**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, staff interviews and facility policy review the facility failed to assure that a resident with a pressure ulcer received treatment and services, consistent with professional standards of practice, to prevent pressure ulcers from developing and to promote healing of a pressure ulcer for 1 of 1 resident reviewed (Resident #38). The facility reported a census of 50. Finding include: The Minimum Data Set (MDS) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is a partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, with slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III is 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. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue) which may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound. Other staging consideration include: Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent skin. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. Resident #38's MDS (Minimum Data Set) assessment dated [DATE] identified a BIMS (Brief Interview for Mental Status) score of 10 out of 15, indicating moderately impaired cognition. The MDS identified Resident #38 required extensive assistance of one person with bed mobility and two persons with toileting use. The MDS identified Resident #38 required limited assistance of one person with transfers. The MDS included diagnoses of cerebrovascular accident (stroke), aphasia (difficulty with language), arthritis and overactive bladder. The MDS identified Resident #38 was at risk for developing pressure ulcers and did not have any pressure ulcers on assessment. The MDS documented Resident #38 had a pressure reducing device for the chair. Resident's 38's Care Plan dated 9/14/23 documented the resident has a self-care performance deficit related to a history of a stroke. The care plan directed staff that she was able to move herself in bed but required assist by staff to get in and out bed, and required one staff assist for ambulation, toileting and transfers. A Wound RN assessment dated [DATE] revealed Resident #38 had a new stage 2 pressure ulcer to the right buttocks. The Progress Notes on 11/25/23 lacked documentation regarding a new stage 2 pressure ulcer to the right buttocks. The Care Plan dated 11/29/23 documented the resident has a stage 2 pressure ulcer to her right buttock related to immobility. The care plan directed staff to: -Monitor/remind/assist to turn and reposition at least every 2 hours. Reposition with repositioning wedge in bed. -Assess/record/monitor wound healing daily. Report improvements and declines to the healthcare provider. -Provide an air mattress on the bed and a roho cushion to chair/wheelchair. -Notify the nurse immediately of any new areas of skin breakdown: redness, blisters, bruises, discoloration, etc. noted during bath or daily care. The Care Plan lacked information regarding applying a treatment to the wound, nutrition and/or hydration interventions to promote healing. The Care Plan prior to 11/29/23 did not identify Resident #38 was at risk for skin impairments and/or developing pressure ulcers. The care plan lacked focus areas, goals and interventions/tasks to manage, treat and prevent skin impairments and pressure ulcers. The Braden Scale assessments (tool used to evaluate risk of development of a pressure ulcer) documented a score of 10-12 indicated that the resident had a high risk for pressure sore development, 13-14 meant the resident had a moderate risk, and 15-18 meant the resident had a risk for pressure ulcer development. The review of the Braden Scale assessments completed for Resident #38 from 9/23 to 10/23 documented scores on the following dates: 1. 9/14/23= 16 2. 9/25/223=14 3. 10/2/2=16 4. 10/9/23= 15 Resident #38's clinical records lacked a Braden Scale assessment after the development of the stage 2 pressure ulcer. On 11/30/23 at 7:34 AM, The DON (Director of Nursing ) reported the facility had no straight policy for completing the Braden Scale. The DON stated the facility does the Braden Scale on Admission, Quarterly, and with Significant changes. The facility policy titled Pressure Ulcer Treatment revised 2/7/23 instructed once a pressure ulcer had been identified, licensed personnel will complete a Braden Scale and implement additional interventions as appropriate. Resident 38's wound evaluation form revealed the following information: -11/25/23: Stage 2 pressure area to right buttocks that measured (Length x Width x Depth) 0.5cm x 1cm x 0cm. Wound bed not assessed. No drainage. Peri wound indurated. Comments on form stated: Will apply foam and tape to the area, apply air mattress to bed and roho cushion to wheelchair