**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide one out of one residents (Resident #32) care and services to prevent and promote healing of pressure ulcers resulting in worsening wounds, facility acquired stage 3 pressure wound (full thickness skin loss ), osteomyelitis, and hospitalization. Findings Include: Resident #32(R32) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R32 was a [AGE] year-old female admitted to the facility on [DATE], with most recent re-admission 3/10/25 related to osteomyelitis (wound infection) with other diagnoses that included stage 4 pressure ulcer(full thickness skin and tissue loss, exposing muscle, tendon or bone), diabetes Mellitus, irregular heart rhythm, anxiety and depression. The MDS reflected R32 required substantial/maximal assistance with repositioning in bed. During an observation and record review on 4/28/25 at 9:46 AM, R32 was observed laying in bed, flat on back, with eyes closed on specialty air mattress that appeared slightly deflated. Observed air mattress pump located at foot of the bed with no lights or sound noted with electrical cord laying on the floor and unplugged from wall outlet, revealing no power to pump. Review of the MDS Indicators reflected R32 had a major wound infection and several hospitalizations. During an observation on 4/28/25 at 3:57 p.m., R32 was laying in bed, flat on back and air mattress pump continued to be non-functioning with no light and unplugged from wall outlet. R32 bed continued to appear deflated with sheets corners off of the mattress. During an observation and interview on 4/29/25 at 8:40 AM, R32 was laying in bed with air mattress now plugged into wall outlet. R32 reported had a wound on buttock area that caused her a lot of pain. When asked if staff provided her with medication for pain control, she reported they offer her Tylenol that does not help. R32 reported unable to independently reposition self in bed and staff do not assist or offer every two hours but instead about two times per shift. R32 reported did not get out of bed yesterday and bed seems more comfortable today than yesterday. Review of R32 Physician Progress Note, dated 4/11/25, reflected, [named R32] is a [AGE] year-old female who is recently in the hospital for UTI [urinary tract infection] and osteomyelitis. She had been on IV Zosyn which she developed an allergy to. She's being monitored for improvement of her rash before starting her next dose of antibiotics. The rash appears to be improving. [named R32] also has a wound on her sacrum area that does not appear to be improving. Referral to [named wound clinic] clinic has been placed Review of R32 Wound Evaluation, dated 12/5/24, reflected R32 had a new stage 3 pressure wound to right gluteus that measured 2.93cm length x 2.74cm width x 0.2 cm depth described as 80% epithelial and 20% granulation and no slough. The note reflected, Resident re-admitted from hospital with pressure injury . The picture appeared to be a small shallow wound that appeared to look like stage 2 pressure injury (partial thickness loss of dermis presenting as shallow open ulcer with a red or pink wound bed, without slough). Review of R32 Wound Evaluation, dated 1/27/25, reflected R32 now had two pressure wounds including one new facility acquired pressure wound. --#3-Stage 3 pressure wound to Sacrum(Prior #2) measured 2.95cm x 1.1cm x 0.1cm described as 90% epithelial and 10% granulation tissue with PUSH(pressure ulcer scale for healing, with 0-17 with 0 as healed) of 9. --#4-NEW facility acquired unstageable pressure wound right gluteus measured 2.81cm x 1.1cm with no depth described as 60% slough(dead skin), 40% granulation tissue with PUSH score of 11. The assessment reflected, Previous pressure injury re-opened . Review of the Wound Evaluation, dated 2/24/25, reflected worsening of two wounds and suspected wound infection. --#3-unstageable pressure wound Sacrum-12.93cm x 17.16cm with no depth and PUSH score of 15. --#4-Facility Acquired Stage 3 Pressure wound Right Gluteus-1.73cm x 1.04cm x 0.1cm with PUSH score of 7. Review of R32 Nurse Progress Note, dated 2/23/25, reflected, PRN[as needed] standing order for Tylenol 325mg. Resident is observed lying in bed yelling out in pain and discomfort from sacrum wound. Staff have attempted to reposition resident several time but resident has no relief. Review of R32 Progress Note, dated 2/25/25, reflected, Tx[treatment] to sacrum completed as the resident would not allow it to be done earlier. The resident c/o[complain of] pain to the area and saying Oh it hurts it hurts. The resident was given Tylenol but spit it out. The resident (sp) continues to assist the resident and reassure her. Review of R32 Active Discharge Planning Progress note, dated 2/26/25, reflected, .History Of Present Illness: [named R32] was seen today as she hasn't been eating and has been refusing all meds. Due to her refusal and inability to take oral meds, was started on IM [intramuscular] Rocephin as wound appears infected . Review of R32 Nurse Progress Note, dated 3/4/25, reflected, The resident was re-admitted to [named facility]. Transferred to her room per EMT's[emergency medical staff] from [named] Hospital .Skin assessment completed at admit. Debrided wound to the sacral/coccyx. Bandage intact changed and wounds assessed. Wound is beefy red with small amount of bloody drainage on the drsg[dressing]. The resident is c/o severe pain to the area. Tylenol given p.o[by mouth] .Assisted with HS[night] care and repositioning in the bed x 1PA[one person assist] . Review of R32 Wound Evaluation, dated 3/4/25, reflected R32 had three pressure wounds: --#5-unstageable pressure wound Sacrum(Prior #3)-6.51cm x 7.79cm with no depth and 3cm undermining and PUSH score of 17. --#6-New unstageable pressure Sacrum superior-3.95cm x 1.31cm and no depth with 10% slough, 20% granulation and 70% epithelial tissue with PUSH score of 12. --#7-Facility acquired unstageable Right Gluteus(Prior #4)-3.86cm x 3.07cm with no depth with 20% slough, 10% granulation and 70% epithelial tissue with PUSH score of 13. Review of R32 Physician Progress Note, dated 3/5/25, reflected, [named R32] is a[AGE] year-old female who is a long-term resident of [named facility] who was sent to [named hospital] on 2/26/25 for worsening mental status, low grade temp and worsening sacral decubiti. She had recently completed rx[medication] for a UTI. In the ER she met septic protocol with leukocytosis, tachycardia, lactic acidosis and tachypnea. She was started on sepsis protocol and started on IV Vanco and Rocephin. She was admitted for urosepsis and an infected decubiti, which appeared necrotic. She underwent debridement of her wound. Infectious disease was consulted and she continued on Vanco and Rocephin. [named R32] was stabilized and transferred back to [named facility] on Augmentin. Wound culture done at [named facility] prior to being sent out resulted ESBL E.coli/ Providencia stuarti and Enterococci/the later of which was treated based on sensitivities. Placed on Bactrim/Levaquin in place of Augmentin on return to facility . Review of R32 Nurse Progress Note, dated 3/7/25, reflected, resident still unable to keep medications down she is now reporting intermittent chest pain with new irregular tachycardic pulse . new orders for resident to be transferred to hospital. Resident is aware and agreeable she states she feels overall terrible. Review of R32 Nurse Progress Notes, dated 3/10/25 at 3:36 p.m., reflected, Resident arrived back to the facility from [named hospital] at approximately 1411[2:11 p.m.] .Resident has a picc[peripheral inserted central catheter] line in her right arm and appears to be clean . Review of R32 Physician History and Physical, dated 3/13/25, reflected, [named R32] was sent back out to [named hospital] on 3/7/25 after c/o[complaints of] nausea and being unable to keep fluids down since returning from hospital. Was hospitalized from [DATE] through 3/3/25 for Enterococci UTI [urinary tract infection] and stage 4 sacral decubiti that was debrided .CT of abdomen pelvis showed left product decubitus ulcer with abscess and possible osteomyelitis of the coccyx .She was seen by ID[infectious disease] and felt to have osteomyelitis of sacrum. She had PICC [peripheral inserted central catheter] placed in her right upper arm and started on IV Zosyn. Transferred back to [named facility] to complete 6 weeks IV Zosyn for osteo[osteomyelitis] . Review of R32 Wound Evaluation, dated 3/11/25, reflected R32 had pressure wounds as follows: --#8-Facility Acquired unstageable pressure wound right gluteus(Prior#7)-2.49cm x 1.74 with no depth with PUSH score of 12. --#9-unstageable pressure wound Sacrum (Prior #5) - 4.98cm x 5.99 with no depth with PUSH score of 17. Continued review of the Wound Evaluation reflected, Resident re-admitted with wound. Resident on course of IV antibiotics for osteomyelitis related to wound. Surrounding tissue is non-blanchable & fragile & is at high risk for breakdown. Further tissue damage is probable . APM[air mattress] & Roho cushion in place & properly functioning . Review of R32 Wound Evaluation, dated 4/29/25, reflected wounds as follows: --#8 - Facility Acquired Stage 3 pressure wound right gluteus - 0.54cm x 1.8 cm x 0.1 cm with PUSH score of 6. The Evaluation note reflected, Surrounding tissue is non-blanchable & is at high risk for breakdown . --#9 - Unstageable Pressure wound Sacrum - 4.63cm x 3.59cm with no depth with 10% slough, 10% escar and 80% granulation tissue and PUSH score of 14. Wound Evaluation note reflected, Resident currently receiving course of Zyvox for osteomyelitis r/t[related] to wound. Surrounding tissue is non-blanchable & fragile & is at risk for breakdown. Further tissue damage is possible . Review of R32 SKIN MANAGEMENT Care Plan, revised 3/1025, reflected interventions that included, Encourage me to make small, frequent shifts