**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #317 Review of admission Record revealed Resident #317 was originally admitted to the facility on [DATE] with pertinent diagnoses which included pressure ulcer of sacral region. Review of a Minimum Data Set (MDS) assessment for Resident #317, with a reference date of [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 11/15 which indicated Resident #317 was moderately cognitively impaired. Review of Skin Conditions revealed that Resident #317 was at risk for developing pressure ulcers. Review of Resident #317's Care Plan revealed, .has potential/actual skin impairment to skin integrity r/t (related to) stage IV pressure injury to sacrum (tailbone), impaired mobility. Date initiated [DATE]. Goal: Resident's skin integrity breaks will exhibit healing by next review date. Interventions: Elevate heels off bed surface while at rest in bed .Keep skin clean and dry .Follow physician orders for treatment of skin impairments .Provide pain management for treatments as needed .Date initiated [DATE] . There were no interventions related to Resident #317's pressure injury on the sacrum. During an interview on [DATE] at 08:29 AM, Resident #317 reported concern that call lights did not get answered quickly enough,which led to several occasions where Resident #317 had incontinence while waiting for assistance to use the restroom and was left wet. During an observation on [DATE] at 03:30 PM, Resident #317 was observed in her room sitting in her wheelchair. There were no pillows underneath Resident #317 hips or bottom to offload the sacral pressure ulcer. During an observation on [DATE] at 7:55 AM, Resident #317 was in her bed, lying on her back with the head of bed elevated at approximately 45 degrees. There were no pillows were observed underneath Resident #317 hips or bottom to offload the sacral pressure ulcer. Resident #17's feet were observed lying directly on the surface of the bed. During an interview and observation on [DATE] at 09:14 AM, Resident # 317 was observed lying in her bed in the same position as previous observation. Resident #317 reported that the wound on her butt was painful and facial grimacing was noted throughout interview. Resident #317 reported that she felt the staff were unreliable and inconsistent, and she was not getting repositioned every two hours. During an interview on [DATE] 09:20 AM, Registered Nurse (RN) X reported that she was aware that Resident #317 was in pain and that had already given her Tylenol and oxycodone (pain medication) for this, and that Resident #317 needed a better mattress. RN X also reported that she had been in Resident #317's room every 35 seconds this morning. Review of Medication Administration Record indicated Resident #317 received Acetaminophen (Tylenol) 500 mg at 08:00 AM, and Oxycodone 5 mg at 07:09 AM. RN X documented Resident #317 pain level at 0 under pain evaluation, and 1 under pain level for administration of Oxycodone. During an observation on [DATE] at 10:22 AM, Resident# 317 was observed sitting in her wheelchair without any pillows for offloading or positioning, and sitting directly on her pressure wound. During an observation on [DATE] at 11:16 AM, Resident #317 was observed on her back with the head of the bed elevated to approximately 45 degrees. There were no pillows observed for offloading the wound of Resident #317's sacral area. Resident #317 was positioned on her pressure wound and her feet were directly on the surface of the bed (not elevated). During an wound care observation on [DATE] at 11:24 AM, Resident #317 was lying in bed on her right side. Physician Assistant-Wound Care (PA-WC) DD removed Resident #317's incontinence brief which revealed a large gaping wound approximately fist size, with slough and eschar (dead tissue) in the wound bed, and reddened skin surrounding the wound. Resident #317 was positioned on her back following wound care and stated Ouch it hurts. PA-WC DD reported that Resident #317 should have an alternating pressure air mattress due to her sacral wound, and LPN UM D reported that she would get it ordered. During an interview on [DATE] at 12:47 PM, PA-WC DD reported that her clinical recommendations for Resident #317's wound care would include an alternating air pressure mattress, repositioning at least every two hours, and she would not want to see Resident #317 in a position where she is sitting directly on the wound. PA-WC DD reported that offloading with pillows would help decrease the pain from the wound. During an observation on [DATE] at 01:32 PM, Resident #317 was observed sitting up in bed in the same position as previous observation on [DATE] at 11:24 AM. Resident #317 had been in the same position for greater than 2 hours. Resident #17's feet were observed lying directly on the surface of the bed. During an interview on [DATE] at 02:05 PM, Certified Nursing Assistant (CNA) O reported that she goes from room to room to check on residents, and she determines which residents need to be repositioned every two hours by just asking the residents. CNA O did not identify that Resident #317 required every 2 hour repositioning. During an observation on [DATE] at 08:29 AM, Resident #317 was observed lying in bed with the HOB approximately 45 degrees, and there were no pillows to offload Resident #317's sacral pressure ulcer. Resident #317's bed did not have an alternating air pressure mattress. Review of Resident #317's Order summary report did not include orders for frequency of repositioning or alternating air pressure mattress. Review of Resident #317's Kardex (CNA care guide) revealed, elevate heels off bed surface while at rest in bed, keep skin clean and dry . There were no interventions related to repositioning. This citation pertains to MI00133137 and MI00131737. Based on observation, interview, and record review the facility failed to consistently implement pressure ulcer prevention and treatment interventions and ensure complete and accurate skin assessments were performed to monitor, identify and treat skin alterations for 5 residents (Resident #11, #48, #7, #317, and #65) out of 7 residents reviewed for pressure ulcer care, resulting in the formation of new facility acquired