**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to protect the residents' right to be free from sexual and physical abuse by other resident's. Findings include: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R101 was an [AGE] year-old male admitted to the facility on [DATE], with diagnoses that included dementia, anxiety and depression. The MDS reflected that R101s had a BIM (assessment tool) score which indicated his ability to make daily decisions was severely impaired. Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R102 was an [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included dementia, anxiety, falls, unsteady on feet, and depression. The MDS reflected that R102s had a BIM (assessment tool) score which indicated her ability to make daily decisions was severely impaired. Review of the complaint received by the State Agency on 9/24/25 alleged the facility failed to prevent and report abuse allegations to the State Agency. During a telephone interview on 9/25/25 at 11:59 a.m., Complainant “Y” verified complaint and reported often worked in basement of facility on dementia unit. Complainant “Y” reported on 8/23/25 R101 walked up to R102 and started shoving R102 and hitting R102 on the shoulder and staff separated residents and incident was reported to supervisor who was told incident needed to be reported to Director of Nursing (DON) “B” and Nursing Home Administrator (NHA) A” because abuse allegation. Complainant “Y” believes Nurse Supervisor notified DON “B” and was told did not need to be reported because both residents had dementia and NHA “A” followed up and told Complainant Y the same. Complainant “Y” reported on 9/6/25 R101 was ramming wheelchair into R102 while she was eating and staff separated residents, assessments were completed. Complainant “Y” reported R101 behaviors increased and at one-point R101 placed hands on R102 shoulders and started shaking R102 violently making R102s entire body move. Residents were again separated and assessments completed, and same nurse supervisor was notified along with physician who ordered intramuscular Ativan. Complainant “Y” reported R101 was a strong male and R102 was frail [AGE] year-old women. Complainant “Y” reported Certified Nurse Assistant (CNA) “R” got to R102 first and separated residents and R102 was taken to her private room and event was also reported to DON “B” and NHA “A” and physician via secure conversation/text. Complainant “Y” reported was questioned after event by NHA “A” who reported not to use word, “violent” in documentation and Complainant “Y” reported there was no other word to describe the event. Complainant “Y” reported NHA “A” reported intervention would be to remove wheelchair but Complainant Y reported was unsure how that would even help because R101 was not in wheelchair when he approached R102 and started shaking her. Complainant “Y” reported was told neither resident to resident incident was reported to the State of Michigan because both residents had dementia. During an observation on 9/29/25 at 9:55 a.m., R101 and R102 was observed in dementia unit, located in the facility basement. R101 and R102 were in the common area sitting in recliners that were lined up around the television four chairs apart from each other. R101 had a brace on right knee and observed staff assisted R101 to the bathroom via a wheelchair. The unit had two certified nurse aids and one nurse and about 10 residents present. During an interview on 9/29/25 at 1:00 p.m., Nursing Home Administrator (NHA) “A” reported was the facility Abuse Coordinator. NHA “A” reported had two reported allegations of abuse in past 10 months. The two abuse allegations did not include R101 or R102. Requested all Incident/Accident reports with complete investigations for R101 and R102 on 9/29/25 at 2:37 p.m. Received all R101 and R102 Incident/Accident reports for last six months with no resident-to-resident incidents on 9/29/25 at 3:23 p.m. Review of R101 Nurse Progress Note, dated 6/20/25 at 9:35 p.m., reflected, “CNA [certified nurse aid] came up to writer and reports that she has seen resident put his finger in another patients face [R102] and shouldn't sit next to her because he tried to control her and calls her his wife. States she doesn't think they should sit together anymore.” Review of R101 Nurse Progress Note, dated 8/23/25 at 8:31 p.m., reflected, “Reported to supervisor at 2024[8:24 p.m.] that this resident was seen by CENA [Competency Evaluated Nursing Assistant] striking a female resident multiple times on shoulder and chest earlier this shift. Writer was not made aware of this until approximately 2000.” Review of R101 Nurse Progress Note, dated 8/23/25 at 9:50 p.m., reflected, “DON notified of CN [charge nurse] report of incident.” Review of R101 Behavior Progress Note, dated 9/6/25 at 3:00 p.m., reflected, “Resident being very aggressive to staff. Trying to run into CNAs with WC [wheelchair]. Trying to approach a female resident thinking she is his wife. Tried to go into female resident room. Phone call placed to [named Medical