in my position . I have pressure reducing device on bed- APM[alternating pressure mattress] mattress set to my comfort. LN[licensed nurse] to ensure it is functioning q shift . Review of the Wound Clinic Consult, dated 4/30/25, reflected R32 was seen for infection of stage 4 Pressure Ulcer to Coccyx and right ischium open area. The consultation reflected orders to change dressing to coccyx wound two times daily and as needed and to reposition R32 every two hours while lying and every 15 to 20 minutes while sitting. During an interview on 4/30/25 at 9:48 AM, Registered Nurse Wound Nurse (WN) M reported had been wound nurse for about three years at the facility. WN M verified R32 admitted to the facility 1/5/24 with no wounds and developed wounds post hospital admissions and did not have any facility acquired pressure ulcers. WN M verified wound #2 was present on admission post hospital on [DATE] as stage 3 that was later wound #3 then #5 and currently #9 unstageable pressure sacrum wound. WN M reported wound #9 had depth but because it had area of escar depth was not able to be measured. WN M verified wound worsened and was currently being treated for osteomyelitis. WN M reported R32 had new open wound (#4) on 1/27/25 to right gluteus that had history of prior pressure wound. WN M verified New wound #4 was later #7 then #8 current stage 3 pressure wound to right gluteus. WN M verified R32 wound #8 had worsened between onset of 1/27/25. WN M reported would expect staff to follow care plans and [NAME] interventions including turning and repositioning R32 every two hours and making sure air mattress was functioning. WN M reported staff expected to complete change of condition for new wounds and verified no change of condition completed on 1/27/25 because new wound had a history. WN M reported wound #4 that developed on 1/27/25 was not facility acquired because of prior history of wound and would provide evidence to support. During an interview and record review on 4/30/25 at 10:43 AM, Clinical Care Coordinator RN N verified occasionally covered for wound nurse and when reviewing wounds uses PUSH scores to document wound progress. RN N reported would expect staff to follow care plans and [NAME] and nurse to monitor R32 functioning of air mattress every shift and document. RN N verified R32 required assistance with bed mobility for repositioning and staff expected to assist related to standard of practice and not required to document as completed task. During a second interview on 4/30/25 at 12:25 p.m., WN M verified R32 wound #4 was identified incorrectly and should have been identified as facility acquired pressure ulcer on 1/27/25 that was currently wound #8 stage 3 pressure wound to right gluteus. During an interview on 4/30/25 at 12:32 p.m., Director of Nursing (DON) B reported would expect staff to follow Care Plan and [NAME] interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This deficiency pertains to Intake MI00150515 Based on interview and record review, the facility failed to provide timely notification to the physician for one Resident (#106) of three residents reviewed for a change in condition. This deficient practice resulted in a delay in medical treatment for a significant change in condition with diabetic ketoacidosis. Findings include: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R106 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included multiple pelvic fracture post fall 2/4/25, hypertension(high blood pressure), insulin dependant diabetes mellitus (elevated blood sugar), and mild dementia. R106 was re-admitted to the hospital 2/17/25 for diabetic ketoacidosis. The MDS reflected R106 had a BIM (assessment tool) score of 12 which indicated her ability to make daily decisions was moderately impaired. During a telephone interview on 3/10/25 at 9:24 a.m., complainant H reported R106 was admitted to the facility on [DATE] for rehab after falling at home and breaking pelvis. The complainant H reported when the resident was at the hospital recovering from fall, the doctor changed R106's long-acting insulin to a short acting insulin with meals as needed. Complainant H reported R106 had been on 25 units long acting insulin prior to fall for diabetes with recent A1C(test that measures average blood sugar levels over past two to three months) of 7.8% (normal below 5.7%). Complainant H reported R106 had order for insulin from the hospital but was unsure if facility was giving R106 insulin. Complainant H reported on 2/14/2025 that R106 became very sick, including, nausea, vomiting and diarrhea and unable to keep anything down for three days and blood sugar was elevated. Complainant H reported Physician had discussed possibly related to Ozempic and Complainant H reported R106 had been on Ozempic for over three years. Complainant H reported requested R106 to be taken to the hospital because she was continuing to decline on 2/17/25. Complainant states the resident was taken to the hospital and R106's blood sugar level was over 650 and was told R106 was in diabetic ketoacidosis and later passed away 2/19/2025 after several life saving efforts. Complainant H reported the R106's medication list that the hospital doctors pulled from the facility didn't have insulin listed as a prescribed medication and facility Physician was aware R106 had been on long-acting insulin prior to admission. Review of R106 facility Progress Notes, dated 2/7/25 at 4:00 p.m., reflected, Res. is a [AGE] year old female, married. She is coming to the facility from [named] hospital after a fall at home. She has a dx[diagnosis] and hx[history] of non-displaced fx[fracture] L[left] acetabulum, fx L pubis, falls, DM2[diabetes mellitus type 2], GERD[gastroesophageal reflux disease], OA[osteoarthritis], HTN[hypertension], hyperlipidemia, Dementia, diverticulosis, osteoporosis, OA, depression. She is A&Ox3[alert and oriented x 3] to person, place, time. She is able to answer questions appropriately. She is able to make needs and wants known. She scored 12/15 on BIMS. She can be forgetful at times and may need reminders. Her mood appears stable, very social with writer and reminisced about daughter. She denied concerns with mood. She is on Lexapro. She declined psych services. No trauma indicated. Her speech is clear and understandable, can hear a normal conversation, no glasses present. She is a full code. She is here for short term rehab. Plan to return home with husband. Also has support of son and and granddaughter as needed. She was independent prior . Review of R106 Nurse Progress Note, dated 2/7/25 at 6:48 p.m., reflected, Resident admitted from [named] Hospital . Able to speak in full sentences .Wishes to be full code at this time. Denies any pain/ discomfort. Appears to be resting comfortably in bed with call light in reach. Family at bedside. Review of R106 Hospital discharge instructions, dated [DATE], reflected medication list that included, Continue Medications (10) These are your current medications to keep taking at home. The list included, Insulin Detemir(long acting insulin) U-100 100 units/ml pen, 10-15 units subcutaneous daily (hand written DC ok per provider next to order); metformin 1000 mg twice daily; Ozempic 0.5mg weekly. Continued review of hospital documents reflected R106 had received last dose of Insulin Detemir 10 units on 2/7/25 at 9:49 a.m. along with Lispro Insulin (fast acting insulin) per sliding scale of 3 units. Review of the Physician orders dated 2/7/25 through 2/15/25, reflected no orders for insulin for R106 with known insulin dependent diabetes mellitus. Continued review of R106 physician orders reflected, Accu-check two times a day related to TYPE 2 DIABETES MELLITUS WITH UNSPECIFIED COMPLICATIONS .Notify provider of blood sugar <70 or >400 Review of R106 Electronic Medical Record(EMR), dated 2/7/25 through 2/17/25, reflected R106 and 12 readings greater than 250 including 9 blood sugars over 300. Review of R106 Physician Note, dated 2/10/25 at 5:01 p.m., reflected, Chief Complaint / Nature of Presenting Problem: Fall with non-displaced left acetabular fracture with inferior left pubic rami fracture and left sacral ala fracture. History Of Present Illness: Available records reviewed. Patient was seen and examined 2/10/2025 .hospitalized at [named hospital] from 2/4/25 - 2/7/25. [named R106] is a 93 y.o w/f[year old white female], who fell backwards at home and landed on her buttocks. She had severe pain with movement and was taken to [named] Hospital where pelvic/hip x-ray revealed non-displaced left acetabular fracture with inferior left pubic rami fracture and left sacral ala fracture. Seen by ortho and recommended 4-6 weeks of non-weight bearing with PT/OT .Transferred to [named facility] for SAR[sub acute rehab] services. Seen with granddaughter and husband present with patient consent .Plan .Type 2 diabetes mellitus without complications: continue metformin, Ozempic, monitor bs, check hgba1c, appeared to be on insulin at home. Will monitor accu-checks and adjust meds///add Jardiance 10mg/d, hgba1c pending//accuchecks on high side . Review of R106 Nutritional Note, dated 2/11/25, reflected, BS reviewed, ranging from 131-374mg/dL . Diet: regular texture/thin liquids, consuming 50-100% of meals per FARs. Agreeable to DM diet modifications. NKFA[no known food allergies]. Food preferences honored/updated. Tolerating current PO[oral] diet, no issues c/s food or fluids- wears dentures, fit well. Able to feed self and make wants and needs known. Review of R106 Rehab Services Screening Form, dated 2/12/25, reflected, BIMS 5/15. Kitchen staff reported to SLP [speech-language-pathologist] that pt[patient] was having difficulty swallowing; pt denies difficulties but further ST [speech therapy] assessment warranted. Pt stated she was (I) with IADLs[independent activities of daily living] at baseline, so further cognitive communication assessment