**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to complete a post fall assessment of a resident immediately following a fall; failed to ensure a resident's physician was notified after a fall; failed to ensure residents received medications as ordered by the physician; and failed to ensure the physician was notified of abnormal lab results. These failures applied to three of four residents (R3, R4, R5) reviewed for quality of care and resulted in R3 having a delay in care of approximately two days after a fall in which R3 was found to have a hip fracture that required surgical intervention. Findings include: 1. R3 is a [AGE] year-old male with a diagnoses history of COPD, Heart Failure, Unspecified Convulsions, and Alcohol Abuse who was admitted to the facility 08/14/2024. R3's Current Care Plan documents he is at risk for falls related to requiring assistance with activities of daily living and for transfers and mobility related tasks with interventions implemented 08/15/2024 including be sure call light is within reach and encourage the resident to use it for assistance as needed, staff to respond promptly to all requests for assistance, and complete the Fall Risk Review per the facility protocol. R3's progress note created by V18 (Licensed Practical Nurse) dated 2/15/2025 at 2:17 PM documents resident appears to be more confused in a.m. and not verbally understood by writer, refused to eat breakfast/lunch even with encouragement/setup, resident is also losing control of bowel/bladder, refuses to get out of bed to toilet self as he normally does or sit up to eat; Orders received to send resident out for altered mental status and failure to thrive; at 4:52 PM writer received call from the hospital charge nurse stated that resident is being admitted for left hip fracture, that left leg is inverted, rotated and shorten, she also stated that fracture appears to be 48 hours old. Resident is scheduled for surgery in a.m. R3's Fall Incident report dated 02/15/2025 documents he was sent to the hospital for evaluation and treatment due to change in condition and was informed by the hospital via phone on 02/15/2025 at approximately 4:52 PM that he had a left hip fracture. Unusual Occurrence Final Investigative Report dated 02/19/2025 documents on 02/15/2025 at approximately 2:17 PM, R3 was sent to the hospital for evaluation due to refusal of meals, incontinence of bowel and bladder, and refusal to get out of the bed which were acute change of condition per nursing assessment. The nurse was informed by the hospital nurse at 4:30 PM that R3 had a left hip fracture and will be admitted to the hospital. Undated witness statement from V7 (Licensed Practical Nurse) documents on 02/14/2025 at 3:45 PM she was off duty and returned to the facility because she forgot her phone and observed aides running to a room to assist R3 off the floor, she assisted the aides at this time to remove R3 off the floor, observed him, and no pain was observed. Witness statement from R12 dated 02/15/2025 documents he reported R3 had a fall trying to pick up a resident that fell in their room and aides assisted R3 from the floor; Witness statements from R13 dated 02/15/2025 documents he reported R3 fell. It was daylight at the time and aides assisted him from off the floor; Witness statement from V18 (Licensed Practical Nurse) dated 02/15/2025 documents she reported his roommates informed that he fell two days ago in their room and aides picked him up off the floor; Witness statement from V9 (Certified Nursing Assistant) dated 02/17/2025 documents she reported she worked from 3-11 PM on Friday and approximately between 3:30 - 4PM she observed R3 on the floor, the nurse checked him and helped place R3 on his bed. R3's roommates reported R3 was trying to help R9 up and fell. R3's hospital report dated 02/15/2025 documents he was admitted from the nursing home for lethargy but noted at baseline while at the emergency department and instead found to have a left thigh fracture and is unable to explain how he fell. R3 was assessed to have an acute fracture of the left hip and the circumstances of the fall are unclear; patient with a high level of risk based on: acute or chronic illnesses or injury which poses a threat to life or bodily function; he is a [AGE] year old male presenting with a fall at the nursing home and left thigh fracture and underwent surgical treatment for fracture on 02/16/2025; the etiology of the fall is unclear, suspect mechanical. On 02/25/2025 at 12:27 PM V2 (Director of Nursing) stated she completed the investigation on 02/19/2025 for R3's fall that occurred 02/15/2025. V2 stated there was confusion about his fall and they were trying to determine when R3 had a fall. V2 stated she concluded after the investigation that R3 had a fracture. V2 stated she wanted to go back to 02/14/2025 because someone said he fell two days ago but he was up and walking on 02/15/2025 so she said that couldn't be correct. On 02/25/2025 at 2:07 PM V2 (Director of Nursing) stated V7 (Licensed Practical Nurse) was suspended for three days because she did not complete an incident report for R3's fall because she said she was off the clock when R3 fell. V2 stated V7 assisted the aides with getting R3 up after he fell on [DATE] and then left the facility immediately after. V2 stated V7 should have let someone know R3 had a fall. V2 stated V7 will be terminated because she failed to inform anyone about a fall that resulted in an injury. V2 stated an injury could occur due to failure to report a fall or failure to properly assess a resident after a fall. V2 stated if you continue to put pressure on an injury after a fall that could result in harm. On 02/25/2025 at 2:52 PM V8 (Certified Nursing Assistant) stated at approximately 3:15 PM on 02/14/2025 as she was entering the unit where R3 's room was located V9 (Certified Nursing Assistant) observed R9 crawling on the floor. V8 stated V9 informed her of this as well as V7 (Licensed Practical Nurse). The nurse walked with her (V8) and V9 towards R9. V8 stated she found R9 crawling on all fours directly outside of R3 's room. V8 stated once they made it to the doorway of R3's room on the other side of the threshold, R3 was laid out parallel to the wall. V8 stated V7 stated R3's was on the floor too. V8 stated V7 then asked R3 if he was ok, what was he doing, asked him if he hit his head then answered for him no you didn't hit your head then instructed her (V7) and V9 to get him up. V8 stated V9 and V7 then assisted R3 off the floor, then she (V8) and V9 helped R9 up into her wheelchair and placed R9 at the nurses station. V8 stated V7 said she's not reporting it, she was ready to go, they didn't hit their head and they're alright. V8 stated V7 then sat at the nurses station until approximately 3:30 then left the facility. V8 stated V7 did not perform an assessment of R3 when he fell. V8 stated neither she nor V9 reported this to anyone else. V8 stated she was trained to report falls to the nurse and the nurse was present and aware of R3 's fall. On 02/25/2025 3:21 PM V9 (Certified Nurse Assistant) stated on 02/14/2025 at approximately 3:15 PM she was coming in from getting a linen bag then approached the nurses station and could see R9 sitting on the floor. V9 stated she informed V7 (Licensed Practical Nurse) that R9 was on the floor. V9 stated then she, V7 and V8 (Certified Nursing Assistant) approached the threshold of R3 's room and observed R3 was on the floor. V9 stated V7 said R3 is on the floor too and then immediately went to assess R3. V9 stated V7 assessed R3's body by patting him on his head, arms, legs, and back and then asked her (V9) and V8 to help R3 into bed. V9 stated she's unsure of R3's response while V7 was assessing him. V9 stated during this time she was observing R9 who was just sitting on the floor. V9 stated she remained standing in R3's doorway in between R9 and R3 while V7 assessed R3. V9 stated V7 asked R3 if he was ok and if anything hurt but she doesn't recall his response. V9 stated R3 looked like he was in pain and grunted when she, V7, and V8 picked him up and placed him in his bed. V9 stated after they placed R9 in the wheelchair, V7 stated she was getting ready to leave then went and got her bags and things and left. V9 stated R9 didn't have any injuries and didn't show any signs of pain other than grunting while being picked up. V9 stated she believes R3 stayed in his bed the remainder of the shift. On 02/25/2025 at 3:48 PM V2 (Director of Nursing) stated V7 (Licensed Practical Nurse) would have had a nurses note in R3 's medical records if an assessment was performed after he fell. V3 (Assistant Director of Nursing) stated a fall assessment, nurses note, incident report, and vital signs should all be documented in R3 's medical record along with notation of whether there was a loss of consciousness, complaints of pain, or changes in range of motion after a resident's fall. R3's medical records did not include documentation of a fall assessment, nurses note, or incident report that included his vital sign measurements, level of consciousness, pain status, or assessment of his range of motion, or physician notification after his fall on 02/14/2025. 