and also encourage Resident #38 to lay in bed between meals. - 11/26/23: Stage 2 pressure area to right buttocks- Wound measurements and wound bed not assessed. Dressing present and intact. Resident #38 reported pain during assessment. No drainage. Peri wound intact and pink. Continue with current treatment. -11/27/23: Stage 2 pressure area to right buttocks- Wound measurements and wound bed not assessed. Dressing present, clean, dry and intact. Minimum serosanguinous drainage. Peri wound indurated. Wound cleaned, foam and tape applied. -11/28/23: Stage 2 pressure area to right buttocks- Wound measurements and wound bed not assessed. Dressing present and intact. No drainage. Peri wound indurated. No undermining or tunneling. Wound cleaned, foam and tape applied. -11/29/23: Stage 2 pressure area to right buttocks that measured 1cm x 2cm x 0.1cm. Wound bed 25% epithelial and 75% granulation tissue. No slough or eschar. Dressing present and intact. No drainage. Peri wound intact and was pink in color. No undermining or tunneling. Applied foam and tape per Physician order. -11/30/23 1st Assessment: Stage 2 pressure ulcer right buttocks that measured 1.8cm x 1.2cm x 0cm with redness and peeling skin surrounding the pressure ulcer with a total measurement of 3cm x 3cm. No dressing present. Center of the ulcer appeared dry. Wound bed 50% granulation and 50% eschar. Minimum amount of serous drainage with no odor. Peri ulcer denuded. Treatment changed per Physician order to clean with wound cleanser, apply Aquacel AG (silver impregnated dressing), foam and tape. -11/30/23 2nd Assessment: Unstageable pressure ulcer to right buttocks that measured 3cm x 3cm x 0cm. The center of the wound bed was dark in color and measured 1.8cm x 1.2cm and unable to see the base of the wound. No dressing present. Center of the ulcer appeared dry. Wound bed 50% granulation and 50% eschar. Minimum amount of serous drainage with no odor. Peri ulcer denuded and reddened. Treatment changed per Physician order to clean with wound cleanser, apply Aquacel AG, foam and tape. The Clinical Record lacked documentation from 11/25/23 to 11/27/23 regarding family and physician notification of the pressure ulcer to the right buttocks. The facility was not able to provide an incident report. The Physician Order dated 11/28/23 directed staff to clean and apply foam/tape to wound on the right lower buttocks twice daily. The Clinical Record lacked a physician order for the treatment of foam and tape to the pressure ulcer to the right buttocks until 11/28/23. On 11/29/23 at 3:20 PM, the DON reported she did not have an incident report for the pressure ulcer identified on 11/25/23. The DON stated she was not aware of the pressure ulcer until the afternoon of 11/27/23. On 11/29/23 at 3:17 PM observed Resident #38 sitting in a recliner with feet elevated in her room with no cushion present in the recliner. Resident #38's wheelchair was in the hallway across from the room with the roho cushion in the wheelchair. On 11/29/23 at 3:30 PM, Staff B, Nurse Manager reported she had communicated the pressure ulcer to the Dietary Manager on 11/28/23 so the Dietician could review Resident 38's nutritional status next time at the facility. On 11/30/23 at 8:45 AM, the DON acknowledged and verified there was no skin care plan prior to the development of the pressure ulcer on 11/25/23 and no documented skin intervention in place to prevent the development of a pressure ulcer. The DON verified the physician was not notified until 11/27/23 of the pressure ulcer and the family was notified on 11/28/23. The DON reported she expected the Dr and family to be notified on the day the pressure ulcer was identified. The DON verified and acknowledged a treatment order was not obtained until 11/28/23. She stated she expected the facility to request a treatment order on the day the pressure ulcer was observed. A Physician Order dated 11/30/23 directed staff to cleanse the right lower buttocks wounds with wound cleanser, add Aquacel AG, cover with foam and tape daily and as needed. On 11/30/23 at 11:52 AM observed Staff E, LPN (Licensed Practical Nurse) complete dressing change to right buttocks. Staff E reported she had looked at the wound earlier in the morning and had a nurse manager look at it also. Staff E stated she called the Physician to get the wound treatment changed as she knew the foam treatment was not going to cut it. Staff E placed a barrier on the bedside table and did not clean or sanitize the table prior. Staff E placed dressing items on top of the barrier (wound cleanser bottle, package of Aquacel AG, foam, scissors). Staff E cleansed her hands with hand sanitizer from the wall unit in