**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents received timely and accurate assessments and monitoring for changes in condition for five of eight residents (Resident #77, Resident #45, Resident #51, Resident #7, and Resident #46) reviewed for quality of care. Findings: Resident #77 (R77) Review of an admission Record revealed R77 was an [AGE] year-old-male, originally admitted to the facility on [DATE] following a 15-day hospital stay, with pertinent diagnoses of a urinary tract infection (UTI), a stage 4 pressure ulcer of the sacrum, congestive heart failure, diabetes mellitus, low blood pressure, and retention of urine. R77 was admitted to the facility as a full code and was able to answer questions. Review of an Inpatient Discharge Summary for R77 dated 07-24-25 at 10:58 AM reflected the following information regarding R77's hospital stay and discharge orders: (a) on 07-14-25, R77 had a surgical excision and debridement of a stage 4 sacral wound, and a wound vacuum (negative pressure wound therapy) was placed, (b) continue wound vac (vacuum) at discharge, and (c) Outpatient Wound Treatment Clinic will need referral placed. An additional hospital consultation note indicated that a diverting colostomy was not advised by the surgeon at that time because the wound vac dressing fit well and provided a tight barrier against stool leaking into the sacral wound. Review of a Medical Equipment Work Order for R77 revealed an order, placed by facility staff and delivered to the facility on [DATE], for a wound vac kit. During an interview on 09-10-25 at 2:10 PM, Medical Records Coordinator (MRC) Q stated that the wound vac was delivered to the facility on [DATE] but staff had not signed for it, and MRC Q did not know where the wound vac was placed after it arrived at the facility. Review of a Skin Assessment for R77, completed by nursing on 07-26-25, reflected no wound measurements nor mention of the ordered and delivered wound vac. Review of a nursing Progress Note for R77, dated 07-27-25, revealed a moderate amount of drainage was noted in the sacral wound. Review of a nursing Progress Note for R77, dated 07-28-25, revealed no documentation regarding the condition of the stage 4 sacral wound. Review of a nursing Progress Note for R77, dated 07-29-25, revealed a large amount of drainage was noted in the sacral wound. Review of a nursing Progress Note for R77, dated 07-30-25, revealed a moderate to large amount of drainage and a faint odor were detected in the sacral wound. Review of an Electronic Treatment Administration Record (Etar) for R77, dated 07-31-25, revealed an order for Negative Pressure Wound Therapy (NPWT) to sacrum. Set vacuum at 125 mmHg (millimeters of mercury). Set to continuous. Inspect settings and visualize dressing is intact every shift. Change every 3 days starting 07-31-25 (seven days after the wound vac equipment had been delivered to the facility). Review of the corresponding Wound Measurement assessment, also completed 07-31-25 for R77, revealed the wound measured 8 cm (centimeters) long x 7.8 cm wide x 2 cm deep that included undermining from 7 o'clock to 12 o'clock that measured approximately 2 cm. Additional documentation on the 07-31-25 Wound Measurement assessment included questions/answers regarding additional descriptives of the sacral wound and the current condition of other skin areas, as well as a narrative written by the nurse regarding assessment notes and review of treatment effectiveness. Review of a nursing Progress Note for R77, dated 08-01-25, revealed no documentation that the dressing for the wound vac was sealed and functioning properly. Review of a nursing Progress Note for R77, dated 08-02-25, revealed no documentation that the dressing for the wound vac was sealed and functioning properly. Review of a nursing Progress Note for R77, dated 08-03-25, revealed no documentation about the change to the wound vac and the condition of the wound including the size, color, amount of drainage, if an odor was detected, or if the dressing for the wound vac was sealed and functioning properly when the dressing change was completed. Review of the next Wound Measurement assessment for R77, completed on 08-05-25, revealed the exact same measurements as those obtained on 07-31-25, the exact same answers to the questions regarding additional descriptives of the sacral wound as those documented on 07-31-25, and the exact same narrative written by nursing regarding assessment notes and review of treatment effectiveness. Review of a nursing Progress Note for R77, dated 08-05-25, revealed no documentation about the change to the wound vac and the condition of the wound including the size, color, amount of drainage, if an odor was detected, or that the dressing for the wound vac was sealed and functioning properly when the dressing change was completed. Additional review of the Etar for R77, dated July 2025, revealed an order for daily weight upon admission for three days. A weight was obtained on 07-25-25 but not on 07-26-25 and 07-27-25. Review of nursing progress notes for 07-26-25 and 07-27-25 revealed no documentation that explained why the last two daily weights were not obtained. Review of the Emar's (Electronic Medication Administration Record) and Etar's for R77 dated July 2025 and August 2025, revealed an order for staff to monitor and record urine output twice daily when emptying the foley (catheter in the bladder to evacuate urine) drainage bag. No documentation for urine output was found for 07-26-25 in the morning, 07-27-25 in the morning, 07-30-25 in the morning, 08-05-25 in the morning, 08-09-25 both in the morning and in the evening, and 08-10-25 in the evening. Review of the Inpatient Discharge Summary for R77 revealed an order to continue Midodrine 5mg (milligrams) twice daily. Midodrine was used to treat hypotension (low blood pressure) and was prescribed with parameters. The hospital administered the medication and used a blood pressure of 90/50 or lower for the parameter. The facility administered Midodrine to R77 without the use of any parameters starting the evening of 07-28-25 until the evening of 08-10-25. (24 doses) Review of an interdisciplinary progress note for an Admission-5 day MDS (minimum data set) review for R77, with the interview documented as completed on 07-28-25, revealed the following: (R77) is here to continue with skilled therapy to regain his strength and endurance so he can return home and (R77) is usually understood and usually understands others verbally. Review of a physician order for R77, dated 07-31-25, revealed an order for a U/A with C&S (urine analysis with a culture and sensitivity) due to a change in R77's mentation (cognitive status). Review of the U/A with C&S for R77, resulted on 08-03-25, revealed R77 had a UTI caused by the bacteria Escherichia Coli (E.Coli) and further noted the phenotypic resistance profile of this isolate is suggestive of an ESBL-producing Enterobacterale. During an interview on 09-11-25 at 10:40 AM, Infection Control Preventionist (ICP) E reported that he had not notified the physician about the results of the U/A and C&S for R77 that were completed on 08-03-25. ICP E stated that R77 was already taking an antibiotic for the UTI identified in the hospital. When ICP E was asked if the antibiotic that R77 was currently prescribed (Linezolid) was resistant or susceptible (effective or not) against E.Coli, ICP E reported not knowing. When ICP E was asked if he notified anyone of the U/A and C&S results for R77, ICP E stated no. Review of a facility prescriber Progress Note dated 08/05/25 reflected no documentation that indicated the nurse-practioner (NP) was made aware of the results of the U/A and C&S for R77 that had been resulted on 08-03-25. Further review of R77's electronic health record (EHR) revealed no documentation that any facility prescriber was made aware of U/A results from 08-03-25 prior to the resident's passing on 08-12-25. Resident #45 (R45) Review of an admission Record revealed R45 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: acute on chronic congestive heart failure (CHF). Review of R45’s “Heart Failure Clinic” consultation report dated 1/10/25 revealed, “…weigh yourself every morning; if you notice a weight gain of > 2 lbs in one day or > 5 lbs in one week, call our office…” Review of R45’s “Order Summary” dated 7/9/24 revealed, “Order Summary: Daily Weights for CHF.” Review of R45’s “Weight Summary” revealed her weights were not obtained on the following days: 7/3/25, 7/5/25, 7/7/25, 7/11/25-7/13/25, 7/16/25, 7/18/25, 7/20/25, 7/21/25, 7/26/25, 7/27/25, or 7/31/25. Confirming the order to notify the provider with a 2 lb weight increase in 1 day could not be completed due to insufficient monitoring. *7/9/25 a weight of 244 lbs, 7/10/25 a weight of 245.3 lbs, (no weights 7/11/25-7/13/25), 7/14/25 a weight of 249.5 lbs, 7/15/25 a weight of 249.6, and no weight obtained 7/16/25. Indicating R45 had a 5.6 lb weight gain in 1 week. There was no documentation that the provider was notified of the weight gain. *7/24/25 a weight of 238.2 lbs and 7/25/25 a weight of 242.2 lbs. Indicating R45 had a 4 lb weight gain in 1 day. There was no documentation that the provider was notified of the weight gain. Review of R45’s July “Treatment Administration Record” revealed: The weight obtained on 7/2/25 (240 lbs) was documented for the 7/3/25 weight assessment. The weight obtained on 7/4/25 (240.3 lbs) was documented for the 7/5/25 weight assessment. The weight obtained on 7/6/25 (240 lbs) was documented for the 7/7/25 weight assessment. The weight obtained on 7/15/25 (249.6 lbs) was documented for the 7/18/25 and 7/19/25 weight assessments. The weight obtained on 7/30/25 (242.4 lbs) was documented for the 7/31/25 weight assessment. Review of R45’s “Weight Summary” revealed her weights were not obtained on the following days: 8/1/25, 8/9/25, 8/12/25, 8/14/25-8/17/25, or 8/22/25. Review of R45’s August “Treatment Administration Record” revealed: The weight obtained on 8/11/25 (243.3 lbs) was documented for the 8/12/25 weight assessment. The weight obtained on 8/13/25 (243.5 lbs) was documented for the 8/14/25 and 8/17/25 weight assessments. Review of R45’s “Weight Summary” revealed her weights were not obtained on the following days: 9/3/25, 9/4/25, 9/5/25, or 9/6/25. Review of R45’s September “Treatment