Based on record review and interview the facility failed to provide appropriate assistance to prevent an avoidable accident for 1 of 3 residents reviewed for accidents hazards. This deficient practice resulted in the resident acquiring right medial and right posterior orbital fractures. (Resident D) Findings include:The clinical record for Resident D was reviewed on 9/22/2025 at 3:15 P.M. An admission Minimum Data Set (MDS) assessment, dated 9/3/2025, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, heart failure, asthma, and respiratory failure. The Resident required maximal assistance to transferring from lying to sitting and sitting to standing.The At Risk for Falls Care Plan, dated 8/27/25 and revised on 9/8/25, indicated the resident will be free of falls. The interventions included, but were not limited to, dated 8/27/25, anticipate and meet the resident's needs; and, dated 9/6/25, resident's room closer to nurses station for closer monitoring.The Physical Therapy Progress Report, dated 8/23/25, indicated the resident required maximum assistA facility incident report, dated 9/6/25, indicated staff found Resident D lying on the floor near the resident's room doorway. The resident had gotten up unassisted and lost balance, the resident was unsure where she was going or what she was needing. The resident had a laceration to the left side of her forehead.During an interview, on 9/22/2025 at 10:45 A.M., Certified Nursing Assistant (CNA) 3 indicated she was getting Resident D up for breakfast on 9/12/2025 and left the resident sitting on the side of the bed while she walked to the far corner of the room to retrieve the resident's wheelchair. While her back was to the Resident, she heard a loud noise and turned to find the resident lying face first on the ground. The resident hit her head hard and broke her dentures. CNA 3 said sometimes Resident C can hold herself up and sometimes she can't. She was told by other staff that the resident had been declining and to be careful with her. Ever since the resident came back from the hospital after this incident, she has required a mechanical lift for transfer and used a specialized mobility challenges ergonomic wheelchair instead of regular wheelchair.During an interview, on 9/22/2025 at 1:30 P.M., Therapy Staff Member 4 indicated Resident C came from home and was at the facility for therapy. Resident C required maximal verbal direction. For example, if you asked her to stand up, she wouldn't understand what you were asking. She was not following direction. She was dropped from seeing therapy after her last fall on 9/12/2025. The last few times Therapy Staff Member 4 helped Resident C she required maximal assistance. She required maximal assistance with two staff members just to get her out of the chair when she was in therapy doing exercises. Therapy Staff Member 4 indicated she would not have left Resident C sit on the side of her bed alone while she retrieved her wheelchair from across the room. During an interview, on 9/22/2025 at 3:40 P.M., RN 5 indicated she was the nurse who responded to Resident C's fall on 9/12/2025. Upon entering the room Resident C was laying on the floor face first with her hands alongside her body like she did not attempt to catch herself. She had a laceration on the side of her face and bruising was already starting. A Hospital Document, dated 9/12/2025 at 8:47 A.M., showed the findings from the computed tomography (CT) scan indicating the resident had a new right medial orbital blowout fracture with opacification of the adjacent ethmoid sinuses. Additionally, a subtle new acute fracture within the posterior right orbital wall. A hematoma in the right cheek with extensive surrounding inflammation. Also, a laceration with a total repaired wound length of 5 centimeters (cm). The current facility policy, titled Falls and Fall Risk, managing, with a revision date of August 2024, was provided by the Administrator on 9/22/2025 at 4:20 P.M. The policy indicated, .the staff will identify interventions related to the residents' specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling .The current facility policy, titled Safe lifting and Movement of Residents, with a revision date of August 2024, was provided by the Administrator on 9/22/2025 at 4:20 P.M. The policy indicated, .In order to protect the safety and well-being of staff and residents, and to promote quality of care, this facility uses appropriate techniques and devices to lift and move residents .This citation relates