Director “X”] and one time order given for 1mg Ativan IM. POA [power of attorney] aware.” Review of R101 Nursing Progress Note, dated 9/6/25 at 3:04 p.m., reflected, “At approximately 1420 [2:20 p.m.], resident ambulated to female pt. [patient] who was sitting in recliner chair in great room and placed his hands on her shoulders and began violently shaking her. Staff intervened and ended this behavior and female pt. was taken to her room to eliminate stimulus. This resident continued to try to locate female pt. whom he thought was his wife and ran his w/c into all staff members intentionally on multiple occasions. Was yelling throughout demanding to know where his wife was. Attempted to provide food, fluids and offered a walk outside all new order for Ativan 1mg IM obtained and given at approximately 1435 [2:35 p.m.].” Review of R101 Nurse Progress Note, dated 9/6/25 at 8:58 p.m., reflected, “At approx 1810 [6:10 p.m.], as most residents had eaten supper, this resident began ramming his w/c into a female resident's w/c. This resident believes this female is his wife and unable to convince him otherwise or distract him. Female resident was still eating when this occurred and residents were separated at this time. This resident went back two additional times and rammed his w/c into hers. Resident was asked why he was doing this and he stated, how else am I supposed to get her attention? Review of R101 Nurse Progress Note, dated 9/7/25 at 3:43 p.m., reflected, “Per report, pt. was fine all first shift. As soon as second shift began, pt. started to ramp up again. Has been yelling about wanting to see his wife, referring to specific female pt. Female was removed from great room prior so that pt would not become fixated on her again. So far this shift he has rammed his w/c into staff X1 [times one] and tried to ram into a visitor that staff was speaking with but staff intervened. Has been yelling quite a bit this shift about specific female pt. and that staff is liars…Since all this tends to happen on second shift, question if this is a circadian cycle for this pt. and if he needs a routine medication to control it. Currently gets Buspar 5mg tid[three times daily] but it is not helping. The 1mg Ativan yesterday did seem to help. Not asking for anything right now but will text you if situation worsens.” Review of R101 Behavior Progress Note, dated 9/12/25, reflected, “At 10:05 am, [named R101] was sitting in a PC[personal chair] chair up at the TV area and began to express, Where is [named wife], I want to see my wife, [named wife]! Staff sat with him explaining that his wife lived at another facility. [named R101] expressed, No she's not, where is she, I just seen her. During an interview on 9/29/25 at 3:46 p.m., Licensed Practical Nurse Risk Manager (RM) “N” reported had been in that role about five months and had worked at the facility for 12 years. RM “N” reported R101 was non-complaint who had no safety awareness with diagnosis of dementia who lives in dementia unit in the basement of the facility. RM “N” reported R101 thinks R102 was his wife and often require one on one care because he becomes fixated on R102. RM “N” reported worked on R101s unit 9/25/25 second shift and reported was not aware prior to that day R101 was fixated on R102 and reported R101 had increased behaviors and had to call DON “B” for additional assistance even with one-on-one care for R101. RM “N” verified she documented the following Nurse Progress Note, dated 9/25/25 at 4:02 p.m., “Elder was sitting in personal chair in dayroom upon my arrival to the unit at 1400[2:00 p.m.]. Noticed he was picking at his arm protectors and wanted to walk. He [R101] stood up without assistance X2[times two]. First time CNA [certified nurse aid] took him to the bathroom with AX2[assist time two], gait belt and w/c[wheelchair]. 2nd time they went for a stroll in his w/c outside for a bit. He was then placed back in his personal chair with CNA sitting beside him. Writer asked CNA what usually helps him stay distracted, and she replied someone sitting with him at all times giving him attention. CNA left the unit to go to lunch. Writer sat beside Elder and conversated with him. He kept directing the topic back to who he thinks is his wife which is truly just another Resident who was sitting within his sight. The other assigned CNA was doing bed checks and toileting Elders. Family members to another Elder came in to visit which intensified his[R101] behaviors. He was so worried who was talking to his wife, I don't know those people, I need to make sure my wife is okay. AX2 [assist time two] with gait belt stood him up to reposition him to his w/c to diffuse the situation by bringing him outside. DON was paged to the unit and Social Work accompanied her. They talked with Elder and wheeled him around the facility prior to bringing him back and doing puzzles together. All was well upon my departure at 4pm.” RM “N” reported reviews and completes resident fall investigations and reported R101 has had several recent falls with recent fracture because of