Administration Record” revealed: The weight obtained on 9/2/25 (243. lbs) was documented for the 9/3/25 weight assessment. Review of R45’s “Electronic Health Record” revealed no documentation for the rationale for not obtaining R45’s weights as ordered. Resident #51 (R51) Review of an admission Record revealed R51 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: systolic and diastolic congestive heart failure. Review of R51’s “Order Summary” dated 2/17/25 revealed, Weight M-W-F (Monday, Wednesday, and Friday). If weight increases by more than 2-3 lbs (pounds) on consecutive measurements or more than 5 lbs. in a week, let provider know in the morning for Fluid overload/CHF (Congestive Heart Failure).” Review of R51’s “Weight Summary” revealed that on 5/6/2025 R51’s weight was 177.8 pounds and on 5/9/2025 R51’s weight was 184.0 pounds (6.2-pound weight gain). Review of R51’s “Weight Summary” revealed her weight was not obtained on 8/1/25, 8/18/25, or 8/25/25. Review of R51’s “Weight Summary” revealed R51’s weight was obtained on 6/30/25 (180.4 lbs) and was not obtained again until 7/7/25. Review of R51’s July “Treatment Administration Record” revealed that the weight obtained on 6/30/25 was documented for the 7/2/25 and 7/4/25 weight assessment. Review of R51’s “Weight Summary” revealed R51’s weight was obtained on 8/6/25 (180.9 lbs) and was not obtained again until 8/11/25. Review of R51’s August “Treatment Administration Record” revealed that the weight obtained on 8/6/25 was documented for the 8/8/25weight assessment. Review of R51’s “Electronic Health Record” revealed no documentation for the rationale for not obtaining R51’s weight on 8/1/25, 8/18/25, or 8/25/25 or documentation that the provider was notified of the 6.2-pound weight gain. A request for documentation that the provider was notified of the 6.2-pound weight gain was requested via email on 09/11/2025 at 10:59 AM. No supporting documentation was received prior to survey exit. Resident #7 (R7) Review of an admission Record revealed R7 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: chronic atrial fibrillation (abnormal beating of the heart). Review of R7’s “Order Summary” dated 7/3/25 revealed, “daily weight one time a day for chf.” Review of R7’s “Weight Summary” revealed no weights were obtained on 7/11/25, 7/12/25, 7/14/25, 7/19/25/25, or 7/20/25. Review of R7’s July “Treatment Administration Record” revealed: The weight obtained on 7/13/25 (100.8 lbs) was documented for the 7/14/25 weight assessment. The weight obtained on 7/18/25 (99.6 lbs) was documented for the 7/19/25 weight assessment. Review of R7’s “Weight Summary” revealed no weights were obtained on 8/2/25, 8/8/25, 8/16/25-8/18/25, 8/22/25, 8/25/25, or 8/31/25 Review of R7’s August “Treatment Administration Record” revealed: The weight obtained on 8/1/25 (100.6 lbs) was documented for the 8/2/25 weight assessment. The weight obtained on 8/7/25 (101.9 lbs) was documented for the 8/2/25 weight assessment. The weight obtained on 8/15/25 (103 lbs) was documented for the 8/17/25 weight assessment. The weight obtained on 8/21/25 (103.2 lbs) was documented for the 8/22/25 weight assessment. The weight obtained on 8/24/25 (104.6 lbs) was documented for the 8/25/25 weight assessment. The weight obtained on 8/30/25 (105.6 lbs) was documented for the 8/31/25 weight assessment. Review of R7’s “Electronic Health Record” revealed no documentation for the rationale for not obtaining R7’s weights. Resident #46 (R46) Review of an admission Record revealed R46 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: heart failure. Review of R46’s “Order Summary” dated 9/3/24 revealed, “Weigh M-W-F - If weight increase by more than 2-3 lbs. on consecutive measurements or more than 5 lbs. in a week, let provider know for chf.” Review of R46’s “Weight Summary” and “Medication Administration Record” revealed her weight was not obtained on 7/2/25, 7/9/25, 8/25/25 or 8/27/25. Review of R46’s “Electronic Health Record revealed no documentation for not obtaining R46’s weights. During an interview via email on 09/11/2025 at 4:23 PM, Regional Nurse Consultant (RNC) “A” confirmed the above residents had missing daily weights and confirmed licensed nurses were utilizing the previous weights in the “Treatment Administration Record” documentation. RNC “A” reported the licensed nurses would receive education regarding the assessment and documentation of daily weights. The facility did not have a policy for congestive heart failure. Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, Daily weights are an important indicator of fluid status. Each kilogram (2.2 lb) of weight gained or lost overnight is equal to 1 L of fluid retained or lost…Weigh patients with heart failure daily…” [NAME], [NAME] A.; [NAME], [NAME] G.; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 1059). Elsevier Health Sciences. Kindle Edition. Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, A weight gain of 0.9 to 1.4 kg (2–3 lb) in 1 day indicates fluid-retention problems… daily weight is measured at the same time of day and on the same scale (Ball et al., 2019). This allows an objective comparison of subsequent weights. Accuracy of weight measurement is important because health care providers base medical and nursing decisions (e.g., drug dosage, medications) on changes…” [NAME], [NAME] A.; [NAME], [NAME] G.; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 558). Elsevier Health Sciences. Kindle Edition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement the facility policy for pressure injury/wound management and ensure treatments were ordered and completed, for 3 of 17 residents (Resident #15, #7, and #5), reviewed for the treatment and prevention of pressure injuries.Findings:Resident #15 (R15) Review of an admission Record revealed R15 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: pressure ulcer of the sacral region with osteomyelitis (infection in the bone.) Review of R15’s “Order Summary” dated 7/27/25 revealed an active order (as of 9/11/25) for “Dakins (full strength) External Solution 0.5 % (Sodium Hypochlorite) Apply to Coccyx Wound topically every shift for Wound cleansing.” Review of R15’s wound clinic “Physician Orders Details” dated 8/1/25 revealed, “…The periwound skin appearance exhibited: Maceration, Rubor…Wound Treatment-Wound #2 Coccyx Cleanser: Dakins Solution 0.5 % 3 X Per Day…Use FULL STRENGTH DAKIN’S SOLUTION to rinse wound then use to apply wet-to-dry dressing Peri-Wound Care: Clotrimazole and Betamethasone 3 X Per Day… Peri-Wound Care: Coloplast CitricAid Clear AF Antifungal 3 X Per Day…every 2 hours and as needed after incontinence episodes Secondary Dressing: Woven Gauze Sponge…3 X Per Day… Secondary Dressing: Tegaderm Film 4x4…3 X Per Day…use to secure dressing, sealed down on three sides, open at the top…” The top of the document was time stamped 08/01/2025 at 4:44 PM with the wound clinics name indicating a fax to the facility was successful/received. The document did not include a fax cover page (page 1) but pages 2-5 were present. Per the State Operations Manual, “Macerated skin has a white appearance and a very soft, sometimes “soggy” texture. The persistent exposure of perineal skin to urine and/or feces can irritate the epidermis and can cause severe dermatitis, skin erosion and/or ulcerations.” Review of R15's Wound Measurement dated 8/1/25 revealed her wound measured 4.1cm length x 1.4cm width x 1.5cm depth. The periwound skin assessment indicated “intact-unbroken skin. Maceration was not documented. Chronic sacral wound, managed by wound care clinic. The wound vac was discontinued by the wound clinic. New orders for cleansing with Dakin's solution 0.5% and wet to dry with Dakin's solution. Cleaning is provided day shift and day shift as well as PRN after bowel movements due to the location of the wound. Her stool tends to go up towards the wound when she has a bowel movement. Wound Clinic requests for resident to reposition every two hours and in a chair for only up to 1 hour maximum. Complicating factors include continued pressure on wound, uncleanly practices, lack of proteins and pt's (patients) dementia, incontinence, educated both pt and spouse about importance of offloading to treat this wound . The facility referenced a diagnosis of dementia indicating R15 would require reminders for offloading/repositioning. The interventions to reposition every two hours and for the resident to be up in a chair for only 1 hour maximum were not implemented on R15’s care plan. Review of R15's Wound Measurement dated 8/7/25 revealed her wound measured 4.0cm length x 1.4cm width x 1.4cm depth. The periwound skin assessment indicated “intact-unbroken skin. Maceration was not documented. Chronic sacral wound, managed by wound care clinic. Orders for cleansing with Dakin's solution 0.5% and wet to dry with Dakin's solution. Cleaning is provided day shift and day shift (sic-presumed night shift) as well as PRN (as needed) after bowel movements due to the location of the wound .Wound Clinic requests for resident to reposition every two hours and in a chair for only up to 1 hour maximum. Complicating factors include continued pressure on wound, uncleanly practices, lack of proteins and pt's (patients) dementia, incontinence, educated both pt and spouse about importance of offloading to treat this wound . The interventions to reposition every two hours and for the resident to be up in a chair for only 1 hour maximum were not implemented on R15’s care plan. Review of R15’s “Order Summary” dated 8/7/25 revealed, “Wound (Coccyx): 1. Use full strength Dakin's solution to rinse wound. 2. Use Dakin's to apply wet-to-dry dressing. 3. Secondary dressing: Woven Gauze Sponge. 