**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake 1238200.Based on interview and record review the facility failed to utilize the required two staff to complete incontinence care for one sampled resident (R4) of four residents reviewed for accidents, resulting in a fall from the bed and a fracture of the right arm. Findings include:During a closed record review of R4's medical record it was noted that R4 was transferred to the hospital after a fall during care. A review of R4's medical record progress notes revealed, 8/17/25 -Writer called to room by nurse assistance. Res (resident) observed on floor, lying on right side. Lying next to bed closest to the window. Nightstand and bed side table next to [R4], close to [R4's] head. Res is alert and verbal. Verbal complaints of pain to right side. Physician in house. Assessed at bedside while on floor. Order received to send to ER (Emergency Room) via 911. Res kept in same position. No active bleeding noted at this time. Awaiting EMT's (Emergency Medical Technicians).Further review revealed, 8/17/25 -Physician Progress Note: Patient was seen today per nursing request due to the above-mentioned concern. No fever or chills no chest pain or SOB (Shortness of Breath) no abdominal pain no headache. Patient fell out of bed during care, [R4] landed on [R4's] right side, [R4] reported that [R4] struck [their] head against on the floor. [R4] is on Eliquis (blood thinner) due to a history of A-Fib. [R4] complains of pain over right arm and wrist. No LOC (Loss of Consciousness). [R4] complains of pain over right arm and wrist. Assessment and plan; 1. S/P (status post) fall on Eliquis 2. Closed head injury, no LOC 3. Paroxysmal atrial fibrillation; on Eliquis 4. Morbid obesity 5. Old CVA (cerebrovascular accident) with right hemiparesis 6. Debility; continue supportive care 7. Plan of care was discussed with nursing Call 911 and transfer patient. to ER for further evaluation and treatment. A continued review of R4's medical record revealed that R4 was admitted to the facility on [DATE], readmitted on [DATE], and discharged [DATE]. A review of R6's Minimum Data Set quarterly assessment dated , 7/3/25 noted R4 with an intact cognition.A review of R4's care plan revealed, . Focus: Self Care Deficit r/t (related to) Physical Weakness, poor endurance, bilateral cataracts, right hemiparesis, and impaired mobility. Goal: Resident Care needs will be met daily. Interventions: Bathing: I am dependent on 2 staff members to provide for my bathing needs. Dressing: I require extensive assistance of 2 staff to assist me with dressing. I am incontinent of bowel and bladder and require total assistance of 2 staff to provide incontinence care. Bed Mobility: I require extensive assistance of 2 staff member and my right-side enabler bar for bed mobility.Toileting Provide extensive assistance with personal hygiene care: nails, hair, oral care, bathing. PHO Care: I am incontinent of bowel and bladder and require total assistance of 2 staff to provide incontinence care. BED MOBILITY: I require extensive assistance of 2 staff member and my right side enabler bar for bed mobility. On 8/20/2025 at 1:18 PM, the Director of Nursing (DON), called R4 at the hospital for an interview regarding the fall. R4 explained they were being assisted by Certified Nursing Assistant (CNA) N to get ready for the day. R4 explained CNA N was the only CNA in the room. R4 continued and explained, they were rolled on to their side and CNA N turned to get the cream for their bottom and that is when they rolled out of bed. R4 stated they hit their head, and their arm was in pain after the fall and was transferred to the hospital.The DON was asked their expectations for following the care plan. The DON explained, staff is to follow the minimum number for staff assistance and to follow the Kardex (CNA care guide). The DON confirmed R4 stated they had an Acute proximal humerus fracture of the right arm. On 8/20/2025 at 3:56 PM, CNA N was asked via phone about the fall with R4. CNA N explained it was during care they asked R4 to grab the bar to turn to the side, because they had a small bowel movement. CNA N explained they had turned their back to get the cream and that is when R4 fell out the bed. CNA N was asked if they knew R4 was a two person assist for ADLs. CNA N confirmed they did know but was unable to locate another staff person to help at that time. A review of the facility's policy titled, Fall prevention Program dated, 2/5/22, noted Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Policy Explanation and Compliance Guidelines .3. Interventions will be implemented by the care team.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to assess, identify, provide treatment and prevent pressure ulcers for two residents (R78 and R21) of seven reviewed for pressure ulcers, resulting in the development and worsening of pressure ulcers. Findings include: R78 On 07/31/24 at 11:12 AM, Registered Nurse (RN) H was observed assessing R78's wound in their room. A strong foul odor was noted coming from the wound when RN H pulled R78's covers back. A review of R78's record revealed they were initially admitted to the facility on [DATE], and readmitted on [DATE] with the following diagnoses: Muscle weakness generalized, wounds and unspecified encephalopathy. The Brief Interview for Mental Status (BIMS) revealed a score of 6/15 indicating a cognitive impairment. On admission R78 was identified as high risk for developing pressure ulcers. A review of the readmission physician note dated 5/24/24 documented, Wound care physician progress note: .L (left) foot callus/hallux- Stage 2 (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed), lower left thigh, anterior (skin graphed area) measuring 3.5 x 1 x 0.0 centimeters (cm)-Stage 4 (Full thickness tissue loss with exposed bone, tendon or muscle), upper left thigh anterior measuring 4 x 1.3 x 3.5cm- left knee diabetic ulcer 2 x 2.5cm. Left hip/Gluteal P/U (pressure ulcer) debrided - measuring 19 x 14.5 x 16cm with undermining of 4cm.- Right buttock Stage 3 (Full thickness tissue loss) 2.5 x 2 x 0.1cm- Pressure ulcer to coccyx 3.8 x 2 x 0.1 cm. See Mar (medication administration record) for new treatment orders-R (right)-Upper Abdomen discolored scar with scabbed area. A review of the physician order dated 5/24/24, and the MAR/TAR (treatment administration record) revealed the following, Cleanse Coccyx with wound cleaner, apply honey and calcium alginate, cover with foam dressing daily and PRN (as needed). Review of the May, June and July MAR/TAR revealed between the dates of 5/24/24 to 7/6/24 there was no documentation showing that treatment was completed for the coccyx wound. Review of physician orders dated for 5/28/24: (Weekly) Skin assessment every Thursday AM (morning) shift. A review of the weekly nursing skin assessments revealed that between the dates of 5/28/24 to 7/11/24, two weekly nursing skin assessments were completed. There was no documented wound assessments or measurements of the coccyx wound between the dates of 6/3/24 to 7/1/24. Further review of the Wound Care Physician Progress Notes documented on 5/26/24, 6/3/24, 6/10/24, 6/17/24 and 6/24/24, measurements and descriptions of left hip wound, left back thigh, upper left thigh surgical site, and documented: Other areas (coccyx and left heel) not measured today due to patient being frustrated and uncomfortable .Other areas not measured Coccyx assessed area remains open continue current treatment and other areas not measured staff reports coccyx is doing well. Patient has been unable to tolerate changing positions. A Wound Care Physician Progress Note dated 7/1/24 includes description and measurements for left hip wound, left back thigh, upper left thigh and stated, Coccyx was able to be viewed today due to positioning area measures 15.1cmx8.7cmx0.5cm. Has thick slough tissue present. Coccyx Cleanse with wound cleanser, apply Santyl to slough tissue, cover with foam dressing daily. 