warranted. Review of the Food Acceptance Record, dated 2/7/25 through 2/17/25, reflected R106 had decrease in food intake starting 2/14/25 including two consecutive refused meals. Continued review of the document reflected continued poor intake including 0-25% intake for three consecutive meals on 2/16/25. Review of R106 Nutritional Note, dated 2/15/25 at 11:05 a.m., reflected, Diet downgraded to mechanical soft texture 2/12 per SLP recommendations. Record review reflected R106 blood sugars were between 313 and 468 on 2/15/25 through 2/17/25 with limited food intake. Review of the Electronic Medical Record(EMR), dated 2/7/25 through 2/17/25, reflected no evidence Physician was notified of change in R106 condition on 2/14/25 or 2/15/25. Continued review of R106 EMR reflected Provider was contacted on 2/16/25 at 8:00 p.m. related to elevated blood sugar of 468 with no mention of poor intake for past 3 days. Review of R106 Nurse Progress Note, dated 2/17/25 at 2:26 p.m., reflected, Resident family expressed increased concern with residents lack of appetite and decreased fluid intake. Would like resident to be Sent to [named hospital] for further evaluation. MD[medical doctor] notified and management aware. Review of R106 Hospital History and Physical, dated 2/17/25, reflected, Problem/Assessment Plan 1-10: Problem 1: Diabetic ketoacidosis Plan 1: Insulin drip, ICU[intensive care unit] consult, secondary to discontinuation of medications and commendation of stress of illness. Problem 2: AKI (acute kidney injury) Plan 2: Secondary to intravascular depletion, IV hydration, dose meds Problem 3: Diarrhea Plan 3: Secondary to recent viral infection . Problem 4: Pelvic fracture Plan 4: Continue to monitor supportive care . CHIEF COMPLAINT .Nausea vomiting diarrhea .History of Present Illness .Is a [AGE] year-old female with history of diabetes type 2 who recently sustained a pelvic fracture 2 weeks ago. the patient was sent to subacute rehab. The patient presented with 3 days nausea vomiting diarrhea .The patient while hospitalized had her long-acting insulin discontinued and she was placed on short acting insulin. This was discontinued in the facility per family report. The patient was found to be in DKA[Diabetic Ketoacidosis]. She was started on a heparin drip. She was hospitalized in the ICU . Review of R106 Hospital Endocrinology Consult, dated 2/18/25, reflected, Problem 1: Diabetic ketoacidosis Plan 1: With a CO2 of 17 high anion gap high lactic acid high troponin and creatinine of 2 patient now going to tachycardia and possible cardiogenic shock .She states after her discharge from the hospital, patinet's insulin regimen was changed. Patients family states she was on Tresiba but it go discontinued at discharge. They state at the facility patient had been receiving metformin and Ozempic. They state about 3 days ago patient started having episodes of diarrhea .She states after 34 hours patient continued to have abdominal pain. They state that diarrhea hot less but patient started having episodes of nausea/vomiting. They also endorse patient was having increased thirst and urination. Family states since patient was not improving it prompted them to bring her to the ED[emergency department] .Upon arrival to ED .glucose 547 .Hemoglobin A1c 8.5 . Review of R106 Discharge Summary Physician, dated 2/19/25, reflected, Discharge .Time of death: 19-Feb-2025 02:55[2:55 a.m.]. Preliminary cause of death Asystole . During a telephone interview on 3/12/25 at 10:35 a.m. Licensed Practical Nurse (LPN) I reported was R106 nurse on 2/16/25 evening shift. LPN I reported completed Change of Condition document for R106 related to high blood sugar of 468 around 8:00 p.m. LPN I reported R106 did not have orders for insulin at that time. LPN I reported R106 had also been complaining of nausea and vomiting on 2/16/25 and reported was unsure if she reported to provider but should be documented on Change of Condition document.(Verified not mentioned). LPN I reported received order from provider to repeat R106 blood sugar check and administer 10 units Humalog (fast acting insulin) on 2/16/25 around 9:00 p.m. LPN I reported to day shift nurse on 2/17/25 around 7:00 a.m. During an interview on 3/13/25 at 11:32 a.m. Clinical Care Coordinator (CCC) C reported facility process for new admissions included three step check. CCC C reported CCC often assist with new admissions and enter medications from hospital discharge documents into EMR queue and before saving call placed to Medical Director to verify orders. CCC C reported if he makes changes staff hand write DC and initial next to medication on hospital discharge document. CCC C reported verify medications with two nurses then reported corporate Nurse Practitioner reviews for third check and reported was unsure who that might be. CCC C reported Medical Director(MD) G was present at facility every Monday, Wednesday, and Friday. CCC C reported MD G routinely adjusted resident diabetic medications on admission including insulin and facility did not use sliding scales. CCC G reported would expect staff to complete Change of Condition form for blood sugar greater than 400 per physician parameters. CCC C reported according to R106 food acceptance on 2/14/25 staff should have completed a Change of Condition form that would include notifying provider and responsible party related to two consecutive meals less than 25% eaten. Request was made for evidence that MD had been notified. Did not receive evidence Provider had been notified of Change of condition between 2/14/25 and 2/15/25 prior to survey exit on 3/13/25. During a telephone interview on 3/13/25 at 1:30 p.m. Medical Director(MD) G reported was familiar with R106. MD G reported staff contact him for new admissions and verify medications orders. MD G reported when R106 admitted to facility he recalled R106 being on a range scale for long acting insulin that was not typical. MD G reported continued R106 oral diabetic medication metformin and weekly Ozempic orders to monitor blood sugar. MD G reported after R106 admission visit on 2/10/25 added additional oral medication Jardiance because of added benefits and stated, low blood sugar is far more emergent than high as it takes years to show damage. MD G reported family was unsure how insulin was used at home and often takes caution related to insulin dosing. MD G reported would expect staff to notify provider of blood sugar greater than 400 as well as change in appetite, change in food acceptance, nausea, vomiting, or diarrhea. MD G reported did recall Nurse Practitioner visit and would plan to follow up with this surveyor. During a telephone interview on 3/13/25 at 2:11 p.m., MD G verified R106 was seen by provider on 2/17/25 and several medication were adjusted including adding insulin same day R106 was transferred to the hospital. MD G reported recalled discussing possible reasons for nausea included Ozempic. MD G verified was not notified of R106 change in intake, nausea, vomiting or elevated blood sugars between 2/14/25 through 2/16/25 at 8:00 p.m. and would expect staff to notify provider.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation refers to intake MI00150353, MI00149992 Based on observation, interview, and record review, the facility failed to provide adequate supervision, conduct timely root cause analysis of fall incidents, implement appropriate interventions to prevent future falls and re-evaluate the effectiveness of interventions for 3 residents (R103, R104, and R105) out of 3 residents reviewed for falls, resulting in R105 falling and re-fracturing recently repaired hip and R103 fall with laceration requiring emergency room treatment and R104 fall with fracture and subdural hematoma and overall decline. Findings included: Resident #105(R105) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R105 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses that included aftercare of left bipolar hemiarthroplasty(surgical repair of left ball of hip) post fall at home, peripheral vascular disease, orthostatic hypotension(drop in blood pressure with change in position), need for assistance with person care, heart disease, hypertension (high blood pressure), and diabetes mellitus. The MDS reflected R105 had a BIM (assessment tool) score of 15 which indicated his ability to make daily decisions was cognitively intact, and he required partial to moderate assist with transfers. Continued review of the MDS reflected dated 11/12/24 through 12/3/24 reflected three unplanned discharges to acute care. An anonymous complaint received by the State Agency alleged the facility failed to prevent avoidable fall for R105 that resulted in re-fracture of the left femur on 12/3/24. Review of R105 Nursing Progress notes, dated 11/12/24, reflected, Resident arrived via stretcher from [named] Hospital. He is alert and oriented times 4 .Lt(left) hip surgical site with derma bond dressing . Pain present at surgical site with movement . Review of R105 Social Service Note, dated 11/13/2024 at 11:55 a.m., reflected, [named R105] was admitted here yesterday afternoon from [named] Hospital. Resident was admitted to hospital after fall at home. Resident has fx[fracture] of left femur. Resident is a [AGE] year WMM[year old white male]. Resident has been living fairly independent in own home with wife. He was independent with own ADL [activities of daily living] .Resident is planning on returning home after short term rehab . Review of R105 Nurse Progress Note, dated 11/19/2024 at 1:00 p.m., reflected, called and spoke with ortho office as resident has not returned since 10:45 appointment. Resident was sent to [named emergency department] from ortho office due to bleeding from left hip incision as well as poor mental status and lethargy . Review of the Nurse Progress Notes, dated 11/20/2024 at 5:02 p.m., reflected R105 returned from the hospital. Review of R105 Physician Progress Note, dated 11/21/2024, reflected, .Chief Complaint / Nature of Presenting Problem: Lethargy, confusion .Patient seen and examined with note entered. [named R105] was initially admitted to [named facility] on 11/12/24 after suffering a fall and suffering a displaced left femoral neck fracture. He was admitted to [named hospital] for such and underwent left bipolar hemiarthroplasty on 11/7/24 .On 11/19/24 he went for follow-up orthopedics appointment but became unresponsive at the appointment and was sent back to [named hospital]. Labs revealed initial blood sugar by accu check of 56 . pt did have bout of hypoglycemia in facility and likely d/t hypoglycemia . Review of R105 Nurse Progress Note, dated 11/24/25 at 10:23 p.m., reflected, LN[licensed nurse] was called into resident room, resident was sitting in chair, shivering. Upon assessment, BP[blood pressure] 112/89, pulse 89, temp 99.1, O279% on room air, BS[blood sugar] 459. Physician was contacted, started on 3L[liter] of O2[oxygen]. Resident to be sent to [named hospital] for further evaluation. Review of the Hospital History and Physical, dated 11/24/25, reflected, Chief Complaint: fever, altered mental status .Code Status Discussed with?: Spouse (patient is not of sound mind to make this decision currently, no advanced directive on chart) .