4: Secure with Tegaderm Film 4x4, sealed down on three sides, leave open at the top. Peri-Wound (Coccyx): Apply Clotrimazole and Betamethasone to the peri-wound with dressing changes. three times a day for Wound Care.” Indicating the treatment change wasn’t implemented for 6 days following the order change at the wound clinic. Additionally, Coloplast CitricAid was not initiated as directed by the wound clinic. Review of R15’s wound clinic “Physician Orders Details” dated 8/15/25 revealed, “…Her wound is still being contaminated with her loose stool and it had to be extensively cleansed of stool contamination today and the debrided… the peri-wound skin appearance exhibited: Rash, Maceration, Rubor…” Additional treatments to initiate with the previous order included: “Impressions/Recommendations: Peri-Wound Care: Duoderm 3x Per Day…apply around wound as a donut Peri-Wound Care: Stoma paste 3 x Per Day…” Review of R15’s wound clinic “Consultation Report” (completed at the time of the wound clinic appointment) dated 8/15/25 revealed, “…Pt (patient) to be checked + (and) changed Q1 hr (every hour), while awake. Q2 (every 2 hours) during sleep. Peri wound- -ostomy paste-duoderm to periwound -Dakins W – D (wet to dry) to wound bed -Top Layer Tegaderm (change) BID +PRN (twice a day and as needed) Cheeks & between legs -Acetic acid wash -ATF & Lotrisone (antifungal cream)…” The fax cover indicated the fax was successful/received on 8/15/25. Review of R15's Wound Measurement dated 8/15/25 revealed her wound measured 2.7cm length x 1.9cm width x 1.5cm depth. The periwound skin assessment indicated “intact-unbroken skin. Maceration was not documented. Chronic sacral wound, managed by wound care clinic. Orders for cleansing with Dakin's solution 0.5% and wet to dry with Dakin's solution. Cleaning is provided day shift and day shift as well as PRN after bowel movements due to the location of the wound Wound Clinic requests for resident to reposition every two hours and in a chair for only up to 1 hour maximum. Complicating factors include continued pressure on wound, uncleanly practices, lack of proteins and pt's dementia, incontinence, educated both pt and spouse about importance of offloading to treat this wound. Wound clinic notes that stool continues to contaminate the wound The facility confirmed the wound clinic notes were reviewed, however, R15's treatment order was not changed in the TAR at that time. Additionally, the wound note indicated the dressing change was being completed twice a day and not three times as directed by the wound clinic. The interventions to reposition every two hours and for the resident to be up in a chair for only 1 hour maximum were not implemented on R15’s care plan. Review of R15's Wound Measurement dated 8/19/25 revealed her wound measured 2.7cm length x 1.9cm width x 1.5cm depth. The periwound skin assessment indicated “intact-unbroken skin. Maceration was not documented. Chronic sacral wound, managed by wound care clinic. Orders for cleansing with Dakin's solution 0.5% and wet to dry with Dakin's solution. Cleaning is provided day shift and day shift as well as PRN after bowel movements .Wound was cleaned as instructed by orders. No measurement changes since the wound clinic visit on Friday .She was given education on calling to be changed as soon as she realizes she has had an incontinence episode to help reduce the amount of feces that gets into the dressing and wound . The note indicated wound care completed as instructed by orders however R15's treatment changes from 8/15/25 continued to go unchanged. The interventions to reposition every two hours and for the resident to be up in a chair for only 1 hour maximum were not implemented on R15’s care plan. The wound was not assessed again until 8/29/25 (10 days). Review of R15's Wound Measurement dated 8/29/25 revealed her wound measured 2.6cm length x 1.9cm width x 1.5cm depth. The periwound skin assessment indicated “intact-unbroken skin. Maceration was not documented. Chronic sacral wound, managed by wound care clinic. Orders for cleansing with Dakin's solution 0.5% and wet to dry with Dakin's solution. Cleaning is provided day shift and day shift as well as PRN after bowel movements due to the location of the wound .Education provided about offloading, protein intake, hygiene, and letting staff at SNF (skilled nursing facility) know when she is incontinent. She states understanding, but has dementia . Confirming the facility was aware that R15 required reminders to offload pressure and frequent check and changes. R15's treatment changes from 8/15/25 continued to go unchanged. The interventions to reposition every two hours and for the resident to be up in a chair for only 1 hour maximum were not implemented on R15’s care plan. Review of R15's Wound Measurement dated 9/5/25 revealed her wound measured 2.5cm length x 1.5cm width x 1.5cm depth. The periwound skin assessment indicated “intact-unbroken skin. Maceration was not documented. Chronic sacral wound, managed by wound care clinic. Orders for cleansing with Dakin's solution 0.5% and wet to dry with Dakin's solution. Cleaning is provided day shift and day shift as well as PRN after bowel movements. Wound Clinic requests for resident to reposition every two hours and in a chair for only up to 1 hour maximum. Complicating factors include continued pressure on wound, uncleanly practices, lack of proteins and pt's dementia, incontinence, educated both pt and spouse about importance of offloading to treat this wound . The interventions to reposition every two hours and for the resident to be up in a chair for only 1 hour maximum were not implemented on R15’s care plan. Review of R15’s “Order Summary” dated 9/9/25 revealed, “Gently cleanse buttocks, groin and peri area and pat dry. Apply Bag Balm ointment to macerated areas. every shift for Skin protectant on macerated skin.” Bag Balm was ordered prior to the implementation of the wound clinic treatments for the periwound. The wound clinics treatment orders continued to go unordered (25 days). Review of R15’s “Interdisciplinary Documentation” dated 9/9/2025 revealed, “Wound: dressing to coccyx completed, large amount of wetness noted. wound bed is moist and pink, surrounding tissue red as well as buttocks and groin hot red, no odor. Bag balm being applied. (R15) is sleeping on a pressure reduction mattress. She does fairly well with bed mobility herself…” Indicating the resident required assistance with bed mobility and offloading pressure. Review of R15’s “Interdisciplinary Documentation” dated 9/10/2025 revealed, “(R15) dressing to her coccyx done large amount of drainage she has a red excoriated rash to her groin, peri area, between her legs and buttocks. She seems to have a constant stream of urine making it a wet environment. Bag balm being applied as ordered…” Indicating the worsening of R15’s skin breakdown. Review of R15’s “Order Summary” revealed no order for ostomy paste and Duoderm to periwound or for acetic acid wash and ATF & Lotrisone for “cheeks & between legs” as of 9/11/25 (27 days). Review of R15’s “Electronic Health Record” revealed no documentation/rationale for the lack of implementation of the wound clinics treatment orders. Review of R15’s “Interdisciplinary Documentation” dated 9/10/2025 revealed, “Resident experiencing frequent episodes of urinary incontinence. Spoke to resident about placing a foley catheter to help with moisture control in order to heal her macerated skin and coccyx wound. Resident voiced understanding and agreed with placement of indwelling foley cath…” Indicating R15’s wound did not show improvement and continued to present with maceration. The facility placed a foley catheter to prevent ongoing breakdown prior to implementing the wound clinics treatment for her periwound. Review of R15’s “Order Summary” dated 9/10/25 revealed, “Place foley catheter for skin integrity one time only for wound healing.” Review of R15’s August “Treatment Administration Record (TAR)” revealed multiple missed treatments for the coccyx treatment ordered on 8/7/25. Missed treatments as follows: 8/8/25 9:00 AM and 2:00 PM treatments, 8/9/25 10:00 PM treatment, 8/13/25 10:00 PM treatment, 8/16/25 10:00 PM treatment, 8/22/25 10:00 PM treatment, 8/25/25 9:00 AM, 2:00 PM, and 10:00 PM treatments, 8/31/25 2:00 PM treatment. Review of R15’s “Order Summary” and July, August, and September “Treatment Administration Record (TAR)” revealed: *An order for Dakins (full strength) External Solution 0.5 % (Sodium Hypochlorite) Apply to Coccyx Wound topically every shift (day shift and night shift)…” Began on 7/27/25 and was ongoing as of 9/10/25. The facility nurses continued to document on the TAR that the treatment was completed. *An order for Betamethasone Dipropionate External Cream 0.05 % (Betamethasone Dipropionate (Topical)) Apply to peri-wound (coccyx) topically every shift…” Began on 7/27/25 and continued until it was put on hold on 9/7/25. The facility nurses continued to document on the TAR that the treatment was completed. Review of R15's wound clinic “Physician Orders Details” intervention recommendations from 8/1/25, 8/15/25, and 8/29/25 revealed, .Off-Loading .Turn and reposition every 2 hours-limit time in wheelchair to 1 hour with each meal and then return to bed .Bathing/Shower/Hygiene .may shower, rewash wound after showering . Additionally, the wound “Consultation Report” dated 8/15/25 recommended R15 to be checked and changed every hour, while awake and every 2 hours during sleep. Review of R15’s “Care Plan” with revisions revealed none of the wound clinic’s intervention recommendations were transcribed or implemented. During an interview on 09/11/2025 at 9:57 AM, Regional Nurse Consultant (RNC) “A” was notified of concerns pertaining to R15’s treatment orders not initiated promptly or at all, her care plan not updated with wound clinic recommendations, treatments not completed, and previous treatments not discontinued. Resident #7 (R7) Review of an admission Record revealed R7 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: pressure ulcer of buttock. Review of R7’s “Order Summary” dated 7/17/25 revealed an active order (as of 9/11/25) for “Left Ischium: cleanse with acetic acid, apply Collagen prism to wound bed, Apply Mepilex border dressing 4x4. Every day shift for wound care.” Review of R7’s wound clinic “Physician Orders Details” dated 8/20/25 revealed, “Wound #3 (left ischium) is healed today…” Review of R7’s “Wound Measurement” report dated 8/21/25 revealed, “…The right Ischial wound has been noted as healed by the wound clinic. We will continue to monitor for changes but will heal the wound for weekly assessments. Wound care notes 8/20/25 Left ischium healed…” Confirming the facility reviewed the wound clinic “Physician Orders Details.” Review of R7’s wound clinic “Physician Orders Details” dated 8/27/25 revealed no documentation/assessments or any new treatments for R7’s Left Ischial wound. Confirming the wound had healed. Review of R7’s “Skin Assessment” dated 8/27/25 revealed, “…Left ischium wound is healing with continued treatment order…” Indicating an inaccurate assessment of R7’s skin. Review of R7’s “Wound Measurement” report dated 8/28/25 revealed, “…The right Ischial wound has been noted as healed by the wound clinic. Discontinue wound treatment .” Review of R7’s wound clinic “Physician Orders Details” dated 9/3/25 revealed no documentation/assessments or any new treatments for R7’s Left Ischial wound. Confirming the wound had healed. Review of R7’s “Skin Assessment” dated 9/3/25 revealed, “…Left ischium wound is healing with continued treatment order…” Indicating an inaccurate assessment of R7’s skin. Review of R7’s “Wound Measurement” report dated 9/3/25 revealed, “…The right Ischial wound has been noted as healed by the wound clinic. We will continue to monitor for changes but will heal the wound for weekly assessments after 2 weeks have passed and it remains healed. Wound clinic notes…” Review of R7's wound clinic “Physician Orders Details” dated 8/20/25, 8/27/25, and 9/3/25 revealed, “Wound Treatment…Wound #2-Sacrum-Cleanser: Acetic Acid Irrigation…with each dressing change do a 5 minute wound soak with acetic acid… Wound #3 (Left Ischium) Secondary Dressing: Mepilex Border Dressing, 4x4 every other day.” Review of R7’s “Order Summary” revealed no order for the Mepilex Border Dressing for the left ischium or for the acetic acid wound soak for the sacrum as ordered by the wound clinic. Review of R7’s August and September “Treatment Administration Record” revealed the treatment for “Left Ischium: cleanse with acetic acid, apply Collagen prism to wound bed, Apply Mepilex border dressing 4x4 every day shift for wound care” continued to be completed through 9/11/25. Review of R7's wound clinic “Physician Orders Details” intervention recommendations from 8/20/25, 8/27/25, and 9/3/25 revealed, .Off-Loading .Turn and reposition every 2 hours *Other: - Time in chair must be limited to 30 minutes to 1 hour MAX at a time (at mealtimes 3 times per day). Pressure on buttocks MUST be limited . Bathing/Shower/Hygiene *May shower with protection but do not get wound dressing(s) wet. Protect dressing(s) with water repellant cover (for example, large plastic bag) and may then take shower . Review of R7’s “Care Plan” with revisions revealed none of the wound clinic’s intervention recommendations were transcribed or implemented. During an interview via email on 09/11/2025 4:23 PM, RNC “A” stated, “treatment for (R7) should have been discontinued when noted (the left ischial wound) healed and was not.” During an interview on 09/11/2025 at 9:57 AM, RNC “A” and the Director of Nursing (DON) were notified of treatment order discrepancies and wound clinic care planned interventions not implemented for R15 and R7. RNC “A” and DON reported additional and/or supporting documentation would be provided if found. RNC “A” reported that they had identified that there was a delay in the wound clinic providing their progress notes/consultation reports which resulted in treatment order changes not being implemented promptly. On 09/11/2025 at 1:26 PM a request for any additional supporting documentation regarding R15 and R7’s pressure injuries was requested to be submitted by 5:30 PM. No additional documentation was received. R5 Review of an “admission Record” revealed R5 admitted to the facility on [DATE] with pertinent diagnoses which included dementia and complete paraplegia (loss of motor and sensory function). Review of a current end of life Care Plan intervention for R5, initiated revised 2/24/2025, revealed “…Hospice has been elected and the facility & hospice will coordinate care & services…” Review of activities of daily living “Care Plan” intervention for R5, initiated 9/6/2024, revealed R5 was using an Alternating Pressure Air Mattress (APM). (APM mattresses use a pump to inflate and deflate cells or channels within the mattress in a cyclical pattern to prevent the body’s weight from resting on one area too long to prevent pressure ulcers.) Further review revealed an intervention revised 4/9/2025 to “ensure mattress is on soft setting and static feature is not activated.” Review of R5’s “Wound Measurement”, dated 1/13/2025, revealed his left heel wound was healed and he had no other wounds at that time. Review of R5’s “Interdisciplinary Documentation” note, dated 1/30/2025 at 3:36 PM, revealed a new open area on his sacrum measuring 0.8 by 0.6 by 0.1 cm. Review of R5’s “Interdisciplinary Documentation” note, dated 2/3/2025 at 5:45 PM, revealed R5’s coccyx wound was significantly worsening, and Clinical Care Coordinator (CCC) “F” was notified. Review of R5’s “Interdisciplinary Documentation” note, dated 2/19/2025 and documented by former CCC/Wound Nurse “F”, revealed “…(R5) treated for wound infection with cephalexin (anti-biotic) …Wound occurred from unfavorable mattress setting…” Review of R5’s “Wound Measurement” documentation during this time frame revealed: 2/4/2025- Coccyx pressure- 8.5 by 5.0 by 0.2 cm, stage IV Left buttock blister- 4.0 by 2.0 cm, stage II Right scapula pressure- 11.2 by 9.0 cm, suspected deep tissue injury Left heel pressure- 7.4 by 6.0 cm, suspected deep tissue injury “…New orders placed for daily cares, confirmed air mattress on correct settings…” 2/10/2025- Coccyx pressure- 10 by 14.5 cm, stage IV Right scapula pressure- 4 by 3.8 by 0.2 cm, stage II Left heel pressure- 2.4 by 3.5 cm, suspected deep tissue injury “…buttock wound merged with coccyx wound…” 2/19/2025- Coccyx pressure- 8 by 5 by 4 cm, stage IV Left buttock pressure- 3 by 3 by 0.1 cm, stage II Right scapula pressure- 3 by 2.6 by 0.1 cm, stage II Left heel pressure- 2.6 by 3.6 cm, suspected deep tissue injury In a telephone interview on 9/10/2025 at 2:50 PM, former CCC/Wound Nurse “F” reported she performed an investigation when she was informed of R5’s new wounds and found that his APM mattress was in static mode (a setting where the mattress maintains a firm, constant pressure rather than the usual cyclic inflation and deflation of air cells). Former CCC/Wound Nurse “F” reported she could not confirm how long the bed had been in static mode and staff were educated to ensure that the bed was not left in static mode in the future. In in interview on 9/11/2025 at 8:15 AM, Regional Nurse “A” reported she completed an audit on the air mattresses in the facility on 2/4/2025 when R5’s APM mattress was found to be in static mode. Regional Nurse “A” reported R5’s mattress should always be left in alternating mode and not in static mode, according to his individualized care plan. R5’s Treatment Administration Record (TAR) was reviewed. Undocumented wound treatments in August 2025 were discussed, as well as incorrectly ordered frequency of dressing changes (scheduled too often in some cases). Regional Nurse “A” reported dressings should be performed as ordered, with no missing documentation. Regional Nurse “A” reported treatments should not be completed more often than ordered, as this can also cause wounds to worsen. Review of R5’s August 2025 TAR revealed: “Apply border foam dressing to right knee for skin breakdown preventative. Change every 5 days”- Dressing documented as completed on 8/1/25, 8/2/25, 8/3/25, 8/4/25, 8/5/25, 8/6/25, 8/11/25, 8/12/25, 8/16/25, 8/18/25, 8/19/25, 8/20/25, and 8/21/25 (more often than every 5 days). “Coccyx: cleanse with (normal saline), soap and water, or wound cleanser, apply calcium alginate dressing (cut to size), cover with nonstick telfa and foam every day shift for wound care”- Undocumented dressing changes on 8/17/25, 8/22/25, 8/24/35, and 8/25/25. “Coccyx: cleanse with (normal saline), soap and water, or wound cleanser, apply wet to dry dressing, cover with abd secure with paper tape every day shift for wound care”- Undocumented dressing changes on 8/1/25, 8/3/25, 8/7/25, 8/8/25, 8/9/25, 8/10/25, 8/13/25, 8/14/25, and 8/15/25. Review of facility policy/procedure “Skin at Risk Assessment: Documentation, Staging, & Treatment”, revised 1/2020, revealed “…It is the policy of this facility to assess resident risk factors for the development of impaired skin integrity and intervene as indicated utilizing the admission assessment, plan of care, and Minimum Data Set as formal assessment tools. It is the policy of this facility to assess skin on a regular basis to determine whether changes in the patient’s skin condition have occurred. Weekly measurements and narrative assessments are conducted on existing pressure injuries…”

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #MI00149026. Based on interview and record review, the facility failed to prevent significant medication errors for 1 resident (Resident #101) of 4 residents reviewed for medication administration, resulting in Resident #101 (R101) becoming bradycardic (low heart rate) and requiring to be transferred to a local hospital for treatment. Findings include: Review of an admission Record revealed Resident #101 admitted to the facility on [DATE] with pertinent diagnoses which included dementia and congestive heart failure. Review of R101's Medication Discrepancy report, dated 12/13/2024 at 7:40 AM, revealed R101 received the wrong resident's medications the morning of 12/13/2024. Further review revealed the facility Medical Doctor (MD) K was contacted by Registered Nurse (RN) A. Facility MD K gave orders for nursing staff to monitor R101's vital signs and hold his morning medications. Review of R101's Provider Progress Notes, dated 12/13/2024 at 11:07 AM, revealed MD K documented R101 received the wrong patient's medications including 1) Colace 100mg (a stool softener laxative), 2) Aspirin 81mg (a nonsteroidal anti-inflammatory used to reduce pain, fever, and inflammation), 3) metoprolol 25mg (a beta-blocker used to treat high blood pressure that can cause bradycardia), 4) Renflexis 75mg (used to treat arthritis), 5) atorvastatin 20mg (used to treat hyperlipidemia), 6) sotalol 80mg (a beta-blocker used to treat arrhythmias that can cause bradycardia), 7) leflunomide 20mg (used to treat arthritis), 8) pantoprazole 40mg (used to treat gastroesophageal reflux disease, 9) gabapentin 100mg (used to treat nerve pain), 10) MiraLAX 17g (a laxative used to treat constipation), 11) bupropion 75mg (used to treat depression), 12) ibuprofen 400mg (a nonsteroidal anti-inflammatory used to reduce