poor safety awareness and again reported had no prior knowledge of R101 behaviors towards R102. (Evidence that thorough investigation had not been completed for frequent falls and resident to resident events to determine root cause related to ongoing behaviors.) During an interview and record review on 10/1/25 at 1:34 p.m., NHA “A” reported facility had additional information that had not yet been provided related to R101 and R102 that facility felt was an issue with staff performance of Registered Nurse (RN) “P”. NHA “A” provided file for R101 and R102 resident to resident events on 8/23/25 and 9/6/25 on facility letterhead of typed events. NHA “A” reported RN “P” no longer worked at facility. Review of the file reflected handwritten statement from CNA “R”, dated 8/23/25, that reflected, “On 8/23 [named R101] became agitated at [named R102] and open hand smacked her on her shoulder/chest area. This happened approximately around 3:30 p.m.” The statement was signed by CNA “R”. Continued review of the file reflected a second timeline of events on facility letter head for R101 and R102, dated 9/6/25, reflected two, “Hey Social Work” documents, dated 9/6/25. Review of R101's first, Hey Social Work documents reflected, “Resident is being aggressive with other residents, shaking them, in their face, yelling at them accusing them.” The form included R101 had the following behavior: yelling, abusive language, grabbing, accusing, pushing, and expressing anger and unable to redirect. The document was signed by CNA “R”. Review of the second Hey Social Work document, dated 9/6/25, reflected, “resident is being aggressive towards other residents especially [named R102] he thinks she is his wife. He is running into nurse and aides with wc[wheelchair].” The form included R101 had the same marked behaviors as the first document. During a telephone interview on 10/1/25 at 3:11 p.m., CNA “R” reported usually worked on the dementia unit in the basement on second shift with both R101 and R102. CNA “R” reported R101 frequently gets very fixated on R102 and yells at her, grabs her and has shaken R102 in the past. CNA “R” reported staff attempt to keep R101 and R102 separated, and staff try to intervene to reduce risk of altercation. CNA “R” reported R102 was[AGE] years old with dementia and is unsure if she knows what is happening and R101 is convinced R102 is his wife. CNA “R” reported recalled incident in August 2025 when R101 was patting R102 and shoulder and shouting hay, hay. CNA “R” reported on 9/6/25 R101 approached R102 and grabbed R102 shoulders and started shaking R102 back and forth and both CNA staff separated residents. CNA “R” reported told R101 he was not allowed to put his hands on other residents, and he became upset and incident was reported to RN “P” and completed, “Hey Social Worker” document. CNA “R” reported incident was reported to nurse because potential allegation of abuse that was required to be reported immediately. CNA “R” reported after 9/6/25 incident there were no changes in interventions but to continue to attempt to keep R101 and R102 separate. CNA “R” reported R101 does get mad and R102 and had called her an old hag and reported residents do not deserve to be treated that way or called names and should be reported. During a telephone interview on 10/2/25 at 10:26 a.m., CNA “V” reported often worked second shift with both R101 and R102. CNA “V” reported R101 was obsessed with R102 and staff constantly have to separate them and R101starts to escalate behavior to be right next to her with attempt to even try to push her wheelchair. CNA “V” reported R101 aggressive behaviors toward R102 have increase over past four to six weeks and staff have expressed concerns to several management staff including DON “B”. CNA “V” reported R101 has also had several falls because he is so determined to get to R102 including recent fall with fracture. CNA “V” reported staff attempt to redirect but often not effective and R101 requires one on one supervision that is not always possible to properly care for other residents. CNA “V” stated R101 is often, “Locked on that thought and nothing else matters to him.” CNA “V” reported R101 has called R102 a bitch and other residents as well. CNA “V” reported R101 resident to resident altercations to second shift supervisor “AA”. CNA “V” reported R101 behaviors have been progressively getting worse and occur at least 3 times per week minimum and are reported to charge nurse because potential allegations of abuse. CNA “V” reported last week DON “B” had to take R101 off the unit because R102 had family that was visiting and R101 was agitated that he did not know who they were and did not want them with R102 and reported R102 appeared frustrated with situation. During an interview on 10/2/25 at 10:48 p.m., Social Worker (SW) “K” reported R101 had behaviors that included he had history of being combative with staff and thinks a female resident is his wife and gets focused and agitation often increases in afternoon. SW “K” reported the, “Hey Social Worker” was a tool that staff