7/15/24-Wound Care Physician Progress Note includes description and measurements of left hip wound, left back thigh wound, upper left thigh, and stated, Coccyx measures 10.9x7.7cmx0.5 (which was previously measured on 5/24/24 at 3.8 x 2 x 0.1 cm). Has thick slough present. A review of a Wound Care Physician progress note dated 7/22/24 lists descriptions and measurements for left hip wound and upper left thigh and coccyx, and stated, .Wound looks worse. Spoke with daughter in person and discussed hospice care. On 8/1/24 at 9:23 AM, Licensed Practical Nurse (LPN) Fand LPN G were observed performing wound care to R78. When queried about an oberserved open area approximately 1cm (centimeter) x 0.5cm was noted at the top right area above the large coccyx wound, LPN F said, I think thats new. A foam dressing was observed on R78's left ankle and a gauze wrap was observed on R78's left foot, both of which were not dated. LPN G was asked if there were any wound on R78's foot or ankle and was observed to remove the dressing from R78's foot and ankle revealing multiple unstageable pressure ulcers with eschar (dead tissue) to the bony prominences of R78's inner left foot and a 3cmx1cm linear wound on R78's anterior ankle. R78's left heel was noted to be black over the entirety of the heel and up both sides of the foot. A review of the resident's medical record revealed no assessments, treatments, or physician orders for R78's left heel. On 8/1/24 at 11:42 AM, during a phone interview, Nurse Practitioner (NP I) was asked about R78's wound progression and care since their facility admission. NP I stated (R78) was [initially] admitted to the facility with a left hip wound, some excoriation to their bottom and a surgical incision to their left thigh.NP I stated, I did not look at (R78's) bottom because the nursing staff said it was stable and they did not want to cause R78 any trauma. NP I explained around 7/15/24 they realized that R78's coccyx had declined and had to be addressed saying, there was dead tissue, and the slough was so thick it was like leather. NP I stated they talked to R78's daughter about hospice. NP I' confirmed the assessments were not performed and explains that it was their expectation that the nurses would notify them of a change. NP I was asked if they had seen the wounds on R78's left foot. NP I responded that they do not remember seeing areas on the left foot. On 8/1/24 at 11:59 AM, an interview was conducted with the Director of Nursing (DON). The DON explained the unit nurses do the daily wound care treatments even when the wound care nurse is not on leave. The DON was asked if the unit nurses document a skin and wound assessment. The DON explained a comprehensive wound and skin assessment is done on admission and then weekly. The DON was asked who places the orders for wound care and how the orders get entered into the EMR (electronic medical record). The DON stated, It depends, sometimes the wound care nurse puts them in and sometimes NP I enters them. Either one can put orders in. The DON was informed that there was no documentation of treatment of or assessment of R78's Coccyx wound between 6/3/23 and 7/1/24. The DON stated, I'm not sure how that could be because (NP I) was the person that was monitoring it. The DON confirmed that there was an assessment of R78's buttocks/sacral area documented on 6/3/24 and the next documented assessment of R78's coccyx is on 7/1/24. It was brought to the DON's attention that wound care orders placed for the coccyx wound were not implemented on the treatment record and were not performed. The DON is observed reviewing the EMR and stated, I agree. I don't see that and I don't know why. The DON confirmed that the wound care order placed 5/24 for R78's coccyx wound does not have a schedule and does not appear on the treatment record. The DON stated Nope, it didn't even show up. R21 On 7/30/24 at 12:40 PM, R21 was observed lying in bed on their back, feet flat on the bed. Attempts to ask the resident questions were to no avail due to their cognition. A review of the facility's acquired pressure ulcers revealed R21 had developed a new Stage 2 (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough or bruising) pressure ulcer. A review of R21's medical record revealed they were admitted into the facility on 8/17/22 with diagnoses of Cerebrovascular Disease, Multiple Sclerosis, and Hyperlipidemia. Further review revealed the resident was cognitively impaired, and required dependence for Activities of Daily Living. Further review of the medical record revealed the Stage 2 pressure ulcer on R21's coccyx worsened, and they also developed a Stage 2 pressure ulcer on their buttocks. A review of R21's Care Plan revealed the following, Focus: [R21] has a potential/actual impairment to skin integrity r/t immobility and incontinence. Date initiated: 04/20/2024 .Outcome: [R21] will have no seruous complications related to skin. Date Initiated: 04/20/2024 .[R21] skin injury of the coccyx will not worsen due to unavoidable clinical status, and will progress through the healing stages through next review date. Date initited :05/01/2024 . A review of R21's Nursing Skin Evaluations for the month of April 2024 revealed that evaluations on 4/2/24, 4/23/24 and 4/30/24, there were no skin impairments noted for R21. A review of the 5/14/24 Nursing Skin Evaluation noted a wound to the resident's coccyx. A review of R21's skin/wound progress notes revealed the following: -4/22/2024 15:38 (3:38pm), Wound Care Physician Progress Note: Patient was seen for pressure injury .Patient was seen today per nursing staff request due to the above concerns, patient lying in bed, Patient developed a stage 2 to coccyx. Area measures 2.3cmx2.0cm (centimeters). Minimal drainage observed . -5/13/2024 15:24 (3:24pm), Wound Care Physician Progress Note: Patient was seen for pressure injury .Patient was seen today per nursing staff request due to the above concerns, patient lying in bed, Patient developed a stage 2 to coccyx. Area measures 5.6cm x 5.6 cm x 0.3cm. Minimal drainage observed. No c/o (complaint of) pain. Wound measured larger today . -5/20/2024 16:16 (4:16pm), Wound Care Physician Progress Note; Patient was seen for pressure injury .Patient was seen today per nursing staff request due to the above concerns, patient lying in bed, Patient developed a stage 2 to coccyx. Area measures 2.6cmx 3.6 cmx 0.1cm. Minimal drainage observed. No c/o pain . -5/26/202419:28 (4:28pm), Wound Care Physician Progress Note; Patient was seen today per nursing staff request due to the above concerns, patientlying in bed, Patient developed a stage 2 to coccyx. Area measures 2.3cmx 2.1 cmx 0.2cm. Minimal drainage observed. No c/o pain. Wound looks better. Skin growing over top of wound . -6/4/2024 17:06 (5:06pm), Skin/Wound Note. [R21] was seen by wound caretoday for p/u to coccyx measuring 2 x 2 x 0.1cm. Wound bed is pink with even edges, has min (minimal) drainage, non-painful to touch.Continue current wound care orders . -6/10/2024 15:30 (3:30pm); Wound Care Physician Progress Note: Patient was seen for; pressure injury, lump right breast .Patient was seen today per nursing staff request due to the above concerns, patient lying in bed, Patient developed a stage 2 to coccyx. Area measures 3.7cm x 3.1 cm x 0.2cm . -6/24/2024 15:12 (3:12pm), Wound Care Physician Progress Note: Patient was seen today per nursing staff request due to the above concerns, patient lying in bed, Patient developed a stage 2 tococcyx. Area measures 5.0cm x 5.3 cm x 0.1cm. Minimal drainage observed. No c/o pain.Wound bed beefy red. Was larger this week . -7/1/2024 17:26 (5:26pm); Wound Care Physician Progress Note: Patient was seen today per nursing staffrequest due to the above concerns, patient lying in bed, Patient developed a stage 2 to coccyx. Area measures 2.9cm x 2.9 cm x 0.1cm. Minimal drainage