the room and then put on a pair of gloves that were in her uniform pocket. Staff E proceeded to unfastened Resident #38's brief and assisted with rolling her on her left side. Staff E removed the old dressing from Resident #38's right buttocks and threw it in the garbage can next to the resident's bed. Staff E reported the old dressing contained a small amount of sanguineous drainage. Staff E then picked up the wound cleanser and sprayed the cleanser onto a piece of gauze and cleansed the wound. Staff E reported she did not stage the wound but felt the wound bed had slough in it. Observed wound edges to be red and irritated. Staff E then cut a piece of Aquacel AG and placed it on the wound on the right buttocks. Staff E then cut a piece of foam and Mepilex tape (soft silicon tape) and placed it over the Aquacel AG. Staff E did not label or date the dressing. Staff E did not change her gloves or sanitize her hand between cleansing the wound and applying a new dressing. Staff E verified and acknowledged she wore one pair of gloves through the entire dressing change and did not change her gloves or sanitize her hands between dirty and clean. Staff E acknowledged she touched the Aquacel AG, foam, and Mepilex tape with contaminated gloves. Staff E acknowledged she did not date or initial the dressing. On 11/30/23 at 12:05 PM, Staff H, Nurse Manager reported she had looked at Resident #38's pressure wound that morning per request of Staff E. Staff H reported she felt the wound needed some sliver to help it heal as it had some drainage. Staff H stated she does not stage wounds. She stated another nurse manager does the wound measurements and staging so one person was doing the assessments consistently. Staff H verified she felt the pressure wound bed had slough present. She also verified the wound edges were red and irritated. On 11/30/23 at 12:35 PM, the DON reported her expectation was for staff to change gloves and clean their hands between dirty and clean tasks. She stated she would prefer staff not to keep gloves in their pockets. The DON stated the expected staff to date and initial dressing changes. On 11/30/23 at 2:35 PM, the DON reported if there was eschar documented in the wound bed then she would not consider the pressure ulcer a stage 2 and agreed the assessment was not accurate. The DON reported if the pressure ulcer was getting worse, then the facility would need to send Resident #38 to the clinic to be seen. The DON reported there was a wound nurse at the clinic that could see the wound. On 11/30/23 at 2:45 PM, Staff B acknowledged she had coded 50% eschar and staged the wound a stage 2 pressure ulcer on Resident #38's wound assessment. Staff B acknowledged a stage 2 pressure ulcer does not have eschar present in the wound bed. Staff B stated she was not sure what to stage the wound but thought it might be unstageable due to the center of the wound bed was not being visible under the hard tissue. Staff B reported she was not sure how much of the wound bed had to be not visible to be coded unstageable. Staff B reported that she needed to have more training in wound care and that she was not an expert in wounds. On 11/30/23 at 3:12 PM, Staff B completed an updated wound assessment and coded the pressure ulcer on right buttocks as unstageable. A facility policy titled Skin Assessment Pressure Ulcer Prevention and Documentation revised 4/26/23 documented the purpose of the policy are the following: -To systematically assess residents regarding risk of skin breakdown -To accurately document observations and assessments of residents -To appropriately use prevention techniques and pressure redistribution surfaces on those residents at risk for pressure ulcers. The policy directed staff to do the following: a. If a pressure ulcer is identified, cleanse the area prior to observation being made to allow the wound bed and depth to be more accurately observed. The registered nurse should record the type of wound and the degree of tissue damage on the wound assessment. b. Notify the physician of the ulcer and the resident's condition to obtain orders for a treatment. c. Notify the resident and/or family of the pressure ulcer, orders and planned interventions. d. The interdisciplinary team should determine any modifications that are necessary to the resident's plan of care. Interventions should focus on physical, mental and psychosocial aspects that may be impacted. Treatments and interventions should be consistent with the resident's goals. Education should be provided to the resident and/or family.