2. R4 is an [AGE] year-old female with a diagnoses history of Dementia, Hallucinations, Stroke, Anxiety Disorder, Malignant Cancer of Left Breast, Metabolic Encephalopathy, and Repeated Falls who was admitted to the facility 09/02/2022. R4's Physician Order history includes an active order effective 10/12/2024 for 1 mg Anastrozole (Hormone Based Chemotherapy) Tablet to be given by mouth one time a day related to Breast Cancer. R4's February 2025 Medication Administration Record reviewed to document Anastrozole scheduled to be given once daily in the morning was not administered on 9 different days from 02/01/2025 - 02/11/2025. R4's medication administration progress note dated 2/1/2025 documents her Anastrozole Oral Tablet (Hormone Based Chemotherapy) to be given by mouth one time a day related to Breast Cancer is awaiting delivery. 3. R5 is a [AGE] year-old male with a diagnoses history of Quadriplegia, Heart Failure, End Stage Renal Disease, Chronic Kidney Disease, Dependence on Renal Dialysis, Urinary Tract Infection, Metabolic Encephalopathy, Partial Paralysis following Stroke, and Dehydration (02/15/2025) who was admitted to the facility 01/31/2025. R5's Physician Order history includes an order effective from 02/01/2025 - 02/26/2025 for one Lanthanum Carbonate Oral Tablet Chewable 1000 MG tablet to be given by mouth three times a day with meals to reduce Phosphates level, in kidney disease; and an order effective from 02/01/2025 - 02/13/2025 for 5ml Nystatin Mouth/Throat Suspension to be given by mouth four times a day for oral anti-fungal, swish and swallow for 10 days. R5's February 2025 Medication Administration Records documents his Lanthanum Carbonate Oral Chewable tablet to be given by mouth three times a day with meals was not administered as ordered from 02/01/2025 - 02/24/2025 and his Nystatin Mouth/Throat Suspension medication to be given by mouth four times a day for oral anti-fungal was not administered as ordered on multiple days across multiple shifts from 02/01/2025 - 02/09/2025. R5's medication administration progress note dated 2/3/2025 at 05:35 AM documents his Nystatin Mouth/Throat Suspension antifungal was on order. R5's Physician Progress Note dated 2/4/2025 at 12:15 PM documents his phosphorus levels were 3.8. R5's blood labs dated 02/04/2025 document abnormalities including high phosphorus levels at 6.9. R5's progress notes did not include documentation of physician notification of abnormal blood labs. On 02/26/2025 at 12:00 PM V2 (Director of Nursing) stated according to R4's February 2025 Medication Administration record she was not receiving her chemotherapy medication as ordered based on all the 9's documented. V2 stated she had to in-service V5 (Licensed Practical Nurse) on ordering and passing medications. V2 stated R5 should have received his Lanthanum Carbonate Oral Chewable 1000 MG (Phosphorus Lowering) tablet during dialysis. On 02/26/2025 at 1:16 PM V2 (Director of Nursing) stated since Lanthanum Carbonate (Phosphorus Lowering) and Nystatin Mouth/Throat Suspension (Antifungal) was ordered for R5 he should have received it however he didn't receive it. In response to being asked by surveyor what are the risks from R5 not receiving his Lanthanum medication, V2 replied abnormal labs and phosphorus levels. V2 stated R5's high phosphorus levels documented in his lab report dated 02/04/2025 could indicate he was not receiving dialysis, not being properly dialyzed, or not receiving his Lanthanum medication. V2 stated R5 was admitted to the facility on Friday 01/31/2025. In response to surveyor asking what the risks from R5 not receiving his Nystatin medication, V2 replied possibly thrush on his tongue. When asked by surveyor what are the risks of R4 not receiving her Anastrozole Oral Tablet (Hormone Based Chemotherapy), V2 replied R4 needs her chemotherapy medication for cancer but could not explain what the risks are from not receiving her chemotherapy medication. V2 stated everyone should receive their medications. V2 stated indications of dehydration include high BUN (Blood Urea Nitrogen) and High Creatinine levels. V2 stated R5's lab work from 02/04/2025 were obtained from the dialysis nurse and should have been reported to the floor nurse and urologist. V2 stated there should be follow up from abnormal labs including consulting with the physician to determine if additional labs should be repeated, if there any changes needed in medications or with dialysis treatment. On 02/26/2025 at 1:57 PM V2 (Director of Nursing) stated the dialysis nurse V17 (Registered Nurse) explained R5 did not receive his initial dialysis until Monday 02/03/2025. V2 stated the purpose of R5's Lanthanum Carbonate medication is to keep his phosphorus levels down and agreed his levels would elevate if he were not receiving his medications or not receiving dialysis. The facility's Fall Risk and Post Fall Assessment Policy and Procedures received 02/26/2025 states: The purpose of the policy is To conduct appropriate assessments after falls. Post Fall Assessment Procedures include: conduct physical and mental status assessment, assess resident's airway breathing and circulation, note level of consciousness and perform neuro checks whenever there is potential for actual head injury, assess limb strength and motion by asking the resident if he has pain and the location of said pain; ask if he can do active range of motion. The facility's Fall Policy and received 02/27/2025 states: Observed and reported by staff member. Licensed nurse should conduct assessment immediately, including events leading up to the fall to determine when possible causative factors. Assess for respiratory difficulties, bleeding and fractures. Additional Measures include: Notify Physician. Document all assessment findings and observations, physician and family notifications in the resident's clinical record in accordance with the assessment guidelines. The facility's Medication Administration Policy and received 02/26/2025 states: Medications must be administered in accordance with a physician's order. The facility's Physician Orders Policy received 02/26/2025 states: These guidelines are to ensure that: Changes in resident status/condition are assessed and physician notification is based on assessment findings; Any orders given by Physician are carried out. Any calls to physician will be documented in the nurse's notes indicating information conveyed and received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to follow resident care assessment and plan in providing adequate supervision and monitoring of residents with severe cognitive impairment for two (R3 and R4) of four residents reviewed for accidents and supervision. This deficiency resulted in R4 had a fall in the dining room and sustained a comminuted and mildly displaced fractures of the left medial acetabular wall and root of the superior pubic ramus (hip/pelvic area). Findings include: 1. R3 is an [AGE] year old, female, admitted to the facility on [DATE] with diagnoses of Parkinson's Disease without Dyskinesia, without Mention of Fluctuations; Depression, Unspecified; Schizoaffective Disorder, Unspecified; Dementia in other Diseases Classified Elsewhere, Unspecified Severity, without Behavioral Disturbance, Mood Disturbance and Anxiety; and History of Falling. MDS (Minimum Data Set) dated 12/10/24 recorded R3 has BIMS (Brief Interview for Mental Status) score of 7 which means severe cognitive impairment. MDS dated [DATE] indicated R3 needs substantial/maximal assistance during chair/bed to chair transfer. R3's care plans documented the following: 1.Self-care deficit, initiated 04/10/23: Interventions: Provide assistance with all ADLs (activities of daily living) as required per resident's need dependence: eating, transferring, bed mobility, bathing, dressing, personal hygiene, ambulation and personal hygiene. 2. ADL self-care performance deficit related to disease process Parkinson, initiated 10/06/23: Interventions: Transfer (01/27/25): R3 requires the assistance of 1 staff member when transferring. On 02/04/25 at 10:35 AM, observed R3 was coming out from the dining room, in her wheelchair to hallway. There was an ongoing activity in the dining room and R3 was attending. R3 was using both feet in propelling her wheelchair. R3 went to her room and made several attempts to transfer self from wheelchair to a chair. Finally, R3 was able to transfer self to the chair without any supervision from staff. R3 was able to leave the dining room unnoticed. On 02/04/25 at 11:00 AM, V21 (Licensed Practical Nurse, LPN) was interviewed regarding R3 supervision, monitoring and transfer. V21 replied, She is alert, oriented to self and place, with periods of confusion. Sometimes when you speak to her, she will answer you but will start with something else. She is on a wheelchair and dragged her wheelchair using her feet to move around. She cannot transfer herself. We all have eyes on her. She will try to get up on her own. Monitor her every hour while in room. During activities, she is monitored. She tried to leave the dining room; staff usually call the nurse. We cannot leave her unsupervised. Fall risk review dated 01/31/25 recorded R3 is high risk for falls. R3's progress notes documented the following: 01/14/25: R3 was observed laying on the floor next to bed during rounds. 01/30/25: R3 was observed in the hallway sitting on the floor in front of her wheelchair. 