observed. No c/o pain.Wound bed beefy red. Developed MASD (Moisture associated skin damage). Coccyx measures; 4.5cm x 2.0cm x 0.1cm . -7/15/2024 13:45 (1:45pm), Wound Care Physician Progress Note: Patient was seen today per nursing staffrequest due to the above concerns, patient lying in bed, Patient developed a stage 2 to coccyx. Area measures 1.7cm x 0.8 cm x 0.2cm. Minimal drainage observed. No c/o pain.Wound bed beefy red. Developed MASD. Coccyx measures; 3.4cm x 2.0cm x 0.5cm . -7/29/2024 15:51 (3:51pm), Wound Care Physician Progress Note: Patient was seen today per nursing staff request due to the above concerns, patient lying in bed, Patient developed a stage 2 to coccyx and right buttock. Area measure to right buttock measures 3.0cm x 2.1 cm x 0.8cm. Minimal drainage observed. No c/o pain. Wound bed beefy red. Coccyx measures; 6.0cm x 4.2cm x 0.3cm . On 8/1/24 at 12:05 PM, the Nursing Home Administrator was asked about the concerns with pressure ulcers amnd acknowledged the concern is something the facility is aware of, and is being followed in their Quality Assurance meetings. A review of the Pressure Injury Prevention Guidelines revealed the following, .Policy Explanation and Compliance Guidelines:1.Individualized interventions will address specific factors identified in the resident ' s risk assessment, skin assessment, and any pressure injury assessment (e.g., moisture management, impaired mobility, nutritional deficit, staging, wound characteristics) .3.Interventions will be implemented in accordance with physician orders, including the type of prevention devices to be used and, for tasks, the frequency for performing them. 4. In the absence of prevention orders, the licensed nurse will utilize nursing judgment in accordance with pressure injury prevention guidelines to provide care and will notify physician to obtain orders .8.Compliance with interventions will be documented in the medical record. a. For at-risk residents: treatment or medication administration records. b.For residents who have a pressure injury present: treatment or medication administration records; weekly wound summary charting. 9.The effectiveness of interventions will be monitored through ongoing assessment of the resident and/or wound. Considerations for needed modifications include: a.Development of a new pressure injury. b.Lack of progression towards healing or changes in wound characteristics. c.Changes in the resident ' s goals and preferences, such as at end-of-life or in accordance with his/her rights .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake M100144181. Based on observation, interview and record review, the facility failed to implement measures to prevent multiple falls for one (R701) of eight residents reviewed for falls, resulting in a right femur fracture that required a surgical repair, additional assistance with transfers and pain management. Findings include: Review of the facility record for R701 revealed an admission date of 05/19/23 with diagnoses that included Alzheimer's Disease, Diabetes Mellitus, and Difficulty in Walking. The Minimum Data Set (MDS) assessment dated [DATE] included a Brief Mental Status (BIMS) score of 03/15 indicating Severe Cognitive Impairment. Review of R701's admission Fall Risk Evaluation dated 05/19/23 revealed a score of 10 (evaluation instructions state If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. Prevention protocol should be initiated immediately and documented on the care plan.) On 05/01/24 at 11:45 PM, R701 was observed sitting in their wheelchair in their room. R701 responded verbally to the surveyor but was not able to answer questions in a reliable manner. Further review of R701's record revealed an initial fall on 05/26/23 (one week after admission). Review of R701's care plan history indicated that a fall prevention care plan focus and interventions were not established until 05/30/23. The care plan intervention initiated on 05/30/23 stated Monitor/document/report PRN (as needed) x 72h (every 72 hours) to MD (physician) for s/sx (signs/symptoms): Pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation. R701's next fall occurred on 09/06/23. Review of the care plan history revealed no new fall prevention interventions were added in response to this fall. R701's next fall occurred on 09/12/23. On 09/13/23 the following interventions were added: 1. Provide activities that promote exercise and strength building where possible. 2. PT (Physical Therapy) consult for strength and mobility. R701's next fall occurred on 10/04/23 and no new fall prevention interventions were added to the care plan in response. R701's next fall occurred on 11/18/23. No new fall prevention interventions were added to the care plan in response. R701's 11/19/23 progress note indicated that the resident was expressing signs/symptoms of pain and X-ray results on 11/20/23 revealed R701 sustained a right femur/hip fracture. R701 was discharged to hospital for surgical repair of the right hip. R701 was readmitted to the facility on [DATE]. The new admission Fall Risk Evaluation was scored 9 (lower risk score than at original admission). The evaluation question History of falls (past 3 months) was answered B. 1-2 falls in past 3 months. R701 actually had four falls in the prior three months. Review of the care plan established upon readmission revealed the same three fall prevention interventions that were previously in place were renewed and no new interventions were recommended or added. R701's next fall occurred on 12/24/23. No new fall risk care plan interventions were added in response. Further review of R701's care plan history indicated per the transfer safety focus area that R701 required hand-held assist for transfers at admission and at readmission following the fall with right femur fracture Maximum (approximately 75% of workload) assistance for transfers was required. R701's 11/28/23 readmission progress note indicated that the resident required a right hip surgical site pain pump. On 05/02/24 at 3:30 PM, the facility Director of Nursing (DON) acknowledged that the fall prevention care plan had not been established until after R701's first fall rather than following the admission Fall Risk Evaluation indicating High Risk. The DON acknowledged that new interventions had not been added to the fall prevention care plan after four of six falls but indicated that their understanding was that there was also a safety focus area in the care plan that may have fall interventions added. Review of the Safety focus area in R701's care plan revealed no fall prevention interventions. When asked what their expectation was regarding revision of the care plan following repeated falls the DON reported that it would be their preference that new interventions be added in the fall prevention focus area. Review of the facility policy Fall Prevention Program dated 02/05/22 revealed the Policy statement Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. The Policy Explanation and Compliance Guidelines section includes the following entries: 1. The facility utilizes a standardized risk assessment for determining a resident's fall risk. a. The risk assessment categorizes residents according to low, moderate, or high risk. 2. Upon admission, the nurse will complete a fall risk assessment along with the admission assessment to determine the resident's level of fall risk. 3. The nurse will indicate on the FALL COMS the resident's fall risk and initiate interventions on the resident's baseline care plan, in accordance with the resident's level of risk. 4. The nurse will refer to the facility's High Risk or Low/Moderate Risk protocols when determining primary interventions. 