pain, fever, and inflammation), and 13) metformin 850mg (used to treat diabetes). Further review revealed R101's morning medications were held on 12/13/2024. R101's vital signs were monitored, and he developed bradycardia with his pulse confirmed by MD K to be in the high 40's (normal pulse range is between 60-100 beats per minute). Further review revealed .Given that low heart rate and that he got patient's wrong medications including metoprolol and sotalol will have ER (Emergency Room) evaluate . Review of R101's Emergency Department Provider Notes, dated 12/13/2024 at 4:45 PM, revealed R101 was evaluated and monitored at the local Emergency Department for 8 hours following the ingestion of the wrong medications per recommendations from Poison Control. In a telephone interview on 1/16/2025 at 9:10 AM, RN A reported that she set up R101's medications the morning of 12/13/2024 and another resident's medications with the same first name. RN A reported it was busy, and she asked RN E to give R101 the medications that she had prepared. RN A stated, We shouldn't do that, reporting nurses are expected to administer medications that they prepare. In at telephone interview on 1/17/2024 at 9:00 AM, RN E reported RN A handed medication to her the morning of 12/13/2024 and asked her to administer them to R101. RN E reported she administered the medications that RN A had prepared to R101, and then RN A realized that the medications were given to the wrong resident. RN E reported nurses should not give medications that were prepared by another nurse under normal circumstances. In an interview on 1/16/2025 at 9:50 AM, the Director of Nursing (DON) reported nursing staff should not administer medication that another nurse prepared. Review of facility policy/procedure Medication Administration by the Various Routes, reviewed December 2024, revealed .Only authorized personnel who prepare the medication may administer it . Medications supplied for one resident are not administered to another resident .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake # MI00141875 Based on interview and record review, the facility failed to 1.) implement the facility policy for pressure injury/wound management 2.) ensure pressure injury/wound assessments were comprehensive and accurate, and 3.) ensure treatments were ordered and completed, for 3 of 6 residents (Resident #42, #44, and #17) reviewed for alterations in skin integrity, resulting in incomplete wound assessments, a delay in wound healing, and the worsening of wounds. Findings: Resident #42 (R42) Review of an admission Record revealed R42 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: dependence on ventilator, heart failure, and pressure injuries. Review of R42's Wound Measurement dated 5/1/24 revealed, .right heel 3.2 x 3.4 unstageable . Heel has large eschar cap . Consider wound care clinic referral . No additional wound description reflected in the wound assessment. Comprehensive wound assessments are to include location, dimensions, description of wound bed, exudate type, exudate amount, presence of odor, wound edges, peri-wound assessment, tunneling/undermining, and pain. Review of R42's Wound Measurement dated 5/21/24 revealed no measurements. The right heel was documented as unstageable, however, documentation then showed .The following questions apply to: abdomen, right and left lower leg, heel .Pressure wounds have beefy red granulation tissue at base . (The wound base on R42's right heel was documented as unstageable and therefor staff would be not be able to visualize the wound base). No additional wound description reflected in the wound assessment. Per [NAME] and [NAME], Unstageable pressure injury: Obscured full-thickness skin and tissue loss *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 (see Fig. 48.4F). If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Review of R42's Wound Measurement dated 6/5/24 revealed R42's right heel measured 3 x 3.1 x 0.2 and was documented as a Stage 4 pressure injury.R HEEL- sharp debridement of black eschar tissue completed by provider, lidocaine 4% applied 5 minutes prior to procedure, 80% of slough tissue to wound bed noted, minimal bleeding controlled with pressure, Vaseline gauze covered with dry gauze wrapped with Kerlix. resident tolerated well. No additional wound description reflected in the wound assessment. Debridement is the removal of non-viable/dead tissue: necrotic material, slough and biofilm. (15 days after the last wound assessment.) Review of R42's Wound Measurement dated 6/12/24 revealed, .R (right) HEEL- 3.5 X 3.2 X 0.5 sharp debridement of slough tissue completed by provider, see updated orders. resident tolerated well . No additional wound description reflected in the wound assessment. Review of R42's Order Summary dated 6/12/24 revealed, Right heel: cleanse with normal saline, apply santyl, cover with gauze, wrap with kerlix. every shift for wound. Review of R42's Wound Measurements revealed no comprehensive wound assessment was completed on 6/19/24. Review of R42's Wound Measurement dated 6/26/24 revealed the right heel measured 3.0 x 2.5 x 1.8 and was documented as a Stage 4 pressure injury.R HEEL- (nurse practitioner name omitted) performed sharp debridement to right heel immediately prior to wound measurements. no s/s of infection. no change to tx . No additional wound description reflected in the wound assessment. (14 days after the last wound assessment) Review of R42's Wound Measurements revealed no comprehensive wound assessment was completed on 7/3/24. Review of R42's Skin Assessment dated 7/7/24 revealed R42's right heel was documented as vascular indicating an inaccurate wound assessment. Review of R42's Wound Measurement dated 7/10/24 revealed the right heel measured 3 x 2 x 1.5 N/A stage.R HEEL- after wound measurements were taken by writer, (nurse practitioner name omitted) performed sharp debridement to right heel and obtained cultures r/t (related to) odor and purulent (pus filled) drainage . Indicating the worsening of the wound from the previous assessment. No additional wound description reflected in the wound assessment. (14 days after the last wound assessment). Review of R42's Wound Measurements revealed no comprehensive wound assessments were completed after the assessment dated [DATE] through her transfer to the hospital. Review of R42's Provider Progress Note dated 7/10/24 revealed, .multiple chronic wounds, measurements in (Electronic Health Record), right heel noted with foul smelling drainage . Sharp debridement completed to right heel, after procedure minimal bleeding was controlled with light pressure, wound measures 3.0 cm x 2.5 cm x 1.8 cm. Indicating the worsening of the wound. No additional wound description reflected in the progress note. Treatment changes for R42's right heel were not made despite the deterioration of the wound with increased exudate and odor documented. The treatment order had been in place since 6/12/24 (4 weeks). Review of R42's Provider Progress Note dated 7/11/24 revealed, There is open skin on the heel with foul odor . No additional wound description or measurements reflected in the progress note. Review of R42's Skin Assessment dated 7/14/24 revealed R42's right heel was documented as vascular indicating an inaccurate wound assessment. Review of R42's Provider Progress Note dated 7/15/24 revealed, .Start cefepime 1 g IV x 1 then cefepime IV 500 mg every 24 hours for wound infection . No additional wound description or measurements reflected in the progress note. Review of R42's Provider Progress Note dated 7/17/24 revealed, .Patient is being seen today for wound evaluation . right heel wound measures 2.2 cm x 2.5 cm x 1.5cm . No additional wound description reflected in the progress note. Review of R42's Skin Assessment dated 7/21/24 revealed R42's right heel was documented as vascular indicating an inaccurate wound assessment.Right heel has been recently debrided as well as continuing with Santyl application BID (twice a day) with noted signs of improvement . There were no measurements or further wound descriptions reflected in the skin assessment. (Improvement was noted despite the lack of assessment and inaccurate staging of the pressure injury.) Review of R42's Provider Progress Note dated 7/22/24 revealed, .Patient is being seen for irregular lab results .Nursing has no acute concerns at this time . There was no wound assessment and measurements reflected in the progress note. Review of R42's Skin Assessment dated 7/28/24 revealed no measurements or wound assessments.wound to right heel dressing bid wound is odorous and no improvement noted . Review of R42's Provider Progress Note dated 7/29/24 revealed, .worsening odor of wound (Rt heel) .staff reports of worsening right heel wound .Right heel noted with foul smell, boggy, skin is very thin and fragile . Right heel wound culture C&S (culture and sensitivity) if indicated . Indicating the worsening of the wound. A debridement was completed to remove dead tissue during this visit. This assessment was completed 12 days after last provider wound assessment. Review of R42's Skin Assessment dated 8/1/24 revealed the right heel was documented as vascular and measured 7.5 x 8 (centimeters). No additional wound description or measurements reflected in the skin assessment. Review of R42's Provider Progress Note dated 8/1/24 revealed, .Patient is being seen today for irregular labs and worsening heel wound .right lower extremity, without measurements .start cefepime 2g IV q 24 hours x 10 days .right heel xray stat . No treatment changes noted. Review of R42's vital signs dated 08/01/24 at 8:59 AM revealed a blood pressure of 82/50, a pulse of 100, and respirations of 30. R42's vital signs were indicative of sepsis. Review of R42's xray results revealed the xray was obtained on 8/1/24 and was reviewed by the radiologist on 8/3/24. Ulceration at the posterior aspect of the heel with underlying calcaneal osteomyelitis and extensive soft tissue gas that is concerning for necrotizing/gas-forming infection . Review of R42's Interdisciplinary Documentation dated 8/2/24 revealed, Wound care completed to BLE (bilateral lower extremities) and Right heel. right heel noted increased brown drainage and increased involvement of entire heel area. Notified on-call provider (name omitted) of findings . Review of R42's