**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 3 resident's reviewed (Resident #1). The facility reported a census of 43 residents. Resident #1 had wounds that were deteriorating. The resident was seen in the wound center. The facility sent the assessment of the wound in a fax to the PCP on 8/21/25 and wrote the resident would be seen in the wound center 8/22/25. The PCP replied okay. The PCP was not the wound center provider. The resident did not have an appointment on 8/22/25. The facility did not follow up until 8/27/25 with an assessment. The fax notified the wound center physician that the wound deteriorated and had a foul odor. The physician ordered a different treatment until seen on 8/29/25. The nurse who did the assessment had hoped he would want to see her sooner, but did not convey that in the fax. The resident admitted to the hospital 8/28/25 in respiratory distress, with fever and a large buttock ulcer, which likely caused her symptoms. The resident became septic (a life threatening complication of an infection). Findings include:According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #1 demonstrated long and short term memory problems and severely impaired cognitive skills for daily decision making. The resident had diagnoses including a stroke with hemiplegia (paralysis of 1 side of the body) of the right dominant side.The Care Plan identified the resident at risk for alteration in skin integrity related to immobility, right sided weakness Status Post (S/P) stroke, anticoagulant and antiplatelet usage. On 7/30 pressure ulcer R buttock, and 8/15 pressure ulcer L buttock. Interventions included: Administering medications as ordered, administering treatment per physician orders, barrier cream to peri area/buttocks as needed, educating the resident and/or family/caregiver as to causes of skin breakdown, including transfers/positioning requirements, encouraging good nutrition and hydration in order to promote healthier skin, encouraging to reposition, following facility policies/protocols for the prevention/treatment of skin breakdown, observing skin condition with care, pressure reducing device on bed, pressure reducing device on chair, providing preventative skin care, using pillows/positioning devices as needed.The Progress Notes documented the following: a. On 7/31/25 at 9:32 a.m. a reddish-purplish colored area remained on the resident's left upper buttock due to Moisture Associated Skin Damage (MASD). The skin was peeling over this area with yellowish colored drainage and the Mepilex saturated. They used a Mepilex dressing to this area for protection on bath days. They questioned changing the Mepilex dressing daily to this area, start Vitamin C 500 mg, Zinc 50 mg daily, and 4 oz of supplement 2 times a day, to promote wound healing. b. On 7/31/25 at 4:01 p.m. a fax received from the Primary Care Provider (PCP) regarding the compromised area on the left upper buttock. New orders included changing the Mepilex dressing daily to the area, and starting Vitamin C, Zinc, and supplement. c. On 8/4/25 at 10:51 a.m. the open area to the resident's left buttock was purple, with blisters, appearing to turn into a pressure area. A moderate amount of drainage to the area, and the Mepilex saturated this a.m. The resident had pain when touched the area. Asked for an order to have the resident seen at the wound clinic. d. On 8/4/25 at 3:46 p.m. the fax returned regarding an order for the resident to be seen at the wound clinic for the open area to her buttock. The physician responded yes. e. On 8/7/25 at 11:33 a.m. a weekly skin assessment revealed a reddish-purplish colored area remained on the left upper buttock. The skin was peeling over the area with serous drainage. The area had deteriorated and measured 8.2 cm x 8 cm. They used a Mepilex dressing to the area daily. She also had a red 1.2 cm x 1.3 cm blanchable area on her left buttock with intact skin. Moisture barrier cream applied to the area. She would be seen in the wound clinic the next day. They would continue to monitor the area. f. On 8/7/25 at 9:19 p.m. received a fax regarding the resident's weekly skin assessment. The physician responded agree. g. On 8/8/25 at 11:25 a.m. the resident returned from the wound care appointment with a new order for Santyl ointment to the right buttock wound and cover with Mepilex 3 times per week. h. On 8/14/25 at 9:01 a.m. the weekly skin assessment revealed a reddish-purplish colored area remained on the left upper buttock with the skin peeling, serous drainage, and some yellow slough. The