[named R105] is a [AGE] year old male with history of diabetes, hypertension, abdominal aortic aneurysm, claudication, emphysema and chronic kidney disease. Patient is currently residing at [named facility] for rehabilitation. This is his third admission this month since fracturing his left hip approximately 3 weeks ago. Prior to that spouse and son report that he was independent and functional. EMS[emergency medical services] was contacted by SNF[skilled nursing facility] staff due to altered mental status .At moderate risk for fall .Active Problems .Acute metabolic encephalopathy .Exam .Neuro: General: oriented to person and confusion (reports he is at church when asked) . Review of R105 Hospital Progress Note, dated 11/25/24, reflected, Patient admitted for sepsis secondary to UTI[urinary tract infection], there was also concern of possible surgical site infection of the left hip. The patient was started on broad-spectrum antibiotics .Patient seen and examined at bedside. He is alert and oriented to self only .Patient is exhibiting some confusion . Review of R105 Hospital Rehabilitation Service Note, dated 11/15/24, reflected, Acute Care OT(Occupational Therapy) Assessment .Transfers Sit to stand: Contact Guard .Toilet Transfer: Contact Guard Comments:: PT CURRENTLY REQUIRES US OF FWW[4 wheel walker] AND 1 PERSON ASSIST FOR TRANSFERS AND MOBILITY. Cognition Orientation: Minimally impaired .Judgement: Minimally impaired .Short Term Memory: Moderately Impaired .Follows Commands: Minimally Impaired .Comments .BED ALARM ON FOR SAFETY .Assessment: .UPON OT EVALUATION, PT IS PHYSICALLY FUNCTIONING SLIGHTLY BELOW HIS BASELINE STATUS OF MOBILITY AND INDEPENDENCE. HE FATIGUES QUICKLY. HE CONTINUES TO REQUIRE USE OF FWW TO ENSURE BALANCE AND SAFETY DURING MOBILITY AND TRANSFERS. HE REQUIRES 1 PERSON ASSIST FOR ADL ROUTINE. HE WILL BENEFIT FROM RETURNING TO REHAB IN ORDER TO MAXIMIZE INDEPENDENCE AND FUNCTIONING PRIOR TO RETURNING HOME WITH HIS WIFE . Review of the Fall Incident/Accident report, dated 12/3/24 at 4:30 p.m., reflected R105 had an unwitnessed fall in bathroom after self-transfer with left thigh fracture. The document reflected, Immediate Action taken: Neuro assessment completed prior to transferring resident from floor to wheelchair. Resident's ROM in left leg decreased .Resident rated pain in left hip 4/10. Resident transferred from floor to wheelchair with 2PA[two person assist], NWB[non weight bearing] to LLE[left lower extremity] maintained during transfer. VS[vital signs] obtained, BP[blood pressure] slightly low without s/sx[signs and symptoms] of hypotension. Skin tears present on left elbow & left forearm. Both areas cleansed & treatment with Xeroform completed. All appropriate parties notified. Provider ordered a STAT[immediately] left hip X-ray to R/O fx[rule out fracture]. Resident educated regarding use of call light for safe transfers & ambulation. Continued review of the document reflected, Predisposing Situation Factors, including the following marked; call light not used, admitted within last 72 hours, Ambulating without assistance. The document reflected R105 wife was present in room at time of fall and no witness statements found. Continued review reflected R105 wife was notified at 4:30 p.m. and the Provider at 4:40 p.m. and the form was completed by CCC D.(Not R105's nurse at the time.) Review of Electronic Medical Record (EMR) Census, dated 12/3/24, reflected R105 re-admitted to the facility on [DATE] at 4:08 p.m.(Just prior to R105 unwitnessed fall with fracture on 12/3/24). Review of the Progress Notes, dated 12/3/24, reflected no mention of R105 fall. Review of R105 Nursing Progress Note, created 12/3/24 at 6:36 p.m., reflected, Resident arrived to facility via private transportation. Resident has had full skin assessment performed with no skin breakdown noted on bony prominences. Residents lungs cta[clear to auscultation],heart rate regular. No cough or sob[short of breath] noted. Residents' radial and pedal pulses present and palpable bilaterally. Resident has swelling noted to left lower extremity from hip to toes. Resident has left hip incision with large scab noted and swelling with no heat redness or drainage noted. Resident has been re-oriented to facility, resident able to use call light unassisted. Resident aware that he is not to get up unassisted. Resident wife here at bedside. (No mention of R105 fall that occurred about two hours prior to note created.) Review of R105 fall assessment, dated 11/20/24, reflected, Fall risk assessment completed upon admission. Resident is at high risk for fall secondary to hx[history] of falls .Additional fall risks include; medical hx, recent hospitalization, & medications .Staff to follow current POC [plan of care]. Review of R105 Fall Assessment, dated 12/3/24 at 4:30 p.m., reflected, Root Cause: Resident is at high risk for falls r/t to recent hospitalizations, medical history & medications. Resident has multiple cormorbidities that attribute to fall risk including; recent left hip replacement, active infections (UTI & bacteremia), fatigue & weakness, hx of falls, pain, intermittent claudication of B/L Les[bilateral lower extremities], & PVD[peripheral vascular disease]. Resident assisted to bathroom prior to fall. CENA[competency evaluated nursing assistant] instructed resident to pull call light when he was ready to exit bathroom (resident a&o x4 with a bims of 15). Resident did not comply with CENA instructions and attempted to self-transfer/ambulate. Resident stated he thought he could get out of the bathroom without help. Immediate Safety Intervention: Resident educated regarding use of call light for safe transfers & ambulation [Not effective intervention as was already attempted and failed resulting in fall]. IDT review day #1 12-4-24: IDT agrees with root cause and intervention. Care plan reviewed and updated. Will continue to monitor. X-Ray obtained post fall. Femur fracture noted. Resident sent out to hospital. Review of R105 Brief interview of Mental Status (BIMS), dated 12/3/24 at 6:57 a.m.(over eight hours prior to R105 return to the facility), reflected BIMS score of 15. Review of R105 Rehab Services Screening Form, dated 12/3/24 at 6:38 p.m., reflected, Per discussion with nurse, patient sustained a fall while he was in the bathroom and attempted to self-transfer shortly after he was admitted . Awaiting x ray to r/o[rule out] fracture. OTR[Occupational Therapist, Registered] spoke with family and educated about not bearing weight into lower extremities until x ray is completed and imaging report is received. Will hold therapy evaluation until clearance is provided on weight bearing status. Review of the eINTERACT Transfer Form, dated 12/3/24 at 8:30 p.m., reflected, R105's most recent admission was 12/3/24 at 4:08 p.m. with diagnosis that included, sepsis, urinary tract infection, fracture of unspecified part of neck of left femur. Review of R105 Nurse Progress Note, dated 12/3/24 at 8:30 p.m., reflected, Resident transferred to hospital after X-ray results came in. Dr. G ordered. Nurse notified resident's wife [named] and on call manager of send out. Resident a&ox3 and states pain is 8/10. Review of R105 Radiology Report, dated 12/3/24 at 7:32, reflected the left hip and pelvis indicated, Acute nondisplaced mid femoral fracture extending away from the distal tip of the femoral THA[total hip arthroplasty] stem. During an interview on 3/11/25 at 2:45 p.m., Interim Director of Nursing (IDON) B reported had soft file on R105's fall on 12/3/24 and facility had completed Past Non-Compliance related to falls with alleged compliance date 1/31/25 after recognizing several falls including falls with major injury. IDON B provided complete investigation for R105, R104 and R103 falls along with past noncompliance binder. Review of the facility Staffing Assignment Sheet, dated 12/3/24 2nd shift, reflected R105 nurse was Clinical Care Coordinator Registered Nurse (CCC) C and two Certified Nurse Aids(CNA) were assigned to R105 hall(CNA J and CNA E) with a facility census of 93. Review of R105 Fall investigation Interview Statement, dated 12/4/24, reflected CNA J completed witness statement. The document reflected, To whom it may concern on the day in question. [named CNA E] and I were told to go assist with getting [named R105] out of the car. He had just arrived at our facility. We brought him into the building and immediately took him to get weighted. On the way to his room, he stated he had to go to the restroom. [named CNA E] and I assisted him with gait belt from his wheelchair to the toilet. He stated he needed a few minutes so we educated him on pulling the red string on the call light so it would let us know he was finished. [named CNA E] and I left him on the toilet . Review of R105 fall investigation witness statement, undated and unsigned, reflected, Resident was placed on toilet by CNAs, CNAs gave resident call light and was told to call when ready, CNAs left resident for privacy, CNA asked if he was ready, but needed more time, CNA went to answer call light going off and upon returning resident was on the floor. Review of R105 Fall investigation Interview Statement, undated, signed by CCCRN C reflected R105 had fall on 12/3/25. The statement reflected, Resident re-admitted to the facility apx[approximately] 18:15 p.m.