use to communicate behaviors residents might be having with Social Worker and reported had not received any for R101. SW “K” reported was not aware of any resident-to-resident altercations with R101 and R102 other than when R101 taps R102 on shoulder to get her attention. SW “K” reviewed, “Hey Social Worker” forms provided by NHA “A”, dated 9/6/25, and verified had never seen either one. SW “K” reported if she had received the documents would have reported to NHA “A” immediately because allegations of physical abuse that needed to be reported and investigated and need to follow up with all parties involved because facility SW. During an interview on 10/2/25 at 11:26 a.m., NHA “A” reported had been in position for five years and was also the abuse coordinator. NHA “A” reported staff are expected to report all allegations of abuse to nurse supervisor, DON “B”, or NHA “A” immediately. NHA “A” reported did not reported R101 and R102 allegations of abuse to the State of Michigan (SOM) because they delt with it as personal issue not allegation of abuse and stated, “in hindsight that was incorrect.” NHA “A” reported should have reported R101 and R102 incidents on 8/23/25 and 9/6/25 to the SOM as allegations of abuse and verified that was wrong. During an interview on 10/2/25 at 11:56 a.m., DON “B” reported received a call from supervisor that RN “P” had reported an incident that occurred at the beginning of the shift that CNA staff reported R101 was going after R102 related to both incidents on 8/23/25 and 9/6/25. DON “B” reported did not believe RN “P” but should have believed CNA staff that included written witness statements, should have reported to the NHA “A”, State of Michigan, and completed thorough investigation. Review of the medical record reflected R104 was admitted to the facility on [DATE], with diagnoses that included dementia. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/2/25, reflected R104 scored 7 out of 15 (severe impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the medical record reflected R105 was admitted to the facility on [DATE], with diagnoses that included dementia, need for assistance for personal care, mild cognitive impairment, and Alzheimer's disease. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/6/25, reflected R105 was unable to have a Brief Interview for Mental Status (BIMS-a cognitive screening tool) conducted due to severe cognitive impairment. On 9/25/25 at 2:57 PM, R104 was observed in his room seated in his wheelchair. R104 was talking out loud said “ehhhh” and “ohhh.” After entry into his room, R104 was welcoming to conversation and stated that he had a bird that he loves to talk with. On 9/25/25 at 3:12 PM, R105 was observed in bed resting. Review of R104's Care plan reflected an added intervention on 3/27/23 and revised on 3/21/25 which stated “…He is also inappropriate at times. If [R104] is participating in a group setting such as eating in the dining room or an activity, wait to bring the resident down until at least one staff member is present to monitor. [R104] also sits by male residents during activities and in the dining room…”. Review of R105's Electronic Medical Record reflected that R105 was nonverbal and used nonverbal cues and sounds/cries in an attempt to make needs known. Review of a Behavior Note on 2/21/25 revealed R104 had to be corrected many times during the 6-2 shift about being inappropriate with other residents and with the CNA's. He tried to grab a CNA's bottom while they were walking by. He kept whistling at another resident until it made her upset and she had to propel away. He heckled the CNA'S whenever he was in the halls and not in bed. Review of a Behavior Note dated 3/7/25 revealed R104 stated to a female resident while in dining room, Hey baby, let me feel your tits. Writer did not know about this until several hours post incident but did speak to resident about it and told him how inappropriate it was. In an interview on 9/25/25 at 12:53 pm, Registered Nurse (RN) P stated that she received information during shift report during a shift in late March 2025 that R104 was observed groping R104's breasts in the activity room. LPN P was advised to ensure that R104 and R105 were not seated near each other to maintain R105's safety. In an interview on 9/29/25 at 9:59 am, Certified Nursing Assistant (CNA) J reported that she was working the day, back in March 2025, that R104 was observed fondling R105's breasts. CNA J stated that both residents were in the activity room and CNA J overheard a commotion. When CNA J responded, R104 was observed handling R105's breasts. Moving forward, staff was instructed to ensure that R104 and R105 were not placed near each other. CNA J reported this to the nurse. In an interview on 9/29/25 at 4:04 pm, CNA L stated that he overheard R105 yelling and immediately identified that R105 was upset about something. CNA L entered the activity room to observe R104 grabbing R105's breasts. R105 was visibly disturbed about the actions of R104. CNA L stated he separated the residents immediately and