01/31/25: R3 was found lying on floor with wheelchair on top of legs. On 02/04/25 at 2:13 PM, V2 (Director of Nursing/Fall Coordinator) stated, She (R3) is provided with supervision and monitoring by placing her at the nurses' station or in activities. We keep an eye on her. Since she came back from the hospital, she needs assistance during transfers, she needs help. 2. R4 is an [AGE] year-old, female, admitted in the facility on 11/02/2020 with diagnoses of Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety; and History of Falling. MDS (Minimum Data Set) dated 12/02/24 recorded R4's BIMS (Brief Interview for Mental Status) score is 3 which means severe cognitive impairment. R4's care plans documented the following: 1.At risk for increasing confusion secondary to dementia, initiated 11/02/20: Interventions: Provide cueing and prompting PRN (when necessary). Involve in small group/low stress activities. Reality orientation as needed. Calm/quiet environment. 2.Self-Care Deficit, date initiated 11/12/202: Interventions: Provide assistance with all ADLs as required per the resident's need dependence: eating, transferring, bed mobility, bathing, dressing, personal hygiene, ambulation and personal hygiene. R4's progress noted dated 01/30/25 documented R4 was found sitting up on the floor mat sitting up on buttocks with heel protectors in place wrapped in bed sheet. No apparent injury noted. No new orders received at this time. Bed in lowest position. R4's care plan recorded the following: 1.At risk for falls related to resistive to care at times and history of fall, initiated 11/08/20: Interventions: Frequent room rounds when resident is in room. Gather information on past falls and attempt to determine the root cause of the fall (s). Anticipate and intervene to prevent recurrence. Fall Risk Review dated 01/06/25 indicated R4 had been determined not to be a high risk for falls. Fall incident report dated 01/22/25 documented that on 01/16/25 at approximately 2:04 PM, R4 had a fall in the 100-unit dining room. There were no open areas. The nurse assessed R4, noted to have facial grimaces when moving the left leg. R4 was sent out to the hospital as ordered for further treatment and evaluation. R4's CT (computed tomography) scan and X-ray of left hip and pelvis dated 01/16/25 performed in the hospital revealed the following results: CT pelvis without contrast: comminuted and minimally displaced anterior column fracture with incomplete nondisplaced posterior hemi transverse component. X Ray hip 2 views left and pelvis: comminuted and mildly displaced fractures of the left medial acetabular wall and root of the superior pubic ramus. On 02/03/25 at 11:31 AM, R4 was in the dining room, up in wheelchair. R4 is alert, oriented to self, confused. R4 was sitting at a table with other residents attending activities. R4 was asked regarding recent fall incident wherein she sustained fracture. R4 stated she does not know what happened and had no recollection of the fall incident. On 02/04/25 at 10:55 AM, R4 was in the dining room; up in wheelchair; attending activities. She is alert to self but did not respond when surveyor asked on how she was doing. On 02/04/25 at 11:24 AM, V15 (LPN) stated, R4 is alert and confused. She is dependent on staff. She uses a wheelchair. I was the nurse assigned to her on 01/16/25. I was coming in from break, the aide called me and told me that she (R4) had a fall in the dining room while I was on break. V20 was the CNA assigned in the dining room. Usually there is one CNA assigned every hour in the dining room with the usual of no more than 20-25 residents in the dining room for 1 CNA. There were about 20 residents that time. I did the assessment on R4, there was no apparent injury. Vital signs were normal. When I found her, she was laying on the floor opening graham crackers. She appeared to be herself. She cannot recall what happened. The CNA told me that she was attending to another resident, when she turned around, she saw R4 fell. She was the only CNA in the dining room at the time. She (R4) was assisted back to her chair. I called physician and told me to get an X-ray and she (R4) was later sent out. On 02/04/25 at 1:01 PM, V20 verbalized, On 01/16/25, I was in my dining room time. She (R4) does ambulate. I was keeping eye on another resident. On the other side. R4 was standing, it was fine because she ambulates, and she can walk. When I turned towards my left, I saw her (R4) going to the floor and fell. I was the only one in the dining room at the time. I believe it was after lunch. Usually, after lunch, there's only one CNA who rotates every hour for dining room supervision. There were 15 or slightly more residents at the time. Majority of residents were in wheelchairs. She (R4) was in the chair not in wheelchair because she can still walk. When I saw her fell to the floor, I called the nurse. V20 was asked what interventions should be implemented to prevent R4's fall. V20 mentioned, Close supervision, make sure she doesn't stand or ambulate. On 02/05/25 at 10:15 AM, V15 was asked regarding staff assignment for dining room supervision. V15 stated, We, nurses on the floor are the ones responsible for assigning a CNA to monitor the dining area. I'm on 100 unit. Only one CNA is assigned regardless of the number of residents in the dining room. The rotation is every hour. At 10AM to 11 AM and 2 PM to 3 PM, it is our activity time. Activity aides are assigned to conduct activities and there's no CNA assigned around this time. Between the hours of 3 PM to 4 PM, an activity aide and an assigned CNA should be in the dining room monitoring residents. This is the typical schedule for the day. R4 is in the 100 unit. I am her regular nurse. Per R4's incident report, she had a fall at approximately 2:04 PM. V15 stated that between 2 PM to 3 PM, it is scheduled activity time and activity aides should be conducting activities on resident. Facility was asked to provide schedule sheets for dining room supervision. V1 (Administrator) stated they don't document staff schedules. On 02/04/25 at 2:13 PM, V2 was asked regarding R4 and fall supervision and monitoring. V2 replied, Every hour, there could be one CNA assigned in the dining room. During monitoring of residents in the dining room, there should be one CNA assigned regardless of the number of residents present. Staff monitor residents, attend to their needs. For R4, we make sure she is clean, dry, fed, assisted with feeding, when she is up, she is in the dining. She can participate in activities, keeping her busy. She was not a fall risk before, she used to ambulate and still walking. I investigated her (R4) fall on 01/16/25. She had a fall in the dining room. She got up and she took some steps and lost her balance. She was sitting in the chair, stood up and fell on her left side. The nurse assessed her, and she was sent out. She sustained pelvic fracture. She was admitted for a few days and came back for readmission. She can get agitated, she can get impulsive, we try to approach her in a calm manner. She is confused. She likes to get up and move We have to bring her out to activities. We don't know exactly why she (R4) stood up but she had that fall. R4 is able to walk around, we just monitor her. We don't need to supervise her when walking, because she is able to walk around, prior to fall. R4's MDS dated [DATE] also recorded: Section GG - sit to stand: supervision or touching assistance; walk 10 feet: supervision or touching assistance. Supervision or touching assistance is coded as helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. On 02/04/25 at 1:14 PM, V22 (Physician) stated, I am her physician and been seeing her. I was notified that she had a recent fall. She is confused, walked around, and fell down, she had fracture in the pelvis. She just fell. For high risk residents for falls, I expect staff to constantly watch them. In the dining room, there should be close supervision. For a staff to be watching more than 15 residents in the dining room, and majority are in their wheelchairs, it is almost impossible to provide close supervision. If you are constantly looking into another resident and one resident may stand up, walk and fell, it's almost impossible. I expect staff to provide close supervision; eyes on them at all times and follow the facility fall protocol. Facility's policy titled Fall Prevention Program dated 2/28/14 documented in part but not limited to the following: Policy: It is the policy of this facility to have a Fall Prevention Program to assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Quality Assurance Programs will monitor the program to assure ongoing effectiveness. Program contents: The Fall Prevention Program includes the following components: 4.Use and implementation of professional standards of practice. 5. Changes in interventions that were unsuccessful. 10.Care plan incorporates: b. Interventions are changed with each fall, as appropriate. c. Preventative measures. 