6. High Risk Protocols: a. The resident will be placed on the facility's Fall Prevention Program. i. Indicate fall risk on care plan. b. Implement interventions from Low/Moderate Risk Protocols. c. Provide interventions that address unique risk factors measured by the risk assessment tool: medications, psychological, cognitive status, or recent change in functional status. d. Provide additional interventions as directed by the resident's assessment, including but not limited to: i. Assistive devices ii. Increased frequency of rounds iii. Sitter, if indicated iv. Medication regimen review v. Low bed vi. Alternate call system access vii. Scheduled ambulation or toileting assistance viii. Family/caregiver or resident education ix. Therapy services referral 8. Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. a. Interventions will be monitored for effectiveness. b. The plan of care will be revised as needed. 9. When any resident experiences a fall, the facility will: a. Assess the resident. b. Complete a post-fall assessment. c. Complete an incident report. d. Notify physician and family. e. Review the resident's care plan and update as indicated. f. Document all assessments and actions. g. Obtain witness statements in the case of injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake: MI00127355. Based on observation, interview and record review, the facility failed to prevent, accurately assess and identify, and notify the physician of worsening of pressure ulcers, for two (R's 74 and 27) of two residents reviewed for Pressure Ulcers, resulting in a facility acquired Stage IV (full thickness skin and tissue loss with exposed or directly palpable fascia muscle, tendon, ligament, cartilage or bone in the ulcer) infected coccxy Pressure Ulcer for R74 and a Stage IV Left Gleuteus Pressure Ulcer that required surgical debridement for R27. Findings include: R74 Observations were made of R74 lying in bed on their back on 5/2/22 at 9:07 AM, 5/3/22 at 10:43 AM and 5/4/22 at 11:16 AM with the mattress pressure device setting on normal pressure. The device had two pressure settings, normal and low pressure. The device was set at normal pressure all three days of observation. Review of the clinical record revealed R74 was admitted to the facility on [DATE] with diagnoses that included: dementia, hypertension, and unspecified severe protein-calorie malnutrition. A MDS assessment dated [DATE] documented a BIMS score of two indicating severely impaired cognition and required staff assistance for all ADLs. Review of an admission Skin Only Evaluation dated 1/4/22 at 9:33 PM, revealed a skin tear to the left shoulder, left hip, left elbow (no measurements documented), bruising to the left ankle, left hip (no measurements documented) and a deep tissue injury to the right lateral foot (no measurements documented) and Resident has dry flaky LLE (left lower extremity), and Bil (bilateral) feet. Resident fungal toenails, and dry scab to right ankle and scab to right knee. Further review revealed no skin issues or concerns to the resident sacral/coccyx area. Review of an admission Braden Scale for Predicting Pressure Ulcer Risk dated 1/4/22 at 3:48 PM, documented a score of 14, indicating Moderate Risk. The Abnormalities section documented must be acknowledged, when staff check off the concerns and acknowledge the abnormalities the facility program generate clinical suggestions also known as interventions for the staff to implement to prevent development of or worsening of pressure ulcers. The abnormalities section was not acknowledged by the staff; therefore the clinical suggestions were not generated for the staff to implement per the facilities protocol. Review of a facility policy titled Wound Care Policy revised 10/16/19, documented in part . Care Plans will be completed that are reflective of the resident's risk factor for pressure development in association with their current Braden Score . If a resident's Braden score is 14 or lower, they will be considered moderate risk and the following preventative measures will be care planned and put into place . Turn and reposition resident while in bed at least every two hours, as tolerated, Use positioning devices as needed to maintain position and prevent pressure development on high-risk pressure area . Float heels while in bed, as tolerated . Pressure reduction mattress . These interventions were not timely implemented as instructed in the policy. Review of the clinical record revealed the following: A Nursing note dated 1/17/22 at 3:36 PM, documented in part . Writer called into room by CNA (Certified Nursing Assistant) upon AM care, Observed partial skin opening to res (resident) coccyx. Res has thin skin and frail in body type, high risk for pressure injury. Dependent on staff for bed mobility. Cleanse area to coccyx, apply allevyn, Order to change q (every) 3 days. Order for res to have I-heal mattress . A weekly Skin Only Evaluation dated 1/17/22 at 3:00 PM (36 minutes before the CNA notified the nurse of a coccyx opening), the nurse completed a body skin assessment and there was no documentation of skin issues or an opening to the coccyx area noted. A Nursing noted dated 1/17/22 at 8:04 AM, documented in part . noted to have open area to coccyx measuring 2x3 cm with slough present in the wound center and pink tissues on edges . Resident was on a standard mattress new order for IHEAL mattress to be in place. No cloth incontinent pads, frequent turning and repositioning . Will re-assess per policy as needed . A Wound Care Progress Note dated 1/26/22, documented in part . Coccyx stg (stage) III . Slough % 5 . Serous . Clean wound with NS (Normal Saline) . Apply to wound bed . Medihoney gel . Frequency: Q (every) day . Review of a care plan titled . has actual skin impairment, deep tissue injury . revealed interventions to Follow (name of facility) policies/protocols for the prevention/treatment of skin breakdown, . frequent repositioning intervention was implemented on 1/17/22, the day of the identification of the coccyx wound and 13 days after admission into the facility. Review of a care plan titled Skin Tear, Bruise, Scabbed Area, DTI . documented an intervention for a low air loss mattress implemented on 1/25/22. This intervention was implemented eight days after the identification of the coccyx wound and three weeks after being admitted into the facility. On 5/4/22 at 1:15 PM, the Director of Nursing (DON) was interviewed and asked about the delay of interventions to prevent the development of R74's coccyx wound, the accuracy of the admission Braden assessment score, the accuracy of the weekly body assessment completed on 1/17/22 and why the resident's bed was currently set at normal pressure instead of low pressure. The DON stated they would look into it. Further review of the medical record revealed the following: A Wound Assessment Report consultation dated 3/14/22 at 10:41 AM, documented the following in part . Pressure injury - Stage III . Sacrum/Buttock, Coccyx . L (Length) x W (Width) x D (Depth): 4.8 x 3.4 x 0.4 cm2 (centimeter squared), Area: 9.7 cm2, Volume: 3.9 cm2 . Odor: malodorous . A Wound Care Physician Progress Note dated 3/21/22 at 3:58 PM, documented in part . Coccyx measures 8.6 cmx7.2cm.1.2cm, area opened up, large amount of foul-smelling exudate. Possible tendon exposure. WBC (White Blood Cell) have been elevated, believe this is the source of infections . Stage 4 wound is unavoidable . Will order Doxycycline 100 mg (milligram) BID (twice a day) x 7 days . Review of a laboratory report dated 3/4/22 at 10:46 AM, documented a WBC of 17.2 (normal 4.00 - 11.00). Indicating a high reading, which usually indicates the body producing increased WBC to fight an infection. Review of the progress notes revealed no documentation by the nurses from 3/14/22 to 3/21/22 of the identification of large amounts of foul-smelling exudate from the coccyx wound and no documentation of notification to the physician of the wound worsening. On 5/4/22 at 5:31 PM, Wound Nurse Practitioner (WNP) BB was interviewed and asked if they were notified prior to 3/21/22 wound consultation of the wound worsening, WNP BB stated