**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure services were effectively provided to identify, monitor, and treat an area of facility-acquired skin impairment and failed to ensure interventions were implemented to provide effective pressure relief to the wound for a resident admitted without skin impairment for 1 of 4 residents reviewed for pressure injuries. (Resident 243) This deficient practice resulted in the facility-acquired skin impairment deteriorating to a stage three pressure injury with infection that required antibiotic therapy. Findings include: Resident 243's record was reviewed on 9/17/24 at 10:46 AM. Diagnoses included unspecified focal traumatic brain injury with loss of consciousness status unknown, type 2 diabetes mellitus with diabetic polyneuropathy, and paresthesia of skin. A hospital Discharge summary, dated [DATE] at 12:25 PM, indicated no skin rashes or lesions were present on Resident 243's skin. An admission assessment, dated 9/1/24 at 5:52 PM, indicated Resident 243's skin was warm, dry, and intact, had normal color and turgor with two abrasions noted on the left knee. No pressure ulcers were indicated on the admission skin assessment. A section of the admission assessment labeled care plan included selections of continue current care plan, initiate care plan and plan of care updated. None of the selections indicated a care plan was initiated, or interventions were implemented. A Braden Scale assessment, dated 9/1/24 at 5:52 PM, included in the admission assessment indicated Resident 243 had a slightly limited ability to respond meaningfully to pressure or discomfort, his skin was occasionally moist, and required a linen change about once a day. The assessment indicated Resident 243 was bedfast, was able to make frequent slight position changes, and had adequate meal intakes. The assessment indicated friction and shear were not an apparent problem. Intervention and care plan actions were blank with no interventions selected for pressure ulcer prevention. A weekly skin assessment, dated 9/2/24 at 2:09 PM, was blank with no indication whether skin conditions were present or not. A skilled nursing note, dated 9/3/24 at 2:34 PM, indicated skin impairment was present, but no corresponding wound assessment was available for review. The type, characteristics, and location of skin impairment was not specified on the assessment. A skilled nursing note, dated 9/4/24 at 4:23 PM, indicated Resident 243's skin was intact with no impairment. No skilled nursing notes, progress notes or wound assessment records for 9/5/24 were available for review. A skilled nursing note, dated 9/6/24 at 3:42 AM, indicated Resident 243's skin was intact with no impairment. No skilled nursing notes, progress notes or wound assessment records for 9/7/24 were available for review. A skilled nursing note, dated 9/8/24 at 1:51 AM, indicated skin impairment was present, but no corresponding wound assessment was available for review. The type, characteristics, and location of skin impairment was not specified on the assessment. Resident 243's current admission Minimum Data Set (MDS) assessment, dated 9/8/24, indicated his Basic Interview for Mental Status (BIMS) score was 12 (mild cognitive impairment). The MDS indicated Resident 243 was dependent on staff to roll back and forth in bed and move from a lying to sitting position in bed. The MDS indicated Resident 243 did not have recorded occurrences of rejection of care. The MDS indicated he was at risk for development of pressure ulcers and had no current pressure ulcers. The comprehensive plan of care, dated 9/3/24 through 9/9/24, did not include documentation to indicate a plan of care to provide pressure relief to the left elbow skin impairment was developed. Resident 243's current care plan, initiated 9/9/24, titled Skin Integrity? indicated Resident 243 was at risk for skin breakdown related to incontinence, impaired mobility, diabetes mellitus, and indicated the resident had a problem of risk for skin breakdown. Interventions included: remove the headboard from the bed and place an air mattress; assess for presence of risk factors, treat, reduce, and eliminate factors to extent possible; avoid shearing resident's skin during positioning, transferring, and turning; conduct a systematic skin inspection, pay particular attention to bony prominences; keep clean and dry as possible; minimize skin exposure to moisture; keep linen dry and wrinkle free; pressure reducing cushion to wheelchair; pressure reducing mattress to bed; report any signs of skin breakdown(sore, tender, or broken areas); and use