area remained the same and measured 8.2 cm x 8 cm. She also has a reddish-purple 2.2 cm x 2.2 cm area that had deteriorated on her left buttock with intact skin. Moisture barrier cream applied to the area. She would be seen in the wound clinic the following day. They would continue to monitor the area. i. On 8/15/25 at 12:36 p.m. the resident went to the wound clinic with orders for Santyl & Mepilex to the right buttock and sacrum 3 times a week and as needed (prn). Aquacel AG/small Mepilex border to the left buttock 3 times a week and prn. Follow up appointment 8/29/25 at 9:30 a.m. Family notified and planned to go with the resident to the appointment. j. On 8/18/25 at 6:27 p.m. a communication with the physician, changed the resident's left upper buttock dressing due to soiling. The area measured 3.3 cm x 2 cm, the wound edges were reddened, the wound bed had eschar, exudate moderate/purulent with foul odor. Area cleaned and patted dry, and Aquacel ag, and Mepilex border applied. Asked if had any other suggestions.Changed dressing to right upper buttock due to soiling. The area measured 8.7 cm x 10.7 cm with a moderate amount of purulent exudate with a foul odor, wound edges reddened and wound bed had eschar. Cleaned the area patted dry and Santyl and a Mepilex border applied. Asked if had any other suggestions, k. On 8/19/25 at 6:33 p.m. received a fax regarding dressing change and findings. The physician replied with he would continue the same dressing change, and prn when soiled until Friday (8/22/25). The fax returned by the wound center physician on 8/19/25 included follow up on Friday (8/22/25). l. On 8/21/25 at 3:54 p.m. the weekly skin assessment revealed a reddish-purplish colored area remained on the left upper buttock with some yellow slough and measured 2.7 cm x 2 cm. She also had an open area that measured 8 cm x 10.5 cm that had deteriorated on her right buttock with yellow slough around the edges and brown discolored skin in the center. She would be seen in the wound clinic the following day. They would continue to monitor. The fax with the above information returned by the Primary Care Provider on 8/22/25 read okay. The clinical record lacked documentation the resident had an appointment at the wound center on 8/22/25, or follow up on the wound status. The clinical record lacked documentation the facility notified the wound center physician of the deteriorating wound. m. On 8/27/25 at 7:18 a.m. a weekly skin assessment documented an open area remained on the resident's left upper buttock with yellow slough around the edges and a brown colored center. The area measured 2.7 cm x 2 cm. She also had an open area that measured 8 cm x 9.9 cm with a depth of 1 cm, that had deteriorated on her right buttock with yellow slough around the edges and brown discolored skin in the center, and the areas were lifting around the edges and had a very foul odor. They would continue to monitor the area. n. On 8/27/25 at 12:53 p.m. received a new order for the wound to the resident's left buttock. The fax returned by the wound center physician on 8/27/25 read okay, would see her Friday, and use a dressing with Dakin's solution daily. o. On 8/28/25 at 2:25 p.m. the resident had labored breath sounds, with wheezing heard bilaterally. The head of the bed elevated to prevent shortness of breath. A Foley catheter remained in place. Bowel sounds present in all 4 quadrants. Abdomen soft and non- tender. The resident alert and oriented to self only. Speech and respirations labored. The resident denied pain or shortness of breath when asked. Call placed to PCP and received the okay to send the resident to the emergency room (ER) by ambulance. Call received from ER notifying the resident admitted through the weekend for intravenous (IV) antibiotics. p. On 8/28/25 at 3:08 p.m. the transfer to the hospital summary included the resident's vitals were temperature 103.5 (norm 97-99), pulse 114 (norm 60-100), respirations 28 (norm 12-18), blood pressure 166/108 (high), and pulse oximetry 95% on room air. Breathing was labored and lung sounds with course crackles bilaterally.The Hospitalization report dated 8/29/25 at 3:55 p.m. documented the resident admitted with respiratory distress, fever and a large right buttock ulcer. The resident had urine, blood and wound cultures done in the ER before starting IV antibiotics. The resident had gradually developed a large right buttock ulcer after having a stroke, causing right hemiparesis and expressive aphasia (loss of ability to produce language). She was on oral antibiotics based