they were not notified. WNP BB stated the wound had opened up and the foul odor was horrific. WNP stated that it didn't just worsen that day and was unsure on why the facility staff did not notify them of it worsening prior to the 3/21/22 visit. On 5/4/22 at 1:15 PM, the DON was also asked why the front-line staff (CNAs & Nurses) failed to identify the worsening of the coccyx wound and report the changes to the practitioner and the DON stated they would look into it. At 3:06 PM, the DON returned and stated they could not provide any further explanation or documentation regarding all questions asked. Further review of the care plan titled . has actual skin impairment, deep tissue injury . documented the following interventions in part, . Report . declines to the MD (Medical Doctor) . Any changes or findings; please document, inform wound care, unit manager, DON, and physician . report to MD PRN (as needed) changes in skin status . Further review of a care plan titled Skin Tear, Bruise, Scabbed Area, DTI . documented the following intervention in part, . Monitor skin for increased redness, drainage, foul odor, secretions, and temperature. Notify MD or MD extender as occurs . No further documentation was provided by the end of survey. This citation pertains to intake: MI00127355. Based on observation, interview and record review, the facility failed to prevent, accurately assess and identify, and notify the physician of worsening of pressure ulcers, for two (R's 27 and 74) of two residents reviewed for Pressure Ulcers, resulting in a facility acquired Stage IV (full thickness skin and tissue loss with exposed or directly palpable fascia muscle, tendon, ligament, cartilage or bone in the ulcer) Pressue Ulcer that required surgical debridement and a Stage IV infected coccxy Pressure Ulcer for R74. Findings include: R27 On 5/2/22 at 9:37 AM, R27 was observed lying in bed. An intravenous (IV) bag of Meropenem (antibiotic) 500 mg/100 ml (milligrams per milliliter) was hanging on an IV pole next to the bed. R27 was asked what the antibiotic was for. R27 appeared confused and did not know the answer. Review of the clinical record revealed R27 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that included: heart disease, adjustment disorder with depressed mood and hypertension. According to the Minimum Data Set (MDS) assessment dated [DATE], R27 had severely cognitive impairment and required the extensive to total assistance of staff for all activities of daily living (ADL's), including bed mobility. Review of R27's physician orders revealed an order with a start date of 4/14/22 for Meropenem Solution Reconstituted 500 MG, use 1 dose intravenously every 8 hours for wound infection for 30 Days. Review of R27's pressure ulcer care plan initiated 4/14/22 revealed interventions that read in part, .Follow CfCC [sic] policies/protocols for the prevention/treatment of skin breakdown . Monitor/document/report to MD PRN (as needed) changes in skin status . Review of R27's wound care notes revealed an initial Wound Care note dated 2/9/21, signed by Dr. DD read in part, .Rt (right) Parasacral (coccyx) UTD (unable to determine) . chronic . Length 4.2 Width 5.2 . It should be noted that the only wound R27 had upon admission was a chronic wound to the coccyx. A Wound Assessment Report dated 2/28/22, by NP BB read in part, .Pressure Injury - Stage II . Gluteus, Left . 2.4 x 3.1 x 0.2 cm (centimeters) A Wound Care Physician Progress Note by Nurse Practitioner (NP) BB dated 4/4/22 at 1:04 PM read in part, .Bedside debridement performed, removed moderate amount of slough/necrotic tissue with curette and suture removal kit. Large amount of malodorous drainage present. Wound has deteriorated. lower spine exposed, slow to blanche erythema around wound .Will sent patient to hospital for further evaluation . Review of the progress notes from 2/28/22 to 4/5/22 revealed no documentation by the nurses of the identification of large amounts of foul-smelling exudate from the left gluteal wound and no documentation of notification to the physician of the wound worsening. Review of a hospital admission note dated 4/5/22 read in part, .a transfer from ECF (extended care facility) for further evaluation of worsening sacral decubitus ulcer and concern for infection vs osteo (osteomyelitis - infection the bone) . was given IV fluids in the ED (Emergency Department) and started on broad-spectrum antibiotics . admitted for further monitoring and treatment with consults made to infectious disease and general surgery . A Wound Care Physician Progress Note dated 4/18/22 at 2:22 PM read in part, .Patient returned from hospital, where she had surgical debridement. Along with IV ABt (antibiotic therapy) therapy . A Wound Assessment Report dated 5/2/22 by NP BB read in part, .Pressure Injury - Stage IV . Gluteus, Left . 11.7 x 6.8 x 2 cm . Review of R27's Braden Scales revealed the initial score on 2/6/21 was 16, indicating At Risk. No documentation of a Braden Scale until a year later on 2/2/22 with a score of 13, indicating Moderate Risk. The next Braden Scale was 4/14/22 with a score of 11, indicating High Risk. It should be noted that both the 2/22/22 and the 4/14/22 listed R27 as chairfast not bedbound and the 2/2/22 listed Friction & Shear as Potential Problem not Problem, therefore due to the score indcating moderate Risk, no interventions to prevent pressure injuries were put into place until 4/14/22 when R27 was deemed High Risk for pressure injury development. On 5/3/22 at 11:06 AM, an observation of R27's wounds was performed by LPN B. The Left Gluteal wound appeared to have a pink base with slough (non-viable . tissue .), and undermining at the edges. On 5/4/22 at 11:51 AM, NP BB was interviewed and asked about R27's wounds. NP BB explained she had started as the facility's Wound Care NP in mid-February 2022 and identified wounds on R27's bottom area. NP BB continued to explain that the coccyx wound was chronic, and she had been admitted with that one, and the Left Gluteal had worsened and required surgical debridement and antibiotics. When asked why the Left Gluteal had required surgical debridement, NP BB explained she had done bedside debridement, and had started to use a chemical debridement treatment, and the wound opened up and then they could see it was necrotic, down to the bone and needed surgical debridement. On 5/4/22 at 1:06 PM, the DON was interviewed and asked how a facility acquired wound progressed to a Stage IV and required surgical debridement and IV antibiotics. The DON explained R27 was quite compromised and required total care. When asked how frequently a Braden Scale should be done on a resident, the DON explained they should be done at lease quarterly, or more frequently if there were new pressure injuries. The DON was asked about R27 having only three Braden Scale assessments since her admission and why none of the assessments scored her has Very High Risk when she had aquired pressure ulcers at the faciliy. The DON had no answer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation has two Deficient Practice Statements (DPS). #1 DPS Based on observation, interview and record review the facility failed to implement a fall care plan for a resident at risk for falls upon admission, implement, modify, and review the effectiveness of the interventions once the care plan was implemented, and identify the root cause analysis for multiple falls for one (R45) of eight residents reviewed for accidents, resulting in R45 having to be transferred to the hospital and receiving four staples to their head. Findings include: On 5/2/22 at 9:51 AM, an observation of R45 was made sitting in a broda chair (specialized chair) in the hallway at the nurse's station. When interviewed the resident didn't consistently answer the questions appropriately. Review of the clinical record revealed the following: R45 was admitted to the facility on [DATE] with diagnoses