11. Periodic quality assurance audit activities of records relating to falls that exhibit adherence to facility policies and implementation of the plan of care. Standards: 3. Safety interventions will be implemented for each resident identified at risk using a standard protocol. Safety Precautions for residents at risk: In addition to the use of Standard Fall Precautions, the following interventions will be implemented for resident identified at risk. 1.The resident will be checked approximately every two hours, or as according to the care plan, to assure they are in a safe position. The frequency of safety monitoring will be determined by the resident's risk factors and the plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to identify and treat wounds on a resident (R1) before R1 was sent out to the hospital for one of three residents reviewed for wound care in a total sample of eight. This failure resulted in the unidentified wounds being present on R1's heels for an unknown amount of time without being treated. Findings Include: R1 is an [AGE] year old with the following diagnosis: type 2 diabetes, peripheral vascular disease (PVD), and rheumatoid arthritis. A Nursing note dated 11/3/24 documents R1 had a boil on the sacrum that burst and left an open area. The nurse practitioner was notified and ordered to cleanse the wound daily and apply a dry dressing. A Physician note dated 11/13/24 documents R1 currently has no concerns and is at baseline. The Treatment Nurse Initial Skin Alteration Review dated 11/4/24 documents a full thickness wound to the sacrum was identified on 11/3/24 and measured 0.3 cm x 0.3 cm x 1 cm. The wound bed had 100% granulation tissue with a small amount of serous drainage. R1 turns and repositions independently. A preventative measure includes daily skin checks during CNA rounds. On 12/24/24 at 12:37PM, V14 (Nurse) stated R1 was sent out the morning of 11/20/24 for altered mental status changes. V14 denied performing a skin assessment on R1 before leaving for the hospital because V14 was a newer nurse and wasn't aware V14 should do that. When asked why doing a skin assessment before a resident leaves the facility is beneficial, V14 reported the nurse needs to be responsible in being aware of what condition the resident left the facility in, so if anything comes up the facility can say who was at fault. On 12/24/24 at 2:12PM, V15 (Wound Care Nurse) stated R1 was being seen by wound care for a wound to the sacrum. V15 reported a full head to toe assessment must be performed daily on resident's with wounds. V15 stated V15 along with the CNAs and floor nurses are responsible for completing the daily skin assessments. V15 reported V15 likes to do a skin assessment before the resident leaves the facility so the facility knows what wounds occurred at the facility and what wounds did not happen at the facility. V15 denied being aware of any wounds to R1's ankle or heels. On 12/26/24 at 1:55PM, V16 (Wound Physician) stated a wound needs to be treated as soon as it develops because the wound could decline or not heal from not being treated. V16 reported the expectation of staff is to have due diligence in checking the skin if a resident is prone to developing the skin. V16 was unable to say how long the wounds on the left heel and left ankle took to develop. On 12/26/24 at 3:41PM, V18 (DON) stated R1 had a wound to the sacrum that was being treated at the facility. V18 reported if a wound develops in the facility, then staff need to identify the wound and treat it. The Weekly Skin Alteration Review dated 11/11/24 documents a full thickness wound to the sacrum that measured 0.3 cm x 0.3 cm x 0.8 cm. The wound bed had 100% beefy red granulation tissue with a small amount of serous drainage. The drainage had no odor. The wound is documented as improving as evidenced by decreased depth. The family was called and notified of the wound changes on this day. The Weekly Skin Alteration Review dated 11/19/24 documents a full thickness wound to the sacrum that measured 0.5 cm x 0.3 cm x 0.9 cm. The wound bed had 100% beefy red granulation tissues with a scant amount of serous drainage. The wound was stable due to no changes. The Wound Physician note dated 11/19/24 documents this was the initial evaluation by the wound care physician. R1 was in no acute distress. The wound on the sacrum is a full thickness wound that measured 0.5 cm x 0.3 cm x 0.9 cm. The wound is documented as being caused by an abscess that spontaneously drained. The dressing was changed to iodoform to be changed daily. There was no other documentation that R1 had any wounds to the left ankle or heel. The Bath and Skin Report Sheet dated 11/2024 documents skin assessments were completed on shower days on 11/2/24, 11/6/24, and 11/9/24 and the only documented wound is to the sacrum. A Nursing note dated 11/20/24 documents R1 showed signs of altered mental status and was sent out to the hospital. R1 was admitted to the hospital with a diagnosis of altered mental status and congestive heart failure. The Hospital Records dated 11/19/24 documents R1 presented from the nursing home with altered mental status. A skin assessment was performed by the wound care team. A full thickness wound to the sacrum was noted. The wound is down to the bone and has a foul odor. There is also dark discoloration to the left heel consistent with a deep tissue injury. The left lateral ankle and hallux has a small opening to the skin with eschar present. This is consistent with an unstageable pressure injury. R1 was admitted to the hospital with a diagnosis of sacral wound infection and altered mental status. The Care Plan dated 5/8/20 documents R1 is at risk for alteration in skin integrity due to skin being occasionally exposed to moisture due to incontinence and being at risk for friction/shearing. An intervention includes to check skin during routine care on a daily basis and during the bi-weekly bath or shower schedule. The Care Plan dated 4/17/23 documents R1 has an alteration in skin integrity and is at risk for additional and/or worsening of skin integrity issues related to diabetes, anemia, abnormal posture, and peripheral vascular disease. An intervention includes to check skin during routine care on a daily basis and during the weekly/biweekly bath or shower schedule. The Care Plan dated 12/1/23 documents R1 has PVD and is at increased risk of skin integrity issues with a potential for diminished blood flow to the lower extremities. An intervention includes to observe for discoloration for the skin. The policy titled, Pressure Ulcer Prevention, dated 09/2014 documents, Purpose: To prevent and treat pressure sores . Procedure: .2. Inspect the skin several times daily during bathing, hygiene, and repositioning measures. The policy titled, Pressure Injury and Skin Condition Assessment Policy, documents, Purpose: To establish guidelines for assessing, monitoring, and documenting the presence of skin breakdown, pressure and other ulcers and assuring interventions are implemented .Standards: .4. Each resident will be observed for skin breakdown daily during care and on the assigned bath day by the CNA. Changes shall be promptly reported to the Charge Nurse who will perform the initial assessment .6. Care givers are responsible for promptly notifying the Charge Nurse of skin observations, including but not limited to: A. redness/swelling B. bruises C. skin tears D. blisters E. excoriations F. wound drainage G. crusts H. scales I. any type of lesion J. skin discoloration K. bleeding L. changes in skin temperature The policy titled, Discharge/Transfer of Resident, dated 04/2014 documents, .7. Complete Transfer Form accurately and completely including vital signs. Ensure that resident's current physical and psycho/social assessment, medications, and current treatment is completely described and available to the receiving facility upon transfer .10. Thoroughly assess resident prior to discharge/transfer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to monitor a high fall risk resident (R2) during a scheduled monitoring period for one out of three residents reviewed for falls in a total sample of eight. This failure resulted in R2 suffering a right fractured hip after falling from a chair while reaching out for a nearby object when unsupervised. Findings Include: R2 is an [AGE] year old with the following diagnosis: history of falling, dementia, and age-related osteoporosis. A Nursing note dated 12/8/24 documents it was reported by the CNA (V9) that R2 slid out of a chair attempting to reach for something that was in another chair. V9 reported R2 fell onto the right hip. R2 denied any pain upon assessment and was placed back into bed. X-rays of the hip/pelvis were ordered. R2 remains alert and oriented times one per baseline. The Unusual Occurrence Final Investigative Report Form dated 12/13/24 documents R2 slid out of a chair while attempting to reach for something that was in another chair. R2 fell onto the right hip. R2 was sent out to the hospital for evaluation. R2 returned from the hospital with a diagnosis of a closed femur fracture. A statement from V9 documents V9 was providing care to another resident in the room when R2 was noted reaching for an object in another chair. V9 reported the object was a few feet away from R2 and R2 fell onto the right side while reaching to get it. The Hospital Record dated 12/8/24 documents R2 presented to the hospital after a fall. R2 is alert and oriented times one per baseline. X-ray of the hip was consistent with a right femoral neck