[6:15 p.m.]. Resident arrived via private transportation with wife present. Resident had initial skin assessment vital signs and education performed at apx 1820[6:20 p.m.] Resident was recently a resident in this same room and hallway, during education resident remembered the names of staff assisting him. He was aware of where he was, date, moth and also remembered room, bathroom and how to use call light. Resident was toileted per his request at apx 18:25[6:25 p.m], he was transferred to toilet with 2 CNAs . (Interview statement does not appear to reflect correct time according to all other documents and evidence). During a telephone interview on 3/12/25 at 1:57 p.m., Certified Nurse Assistant (CNA) K reported knows how to care for residents by reviewing Kardex and verified received recent fall training from facility at end of January. CNA K reported residents with high risk for falls should never be left alone in bathroom especially with history of post hip surgery related to fall. During an interview on 3/12/25 at 3:30 p.m., CNA J reported was working on 12/3/24 when R105 fell in bathroom. CNA J reported her, and CNA E were told to assist R105 from personal car, driven by wife, into the facility. CNA J reported obtained R105 weight and then R105 reported had to use restroom and the two CNAs assisted R105 from the wheelchair onto the toilet and instructed to use call light when done and left R105 in bathroom alone. CNA J reported had returned to check on R105 who was not ready and upon returning again had fallen in the bathroom after attempting to self-transfer. CNA J reported assisted R105 off the floor with two to three staff by picking up under R105 arms and transferring to the wheelchair then from wheelchair to bed with pivot transfer and at least two assist. CNA J reported nurse took over from there. CNA J reported completed witness statement after fall but not same day as R105 fall and received education from facility to not leave residents alone especially if high risk for fall. During a telephone interview 3/13/25 at 10:49 a.m., R105's Family Member F reported R105 was doing well enough at the hospital, and she transported him in a personal car from the hospital to the facility on [DATE]. FM F reported two staff met her at the car and they wheeled R105 in the facility. FM E reported R105 had to use the bathroom right away so two staff took R105 in his bathroom and before nurse staff could even complete body check. FM F reported stepped out of room for moment to make call and returned and asked roommate, is he still in there?' and roommate reported yes. FM F reported waited outside the door for maybe five minutes and figured staff were in the bathroom with him and then heard a big crash. FM F reported opened the door and R105 was on the floor with no staff present. FM F reported it concerned her R105 had been left alone because he was such a high fall risk they had not been back in facility for more than 15 minutes. FM F reported went and found the nurse and reported R105 was on the floor, who responded, can he get up? FM F reported they got him in bed did body check, they didn't see anything significant but R105 was complaining of pain to left hip area. FM F reported they ordered X-ray right away, but it was a few hours before they got there and it was around 8:00 p.m., when they received call R105 left leg was broken and facility planned to send R105 to local hospital. FM F reported local hospital transferred R105 to a trauma center who performed eight-hour surgery to repair R105 re-fractured, shattered left leg. FM F reported R105 was currently on hospice and stated, it shouldn't have happened .To leave him unassisted and I don't know the circumstances, I know they were busy and understaffed, that's not a reason to leave him unattended. FM F reported R105's second fall with fracture on 12/3/24 extended the first one and shattered left leg and hardware had to be removed and replaced and continued to decline. FM F reported staff did not mention using call light after the fall and was chaotic scene. FM F reported the roommate thought the staff was in bathroom with R105 but staff must have exited shared room door because the roommate said they never saw the staff leave the bathroom. FM F was queried of R105 would have used call light when done? FM F stated, I would not have trusted him to do that even if he was well enough. During a telephone interview on 3/13/25 at 12:35 p.m., CNA E reported was working on 12/3/24 when R105 had a unwitnessed fall in the bathroom. CNA E reported CCCRN C requested CNA E and CNA J assist transfer R105 from personal car to room. CNA E reported transported R105 in wheelchair from parking lot with CNA J to room and R105 requested to use the bathroom, and both CNAs assisted R105 from wheelchair to toilet. CNA E reported was not told R105 could not be left alone and both CNAs left R105 on toilet alone and left to answer call lights on the hall. CNA E reported returned in about five minutes and R105 was on the bathroom floor, called for Registered Nurse (RN) L, FIT team paged overhead (fall team). CNA E reported Occupational Therapy Staff (OT) M was present and R105 was transferred from floor to wheelchair but unable to recall how and reported R105 was then transferred from wheelchair to bed with two-person pivot assist with OT M. CNA E reported resident acuity was high that day for only two CNA staff on hall. CNA E verified he wrote witness statement several days after R105 fall that was not dated or signed. CNA E reported was not aware R105 was high fall risk or even know transfer status when told to assist R105 from personal car on 12/3/24, prior to readmission. During an interview on 3/13/25 at 1:13 p.m., OT M reported was called down to 100 hall on 12/3/24 after R105 had fallen in bathroom by CNA E. OT M reported R105 was sitting on bathroom floor with definite signs of pain including facial grimacing. OT M reported was familiar with R105 because worked with R105 after original admission post hip repair within prior month. OT M reported RN L was present after fall and R105 was transferred from the floor to the wheelchair with 2-person assist with gait belt. OT M reported did not complete witness statement because she did not witness fall. OT M reported staff are expected to follow hospital transfer status until therapy evaluation completed at facility. During an interview on 3/13/25 at 1:50 p.m., CCC C reported was R105 nurse on 12/3/24 at the time of R105's unwitnessed fall in the bathroom that resulted in re-fracture of left hip and later transfer to hospital. CCC C reported completed R105 admission assessment shortly after arrival and then R105 requested to use the bathroom and was transferred by two CNA staff. When asked if the resident had fallen before or after admission assessment CCC C reported I am sure R105 had fallen after but do not recall and stated, what does my documentation say? CCC C was unable to say why witness statement did not match EMR documents related to R105 fall. Resident #103 (R103) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R103 was an [AGE] year old female admitted to the facility on [DATE], and most recently re-admission post fall with facial hematoma and contusion with other diagnoses that included dementia, heart disease, atrial fibrillation with use of blood thinners, hypertension (high blood pressure), depression and anxiety. The MDS reflected R103 had a BIM (assessment tool) score of 11 which indicated her ability to make daily decisions was moderately impaired. During a telephone interview on 3/10/25 at 11:29 p.m. R103 Family Member (FM) N reported R103 had an unwitnessed fall on 1/23/25 with facial injuries that required transfer to hospital. FM N reported facility was not able to answer how R103 fall occurred or how long R103 was on the floor before staff found R103. FM N reported R103 had significant facial bruising over entire face with open area to area above left eye several days after alleged fall. During an observation on 3/10/25 at 1:47 p.m., R103 was observed sitting in Main Dining Room during group activity with nickel size scabbed area located above left eyebrow. Review of R103 Nurse Progress Note, dated 1/23/2025 at 11:11 p.m., reflected, LN[licensed nurse] was alerted resident was on the floor of residents room. resident was laying on her stomach next to bed. resident stated she slipped out of her chair. Helped resident back into her chair. contacted on call doctor on call manager and residents daughter. [NAME] checks were started at 1920[7:20 p.m.]. resident sent to hospital for CT[computed tomography] scan as resident is on a blood thinner. Review of R103 Nurse Progress Note, dated 1/24/2025 at 6:07 a.m., reflected, resident returned from the hospital via ambulance after a fall. assessment completed. all bony prominences checked and intact. Review of R103 Fall Incident/Accident Report, dated 1/23/25 at 8:42 p.m., reflected R103 had an unwitnessed fall in room and was found lying on stomach next to the bed with abrasion noted on face. The report reflected, Resident states that she slipped off her chair . The report reflected R103 had impaired memory and no witness statements were found and Physician was contacted at 7:30 p.m.