to Intake 2616965.3.1-45(a)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to transfer a resident, that required a full body mechanical lift, safely using the appropriate lift resulting in a fracture for 1 of 3 residents reviewed for accidents. (Resident C) Findings include: On 8/9/23 at 11:08 a.m., the Director of Nursing (DON) indicated on 7/27/23 Resident C was being assisted into bed with a lift. The resident yelled out in pain and was sent out to the emergency room (ER). The resident had a fractured left fibula and a follow up appointment with Orthopedics. During an observation and interview on 8/9/23 at 1:57 p.m., Resident C was lying in her bed, her left leg was wrapped and elevated on a pillow. She indicated she required a full body mechanical lift for transfers. On 7/27/23, the day of the incident, she was in the wheelchair for a long time and had asked to be put to bed. The full body mechanical lift had quit working. The staff couldn't find a cord to charge it, so they use a standing aid transfer system (required partial weight bearing) to transfer her to the bed. The resident had asked them not to use the standing aid unit. The staff indicated she had to use it or she could not get back to bed. The Certified Nursing Aides (CNAs) held the back of her pants and had an arm under each of her arms as they assisted her to stand up. She told them to set her back in the chair, but they wouldn't. They rolled her over to the bed, then swung her legs onto the bed. The clinical record for Resident C was reviewed on 8/9/23 at 12:48 p.m. A Quarterly MDS (Minimum Data Set) assessment, dated 6/30/23, indicated the resident was cognitively intact. She required extensive assistance of two or more staff members for mobility, transfers, and toilet use. She was 67 inches tall and weighed 263. The resident's diagnoses included, but were not limit to, cirrhosis of the liver, chronic kidney disease Stage 3, weakness, and anxiety. A Care Plan, with a revision date of 12/18/22, indicated the resident had an Activities of Daily Living (ADL) self-care performance deficit, related to immobility. The interventions indicated the resident required a mechanical lift with two staff assistance for transfers. The resident's record lacked documentation related to the transfer on 7/27/23 at 6:15 p.m. A Progress Note, dated 7/27/23 at 10:34 p.m., indicated Resident C started to complain of chest pain and right foot pain. The right foot was unremarkable. The resident stated that the chest pain was like when she had an MI (Myocardial Infarction). The staff called 911 and the local ER was notified. A Progress Note, dated 7/28/23 at 5:13 a.m., indicated the resident would be returning to the facility with a fracture of the left fibula. An Orthopedic Report, dated 8/1/23, indicated the resident was non-ambulatory at baseline. An x-ray of the left ankle indicated a nondisplaced distal fibula fracture. During an interview on 8/10/23 at 11:17 a.m., CNA 3 indicated on 7/27/23 Resident C had been up since that morning because she had an appointment. The full body mechanical lift (non-weight bearing) was how they got her up that morning, and she was insisting that she had to lay down. Her family member was in the room at the time. They went to get the full body mechanical lift and it was not operating correctly. There was concern for the resident's safety. The nurse was notified, and the care plan only stated, mechanical lift with two assists. It was explained we could use the standing aid transfer system and the resident agreed. Because she was a large person, for safety, a third CNA assisted with the transfer. The standing aid transfer system was placed in front of her, with one staff on each side, one behind her, and her family member in front. She was assisted to a somewhat standing position and the lift pad used with the full body mechanical lift was attached to the standing aid transfer system. During the pivot of the standing aid transfer system the resident cried out indicating she was in pain. She was lowered to her bed, laid down, placed in a comfortable position, and the nurse was notified. During an interview on 8/10/23 at 10:56 a.m., Licensed Practical Nurse (LPN) 2 indicated on the day of the incident (7/27/23) she was the day shift nurse. The incident occurred during the nursing shift change (6:15 p.m.). Resident C had been up since the 1:00 p.m. smoke break and was insisting she wanted to lay down. The CNAs went to get the full body mechanical lift and it was not