fracture. R2 was admitted and ortho was consulted for surgery. R2's admitting diagnosis was displaced fracture of the right femoral neck. On 12/20/24 at 1:59PM, R2 was sitting in a chair in R2's room. V2 (CNA) was sitting within arm's reach of R2. R2 was unable to answer any questions due to mental status. V2 reported R2 fell and broke the right hip but was not able to answer and detailed questions about the fall. V2 stated R2 has a behavior of constantly trying to get up without asking for assistance. V2 reported R2 is always confused and needs multiple attempts to redirect before R2 will listen. V2 stated one staff member is assigned to sit in the room to monitor residents due to being high fall risk. V2 reported if any other care tasks need to be completed while assigned to monitoring then another staff member must come and sit with the residents in the room to make sure they stay safe. On 12/24/24 at 10:10AM, V9 (CNA) stated V9 got R2 ready for the morning then sat R2 in a chair while V9 began providing morning care to R2's roommate. V9 reported there was linen sitting on another chair about three to four feet away from R2 and R2 began reaching for the linen. V9 stated by the time V9 looked up and saw R2 reaching that it was too late to tell R2 to stop because R2 was in the middle of falling. V9 reported R2 has a behavior of trying to get up unassisted and walk alone. V9 stated R2 is a high fall risk because R2 is confused and R2's gait is unsteady. V9 reported V9 should have gotten another staff member to watch R2 but V9 did not think R2 would try to get up unassisted at that time. V9 stated V9 was responsible for monitoring the residents in that room at the time R2 fell. On 12/24/24 at 10:24AM, V10 (Nurse) stated V9 came to the nurse's station and told V10 that R2 fell while reaching for something that was in another chair. V10 reported R2 is a high fall risk because R2 walks on R2's [NAME] toes and is only alert and oriented times one. V10 stated R2 needs constant redirection and supervision due to being impulsive. V10 reported a staff member is always sitting in R2's room monitoring residents. V10 reported if the person assigned to monitoring needs to take care of someone else then another staff should be notified so R2 can be monitored. V10 denied V9 asking for assistance the day R2 fell. V10 said, I was kind of shocked she fell with a CNA in the room with her. On 12/24/24 at 10:36AM, V11 (Former Restorative Nurse) stated V11 resigned before the fall but knows R2 is impulsive and has an unsteady gait. V11 reported the CNAs have monitoring schedules for that room because R2 is such a high fall risk. V11 stated staff switches out throughout the shift so R2 can be constantly monitored. V11 reported the only responsibility staff has during their monitoring time is to monitor the high fall risk residents to make sure they don't fall. V11 stated another staff should be notified to help watch R2 is the staff scheduled for monitoring needs to perform another task during that time. On 12/24/24 at 12:26PM, V13 (Therapy Director) stated R2 was discharged from therapy on 12/3 after reaching the highest performance level. V13 reported they were working with R2 because R2 is a high fall risk and very unsafe. V13 stated R2 has an unsteady gait and is impulsive. V13 reported R2 needs 1:1 supervision to maintain safety. On 12/26/24 at 3:11PM, V17 (Medical Director) stated R2 fell in early December and suffered a hip fracture. V17 reported R2 fell while reaching for something while in a sitting position. V17 stated R2 has severe dementia but is not lethargic. V17 reported being aware the CNAs having a monitoring schedule for R2. V17 stated staff needs to be monitoring residents and redirecting them when get up unassisted during the monitoring time. V17 reported if another resident is in need of care, then more staff need to be called into the room to monitor R2 to make sure R2 does not fall. V17 stated the main priority when staff is assigned to monitoring is to monitor the high fall risk residents and keep them from falling. On 12/26/24 at 3:41PM, V18 (DON) stated an intervention to help R2 from falling is to have staff in the room with R2 or have R2 sit at the nurse's station. V18 reported if the CNA responsible for monitor needs to leave the room or take care of another resident then a nurse or another CNA needs to be called into the room to make sure monitoring is continued. The Physical Therapy Discharge summary dated [DATE] documents R2 resides in a long term care facility and 24 hour a day supervision is needed. R2 needs partial/moderate assistance with transfers and walking. The Daily Assignment Sheet dated 12/8/24 documents V9 was assigned to monitoring at 9AM until 10AM. V9 was also assigned to provide care for the room R2 resided in. The Fall Report dated 12/8/24 documents V9 reported R2 was reaching for an object in another chair and fell out of the chair hitting R2's right hip. Upon attempting to have R2 stand, R2 showed facial grimacing and was unable to stand. R2 is alert to person only. Predisposing physiological factors to the fall are documented as gait imbalance, impaired memory, incontinent, and agitation. Predisposing situation factors are documented as incident occurred during unassisted transfer. The Care Plan dated 1/1/24 documents R2 is high risk for falls related to confusion, being unaware of safety needs, unsteady gait, impulsiveness, and history of falls. The Care Plan dated 12/11/24 documents R2 fractured the right hip. Appropriate interventions are documented. The Minimum Data Set (MDS) dated [DATE] documents the Brief Interview for Mental Status score as five (severe cognitive impairment). Section GG of the MDS documents R2 needs partial/moderate assistance with bed mobility, transfers, and walking. The policy titled, Fall Prevention Program, dated 2/28/14 documents, It is the policy of the facility to have a Fall Prevention program to assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary .In addition to the use of Standard Fall Precautions, the following interventions will be implemented for resident identified at risk. 1. The resident will be checked approximately every two hours, or as according to the care plan, to assure they are in a safe position. The frequency of safety monitoring will be determined by the resident's risk factors and the plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policy by failing to provide an individualized plan of care with effective interventions to prevent falls; the facility failed to provide supervision while walking in corridors per resident assessment. These failures applied to one (R1) of five residents reviewed for falls and resulted in R1 having three falls in the last three months and requiring hospital transfer for medical treatment of a laceration and hematoma after the last two falls. Findings include: R1 is [AGE] years old and has resided at the facility since 2022, past medical history includes Altered mental status unspecified, anxiety disorder, hallucinations, malignant neoplasm of unspecified site of female breast, metabolic encephalopathy, unspecified dementia, unspecified fall, unspecified protein calorie malnutrition, etc. 11/12/2024 2:15PM, R1 was observed in her room sleeping, bed not low and no floor mats on either side of the bed. Resident's walker was noted in the room but not close to the resident, no call lights noted and bedside table with an empty plastic cup was observed in front of resident's bed. Review of resident's health record showed R1 had 5 unwitnessed falls since 1/11/2024 (4 in the hallway and 1 in resident's room) and was sent to the hospital 4 times for medical management after the falls. Minimum Data Set (MDS) assessment dated [DATE] section C (cognition) scored R1 as a 4 for brief interview for mental status (BIMS). Section GG (Functional abilities and goals) coded R1 as requiring partial to moderate assistance for most activities of daily living (ADL). R1 was also assessed as requiring supervision or touching assistance for walking in the room or corridors. Fall risk assessment dated [DATE], 10/7/2024 and 10/13/2024 all documented R1 is a high risk for fall. Care plan initiated 9/3/2022, revised 7/23/2024 stated R1 is at risk for falls related to history of falls. Interventions include encourage resident to take frequent breaks from ambulating on the unit, redirect resident when up and ambulating with walker, gather information on past falls and attempt to determine the root cause of the fall, anticipate, and intervene to prevent recurrence, etc. Progress note dated 8/3/2024 states R1 had a fall in the 100-unit exit door while ambulating with her walker, no visible injury noted. Another note dated 8/5/2024 documented R1 was observed walking around the facility without walker, staff redirecting resident to use her walker. Facility reported incident dated 9/4/2024 stated R1 was ambulating with her walker down the hallway when another resident swung the dining room door open, hitting R1 who fell and sustained a laceration to the left side of her forehead. R1 was sent to a local hospital where her laceration was treated with derma glue. A reportable incident dated 10/13/2024 documented 2 staff nurses were called to the 200 unit for a fall, R1 was found in a sitting position with her walker in front of her, a large hematoma was noted to her left forehead, the incident was unwitnessed. R1 stated her head hurts and was sent to emergency room for further evaluation. 