pressure ulcers for Resident #11 and Resident #48, a delay in the treatment of a DTI (deep tissue injury) to the right foot and a stage 2 pressure injury to the left foot of Resident #65, and the potential for further clinical compromise for Resident #7 and #317. Findings include: Resident #11 Review of an admission Record revealed Resident #11 admitted to the facility on [DATE] with pertinent diagnoses which included quadriplegia and Multiple Sclerosis. Review of a Minimum Data Set (MDS) assessment for Resident #11, with a reference date of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #11 was cognitively intact. Further review of the same MDS assessment revealed Resident #11 required assistance with bed mobility, toileting, and personal hygiene. Review of a current ADL (activities of daily living) Care Plan intervention for Resident #11, initiated [DATE], directed staff that Resident #11 could be up in her powered wheelchair daily for four hours at a time and was then required to lay down for one hour before getting back up for offloading of pressure. Review of a current physical mobility Care Plan intervention for Resident #11, initiated [DATE], directed staff that Resident #11 was totally dependent on staff for repositioning and turning in bed frequently as necessary. In an interview on [DATE] at 11:34 AM, Family Member of Resident #11 KK reported recently only 2 nursing aides showed up for the entire facility, 1 aide for 28 residents. In an interview on [DATE] at 3:19 PM, Family Member of Resident #11 KK reported staff are not turning Resident #11 every two hours and Resident #11's wound recently reopened because there was not enough staff to get her out of her powered wheelchair. In an interview on [DATE] at 9:35 AM, Resident #11 reported she had a wound on her bottom that was healed and then opened back up because she was left up in her powered wheelchair for 9 hours. Resident #11 reported that she was only allowed to be up for 4 hours at a time in her powered wheelchair to relieve pressure on her bottom. Resident #11 reported that 3rd shift was good about turning her every 2 hours, but 1st and 2nd shift were not as good. Resident #11 reported that she is unable to turn herself. Resident #11 reported that she was last turned at 6:45 AM, 3 hours ago. Resident #11 reported that 3rd shift checks on her automatically, but on 1st and 2nd shift she has to request turning. Resident #11 reported that it can take a long time for her call light to be answered, sometimes up to 2 hours. Resident #11 reported that call light response time depends on the staffing that day. In an interview on [DATE] at 10:25 AM, Resident #11 reported that it was a couple months ago that her wound broke back open, after being up in her powered chair for 9 hours. Resident #11 reported that there was a music activity and many residents needed assistance after the activity. Resident #11 reported that there was only 1 aide working on the hall that night and she seemed overwhelmed. In an observation on [DATE] at 11:58 AM in Resident #11's room, Wound Care Provider DD evaluated Resident #11's pressure ulcer on her right medial buttock to be 0.1 by 0.4 centimeters. Review of Resident #11's Wound Care Provider Progress Note dated [DATE] revealed .(Resident #11) is seen today because staff state she has an ulcer on her bottom again. Resident has a history of pressure injuries to her sacrum and right medial buttock . Resident with an ulcer on the right upper medial buttock measuring 0.2by1.1by0.2cm . Pressure injury of right buttock, stage 3 . Resident with a pressure injury to the right upper medial buttock again . Resident #48 Review of an admission Record revealed Resident #48 admitted to the facility on [DATE] with pertinent diagnoses which included spinal stenosis and lack of coordination. Review of a Minimum Data Set (MDS) assessment for Resident #48, with a reference date of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #48 was cognitively intact. Further review of same MDS assessment revealed Resident #48 required assistance with bed mobility, toileting, and personal hygiene. Review of a current Kardex for Resident #48 directed staff that Resident #48 needed extensive assistance of 1 staff with bed mobility. In an interview on [DATE] at 10:05 AM, Resident #48 reported she needs help turning in bed and stated, they keep turning the call light off, don't come right away. In an observation and interview on [DATE] at 12:19 PM in Resident #11's room, Unit Manager E reported that a new wound was found over the weekend on Resident #11's left heel. Wound Care Provider DD evaluated the wound to be a 3.5 by 6.6-centimeter unstageable deep tissue injury. Observed left heel wound to be a large, blood-filled blister. In an interview on [DATE] at 8:54 AM, Resident #48 reported staffing was short over the weekend when her new left heel wound was found. Resident #48 reported when staffing is short they do not come in to assist her with repositioning in bed. Resident #48 reported when staffing is short it takes a long time for her call light to be answered. Review of the facility worked schedule on Saturday, [DATE] revealed there were only 3 nursing assistants working in the entire building from 11:00 AM until 11:00 PM. In an interview on [DATE] at 10:42 AM, LPN AA reported staffing has been challenging for months. LPN AA reported there were only 3 aides in the facility that morning and only 1 aide working with her on the 100 hall with 23 residents to care for. LPN AA reported when there is only 1 aide on the hall, there is not enough time to give residents showers and it is not possible to check, change, and turn residents every two hours. LPN AA reported when staffing is short, the aides work methodically through the unit to get to everyone as quickly as possible. In an interview on [DATE] at 10:06 AM, Certified Nursing Assistant (CNA) S reported that she was the only CNA on 100 hall the previous day. CNA S reported that happens at least once a week. CNA S reported there is no time for resident showers when she is the only CNA on the hall and it is not possible to perform check and changes and turns every two hours. In an interview on [DATE] at 2:55 PM, CNA U reported