working. They notified the nurse and the only plausible solution for immediate transfer was by using the standing aid transfer system. The resident was agreeable to the standing aid transfer system, because she insisted, she was not going to sit up all night. They normally used the full body mechanical lift for her transfers, but her care plan only indicated a mechanical lift with two-assist. To ensure her safety a third CNA was sent into the room to assist with the other two staff doing the transfer. She had not contact maintenance about the full body lift since the girls had already posted in the notification that the full body lift was down (not working) twice. During an interview on 8/10/23 at 10:12 a.m., the DON indicated when the facility rented the full body mechanical lift, and it was not working the decision was made to use the standing aid transfer system to put the resident in bed. The resident's requested to go to bed. The resident was agreeable to use the standing aid transfer system. She just wanted to get to bed. A third CNA was sent in to assist the other two CNAs for safety. The resident's family member was also present in the room during the transfer. The CNAs had indicated that as they were turning the standing aid transfer system, the resident stated, oh my leg, and they immediately sat her on the edge of the bed with the unit. A Physical Therapy Discharge summary, dated [DATE] through 1/31/23, provided by the PT (Physical Therapy) Manager on 8/10/23 at 1:47 p.m., indicated Resident C was non-ambulatory. During an interview on 8/10/23 at 1:48 p.m., the PT Manager indicated the standing aid transfer system was a mobility frame sit to stand unit. It was primarily used by the therapy department. There were only two nurses who had been trained to use the mobility frame and it had never been used with Resident C. A Physical Therapy Evaluation and Plan of Treatment, dated 12/28/22, indicated Resident C required assistance for transfers using a full body mechanical lift. During an interview on 8/10/23 at 1:57 p.m., the DON indicated the Fire Department was not contacted for assistance with a transfer for Resident C on 7/27/23. During an interview and observation on 8/10/23 at 2:03 p.m., CNA 4 demonstrated to the DON how the standing aid transfer system was to be used. The DON indicated she was not aware the unit was not a mechanical lift. During an interview on 8/10/23 at 3:06 p.m., the DON indicated there were 14 residents that resided in the facility that required a full body mechanical lift for transfers. The full body mechanical lift was fixed on 7/28/23. The current facility policy, titled Resident Transfers , with a revision date of 9/2022, was provided by the DON on 8/10/23 at 1:45 p.m. The policy indicated, .to ensure the safety of residents and staff when performing mobility/transfer task .SOP DETAILS .1. Shall determine the type of transfer device, amount of assistance required to assist with safe mobility .b. weight bearing status .3. Determine the amount of assistance required for transfers and record this on the .Resident Care Plan . The current facility policy, titled Accidents/Incidents/Investigation, with a revision date of 10/2022, was provided by the DON on 8/10/23 at 1:45 p.m. The policy indicated, .3. In compliance with current rules and regulations governing accidents and or incidents involving a medical device . This Federal tag relates to Complaints IN00414379 and IN00413989. 3.1-45(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an interview on 01/03/23 at 1:44 P.M., Resident 9 indicated she had a wound on her right heel. She would go to the wound clinic once a week and they would change the dressing there. The facility no longer changed the dressing. She had the wound for several months. The clinical record for Resident 9 was reviewed on 01/04/23 at 3:33 P.M. A Quarterly MDS assessment, dated 11/20/22, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, acute osteomyelitis of the right ankle and foot, anemia, diabetes, and sacral spina bifida. The resident had impairments to both sides of the lower extremities and a diabetic foot ulcer. A Progress Note, dated 08/08/22 at 4:06 P.M., indicated staff called the ADON to the resident's room. The resident had an open area to the right heel that was a Stage 2 pressure area. New orders were obtained to cleanse the wound bed with wound cleanser, apply collagen to the right heel wound bed, and cover with a dry dressing. An Initial Wound Assessment, dated 08/08/22, indicated