11/13/2024 at 12:43PM, V7 (Restorative Nurse) said R1 has a walker and ambulates by herself but still requires staff supervision. 11/13/2024 at 1:00PM, V4 (LPN) said the day R1 had a fall, V4 was paged to the front lobby. R1 was walking in the hallway by the main dining room, another resident was coming out of the dining room, opened the door and hit R1 accidentally. V4 added R1 was on the floor when she got to the scene, she noted some blood coming from a laceration above her right eye was about 2 centimeters in length. R1 was asked what happened and she stated she fell. V4 said no one witnessed the fall. V4 said R1 falls all the time. R1 walks with her walker but will discard the walker sometimes. Staff tries to redirect her. R1 is hard to monitor because she walks all the time and can be aggressive, and one time she tried to throw her walker to a staff. 11/13/2024 at 1:48PM, V8 (C.N.A) said she was assigned to R1 the day she had a fall. R1 likes to walk by herself with her walker and she is confused. V8 said she did not witness the fall; she was charting at the nursing station and was notified by another C.N.A R1 was on the floor. When V8 got there, R1 was sitting on her bottom with her walker in front of her. There was no staff at the nursing station where resident fell. 11/13/2024 at 2:50PM, V2 (DON) said R1 is alert with confusion, walks around with a rolling walker and will sometimes leave her purse and staff will bring it to her. V2 stated R1 requires supervision and her last 3 falls were unwitnessed. V2 said after the last 2 falls the only changes to resident's intervention is sending resident to the hospital, fall care plan should be individualized. R1 may need more supervision to avoid further falls with injury. 11/4/2024 at 3:53PM, V9 (C.N.A) said she was charting at the nursing station when R1 walked past her then she heard a thump and went to check it out. V9 saw R1 on the floor, and R1 said her head hurt. There were no visible injuries or bleeding noted. V9 said, R1 walks around all the time with her walker, staff tries to redirect her, but she does not listen. There was no body in the hallway when R1 fell. Fall policy dated 2/28/2014 presented by V1 (Administrator), stated in part it is the policy of the facility to have a fall prevention program to assure the safety of all residents in the facility, when possible. The program will include measures which determine individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Under safety precautions for residents at risk, the policy states in addition to standard fall precautions, the following interventions will be implemented for resident identified at risk: 1. The resident will be checked approximately every two hours, or according to the care plan, to assure they are in a safe position. The frequency of the checks will be determined by the resident's risk factors and plan of care. 2. In the event safety mentoring is initiated for 15-30 minute periods, a documentation record will be used to validate observations. Assigned nursing personnel are responsible for completing the safety checks ad documenting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records reviewed the facility failed to ensure one resident (R6) remained free from resident to resident sexual assault. This affected two of three residents (R6, R8) reviewed sexual abuse. This failure resulted in R6 being kissed in the mouth unwantedly by R8. R6 said she feels scared and on-guard when walking past R8. Findings include: Final Facility Incident Report shows R6 reported to facility that R8 kissed R6 on the lips. The following conclusion was determined about the allegation: abuse is founded. R8 has diagnosis including but not limited to Alzheimer's Disease, Dementia, Psychosis, Weakness, Cognitive Communication Deficit, Violent behaviors, and Homicidal Ideations. R8's cognitive assessment dated [DATE] indicates a score of 9, impaired. R6 diagnosis include but are not limited to Hemiplegia following Cerebral Vascular Infarction, Hypertensive Heart Disease, Dysphagia, Hyperlipidemia, Alcohol Abuse, and Cocaine Abuse. R6's cognitive assessment dated [DATE] indicates a score of 13, intact. On 5/30/24 at 9:40AM R8 was observed in his room, in bed, resting. The surveyor asked R8 where he is, and R8 responded 'in a hospital'. R8 said he does not know anyone here and has not made friends. R8 said he does not have a girlfriend or wife in the facility. R8 said he has never kissed any women in the facility. On 5/30/24 at 9:45AM R6 said, I was passing his (R8) room in the hallway, he was standing by his door, and he tapped me on the shoulder when I turned, he kissed me on the lips. I couldn't believe it. No, I didn't want him to kiss me. R6 said, When I see (R8), I feel scared he will try again. I'm 'on guard' now when he comes around me. There were two CNAs in the dining room, and they saw it and they said he has done it before. On 5/31/24 at 1:48PM V43, Nurse, said R6 reported R8 had tried to kiss R6 or R8 did kiss her. R6 said R8 was in the dining room. R6's Screening for Indicators of Aggressive and or Harmful Behaviors dated 5/1/24 documents, R6 has factors that increase vulnerability: yes. Review of R8's Progress notes dated 5/19/24 R8 observed being sexually aggressive towards 2 female residents, grabbing their faces and trying to kiss them. Both females were visibly upset. Review of R8's Progress notes dated 3/16/24 documents as follows: Resident received in bed, alert with confusion and aggressive behavior. R8 stated to CNA, I just want to beat her a-- !!. Resident has been noted to be aggressive when staff come in room, staff (nurse) are noticing aggressive behavior to increase, with attempt with aggressive physical contact with staff. Review of R8's care plan does not include interventions for aggressive behaviors. Review of police narrative states, on 5/19/24 R6 stated a male approached her, placed both hands on her face and kissed her upon the lips. The male was later identified as R8. R6 said she did not welcome or consent to R8 having kissed her. The facility undated Abuse Prevention Program Facility Policy states, in part, the facility affirms the right of our residents to be free from abuse.

Based on interview and record review the facility failed to ensure a resident was transferred in a safe manner for 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 7. This failure resulted in R1 sustaining a fall which required emergency medical transport to a local hospital where she was admitted and diagnosed with a subdural hematoma (brain bleed). The findings include: R1's fall investigation report dated June 20, 2023, showed R1 sustained a fall when she was ambulating with the CNA (certified nursing assistant) to the bathroom. The report showed R1 fell back, hitting her head on the bathroom floor. A hematoma was noted to the back of R1's head after her fall. R1 was sent to a local hospital, by ambulance, where she was diagnosed with a subdural hematoma, as a result from her fall. R1's care plan revised May 11, 2023, showed R1 had diagnoses including dementia, altered mental status, anxiety, lack of coordination, and difficulty walking. The care plan showed R1 was at increased risk for falls due poor balance, impaired ambulation, and decreased safety awareness. R1's Restorative Nursing Review dated June 1, 2023, showed R1 required the extensive assistance of one staff for transfers. R1 was totally dependent on one staff for toileting/incontinence care. On July 27, 2023, at 11:55 AM, V16 Family of R1 stated, The nurse called me from the facility, on June 20, 2023, to tell me (R1) had fallen while she was being walked to the bathroom. I don't understand why they walked her to the bathroom. (R1) was wheelchair-bound at that time. She didn't walk anywhere. On July 28, 2023, at 8:50 AM, V9 CNA stated, I was taking care of (R1) when she fell. I was standing in front of her, holding her hands, as I helped her walk from her bed into her bathroom. I was walking backwards, facing (R1), as she tried to walk forwards. I didn't use a gait belt. I held onto both of her hands. We walked into the bathroom and there was stool on the toilet seat. (R1) saw the stool, got upset, and lost her balance. She fell back onto the floor, hitting her head. I couldn't catch her. I went and got the nurse right away. She wasn't bleeding but she had a medium sized lump to the back of her head . I should have wheeled her to the toilet, in her wheelchair, and then used a gait belt to transfer her from her wheelchair to the toilet. On July 28, 2023, at 9:22 AM, V10 Restorative Nurse stated, (R1) was wheelchair-bound. She couldn't walk on her own. She was at risk for falls. She had been on a walking program for restorative programming. Some days were good days and she could walk with our help. She could take 2-3 steps. Some days she couldn't walk even with our help. To ensure her safety when we walked her, one staff member would walk next to her, holding onto the gait belt, that was around her waist. Another staff member would walk directly behind (R1), with a wheelchair, in case she had to sit down. (R1) was also supposed to use a walker when staff ambulated her also. On July 28, 2023, at 10:45 AM, V4 Assistant Director of Nursing stated, (R1) was confused and wheelchair bound. She didn't really walk at all. She could pivot-transfer with one person assisting. Staff should have always used a gait belt when transferring her because of her being at risk for falling. On July 28, 2023, at 10:30 AM, V12 Physician stated, (R1) really didn't walk. She was primarily wheelchair bound. She needed assistance with all her ADLs (activities of daily living). Due to her being a fall risk, staff were supposed to use a gait belt when transferring her. The facility's Gait Belt policy dated June 2014, showed, Purpose: To provide support and safety during ambulation, lifting, or transferring residents. Place belt around resident's waist .Grasp belt webbing securely at resident's back and resident's right or left side to support resident balance during transfers .Stand slightly behind and to the side of the resident .