was asked to fill out an incident report. On 10/2/25 at 11:26 AM, Nursing Home Administrator (NHA) A verified that he was the abuse coordinator and explained the process of reporting abuse allegations. When asked if he had any awareness of this incident, NHA A denied knowing about R104 incident with R105, however, did state that the incident should have been reported to him and that he would have reported it to the State of Michigan and completed an investigation. NHA A and Director of Nursing B both reported that there were no incident reports or investigations for this incident. Review of the Abuse, Neglect and Exploitation Policy implemented 9/2021 and reviewed 9/2024 defined sexual abuse as non-consensual sexual contact of any type. The same policy stated, an immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect or exploitation occur . reporting of all alleged violations to the Administrator, state agency .immediately, but no later than 2 hours after the allegation is made . Applying the reasonable person standard, it can be expected that R105 would have experienced emotional distress as a result of the abuse, as such a reaction aligns with how an average person would respond under similar circumstances.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the necessary standards of care and services for wound and skin care management in one (Resident #106) of three reviewed for quality of care. This deficient practice resulted in R106's hospitalization for septic shock, cellulitis, increased pain, and the need for intravenous antibiotic therapy, and implementation of hospice(end of life services) and death. This citation pertains to intake 2626820 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R106 was an [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included congestive heart failure (CHF), diabetes mellitus, hypertension (high blood pressure), legally blind, cellulitis, and lymphedema. The MDS reflected that R106s had a BIM (assessment tool) score of 14 which indicated her ability to make daily decisions was cognitively intact, and she required staff supervision with locomotion on unit, dressing, hygiene, bathing, and transfers. Continued review of the MDS reflected no history of refusal of care. Review of the complaint received by the State Agency alleged the facility failed to provide wound treatments as ordered resulting in sepsis and death. During a telephone interview on 9/25/25 at 11:59 a.m., Complainant Y verified complaint and reported R106 passed away after returning from hospital on hospice services. Complainant Y reported R106 was treated in the hospital for septic shock and cellulitis after a Licensed Practical Nurse (LPN) F did not follow physician orders and placed black plastic trash bags over R106's lower legs for over two days that caused infection. Complainant Y reported R106 required frequent as need dressing changes related to increase bilateral lower leg swelling and weeping around 6/20/25 and was told nurse placed trash bags on 6/21/25 and remained in place until 6/23/25 when found by the facility wound nurse who informed the Director of Nursing (DON) B. Complainant Y reported when the bags were removed from R106s legs on 6/23/25 the skin just slid off R106 legs and the wounds were significantly worse than prior week. Complainant Y reported was told R106 wanted to go to activity on 6/21/25 but legs were weeping so much the plastic bags were placed and the next shift was not informed and remained in place until found on 6/23/25 (two days later). Complainant Y reported R106 reported increased pain and was treated in the facility for cellulitis initially then transferred to the hospital after being found unresponsive on 7/10/25. Complainant Y reported had spoke with Medical Director X after R106 hospital admission and discussed black trash bags used as treatment and reported Medical Director X was shocked and unaware of situation. Complainant Y' reported facility risk manager was one of R106's nurses that weekend and stated, Common sense tells you it will cause a problem. What the h*ll were they thinking? Complainant Y reported R106 was alert and oriented who often went out with friends and had good quality of life prior to worsening of bilateral lower leg wound cellulitis on 6/23/25. Review of the Wound Evaluations, dated 6/20/25, reflected R106 had three new in-house acquired venous wounds (ruptured blisters) to bilateral lower legs with 0/10 on pain scale that included:-#4 venous, Left Medial Malleolus - Middle-- measurement 3.3x3x0.1, cluster of 2, moderate serious drainage with no signs of infection.-#5 venous, Right Medial Calf - Middle-- measurement: 4x2x0.1, moderate serious drainage with no signs of infection.