(Report had discrepancy in times, no mention of interventions that were in place on not in place including footwear, dysem or grip strips on floor). Review of R103 Hospital Radiology Report, dated 1/23/25, reflected CT scan of the brain revealed, LEFT frontal scalp soft tissue contusion and/or organized hematoma . Review of R103 Physical Therapy Assessment, dated 1/24/25, reflected, Reason for Referral/Current Illness: Patient is a [AGE] year old female with history of dementia who is a LTC[long term care] resident of the facility. She has a history of falls and has had 5 falls in the last year. She has been referred to skilled PT services following patient having a recent fall on 1/23. She sustained a bump with bruising to her forehead. She was transferred to the hospital for further evaluation and then returned to this facility. Per nursing notes, patient reported she slipped out of her w.c[wheelchair]. Patient told PT this date that she was walking without AD[assistive device] and only had socks on and slipped on the floor. Educated patient on having assistance, wearing shoes/grippy socks and using walker for safety . Review of R103 Physician Progress Note, dated 1/29/25, reflected, [named R103] had a fall the other day and was sent to ED[emergency department] as she has been on eliquis for hx of paroxysmal atrial fib . quarter size hematoma on left frontal area/diffuse echymosis both cheeks, infraorbital with subconjunctival hemorrhages bilateral . s/p fall with facial bruising d/t eliquis/ASA[aspirin] hx[history] paroxysmal atrial fib, currently in NSR[normal sinus rhythm] by exam//feel risk of continuing eliquis at this time outweighs the benefit and will stop and continue to assess as needed . Review of R103 Fall Care Plan, dated 10/28/2019, reflected, FALLS: At risk for falls due to Dementia, weakness, medications, Major Neuro cognitive Disorder, insomnia, bowel and bladder urgency .Interventions .I have gripper strips in front of my bed to prevent slipping .I will wear non-slip footwear for all transfers and walking . Review of R103 Fall Risk assessment, dated 11/23/25, reflected, The resident continues to be at risk for falls due to poor cognition and poor safety awareness. She continues at risk for further falls. Resident stood up unassisted and fell back when she missed her chair. Intervention: Upon standing, remind me to reach back for wheel chair before sitting . During an interview on 3/12/25 at 3:15 p.m., Certified Nurse Aid (CNA) O reported had found R103 on 1/23/25 in room on the floor after fall. CNA O reported was unsure if R103 had grip socks or shoes on or if wheelchair breaks were on or if gripper strips were in place on the floor by bed. CNA O reported did not complete witness statement because she did not witness fall. CNA O reported was unsure how long resident had been no floor prior to finding and reported facility had recently provided fall training at end of January. CNA O reported training included more frequent supervision of all residents especially residents with increased risk for falls to be able to encourage assistance and make sure interventions were in place. During an observation and interview on 3/13/25 at 9:30 a.m., R103 was sitting in Main Dining Room in wheelchair watching television with regular socks with no grip on them. R103 had nickel size abrasion noted to area above left eyebrow and was very hard of hearing. R103 reported fell out of bed and laid on floor until staff arrived and then was sent to hospital for several hours. R103 reported she is careful now and was told she had to wear shoes. Resident #104 (R104) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R104 was an [AGE] year-old male admitted to the facility on [DATE], and most recently re-admission post fall at facility with left displaced hip fracture requiring surgical repair, compression fracture T-12(spinal fracture, and traumatic subdural hematoma. R104 had other diagnoses that included dementia, hypertension (high blood pressure), depression and anxiety. The MDS reflected R104 had a BIM (assessment tool) score of 3 which indicated his ability to make daily decisions was significantly impaired. The MDS reflected R104 did not have behaviors including wandering or rejection of care. An anonymous complaint received by the State Agency alleged the facility failed to prevent fall for R104 that resulted in hip fracture and passed away. Review of R104 Nursing Note, dated 2/4/25 at 1:52 p.m., reflected, Resident agitated. Hitting staff. Staff is unable to redirect resident. Resident throwing LN[licensed nurse] equipment off of medication cart. LN was eventually able to get resident to sit in his recliner in his room LN sat with him for a few minutes. Resident then got back out of his chair and starting yelling again. Review of R104 Social Service Note, dated, 1/5/2025 at 9:11 a.m., reflected, IDT[interdisciplinary team] reviewed alert for res.[resident] agitated, hitting staff, yelling out, throwing things. Staff reapproach, assist to calmer environment. Did yell out again. The review reflected no mention of staffing or adjustments. Review of R104 Unusual Occurrence Note, dated 1/6/2025 at 3:46 p.m., reflected, LN was alerted by a family member (visitor) that resident was laying on the floor at the end of the hallway. When LN arrived at residents side he was laying on his left side, head up against the wall feet outstretched into the hallway, by room [ROOM NUMBER] at the end of 500 long hall. Resident was noted picking up his hat when he fell over. Resident did not ask for assistance with his hat. Resident is noted wearing hipsters and non-slip footwear. Resident was noted ambulating in the hallway 15 minutes prior and offered a chair to rest. LN asked resident what he was attempting to do when he fell over? resident stated, just give me my damn hat LN did a full head to toe assessment on resident has full range of motion of both upper extremities without pain or difficulty. Resident has full range of motion in right hip. LN noted external rotation of left hip upon assessment. C/O[complained of] pain with minimal movement. no other injuries noted. Staff members were unable to assistance resident off the floor with a gait belt, resident was assisted off the floor by a hoyer lift with a sling and assisted to his bed. A staff member sat with resident until EMTS[emergency medical technicians] arrived . Review of R104 Social Service Note, dated 1/12/25 at 10:10 a.m., reflected, [Named R104] was readmitted yesterday evening from Hospital. Resident was readmitted with Dx of HX[history] of interchanteric FX[fracture] of left femur. Unspecified part neck Left Femur. Traumatic subdural hemorrhage without loss of consciousness. Occlusion and stenosis of unspecified cardio artery. Falls. CKD[chronic kidney disease] stage 3. Gastro reflux. Anxiety disorder. Insomnia, Alzheimer's disease. Vascular dementia. Hyperlipidemia. HTN[hypertention]. Major depression. Resident remains alert and oriented to person or name. No significant change in cognition. Staff anticipate and assist with support care and redirection . Review of R104 Hospital Discharge summary, dated [DATE], reflected, .Hospital Course-80 y M[year male] with history of .dementia as a transfer from [named] after being found down at his facility. Patient sustained Parietal subdural hematoma, Left displaced comminuted intertrochanteric femur fracture and acute compression fracture of T12. Patient underwent Left intertrochanteric InterNail repair on 1/7/25. The parietal SDH[subdural hematoma] and T12 compression fracture was managed non-op[non-operative]. Hospital course was significant for agitation that was managed with Zyprexa. Otherwise, patient progressed will during hospital course. Patient is weight-bear as tolerated to the left lower extremity with a walker and is to be on TLSO[thoracolumbar sacral othosis] brace when out of bed . Review of[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review facility failed to: 1) accurately assess, monitor, treat and prevent the development of pressure ulcers consistent with professional standards of practice to prevent avoidable pressure ulcers; and 2) implement care-planned and non-care-planned interventions for three Residents (R103, R107 and R109) of four reviewed for pressure ulcers, resulting in R109 facility acquired stage 2 pressure ulcer, and the increased likelihood for delayed wound healing and or worsening of wounds and overall deterioration in health status, and worsening of pressure ulcer wounds with sepsis. Findings include: Resident #103(R103) Review of the Face Sheet and Minimum Data Set (MDS) with ARD date 11/26/23, reflected R103 was a [AGE] year old female admitted to the facility on [DATE] related to cerebral infarct with dysphasia, diabetes mellitus, dementia, metabolic encephalopathy, hypertension (high blood pressure), renal failure, The MDS reflected R103 had a BIM (assessment tool) of 13 which reflected R103 was cognitively intact. The MDS assessment reflected R103 had no behaviors including no rejection of care. According to the National Pressure Ulcer/Injury Advisory Panel (NPUAP); Unstageable Pressure Ulcer/Injury is full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar (necrotic dead tissue). If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Pressure Injury: A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, comorbidities and condition of the soft tissue. Stage 1 Pressure Injury: Non-blanchable erythema of intact skin Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bonemuscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Review of the facility, Wound Management Program, revised 8/17/2017, reflected, Policy: To assure that residents who are admitted with, or acquire, wounds receive treatment and services to promote healing, prevent complications and prevent new skin conditions from developing .forms or documentation applicable to this policy .care plan/[NAME], weekly hydration and skin assessment .point of care(POC) .Unless otherwise specified, the Charge Nurse is responsible for the following .Monitor skin changes during routine daily care(CNA) .Report concerns/observations to the Charge Nurse(Nurse) via POC alert .Report any abnormal findings to the physician and Certified Dietary Manager(CDM) or Registered Dietician(RD) via Alert in PCC .Initiate treatment according to physician guidance .Assess protein and calorie needs, hydration status and overall nutritional status admission and as needed .Initiate interdisciplinary plan of care .Monitor any acute illness or change in condition .Process (Management of Pressure Ulcers/Non Pressure Wounds) .Complete the following steps if pressure ulcer identified: 1.1.Refer to the [named facility corporation] health System Managed Community Wound Protocol and Support Surface Product Formulary for treatment and intervention options .Complete the following daily (Charge Nurse): 3.1.Verify that resident-specific Care Plan interventions are in place (pressure relieving devices, turning schedules, etc.). 