**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, family and staff interviews, the facility failed to prevent the development of two Stage III (3) pressure ulcers for one of two residents reviewed. (Resident #120). The facility reported a census of 68 residents. Findings Include: The MDS (Minimum Data Set) Assessment identifies the definition of Pressure Ulcers: Stage I - 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 - A Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III - 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 - Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue). may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound bed. Other staging considerations 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 soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. 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. A review of the Admit Screener Form (Nurse's admission Assessment) dated 10/28/22 at 5:20 PM revealed Resident #120 did not have any skin concerns. The MDS admission assessment dated [DATE] identified Resident #120 as severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 3 out of 15 points and had the following diagnoses: Coronary Artery Disease, Heart Failure, Diabetes Mellitus and Cerebrovascular Accident (stroke). The MDS also identified the resident required extensive staff assistance with most activities of daily living and totally dependent on staff for locomotion off the unit. It also identified the resident did not have any pressure ulcers. A review of the Nurse's Notes dated 11/8/22 at 12:39 PM revealed the following documentation: a. Open lesion to the left heel which measured 4 centimeters (cm) long and 3 cm wide with sanguineous (bloody) drainage. b. Right plantar foot identified with skin condition identified as other open lesion which measured 4 cm long and 3 cm wide and no drainage. A review of the November 2022 Treatment Administration Records (TAR's) revealed an order was not obtained until 11/10/22 (2 days after the wounds were identified and the order was requested by the facility). The TAR had the following orders dated 11/10/22: a. Cleanse right heel with normal saline and apply Hydrogel dressing daily until healed. b. Sure Prep to the left heel twice daily until healed, if opens, call doctor for new orders. A review of the Wound Care Physician Note dated 11/15/22 had documentation of the following: a. On 11/15/22 - Stage 3 pressure wound on the left heel for 7 days (date of onset 11/8/22) with Measurements: Length (L) =6 centimeters (cm), Width (W) = 6 cm and Depth (D) =not measurable. b. The right heel (no date of onset) had an Unstageable Deep Tissue Injury (DTI) with Measurements: L =6 cm W=6 cm D= 0.5 cm 80% necrotic tissue, no exudate. c. Recommendations: Float heels in bed, offload wound, reposition per facility protocol, turn side to side and front to back every 1-2 hours if able, sponge boot, may take off sponge boot for ambulation, therapy, otherwise should be on 100% of the time. A review of the November 2023 TARS revealed the following orders dated 11/15/22 (after the resident was admitted [DATE]): a. Prafo Boots on at all times except when working with therapies twice a day. b. Right heel wet to dry with ¼ strength Dakin's Solution, cover with ABD pad and secure with Kerlix twice daily On 11/15/22, the Care Plan identified Resident #120 with the problem of skin breakdown related to decreased mobility, need for repositioning assistance. Has Stage 4 to the right heel and stage 3 to left heel and did not include the recommendations by the wound physician dated 11/15/22. A review of the Wound Care Physician's Note dated 11/29/22 documented the right heel was now open and identified as a Stage III pressure ulcer which measured 5 cm long, 5 cm wide and 0.5 cm deep with 50% necrotic tissue. The MDS dated [DATE] identified Resident #120 with a facility acquired Stage III pressure ulcer and a stage IV pressure ulcer. In an interview on 7/17/23 at 3:43 PM, Resident #120's spouse reported the footboard on the bed had metal brackets facing the mattresses. On 11/1/22, the resident ripped his feet on the footboard from rubbing his heels on the footboard. He had to have a Peripherally Inserted Central Catheter (PICC) line and Intravenous (IV) antibiotics for a month which she had to give Resident #120. In an interview on 7/25/23 at 8:17 AM, Staff O, Licensed Practical Nurse (LPN) reported Resident #120 did not have pressure ulcers when he was first admitted . He was considered high risk for developing pressure ulcers as he was diabetic and had limited mobility from a previous stroke. Resident #120 was very tall and would slide down in the bed and rub his feet on the footboard. He had one ulcer on his left foot and that is when they put the Prevalon boots on both feet. The bed extender was not placed on his bed until after the ulcers developed. She also reported when a wound is first identified, orders to treat it should be obtained within 24 hours. When treated at the Wound Clinic, if the Physician documents recommendations, these should be considered as new orders and should be addressed on the Care Plan. The nurse taking care of the resident had the responsibility to review Wound Clinic Notes for new orders and follow-up with orders to treat the wounds. The Care Coordinator had the responsibility to update the Care Plans. In an interview on 7/25/23 at 7:54 AM, Staff P, LPN reported the following: Resident #120 was considered high risk to develop pressure ulcers as he was diabetic and not as mobile as he used to be. She could not recall if the Prevalon boots had been placed