant 5.6 % weight loss from 5/22/25 through 5/28/25. R28's Nutrition Note entered 3/27/25 by V4 showed, Patient with pressure wound to coccyx . additionally, this writer recommends Active Liquid Protein 60 ml/daily. This will provide 200 kcal and 30 grams protein. On 6/05/25 at 9:56 AM, V4 RD (Registered Dietitian) said, They didn't notify me of that change, he is a monthly weight, so we obtain his weight the first shower of the month. I question the weights. It was as of yesterday that I was notified of his weight being 216. When I visibly look at him his chest and abdomen area does seem smaller. I think the readmission weight may have been incorrect because he was in the hospital . He comes out to the dining room to eat and when he first came back he wasn't wanting to eat. He used to eat 100% of his meals and he is telling me he isn't wanting to eat as much now. When they enter a weight, if it is significantly off I think it sends them a notification but I think there may be an issue with how it calculates the changes as 30 day, 60 day, 90 day changes. The nurses monitor the weights and let me know if there are changes. My hope would be after they enter the weight, it would be good practice to then look at their weight history to see if they have had a significant weight change . On 6/05/25 02:29 PM V2 DON (Director of Nursing) said the RD's dietary recommendations would be handed off to the unit manager or the nurse on the floor. The recommendations would be communicated to the Nurse Practitioner and they would give it as order. 2. R3's facesheet showed she was admitted to the facility 10/10/24 with diagnoses to include muscle weakness, moderate protein calorie malnutrition, anemia, hypothyroidism, major depressive disorder, delusional disorder, anxiety disorder, and rheumatoid arthritis. R3's facility assessment dated [DATE] showed she has severe cognitive deficit and is dependent upon staff for all cares. R3's care plan initiated 5/23/25 showed, Nutritional Status; [R3] has increased nutrient needs related to need for healing as evidenced by history of stage 4 pressure wound to sacrum. Also as increased potential for pressure wounds related to limited mobility. [R3] will have nutritional needs met and will not have an unplanned significant weight change over the next review period . R3's Nutrition Risk assessment dated [DATE] showed, . Current weight: 120 pounds . Nutrition: Increased nutrient needs related to need for healing as evidenced by presence of multiple pressure wounds . Interventions: Diet as ordered . Continued 1:1 assistance at meals. Goals: . weight remain stable. R3's medical record shows the last weight obtained for R3 was 120 pounds on 5/10/25. R3's medical record showed she was discharged to the acute care hospital 5/20/25 and returned as a readmission to the facility 5/23/25. R3's record contained no weights between her return to the facility 5/23/25 and 6/5/25. On 6/05/25 at 10:32 AM, V4 RD (Registered Dietitian) said R3 came back from the hospital 5/23/25 and no weights have been done since her readmission. V4 said R3's record showed a significant weight loss prior to her hospitalization but she feels that the weight that had been entered on 4/2/25 was not accurate. V4 said if a reweigh was done and a weight confirmed her record would show confirmed next to it. V4 said R3's 127 lb weight was not confirmed but R3 usually stays around 120 lbs. V4 said upon admission or readmission the facility policy is to get a weight every day for 3 days, then once weekly for 4 weeks, and if stable they would start doing monthly weights to monitor. V4 said she would have expected them to get readmission weights. V4 reviewed R3's record and said weekly weights were scheduled on the eMAR (electronic Medication Administration Record) but none of them were signed off. V4 said it is important to get readmission weights so she can assess R3 for significant loss. V4 said if she doesn't have those weights she has nothing to compare them to. On 6/05/25 at 2:21 PM, V2 DON (Director of Nursing) said weights are done with the first shower of the month, so they are all in the system by the 7th. V2 said the CNAs are getting the weights and entering them in the system and if they don't enter them sometimes the nurses do. V2 said if there was a significant change the system should flag it and it asks them if they really want to enter it. V2 said she does not know how the Registered Dietitian gets notified of significant weight changes. V2 said V4 (Registered Dietitian) should be looking at the weights at least every month. V2 said if there is anyone that has significant weight loss V4 would be documenting it and talking about it in their meetings. V2 said V4 should be able to print out all the residents weights every month. If there is a reweigh needed V4 will ask us for that. V2 said V4 is the expert with weight loss, she is the one who can give us the input on recommendations. V2 said it is V4's expertise the facility relies on for recommendations for getting supplements in place if needed. The facility's policy and procedure with approval date 06/2025 showed, Weight Monitoring . It is the policy of [the facility] that appropriate nutritional care shall be provided to residents who have a significant weight change. A significant weight change is identified as a weight loss or gain of 5.5% in 30 days, 7.5% in 60 days, or 10% in 180 days. Each resident should be weighed daily for the first three days of admission, weekly for the first four weeks, and monthly thereafter . Residents with a weight change of 5 lbs or greater should be reweighed to determine an accurate weight. The accurate weight should be entered in the resident's medical record . The RD should make recommendations for nutritional interventions based on the information obtained from the weekly Resident At Risk Review huddle meetings. RD recommendations should be reviewed and initiated by nursing associates . A nursing or nutrition associate should notify the health care provider of any significant weight change that is unexplainable or in which the RD has requested a nutritional intervention . 