the facility needs a minimum of 5 CNA's to perform adequate resident care. CNA U reported that a couple times a month she works as the only CNA on a hall. CNA U reported when she is the only CNA working on a hall resident showers cannot be completed, waters might not get passed, and it is not possible to perform two hour resident checks and changes and turns. CNA U reported it takes closer to 4 hours to perform check and changes and turns when she is working alone on a hall. For patients at risk for skin breakdown who are able to sit in a chair, limit the amount of time they sit to 2 hours or less at any given time. In the sitting position the pressure on the ischial tuberosities is greater than in the supine position . Support surfaces are specialized devices for pressure redistribution designed for management of tissue loads, microclimate, and/ or other therapeutic functions (i.e., any mattress, integrated bed system, mattress replacement, overlay, seat cushion, or seat cushion overlay) (NPUAP, EUPAP, PPPIA, 2014). Support surfaces reduce the hazards of immobility to the skin and musculoskeletal system. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing - E-Book (Kindle Locations 72248-72276). Elsevier Health Sciences. Kindle Edition. Positioning interventions redistribute pressure and shearing force to the skin. Elevating the head of the bed to 30 degrees or less decreases the chance of pressure ulcer development from shearing forces (WOCN, 2010). Change the immobilized patient's position according to tissue tolerance, level of activity and mobility, general medical condition, overall treatment objectives, skin condition, and comfort (NPUPA, EUPAP, PPPIA, 2014). A standard turning interval of to 2 hours does not always prevent pressure ulcer development. Consider repositioning the patient at least every 2 hours if allowed by his or her overall condition. When repositioning, use positioning devices to protect bony prominences (WOCN, 2010). The WOCN guidelines (2010) recommend a 30-degree lateral position (Figure 48-15), which should prevent positioning directly over the bony prominence. To prevent shear and friction injuries, use a transfer device to lift rather than drag the patient when changing positions (see Chapter 39). [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing - E-Book (Kindle Locations 72244-72253). Elsevier Health Sciences. Kindle Edition. Review of facility policy/procedure Skin Monitoring and Management- Pressure Ulcer, dated [DATE], revealed .It is the policy of this facility that: A resident who enters the facility without pressure ulcers does not develop pressure ulcers unless the individual's clinical condition or other factors demonstrate that a developed pressure ulcer was unavoidable; and a resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection, and prevent new, unavoidable sores from developing . Prevention . Reposition the resident .Treatment . Continue preventative measures as appropriate, including but not limited to : pressure reduction, continence care, mobility, nutrition management, hydration management . Resident #65 Review of an admission Record revealed Resident #65 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: muscle weakness and severe protein/calorie deficiency. Review of a Minimum Data Set (MDS) assessment for Resident #65, with a reference date of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #15 was cognitively intact. Review of the Functional Status revealed that Resident #15 required extensive assistance of one person to reposition in bed, and extensive assistance of two people for toileting needs. Review of Skin Conditions revealed that Resident #65 was at risk for pressure ulcers and did not have any pressure ulcers or other skin conditions. In an interview on [DATE] at 12:43 PM, Family Member (FM) LL reported that Resident #65 was sent to the hospital on [DATE] and died a few weeks later. FM LL reported that Resident #65 had uncontrolled pain, was dehydrated, and had wounds on both feet, that the facility had not identified during their skin observations. FM LL reported that Resident #65 was too tall for his bed and his feet pressed against the foot board. Review of Resident #65 Hospital Records indicated admission via emergency room on [DATE], wound consult on [DATE], transition to palliative care on [DATE], and death in the hospital on [DATE]. Images from [DATE] reviewed and indicate wounds on the bottom of both feet. Wound Care Services on [DATE] at 5:30 AM .The Wound Healing Program is consulted for bilateral black wounds on 5th toes. He is a poor historian and does not know how long the wounds have been present or how he got them. He states he does not ambulate .Pressure injury of deep tissue of right foot, Assessment & Plan: Plantar surface (bottom of foot) over right 5th MT (metatarsal: bone on outside on foot) Dark tissue from evolving DTI (deep tissue injury) likely from pressure, 1.4 x 1.5 x 0.1 cm .Pressure injury of left foot, stage 2. Assessment & Plan: Appears to be recovering DTI, Wound is located over the 5th MT, 0.6 x 0.5 x 0.1 cm, Partial thickness likely from pressure . In an interview on [DATE] at 10:49 A.M., DON reported that Resident #65's record did not indicate that Resident #65 had any wounds, and that DON had evaluated Resident #65's skin at the request of FM LL, and the only finding was dry skin. Review of Resident #65's Nursing admission Assessment dated [DATE] indicated that Resident #65 did not admit to the facility with wounds. Review of Resident #65's Weekly Skin Observations from admission through to the last one complete on [DATE] all indicated that Resident #65 had No New Skin Conditions. Review of Resident #65's Physician admission Assessment dated [DATE] did not include Skin in the examination and did not indicate Resident #65 had skin wounds under History or Assessment and Plan. Review of Resident #65's Physician Orders revealed no orders related to dry skin or wounds. Review of Resident #65's Braden Scale for Predicting Pressure Ulcers dated [DATE] indicated that Resident #65 was at moderate risk for developing pressure ulcers. Review of Resident #65's Skin Care Plan revealed, .has potential/actual skin impairment to