-#6 venous, Front Right Lateral Lower Leg-- measurement: 11x14x0.1, cluster of 11, moderate serious drainage with no signs of infection. Review of R106 Nurse Progress Note, dated 6/21/25 at 7:57 p.m., reflected, Wound Treatment Charting - The patient has had to have her bilateral leg dressings completed 4 times today 6 am - 8 pm. When the patient stands up the urine just runs all over her legs and the dressings are saturated with urine. The patient receives 2 Bumex 1 mg every am. The bilateral legs were washed with warm soap and water each time and new dressings applied. Supervisor notified. Review of R106's Treatment Administration Record (TAR), dated 6/21/25 through 6/23/25, reflected R106 had physician ordered treatments that included the following: Left distal medial low leg: Cleanse with normal saline, apply skin prep to periwound, cover wound with calcium alginate (2x2), cover with 4x4 bordered dressing every day shift.Left distal pretib: Cleanse with normal saline, apply skin prep to periwound, cover wound with calcium alginate (2x2), cover with 4x4 bordered dressing every day shift.Left Superior Pretib: Cleanse with normal saline, apply skin prep to periwound, cover wound with calcium alginate (2x2), cover with 4x4 bordered Dressing every day shift.Right Medial calf: Cleanse with normal saline, apply skin prep to periwound, cover wound with calcium alginate (2x2), cover with 4x4 bordered dressing every day shift.Right Pretib: Cleanse with normal saline, apply skin prep to area. Cover with ABD pads x 2, secure with kerlex and secure with tape every day shift.Continued Review of R106 TAR, dated 6/17/25, reflected whole (no documentation) for, Bilateral lower legs: 2 layer compression every day shift every Tue. Continued Review of R106 TAR revealed one documented treatment completed on 6/21/25 for each of the listed areas and documentation that R106 refused all the above listed treatment on 6/22/25. Review of R106 Secure Conversations Progress Note, sent by facility Wound Nurse M, dated 6/23/25 at 11:03 a.m., reflected, Resident's legs have detoriated since friday and is now open on both shins circumferential. Will have [named facility wound provider U] see on Wednesday. In the meantime her legs are seeping copious amounts of fluid. Okay to change treatments to opilocks and kerlex changed q [every] shift? Continued review of Progress Note revealed Medical Director X responded, Yes, thanks. at 11:16 a.m. (According to Nurse Progress Note dated 6/21/25 at 7:57 p.m. R106 had a change in condition with increased bilateral lower extremity drainage that required dressing changes four times instead of one time daily as ordered with no evidence that Physician had been notified prior to 6/23/25.) Review of R106 Psychosocial Progress Note, dated 6/24/25 at 2:41 p.m., reflected, SW [Social Work] met with [named R106] today. She did not have any concerns at this time. She is a little annoyed/frustrated about her current health condition. SW provided support, encouragement and validation of her feelings. Review of R106 Nurse Progress Note, dated 6/25/25 at 6:44 p.m., reflected, Resident will begin Doxycycline for bilat.[bilateral] lower leg cellulitis tomorrow morning. Review of the Wound Evaluations, dated 6/25/25, reflected R106 had deteriorating bilateral lower leg wounds with increased pain 7/10 on pain scale that included the following:-#4 transitioned to #7 venous, front Left Lateral Lower Leg-measurements 10.5x17.5x0.1, heavy serious drainage, angry red color with signs of infection.-#5 transitioned to #6 venous, front Right Lateral Lower Leg-measurements 13.5x25x0.1, heavy serious drainage, redness, inflammation, signs of infection and documented cellulitis. Review of R106 Nurse Progress Note, dated 6/27/25 at 8:34 p.m., reflected, Treatment to right lower leg redone d/t dressing extremely wet. Pt. was painful throughout this drsg. [dressing] change. Review of R106 Nurse Progress Note, dated 6/28/25 at 9:56 p.m., reflected, Treatments to bilateral lower legs redone. Right was saturated with drng [drainage], left was around ankle. Areas remain red with several open areas. Right leg is painful. Continues to take Doxycycline for cellulitis BLE [bilateral lower extremities]. Review of R106 Nurse Progress Note, dated 6/30/25, reflected, Late entry for 6/29/25 day shift Infection note: [named R106] is on an oral antibiotic for tx [treatment] of cellulitis of her lower extremities. [named R106] has open wounds on bilateral lower extremities that are weeping fluids. [Named R106] expressed pain in her right lower extremity is more prevalent than the minimal pain felt in her left lower extremity. [Named R106] rates her right lower extremity pain to be varied between minimal and 7/10 depending on the position and if treatments are being completed. [Named R106] was sleepy the first part of the morning stating she did not sleep well r/t discomfort of her lower extremities.Review of R106 Nurse Progress Note, dated 7/3/25 at 12:12 p.m., reflected, Elder stayed in her room all shift thus far. Ate both meals in her room. Uses her call light appropriately for assistance and to voice needs. Complained of headache and requested PRN Tylenol. Review of R106 Nurse Progress Note, dated 7/5/25, reflected, The patient is on Doxycycline Hyclate oral tab 100 mg by mouth am and bedtime for BLE Cellulitis. x 10 days. The patient has one more dose this evening and she will complete her ABT[antibiotic] regime.The patient's treatment was completed at 9 am and again at 2 pm for urine saturated dressings. Review of R106 Nurse Progress Note, dated 7/10/25 at 6:45 a.m., reflected, Took resident's blood pressure via wrist cuff measures 63/30 with a heart rate of 100. Resident in and out of consciousness. 