4. R55's Face Sheet showed she was admitted to the facility on [DATE] with diagnoses to include Alzheimer's (dementia), a Stage 4 pressure ulcer, and a hip fracture. R55's active order set showed an order for monthly weights, which was ordered on admission. R55's electronic health record (EHR) showed she weighed 154.6 pounds on 2/11/25; 142.8 pounds on 3/23/25; and 132.4 pounds on 4/4/25. R55's EHR showed this was a weight loss of 14.3 percent. R55's electronic health record showed no weight documented following the 4/4/25 weight as of 6/3/25 at 4:00 PM. R55's 5/21/25 progress note from 12:58 PM (Authored by V4, Registered Dietitian) showed: Late Entry for month of May. Resident weight for month of May not documented [in] EMR (electronic medical record). Will assess weight trend when June weight measurement received . On 6/04/25 at 1:44 PM, V15, Registered Nurse, stated monthly weights are done for all residents with the first shower of the month. V15 stated the CNAs (Certified Nursing Assistants) will notify her of the resident's weight, and she will enter the weight in the electronic health record. V15 stated the facility does not document weights in any other location other than the electronic health record. V15 stated R55 does not refuse care. On 6/04/25 at 1:59 PM, V16, Certified Nursing Assistant (CNA), stated CNAs measure residents' weights on their first shower of the month. V16 said the CNA will notify the nurse of the weight. V16 said CNAs can also enter weights into the EHR. V16 said she is R55's CNA, and R55 does not refuse care. On 6/04/25 at 2:21 PM, V4 stated R55 should have been weighed in May 2025 when she had her first shower of the month. V18 said she had noticed the missing weight in May, and per her normal practice, she would have sent a list of residents with either missing weights or weights that needed to be redone. V18 said monthly weights are important so she knows if her interventions are working and if they need to be adjusted to the unit manager. (The facility was requested to weigh R55.) On 6/04/25 at 03:42 PM, V2, Director of Nursing, stated R55's weight was 150 pounds. The facility's Weight Monitoring policy (last approved 6/2025) showed: Each resident should be weighed daily for the first three days of admission, weekly for the first four weeks, and monthly thereafter . 3. R41's electronic face sheet printed on 6/5/25 showed R41 has diagnoses including but not limited to epilepsy, acute kidney failure, Bipolar Disorder, Alzheimer's Disease, and type 2 diabetes. R41's facility assessment dated [DATE] showed R41 has experienced a weight loss and is not on a physician-prescribed weight-loss regimen. R41's care plan dated 2/25/25 showed, (R41) has increased potential for weight changes related to fluctuating intakes. Has a history of both significant weight gains and losses .(R41) is offered diet and oral nutritional supplement as prescribed, see physician order sheet. R41's Nutrition Risk assessment dated [DATE] showed, Comments/Recommendations: Interventions: Diet as ordered. Recommend Ensure 240ml once daily. This will provide 350kcal and 20g protein . R41's physician's orders for May 2025 and June 2025 showed no orders for R41 to receive a nutritional supplement. On 6/5/25 at 9:40AM, V4 (Registered Dietician) stated, The last time I reviewed (R41's) nutritional status was on May 12th and her weight had stabilized at that point since her previous significant weight loss. She is a picky eater, and I didn't want her weight to go down at all if possible, so I recommended a daily nutritional supplement for her. My recommendations go to the physician or nurse practitioner for each resident to approve. I put the recommendations in their box so they can sign off on it and then nursing enters the orders. I don't see the order for her supplement in her record though so I'm not sure what happened. If there isn't an order, then she won't receive it. The facility's policy titled, Weight Monitoring dated 01/2023 showed, It is the policy of (facility) that appropriate nutritional care shall be provided to residents who have a significant weight change .E. The RD (Registered Dietician) should make recommendations for nutritional interventions based on the information obtained from the weekly Resident at Risk Review huddle meetings. RD recommendations should be reviewed and initiated by nursing associates .