skin integrity r/t (related to) decreased mobility, decreased awareness of needs, incontinence. Date initiated [DATE] .Goal: Resident will maintain intact skin through the next review. Interventions: Educate resident/family/caregivers .Encourage good nutrition and hydration .Follow physician orders for treatment of skin impairments. Refer to eTAR (electronic treatment administration record) for specifics .Observe skin daily .Weekly treatment documentation to include measurement of each area of skin breakdowns . The care plan was created and initiated on [DATE] and did not have any revisions. Review of Resident #65's Skilled Nursing Note dated [DATE] at 09:25 AM revealed, Resident's guardian came to facility to speak with med staff about resident's pain control. MD (Medical Director), NP (Nurse Practitioner), DON and UM (unit manager) met with guardian .Guardian expressed interest in having resident examined, as he appeared to have continued dryness to his skin. Med staff to see today . Review of Resident #65's Progress Note dated [DATE] at 6:45 PM revealed, Acute Care Transfer .Resident c/o (complains of) significant pain with sudden onset of worsening pain .Order to send to ER . Resident #7 Review of the face sheet revealed Resident #7 orginally admitted to the facility on [DATE] and discharged on [DATE] and readmitted on [DATE] with diagnosis that included multiple sclerosis, paraplegia, pressure ulcers, and urostomy (opening in the abdomen that connects to the urinary tract to allow urine to drain). Review of the Physician order dated [DATE] at 1:59 pm revealed Resident #7 was to have Wound Care for Stage 4 pressure ulcer to right ischium : Cleanse with NS; Apply thick layer of zinc barrier cream to peri wound. Pack wound with thin strip of Aquacel AG (about 2 cm deep). Cover with Mepilex. Change daily. In an observation on [DATE] at 12:58 PM, Physician Assistant/Wound Care Provider (PA/WCD) DD and Licensed Practical Nurse/Unit Manager (LPN/UM) E were preparing to change Resident # 7 pressure ulcer dressing on her right ischium. PA/WCD DD retrieved zinc oxide and placed it into a cup. LPN/UM E reported the wound is to be dressed using aqua cell AG and PA/WCD DD and LPN/UM E began looking for it. LPN/UM E stated I don't think we carry that. PA/WCD DD reported that the facility doesn't have it, and only the wound clinic has it. PA/WCD DD removed Resident #7's brief and there was a bandage on right lower ischium that was undated and unsigned. PA/WCD DD removed calcium Alginate packing (note, dressing material was not what was ordered)Resident #7's wound edges were clean, dry and intact. PA/WCD DD measured the wound depth to be 1.0. The wound was circular and approximately 1-2 cm. PA/WCD DD decided to use iodoform instead of Aquacel AG since they did not have any and stated the order is for aqua cell but can't follow the order because we don't have the material. PA/WCD DD packed iodoform in the wound, placed gauze into hole and covered with a bandage. Resident #7 then received a new brief, was boosted back up in bed by PA/WCD DD and LPN/UM E. Resident #7 voiced no complaints for procedure. Note that the ordered aqua cell was not used and zinc oxide was not placed in peri wound area. In an interview on [DATE] at 3:14 PM, LPN/UM E reported the Aqua Cell should have arrived by pharmacy if done by physician orders and it should have been delivered the next day the 29th. LPN/UM E reported the order was not entered correctly by the LPN who put the order in as other category instead of pharmacy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide adequate supervision for 1 of 4 residents (Resident #14) reviewed for accidents/hazards, resulting in the potential for residents to sustain a fall injury which have the potential to negatively affect the residents highest practicable physical, mental, and psychosocial well-being. Findings include: Review of an admission Record revealed Resident #14 was a female with pertinent diagnoses which included heart failure, diabetes, GI bleed, muscle weakness, cervical disc degeneration (compression on the vertebrae in the neck causing pain), colon cancer, diverticulosis (pockets or small pouches in the intestine which can become inflamed), kidney disease, anxiety, bursitis (inflammation in the cushions of the joint) of the left hip, chronic pain, spinal stenosis, anemia, shortness of breath, respiratory failure, and abnormalities of gait. Review of a Minimum Data Set (MDS) assessment for Resident #14, with a reference date of 3/20/2023 revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated Resident #14 was cognitively intact. Review of a Minimum Data Set (MDS) assessment for Resident #14, with a reference date of 11/01/2022, revealed, .Extensive Assistance .Two+ persons physical assist .Upper extremity .Impairment on one side . Review of current Care Plan for Resident #14, revised on 3/14/2021, revealed the focus, .Resident has an ADL (activities of daily living) self-care performance deficit r/t (relate to) impaired mobility (cervical disc degeneration, bursitis left hip, sciatic RIGHT LE (lower extremity) . with the intervention .Encourage and/or assist resident to meet toileting needs either with utilization of bathroom, bedpan, commode, urinal per resident request, preference, and as needed . In an interview on 05/01/23 at 08:04 AM, Resident #14 reported she fell and broke her leg last December 2022. Resident #14 reported the aide didn't' know how to get me up as she utilized a sit to stand for transfers. Resident #14 stated, .I was slipping out of the sling, she didn't buckle the two buckles, it was a smaller of the vest and I couldn't breathe .I think that I fainted .I guess I let go of the handle bars, slid out and flat on my back .I twisted my leg somehow and broke my femur .I was in terrible pain, screaming and the ambulance came and took me to the hospital . Review of Event Note dated 12/19/2022 at 10:50 PM, revealed, .During transfer resident slid out of [NAME] pad and onto the floor. CNA witnessed this event and state resident did not hit her head. Resident immediately stated pain in her right knee. Right knee appears swollen. On call provider notified and order to send resident to the