moisture barrier product to perineal area. A skilled nursing note, dated 9/9/24 at 10:38 PM, indicated Resident 243's skin was intact with no impairment. A progress note, dated 9/10/24 at 8:55 AM, indicated Nurse Practitioner (NP) 5 had been notified of an open area on the left elbow NP 4 had addressed earlier and a bandage was in place. A Wound Management Detail Report, dated 9/10/24 at 10:11 AM, indicated the facility-acquired skin impairment on the left elbow was a Stage III (three) pressure ulcer measured 2.0 centimeters (cm) length (L) by 1.8 cm width (W) by 0.0 cm depth (D), had light exudate (drainage), 20 precent granulation tissue and 80 percent slough (necrotic tissue). The report indicated the ulcer had well defined wound edges and edema (swelling) of the skin surrounding the wound. A skilled nursing note, dated 9/10/24 at 10:53 AM, indicated skin impairment was observed but no corresponding wound assessment was available for review. The type, and location of skin impairment was not specified on the assessment. A progress note, dated 9/10/24 at 11:26 AM, indicated NP 4 had been notified of a skin tear on the left elbow by nursing staff. She indicated the left elbow wound had full thickness loss, with 80 percent slough in the wound bed, 20 percent granulation tissue and a small amount of serosanguinous exudate (blood-tinged drainage) with blanchable redness surrounding the area. NP 4 provided orders to cleanse the wound, pat dry, apply Medi-honey to the wound bed, cover with a foam dressing, change every other day and as needed upon soilage or dislodgement. The Centers for Medicare and Medicaid Services (CMS) Long-Term Care (LTC) Facility Resident Assessment Instrument (RAI) User's Manual Version 1.18.11 October 2023 Section M0300C, page M-13, indicated, .Stage 3 [three] Pressure Ulcer .Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. Untimed Physician orders, dated 9/10/24, indicated Resident 243's pressure sore should be measured with progress documented weekly. Untimed Physician's orders, dated 9/10/24, indicated an air mattress was ordered. A Treatment Administration Record (TAR), dated September 2024, indicated beginning 9/10/24 at 2:00 PM, through 9/18/24, staff should change Resident 243's position every two hours or more often, and pressure should be avoided to the affected area. A skilled nursing note, dated 9/11/24 at 9:23 AM, indicated a skin impairment was observed and indicated Resident 243 had no orders for any type of dressing. No description of the left elbow ulcer or assessment details were available for review. A skilled nursing note, dated 9/12/24 at 11:25 PM, indicated a skin impairment was observed and indicated Resident 243 had no orders for any type of dressing. No description of the left elbow ulcer or assessment details were available for review. No skilled nursing notes, progress notes or wound assessment records for 9/13/24 were available for review. No skilled nursing notes, progress notes or wound assessment records for 9/14/24 were available for review. A skilled nursing note, dated 9/15/24 at 7:00 AM, indicated skin was intact without impairment, and Resident 243 had no orders for any type of dressing. The September 2024 TAR indicated the resident should have an air mattress and staff should measure and document wound progress weekly. The record did not include documentation to indicate staff measured the left elbow wound or the wound progress was evaluated between 9/10/24 and 9/17/24. A skilled nursing note, dated 9/16/24 at 3:59 AM, indicated a skin impairment was observed, but Resident 243 had no orders for any type of dressing. No description of the left elbow ulcer or assessment details were available for review. A Braden Scale assessment, dated 9/16/24 at 12:58 PM, indicated Resident 243 had very limited ability to feel or communicate pain, had very moist skin, required linen change at least once a shift, and was chairfast with very limited ability to make frequent or significant changes in position. The assessment indicated Resident 243 had adequate meal intakes, and shearing and friction were a problem. The assessment indicated Resident 243 was at high risk for skin breakdown. The assessment indicated no interventions or care plan changes were made to increase pressure relief for Resident 243's left elbow. A skilled nursing note, dated 9/17/24 at 12:20 AM, indicated a skin impairment was observed, but Resident 243 had no orders for any type of dressing. No description of the left elbow ulcer or assessment details were available for review. A Wound Management Detail Report, dated 9/17/24 at 10:38 