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R95's Physician Orders Summary for August 2024 shows an order, with a start date of 1/23/24, for oxygen at 2-4 liters continuous, and an order with a start date of 2/24/24, for (ear protectors) applied to oxygen tubing at all times. R95's current Care Plan shows he has a self care deficit and requires extensive staff assistance for his Activities of Daily Living due to weakness. The Care Plan also shows on 7/17/24 he was found to have stage 2 pressure ulcer behind his right ear. A Wound Assessment Report completed on 7/17/24 shows R95 has a new facility acquired stage 2 pressure ulcer measuring .30 cm long, X .30 cm wide, X .20 cm deep with a scant (small) amount of serous (clear) drainage. A Braden Risk Assessment reported, completed 7/17/24, shows R95 is at high risk to develop a pressure injury. On 8/5/24, at 10:30 AM, R95 was lying in bed with his wife at his bedside. R95 had oxygen running via a nasal cannula tubing which was behind both ears. Behind and under his right ear were some gauze bandages, and behind his left ear wrapped around the tubing was a Styrofoam circular tube. On 8/6/24 at 11:42 AM, V7 (R95's spouse) said, He (R95) has been on oxygen continuously since he has been at the facility and he has a sore behind his ear from the oxygen tubing. The grips they use on the tubing are useless, they slide around all the time and fall off when staff reposition him. I come to the facility every day and sometimes the grips are just lying on his bedside table and not even on the tubing. On 8/6/24 at 1:02 PM, V4 (Wound nurse) said the oxygen tubing around R95's ear caused a stage 2 pressure injury. V4 said they use (ear protectors-- grips like a foam pool noodle) to try to prevent it, but they are not effective they don't stay in place and they pop off the tubing from him moving. On 8/7/24 at 9:16 AM, V6 (Regsitered Nurse/RN) said R95's tube grips fall off and slide around. He said he is unaware of any other interventions that were tried to prevent the pressure injury. V6 said the staff do not do daily checks behind the ears of residents on oxygen; they check when a resident is bathed, or once a week on skin check days and oxygen tubing change days. The facility provided Pressure Injury Assessment/Treatment policy, revised 7/2024, shows pressure relieving devices should be observed for effectiveness and interventions changed or implemented to prevent the development of pressure injuries. Based on observation, interview, and record review, the facility failed to assess and notify the wound care physician with changes in a pressure injury, and failed to implement pressure relieving intervention to prevent a pressure injury. This applies to 2 of 8 residents (R95 & R100) reviewed for pressure injuries in the sample of 23. These failures resulted in R100's pressure injury deteriorating to an unstageable pressure injury. The findings include: 1. R100's face sheet lists his diagnoses to include: nondisplaced intertrochanter fracture (hip fracture), type I diabetes mellitus, and coronary heart disease. R100's wound assessment report, dated 7/3/24 shows a newly identified stage 1 pressure ulcer was found on his right heel. The pressure ulcer measured 7.00 cm (centimeters) X 5.00 cm. R100's care plan, with problem onset of 7/10/24, shows, Problem/Need: Pressure ulcer stage 2 to right bottom heel. Approaches: Measure wound at least weekly. Record HxWxL (height x width x length), appearance, amount and odor of any drainage. Report any decline in would status to physician. R100's local hospital vascular surgery progress notes, dated 7/22/24 show, This is a [AGE] year-old gentleman who has a history of insulin dependent diabetes. Most recent A1C (blood check for insulin) from April of 2024 A1C 7.7. He has been following with podiatry for tissue loss. He unfortunately had a left hip fracture and was admitted to rehab From the standpoint of his lower extremity vasculature he has normal toe pressures bilaterally. On the left his ABI (ankle brachial index) is likely falsely elevated secondary to medical calcinosis with the waveform morphology demonstrates small T-wave phasic waveform. On physical exam he has clearly audible posterior tibial signal. From the standpoint of his lower extremity aterial perfusion I do believe with his toe pressure within normal limits he has enough perfusion to heal this superficial wound to the posterior heel We would recommend continued local wound care either with the podiatry clinic or with the wound care center. R100's wound assessment report dated 7/30/24 shows the same pressure ulcer was now a stage 2 measuring 3.00 cm X 3.00 cm with 5% slough and 95% granulation. Stage 2 pressure ulcer to bottom of right heel/foot assessed. Wound continues improving . On 8/7/24 at 9:05 AM, V4, Wound Care Nurse (WCN), stated R100 had a pressure ulcer on his heel that was healing. She sees him weekly to do assessments, otherwise, the floor nurses do the dressing changes daily. R100 had gone to a vascular appointment on 7/22/24 that was previously scheduled prior to admit to the facility. At that appointment, they did a doppler to check the pressures in his legs. They did not find anything significant and referred him to a wound care doctor to follow for his pressure ulcer. She stated he has not seen any wound care doctors yet and does not have any appointments set up. On 8/7/24 at 10:00 AM, R100 was lying in bed. He had a quarter size black soft circular wound to his right heel. He winced in pain when V4, WCN (Wound Care