the resident right heel wound measured 1.3 cm x 1.3 cm x 0.2 cm. A Weekly Wound Assessment, dated 08/10/22, indicated the resident had a diabetic wound to the right heel that was acquired in house. The wound measured 1.3 cm x 1.3 cm x 0.2 cm. There was 76 to 100% (percent) granulation tissue to the wound bed. A Weekly Wound Assessment, dated 09/07/22, indicated the resident had a diabetic wound to the right heel that was acquired in house. The wound measured 2 cm x 1.9 cm x 0.2 cm. There was 76 to 100 % epithelial tissue present. The wound had deteriorated. A Weekly Wound Assessment, dated 10/12/22, indicated the resident had a diabetic wound to the right heel that was acquired in house. The wound measured 2.5 cm x 2 cm x 0.3 cm. There was 0 to 25% granulation tissue and 51 to 75% slough. The wound was improving. A Weekly Wound Assessment, dated 12/14/22, indicated the resident had a diabetic wound to the right heel that was acquired in house. The wound measured 1.7 cm x 1.2 cm. There was 76-100% epithelial tissue present. The wound was improving. No current wound measurements were provided from the wound clinic or the facility. The clinical record including the August, September, October, and November 2022 EMAR/ETAR lacked documentation that the right heel wound treatment was completed as ordered on the following dates: - 08/20/22, - 08/21/22, - 09/11/22, - 09/19/22, - 10/10/22, - 11/02/22, - 11/28/22, and - 11/29/22. The clinical record lacked documentation that the resident had any preventative interventions in place for the right heel prior to the wound developing. An intervention to elevate the right heel off the bed with pillows while in bed was initiated on 09/12/22, after the wound was identified on 8/8/22 A Wound Clinic Visit Note, dated 10/10/22 and 11/21/22, indicated the resident was seen for a wound check of a Stage 3 (full thickness skin loss involving damage or necrosis of subcutaneous tissue) pressure ulcer to the right heel. A Progress Note, dated 08/10/22 at 2:54 P.M., indicated a new order was obtained to cleanse the wound with normal saline or sterile water, apply alginate to the right heel wound bed, and cover with a clean dressing, daily. A Progress Note, dated 09/12/22 at 4:58 P.M., indicated the resident was seen by an outside wound clinic. New orders were obtained for Dakin's wet to dry dressing to the right heel daily, and make sure the right heel is elevated off the bed with pillows. A Progress Note, dated 11/07/22 at 12:49 P.M., indicated the resident's right leg was noted to be angry red, warm to touch, with 2+ pitting edema. The resident was to be seen at the outside wound clinic for an appointment later in the day. A Progress Note, dated 11/11/22 at 4:34 P.M., indicated the writer had received report from the local hospital. The resident had been receiving treatment for osteomyelitis and MRSA of the right foot. The nurse reported the resident had a PICC line in the right upper extremity and was receiving IV antibiotics. The treatment for the right heel was to administer Dakin's 1/4 strength solution to the wound daily. The complete Care Plan was provided by the DON on 01/06/23 at 3:06 P.M. A diabetic ulcer to the right foot Care Plan was developed on 01/04/23, indicated the following: - avoid exposure to temperature extremes: heating pads, hot water bottles, heat lamps, hot or cold solutions and socks, sunburn, icepacks, - avoid mechanical trauma, - diet as ordered, - encourage and assist resident to reposition frequently, - ensure appropriate protective devices are applied to affected areas, - labs as ordered, - meds as ordered, - monitor blood sugar levels, - monitor and document wound size, - monitor, document, and report any sign or symptoms of infection, - monitor, document, and report any changes in wound, - NAR (Nutritionally at Risk) to follow, and - refer to foot care nurse or podiatrist. An at risk for skin integrity Care Plan, with a start date of 02/22/22, indicated the following: - diet as ordered, started 11/17/22 - educate resident, family, caregivers of causative factors and measures to prevent skin injury, started 02/22/22, - encourage good nutrition and hydration to promote healthier skin, started 02/22/22, - follow facility protocols for treatment of injury, started 02/22/22, - keep skin clean and dry, use lotion on dry skin, started 02/22/22, - labs as ordered, started 02/22/22, - observe skin with daily cares, notify the nurse of any new or worsening areas, started 02/22/22, and - treatments