on her last wound culture results before coming to the hospital. At the hospital they started the resident on Rocephin 1 gm every 12 hours and Vancomycin 1500 mg daily. Albumen 25 mg was added to her medications due to poor nutritional status and hypoalbuminemia. The resident's family preferred a larger hospital for her care where she could have advanced wound care for her large buttock ulcer which likely caused her symptoms. Prior to her transfer the resident had an episode of atrial fibrillation with rapid ventricular response requiring IV medication for heart rate control, IV Lasix, morphine and oxygen with a mask for her respiratory distress. She also had a dose of IV Tylenol for the fever. Her heart rate and blood pressure stabilized by the time she transferred. Prior to the resident's transfer, her blood cultures became positive. The principal diagnosis on discharge was sepsis with acute respiratory failure, and the active problems included open wound of right buttock with complication.On 9/3/25 at 9:07 a.m. Staff A Licensed Practical Nurse (LPN) stated the day she sent Resident #1 out she thought she was having respiratory issues. She had vitals that were high, her blood pressure pulse and respirations. After she sent the resident, out she received a return call later from a Registered Nurse (RN) at the hospital stating they were keeping for her bottom, and she would be on IV antibiotics. Staff A stated the day she sent her out she hadn't looked at her bottom because she was quite concerned about the condition she found her in. She said she had never done the dressing to the resident's bottom because she had just recently oriented to a nursing position. She said she had worked at the facility for years and just recently became an LPN. She said she did see the dressing change when orienting but she did not know the date that she saw it. She said the wound appeared to be large and appeared to have purulent drainage. She said the resident did not express pain during the treatment change. She was not sure which buttock that would have been on.On 9/3/25 at 11:30 a.m. Staff B LPN stated when she looked at the wound and did the dressing change on 8/27 the smaller one seemed the same. The other one appeared deeper and the edges were starting to come off and she was draining serous drainage although it was hard to tell if it was actually drainage or some of what they were putting in the wound.On 9/3/25 at 12:20 p.m. Staff C LPN Stated she was doing the wound assessment every week since the MDS coordinator left for vacation, and then decided not to come back. She said she did this normally on Thursdays and then she would fax the doctors with the results. She said the resident's wounds had been deteriorating and she had done the assessments on a Wednesday prior to 8/29/25 and the wound stunk. She sent a fax to the doctor and he returned with using Dakin's solution until he saw her on the 29th. She had hoped that he would want to see her before that. Regarding whether the resident had an appointment on the 22nd, she said she wasn't sure. She said it's possible she looked at the wrong week and that's why she thought there was one, but she couldn't say for sure.On 9/3/25 12:47 p.m. Staff D LPN stated between the last two times she had seen the resident's bottom, it had gotten much worse. She said it had opened up and it was deeper. She said between the two times it had gone from being changed twice a week to daily. She doesn't remember odor but she had drainage. In the last two days she worked there was a lot more drainage. She said she had to call the resident's family member to let her know about a new order regarding her potassium and she talked to her at that time about the wound, and the family member was going to her next appointment with her. On 94/25 at 9:10 a.m. the Provisional Administrator confirmed the resident did not have an appointment on 8/22/25 at the wound center.The facility undated Skin Management policy documented the potential ongoing management strategies may include risk factor management interventions including management of acute changes in the resident's condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure a resident received adequate supervision to prevent accidents for 1 of 3 residents reviewed (Resident #2). Resident #1 fell on 7/10/25 fracturing his right elbow that would require surgical repair, and a laceration near his right eye requiring 7 sutures. The resident had a pressure alarm that did not sound to alert staff the resident was getting up without assistance. Staff