22g IV [intravenous line] started x1 attempt in right hand. IV fluids started. Resident came up to 120/60. Fluids turned down to 75 cc/hr as resident has dx [diagnosis] of CHF. Resident more alert after blood pressure came up and started she feels dizzy and she is having chest pain. Continued review of Progress Notes revealed no notes between 7/5/25 and 7/10/25 at 6:45 a.m. when R106 found unresponsive. Review of R106 Nurse Progress Note, dated 7/10/25 at 6:46 a.m, reflected, Sending elder to [named local emergency room] for evaluation She is a full code and BP[blood pressure] dropped from 99/65 to 69/30. Elder very pale with an irregular heart rate usually alert but slow to respond at this time. Review of R106 Secure Conversations Progress Note (sent to Medical Director X), dated 7/15/25 at 1:13 p.m., reflected, [Named R106] arrived to the unit at 1245. Son at side. Option for End of life Comfort care per [named facility] policy was chose, as well as DNR[do no resuscitate]. Review of R106 Nurse Progress Note, dated 7/15/25 at 1:35 p.m., reflected, [named R106] arrived on the Unit for readmission at 1245 via stretcher with [named] transport service. [Named R106] is on oxygen at 4-5 L via nasal cannula upon arrival. A 4 person slide transfer to her bed completed. Audible negative vocalization heard. EMS [emergency medical service] staff reported [named R106] last pain medication was at 1055 when she left the Hospital. [named R106] expressed verbally Just give me a Shot. Pain medication discharge orders reviewed with [named physician] with orders for Morphine sulfate concentrate 20mg/ml, give 0.25 ml every 4 hours scheduled and 0.25 ml every 2 hours as needed for pain and dyspnea. Review of the Hospital records, dated 7/10/25, reflected R106 was treated at local hospital for cellulitis, septic shock and non STEMI (non ST elevation myocardial infarction) and was transferred to a level 2 trauma center. Continued review of R106 hospital records revealed elevated while blood count (WBC) and no evidence of urinary tract infection. Continued review of R106 History and Physical, dated 7/10/25, reflected, Usually is alert and orientedx3.Found decreased level of responsiveness today and hypotension. Started an IV and IV fluids. When EMS arrived she was still hypotensive and was still decreased level of responsiveness. When became more aroused and awake she started complaining of chest pain. Upon arrival to the ER [emergency room] she is more alert she states she has a little bit of chest pain but mostly pain in her knees which she always has. Additionally she states she has edema and weeping from both legs. They are both wrapped and she has noticed some increased redness to the left leg recently. Review of R106 Hospital Cardiology Consult, dated 7/11/25, reflected, [AGE] year-old female history of HFpEF [diastolic heart failure], lymphedema, CKD [chronic kidney disease] who presents from nursing home with altered mental status, lower extremity swelling/redness, hypotension, concern for infection. Upon arrival, she was given IV antibiotics, BP [blood pressure] stabilized. She is now more awake and alert. She does state intermittent chest discomfort though she states it is more so constant pain in the middle of her back which somewhat radiates to the center of her chest. States she is acutely short of breath, feels like she is wheezing and it is difficult to take a deep breath. She has not had significant palpations-dizziness. She is aware that her LE edema is chronic but states it has much worsened lately as well as redness, tenderness and some drainage.WBC H 28.5 [white blood cell count indicator of infection with normal range less than 11].Diagnosis NSTEMI-troponin down trending.Acute HFpEF.Sepsis-likely secondary to cellulitis. Review of R106 Hospital Wound Ostomy Continence Note, dated 7/11/25, reflected, Bilateal [bilateral] lower leg cellulitis, legs are bright red, swollen, tender, moist satellite wound beds. Venelex ordered to be applied when it comes from pharmacy. Review of R106 Hospital Care Management Team Note, dated 7/15/25, reflected, IP [in patient] day 5, admitted with Nstemi and septic shock Palliative consult, and was decided that patient will return to [named facility] with hospice services.Clinical Formulation.admitted with Nstemi and septic shock likely caused from cellulitis of leg wounds. Review of R106 Hospital Discharge summary, dated [DATE], reflected, Discharge diagnosis Septic shock, Cellulitis. Review of the Death Certificate, dated 7/18/25, reflected R106's cause of death included NSTEMI with contributing causes that included kidney disease, diabetes, hypertension and CHF. Review of the facility staffing schedules, dated 6/20/25 through 6/23/25, reflected