AM, indicated a Stage III pressure ulcer on the left elbow measured 2.0 cm (L) by 1.5 cm (W) by 0.0 cm (D), moderate serous (clear) exudate and 80 percent covered by slough. The left elbow ulcer had well defined wound edges and edema (swelling) of the skin surrounding the wound. A progress note, dated 9/17/24 at 11:41 AM, indicated NP 4 determined there was a decline in the left elbow ulcerated area with evidence of cellulitis. She indicated an antibiotic would be started to treat the cellulitis. No description of the left elbow ulcer or assessment details were documented in the notes. Physician's orders, dated 9/17/24, indicated to give doxycycline hyclate (an antibiotic) 100 milligrams twice daily for ten days. An untimed progress note, dated 9/18/24, indicated an ABD pad may be substituted for the foam dressing ordered to the left elbow due to foam dressing not being available one time only. During an observation on 9/18/24 at 10:25 AM, Resident 243 was observed lying on his back in bed with his left arm propped on a pillow and covered with a sheet. Registered Nurse (RN)2 entered the room carrying an abdominal (ABD) pad and a package of Medi-honey (a treatment to dissolve dead tissue in a wound). She indicated she was not prepared, returned a few minutes later carrying a bottle of wound cleanser and was accompanied by the Infection Preventionist (IP). She approached the resident with the wound cleanser when the IP prompted her to don a gown prior to beginning the procedure. After donning the gown and gloves, RN 2 pulled the sheet back and cleansed the wound. The tip of Resident 243's elbow had a nickel-sized, brown centered, round wound surrounded on all edges by yellow slough with bright red skin surrounding the immediate edges and swollen, pink skin surrounding two to three inches of the arm. RN 2 performed hand hygiene, changed her gloves and applied a piece of Medi-honey to the wound bed, touching the wound bed with her gloved hand in the process. She then picked up the dressing, placed it on the wound, secured it in place without performing hand hygiene use or applying clean gloves after touching the wound bed. According to medihoney.com an article, titled Manufacturer's Guideline, dated January 2024, indicated Medi-honey was used to promote a moist wound environment to aid and supports autolytic debridement (dissolves dead tissue). During an interview on 9/18/24 at 10:25 AM, Resident 243's wife indicated he had an infected left elbow, and the nurse was going to return to the room to perform a dressing change within the next few minutes. Resident 243's wife indicated she was concerned about Resident 243's elbow because she reported to the nurses that it had looked infected and was warm to touch several days before a Nurse Practitioner saw it and ordered an antibiotic. During an interview on 9/18/24 at 10:45 AM, the IP indicated hand hygiene should be done before each procedure, after removing any dressing, and after wound care is complete. She indicated she would have to review the policy to see if hand hygiene and glove change is required after touching the wound during the packing of a treatment product. During an interview on 9/19/24 at 10:22 AM, CNA 3 indicated the facility did not use a written reporting system for CNA staff to notify the nurse of skin concerns. She indicated she informed her nurse verbally sometime during her shift over that weekend and she believed the nurses were aware of the area on the elbow prior to that because it had been there for a while. She could not recall when she first observed the area on the elbow. She indicated the area looked like a scab but could not recall the size or what the skin around it looked like. During an interview, on 9/19/24 at 1:18 PM, Nurse Practitioner 5 indicated on 9/10/24 an unidentified CNA asked if she needed to order a bandage for Resident 243's left elbow. She indicated the elbow had an area around the size of the end of her thumb (about the size of a dime) with slough in the center. She indicated it did not appear to be a result of a skin tear. She indicated the area was positioned on a pressure point and was the result of pressure. She indicated she was not aware of any skin impairment on the left elbow prior to that encounter. A current policy titled Clean Dressing Change Policy, dated 3/10/24, provided by the IP on 9/18/24 at 1:00 PM, indicated hand hygiene and donning new gloves should occur if a wound is touched during the assessment process. A current policy titled Skin and Wound Care Best Practices, last revised 6/10/22, provided by the IP, on 9/18/24 at 3:07 PM, indicated pressure reduction and redistribution should be provided to residents determined to be at risk. The policy indicated full body skin assessments should be conducted upon admission, with a second full body assessment conducted within the first 24 hours of admission. Staff should complete a Weekly Skin Check and review nursing assistant's shower sheet skin reviews. The policy indicated pressure injuries and wounds should be treated with evidenced based interventions as ordered by the provider. 