3.2. Inspect dressing to assure it is intact. 3.3. Inspect skin surrounding pressure ulcer. 3.4.Inspect any pressure ulcer that does not require a dressing . Review of the facility Matrix(802), dated 5/1/24, reflected no residents with pressure ulcers not present on admission. During a telephone interview on 5/1/24 at 12:22 p.m. Complainant G reported R103 admitted to the facility 11/20/23 after short hospital stay related to stroke for rehabilitaiton. Complainant G reported R103 had poor oral intake, was sedated, and small wound to coccyx area that significantly worsened including odor and increase in size and fever. Complainant G reported R103 was transferred to the hospital on [DATE] and admitted and treated for septic shock and later died related to complications related to coccyx wound. Review of the Hospital Records, dated 11/17/23 through 11/20/23, reflected Occupational Therapy Assessment that included, Bed Mobility: sit to supine: Moderate Assistance of 2, Supine to Sit: moderate assistance of 2 .upon OT evaluation, pt is physically and cognitively functioning significantly below her baseline status of independence. She is currently alert to self. She is requires max pa x 1 for all aspects of badl routine and mobility at this time . Review of the Hospital Lab Results, dated 11/19/23, reflected R103 GFR result was 42. (GFR is indicator for chronic kidney disease. GFR healthy adult 90 or greater. Stage 3b = moderate to severe loss of kidney function 30-44, Stage 4=severe loss of kidney function 15-29. The Labs reflected R103 BUN was elevated at 27(indicator of kidney function but also may be elevated if dehydrated). Review of the Lab Results, dated 11/22/23, reflected R103 GFR was 38 (worsened) and BUN was 33 (worsened). Review of the Skin Care Plan, dated 11/20/23, reflected R103 had interventions that included, Please help me turn and reposition while in bed or in my wheelchair as needed .Bed mobility with 1 assist as needed . Review of the Physician Orders, dated 11/20/23, reflected, Cleanse coccyx with soap & water, pat dry, apply zinc oxide twice daily for skin protection for 30 Days -Start Date-11/21/2023 0700-D/C Date- 11/22/2023. Review of the Physician Orders, dated 11/23/23, reflected, Cleanse coccyx with wound cleanser, pat dry, an Aquacel foam dressing. every day shift every 3 day(s) for pressure injury wound care -Start Date-11/23/2023 During an interview on 5/2/24 at 10:05 a.m., Wound Nurse(WN) RN I reported had been facility wound nurse for one year and reported had not completed certified wound training. WN I reported completed weekly wound rounds including pictures and documented in Electronic Medical Record(EMR) Skin and Wound Evaluations and Progress Notes. WN I reported new admission residents are assessed next business day then every seven days. WN I verified R103 admitted on Monday 11/20/23 with pressure ulcer documented on admission assessment with no description including measurement. WN I reported admitting nurses inform her or Clinical Care Coordinator (CCC)RN C of wounds and seen by next business day. WN I verified R103 was assessed by RN C on 11/22/23 and reported she (WN I) had been on vacation at that time and was unsure why delay in treatment. WN I reported facility had standing physician orders for wound care treatments and physicians not contacted unless need for change in treatment or new or worsening wounds noted. WN I reported R103's coccyx wound was documented on 11/22/23 as deep tissue injury pressure ulcer, present on admission, staged by in-house nursing that measured 3.9cm by 2.2 cm by 0.2cm depth with 100% of wound covered with epithelial and surface intact, serous drainage(however documented as intact skin) and no odor. WN I reported R103 intervention included roho cushion for wheelchair, low air loss mattress, daily multivitamin, repositioning devices, aquacel foam dressing every three days and an needed. Review of R103, Skin & Wound Evaluation V7.0, dated 11/22/23 and edited 11/30/23, reflected R103 had deep tissue injury pressure wound to coccyx present on admission. The document reflected notes, Resident admitted with pressure injury. Segments of wound are maroon in color & persistently non-blanchable. Treatment order in place: Cleanse coccyx with wound cleanser, pat dry, an Aquacel foam dressing q3 days & prn soiled or dislodged dressing. Roho cushion placed on wheelchair. Low air loss mattress ordered. Multivitamin ordered daily to promote wound healing .Resident educated regarding;*Weekly wound rounding program*Importance of frequent repositioning while in bed, wheelchair, and chair to promote wound healing and hinder any further tissue damage. *Use of APM mattress, roho cushion, and daily multivitamin to promote wound healing. *Treatment order in place . Review of the attached picture dated 11/22/23 reflected evidence of deep tissue injury with open area. Review of R103, Skin & Wound Evaluation V7.0, dated 11/30/23, reflected R103 had deep tissue injury pressure wound to coccyx that measured 2.7cm by 1.8cm by 0.1cm depth. The document reflected 70% epithelial and 30% granulation with notes that reflected, PUSH score indicates wound progress is stable. Segments of wound remain maroon in color & persistently non-blanchable. Tx order in place: Cleanse coccyx with wound cleanser, pat dry, an Aquacel foam dressing q3 days & prn soiled or dislodged dressing. Document did not reflect physician notified. Review of the attached picture, dated 11/30/24, reflected large open area with non viable skin, continued deep tissue injury, discolored peri area with overall worsening in wound. Review of R103 EMR, dated 11/20/23 through 12/4/23, reflected R103 admission weight was 132 pounds on 11/20/23 and 127 pounds on 12/4/23(5 pound weight loss in 14 days). Review of the food acceptance reflected food acceptance that included R103 had eight entries of 0-25% eaten and 16 entries of 25-50% eaten documented in 14 days prior to transfer to hospital. Review of R103 vitals with slowly elevated blood pressure and heart rate over 14 days. Review of the EMR reflected no mention of urine output or fluid input. Continued review of EMR reflected R103 was transferred to the hospital on [DATE] related to altered mental status, abnormal vitals, fever, increased assistance with ADLS, decline in mobility and eating, tachycardia. Review of the facility POC Task charting(Certified Nurse Aid documentation), dated 11/20/23 through 12/4/23, reflected no evidence of frequent repositioning, repositioning devices, hydration, toileting or skin observations. During an interview on 5/2/24 at 11:30 a.m. Director of Nursing (DON) B was asked how CNA staff know what resident needs are DON B reported they follow the care plan and [NAME] and reported turning and reposition residents was a standard of care every two hours and just know to do and they do not document task as completed. When asked why, DON B repeated because standard of care. DON B reported does not no a lot about wound care but has a wound team at facility that included wound care nurse WN I who he trusts with wounds. During an interview on 5/2/24 at 1:36 p.m., CNA J reported know how to care for residents by following [NAME]. CNA J reported assist with Activities of Daily Living(ADL) including repositioning or input or output as needed but unable to document ADL tasks performed. CNA J reported if resident did not have output for shift or change in condition would verbally report to nurse. During an interview on 5/2/24 at 1:40 p.m., CNA K reported CNA charting changed about one year ago and no longer document several ADL tasks as completed because they are standard of care. CNA K reported if CNA staff notice change in resident verbally report to nurse but not able to document in EMR. During an interview on 5/2/24 at 2:15 p.m., CNA L reported know how to care for residents by reviewing [NAME]. CNA L reported about one year ago documentation changes with no need to document ADL tasks as completed including turn and reposition, toileting/check and change, input/output, grooming, and oral care. CNA L reported if cna staff notice change for resident verbally report to nurse or can enter new alert in charting for including change in wound, new skin breakdown, or change in input or output. During an interview on 5/2/24 at 2:47 p.m., CNA M reported had worked at the facility for more than a year and had changed resident dressings occasionally after nurse provided dressing supplies and asked CNA M to change dressings. CNA M reported had not been asked to perform dressing changed in several weeks and reported aware nurse tasks and reported would help when asked. During an interview on 5/2/24 at 