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R24 is a [AGE] year-old individual admitted to the facility on [DATE]. R24's medical diagnosis includes but not limited to: paraplegia, unspecified, Chronic Obstructive Pulmonary disease, pressure ulcer of other site, stage 3, obstructive sleep apnea, other specified noninfective disorders of lymphatic vessels and lymph nodes, acute embolism and thrombosis of deep veins of the right upper extremity. R24's Brief Interview for Mental Status (BIMS) dated [DATE], document R24's BIMS as 12/15. R24's Activities of Daily Living (ADL) Assistance dated [DATE], documents R24's Bed mobility, Transfer, Toilet use, Personal hygiene as R24 needing extensive with two or more persons. R24's MDS section M (skin conditions) dated 2/14/2023 document R24 as having a pressure ulcer/injury, and skin treatments to include pressure reducing device for bed. On 2/21/2023 at 11:17am, R24 was observed lying on bed on a low air mattress. With V11 in R24's room, V11 was asked to check R24's weight setting on R24's low air mattress pump. V11 with surveyor checked the air pump and the weight on the pump was set at 540 lbs. V11 commented that R24's weight is way less than 540 lbs. V11 said that if R24's air mattress was not set using the correct weight for R24, then the air mattress is not therapeutic and can contribute to more pressure ulcers. V11 said that the wrong air pressure can make R24 very tired and uncomfortable. V11 said the air mattress needs to be set using R24's weight. 02/23/23 11:04 AM, V15 (Wound care nurse) said allow air mattress for R24 should be set on the correct weight to improve wound healing, for offloading and to provide the correct firmness to prevent pressure ulcers from developing or get worse. R24's physician orders dated 2/13/2023 13:27document R24's weight as 435.0 Lbs. R131 is a [AGE] year-old individual admitted to the facility on [DATE]. R131's medical conditions include but not limited to: Pressure ulcer of the sacral region, stage 4, cellulitis of the left external ear, pressure ulcer of the left buttock, stage 2, other, pulmonary embolism without acute cor pulmonale. R131's Brief Interview of Mental Status (BIMS) Activities of Daily Living (ADLs) is not completed at this time. On 2/21/2023 at 10:30am, R131 was observed lying on her bed. V11 (Licensed Practical Nurse) was observed in R131's room and stated she (V11) was checking on R131. Observed R131 laying on a low air mattress, pump setting for R131's weight set at 220 lb. V11 was asked what R131's weight was, and if the weight on low air mattress pump was correct. V11 said There is no way R131's weight is 220lbs. I will go and check on R131's chart. V11 came back to R131's room and stated that there were not weights on record for R131. V11 was asked how the setting on air low mattress was determined without R131's weight. V11 said V11 does not know who set R131's low air mattress. V11 said R131's mattress should be set according to R131's weight because the weight goes with the amount of pressure released from the air mattress. V11 said it is a problem to have the air mattress at the wrong setting because wrong setting means the air mattress is not therapeutic and can lead to pressure ulcers or worsening of the existing pressure ulcers. On 2/22/2023 at 2:40pm, V15 (wound care Nurse) said air mattress should be set at the right weight. V15 said if the air mattress weight is set at a higher weight than the resident's, then the mattress will be too firm, or uncomfortable for the resident. V15 further commented that air mattresses are used for offloading, wound healing and for preventive measures to prevent skin breakdown. R131's physician orders, dated 2/15/2023 document: Low air loss mattress R131 weights on 2/21/2023 12:25 document R131's weight as 133.7 lbs. R130 is an [AGE] year-old individual admitted to the facility on [DATE]. R130's medical diagnosis includes but not limited to: pressure -induced deep tissue damage of other site, difficulty in walking, not elsewhere classified, dysphagia, underweight, venous insufficiency(chronic)(peripheral). R130's MDS (Minimum Data Set) section C-Brief Interview for Mental Status (BIMS) dated [DATE]. R130's Activities of Daily Living (ADL) Assistance, dated [DATE], documents R130 is total dependence, two plus personal assistance with bed mobility, transfer, dressing, eating, and walking. R130's section M dated 1/13/2023 documents R130 has pressure ulcer injury, skin tear, pressure reducing device for bed and chair. On 2/21/2023 at 11:00am, R130 was observed lying in bed on a low air pressure mattress. Surveyor with V11 (Licensed practical Nurse-LPN) in R130's room observed R130's low air mattress pump set at weight of over 350 lbs. V11 said R130 is not over 350 lbs. I don't know who set it to over 350lbs. V11 said setting the weight at over 350lbs is not therapeutic for R130 and can cause pressure ulcers and discomfort to R130. V11 said for the air mattress to be therapeutic, it needs to be set at the right weight so that it can provide the correct amount of pressure therapeutic to R130. 02/23/23 11:04 AM V15(Wound Nurse) said some of R130's wounds are improving, and others are getting worse. V15 said allow air mattress for R130 should be set on the correct weight to improve wound healing, for offloading and to provide the correct firmness to prevent pressure ulcers from developing or get worse. R130's weight dated 2/17/2023 documents R131's weight as 83.6lbs. R130's physician orders dated 12/8/2022 document-Low Air Loss Mattress Facility provided manufacture's instructional manual for low pressure mattress, no title, no date under HOW TO USE, documents: position of knob pressure to correlate with weight to produce amount pressure related to weight. Facility Policy titled Low air mattress, no date, documents: Set device according to resident's weight. Based on observations, interviews, and record reviews, the facility failed to: (A) follow their wound prevention and management policy to ensure residents do not develop pressure sores for 3 [R55, R67 R74] residents; (B) ensure resident [R74] received prescribed amount of nutritional feeding via gastric tube; (C) assess resident [R67] for a new pressure ulcer and provide treatment and (D) ensure air loss mattresses were functioning properly and set according to manufacturer's instructions for 5 [R1, R24, R55, R130, R131] residents. These failures resulted in R55, R67, and R74 developing facility acquired pressure wounds; [R55] unstageable DTI [Deep Tissue Injury] (right hip) partial thickness, unstageable due to necrosis (sacrum) full thickness, [R74] unstageable DTI [Deep Tissue Injury] of the left ischium partial thickness, and [R67] two open beefy red, pink wound bed area on (right buttocks). Findings include: On 2/21/22 at 9:40 AM, surveyor and V17 [Licensed Practical Nurse] observed R55 lying in supine position in a deflated air loss mattress bed, flat to the metal frame. V17 stated, I gave R55 her medications this morning, but I did not notice the air loss mattress flat. I am not sure how long R55's mattress been flat. I don't know anything about these air mattresses, I'll get the housekeeper to fix the air mattress. On 2/21/22 at 9:55 AM, V18 [Housekeeper] stated, I'm not in charge of the air loss mattress, but I can usually get them back working. R55's air mattress will not turn on because it is unplugged from the outlet. Give it a few minutes to fill back up with air. On 2/21/22 R55's medical record documents in part; admitted on [DATE], medical diagnosis of dementia, quadriplegia, muscle wasting and atrophy, atherosclerotic heart disease, Alzheimer's disease, and weakness. R55's weekly wound assessment dated [DATE]- (right hip) facility acquired unstageable pressure DTI [Deep Tissue Injury] with partial thickness, measures [L-length, W-width, D-Depth] (L) 6.2 x (W) 4.8 x (D) not measurable cm and (sacrum) unstageable facility acquired pressure wound due to necrosis, full thickness (L) 9.0 x (W) 8.2 x (D) Not measurable cm. Weekly wound assessment dated [DATE]-stage 4, sacrum facility acquired pressure wound with full thickness measures (L) 8.5 x (W) 7.3 x (D) 0.7cm. On 2/13/23 last weekly wound assessment- stage 4 sacrum facility acquired