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, interview and record review, the facility failed to prevent a non-pressure related wound from resting directly on the floor for 1 of 2 residents reviewed (Resident E). This resulted in Resident E's wound becoming infected requiring antibiotics. Findings include: On 1/24/24 at 11:01 A.M., Resident E was observed seated in a wheelchair next to her bed. Her bare feet was in direct contact with the floor with no barrier. The right foot was wrapped with a gauze dressing from the midfoot to above her ankle. Her right pant leg was pulled up and her calf was visible. The exposed calf was red in color with thick white scales of skin. The exposed forefoot skin was swollen, reddened with thick scales. There were old non-skid strips beneath her feet. There were numerous food and skin particles beneath her feet and across the floor. The mattress on her bed was stained and had no linens on it. On 1/24/24 at 1:20 P.M., the resident was observed still seated in her wheelchair next to the bed. Black socks had been put on and covered the forefoot of both feet. The right foot gauze dressing remained in direct contact with the floor. Her bed remained without bedding. When questioned, the resident indicated she couldn't sit in the recliner chair and elevate her feet because the path was too narrow between her bed and window. She had to back herself into the chair with her walker and staff assistance. It wasn't safe for her to do this so she was unable to elevate her legs. She indicated she'd had an episode of confusion the other night and thought she had been in another home. She was taking antibiotics for her wound, had some diarrhea and indicated that could be what was causing the confusion. -At 3:05 P.M., Resident E was observed still seated in her wheelchair with feet in direct contact on the floor and black socks pulled over both forefeet. She appeared to be sleeping with her eyes closed. On 1/25/24 at 9:57 A.M., Resident E was observed seated in her wheelchair with both feet flat on the ground. On her right foot, she wore a sock over the forefoot while the gauze dressing on her heel wound was in direct contact with the floor. On her left foot, she wore a blue slipper. She indicated she hadn't felt well all night and felt confused at times. She complained of having diarrhea again and her mattress was bare of linens. She indicated staff told her they were going to get a stool culture to check for infection due to the antibiotics she was taking. On 1/25/24 at 1:50 P.M., LPN 4 left the resident's room carrying a stool sample. She indicated staff had just laid the resident down after the resident had a very large watery stool and would return to the room to complete the resident's wound care. -At 1:57 P.M., Resident E was observed lying in bed with gray colored skin. She indicated she hadn't felt good. LPN 4 and the LPN 5 (facility wound care nurse) assisted the resident to turn to her side and pulled up her leg pant. On the bed sheet, where the right heel had sat, was red-brown wet drainage and the gauze dressing around the right heel was saturated with red-brown drainage. LPN 4 removed the saturated dressing and a very large wound engulfing the entire swollen right heel was observed. The wound was round and approximately 5 inches around. The wound bed was gray to green in color and appeared very moist. In the center of the wound was an elevated eschar (necrotic-dead skin tissue) cap, black in color. On the outer edge of the circular shaped wound, was an area of pale gray moist and soft appearing tissue. Surrounding the entire wound were deep scales of thickened, dry and reddened skin extended onto the resident toes. The wound itself and drainage had a strong foul odor. The resident had been given pain medication prior to the dressing change and denied pain during the procedure. On 1/24/24 at 1:00 P.M., Resident E's record was reviewed. Diagnoses included diabetes with polyneuropathy and peripheral vascular disease with an arterial ulcer to her right heel since 8/4/23. A Doppler study, done on 8/23/23, indicated the resident had