as ordered, started 11/17/22. During an interview on 01/05/23 at 9:26 A.M., QMA (Qualified Medication Aide) 4 indicated the resident needed assistance with showers. She had a wound on one of her legs that she went to the wound clinic for. She was compliant with care. During an interview on 01/05/23 at 5:37 P.M., the Wound Clinic Nurse indicated the resident had been receiving wound care services for a Stage 3 pressure ulcer to the right heel since 09/12/22. The wound was a Stage 3 at the first appointment prior to debridement. Currently, the wound had greatly improved since the resident first came in for treatment. On 12/20/22, the wound clinic changed the resident's orders and indicated that the facility was no longer to change the dressings. It was only changed once a week at the wound clinic. The resident had been sent to the hospital from her appointment on 11/07/22 for osteomyelitis in the wound. During an interview on 01/06/23 at 10:06 A.M., RN 2 indicated she started following the resident's wound on 09/14/22. The wound was identified by the facility on 08/08/22 as a diabetic ulcer. The resident had started going to the wound clinic on 09/12/22. In November she was sent from a wound clinic appointment to the hospital with osteomyelitis. If the wound clinic classified a wound as a pressure ulcer, then the facility should change their documentation of the wound. The treatments should be completed per the MD orders. During an interview on 01/09/23 at 2:32 P.M., RN 2 indicated she was unsure of what caused the wound on the resident's heel. 3. During an observation and interview on 01/03/23 at 12:34 P.M., Resident 13 was sitting in his wheelchair in his room. He was wearing non-skid socks. He indicated he had a blister on his left heel. He took off his sock and revealed an island dressing covering his heel that was dated 01/03/23. The clinical record was reviewed on 01/05/23 at 12:29 P.M. A Quarterly MDS assessment, dated 11/08/22, indicated the resident was moderately cognitively impaired. The diagnoses included, but were not limited to, coronary artery disease, orthostatic hypotension, and transient visual loss. The resident was at risk for pressure ulcers and had two Stage 2 pressure ulcers. The resident required extensive assistance of one staff member for bed mobility, transfers, dressing, toileting, and personal hygiene. The Weekly Wound Assessment records from the EHR (Electronic Health Record) were provided by the DON on 01/06/23 at 2:25 P.M. The records indicated the resident had a facility acquired suspected DTI (Deep Tissue Injury) to both the left and right heels. The left heel wound was first identified on 10/19/22. Wound descriptions were as follows: - 10/19/22, initial assessment, Left lateral heel noted with fluid filled blister to site with skin intact. No measurements were documented on the assessment. (A paper document, titled Wound Assessments was provided by RN 2 on 01/09/23, and indicated the wound measured 4 cm x 2.5 cm) - 11/23/22, Area noted with light pink and patial pale moist appearance with scattered scaly surrounding skin, size 3 cm x 2.5 cm (no depth listed); 0 to 25% slough; 51 to 75% epithelial tissue. - 01/04/23, Area noted with scabbing intact to site, size 0.7 cm x 0.7 cm; 76 to 100% epithelial tissue. The right heel wound was first identified on 11/16/22. Wound descriptions were as follows: - 11/16/22, DTI noted to right heel. No measurements were documented on the assessment. (A paper document, titled Wound Assessments was provided by RN 2 on 01/09/23, and indicated the wound measured 2 cm x 1.8 cm) - 11/23/22, right heel noted with improvement, area noted with scattered scaly skin with small light pink moist appearance, size 2 cm x 2 cm x 0.1 cm; 26 to 50% epithelial tissue; 26 to 50% granulation tissue. - 01/04/23, area noted with scab intact to site, size; 1.3 cm x 0.6 cm. The complete Care Plan, including resolved Care Plans, were provided by the DON on 01/05/23 at 12:30 P.M., and included, but were not limited to, the following: - A Care Plan for a blister to the resident's left heel, with an initiated date of 09/07/22, and a resolved date of 11/04/22, indicated the resident had received antibiotic therapy for the wound with an initiated date of 09/12/22. - A Care Plan for being at risk for impaired skin integrity related to a history of open areas to his bilateral lower extremities, with an initiated date of 04/12/22, and a revised date of 06/24/22. The current interventions included: Diet as ordered, labs