pressure wound with full thickness measures (L) 9.0 x (W) 8.0 x (D) 0.8 cm. Care plan dated 12/13/22- facility acquired pressures wounds on sacrum and right hip. Interventions; low air mattress. Physician order dated 1/27/23 Calcium Alginate External, apply to sacrum topically every day shift, cleanse area with normal saline, pat dry, and cover with border gauze. Order dated 2/13/23, Dakin's ¼ strength External solution 0.125%-apply to right hip topically every day shift, clean wound area with Dakin's pack wet to moist and Santyl cover with bordered gauze. On 2/22/23 at 8:15 AM, R55 was transferred to the hospital, surveyor unable to observe wound care. On 2/21/23 at 9:45 AM, surveyor and V17 entered R1's room and observed R1 lying in supine position in a deflated air loss mattress bed, flat to the metal frame. V17 stated, R1 sometimes refuse help, I am not sure why R1's air loss mattress is off and not working. The housekeeper will come and check on her bed. On 2/21/23 at 10:00 AM, V18 [Housekeeper] stated, R1's air loss mattress is plugged into the outlet, but I cannot get the air pump to turn on, I will change out the air loss mattress for another one. On 2/22/23 at 8:01 AM, surveyor observed R74 resting in bed with the port from the tube feeding laying on the floor. The Glucerna 1.2 bottle was labeled with R74's name, dated 02/21/2023 to run at 50 mL per hour, to start at 12:00 PM. Surveyor saw the tube feeding bottle was only missing 500ml out the bottle. On 2/22/23 at 8:31 AM, V7 (Licensed Practical Nurse) stated, I did not disconnect R74 from the gastric tube feeding because the night nurse disconnected her (R74) from the tube feeding machine at 7:30 AM this morning on 02/22/2023. V7 stated, the initials on the Glucerna bottle are mine and I started the infusion at 12:00PM yesterday (02/21/2023) and only 500mL was infused over 20hours. I'm not sure what happened after my shift. According to the order, R74 is supposed to receive 1000mL over 20 hours but she (R74) only received 500mL. R74's medical record documents in part; admitted on [DATE], medical diagnosis-protein calorie malnutrition, history of sepsis, essential hypertension, pressure ulcers, type II diabetes, depression, altered mental status, and anemia. R74's weekly wound noted dated 12/16/22-(left ischium) unstageable pressure wound DTI of the with partial thickness, measures (L) 2.9 x (W) 2.0 x (D) not measurable cm. Weekly assessment dated [DATE] noted the left ischium is not full thickness stage 4 pressure ulcer measures (L) 2.3 x (W) 2.5 x (D) 0.7cm. Care plan dated facility acquired Left ischium noted 12/16/22. Interventions; air loss mattress, nutritional supplements per dietician recommendations. Physician order dated 1/18/23- Enteral feed order every shift Glucerna 1.2 calorie at 50 ml/hour for 20 hours turn on at 12 noon, turn off at 8am. Treatment order dated 2/10/23 Calcium alginate external, apply to left ischium topically every day shift for wound care, cleanse the area with normal saline, pat dry, cover with bordered gauze. Treatment order dated 2/13/23- Collagen antimicrobial external sheet, apply to left ischium topically every dayshift for wound care, cleanse the area with normal saline, pat dry and cover with bordered gauze. On 2/22/23 at 10:35 AM, R67 stated, Please get the nurse, my butt is hurting and burning. On 2/22/23 at 10:40 AM surveyor and V15 entered R67's room to completed body check. V15 stated, R67 does not have any wounds, but we will continue with the body assessment. On 2/22/23 at 10:45 AM surveyor observed on R67's right buttock, 2 open beefy red, pink wound bed areas on (right buttocks). V15 cleans the area and measured the areas. V15 stated, The two areas equal together (L) 2.0 x (W) 0.6 x (D) not measurable. I do not measure each area separately, because they are close to each other. I don't feel these open areas are pressure ulcers, so at this time I will not complete a wound assessment, but I will place an order and notify the physician and family on a progress note. R67 medical record documents in part: admitted on [DATE], with medical diagnosis of hemiplegia with hemiparesis, essential hypertension, weakness, type II diabetes and acute kidney failure. No physician treatment orders noted. Care plan dated 9/12/22-R67 is at risk for skin integrity issues, Interventions: Skin will be checked during routine care on a daily basis. On 2/22/23 at 1:19 PM, V14 [Wound Care Physician] stated, I am the wound care physician and make rounds once a week. The air mattress should not be flat, the supporting mattress should be afloat with air. I will not say if a resident lays on a metal frame it could potentially cause a wound to worsen. However, I will say a resident with wounds should be on a group two mattress and has been set to appropriated manufactures recommendation and function properly. Group two mattress are low air mattress, and special memory foams to meet the requirements per manufacture manual to provide benefits. I last assessed R55's wounds on 2/13/23, during that time her [R55] wounds have gotten better, and over the last couple of months some of R55's wounds deteriorated but also gotten better, due to R55's medical diagnosis of anemia, and comorbidities. R74's wound assessment today, some of her [R74] wounds have deteriorated due to R74 not absorbing the enteral gastric nutrition, and failure to thrive. On 2/23/22 at 1:45 PM, V15 [Wound Care Nurse] stated, R55 developed a facility acquired right hip pressures ulcer and facility acquired sacrum wound noted on 12/12/22. The size of R55's wounds have decreased and increased over the past couple of months. The air loss mattress is an intervention to prevent and assist in wound healing. If the air loss mattress is not functioning properly or not turn on, it could potentially interfere with the wound healing process. R74 was admitted with a sacrum, left hip, right hip wounds. On 12/16/22 R74 developed a facility acquired left ischium wound. All R74's wounds have got better and worsen over the past few months, due to her malnutrition and her [R74] contractures. After R74 was admitted to the facility, R74 received an gastric tube placed to help with her malnutritional status. If a resident is not receiving their gastric tube nutrition as prescribed, it could potentially interfere with wound healing. On 2/23/22 at 2:15 PM, V3 [Director of Nursing] stated, Air loss mattresses are to be monitored by the staff nursing daily. The nurses upon making rounds, passing medication, and answering call lights are to monitor the air loss mattresses. If there are any problems, notify housekeeping, and me for further instruction. R55 and R1's nurse V17 [Licensed Practical Nurse] will be in-serviced regarding the air loss mattresses. The air loss mattress not being on at all, could potentially cause a pressure ulcer or worsening of a pressure ulcer due to the pressure on the metal frame. If a resident is not receiving the prescribed amount of gastric tube nutritional feeding it could potentially make the wound worsen or interfere with the wound healing process. When residents receive showers, bed baths, or incontinence care, the certified nurse assistance and nurses are to monitor the resident's skin and peri area for any sign of skin alterations. If any skin breakdown or alteration is noted, the staff should report it immediately to the nurse, and treatment nurse. Then the nurse would assess, clean, and place a bandage on the area. Notify the physician, family, wound care nurse and document the findings. If the protocol is not followed, the resident will have a delay in treatment. I will in-service the staff in regard to R67 new open areas found by the surveyor. On 2/24/22 at 11:12 AM, V21[ Dietician] stated, R74 was admitted to the facility under weight, the family finally agreed to a gastric enteral feeding tube to assist with R74's nutrition. R74 was to receive Glucerna 1.2 at 50ml per hour for 20 hours per day, equals 1000ml per day to meet R74's caloric needs. If R74 only received 500ml of the 1000mls ordered, it could potentially cause weight loss, and not provide sufficient amount of feeding to help with wound healing. Policy documents in part: Pressure Ulcer Prevention Handout dated 9/2014 -A pressure ulcer is defined as any lesion caused by unrelieved pressure that result in damage to underlying tissue. Pressure ulcers usually occur over bony prominences and are graded or staged to classify the degrees of tissue of tissue damage observed. -Defined and implemented interventions that are consistent with resident needs, goals, and recognized standards of practice; monitored and evaluated the impact of the interventions revised those approaches as appropriate. -Stage II pressure ulcer- loss of dermis presenting as a shallow open ulcer with a red, pink wound bed without slough or bruising - Skin assessments must continue on a daily basis for all residents that are at risk for skin breakdown. -Poor diet intake can play a role in pressure ulcer development and delayed healing -The important thing to check for when using a pressure reducing overlay or mattress is bottoming auf. Place your hand under the overlay at the point of the sacral contact. If the sacrum is making contact with the bed mattress the pressure relief is not being achieved.