Nurse), removed the dressing and pressed in the middle of the wound. He stated the wound hurt and was painful. At 10:40 AM, V4, WCN, stated, The wound has deteriorated in one week since I last saw it. Now it has eschar (dead tissue). I would expect the floor nurses to notify me and the doctor of any changes in the wound. She had not heard anything about any changes in the wound. On 8/7/24 at 10:35 AM, V11, Wound Care Doctor, stated, If the wound is soft (boggy) as being described, I would call it an unstageable necrosis. I would expect the facility to manage a stage 1 or 2 pressure injury, but beyond that they should be consulting with someone with experience (him or an outside wound care clinic). The facility's Procedure: Pressure injury assessment/treatment, dated July 2024, shows, Purpose: The purpose of this procedure is to provide guidelines for a consistent method of identification of and for the initial care of identified pressure injuries, alterations in skin integrity, and the prevention of acquiring additional pressure injuries Definitions and descriptions: B. Pressure injury: A localized injury to the skin and/or underlying tissues as a result of pressure or pressure in combination with shear/friction. Pressure injuries usually occur over a bony prominence and are staged to classify the degree of damage. I. Eschar tissue: Dead or devitalized tissue that is hard or soft in texture; usually black, brown or tan in color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/edges of the wound Stage 2 Pressure injury: Partial-thickness loss of skin with exposed dermis. The wound bed is 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 visible, Granulation tissue, slough and eschar are not present Unstageable: Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough (yellow, tan, gray, green or brown) or eschar (tan, brown or black) in the wound bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a safe transfer for a resident. This failure resulted in R1 being transferred without a stand lift device and sustaining a spiral fracture to her right tibia and fibula. This applies to 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 8. The findings include: The Diagnosis/History Report, dated 11/14/23, showed diagnoses including iron deficiency anemia, hypothyroidism, atrial fibrillation, congestive heart disease, chronic obstructive pulmonary disease, cellulitis of left lower limb, neuralgia, neuritis, contusion of left lower leg, and transient ischemic attack. R1's Minimum Data Set, dated [DATE], showed she needs substantial/maximal assistance for transfers. R1's Care Plan Card, dated 6/28/23, showed she was to be transferred with a stand lift and two people. The Facility Reported Incident, dated 11/8/23, showed R1 was observed with swelling and tenderness to her right lower extremity on 11/7/23 at 12:30 PM. The physician was notified and orders were received to send R1 to the hospital. An X-ray was performed at the ER (Emergency Room), which indicated an acute fracture of the right distal tibia and distal fibula. The resident returned to the facility at 4:04 AM on 11/8/23, at which point the facility became aware of the fracture diagnosis. Resident states her pain began after she was transferred into her bed at bedtime on 11/6/23. Investigation initiated immediately. The hospital emergency room Triage Note, dated 11/7/23, showed R1 went to the hospital with a chief complaint of lower right leg swelling. The After Visit Summary, dated 11/7/23, showed an X-ray was done of R1's right leg (tibia-fibula) for ankle pain with the twisting motion, generalized tenderness to palpation of the ankle and distal tibia and fibula. The findings showed an acute oblique fracture of the distal tibia. Acute nonocclusive fracture of the distal fibula. An X-ray was done of R1's right ankle and showed the resident stated her ankle was twisted when she was lifted from a chair. The findings showed and acute mildly displaced fracture of the distal fibula. An oblique nonocclusive fracture of the distal tibia extending through the medial malleolus. The facility's interview, dated 11/8/23, with V6, CNA (Certified Nursing Assistant), showed V6 stated she was assigned to R1 on 11/6/23. States R1 was to weak to use the stand lift. V6 stated that she pivot transferred the resident into bed. The facility's interview, dated 11/9/23 with V6, CNA, showed, V6 stated she was aware at the last meeting that staff was told to do a mechanical lift if the patient cannot stand with the stand lift. When asked why she pivot transferred the resident when she felt the resident could not safely complete a stand lift transfer? V6 stated she did not attempt to place the mechanical lift sling under the patient, as she did not feel the patient could safely stand, so she could place the sling. V6 stated she did not try to get help, as other staff were also busy with patient cares. On 11/14/23 at 9:37 AM, V1 (Administrator), V2, DON (Director of Nursing), and V5 (Quality Director) were present for an interview together regarding an injury that occurred to R1's right leg during a transfer on 11/6/23. V1 stated they started an investigation and identified V6, CNA (Certified Nursing Assistant), as the staff member that transferred R1, by standing and pivoting R,1 instead of using the stand lift. V1 stated V6 did not transfer R1 how she was