arterial stenosis (blood vessels which are narrowed or blocked) to 3 arteries in her right leg. There were no nursing assessments of the wound available for review. A quarterly MDS (Minimum Data Set) assessment, dated 11/29/23, indicated the resident was alert and oriented without cognitive impairment. She had no behaviors or rejection of care. She had no functional impairment to her upper or lower extremities but had impaired balance and weakness due to effects of childhood illness. She walked very short distances using her walker or wheelchair along with maximal assistance from staff. She was dependent on staff for putting on and taking off her footwear. She had an arterial ulcer which was being treated. Care plans were as follows: 12/1/23-Resident had skin breakdown. The goal was to have no further skin breakdown. Interventions included: turn and reposition as indicated; pressure reducing cushion to wheelchair and pressure reducing mattress; and float heels when in bed as the resident allows. 12/1/23-Resident with actual skin impairment: right heel arterial wound, surgical wound to top of head, and moisture associated skin disorder to buttocks. The goal was for areas to heal without signs or symptoms of infection. Interventions were: diet as ordered; complete skin checks and assessment per protocol; follow physician orders and treatments as indicated; refer to registered dietician; and use pressure reducing devices as indicated. 1/3/24-Resident with infection to right heel ulcer: the goal was for the ulcer to heel. Interventions included: assess for pain every shift; encourage activity as tolerated; encourage to be out of bed as tolerated; provide medications and antibiotics as ordered; monitor the right heel ulcer; and notify physician of changes. Wound Management Detail Reports, dated 11/6/23, 11/13, 11/20, 11/27, 12/5, 12/11, and 12/18/23, indicated the right heel wound had remained stable with daily treatment and dressing changes. The wound remained approximately the same size of 6 cm (centimeters) by 6 cm with black eschar and no drainage. The peri wound was consistently described as pink. A Wound Management Detail Report, dated 12/26/23 at 6:48 p.m., indicated the wound was stable but had light serosanguineous (blood and serum) drainage with no odor. The resident was encouraged to elevate the right leg when able to. A Wound Management Detail Report, dated 1/2/24 at 7:56 p.m., indicated the wound had purulent (pus) drainage, the peri wound was pink to red, with a mild odor. The medical NP was notified and ordered lab work, an x-ray to be done of the right foot to check for a bone infection, and a course of antibiotics. The resident was encouraged to elevate the right leg when able to. On 1/2/24 the medical NP ordered doxycycline (an antibiotic)100 mg po BID for 10 days. A Wound Care note by the Wound NP (Nurse Practitioner), dated 1/3/24, indicated the resident had been seen for care of her chronic arterial wound. The wound measured 6 cm by 6.5 cm and was covered with an eschar cap that was starting to lift up with open edges to the wound. The wound had a small amount serosanguineous drainage without odor and wound bed was 20% slough and 80% eschar. Assessment and Plan: x-ray of the foot was negative for osteomyelitis (bone infection) per LPN 5. Orders were given to change the treatment and continue with the antibiotics as ordered by the house NP. The right heel was to be offloaded (pressure off of heel) at all times. Wound Management Detail Reports, dated 1/8/24 at 6:23 p.m. and 1/15/24 at 10:48 p.m., indicated the right heel wound measured 6.5 cm by 7 cm with seropurulent drainage with mild odor. The resident was encouraged to elevate the right leg when able to. A Wound Care note by the Wound NP, dated 1/19/24, indicated the resident's right heel wound measured 6.5 cm by 7 cm and had a small amount of serosanguineous drainage with odor. The wound bed had 30% slough, 60% eschar and 10% granulation tissue. Edges of the wound were open and the eschar cap was lifting. Skin surrounding the wound was reddened and the wound was worsening in size, increased drainage and wound odor. Assessment and Plan: X-ray reordered by Medical NP as well as venous ultrasound. Treatment to wound was changed and right leg was to be offloaded at all times. On 1/25/24 at 10:55 A.M., CNA 6 (Certified Nurse Aid) was interviewed. They indicated the resident still walked with assistance to the bathroom but was very shaky and last week had almost fallen while being assisted. CNA 6 indicated the resident wasn't able to sit in her recliner chair because she had to back up