that included: Alzheimer's disease, falls, difficulty in walking and hypertension. A Minimum Data Set (MDS) assessment dated [DATE] documented Severely Impaired for cognitive skills for daily decision making and required staff assistance for all Activities of Daily Living (ADLs). A hospital Clinical Discharge Instructions provided to the facility dated 2/2/22 at 1:43 PM, documented in part . Principal Diagnosis at discharge: 1: Frequent falls . An admission Fall Risk Evaluation dated 2/2/22 at 7:11 PM, documented a score of 14 At Risk. Further review of the fall risk evaluation revealed the Medication section documented as None of these medications take currently or within last 7 days was marked for Medications. On the top of the fall risk evaluation, the form documented in part, . Medications: Respond based on the following types of medications: Anesthetics, Antihistamines, Antihypertensives, Antiseizure, Benzodiazepines, Cathartics, Diuretics, Hypoglycemics, Narcotics, Psychotropics, Sedatives/Hypnotics . Review of the resident's discharge orders and physician orders at the facility revealed the resident was currently taking a hypertensive medication (benazepril) . The admission fall risk evaluation did not acknowledge the hypertensive medication and was not completed accurately. Review of the clinical record revealed six falls documented from 2/4/22 to 4/16/22. Review of a Physician note dated 2/3/22 at 9:43 AM, documented in part . admitted from an acute care facility after she was treated for Status post fall at home . confused and a poor historian . complains of weakness . unsteady gait . dementia . Gait disturbance: start fall precautions . Review of a care plan titled in part . risk for falls r/t Confusion, Gait/balance problems, Incontinence, and a HX (history) of falls . was implemented on 2/18/22, more than two weeks after the resident was admitted into the facility. Review of the clinical record revealed the following: A Nursing note dated 2/5/22 at 3:16 PM, documented in part . 11:45 AM Fall was witnessed . fall location: dining room, Activity at the time of fall: standing alone . Reason for fall: wheelchair not locked standing unassisted . resident in dining room at table awaiting lunch service, resident attempted to stand unassisted, wheelchair wasn't locked. Resident a/o (alert and oriented) x 1 . Contributing factors note: confusion new admit . History of falls at home - prior to admission . Clinical Suggestions (blank) . A Post Fall Evaluation dated 2/5/22 at 3:16 PM, documented in part . Date/ Time of Fall - 02/04/2022 11:45 . Reason for fall - wheelchair not locked standing unassisted . Pre-Fall/Post Fall Risk Score (blank) . Date of safety evaluation (blank) . Contributing Factors Note - confusion new admit . Conclusion Note (blank) Review of a facility fall incident report dated 2/4/22 at 12:04 PM, documented the same information as the progress note and post fall evaluation. Further review of the clinical record revealed no implementation of interventions to prevent further falls or documentation of the Interdisciplinary team (IDT) reviewing the root analysis of the fall. Review of a facility policy titled Falls and Fall Risk, Managing and Prevention dated 2/28/2008 documented in part, . Based on previous evaluations and current data, interventions will be identified related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling . The interdisciplinary team will identify appropriate interventions to reduce the risk of falls . The Interdisciplinary treatment team will identify and implement relevant interventions (e.g., w/c (wheelchair) positioning or treatment of osteoporosis, as applicable) to try to minimize serious consequences of falling . Review of a facility incident report dated 3/14/22 at 7:38 PM, documented in part . Resident found sitting up against bathroom door. Flat on resident's buttocks, resident experienced a fall . Resident stated the floor was slippery as she tried to walk to the bathroom from her bed . Predisposing Situation Factors - Improper Footwear, Ambulating without Assist . No Witnesses found . Further review of the record revealed no documented progress note, post fall evaluation, modification of interventions or documentation from the IDT team identifying the root cause analysis of the fall. Review of a Nursing note dated 3/16/22 at 10:02 PM, documented in part . Writer found resident in the bathroom next to toilet sitting up on her bottom. Resident has minor skin tear on left elbow . Resident was placed at the nurses' station in wheelchair to be monitored for the remainder of the night . Review of a Nursing note dated 3/20/22 at 12:25 AM, documented in part . 03/19/2022 10:30 AM Fall was not witnessed. Fall occurred in the hallway. Activity at the time of fall: Attempting to walk The reason for the fall was not evident. Was a safety evaluation completed/documented prior to the fall: No. Safety teaching documented before the fall: No . Any similarities between current and post falls: No . Clinical Suggestions: (blank) . Review of a Post Fall Evaluation dated 3/20/22 at 12:25 AM, documented the same description as documented in the 3/20/22 Nursing note. Review of a facility incident report dated 3/19/22 at 10:12 PM, documented in part . Nursing Description: Patient observed on floor in hallway . Resident Description: Patient is confused. Continues to want to get up and do things . Mental Status - (blank) . Predisposing Environmental Factors - (blank) . Predisposing Situation Factors - (blank) . No witnesses found . Further review of the clinical record revealed no identification of the root cause analysis of the fall by the Interdisciplinary team. Review of a Nursing note dated 3/28/22 at 9:18 PM, documented in part . 03/28/2022 6:30 PM Fall was not witnessed. Fall occurred in the hallway. Activity at the time of fall: standing/walking w/o (without) assistance. The reason for the fall was not evident. Was a safety evaluation completed/documented prior to the fall: No . History of falls at the facility. Any similarities between current and post falls: Yes . Clinical Suggestions: (blank) . Review of the Post Fall Evaluation dated 3/28/22 at 9:18 PM, documented the same documentation of the fall as the 3/28/22 Nurse's note. Review of a facility incident report dated 3/28/22 at 10:11 PM, documented in part . Writer observed resident laying on the floor on the right side of her body with her right arm under her head. Resident denies pain or discomfort at this time . Resident stated, I fall trying to walk over to that table . Mental Status (blank) . Predisposing Environmental Factors - None . Predisposing Physiological Factors - None . Predisposing Situation Factors - None . Further review of the clinical record revealed no documentation by the Interdisciplinary team identifying the root cause analysis of the fall or modification/implementation of additional interventions to prevent further falls. Review of a Nursing note dated, 4/16/22 at 10:17 PM, documented in part . Resident was sitting in her w/c (wheelchair) at the nursing station, she was trying to self-transfer and fell in <sic> hit the back of her head. She had on non-skid socks, w/c was found behind her with the locks on. Action: Writer assessed patient from head to toe, writer seen blood coming from the back of the head, writer cleaned with normal saline and wrapped to stop bleeding . Resident was discharged to hospital . Review of a hospital Discharge Instructions dated 4/16/22 at 9:55 PM, documented in part . Stapled skin wound; 2: Head injury . 