2:57 p.m., CNA N reported occasional changed resident dressings if asked to complete by nurse and reported knows was not ok because he does not have skills to assess or recognize change in wound. During an interview on 5/2/24 at 3:18 p.m., CNA O reported had worked at the facility for about one year reported knows what resident needs are by reviewing the care plan and speaking to residents and staff. CNA O reported only able to document limited ADL tasks in EMR including amount eaten, showers, ambulation if ordered and weights. CNA O reported not able to document change in input or output or change in skin and can verbally report to nurse. CNA O reported was not aware of alert charting until recently. During a telephone interview on 5/2/24 at 4:50 p.m., Confidential Staff(CS) P reported had worked at facility for several years. CS P reported had changed resident dressings several times, at least one to two times weekly as asked by the nurse staff. CS P reported was not part of job duties because not trained as nurse to assess for changes in wounds including infections and reported management staff was aware. CS P reported about one year about POC charting changed and now only document limited ADL tasks and if change for resident verbally report to nurse and or can complete new alert. CS P reported R109 has had open wound on right hip for several weeks that has worsened with R109 showing signs of increased pain and nurses have been informed. CS P reported observed dressing had been changed from foam dressing to bandaid after after worsening of wound bed from pencil tip size to nickel size open area currently on right hip. Review of the Hospital Records, dated 12/4/23 at 5:15 p.m., reflected Emergency Department Note that reflected R103 vitals were Temperature 103, heart rate 95, respirations 27, blood pressure 86/41(abnormal). Continued review of the records reflected, Skin: There is a stage II decubitus ulcer with surrounding erythema, warmth and foul odor. Continued review of the records reflected wound assessment completed on 12/4/23 that included measurements 3.2cm by 2.5cm pressure injury with yellow/gray/eschar with skin note,bright red ring of skin around open area then darker red/purple skin-nonblanchable measuring 8x7 . Review of the History and Physical(H&P), dated 12/4/23, reflected reason for visit was septic shock. The H&P reflected, Septic Shock .Patient was positive SIRS criteria with temperature of 103, heart rate of 95 white blood count of 21.5 initial lactic acid 3.2. blood pressure is 82/41 despite receiving 30cc/kg of normal saline .fluid bolus .Was likely source of infection is UTI and sacral decubitus ulcer with surrounding cellulitis in the presence of urinary and fecal incontinence Review of the Hospital wound consult, dated 12/6/23, reflected,Pt has 3cm x 3cm sacral pressure ulceration present. Wound bed is covered with a thin layer of slough/escar making staging difficult, however she has [NAME] little fatty tissue under this ulcer, thus this is most likely a stage 4 . Review of the Discharge summary, dated [DATE], reflected R103 had admitting diagnosis of generalized weakness, decubitus ulcer of sacral region(unstageable), urinary tract infection, encephalopathy, cellulitis, chronic kidney disease 3b. The summary included, Moderate parenchymal atrophy. Patient was given IV fluids and broad-spectrum antibiotics in ED. Initially during her stay the patient had hypotension requiring Levophed which was discontinued following fluid resuscitation. Patient completed 7 days of antibiotics for her cellulitis which appears to have improved. Patient underwent chemical debridement and wound care of her chronic sacral pressure ulcer . Review of the Hospital Discharge summary, dated [DATE], reflected R103 was admitted to the hospital on [DATE]. The record reflected, Patient admitted with large sacral decubitus ulcer with osteomyelitis status post debridement on 12/26/23, with wound cultures growing Proteus, staph and Vanco resistant Enterococcus with Candida .) Review of the Death Certificate, dated 3/1/24, reflected R103's cause of death was sepsis, osteomyelitis, and protein calorie malnutrition. During a telephone interview on 5/3/24 at 3:00 p.m. Medical Director (MD) Q reported would expect staff to notify physician of change in wound or new wounds. MD Q reported was not aware of R103 coccyx wound and verified review of physician visit with no mention of pressure wound and reported wound have mentioned if made aware by staff. Resident #107(R107) Review of the Face Sheet and Minimum Data Set (MDS) with ARD date 4/15/24, reflected R107 was a [AGE] year old male admitted to the facility on [DATE] related to pneumonia, diabetes mellitus, heart disease, hip replacement, hypertension (high blood pressure), The MDS reflected R103 had a BIM (assessment tool) of 14 which reflected R107 was cognitively intact. The MDS assessment reflected R103 had no behaviors including no rejection of care. During an observation and interview on 5/1/24 at 330 pm. R107 was lying in bed and reported had open area on bottom with very painful to sit on. R107 appeared to be able to answer questions without difficulty. During an interview and record review on 5/2/23 at 10:05 am WN I reported R107 was re-admitted to facility on 4/9/24 had was seen by RN C for wound assessment and determined to be moisture associated dermatitis related to irregular borders on both sides of buttock cheeks. WN I reported she stages wounds and follows standing orders for treatments until communication with provider. RN I verified R107 had picture taken of wound on 4/10/23 that was described with escar present.(no eschar present on moisture associated wounds). WN I reported difficult to change staging after initial identification. Resident #109(R109) Review of the Face Sheet and Minimum Data Set (MDS) with ARD date 2/15/24 , reflected R109 was a [AGE] year old male admitted to the facility on [DATE] related to bipolar disorder, seizure disorder, hypertension (high blood pressure). The MDS reflected R103 had a BIM (assessment tool) which reflected R107 was severely impaired. During an observation on 5/3/24 at 8:30 a.m. R109 was laying in bed directly on right hip. During an interview on 5/3/24 at 835 am, RN R reported R109 had a facility acquired pressure ulcer on the right hip with treatments in place. Review of the EMR dated 4/1/24 to current reflected no mention of pressure ulcer including weekly skin notes or MDS records. Continued review of R109 EMR reflected nurse progress notes that included,4/3/2024 09:08 Nurses Note DOCUMENT RELEVANT INFORMATION ABOUT THE RESIDENT:: Right hip area assessed. Skin is light red in color & blanchable. Area of excoriation has increased, measuring approximately 0.4cm x 0.5cm. Skin is dry & flaky. No s/sx of pain noted. New treatment order placed: Cleanse R hip with wound cleanser, pat dry.Apply wound gel and cover with Aquacel foam dressing BID. During an interview on 5/3/24 at 10:14 am, DON B escorted CNA N to this surveyor, DON B reported CNA N wanted to clarify statement made yesterday. CNA N reported he meant he assisted nurse with dressing changes. DON remained present during interview. During an interview on 5/3/24 at 1115am RN T reported R109 would not allow dressing change at this time and might after lunch. During an observation on 5/3/24 at 12:20 p.m., CNA U entered R109 room with full Personal Protective Gear(PPE) related to current contact isolation with MRSA, in attempt to get R109 out of bed. Observed dressing in place on right hip dated 5/2/24. CNA U reported plan to get nurse for dressing change prior to getting R109 out of bed. This surveyor remained in room. R109 continued to lay directly on right hip with facial grimacing observe with position changes with staff assistance. At 12:40 p.m. RN C and WN I entered room to performed wound care. Foam border dressing was removed from R109 right hip with dime size open area that appeared to be stage 2 pressure ulcer with possible fatty tissue observed. Peri wound was bright red non-blanchable about baseball size. RN C changed dressing and cleaned area with wound cleanser, used lounge depressor to apply get directly to open area on R109 right hip and covered with aquacel foam dressing. During an interview on 5/3/24 at 1:09 p.m. WN I and RN C entered conference room. When asked what type of wound R109 had on right hip RN C responded stage 2 pressure ulcer that was identified today. WN I reported observed R109 skin on 4/3/24 and completed progress note. When asked WN I what type of would it was at that time RN C could not stay and stated, what the note said it was. WN I verified was area of excoriation and explained as red, raised streaks but not open. WN I reported saw R109 right hip skin on 1/11/24 and changed treatment to zinc oxide and reported no discussion with physician. WN I reported saw R109 on 2/13/24 and continued worsening of excoriation to right hip and treatment changed to wound gel and and cover with dressing twice daily. WN I reported area improved and saw again on 3/12/24 and changed treatment to A & D ointment. WN I reported right hip skin area worsened and seen on 4/3/24 (not above). RN C reported today R109 hip was open stage 2 with blanchable peri wound. When asked if RN C would explain, blanchable, RN C could not say what blanchable was and stated, Do you want me to Google blanchable? This surveyor ask for RN C professional judgement. RN C reported when pressure applied to red area turns white. RN C and WN I verified R109 was not followed weekly for wound because was not pressure ulcer until today and did not report to physician because they followed standing orders. During a telephone interview on 5/3/24 at 2:30 p.m. Medical Director (MD) Q reported was not aware R109 had skin breakdown on right hip. MD Q reporter would expect staff to contact physician with new or change in skin breakdown.