Interdisciplinary Documentation dated 8/3/24 revealed, Received orders to send [NAME] to ER for an evaluation of x-ray results showing possible osteomyitis (sic). Osteomyelitis is an infection in the bone. Review of R42's Interdisciplinary Documentation dated 8/3/24 revealed, Called (emergency department) for update on resident. Spoke with RN who stated that resident was slated to be transferred to [NAME] Ford Hospital in Detroit for further evaluation d/t (due to) necrotizing fasciitis in Right heel . Necrotizing fasciitis is a severe, rapidly spreading bacterial infection of the skin. During an interview on 08/07/24 at 01:25 PM, Regional Nurse Consultant (RNC) D confirmed R42 did not have wound assessments completed weekly and the wound assessments were not complete/comprehensive. RNC D reported that wound assessments were to be completed weekly utilizing the Wound Measurement assessment tool and should include a comprehensive description of the wounds, not just the measurement of the wound. There were no treatment changes for R42's right heel from 6/12/24 through her discharge to the hospital despite the deterioration of the wound and/or lack of wound healing. Wound assessments were not completed weekly, and the assessments were not thorough/comprehensive as required to promptly identify the deterioration of the wound. A time related assessment has also been applied to the process of healing of a wound that is diagnosed as chronic. If during 4 weeks of standard of care, the wound surface area is reduced by 50%, it is likely to heal on the same treatment in 12 weeks. If less than a 50% reduction occurs, it is unlikely to heal on this treatment and a reassessment and change of treatment should be considered. [NAME] E, [NAME] PY, [NAME] GS, [NAME]-Green MM, [NAME] R, [NAME] D, Gould LJ, [NAME] DG, [NAME] GW, [NAME] R, Olutoye OO, [NAME] RS, [NAME] GC. Chronic wounds: Treatment consensus. Wound Repair [NAME]. 2022 Mar;30(2):156-171. doi: 10.1111/wrr.12994. Epub 2022 [DATE]. Erratum in: Wound Repair [NAME]. 2022 Jul;30(4):536. doi: 10.1111/wrr.13035. PMID: 35130362; PMCID: PMC9305950. Chronic wounds are those that do not progress through a normal, orderly, and timely sequence of repair. They are common and are often incorrectly treated .The mainstay of treatment is the TIME principle: tissue debridement, infection control, moisture balance, and edges of the wound. After these general measures have been addressed, treatment is specific to the ulcer type . Assessment of wounds should begin with a thorough physical examination. A more focused examination of the wound itself can then help guide treatment. The wound location, size, and depth; presence of drainage; and tissue type should be documented. Based on the location and appearance, most chronic wounds can be categorized by etiology, which allows for adequate workup and treatment recommendations . Venous ulcers are the Moisture balance is an essential part of wound care. Chronic wounds should never be exposed to air to dry out, as is often recommended. Moist wounds heal more quickly and have less risk of infection. If a wound appears dry, moisture needs to be added; this is accomplished by choosing an appropriate dressing (Table 3). Conversely, if a wound is draining, the drainage needs to be controlled and kept off of the periwound. The proper dressing should hold the moisture on the wound bed to prevent desiccation. [NAME] S, [NAME] E. Chronic Wounds: Evaluation and Management. Am Fam Physician. 2020 [DATE];101(3):159-166. PMID: 32003952. Resident #44 Review of an admission Record revealed R44 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: dementia. Review of R44's Skin Assessment dated 7/3/24 revealed R44 had redness identified on her coccyx . Addendum 07/06/24: Res has a red area near her coccyx approximately 4cm round. It is not open at this time . Review of R44's Electronic Health Record revealed no documentation that R44's responsible party or the wound nurse were notified. There was no treatment ordered/initiated at that time. A short term care plan was not initiated and/or the care plan was not updated. Review of R44's Provider Progress Note dated 7/8/24 revealed, .nickel-sized area over coccyx that needs to be 'watched' per nursing XXX[AGE] year-old female with a long-term care resident being seen for staff reporting redness over coccyx .Skin: 1 cm x 1 cm x 0.1 cm circular open area noted to right buttock, skin is very thin and fragile . No treatment ordered for the Stage II open area. Review of R44's Skin Assessment dated 7/11/24 revealed no breakdown to coccyx. Review of R44's Provider Progress Note dated 7/17/24 revealed, .Nursing reports no significant concerns. Seen earlier this month by nurse practitioner (name omitted); had a nickel sized area over coccyx she started some treatment to the area . Skin not fully examined today but there is mention of her stage II buttock sore . No treatment ordered for the Stage II open area. Review of R44's Skin Assessment dated 7/17/24 revealed, .Redness to bilateral buttocks . Review of R44's Skin Assessment dated 7/22/24 revealed no breakdown to coccyx. Review of R44's Skin Assessment dated 7/28/24 revealed, .Res (resident) has an area of less than one cm in diameter open area where epidermis is missing on the inner aspect of the right buttock . Review of R44's Electronic Health Record revealed no documentation that R44's responsible party or the wound nurse were notified. Review of R44's Skin Assessment dated 7/31/24 revealed an open area Stage II to her right buttock measuring 1cm x 1cm.Res has an area of less than one cm in diameter open area where epidermis is missing on the inner aspect of the right buttock . Review of R44's Order Summary dated 7/31/24 revealed, right buttocks: cleanse with normal saline or soap and water, pat dry apply TAO and 2x2 q 2 (every 2) days and prn one time a day every 3 day(s) for wound care. Resident #17 (R17) Review of an admission Record revealed R17 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: stroke. Review of R17's Skin Assessment dated 6/26/24 revealed, .Redness to bilateral buttocks . Review of R17's Provider Progress Note dated 6/26/24 revealed, .being seen today for staff reported impaired skin integrity . Skin: 1.5cm x 1.0cm x 0.2 area of shearing noted to left buttocks, minimal drainage noted to dressing, skin is very thin and fragile . Indicating a Stage II pressure injury. Review of R17's Order Summary dated 6/26/24 revealed, Left buttocks: cleanse with soap and water, pat dry, apply TAO, cover with border foam dressing q day. one time a day for wound care. Review of R17's Electronic Health Record revealed no documentation that R17's responsible party or the wound nurse were notified or that a short term care plan was initiate/care plan was updated. Review of R17's Skin Assessment dated 7/3/24 revealed, .Skin is unremarkable other than on going (sic) redness to bil buttocks . Review of R17's Skin Assessment dated 7/6/24 revealed, .ADDENDUM; During care this morning it was observed that the inner aspect of res right thigh and groin area is excoriated, and has an open area. The first few layers of skin have open related to excoriation . Review of R17's Interdisciplinary Documentation dated 7/6/24 revealed, During personal care it was observed that res had excoriation with an open area to her inner right thigh/peri area. Area cleansed with mild soap and water, barrier cream applied and moisture wicking pad placed to help relieve some of the moisture that is causing the excoriation. Review of R17's Electronic Health Record revealed no documentation that R17's responsible party or the wound nurse were notified or that a short term care plan was initiate/care plan was updated. Review of R17's Skin Assessment dated 7/10/24 revealed R17 had redness noted to bilateral buttocks. There was no documentation of open areas. Review of R17's Provider Progress Note dated 7/11/24 revealed, .Skin: Treatment in place for groin excoriation, left buttock wound, treatment in place . Review of R17's Skin Assessment dated 7/17/24 revealed R17 had redness noted to bilateral buttocks. Coccyx-other (specify) was documented with no additional assessment findings. Review of R17's Skin Assessment dated 7/24/24 revealed R17 had redness noted to bilateral buttocks. Coccyx-other (specify) was documented with no additional assessment findings. Review of R17's Skin Assessment dated 7/31/24 revealed R17 had redness noted to bilateral buttocks. Coccyx-other (specify) was documented with no additional assessment findings. Review of R17's June Treatment Administration Record revealed the left buttock treatment was not completed on 6/28/24 or 6/30/24. Review of R17's July Treatment Administration Record revealed the left buttock treatment was not completed on 7/11/24, 7/17/24, 7/18/24, 7/20/24, 7/21/24, 7/27/24, 7/28/24, or 7/31/24. Review of R17's August Treatment Administration Record revealed the left buttock treatment was not completed on 8/3/24. During an interview on 08/07/24 at 02:37 PM, Director of Nursing (DON) and RNC D confirmed the R44 and R17's care plans were not updated/STCP initiated following the identification of the skin impairment. RNC D reported that changes in resident condition, including skin breakdown, was discussed in the managers morning meetings utilizing a 24-hour report. An addendum was made to R44 and R17's Skin Assessments and a progress note was not completed causing it to be missed by management in the morning meeting. Additionally, the nurse did not notify the responsible party and wound nurse of the skin breakdown. Review of the facility policy Skin at Risk Assessment Documentation, Staging & Treatment last revised January 2020 revealed, Policy: It is the policy of this facility to assess resident risk factors for the development of impaired skin integrity and intervene as indicated utilizing the admission assessment, plan of care, and Minimum Data Set as formal assessment tools. It is the policy of this facility to assess skin on a regular basis to determine whether changes in the patient's skin condition have occurred. Weekly measurements and narrative assessments are conducted on existing pressure injuries. Purpose: To provide prompt identification and intervention for residents at risk of impaired skin integrity corresponding to risk factors. To limit the development of avoidable pressure ulcers and provide evidenced based guidance on effective strategies to promote pressure ulcer healing . 