supposed to, which lead to a fracture of R1's (right) leg. V5 stated therapy had evaluated R1 for weakness and had decided the safer transfer for R1 would be to use the stand lift. V1 stated on 11/6/23, R1 was being transferred to bed when this happened. R1 and the staff were interviewed. R1 did not complain of pain until 11/7/23 in the morning. Some pain for R1 is normal due to her history of cellulitis and nerve pain in her legs. On 11/14/23 at 10:06 AM, V5 (Quality Director) stated, (V6, CNA) said she attended the meeting on 10/4/23, that talked about transfers. Staff cannot upgrade transfers they can only downgrade. An example would be if a resident uses a sit to stand for a transfer, the CNA can use a mechanical lift and let the nurse know. The CNA cannot do a stand pivot transfer (upgrade in transfer) instead of the stand lift. V5 stated V6 attended the meeting and knew this. On 11/14/23 at 12:56 PM, V8, CNA, stated they know how to transfer a resident by looking at the care plan in the resident's closet. The care plan will say if the resident is a 1 assist, 2 assist, stand lift transfer etc. V8 stated all mechanical lifts are 2 assist. V8 stated she uses a gait belt for all stand pivot transfers. V8 stated she always transfers a resident by what is on the care plan for the resident's safety. On 11/14/23 at 2:25 PM, R1 stated an orderly broke her leg. R1 stated the orderly did not use the machine to transfer her. R1 stated she was told she could be moved without it. R1 stated she told the person she could not stand. R1 stated the person that transferred her did not use a transfer belt. The orderly picked her up, her leg twisted and it felt different. R1 stated she had pain when it happened, and the pain went away when she laid down. R1 stated she thinks she was in shock or something when this happened. R1 stated the next morning she had pain again. On 11/14/23 at 3:09 PM, V6, CNA, was contacted for an interview. A message was left, and V6 never returned the call. On 11/14/23 at 3:35 PM, V4, LPN (Licensed Practical Nurse), stated on 11/7/23, she was the nurse for R1 and another nurse came to her and stated V15 (R1's daughter) wanted R1 sent out to the hospital. V4 stated she went to R1's room, and V15 wanted her to look at R1's right leg; it was more swollen than the left leg. V4 stated she did not do any range of motion to R1's legs. R1 was sent to the hospital and had a fracture to her right leg. V4 stated she did not know about the transfer the night before until after this happened and they told her about it. On 11/15/23 at 9:41 AM, V14, PT (Physical Therapist), stated, They were using the stand lift for (R1's) transfers. Everyone knew they had to use the stand lift; it is on the care plan for (R1). If staff are unsure they will clarify the transfer with us during the day shift. It is important to follow the care plan for the residents safety. Some residents may not be safe to transfer any other way, anything can happen and someone could get hurt. The facility's Safe Lifting and Moving of Patients policy (1/2022) showed, in order to protect the safety and well being of associates and residents, and to promote quality of care, this community uses appropriate techniques and devices to lift and move residents. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding safe lifting and moving of residents. Manual lifting of residents shall be eliminated when feasible. Nursing associates, in conjunction with rehabilitation associates, shall assess individual residents' needs for transfer assistance on an ongoing basis. Associates will document resident transferring and lifting needs in the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview, and record review, the facility failed to monitor a resident's weight who was experiencing weight loss, and failed to provide the ordered follow-up consults with the Dietician. This applies to one of one resident (R95) reviewed for weight loss in the sample of 23. These failures resulted in R95 experiencing a 15% weight loss. The findings include: The facility face sheet shows R95 was admitted to the facility on [DATE], with diagnoses to include congestive heart failure, repair of left hip fracture, and chronic kidney disease. The facility assessment, dated 5/25/23 for R95, shows her to cognitively intact and requires extensive staff assistance for bed mobility and transfers. The facility care plan for R95 shows on 5/25/23 a problem for weight loss/appetite was added to her care plan with a goal to maintain her current weight and her skin to remain free from pressure wounds. (R95 has a stage 3 pressure wound). Interventions include to weigh the resident as ordered and to record the results and report any significant change to the Physician and Dietician. The facility list of weights for R95 shows a weight of 116.8 pounds on 5/20/23, and on 7/12/23, R95 weighed 98.6 pounds. This is a 15 % weight loss for R95. The Physician Orders for R95 shows on 5/19/23 an order for daily weights. On 6/29/23 an order for weight to be checked every Monday, Wednesday and Friday. The facility weight list for R95 shows weights were not checked daily or three times a week. A gap from 6/17/23 to 7/9/23 shows no weights were obtained. The Physician orders for R95 shows on 6/22/23 an order was written for Dietary follow-up due to poor appetite and weight loss. On 