failed to determine why the alarm did not sound. On 7/11/25 the resident fell again fracturing his left elbow, also requiring surgical repair. The resident's pressure alarm again failed to sound to alert staff the resident was getting up. The facility reported a census of 43 residents. Findings include:The Care Plan documented Resident #2 admitted to the facility on [DATE]. The Care Plan identified the resident had impaired cognitive function, and at risk for falls, on 7/10/25 at 10:30 a.m. fall with no injury, on 7/10/25 at 2:07 p.m. fall with right eyebrow laceration, fracture right elbow, on 7/11/25 at 6:10 a.m. fall with left elbow fracture, left eyebrow laceration, pain in left wrist. On 7/10/25 door alarm initiated and moved to a closer room to the nurse's station.The Progress Notes documented the following: a. On 7/10/25 at 10:30 a.m. the aides summoned the nurse when the resident was found in a sitting position in the opposite room. The resident went to the emergency room for evaluation. b. On 7/10/25 at 2:07 p.m. the resident was found in a sitting position in the room across the hall. The resident was unable to move his right upper extremity. The resident's eye lid on the right side (swelling hemorrhaging). Certified Nursing Assistants (CNA's) held a cold washcloth to the site of his face. Relevant interventions in place at the time of the incident: included a bed alarm.Preliminary Recommendations, if any, for consideration as further preventative measures was a door alarm. c. On 7/10/25 at 2:59 p.m. received a call from hospital. The nurse reported resident had a laceration to his right eyebrow that was sutured. The resident had 7 sutures needing removal in one week. Suture care instructions being sent back with resident. Nurse also reports the resident broke his right elbow in multiple locations and would need surgery. Prior to surgery, the resident needed cardiac clearance. Appointment set up with cardiology for July 16th at 8:45 a.m. They called to schedule a surgery appointment on July 17th. The nurse at the hospital reported the resident had splint and sling in place, the elbow would need to be kept at 90 degrees. The resident could continue same medications, and able to return to the facility at that time. d. On 7/10/25 at 3:13 p.m. received paperwork upon resident's return. Suture instructions: keep wound clean and dry, use hydrogen peroxide and water soaked gauze to wipe clean every day. The goal of each cleaning was to get it back to just stitches and skin, not letting a scab form. They should dress the laceration with antibiotic ointment, and cover with bandages if it could get dirty. No prolonged soaks until healed, quick showers were okay, patting dry afterwards. Stitches out in 7 days, monitor for infection. Tylenol if needed for temp or discomfort. No instructions for splint care. e. On 7/11/25 at 8:03 a.m. the nurse was called into the resident's room at 6:10 a.m.by the CNAs while they were doing physical rounds and saw the resident on the floor face down. No alarm sounded. The fall was not witnessed. It took 2 staff with a gait belt to assist the resident up and into his recliner with a walker. The resident had a slow, unsteady gait. The resident wore his gripper socks. It appeared the resident used his walker at the time of the incident. The floor was dry other than the blood that came from the resident's injures after the fall. The resident was last checked at 4 a.m. and was not incontinent of bowel and the catheter emptied. The resident stated he tried to hold himself up when asked what he was attempting to do. The resident bled from the previous injury to his right eye brow and a new injury to the left eyebrow. The nurse had previously laid eyes on the resident at 5:50 a.m. and he rested in bed. The resident had full range of motion (ROM) to his extremities other than his right arm that had a previous injury to his elbow. He did not complain of discomfort while having resident do ROM other than slight discomfort in his left wrist. Neuros initiated and pupils sluggish. The resident complained of pain in his nose, lower back, and left wrist. The resident got a laceration to his left eyebrow. Made resident comfortable and cleaned blood off. The resident had a pressure alarm under him while in bed. This alarm did not sound. The resident had a history of turning his alarms off and/or moving them. Preliminary Recommendations, if any, for consideration as further preventative measures was a bed alarm that attached to the resident and sounded when the resident tried to get up. f. On 