as ordered, and to observe the skin with daily care. No preventative treatments were initiated on the Care Plan prior to the development of the pressure ulcers to the resident's heels. During an interview on 01/09/23 at 11:00 A.M., RN 2 indicated the resident had a blister on his left heel that was a pressure injury blister that started on 09/07/22. It had healed then it reopened. When she identified a new wound she measured them, completed an initial wound assessment, and notified the physician, the family, and the DON. The current Pressure Prevention policy, with a revised date of 08/2022 was provided by the Chief Nursing Officer on 01/09/23 at 11:31 A.M. The policy indicated, .PURPOSE .To maintain good skin integrity and avoid development of pressure ulcers .Care plan interventions shall be implemented based on risk factors identified in the nursing assessment . The current Pressure/Stasis/Arterial/Diabetic Wounds policy, with a revised date of 09/01/22, was provided by the Administrator on 01/09/23 at 10:39 A.M. The policy indicated, .PURPOSE .To provide weekly documentation of wound measurements and condition .Complete event for each impaired area .Document description of wound .Length .Width .Depth .Re-assessment/measurement weekly . 3.1-40(a)(1) 3.1-40(a)(2) Based on observation, interview, and record review, the facility failed to ensure residents had not acquired in house pressure ulcers and the worsening of pressure ulcers for 3 of 4 residents reviewed for pressure ulcers. This deficient practice resulted in two residents' pressure ulcers worsening to a Stage 4 and Stage 3 and one residents' wound identified as a deep tissue injury. (Residents 25, 9, and 13) Findings include: 1. During an interview and observation on 01/03/23 at 12:04 P.M., Resident 25's right elbow was in a padded heel protector. The resident indicated he had an open wound on his right elbow. The clinical record for Resident 25 was reviewed on 01/05/23 at 12:17 P.M. The 5 day MDS (Minimum Data Set) assessment, dated 10/13/22, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, hypertension, hemiparesis, anxiety, depression, and dementia. The resident required the extensive assistance of one staff member for most ADLs (Activities of Daily Living). The resident was at risk for developing pressure ulcer and had no pressure ulcers at the time of the assessment. An Initial Wound Assessment, dated 11/09/22, indicated the resident had a Stage 2 (full thickness tissue loss) pressure ulcer on his right elbow measuring 3 cm (centimeter) x (by) 2 cm x 0.1 cm. The pressure ulcer was acquired in the facility. The treatment was to apply a medicated pink foam dressing every three days. An additional order was included on the ETAR (Electronic Treatment Administration Record) to ensure the pink dressing was intact to the right elbow every shift. The ETAR lacked documentation nursing staff ensured the dressing was in place from 11/09/22 to 11/14/22. On 11/15/22 A new treatment was obtained to cleanse the right elbow with normal saline or sterile water, apply honey gel and cover with bordered foam dressing every day and as needed for soilage. The ETAR indicated the treatments were completed as ordered except for 11/20/22, when the resident refused. A Weekly Wound Assessment, dated 11/16/22, indicated the resident had a Stage 2 pressure ulcer on his right elbow measuring 3 cm x 2 cm x 0.2 cm. A Weekly Wound Assessment, dated 11/23/22, indicated the resident was seen by the wound doctor in the facility. The pressure ulcer on the right elbow had worsened and was now a Stage 4(full thickness tissue loss with bone, tendon, or muscle exposed, slough or eschar maybe present). The wound measured 3 cm x 3 cm x 1 cm. The resident was sent to the local hospital on [DATE] for cellulitis and wound evaluation of the right elbow and returned on 12/01/22. A Weekly Wound Assessment, dated 12/07/22, indicated the resident had a Stage 4 pressure ulcer on his right elbow measuring 2.5 cm x 2 cm x 0.7 cm. A Weekly Wound Assessment, dated 12/28/22, indicated the resident had a Stage 4 pressure ulcer on his right elbow measuring 1.7 cm x 1.2 cm x 0.2 cm. During an interview on 01/09/23 at 12:03 P.M., RN 2 indicated the resident was added to her wound rounding list on 11/09/22 when the Stage 2 pressure ulcer was discovered. Prior to the development of the pressure ulcer the resident had pain relieving patches placed on the right elbow and believed that was what caused the pressure. His wound was evaluated weekly.