4 staples . Review of the clinical record revealed no post fall evaluation completed for the 4/16/22 fall. Further review of the clinical record and incident report revealed no identification of the root cause analysis of the resident repeated falls or interventions modified and/or additional interventions implemented to prevent further falls. On 5/4/22 at 9:18 AM, the Director of Nursing (DON) was interviewed and asked about the delay in implementation of a fall care plan for a R45 admitted with a diagnosis of falls, the accuracy of the admission fall risk assessment, each of the falls was reviewed and asked if the Interdisciplinary team identified the root cause analysis for the falls to modify/implement additional interventions and to review the effectiveness of the existing interventions to prevent further falls. The DON stated they would look into it. At 3:07 PM, the DON returned and stated they did not have any further information or documentation to provide. No further documentation was provided by the end of survey.Deficient Practice #2 Based on observation, interview, and record review, the facility failed to determine the root cause of injuries (bruises) obtained from assistive devices (wheelchair) and during a transfer; and failed to implement interventions to prevent further injury for two (R32 and R60) of seven residents reviewed for accidents. Findings include: Resident #32 On 5/2/22 at approximately 9:30 AM, R32 was observed seated in a wheelchair in their room. On 5/2/22 at 11:50 AM, R32 was observed self-propelling in a wheelchair, using their right hand to propel the wheel forward. R32 was not observed to be wearing a bra and their right breast was observed near the waist line pressed between and through the arm rest of the wheelchair. On 5/3/22 at approximately 3:30 PM, R32 was observed self-propelling in a wheelchair. They were not wearing a bra and their right breast was observed near the waist line and pressed into the arm rest of the wheelchair as they propelled the wheel forward with their right hand. Review of R32's clinical record revealed R32 was admitted into the facility on 8/4/17 and readmitted on [DATE] with diagnoses that included: Alzheimer's Disease. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R32 had severely impaired cognition and required supervision for locomotion via wheelchair on the unit. Review of R32's progress notes revealed the following documentation: A Skin Only Evaluation note dated 4/30/22 documented, .Resident has current skin issues. Skin Issue: Bruising. Skin Issue Location: (R-right) Breast . A Nurses progress note dated 4/30/22 written by Licensed Practical Nurse (LPN) U documented, Observed resident leaning to right side of w/c (wheelchair), while in hallway with (R) breast in between armrest, some bruising noted to (R) breast area, some discomfort noted .DON (Director of Nursing) notified .Resident repositioned in w/c, Therapy to screen . A Physician Progress Note dated 5/2/22 written by Nurse Practitioner (NP) BB documented, Patient was seen for brusie <sic> to right out breast .Patient was seen today per nursing staff request .staff report patient was observed with purple bruise to right out breast. Staff observed patient leaning to her right in the wheelchair .Does not appear to be of a suspicious nature .Ecchymosis (bruise); continue to monitor status . On 5/3/22 at 8:03 AM, all incident reports and associated investigations for R32 for the past three months were requested from the Administrator. Review of an incident report for R32 dated 4/30/22 at 7:52 PM, completed by LPN U revealed the following documentation: Observed resident leaning to right side of w/c; while in hallway with (R) breast in between armrest, some bruising noted to (R) breast area, some discomfort noted. Resident Unable to give Description. Skin assess (sic) completed .Predisposing Environmental Factors .Resident Equipment . Attached to the incident report was a physician order dated 4/30/22 for Therapy to screen. No additional information was provided. On 5/3/22 at 1:33 PM, the DON was interviewed regarding the bruise observed on R32's right breast and the incident report that documented it was due to R32 leaning in her wheelchair. The DON reported LPN U thought it was likely from the wheelchair, so the physician was notified, and therapy screened the resident. When queried about any interventions implemented to prevent further bruising to R32's breast, the DON reported she was referred to be screened by therapy and did not know. On 5/3/22 at 1:48 PM, an interview was conducted with LPN U via the telephone. When queried about the bruise to R32's right breast, LPN U reported a Certified Nursing Assistant alerted her about the bruise, LPN U assessed R32 and discovered a bruise to the right breast. LPN U reported that she observed R32 leaning to the right of her wheelchair when self-propelling and her posture appeared off so that was likely what caused the bruise. LPN U reported she notified the physician and DON and ordered a therapy screen. When queried about any interventions implemented as a result of the therapy screen, the DON reported she was not sure. On 5/4/22 at approximately 4:30 PM, Therapy Director V was interviewed. When queried about whether R32 was recently referred for a therapy screen, Therapy Director V reported R32 was referred for Physical Therapy (PT) and Occupational therapy (OT) due to generalized weakness. When queried about whether R32 was evaluated for positioning in her wheelchair due to obtaining a bruise on her breast, Therapy Director V reported he had not heard of that but would check into it. Therapy Director V provided a PT Evaluation & Plan of Care that revealed R32 was evaluated for PT on 4/27/22 due to a fall. Review of an OT Evaluation & Plan of Care revealed R32 was evaluated for OT on 5/3/22 to assess for safety and increase independence with activities of daily living. The PT evaluation was prior to the discovery of the bruise to R32's breast and the OT evaluation did not address potential positioning issues in the wheelchair that were said to cause a bruise to R32's breast. Review of R32's care plans revealed a care plan initiated on 10/13/20 that documented, .actual skin impairments . The care plan did not address the bruising to R32's breast and there were no updated interventions since 10/13/20. Resident #60 On 5/2/22 at 9:30 AM, R60 was observed eating breakfast. R60 did not respond when talked to. At 11:53 AM, R60 was observed sleeping. At 1:38 PM, R60 was observed eating lunch with their plate of food on their mattress. R60 explained they were not interested in talking. Review of R60's clinical record revealed R60 was admitted into the facility on 3/19/19 and readmitted on [DATE] with diagnoses that included: hypertension, dementia, and congestive heart failure. Review of a MDS assessment dated [DATE] revealed R60 had intact cognition and required extensive physical assistance from at least two staff members for transfers. Review of a Skin Only Evaluation progress note dated 3/24/22 revealed the following documentation, .Resident has current skin issues. Skin Issue: Bruising. Skin Issue Location: right chest area and right breast Tissue: Painful. determined that area bruised from sling while using sit to stand lift . Review of a Skin Only Evaluation progress note dated 3/27/22 noted, . Skin Issue: Bruising. Skin Issue Location: (R) breast area . Review of a Skin Only Evaluation progress note dated 4/7/22 noted, .Skin Issue Location: right chest area Tissue: Painful . On 5/3/22 at 8:03 AM, the Administrator was asked to provide any incident reports and associated investigations for R60 for the past three months. No incident reports or investigations were provided regarding the documented bruising to R60's right chest and breast area. Further review of R60's progress notes revealed the following: A Draft Nurses progress note dated 3/23/22 at 4:56 AM, written by LPN Y, noted the following: CNA observed bruising on resident's right side of breast while providing care, CNA called writer into room. Resident stated 'I've been sore since the Cena earlier today transferred me' . A Late Entry Alert progress note dated 3/23/22 at 7:30 AM, written by the DON, noted the following: The resident has some bruising to the right