with the walker to get to the chair which was not safe. On 1/25/24 at 2:42 P.M., the Infection Control Nurse was interviewed. She indicated Resident E's right heel wound and it's dressing should not be sitting directly on the floor. A current facility policy, titled Skin and Wound Care Best Practices was provided by the Director of Nursing on 1/25/24 at 2:15 P.M., which stated: Skin Care and Pressure Injury Prevention: Provide pressure reduction/redistribution for those at risk: offload/suspend heels for at risk residents .Pressure injuries and wounds will be treated with evidence-based interventions as ordered by the provider .All clinical staff will receive education on pressure injury prevention and treatment .with focus on education staff in the importance of basic care such as skin care and protection and pressure redistribution WebMD.com indicated aterial wounds are slow to heal, the goals are to remove contact irritation and pressure and dressing should be kept dry and clean. This tag relates to Complaint IN00425543. 3.1-37

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide adequate staff and assistive devices to prevent a fall for 1 of 3 residents reviewed for accidents. This deficient practice resulted in a fall with fracture, pain, and increased anxiety (Resident M). Findings include: A facility reported incident to the Indiana Department of Health, dated 3/13/23 at 1:22 p.m., indicated Resident M rolled out of bed while being assisted with care. She was sent to the hospital where x-rays indicated a tibia/fibula left ankle fracture. On 3/27/23 at 9:43 A.M., Resident M's record was reviewed. Diagnoses included acute fracture of left tibia and fibula from fall, anxiety disorder, major depressive disorder, and mild cognitive impairment. A quarterly MDS (Minimum Data Set) assessment, dated 12/23/22, indicated the resident had moderately impaired cognition. She had no behaviors of rejecting care. She required extensive assistance from 2 staff for bed mobility and toileting. She was always incontinent of bladder, frequently incontinent of bowel, and was non-ambulatory. Care plans indicated the following: -The resident had a self-care deficit related to impaired mobility, cataracts, and failure to thrive (last revised 8/4/21). The goal was for her needs to be met. Interventions included: assist with activities of daily living (ADL), dressing, grooming, toileting, feeding, and oral care; bed mobility with assist; dressing/grooming with assist; and toileting with assist. The care plan hadn't indicated the number of staff required to assist the resident to perform ADL's safely. -The resident was at risk for falls due to history of falls, injuries, and multiple risk factors (last revised 8/4/21). The goal was for the resident to have no fall related injuries. Interventions included: bed in the lowest position; call bell within reach; provide assistance with toileting as needed; and implement preventative fall interventions/devices. -The resident was incontinent of bladder (initiated 8/3/21). The goal was for her to receive assistance with toileting. Interventions included: provide incontinence care as needed. The care plan hadn't indicated the number of staff required to assist the resident with incontinent care while in bed or out. On 3/27/23 at 10:05 A.M., Resident M was observed lying in her bed. The left side of the bed was against the air conditioning unit. The unit's level was below the window. There were quarter bedrails on both sides of the bed. The resident had a flat affect and complained of pain in her left ankle. She indicated she didn't remember the fall that had occurred from bed and wasn't sure how she had gotten back into bed after falling. -1:47 P.M., the resident was observed lying in her bed. The bed had been moved away from the air conditioning unit with an approximate distance of 3 feet between the bed and unit. The Unit Manager (UM), indicated the bed brakes were locked. She tried to move the bottom of the bed which did not move however, when she moved the head of the bed, it was able to move despite the bed brake being on. The resident was observed to have purse lipped breathing and indicated she was having a lot of pain in her left ankle. She indicated she would be much better after the cast was removed from her ankle. Progress notes indicate the following: -3/13/23 at 3:12 a.m., a head to toe evaluation for an occurrence was completed. The nurse had been called to the resident's room where she'd had a witnessed fall from bed. A CNA (Certified Nurse Aide) indicated she had been changing the resident and as she rolled her