on him before or after he developed the ulcers. There were two metal bars on the footboard where he rubbed his feet. His wife had pictures of the footboard and his feet where the sores matched the metal parts of the bed. The right heel opened first then the left one developed a blister. Resident #120 would frequently slide down the bed and his feet would hit the footboard as he was tall. The facility had a couple of extra-long beds in the building but all were in use, however, she reported the facility could have rented one. After Resident #120's wife said something about the footboard, they removed it. When a wound is first identified, the nurse should check the protocol on wounds as there are standing orders for treatments. When treated at the Wound Clinic and if the Physician documents recommendations, these should be considered as new orders and should be addressed on the Care Plan. The nurse taking care of the resident had the responsibility to review Wound Clinic Notes for new orders and follow-up with orders to treat the wounds. The Care Coordinator had the responsibility to update the care plans. In an interview on 7/24/23 at 10:54 AM, Staff L, Registered Nurse (RN) reported Resident #120 was so tall and witnessed him rubbing his heels against the footboard which caused the pressure ulcers. The staff should have placed an extender on his bed to prevent it. When a wound is first identified, orders to treat it should be obtained within 24 hours. When treated at the Wound Clinic and, if the Physician documents recommendations, these should be considered as new orders and should be addressed on the Care Plan. The nurse taking care of the resident had the responsibility to review Wound Clinic Notes for new orders and follow-up with orders to treat the wounds. The MDS Coordinator had the responsibility to update the care plans. In an interview on 7/24/23 at 11:23 AM, Staff G, Certified Nursing Assistant (CNA) reported if a resident was very tall and rubbed his heels against the foot board, she would report it to the nurse, reposition him and if still continues to be a problem, look into getting a different bed. In an interview on 7/25/23 at 12:04 PM, Staff D, CNA reported if a resident was very tall and rubbed his heels against the footboard, he would place an extension on the bed. He remembered putting an extension on Resident #120's bed but could not recall the date when he did. In an interview on 7/24/23 at 12:53 PM, the Director of Nursing (DON) reported the following: Resident #120 did not have pressure ulcers when he was first admitted . He was tall and would slide down in bed and his heels would touch the footboard which had two metal pieces attached to the bed. His feet touched those metal areas and the pressure would have caused the wound. At that point, the staff placed an air mattress on the bed and elevated his heels. The Wound Doctor removed the footboard when he first saw him here. The staff should have put an extender on the bed and put boots on him to prevent the ulcers from developing. She expected orders to be obtained to treat the wounds within 24 hours and would expect any new recommendations made by the Wound Care Physician to be treated as new orders and address this on the TAR and Care Plan. The nurse caring for the resident is responsible for follow-up on obtaining orders. The MDS Coordinator is responsible for updating the care plan. A review of the facility policy titled: Wound Management and Documentation which was last revised 2/1/23 documented the following: a. For all areas, the nurse shall implement a preventive intervention. b. Notify the Physician of the wound, communicate the assessment to the Physician and request a treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The MDS Assessment, dated 4/18/23, listed diagnoses for Resident #9 included: Non-Alzheimer's Dementia, stroke, and anxiety disorder. The MDS assessed the resident independent with transfers, walking in room, and required supervision walking on the unit. The MDS listed the BIMS score as a 3 out of 15, indicating severely impaired cognition. The Care Plan directed staff to monitor the residents' interaction with peers, as she does not like to be touched or have her belongings touched by peers. The Care Plan directed staff to be aware of the need to intervene as needed. An Incident Report, dated 6/8/23, reported during a disagreement Resident #33 pushed Resident #9 down, causing a fracture of her right femur. A Major Injury Determination Form, signed on 6/9/23 by the Medical Director, revealed the Resident #9's right hip fracture qualified as a major injury. During an observation on 7/20/23 at 11:00 AM of the video surveillance of the Memory Care Unit (MCU), revealed Resident #33 and Resident #9 in the dining room. No staff were noted to be in the dining area. Resident #33 pushed a trash can out of his way into the path of Resident #9. Resident #9 started a inaudible conversation with Resident #33. Resident #33 put his right hand on Resident #9 right wrist. Resident #9 pushed her right hand towards Resident #33, while he continued to hold on to her wrist. Resident #9 then her raised left hand and attempted to swing down near Resident #33's head. Resident #33 used his right hand to deflect Resident #9 left hand from hitting his head. Then Resident #9 fell to the ground. During an interview on 7/20/23 at 10:58 AM, Staff T, CNA stated she witnessed the altercation between Resident #9 and Resident #33. Staff T stated she was in the back-dining area, in the doorway of another resident. She explained she could not leave the doorway as the resident is a