side of her breast. Resident who is alert and able to make her needs known explained to staff that she sustained the bruise during a Sit to Stand transfer . On 5/3/22 at 9:56 AM, an observation of R60's skin was conducted with LPN F. A bruise was observed on the lateral aspect of R60's right breast, below the nipple line. It appeared to be linear in shape, was a dark color, and slightly fading along the edges to yellow. LPN F measured the bruise to be 4 cm x 2 cm. When asked how the bruise happened, R60 explained they tried to pick her up and put her in the chair and that it hurt. On 5/3/22 at 3:52 PM, LPN Y was interviewed. When queried about the bruise observed on R60's breast on 3/23/22, LPN Y reported around 4:00 AM the CNA notified her that R60 had a bruise on her breast and chest. LPN Y could not recall who the CNA was, but reported she notified the Administrator and DON. On 5/3/22 at 4:06 PM, LPN Y followed up and reported that she spoke with the Administrator and DON and now remembered the event and that the bruise lined up with the sit to stand lift. On 5/3/22 at approximately 4:30 PM, the DON was interviewed about any investigation into the bruise on R60's breast and the documented statement from the resident that is occurred during a transfer. The DON reported she remembered investigating it but did not have any documentation of the investigation. When queried about how R60 sustained a bruise to the breast and chest from a sit to stand lift, the DON did not offer a response. When queried about who was involved in the transfer and any intervention implemented to prevent further injuries to residents during transfers, the DON reported she did not remember. Review of R60's care plans revealed a plan that was initiated on 8/5/21 that noted, Safe Transfers/Injury prevention R/T (related to) debility, poor/no safety awareness. Interventions initiated on 8/5/21 were, Nursing staff should be evaluating at all times the residents response to the ordered transfer - if the resident needs more assit <sic> and the use of a lift the nursing staff should obtain an order for the new level, place it in the 24 hour report and update the communication board .One person assist Maximum x 2 - gait belt required .When a resident has fluctuating performance with transfers due to fatigue write an order that covers both the least assist needed and also the max assist needed . Review of a facility policy titled, Incident and Accident Assessment, Reporting and Monitoring, reviewed on 10/8/19, revealed, in part, the following: .Incident and Accident Reporting .The Director of Nursing is to be notified of ALL falls &/or resident injuries .The DON will notify the Dominions and it will be determine if the incident is then reportable to the (State Agency) .The Shift Supervisor is to: Initiate investigation by obtaining statements and attempting to determine how the incident & accident occurred .The Nurse manager or designee will: .Review incident and accident reports and follow up with further investigation .Review and finalizes updated care plans .Summarize the incident and follow up actions/outcomes in the note section of I&A .File all completed incident and accident reports and maintain binders .Monitor the incident and accident reports and the reporting process to ensure compliance .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assess, monitor, and ensure appropriate catheter care was provided for one (R14) of two residents reviewed for catheter care, resulting in pain, urethra laceration and acute transfer to the hospital. Findings include: Review of the closed record revealed R14 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that included: acute cystitis with hematuria, benign prostatic hyperplasia (BPH) and Alzheimer's Disease. According to the Minimum Data Set (MDS) assessment dated [DATE], R14 had moderately impaired cognition and required the extensive assistance of staff for all activities of daily living (ADL's). The MDS assessment also indicated R14 had an indwelling catheter. Review of R14's progress notes revealed: A Nurses note by Licensed Practical Nurse (LPN) Y, dated 4/25/22 at 10:06 PM read in part, Resident c/o (complaining of) discomfort at foley (catheter) site. Writer assessed and noticed a split in penis where foley connects with green discharge . A Physician Progress Note by Dr. CC, R14's attending physician, dated 4/26/22 at 8:26 AM read in part, Patient was seen for; urethral split . BPH with obstructioncontinue [sic] with Foley catheter; complicated with a split in the urethra/penis; I called his urologist and discussed the case with him who recommended to monitor patient for now, he needs to be assessed in the office for possible need for SPC (suprapubic catheter - a flexible tube that empties the bladder through an incision in the belly instead of a tube in the urethra) . A Physician Progress Note by Dr. CC dated 4/28/22 at 1:18 PM read in part, Patient was seen for; worsening urethral laceration. Urethra laceration induced by chronic indwelling Foley catheter, worse and longer in length with possible infection, needs immediate attention by urology and cannot be handled as an outpatient . A Nurses note by LPN C dated 4/28/22 at 2:40 PM read in part, Resident c/o pain to penis and groin . Resident will transfer to [Name Redacted - Local Hospital] for Urethral Laceration r/t (related to) Foley. Area is red and swollen . A Nurse note by LPN C dated 4/28/22 at 2:40 PM read in part, Resident transferred to [Name Redacted - Local Hospital] via ambulance at 1420 (2:40 PM) r/t urethral laceration . On 5/3/22 at 2:17 PM, LPN Y was interviewed by phone and asked about what happened with R14's catheter on 4/25/22. LPN Y explained R14 started to yell that his penis hurt, so she and a Certified Nursing Assistant (CNA) stood him up and looked at his penis and it was starting to split, but there was no blood. LPN Y was asked if she had asked R14 how it happened. LPN Y explained R14 told her she knew how it happened but was confused at the time. When asked if she had started an I&A, LPN Y explained she had not. On 5/3/22 at 2:32 PM, LPN C was interviewed and asked about R14. LPN C explained when she had seen the resident in the morning, he was complaining of pain, so when she examined him, she saw the penis was split just above the head approximately 3/4-1 inch in length. LPN C was asked if she had asked R14 how it happened. LPN C explained he did not know. When asked if she had received in the nursing hand-off report that R14 had a urethral laceration, LPN C explained she had not received a report and did not know he had a laceration. Review of R14's catheter care plan revealed the care plan, and all interventions were resolved on 2/11/22. It should be noted R14 continued to have an indwelling catheter up to the time he was discharged on 4/28/22. Review of R14's April 2022 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed no documentation of catheter care, monitoring of the catheter or ensuring an anchor (a device to secure the catheter tubing to prevent pulling) was present. Review of R14's April 2022 CNA documentation revealed no documentation of catheter care or amount of output from the catheter. On 5/3/22 at 2:46 PM, the Director of Nursing (DON) was asked for any documentation of catheter care, monitoring, or anchor placement for April 2022 for R14. On 5/4/22 at 9:17 AM, the DON explained there was no documentation for R14's catheter in April 2022. The DON was asked if there should be documentation of catheter care, and placement of an anchor device, monitoring of the catheter, and output. The DON explained documentation should be done every day. When asked who should be documenting on the catheter, nurses, CNA's or both, the DON did not answer. Review of an undated facility policy titled, Catheter Care Policy read in part, .Catheter care will be performed every shift and as needed by nursing personnel .