6/25/23, another order was written for R95 to have a dietician consult related to a wound. R95's clinical record shows neither consult was completed. The nutrition risk assessment, dated 5/26/23 shows R95 to be at risk for malnutrition and interventions of daily weight was recommended. On 7/13/23 at 10:50 AM, V5, Dietician, said she was aware R95 was losing weight, and said she has been following up on it. V5 said she should have documented the interactions she has had with R95. V5 said she was not aware of the Physician order consult, and the computer had not alerted her to R95's recent weight loss. V5 said she would expect her weight to recorded daily as ordered, so her overall condition could be monitored. On 7/13/23 12:38 PM, V2, Director of Nursing/ DON, said, Weights should be monitored as ordered. It's important to monitor for weight loss or gain as they are an indication for underlying health issues. The facility policy, with a revision date of 1/2023, for weight monitoring shows appropriate nutritional care shall be provided to residents who have a significant weight change. A significant weight change is identified as a weight loss or gain of 5% in 30 days, 7.5% in 90 days or 10% in 180 days. C. a report should be generated from the electronic medical record system identifying all residents with a significant weight change F> A nursing or nutrition associate should notify the health care provider of any significant weight change .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to safely transfer a resident with a stand lift for one of three residents (R2) reviewed for safety in the sample of eight. This failure resulted in a probable hairline fracture to the right ankle. The findings include: R2's Physician Orders for January 2023 shows R2 was admitted to the facility on [DATE], with diagnoses including: Chronic atrial fibrillation, hypertension, bilateral primary osteoarthritis of knee, and history of falling. The facility's Serious Injury Incident Report, dated 1/27/23, shows R2 experience a fall with physical harm or injury on 1/24/23. The incident report shows R2 transfers with a mechanical lift and is interviewable. On 1/24/23, resident was assisted into be using (stand lift) but resident was not far enough back on the bed and began sliding and was assisted to the floor. Upon assessment by the nurse, right ankle was swollen and has a 5 centimeter bruising on the outer side and upon palpation, resident did complain of pain. Provider notified and ordered X-ray to right ankle and 1/26/23 X-ray came back with a probable hairline fracture to the right ankle. R2's Care Plan problem, dated 11/20/21, shows, (R2) has a history of falling related to pain and weakness as evidenced by right femur fracture. 1/25/23-CNA/Nurses to ensure bed is lowered to appropriate height (at the bed of the knee) for transfers with the (stand lift). Problem, dated 1/25/23, New pain as reported by (R2) following injury to right ankle. R2's Pain Evaluation, dated 1/25/23, shows R2 was experiencing pain to her right ankle when she moved it. Moving around R2's ankle increases her pain. The facility's Coaching Feedback shows V3, CNA (Certified Nursing Assistant), was educated on 1/27/23 in regards to safe transfers using (stand lift). Listening to patient/resident, being a patient advocate and ensuring bed is at the appropriate height during transfers to prevent falls/injuries were listed as the specific skill or behaviors to work on. On 2/21/23 at 10:15 AM, R2 said she had a fall from the lift. R2 said she told the CNA (Certified Nursing Assistant) her buttocks wasn't on the bed all the way. R2 said, She ignored me and moved the lift and my butt ended up on the floor. On 2/21/23 at 10:20 AM, V6, CNA (Certified Nursing Assistant), said the strap should be around the resident's legs when using a stand lift. The strap is used to keep the resident's legs on the pedestal and to support their legs. V6 said if the strap is not used, the resident legs could buckle. V6 also said it is important to make sure the resident is as far back on the bed as one can so the resident doesn't slip off. On 2/21/23 at 12:02 PM, V3, CNA, said (V3) was transferring R2 into her bed via the stand lift. V3 said when she was transferring R2 into bed, she didn't put R2 far enough onto the bed. V3 said she pulled the stand lift away from R2 and as she pulled the stand lift away, R2 slid to the floor. V3 said R2's buttocks was on the floor and her legs were bent to the side. V3 said V4, LPN (Licensed Practical Nurse), came in to assess R2 and V4 noticed a bump on R2's leg and R2 said the area was sore. V3 said when she transferred R2 via the stand lift, V3 put the sling around R2's waist and did not use the leg strap. V3 said she is supposed to use the leg strap. V3 said R2 did not let her know she was not on the bed all the way. On 2/21/23 at 1:58 PM, V4, LPN, said she was told R2 slid to the floor. V4 said she went into R2's room to assess her. V4 said when V4 touched R2's right outer ankle, R2 said it hurt. V4 said R2's legs were to the side and her buttocks were on the floor. V4 said she called the nurse practitioner, and the nurse practitioner ordered an x-ray. V4 said R2 was left in bed until after the X-ray. The facility's Safe Lifting and Moving of Patients policy revised 12/2019 shows, In order to protect the safety and