emergency room obtained. Resident transferred via (ambulance service) to (Local Hospital). Review of Incident Report dated 12/19/22 at 21:30 PM, revealed, .Resident slid to the floor during a transfer with the Sara lift .Patient Description: I don't know, I think I passed out.Resident stabilized on the floor, physician and EMS notified. Assisted off the floor by EMS and sent to (Local Hospital) .Pain .Right Knee (front) .Predisposing Physiological Factors: Incontinent, Weakness/Fainted .Other Info .Resident states her pad for the lift wasn't positioned properly . Review of Witness Statement by Agency CNA NN included in the Incident Report revealed, .Her butt was on the edge of the bed, I said to (Resident #14), hold on to the handles I need to push her more and the bed, but she took her hands off the handles, and she slide down to the floor . Review of Statement dated 12/19/22, signed by LPN SS revealed, .During examination by nurse of (Resident #14) it was noted that (Resident #14)'s right knee had swelling .Resident expressed extreme pain in the right knee and was not able to extend leg out .Nurse was supporting (Resident #14) by sitting behind her and holding her so that she was not resting her head and back on the [NAME] stand legs .Three CNAs and two nurses came to assist nurse with resident. Resident was assisted to the floor and [NAME] stand moved from under her safely . Review of Post Fall Assessment dated 12/19/22, revealed, .Previous history of fall .Yes .Injuries related to his fall .Yes .Any pain during ROM (range of motion) or ambulation .Yes .Previous Interventions: Call light within reach, medications as ordered, bed in lowest position .New Interventions: Educate all staff that transfers with mechanical lifts must have 2 people Review of (Local Hospital) Emergency Department Note dated 12/19/22 revealed, .Patient presents emerged department for right knee pain. Patient currently lives in a skilled nursing center. Patient was brought to the emergency department via EMS. According to paramedics, the patient was transferring from wheelchair to bed with assistance. Patient's legs gave out. Patient slid to the floor. Injuring her right knee .Patient is now complaining of right lower extremity pain. She states that she cannot put any weight on her right lower extremity. Patient informs me that she does have a surgery scheduled for tomorrow. She believes it has something to do with her Foley catheter. Patient's prearrival form states that the patient had a bowel prep done today for colonoscopy tomorrow . Musculoskeletal: Right lower extremity: There is obvious deformity over the knee joint. There is gross soft tissue swelling. There is mild shortening or rotation of the right lower extremity when compared to the left. Patient is not able to move the right lower extremity secondary to pain. She has significant tenderness over the generalized femur area . Review of Orthopedic Trauma Consult dated 12/20/22 at 7:22 AM, revealed, .Patient is a 78 y.o. female with a right periprosthetic Distal Femur Fracture s/p twisting injury during transfer at care facility .Clinical impressions: Closed bicondylar fracture of distal femur, right .Closed fracture of distal end of right femur, unspecified fracture morphology . Review of Admit/Readmit Note dated 12/22/2022 at 3:12 PM, revealed, .Resident arrived at facility approximately 1:40 pm accompanied by two paramedics transferred by stretcher from (Local Hospital). Residents admitting Diagnosis to (Local Hospital) Right Femur Fracture. Paramedics transferred resident from the stretcher to bed Resident c/o some discomfort during transfer and repositioning. Assessment completed by writer .Wound Treatments Primapore to Right Femur. (Primapore: a post operative wound dressing .aids in the prevention of bacterial contamination .water resistant dressing). Review of General Progress Note dated 12/28/2022 at 1:35 PM, revealed, .Resident c/o (complaint of) mild pain to leg area .accepted prescribed pain medications, Gabapentin and PRN Tramadol. Also allowed writer to administer Lidocaine patch to upper right thigh prior to scheduled therapy. Resident relaxed calm, with no complaints thereafter administration of pain medication. Residents dressing to right thigh intact without drainage. Will continue to monitor resident . In an interview on 05/03/23 at 10:10 AM, Resident #14 reported she was concerned because she was not being taken to the bathroom. Resident #14 stated, People are not wanting to take me to the bathroom .Telling me they don't have time to take me to the bathroom .Supposed to be two people to get me up and take me to the bathroom but there was only one aide on the hallway, and they have to always look for help to take me to the bathroom . Review of General Progress Note dated 4/4/2023 at 4:32 PM, revealed, .Late entry for 4/3/23 Quarterly MDS w/ ard 3/20. Patient interviewed and confirmed total assist mechanical lift with two assist used for all transfers . In an interview on 05/03/23 at 11:21 AM, Registered Nurse (RN) I reported she was the manager on duty and it was a significant event. RN I reported the CNA was assisting Resident #14 was transfer to her bed, not quite on the bed and she slid out of the sit to stand. RN I stated, When I got down there, she was on the floor, the nurse was with her .She was in a lot of pain and I could tell something was wrong, told staff not to move her, and call EMS to have the come and evaluate her .They started her IV and gave her fentanyl because she was in so much pain .The resident told me she thought she fainted .It was horrible .Education was immediately provided to staff members .She was a two person sit to stand . RN I reported if they were a lift, they were a two person for transfers. In an interview on 05/03/23 at 11:42 AM, Agency CNA NN reported the facility was giving the resident prep for a colonoscopy the next day. CNA NN reported staff were telling me the resident did not need two persons for assist with the [NAME] stand lift. CNA NN stated, .I kept telling people I needed help and she needed two people to transfer .What was I supposed to do? I was the only CNA assigned to that hall and she needed to get to the bathroom because she was drinking