to the side of the bed, the resident let go and slid out of the bed. A left ankle X-ray was ordered and the resident given Tylenol for pain. The left ankle was elevated on a pillow and ice applied. She complained of throbbing pain to her left ankle at a pain level of 4 out of 10 with 10 being the worst. The nurse indicated the resident needed side rails to hold onto during bed changes. -7:36 a.m., a fall follow-up note indicated the resident was alert and oriented with neurological checks within normal limits. She complained of throbbing pain in her left ankle and rated her pain at a 8 out of 10 with 10 being the worst. -8:00 a.m., the resident had dark purple bruising to the left lateral ankle. The bruising measured 5 centimeters by 6 centimeters. -11:20 a.m., an Interdisciplinary team progress note indicated on 3/13/23 at 2:38 a.m., the resident was being given incontinent care when she rolled towards the window and fell from the bed. Physical assessment had shown there was an acute injury with swelling around the left ankle. X-ray of the left ankle was ordered. The resident had increased complaints of pain and requested to go to the hospital. She was to be transferred to the hospital for evaluation and treatment of the left ankle injury. -3:09 p.m., quarter bed rails were applied to both side of the resident's bed to assist with bed mobility and positioning. -4:22 p.m., the resident returned from the hospital. She had increased anxiety and stated I just don't like hospitals; they make me very anxious. She received routine anti-anxiety medication but was not due for the next dose until 8:00 p.m. The psychiatric Nurse Practitioner (NP) was notified and ordered a one time dose of Buspar 5 mg (a different anti-anxiety medication) with the hope the resident's anxiety would be reduced until it was time for her usual anti-anxiety medication at 8:00 p.m. -8:44 p.m., an NP progress note indicated Resident M was seen for a post hospital visit. The resident had sustained a fall from bed while receiving care from staff. She had been to the hospital and returned with a soft cast in place to the left ankle. She was complaining of pain at a level of 9 out of 10, was anxious, and observed to be shaking from the pain. She had an order for as needed pain medication with recommendation to make this a routine order. -3/14/23 at 4:54 a.m., the resident was given an opioid pain medication-Norco 5-325 milligrams (mg) 1 tablet by mouth every 6 hours as needed for pain level of 8 out of 10. -11:41 a.m., fall follow-up documentation indicated the resident had pain in her left ankle which was rated at 7 out of 10. Her pain medication was ordered to be given routinely every 8 hours. -3/15/23 at 9:51 a.m., a psychiatric NP progress note indicated the resident was seen for an increase in anxiety status post fall. Since her fall with fracture, she'd had an increase in anxiety. She was observed to move her hands constantly, was fidgety and restless. She told the NP that she was more anxious and worried but shared no further information. Her mental status exam indicated she was alert and oriented to self, place, and time. She had fair eye contact and was anxious, restless, and fidgety. The plan was to start her on a second anti-anxiety medication-Buspar 5 mg tablets by mouth 3 times per day due to increased, observed anxiety since fall with fracture. -At 2:45 p.m., a fall follow up indicated the resident's pain level was 0 out of 10. The note indicated the NP had discontinued the resident's routine Norco and ordered Percocet 5-325 mg by mouth every 8 hours due to ineffectiveness of Norco for pain management. The NP's note indicated the resident had been on Norco 5-325 mg tablets-1 tablet every 8 hours but her pain had not been controlled. -3/17/23 at 11:07 a.m., an NP progress note indicated the resident had an episode of hypoxia (low blood oxygen) early in the morning and her oxygen level had dropped to 66% on room air (normal is >90%). She was placed on oxygen. The NP suspected the hypoxia had been due to the change in narcotics. Due to the resident's uncontrolled pain, she was being sent STAT to the orthopedic's office for evaluation. The Percocet was discontinued and the routine Norco re-started for pain management. The resident's routine Ativan (anti-anxiety medication) was to be held for 1 week while she was on narcotics. An Orthopedic progress note, indicated the resident had been seen on 3/17/23 and a short leg cast applied to her left ankle. During the visit, the resident was observed with an elevated blood pressure of 160/100 and pulse at 104. -3/22/23 at 7:14 a.m., a