high fall risk and forgets to use her walker or ask for assistance. Staff T stated she heard Resident #9 and Resident #33 arguing, and attempted to verbally redirect them to walk away from each other. She stated the resident she assisted got up from the toilet and started to walk with her pants down, without her walker. Staff T stated she left the doorway to assist the resident, and when she returned to the doorway saw Resident #9 fall to the floor. Staff T stated from her view, it appeared Resident #33 pushed Resident #9 to the floor. Staff T stated the other staff assigned to work in the area, Staff U, CNA was helping another resident in their room. Staff T stated the Unit Nurse had gone to the front of the unit prior to the residents arguing. When queried about the after-meal process, Staff T stated after the residents are done eating, the staff clean up the tables so residents cannot eat leftover food from other residents' plates. She stated there are two garbage cans that staff use for this task. When done with cleaning up one garage can is returned to the area under the coffee maker, and the other is put into the locked kitchen area. Staff T stated the garbage can pushed away by Resident #33 should not have been left in the dining area. During an interview on 7/19/23 at 3:33 PM, Staff U stated she did not witness Resident #9 fall, as she was in another resident's room providing cares at the time. During an interview on 7/20/23 at 2:33 PM, Staff V, RN stated she did not witness the incident. Staff V stated she had watched the video surveillance and could not tell if Resident #33 pushed Resident #9. Staff V stated both Resident #33 and Resident #9 become argumentative and neither one will back down. During an interview on 7/25/23 at 10:40 AM, the DON stated staff had been cleaning up the dining room tables to stop residents from eating leftovers off plates. She stated after this is done the staff are then to assist non-ambulatory residents to their rooms to go to the bathroom and get cleaned up. The residents who are independent with ambulation are not assisted to their rooms, unless they make a request. The DON stated the trash can should not have been left in the dining area. She stated since the incident on 6/8/23 she talked to the Dietary Manager and requested Kitchen Staff clean off the tables after a meal. The DON stated this has helped the time after meals become smoother. The facility policy, dated 3/3/22, titled CCDI (Memory Care Unit) - Policy Statement read the Memory Care Unit will have a homelike atmosphere, yet safe, clean and attractive, the policy did not address dining room safety. Based on clinical record review, observations, family and staff interviews, and facility policy review, the facility failed to prevent falls resulting in hip fractures for two of nine residents reviewed (Residents #9 and #122) and failed to secure a safety strap around the resident's calves for one of three residents observed during transfers with a SPAN mechanical lift (Resident #31). The facility reported a census of 68 residents. Findings Include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #122 as severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 4 out of 15 points. The MDS also identified the resident with the following diagnoses: Diabetes Mellitus, pain in the right hip and pain in the left hip. The MDS documented the resident required limited staff assistance with bed mobility, dressing, toileting and personal hygiene and required extensive staff assistance with bathing. On 1/1/23, the Care Plan identified the resident with the problem of potential for falls related to weakness and on 3/3/23 directed staff to transfer with the assist of one using a gait belt and wheeled walker. A review of a Facility Incident Report dated 3/28/23 at 1:25 PM, documented the resident lost her balance in the hallway, the Report identified she was Care Planned to be allowed to be unattended in fall location. Resident found lying on left side with arms and legs extended, complaining of severe pain to left lower extremity (LLE), sent to ER (Emergency Room). Resident #122 was ambulating independently in hallway to her room. A review of the Fall Scene Investigation Report dated 3/28/23 revealed the following contributing factors: a. Medications given prior to fall: cardiovascular, narcotic, diuretic, hyperglycemic, antidepressant. b. The resident was toileted last at 12:30 PM. c. The Care Plan stated the resident was one to one with transfers and ambulation with walker. The resident was walking by herself with walker and staff thought she was independent. d. Education provided on 3/28/23 by Director of Nursing (DON). e. Resident's Plan of Care indicated she required assist of one with transfers and ambulation. Staff are required to review Activities of Daily Living (ADL's) Card before providing cares and review while on walking rounds at shift change. Nurses are to remind Certified Nurse Aides (CNA's) to tell CNAs to give report and walk the unit for rounds and check ADL Cards every shift. A review of the Major Injury Determination form dated 3/28/23 at 1:25 PM, documented the following: Comminuted intertrochanteric fracture to the left hip, staff observed left lower extremity shortening and rotation and sent to the Emergency Department (ED) for evaluation. The Physician determined the resident sustained a major injury. A review of the nurse's notes revealed the following: a. On 3/28/23 1:58 PM, the resident got up from the dining room table and began to walk towards her room when a peer came walking by quickly. Resident and peer's feet got tangled together