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, facility record review, staff and resident interviews, the facility failed to ensure resident's environment remained free from accidents and hazards for 2 out of 5 residents reviewed (Residents #8, and #54) for falls/incidents. The facility reported a census of 50 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #8 documented a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. The MDS also documented that Resident #8 needed extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene, and was limited to only walking once or twice. The MDS further documented diagnoses of diabetes, anemia, heart failure, anxiety, depression, and morbid obesity. Resident #8's Care Plan dated 8/14/23 revealed that the resident was ambulatory with staff assistance as she desired. In an interview with Resident #8 at 4:27 PM on 11/27/23, she stated that in September she broke her ankle by catching it on the edge of her recliner. She stated that Staff G, Licensed Practical Nurse (LPN) was walking with her from her commode across the room to her recliner when she told her she wasn't going to make it and needed to sit down. She stated Staff G kept saying that she could make it. She stated that when she caught her foot on the recliner, she heard and felt a pop and told Staff G that she broke her ankle. In an interview with Staff G at 9:10 AM on 11/29/23, she stated that Resident #8 had been complaining to staff that she came into the facility walking and no one ever had the time to walk with her now. She stated the resident said this again to her after lunch and she told her that she had time to walk with her now. Staff G stated she assisted the resident to ambulate with a walker and gait belt all the way around the dining room and that she did wonderful. She stated that later that day the resident was on the commode and wanted to go to her recliner. She stated she assisted the resident up, and they started walking across her room to the recliner, (approximately. 15 ft), when the resident's walker bumped the recliner. Staff G stated the resident started freaking out saying I'm gonna fall, get me a chair, I'm gonna fall, I'm gonna go down. She stated she reassured the resident that she wasn't going to let her fall, and Staff G stated I had my knee up her butt, she wasn't going anywhere. Staff G stated that she called for help on her walkie, but she didn't have access to a chair and she knew the resident could do it. She stated the resident lost all confidence in herself after bumping the recliner. She stated as she was helping the resident to sit down in the chair, the resident caught her foot underneath the edge of the recliner and the resident screamed at her you broke my ankle! Staff G stated she did hear a pop, but she personally had rolled her ankle before and heard it pop. She stated the resident did complain of some pain and she gave her ice and Tylenol. At supper time, she stated the resident stood to transfer and did not complain of pain at that time. She stated she let the night nurse know what happened and that she would need to schedule an X-ray for her ankle on Monday since it was the beginning of the weekend. The next day the night nurse reported to her that the resident did not complain of pain or request medication during the night. The facility Investigation documented the incident occurred on 9/22/23 at 1:00 PM and was reported on 9/25/23 at 1:20 PM. The report documented the level of injury at the time to be a moderate injury (resulted in hospitalization/outside medical treatment). The report documented the resident reported she was ambulating with staff on 9/22/23 at 1:00 PM when her foot got caught on her recliner and she heard a pop. The resident stated she had pain all weekend (9/23 and 9/24/23) and ice was provided. Review of Resident #8's clinical record Progress Notes revealed documentation that the resident was scheduled to have an X-ray of her right ankle on 9/25/23 at 1:15 PM, and follow up with the physician at 1:45 PM. The Progress Notes also revealed that on 9/25/23 at 1:12 PM, the facility was notified that the resident had a nondisplaced medial malleolus fracture. The Progress Notes lacked any documentation of the incident on 9/22/23 prior to 9/25/23. The Care Plan for Resident #8 initiated on 10/2/23 documented an actual fall with no injury. The care plan lacked any documentation of an incident with injury or interventions on 9/22/23. 