7/11/25 at 11:15 a.m. called the hospital to check the status of the resident. The ER nurse informed the resident had fractured his left elbow. g. On 7/11/25 at 5:55 p.m. a hospital nurse called and stated the resident admitted with possible return 7/12 or 7/13/25. h. On 7/13/25 at 10:30a.m. the resident returned to the facility. Both arms were in splints with ace wrap form his hands to the upper arm bilat. The resident could move his shoulders and legs. He did not reach with his arms. Fingernails were slightly pale but had + capillary refill (quick medical assessment that measured how quickly blood returned to the capillaries (tiny blood vessels) in the skin, used to evaluate circulation). A hospital after visit summary dated 7/10/25 documented the resident seen for right elbow fracture and right eyebrow laceration. The resident had a right eyebrow laceration repair. Return to care facility instructions included: Sutures out in 7 days, right elbow with posterior splint and sling for support, loosen and reapply if too restrictive. The resident's chart needed labeled a fall risk. An x-ray of the right elbow on 7/10/25 at 9:50 a.m. showed a fracture traversing the base of the olecranon process. There was posterior and proximal migration of the proximal fracture fragment with separation of fragments by at least 2.6 cm. Discussed the case with orthopedics. The resident would need surgical intervention on this. He would need cardiac clearance first. Appointment set up 7/16/25 at 8:45 a.m. A hospital report dated 7/11/25 at 7:05 a.m. documented the resident presented to the ER via ambulance from the care facility secondary to a fall. The resident had been well at morning rounds and a few minutes later he apparently decided to get up and fell in his room. He apparently had a piled enough stuff on his bed alarm so it did not go off. He had a small laceration by the left eyebrow and swelling to the left elbow.An x-ray of the left elbow on 7/11/25 at 8:34 a.m. showed an acute mildly displaced intra-articular fracture of the olecranon. There was prominent dorsal soft tissue swelling. Discussed with the orthopedist and the resident would be scheduled for surgery on his left elbow in conjunction with the prior arranged surgery to the right elbow. These were nearly identical fractures sustained on consecutive days. Resident at significant risk for fall secondary to events of the last 2 days. The resident admitted to the hospital.On 9/3/25 at 9:38 a.m. Staff E Registered Nurse (RN) stated the resident fell on 7/10 around 9 a.m. He had been in bed prior to the fall. He did have an alarm on his bed but, he did not know if the alarm sounded at the time of the fall. He said he just charted it a little bit in the morning and then did a much more in depth documentation that afternoon. On 9/3/25 at 12:12 p.m. Staff F Certified Nursing Assistant (CNA) stated all she knew was that when they went to get the resident to take him to breakfast he wasn't there. They let them know that they needed to look for him and so they started a search, but it didn't take very long for them to find him he was just across the hall in another room. On 9/3/25 at 1:43 p.m. Staff G CNA stated she was the full-time bath aid but she had been called to work on the floor for a couple hours that day. Someone called over the walkie that the resident needed to come out for breakfast. She went to his room and he wasn't in there, and he wasn't in the bathroom, and she said well he's not in his room. They decided they needed to search for him which didn't take very long because he was across the hall. She didn't even know he could walk. She said his alarm did not sound that morning. Staff G said she didn't know why the alarm didn't go off that morning she never found out. On 9/3/25 at 1:51 p.m. Staff H CNA stated she did not hear the alarm sound, and she did not know why it did not.On 9/4/25 at 9:29 a.m. Staff G Licensed Practical Nurse (LPN) stated the resident had the alarm in place on 7/11/25 but it did not sound. She said either they did not turn it on the night before or the resident had turned it off himself. She said she thought he had learned how to turn it off. She said he now had another alarm hooked to him that sounded if he pulled away from it. She said the alarm was in place so when he was getting up they would know, and respond.The undated facility Fall Occurrence policy documented the purpose to ensure residents were evaluated for fall risks and implemented interventions to minimize the risk for falls and/or the risk for injury from falls.