and Resident fell onto her left side. Resident was on her left side and complaining of LLE pain. Resident's left foot was externally rotated. Call placed to medic for transport to ER. b. On 3/29/23 1:09 PM, resident returned from the hospital by ambulance. c. On 4/7/23 5:16 AM, this nurse was called to the resident's room by CNA. The resident was assessed at 5:10 AM and found to have expired. Hospice called. A review of the Hospital Discharge summary dated [DATE] revealed documentation that the resident presented after a fall, LLE externally rotated and shortened upon presentation. Initial workup showing intertrochanteric comminuted fracture. Discussed with resident's family who confirmed patient should be Comfort Care. In an interview on 7/25/23 at 2:32 PM, Staff N, CNA reported she thought that Resident #122 was independent and she was in the dining room when she saw Resident #36 run into Resident #122. She also reported the CNA's carry Pocket Care Plans which shows how residents are supposed to be transferred. In an interview on 7/24/23 at 12:23 PM, the Assistant Director of Nursing (ADON) reported at the time Resident #122 fell, she thought she was independent, that she fell and sustained a hip fracture and sent to the hospital. In an interview on 7/24/23 at 12:53 PM, the DON reported on 3/28/23, Resident #122 got up from the dining room table with her wheeled walker and walked down the hall. Resident #36 was pacing in the hallway and walked in front of Resident #122, however did not have contact with Resident #122. Resident #122 had to stop suddenly and this caused her to fall. The staff should have assisted the resident as she was Care Planned to be assist of one. Resident #122 sustained a fractured femur. The fall could have been prevented if the staff had assisted her and could have stopped Resident #36 from running in front of Resident #122. 2. The MDS dated [DATE] identified Resident #31 as severely cognitively impaired with a BIMS score of 99 and had the following diagnoses: Epilepsy, Non-Alzheimer's Dementia and Osteoarthritis. The MDS also identified the resident required extensive staff assistance with transfers, toileting and bathing. The MDS documented the resident as totally dependent on staff for locomotion on and off the unit, dressing and personal hygiene. On 11/15/17, the Care Plan identified Resident #31 with the problem of self-care deficit and on 7/10/23 it directed staff to transfer the resident utilizing a SPAN lift (A lift that assists a resident to a standing position) with a medium sling. The Care Plan failed to direct staff to apply the straps around the calves of the resident. During an observation on 7/18/23 at 9:13 AM, Staff G, CNA and Staff H, CNA assisted Resident #31 to sit at the edge of the bed. Staff G pushed the SPAN mechanical lift in front of the resident as both aides secured the sling around the Resident #31's waist and secured to the lift and placed her feet on the platform. Resident #31 appeared to have difficulty standing up, Staff H had to hold her behind her back. Neither aide placed a strap around Resident #31's calves before they transferred her to the Geri chair. In an interview on 7/25/23 at 8:17 AM, Staff O, LPN reported when residents are transferred using the SPAN lift, the staff should secure a sling around the resident's waist and a strap around the resident's calves which then are secured to the lift. In an interview on 7/25/23 at 7:54 AM, Staff P, LPN reported when residents are transferred using the SPAN lift, the staff should secure a sling around the resident's waist and a strap around the resident's calves which then are secured to the lift. In an interview on 7/24/23 at 10:54 AM, Staff L, Registered Nurse (RN) reported when residents are transferred using the SPAN lift, the staff should secure a sling around the resident's waist and a strap around the resident's legs which then are secured to the lift. There should not be any reason why they would not be placed on the resident. In an interview on 7/24/23 at 11:23 AM, Staff G, CNA reported when residents are transferred using the SPAN lift, the staff should secure a sling around the resident's waist and a strap around the resident's legs which then are secured to the lift. In an interview on 7/25/23 at 12:04 PM, Staff D, CNA reported when residents are transferred using the SPAN lift, the staff should secure a sling around the resident's waist and a strap around the resident's calves which then are secured to the lift. In an interview on 7/24/23 at 12:23 PM, the ADON reported when residents are transferred using the SPAN lift, the staff should secure a sling around the resident's waist and a strap around the resident's calves which then are secured to the lift. In an interview on 7/24/23 at 12:53 PM, the DON reported when residents are transferred using the SPAN lift, the staff should secure a sling around the resident's waist and a strap around the resident's calves which then are secured to the lift. She thought Resident #31 only required the sling and would have to check the Care Plan to verify if she needed the strap around her calves. A review of the facility policy titled: Manual Lifts which was last revised 2/1/23 had documentation for use of the stand lift as follows: a. The Stand Lift is to be wheeled up to the resident with the resident's legs flush with the shin pads on the lift. b. Have the resident lean slightly forward, grasping the hand grips and place the support strap behind the resident, put the straps into locking cleats to fit the strap snugly and lock in place. c. Always buckle the shin straps around the shin pad.