6. The following guidelines are reviewed and implemented as indicated for each individual risk factors: a. Daily skin inspections with am and pm care b. C.N.A. reporting of abnormal skin inspections to the charge nurse . h. Communication of skin concerns to other team members on the 24 hour report summary . q. Implement standing orders for impaired skin and / or Consult the physician prn for treatment and orders for impaired skin integrity . 9. Re-assess and measure a pressure ulcer a minimum of weekly. a. Whenever possible assign a consistent licensed nurse to an individual wound measurement to improve the uniformity, accuracy and reliability of the measurement and documentation. b. With each treatment observe the ulcer for signs that indicate a change in treatment is indicated (e.g., wound improvement, wound deterioration, more or less exudate, signs of infection or other complication) 10. Document the appearance of the wound with considerations to the physical characteristics as applicable to the resident; a. Location b. Stage c. Size d. Color e. Peri-wound condition f. Wound edges g. Sinus tracts or tunneling h. Exudate i. Odor 11. Reassess the resident, the pressure ulcer and the plan of care if the ulcer does not show signs of healing as expected despite appropriate local wound care, pressure redistribution, and nutrition. a. Expect some signs of pressure ulcer healing within two weeks. b. Adjust expectations for healing in the presence of multiple factors that impair wound healing . Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, When you care for a patient with a chronic complex wound, contact the wound care team if you note a change in the volume and/or consistency of the drainage, a presence of a strong odor in the drainage, and change in wound-healing status. It is also important to plan a dressing change with the wound care team to assess the wound together to determine effectiveness of the treatment plan and if the wound is showing progress toward healing. [NAME], [NAME] A.; [NAME], [NAME] G.; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 1338). Elsevier Health Sciences. Kindle Edition. Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, A wound assessment provides the foundation for developing a care plan, revealing data that aid in identification of nursing diagnoses and the selection of wound therapies best targeted for the condition of the patient's wound. [NAME], [NAME] A.; [NAME], [NAME] G.; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 1384). Elsevier Health Sciences. Kindle Edition. Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, When you identify the presence of a skin wound or pressure injury, closer assessment is required. Assess the type of tissue in the wound base and the factors influencing the patient's risks for poor healing so that you can plan appropriate interventions. The assessment includes the amount (percentage) and appearance (color) of viable and nonviable tissue .Measurement of the wound size provides information on overall changes in dimensions, which is an indicator for wound-healing progress ([NAME], 2016). This includes measuring the length and width of a wound, as well as determining its depth (see Skill 48.2). Use a disposable wound-measuring device to measure wound width and length. This approach offers a uniform, consistent method for measuring meaningful comparisons of wound status across time (EPUAP/NPIAP/PPPIA, 2019b). Measure depth by using a cotton-tipped applicator in the wound bed . Assessment of wound exudate should describe the amount, color, consistency, and odor of wound drainage. Normally a closed surgical wound has minimal serosanguineous drainage immediately after surgery (see Chapter 50). Excessive exudate indicates the presence of infection. Wound pain, including the location, distribution, type, quality, and intensity, and any aggravating or relieving factors also should be assessed ([NAME], 2016) (see Chapter 44). Examine the skin around a wound (periwound) for redness, warmth, and signs of maceration, and palpate the area for signs of pain or induration. The presence of any of these factors on the periwound skin indicates wound deterioration. [NAME], [NAME] A.; [NAME], [NAME] G.; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 1333). Elsevier Health Sciences. Kindle Edition. Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, Unstageable pressure injury: Obscured full-thickness skin and tissue loss o 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 (see Fig. 48.4F). If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e., dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. [NAME], [NAME] A.; [NAME], [NAME] G.; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 1322). Elsevier Health Sciences. Kindle Edition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake # MI0013669. Based on observations, interviews, and record reviews, the facility failed to provide adequate supervision and assistance to prevent falls for 3 residents (R26, R40 and R122) of 4 Residents reviewed for falls resulting in, R40 sustaining multiple injuries including a fracture of spine and hip, and R26 and R122 having multiple falls with injuries that required emergency room treatment. Findings included: R40 Review of R40's face sheet, dated 6/14/23 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: left femur fracture (4/24/23), Alzheimer's Disease, muscle weakness, dysphagia (difficulty swallowing), unsteadiness on feet, and cognitive communication deficit. R40 was not her own responsible party. Review of R40's incident and accident report dated 2/11/2023 at 6:43 PM revealed she had an unwitnessed fall and staff were notified of the fall by another resident. There was no indication if the resident's care plan was being followed at the time of the fall. The root cause listed was impaired cognition. There was no indication of the facility implementing any increased supervision or assistance after this fall. Review of R40's incident and accident report dated 2/20/2023 at 9:03 PM revealed R40 had an unwitnessed fall, R40 was found in her room on her back. R40 sustained a laceration on her left lower leg and a bruise on her left index finger. R40 was sent to the emergency room for treatment. When R40 returned to the facility she had 15 steri-strips and 5 sutures. R40 was noted to be wandering prior to being placed in bed. Root Cause: R40 was unable to state what she was attempting to do at the time of this incident due to her Dementia. She was toileted and ready for bed prior to the incident. After the investigation, it was conducted (sic) R40 was wandering with no known purpose due to Dementia. There were no interventions placed to increase supervision or assistance after this fall. Review of R40's incident and accident report dated 3/14/2023 at 12:45 AM revealed R40 was found on the bathroom floor. R40 had blood on the back of her head. R40 was sent to the emergency room for evaluation and treatment. The root cause was cognitive impairment and resident transferred herself to the bathroom. No intervention to increase supervision or assistance was noted. Review of R40's incident and accident report dated 3/21/2023 at 3:50 PM revealed R40 had an unwitnessed fall. R40 was found in her room on the floor with her head leaning against the bed and her nose was bleeding. R40 was sent to the emergency room for evaluation and treatment. The root cause was cognitive impairment. No intervention to increase supervision or assistance was noted. Review of R40's incident and accident report dated 4/11/2023 at 5:30 AM revealed R40 had an unwitnessed fall. R40 was found on the floor by the nurse's station with her head next to the fireplace. R40 had a hematoma and a laceration on the right side of her face. R40 was sent to the emergency room for evaluation and treatment. R40 was diagnosed with a T9 (spinal) fracture at the emergency room and was sent to another hospital for further treatment. The root cause was impaired cognition and resident does not understand her physical limitations. No interventions to increase supervision or assistance were noted. The intervention placed was adding anti-roll back device to wheelchair (Resident was care planned to have assistance with transfers and ambulation). Review of R40's incident and accident report dated 4/17/2023 at 10:16 PM revealed R40 had an unwitnessed fall. R40 was found on the floor near the nurse's station in the fetal position crying in pain. R40's left elbow and knee were bleeding. R40 was sent to the emergency room for evaluation and treatment. The root cause was impaired cognition. The intervention was to encourage R40 to be in a highly visible area when out of bed. R40 was in a highly visible area at the time of this fall and her last fall, however no staff witnessed this fall or the last fall. There was no indication that the facility had a plan to supervise R40 when she was awake. The physician note dated 4/25/23 revealed R40 returned from the hospital after this fall with a femur fracture and another spinal fracture at T1. Review of R40's physician note dated 4/14/23 revealed, 93 y.o. (year old) female is being re-admit. Patient was transferred to [name of Emergency Room] after a fall on 4/11/23. Patient was noted to have a fracture at T9 (spinal area). She was subsequently transferred to [name of town] for T9 fracture monitoring. Xray of right arm, shoulder, hip neg (negative) in addition to CT (computed tomography) of the head. Review of R40's physician note dated 4/25/23 revealed, [AGE] year-old female is being seen today for readmission related to fall with injury. Patient sustained a fracture of the neck of left femur, closed T1 (spinal area), closed fracture of the eighth thoracic vertebrae, scalp hematoma on 4/18/2023, in addition to T9 vertebral fracture on 4/14/23. Patient denies pain at rest during interview however movement of hands and lower extremities did cause significant disc comfort (sic) as evidenced by facial grimacing and moaning with grunting. Patient complains of lower left leg pain during wound treatment. Patient is alert to self only. Patient denies shortness of breath, chest pain or pressure, does not appear to be in acute distress patient