well-being of associates and residents, and to promote quality care, this community uses appropriate techniques and devises to lift and move residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to supervise a resident at risk for falls and failed to follow the facility's policy and procedure for falls for 2 of 3 residents (R1, R3) reviewed for falls in the sample of 3. This failure resulted in R1 sustaining a fracture to his left hip which required a hospitalization and surgical intervention. The findings include: 1. R1's face sheet showed he was admitted to the facility on [DATE], with diagnoses to include traumatic subdural hematoma, pneumonia, chronic kidney disease, spinal stenosis, vascular dementia, and repeated falls. R1's facility assessment, dated 9/19/22, showed he had mild cognitive impairment and required extensive assistance of staff for transfers, uses a wheelchair, and a walker for ambulation. R1's medical record showed he was sent to the acute care hospital on [DATE], and returned to the facility on [DATE]. R1's admission assessment completed by the facility's nurse practitioner at his initial admission to the facility on 9/15/22 showed, . Chief Complaint: New admit - subdural hematoma . He presented to the [local acute care hospital] on 8/16/22 with fall several days prior Assessment . 5. Weakness/Debility.fall risk: facility fall precautions. Physical Therapy and Occupational Therapy, Monitor. 6. Subdural hematoma: acute on chronic, Continue plan of care, monitor, fall precautions . The facility's fall log for the previous 3 months showed R1 had an unwitnessed fall on 10/3/22 in his room, an unwitnessed fall on 10/13/22 in his room, and an unwitnessed fall on 10/14/22 in the dining room. R1's 10/12/22 Physical Therapy Progress Note showed R1 was ambulating 150 feet with a wheeled walker and contact guard assist of one staff. R1's 10/27/22 Physical Therapy Progress note ( after his fall with fracture) showed R1 required maximum assist to sit up in bed and was unable to ambulate due to pain and confusion. R1's facility fall risk assessment, dated 10/3/22, showed R1 was a high risk for falling. R1's record contained an Incident Witness Statement Form, dated 10/13/22 (the day before R1's fall with major injury), which showed an unwitnessed fall, . 10:30 AM, Left out a patient's room, walking down the hallway unit. Heard patient yelling for help. Went to patient room, saw patient on the floor sitting in upright position . R1's record contained a nursing note on 10/13/22 showing R1 was found sitting on the floor in his room in from of his wheelchair. There was no fall investigation provided upon request for R1's 10/13/22 fall. R1's fall risk care plan showed problem onset as 9/14/22, and an intervention added on 10/13/22 that showed, resident should not be left alone in room while in wheelchair . On 12/27/22 at 2:30 PM, V12 (R1's Spouse) said she and her son came into the facility on [DATE] to visit with R1. V12 said when she entered the facility, she went toward the public bathroom, and her son went to R1's room to take some things into the room. V12 said when she came out of the bathroom, she looked into the dining room as she passed by and saw a man laying on the floor. V12 said she went into the dining room and realized the man was R1 (her husband). V12 said R1 told her (while he was at the hospital) he got up because everyone else in the dining room had left, so he thought he should probably leave too. V12 said she got concerned when the fire department responded to the 911 call and was asking the staff if they saw how R1 fell, and the staff all said no. R1's Serious Injury Incident Report, dated 10/14/22, showed, On 10/14/22 around 12:45 PM, after lunch, dietary aide called for help as resident was noted to be on the floor . Resident is alert and verbalized 'I'm just walking to get out of the dining room.' . resident uses a wheelchair for mobility and stated he stood up and took a step . R1's nursing notek dated 10/14/22k showed, 10/14/22 at 12:00 PM - Writer was looking for resident to check his blood sugar before lunch and questioned CNA's (Certified Nursing Assistant) present on the unit. CNA's were unsure of where he went. Went to check residents room and he was not there. Writer requested [Another Nurse] to call the dining room to see if resident was brought down there to eat and CNA [V6] answered and stated he had brought him to the dining room. Writer stated not to leave resident alone. Writer proceeded down to the dining room to check BS (blood sugar). [V6] was sitting near resident and resident had just gotten food delivered to him. Writer told CNA not to leave resident along in the dining room as he is a fall risk. BS was 269. Writer went back to unit to get medications. While down on unit, writer was requested to give another resident pain medication and speak to a family member. While returning to the med cart writer was notified by [RN-Registered Nurse] that resident had fallen in the dining room. While getting the VS (vital signs) to go care for [R1], I see [V6, CNA on B hall]. I asked CNA what happened and he was unsure. CNA stated he was returning another resident to their room and left [R1] in the dining room for a moment. Upon entering the dining room resident was lying on his left side, legs stretched out . While assessing resident for injuries he