stuff for the colonoscopy .I set her down on the toilet and raised her up, cleaned her bottom .She was getting weak, pulled the light .I really needed help and yelled out the door but no one would answer me .She was feeling lightheaded and she had diarrhea continuously and she was not strong enough to hold on .I had to get her off the toilet, I couldn't get help and I couldn't let her sit there for hours (in the bathroom) .It was in the best interest of the resident .I got her up and got her over to the edge of the bed and asked her to let me get her steady and everything was intact, the sling goes all around behind her, and raised her up and she let go of everything and slid from underneath the Sara lift . I felt the best of my knowledge not to leave her in that, as that is not right either, and not getting help from the other staff . In an interview on 05/03/23 at 02:18 PM, DON B reported the resident let go of the handles during the transfer and does not participate very well with being transferred with the lift. DON B stated, .With the Sara lift we would have to do some of the work for her . DON B reported Resident #14 was to have been a two person assist with transfers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #11 Review of an admission Record revealed Resident #11 admitted to the facility on [DATE] with pertinent diagnoses which included quadriplegia and Multiple Sclerosis. Review of a Minimum Data Set (MDS) assessment for Resident #11, with a reference date of 4/1/2023 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #11 was cognitively intact. Further review of the same MDS assessment revealed Resident #11 required assistance with bed mobility, toileting, personal hygiene, and bathing. Review of a current ADL (activities of daily living) Care Plan intervention for Resident #11, initiated 12/7/2021, directed staff that Resident #11 could be up in her powered wheelchair daily for four hours at a time and was then required to lay down for one hour before getting back up for offloading of pressure. Review of a current physical mobility Care Plan intervention for Resident #11, initiated 8/7/2021, directed staff that Resident #11 was totally dependent on staff for repositioning and turning in bed frequently as necessary. Review of a current ADL (activities of daily living) Care Plan intervention for Resident #11, initiated 8/7/2021, directed staff that Resident #11 should be showered according to the shower schedule. In an interview on 4/27/2023 at 11:34 AM, Family Member of Resident #11 KK reported recently only 2 nursing aides showed up for the entire facility, 1 aide for 28 residents. In an interview on 4/27/2023 at 3:19 PM, Family Member of Resident #11 KK reported staff are not turning Resident #11 every two hours and Resident #11's wound recently reopened because there was not enough staff to get her out of her powered wheelchair. In an interview on 5/1/2023 at 9:35 AM, Resident #11 reported she had a wound on her bottom that was healed and then opened back up because she was left up in her powered wheelchair for 9 hours. Resident #11 reported that she was only allowed to be up for 4 hours at a time in her powered wheelchair to relieve pressure on her bottom. Resident #11 reported that 3rd shift was good about turning her every 2 hours, but 1st and 2nd shift were not as good. Resident #11 reported that she is unable to turn herself. Resident #11 reported that she was last turned at 6:45 AM, 3 hours ago. Resident #11 reported that 3rd shift checks on her automatically, but on 1st and 2nd shift she has to request turning. Resident #11 reported that it can take a long time for her call light to be answered, sometimes up to 2 hours. Resident #11 reported that call light response time depends on the staffing that day. Resident #11 reported staff are not able to shower her when there are staffing problems. In an interview on 5/2/2023 at 10:25 AM, Resident #11 reported that it was a couple months ago that her wound broke back open, after being up in her powered chair for 9 hours. Resident #11 reported that there was a music activity and many residents needed assistance after the activity. Resident #11 reported that there was only 1 aide working on the hall that night and she seemed overwhelmed. In an observation on 5/2/2023 at 11:58 AM in Resident #11's room, Wound Care Provider DD evaluated Resident #11's pressure ulcer on her right medial buttock to be 0.1 by 0.4 centimeters. Review of Resident #11's Wound Care Provider Progress Note dated 3/7/2023 revealed .(Resident #11) is seen today because staff state she has an ulcer on her bottom again. Resident has a history of pressure injuries to her sacrum and right medial buttock . Resident with an ulcer on the right upper medial buttock measuring 0.2by1.1by0.2cm . Pressure injury of right buttock, stage 3 . Resident with a pressure injury to the right upper medial buttock again . Review of the facility Daily Shower Assignment revealed Resident #11 was scheduled to receive showers on day shift on Mondays and Thursdays. Review of Resident #11's Skin Observation Shower sheets provided by the facility revealed that from February 2023 until 5/3/2023, Resident #11 received a shower on 2/2/2023, 2/27/2023, 3/16/2023, 3/20/2023, 3/23/2023, 3/30/2023, 4/17/2023, 4/21/2023, and 4/27/2023. Resident #48 Review of an admission Record revealed Resident #48 admitted to the facility on [DATE] with pertinent diagnoses which included spinal stenosis and lack of coordination. Review of a Minimum Data Set (MDS) assessment for Resident #48, with a reference date of 4/3/2023 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #48 was cognitively intact. Further review of same MDS assessment revealed Resident #48 required assistance with bed mobility, toileting, personal hygiene, and bathing. In an observation and interview on 5/2/2023 at 12:19 PM in Resident #11's room, Unit Manager E reported that a new wound was found over the weekend on Resident #11's left heel. Wound Care Provider DD evaluated the wound to be a 3.5 by 6.6-centimeter unstageable deep tissue injury. Observed left heel wound to be a large, blood-filled blister. In an interview on 5/3/2023 at 8:54 AM, Resident #48 reported