2. The MDS dated [DATE] for Resident #54 documented a BIMS score of 13 out of 15, which indicated intact cognition. The MDS also documented that Resident #54 needed partial to moderate assistance with toileting, applying lower body clothing, shoes, and personal hygiene. It also documented partial to moderate assistance for transfers and ambulation. The MDS further documented diagnoses of stroke, traumatic brain injury, nontraumatic intracranial hemorrhage, irritable bowel syndrome, atrial fibrillation, cataracts, difficulty walking, and muscle weakness. The MDS documented the resident had two or more falls with no injury since the last assessment. Resident #54's Care Plan with a revision date of 11/24/23 revealed that the resident had a Focus Area of falls related to intracranial hemorrhage, making poor choices, and confusion. The care plan directed staff with the following fall interventions: On 7/6/23: Educate resident/family about safety reminders and what to do if a fall occurs. On 11/2/23 revised: Grip strips to bathroom floor. On 8/28/23: Make sure wearing rubber sole shoes. On 10/30/23: Monitor for significant changes in gait, mobility, balance and joint function. Ortho-static blood pressures every shift x 3 days and report to physician due to incident. On 11/24/23 revised: When resident sitting in her recliner in her room, place walker to her right and within reach. On 10/9/23 revised: Ensure/provide a safe environment with bed in low position. Frequently transfers self without calling for assist. Observation on 11/27/23 at 2:20 PM, revealed that the resident did not respond to a knock on her door which was partially opened. The surveyor stepped just inside the resident's door and called out the resident's name which elicited no response from the resident. At 2:25 PM, Staff K, Restorative Nurse Aide entered the resident's room and looked in the bathroom, finding the resident laying on the floor. Staff K called out from the resident's doorway down the hallway saying Get the nurse, we got one down. Review of Resident #54's Progress Notes revealed the resident had falls on 7/20, 7/21, 8/8, 8/9, 8/10, 8/13, 8/26, 9/11, 9/13, 9/23, 10/1, 10/29, 11/2, 11/24, and 11/27/23. The Progress Notes for the resident documented the following: On 9/11/23 at 6:49 PM during report heard residents alarms sounding. Nurse went in room and resident sitting on the floor between her recliner and restroom with walker behind her and toothbrush with basin on the floor next to her. Right side of back with 2 abrasions. Resident stated she was trying to put her toothbrush away in the restroom. Staff reminded not to leave her while doing oral cares. On 9/13/23 at 7:45 PM entered resident room and resident lying on her right side on top of her walker. Blood from under the right temple. Foley catheter intact and out of body laying on the bed. Resident stated it happened last night. Skin tear noted to right arm also. Order to send to the emergency room (ER) for stitches. Motion sensor was not on. On 9/13/23 at 10:42 AM call from the ER who stated the resident will be admitted . On 9/14/23 at 10:07 AM resident will return this morning. On antibiotic for urinary tract infection. Stitches to laceration on head and splint on her arm for a fracture. The facility policy Fall Prevention and Management revised date of 3/29/23 documented the Purpose of the policy: -To promote resident well-being by developing and implementing a fall prevention and management program. -To identify risk factors and implement interventions before a fall occurs. -To give prompt treatment after a fall occurs. -To prevent further injury. -To provide guidance for documentation. The facility policy Procedure included the following: 1. Do not move the resident. 2. Remain calm and reassure and comfort the resident. 3. Stay with the resident and summon the nurse or other help. If able, observed the fall scene. 4. For a fall without injury, skip to Step 6. 5. For a fall with injury, do the following: a. If the resident is bleeding, locate the injured area and apply continuous, firm pressure to the area. b. Do not remove any blood soaked dressings or clothing. c. Cover the resident and have her lay quiet until help arrives. 6. A nurse must observe the resident and perform a full body exam to determine if there may be suspected injury and direct whether to move the resident. a. Obtain vitals. b. If the fall was not witnessed, neurological checks are required. c. Continue to monitor the resident's condition; communicate updates as needed. d. Review medications for recent changes or medication that could have contributed to the fall. e. Notify the physician and resident representative of the incident. 9. Document the physician's comments in the medical record. 17. Update the care plan with any changes/new interventions. 19. Continue to monitor condition and effectiveness of the interventions. In an interview with the Administrator on 11/30/23 at 4:00 PM regarding the concerns, he stated that he had no questions and that everything was pretty black and white.