psychiatric NP progress note indicated the resident was visited for follow up of increased anxiety following a fall with fracture and not eating. The resident had not been eating, had complaints of her stomach not being right, increase in pain, and multiple fixations on changes. During the visit, the resident indicated she was trying to eat but her stomach was in knots. The plan was to continue her Ativan as ordered and increase her Buspar to 10 mg 3 times per day by mouth. On 3/27/23 at 10:00 A.M., Nurse 2 was interviewed. She indicated CNA's referred to the [NAME], located on IPADs, to direct them how to care for a resident and how the CNA's were to document care they provided. She indicated the [NAME] should indicate how many staff members were required to assist a resident with ADL's such as bed mobility, transfers, and incontinent care. A [NAME] report, dated 3/12/23, before the resident's fall and used by CNA's to provide care to Resident M, had interventions for activities, safety, care, skin care, activities of daily living, devices, and daily routine. The [NAME] report hadn't indicated the number of staff required to provide care to the resident. On 3/27/23 at 11:16 A.M., a witness statement was provided by the Unit Manager indicated CNA 3 worked the night shift on 3/12-3/13/23 and cared for Resident M. The CNA was changing the resident's brief and had rolled her onto her left side facing the window. As the CNA pushed the bed pad and brief under the resident, the resident let go of the bed and her body started rolling off. The CNA tried to grab her so she wouldn't fall but the resident's entire body rolled off the bed and landed on the air conditioner unit. CNA 3 moved the bed away from the air conditioner unit so she could turn the resident on her back. The resident's right leg was extended in front of her but her left leg was underneath her and she was sitting on it. CNA 3 pulled the resident beneath her arms away from being between the wall and air conditioner unit. The CNA got the resident's left leg out from underneath her and extended her left leg. The resident's left ankle was swollen immediately. CNA 3 then went to get the night supervisor. On 3/27/23 at 2:26 P.M., Nurse 5, was interviewed. During the interview, she indicated on 3/13/23 at approximately 2:40 a.m., she was summoned to Resident M's room. When she came into the room, she saw Resident M on the floor, between the bed and air conditioner unit, with her head towards the head of the bed. She and CNA 3, along with a mechanical hoyer lift, got the resident off the floor and back into bed. The resident complained of pain in her left ankle. The ankle was swollen and discolored. Nurse 5 indicated the resident's ankle and foot hit the air conditioner as she fell over the side of the bed. The resident did not have side rails or transfer rails on her bed. The nurse indicated when staff assisted the resident to turn over for incontinence care, the resident would reach over the side of the bed and hold on to the bed frame to support herself. When questioned, the nurse indicated either 1 or 2 staff members could assist the resident with bed mobility and incontinence care. A current policy, titled Fall Prevention and Management Policy was provided by the unit manager on 3/27/23 at 2:13 P.M. The policy indicated: Residents will be assessed for fall risk(s) on admission, quarterly, after any fall, and as needed. If risks are identified, preventive measures will be put in place and care planned. All falls will be reviewed and investigated .Individualized interventions will be implemented based on this assessment and care planned accordingly .Falls will be reviewed by an interdisciplinary team and any new interventions identified will be implemented and the care plan updated as necessary. Such review should include results of the new fall risk assessment, discussion with resident and/or any witnessing parties as to potential causal factors, review of the environment where the fall occurred, and discussion as to any new interventions which may help to prevent further falls The deficient practice was corrected by 3/14/2023 after the facility implemented a systemic plan that included the following actions: an audit was completed to ensure resident assistance was clear on CNA [NAME] and appropriate fall prevention devices were in place for residents at high risk, the staff was reeducated regarding giving care accoring to the [NAME], and m onitoring was initiated and completed regarding observations of giving care according to the [NAME]. This Federal tag relates to Complaint IN00403968. 3.1-45(a)