staffing was short over the weekend when her new left heel wound was found. Resident #48 reported when staffing is short they do not come in to assist her with repositioning in bed. Resident #48 reported when staffing is short it takes a long time for her call light to be answered. Review of the facility worked schedule on Saturday, 4/29/2023 revealed there were only 3 nursing assistants working in the entire building from 11:00 AM until 11:00 PM. Review of the facility Daily Shower Assignment revealed Resident #48 was scheduled to receive showers on day shift on Wednesdays and Saturdays. In an interview on 5/1/2023 at 10:05 AM, Resident #48 reported she has been missing many showers. Resident #48 reported missing showers makes her feel dirty and grubby. Review of Resident #48's Skin Observation Shower sheets provided by the facility revealed that from February 2023 until 5/3/2023, Resident #48 received a shower on 2/1/2023, 2/27/2023, 3/23/2023, 3/27/2023, 4/6/2023, 4/24/2023, and 4/27/2023. In an interview on 5/1/2023 at 10:42 AM, LPN AA reported staffing has been challenging for months. LPN AA reported there were only 3 aides in the facility that morning and only 1 aide working with her on the 100 hall with 23 residents to care for. LPN AA reported when there is only 1 aide on the hall, there is not enough time to give residents showers and it is not possible to check, change, and turn residents every two hours. LPN AA reported when staffing is short, the aides work methodically through the unit to get to everyone as quickly as possible. In an interview on 5/2/2023 at 10:06 AM, Certified Nursing Assistant (CNA) S reported that she was the only CNA on 100 hall the previous day. CNA S reported that happens at least once a week. CNA S reported there is no time for resident showers when she is the only CNA on the hall and it is not possible to perform check and changes and turns every two hours. In an interview on 5/3/2023 at 2:55 PM, CNA U reported the facility needs a minimum of 5 CNA's to perform adequate resident care. CNA U reported that a couple times a month she works as the only CNA on a hall. CNA U reported when she is the only CNA working on a hall resident showers cannot be completed, waters might not get passed, and it is not possible to perform two hour resident checks and changes and turns. CNA U reported it takes closer to 4 hours to perform check and changes and turns when she is working alone on a hall. .There is a positive correlation between direct patient care provided by an RN (Registered Nurse) and positive patient outcomes, reduced complication rates, and a more rapid return of the patient to an optimal functional status .Research also correlates poor staffing with missed nursing assessments and missed nursing care . [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing, Tenth Edition - E-Book (Kindle Location 1265 of 76897). Elsevier Health Sciences. This citation pertains to intake #MI00127894 Based on observation, interview, and record review, the facility failed to ensure adequate nurse staffing to promote the physical, mental, and psychosocial well-being in 5 of 60 sampled residents (Resident #31, #14, #42, #11, & #48) reviewed for staffing, resulting in unmet care needs , reopening of a pressure ulcer for Resident #11, a fall with fracture for Resident #14, and the potential for physical and psychosocial harm for all residents in the facility. Findings include: Review of Resident Census and Conditions of Residents (CMS Form 672) submitted for review on 5/1/2023 indicated a census of 60 residents, and that there were 60 residents were either an Assist of One or Two Staff or Dependent on staff for bathing; 59 residents were either an Assist of One or Two Staff or Dependent on staff for dressing; 54 residents were either an Assist of One or Two Staff or Dependent on staff for transferring; and 60 residents were an Assist of One or Two Staff for toilet use . In a confidential group interview on 05/03/23 at 10:29 AM, 7 out of 9 residents reported the staff were coming in the resident's rooms and were turning off the call lights when the need was not met. Residents reported concerns with second shift and third shift. Residents reported it was really hard to get their needs met when there was only one aide on each hallway. Review of the Master Schedule for Nurse Supervisor First Shift 6:45 AM to 3:15 PM had an open position for part time nurse and a full-time nurse; Second shift 2:45 PM to 11:15 PM, had an open position for a part time nurse for coverage on Saturday and Sunday on the first week of the rotation. Nurse Supervisor Third Shirt 10:45 PM to 7:15 AM, had an open full time position . Review of the Master Schedule for Nurse Aide First Shift 7a - 3p had one full time opening, and two part time openings; Nurse Aide Second Shift 3pm-11pm had three full time openings and one part time opening; Nurse Aide Third Shift 11pm - 7am had a part time opening . In an interview on 05/03/23 at 12:24 PM, Scheduler CC reported the facility had a master schedule with the same rotation every two weeks. The staff process to request personal time off should be submitted at least 30 days prior typically, lesser if they need it off for an emergent situation. Scheduler CC reported she would post all open shifts in the schedule book and would send out mass messages to staff informing them of the openings. If not all the shifts were covered, then there would be a meeting held with the unit managers to recruit staff. Scheduler CC reported the facility does utilize an staffing agency to assist with staffing. Scheduler CC reported for aide staffing had been 3 aides for 100 hallway, 3 aides on 300 hallway, and 1 aide on the 200 hallway with a split person. The split person would cover the hallway with the heavier load based on the acuity level. Scheduler CC reported on the weekends staff don't want to work and would call in. Scheduler CC reported the facility does not do mandations but have offered extra pick up pay per hour. Resident #31: Review of a Minimum Data Set (MDS) assessment for Resident #31, with a reference date of 3/15/2023 revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated Resident #31 was cognitively intact .B. Transfer: Total Dependence with Two+ persons physical assist. In an interview on 05/03/23 at 10:42 AM, Resident #31 reported he really had a hard time getting to activities because there were not enough CNAs to get him up for the activities. Resident #31 stated, .Sometimes I get to go and sometimes I don't . Resident #14: Review of a Minimum Data Set (MDS) assessment for Resident #14, with a reference date of 3/20/2023 revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated Resident #14 was cognitively intact. In an interview on 05/01/23 at 08:04 AM, Resident #14 reported she fell and broke her leg last December 2022. Resident #14 reported the aide didn't' know how to get me up as she utilized a sit to stand for transfers. Resident #14 stated, .I was slipping out of the sling, she didn't buckle the two buckles, it was a smaller of the vest and I couldn't breathe .I think that I fainted .I guess I let go of the handle bars, slid out and flat on my back .I twisted my leg somehow and broke my femur .I was in terrible pain, screaming and the ambulance came and took me to the hospital . Review of Orthopedic Trauma Consult dated 12/20/22 at 7:22 AM, revealed, .Patient is a 78 y.o. female with a right periprosthetic Distal Femur Fracture s/p twisting injury during transfer at care facility .Clinical impressions: Closed bicondylar fracture of distal femur, right .Closed fracture of distal end of right femur, unspecified fracture morphology . Review of General Progress Note dated 4/4/2023 at 4:32 PM, revealed, .Late entry for 4/3/23 Quarterly MDS w/ ard 3/20. Patient interviewed and confirmed total assist mechanical lift with two assist used for all transfers . In an interview on 05/03/23 at 11:21 AM, Registered Nurse (RN) I reported she was the manager on duty at the time of the fall and it was a significant event. RN I reported the CNA was assisting Resident #14 was transfer to her bed. RN I stated, When I got down there, she was on the floor, the nurse was with her .She was in a lot of pain and I could tell something was wrong, told staff not to move her, and call EMS to have the come and evaluate her .They started her IV and gave her fentanyl because she was in so much pain .The resident told me she thought she fainted .It was horrible .She was supposed to be a two person sit to stand . RN I reported if they were a lift, they were a two person for transfers. In an interview on 05/03/23 at 11:42 AM, Agency CNA NN reported the facility was giving the resident prep for a colonoscopy the next day. CNA NN stated, .I kept telling people I needed help and she needed two people to transfer .What was I supposed to do? I was the only CNA assigned to that hall and she needed to get to the bathroom because she was drinking stuff for the colonoscopy .I set her down on the toilet and raised her up, cleaned her bottom .She was getting weak, pulled the light .I really needed help and yelled out the door but no one would answer me .She was feeling lightheaded and she had diarrhea continuously and she was not strong enough to hold on .I had to get her off the toilet, I couldn't get help and I couldn't let her sit there for hours (in the bathroom) .I got her up and got her over to the edge of the bed and asked her to let me get her steady and everything was intact, the sling goes all around behind her, and raised her up and she let go of everything and slid from underneath the Sara lift . I felt the best of my knowledge not to leave her in that, as that is not right either, and not getting help from the other staff . In an interview on 05/03/23 at 10:10 AM, Resident #14 reported she was concerned because she was not being taken to the bathroom. Resident #14 stated, People are not wanting to take me to the bathroom .Telling me they don't have time to take me to the bathroom .Supposed to be two people to get me up and take me to the bathroom but there was only one aide on the hallway and they have to always look for help to take me to the bathroom . Resident #42: Review of a Minimum Data Set (MDS) assessment for Resident #42, with a reference date of 1/9/2023 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated Resident #42 was cognitively intact. In an interview on 05/01/23 at 11:30 AM, Resident #42 reported the staff have taken a long time to respond to call lights. Resident #42 reported the staff would come in, say they would get someone to come help me and then they never come back. Resident #42 stated, .I feel sometimes they ignore me . Resident #42 stated, .One day what day I called because I needed my pants changed, they were poopy .They (staff) never came and I was in poopy pants practically all day I was getting a sore in my butt crack and right there (Resident #42 pointed to her vaginal area) .Poopy pants are not good . Resident #42 reported she was not getting her showers or baths as well as the facility was really short on staffing with only one aide on the hallway. In an interview on 05/03/23 at 12:40 PM, CNA Y reported on Monday 05/01/23 reported was super busy and I had no partner to help me. CNA Y reported management was coming out and helping when they could. CNA Y stated, .This does happen a couple times a month .When I have a partner we can usually get things done but when I don't I just try to keep up with the basic stuff, check and changes, and try to touch everybody .Sometimes the resident gets a bed bath instead of a shower .And when the resident was a two person assist there was extra long waiting to get someone else to help me .I really try to communicate with my residents to let them now when I can get to them .It is hard though when they have to go to the bathroom . In an interview on 05/03/23 at 01:58 PM, Director of Nursing (DON) reported the facility maintains a certain level for staffing. The NHA will send out a broadcast if we get to the critical level of staffing. We don't want to go above the number of residents to every one staff. DON B reported it would be 1 staff member for every 8 residents for 1st shift, 1 staff member for every 12 residents for 2nd shift, and 1 staff member for every 15 residents for 3rd shfit. DON B reported we have a staffing meeting and discuss what is happening with staffing for the next few days.