complained of pain in left hip Resident stated he 'was just standing up to walk out of the dining room' .Attempted to roll resident into supine position to be hoyered into his wheelchair. Resident yelled out in pain and could not roll into supine position. Resident stated his pain was in the left knee to ankle at this time and denied hip pain. Resident's wife walked into the dining room at this time to visit with resident and saw him on the floor. Writer went back to the unit to find resident's son and walked him to the dining room per wife's request. The decision was made by the son and wife to send resident to [Local Acute Care Hospital] for evaluation . R1's acute care hospital emergency room documentation showed on 10/14/22 R1's xray of his left femur showed, . Impression: Acute comminuted intertrochanteric fracture left hip . On 12/27/22 at 12:00 PM, V3 (Certified Occupational Therapy Assistant/Therapy Manager) said R1 worked with both occupational and physical therapy from his admission on [DATE], through his discharge to the acute care hospital after his fall on 10/14/22. V3 said R1 returned to the facility on [DATE], and was evaluated by the therapy department on 10/21/22. R1 has not shown much progress since his readmission to the facility. On 12/27/22 at 11:48 AM, V5, RN (Registered Nurse), said R1 is alert with confusion. V5 said R1 transfers with a mechanical lift now. V5 said R1 came into the facility after a fall at home, and then went back to the hospital after a fall at the facility. V5 said R1 will try to transfer himself in his room or wherever he might be at the time. On 12/27/22 at 12:50 PM, V8 (Registered Dietitian) said she was in her office located off the main dining room when she heard a dietary aide yell for a CNA. V8 said she came out of the her office and saw R1 on the floor; she started to head down to the north hall to find a nurse. V8 said as she was going down north to find the nurse a CNA was coming from the south wing. V8 said, The CNAs are supposed to alternate taking residents back to their rooms so there is always a CNA in the dining room but on this day, unfortunately, when I came out of my office there was no CNAs in the dining room, just the dietary aide that found [R1] on the floor was in there. On 12/27/22 at 1:09 PM, V6, CNA, said, At the time the fall took place [R1] was in the main dining room. I was assigned to supervise the dining room. I was taking another resident back to their room and when I started heading back the nurse flagged me down and said [R1] had a fall . On 12/27/22 at 3:15 PM, V2, DON (Director of Nursing), said when a fall occurs the nursing staff should be entering a progress note in the resident's record showing a fall occurred and the details of the fall. V2 said she looked through R1's old chart and new chart and can not find documentation regarding his 10/13/22 fall. V2 said she was unable to find a fall investigation for R1's 10/13/22 fall. V2 said R1 had an unwitnessed fall again on 10/14/22 in the dining room. V2 said R1 should not have been left alone in the dining room, but unfortunately, it happened that way. V2 said R1 should have been supervised. On 12/28/22 at 11:03 AM, V13, NP (Nurse Practitioner), said R1 is very confused and he does try to do things on his own, which has resulted in falls since his admission. V13 said she is not sure if R1 is safe to be left alone in his wheelchair, and would have to see his chart to determine that. 2. R3's face sheet showed she was admitted to the facility on [DATE], with diagnoses to include Type 2 Diabetes, hypertension, atherosclerotic disease, hyperlipidemia, osteoarthritis, and chronic kidney disease. R3's facility assessment dated [DATE] showed she has mild cognitive impairment and requires limited assist of one staff member for all cares. The facility's fall log for the previous 3 months showed R3 had fallen on 10/3/22, 10/22/22, 12/3/22, and 12/23/22. R3's complete medical record was reviewed including agency staff documentation handwritten on paper and showed no progress notes entered in R3's record for there 10/3/22 or her 10/22/22 fall. The fall investigation into R3's 10/3/22 fall was requested and staff were unable to provide the investigation. On 12/27/22 at 3:15 PM, V2 said she was unable to find documentation of R3's falls on 10/3/22 and 10/22/22. V2 said she would expect to find a progress note in R3's record. V2 went on to say she was unable to locate a fall investigation into R3's fall on 10/3/22. V2 said she would expect a fall investigation to be initiated immediately after the fall because the fall investigation documents are kept at each nursing station. The facility's policy titled Falls Prevention, with last approved date of 03/2022, showed, Policy Statement, The intent of this policy is to provide an environment that is free from accident hazards, over which there is control, and provide supervision and intervention to residents to prevent avoidable accidents . The facility's policy titled Falls with last approved date of 01/2022 showed, Policy Statement/Overview, The purposes of this procedure is to provide guidelines for evaluation of a resident in the event a fall occurred and to assist associates in identification of potential causes of the fall . An incident report shall be completed for resident falls by a Licensed Nurse after the fall occurs.