is up in wheelchair. Care conference completed with patient's daughter-in-law regarding option for safety including clip alarm or seatbelt alarm and current interventions including bedroom layout, mattress next to bed, bed in low position, soft touch call light, antirollback (sic) breaking system on wheelchair and winged mattress. During an interview with the Director of Nursing (DON) and Clinical Specialist (CS) C on 6/15/23 at 9:19 AM, R40's timeline of falls provided by the DON was reviewed. R40 had 5 falls between 2/20/23 and 4/17/23. The DON and CS C were not able to locate any interventions placed to increase R40's supervision and assistance after her last 4 falls. R26 Review of R26's Minimum Date Set (MDS), nursing assessment tool dated 3/14/23 revealed R26 was admitted on [DATE] and had a primary diagnosis of stroke. She was [AGE] years old and required physical assistance of one person to transfer and walk. Her Brief Interview of Mental Status score was 4/15 (severely cognitively impaired). Review of R26's incident and accident report dated 12/12/2022 at 11:45 AM revealed she had an unwitnessed fall. Staff were notified by R26's roommate that R26 was on the floor in her room. The investigation revealed R26 was severely cognitively impaired. Root cause was resident does not consistently apply wheelchair brakes while transferring herself in and out of wheelchair. Intervention was to add anti-roll backs to resident's wheelchair. R26 was already assessed to need supervision and assistance for transfers and walking. No intervention was located to supervise R26 when she was awake. Review of R26's incident and accident report dated 2/17/23 at 11:06 PM revealed she had an unwitnessed fall in her room. There was no indication if the resident had been in bed and when the last time she was seen, or care had been provided. The root cause was impaired cognition. There was no indication of any increased supervision or assistance being implemented. Review of R26's incident and accident report dated 3/25/23 at 10:35 PM revealed R26 had an unwitnessed fall. R26 had been in bed and was found on the floor. R26 told staff she was trying to get to her recliner. There was no indication if R26 had been sleeping or when she had last received care. The root cause was R26 was attempting to self-transfer from bed to a recliner. R26 was assessed to have assistance with transfers. No interventions were located that would ensure R26 would be provided assistance with transfers and supervised when awake. Interventions in place were to encourage the use of gripper socks when in bed, mat next to bed, bed in lowest position when not providing care, soft touch call light for easy activation, and perimeter mattress for positioning. Review of R26's incident and accident report dated 5/11/23 at 11:22 PM revealed R26 had an unwitnessed fall. The report indicated that as the staff entered R26's room they saw her lower herself to the floor. R26 was not using her walker. There was no indication of the last time R26 was observed by staff or when care was last provided. There was no indication how long R26 was up walking. R26 was assessed to need assistance with walking and the report indicated R26 was walking independently. The intervention placed was to have R26 rest when walking. R26 was not her own responsible party and was severely cognitively impaired. There was no indication of how the facility planned to supervise R26 when she was walking. Review of R26's incident and accident report dated 5/20/23 at 9:41 PM revealed she had an unwitnessed fall. Staff reported R26's roommate alerted them R26 had fallen. R26 was found on the floor next to her bed. There was no indication how long R26 had been in bed. There was no indication when R26 last had any care provided. The interventions were to remove the green soaker pad from the bed and rearrange the room or remove the recliner. There was no indication of how the facility planned to supervise R26 when she was awake or meet her care needs to prevent R26 from doing unsafe transfers. During an interview with the Director of Nursing (DON) and Clinical Specialist (CS) C on 6/15/23 at 10:00 AM, R26's fall incident reports from 12/12/22 to 5/20/22 were reviewed. They confirmed that they had not implemented any increased supervision or assistance for R26 after the 5 known falls. They did not remove R26's recliner from her room. They reported they were aware that when R26 wakes up she immediately tries to get out of bed and remains at high risk for continued falls due to her impaired cognition. They reported they have had discussions in the quality assurance meeting of the need to improve safety and prevent falls. R122 Review of R122's face sheet dated 6/14/23 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: fracture of the first lumbar vertebra (4/24/23), unspecified fall (4/24/23), difficulty walking, need for assistance with personal care, diabetes mellitus II, and age-related physical debility. R122 was not her own responsible party. R122 was observe sitting on the edge of her bed yelling for help on 6/13/23 at 2:51 PM. R122 said she kicked the mat out of the way, and she needed to go to the bathroom now. R122's call light was on. No staff were observed in the hall and the light over the door was not on (no indication R122 had her call light on). The red light on the wall near the call light cord was lit. The Surveyor told R122 she would find help. Two staff were located at the nurse's station. The nurse's station was not in view of R122's hall or room. Certified Nurse Aide (CNA) D responded to come help R122. The Surveyor reported the call light over R122's door was not functioning. CNA D reported none of the lights over the doors are functional. CNA D said the call system uses pagers. The Surveyor asked CNA D where her pager was and CNA D reported when she started at 2:00 PM there were no more pagers. CNA D said her hall partner would have to yell out for her if a call light was on. CNA D denied knowing R122's call light was on prior to the surveyor notifying her it was on. CNA D took R122 to the bathroom. However R122 was wet prior to reaching the bathroom. Review of R122's incident and accident report dated 4/20/23 at 3:50 PM, revealed she had an unwitnessed fall. R122 was found on the floor in her room. R122 was bleeding from the back of her head and was sent to the emergency room for evaluation and treatment. The root cause was R122 stubbed her toe walking. The intervention was for R122 to slow down when walking and encourage her to wear shoes not slippers. The investigation indicated R122 required assistance of one person to transfer and walk with a walker. The investigation indicated the need for assistance had changed but did not give the date of the change. Review of R122's incident and accident report dated 4/28/23 at 6:30 AM revealed she had an unwitnessed fall. R122 was found on the floor in her room. Resident did not have grippy socks on, her bed was in a low position and her call light was in reach. (no indication if the call light was on). The root cause was R122 had a UTI (urinary tract infection). There was no indication when R122 had last been assisted with care. There was no indication of any interventions placed to increase supervision or assistance. Review of R122's incident and accident report dated 5/5/23 at 12:17 PM revealed she had an unwitnessed fall in her room. The root cause was R122 is very self-determined and prefers to do most things for herself and she does not use the call light to get assistance. R122 self-transfers. The intervention was to encourage R122 to be in the lounge area when awake (R122 is cognitively impaired and not her own responsible party). There was no indication of how the facility planned to supervise R122 if she did not want to sit in the lounge area when awake. Review of R122's incident and accident report dated 5/12/23 at 11:10 PM revealed she had an unwitnessed fall. Resident was found on the bathroom floor with a bump on the back of her head. There was no indication of the last time R122 had been provided assistance with care or using the toilet. The intervention placed was 15-minute checks for 3 days. No long-term intervention for increased supervision or assistance was located. The root cause was R122 needed to use the bathroom and failed to use the call light (R122 was cognitively impaired and not her own responsible party). Review of R122's incident and accident report dated 5/22/23 at 10:00 AM revealed she had an unwitnessed fall. R122 was on the floor in her room. R122 had been in her wheelchair and was reaching for her shoes and slid to the floor. The root cause was R122 is self-determined and chooses not to utilize the call light. (R122 was cognitively impaired and was not her own responsible party). There was no intervention located to increase R122's supervision or assistance. Review of R122's incident report dated 5/26/23 at 7:22 AM revealed R122 was found on the floor in her room bleeding from the back of her head. R122 reported she was getting up and putting on her shoes. Interventions were to place shoes in reach, mat next to bed and R122 is the first to get up and dressed. R122 was sent to the emergency room for evaluation and treatment of the head wound. During an interview with the Director of Nursing (DON) and Clinical Specialist (CS) C on 6/15/23 at 10:00 AM, the observation of the call light not functioning outside R122 door and the CNA not having a pager on 6/13/23 at 2:51 PM was discussed. The DON confirmed she has had problems with not having enough pagers for all staff when they come to work as staff are taking the pagers home. The DON reported she purchased 17 new pagers in May and sent a message out to staff Monday (6/12/23) that they needed to bring the pagers back. The DON said the lights above the door were made inactive years ago. The DON confirmed that R122 was cognitively impaired, has poor safety awareness and was not her responsible party. R122's incident and accident reports were reviewed along with her care plan. The DON was not able to locate any interventions that ensured the facility was supervising R122 when she was awake or ensuring they were able to assist her with her care needs. The DON confirmed that R122 continues to self-transfer and remains at risk for injuries when she is not supervised with her care.