Licensed Practical Nurse (LPN) F was R106's nurse on 6/21/25 and 6/22/25 day shift and LPN D was R106 nurse on 6/23/25 (when complainant alleged black plastic bags were found on R106's bilateral lower legs). During an interview on 9/29/25 at 1:47 p.m. Licensed Practical Nurse (LPN) D reported R106 was alert and oriented, legally blind and had wounds on lower legs and slept in recliner with legs elevated. LPN D reported was R106's nurse on 6/23/25 day shift when she found R106 with black trash bags over bilateral lower legs at start of shift and notified the facility wound nurse M immediately. LPN D reported the wound nurse removed the dressings and contacted the Director of Nursing DON B. LPN D reported was also working when R106 was transferred to the hospital on 7/10/25 when staff reported to her that R106 was confused, had low blood pressure and R106 reported she felt like she was going to faint around 6:15 a.m. LPN D reported 911 was called and R106 was transferred to local hospital. During a telephone interview on 9/29/25 at 2:14 p.m., Wound Nurse (WN) M reported R106 had bilateral venous ulcers that were healing well in early June. WN M reported R106 refused to take physician ordered diuretic few days prior to 6/20/25, when she had seen R106 for wound assessments, related to increased drainage after restarting diuretics. WN M reported were unable to order needed compression supplies mid-June and had to make adjustments in treatments but orders to change bilateral lower leg dressings daily. WN M reported assessed wound weekly and documented in Electronic Medical Record and reported was unsure why R106 did not have wound assessments for 7/8/25 (two days prior to being admitted to the hospital for sepsis and cellulitis). WN M reported was alerted by LPN D on 6/23/25 that R106 had black plastic trash bags on bilateral lower legs and black trash bags were removed and R106's old dressings under bags were heavily saturated with wound drainage and complained of increased leg pain. WN M reported was unsure how to describe R106 leg wound but reported they had significantly worsened since 6/20/25 and stated, legs were weeping so bed they did not know what to do. WN M reported that is when she contacted the facility Wound Nurse Practitioner U and DON B who completed an investigation and staff teaching. WN M reported was unsure why R106 had black plastic trash bags on legs or how long they had been in place and verified was not physician ordered. During an interview on 10/2/25 at 8:55 a.m., WN M reported had been the facility wound nurse for over one year. WN M reported saw R106 on 6/20/25 for wound assessment and thought had changed order to three times daily, however, after reviewing Physician Orders and Treatment Administration Record reported R106 wound treatments were daily but thinks she left extra supplies in zip lock bags for weekend. WN M reported supervisor always has keys that can access her office where supplies are stored. WN M reported R106 had increased drainage over the weekend, and nurse placed black trash bags over R106 legs and verified were removed on 6/23/25 after breakfast. WN M again reported when R106 old dressing were removed on 6/23/25 they were heavily saturated, and wounds were significantly worse from 6/20/25 with right leg worse than left and reported R106 wounds went from small blister area to full leg wounds with R106 complaints of 7 out of 10 pain on scale. WN M stated she was, shocked. WN M reported placing black plastic trash bags over R106 legs was not acceptable nurse practice. WN M reported was informed by the DON B that two nurses received education after the event. WN M stated, reported to DON B because [named R106] wounds were significantly worse and placing black plastic trash bags over dressings was not an acceptable practice and that is not what I want in my building. WN M reported R106 did not have history of refusing treatment and if resident refused treatment would expect to see Nurse Progress Note and verified was unable to locate for 6/22/25. WN M verified R106 supplies were not available on 6/17/25 and waited until 6/20/25 to notify physician because supplies were expected to arrive. WN M reported R106 was started on antibiotics for cellulitis on 6/26/25 after being assessed by facility Wound Nurse Practitioner on 6/25/25. WN M reported was present when R106 was sent to the hospital on 7/10/25 after being alerted R106 was not acting right assessed R106. WN M reported knew R106 was a full code and was non-responsive at time and obtained crash cart and wrist cuff. WN M reported R106 blood pressure was 63 over something and was showing signs of, tanking. WN M reported started IV fluids and after about 100 cc R106 reported chest pain. WN M reported fluids were slowed related to history of CHF and 911 was called and R106 was transferred to local hospital. During a telephone interview on 10/2/25 at 9:42 a.m., LPN F reported was R106 nurse on 6/21/25 and 6/22/25 and reported R106 had copious amounts of drainage from bilateral legs that required several dressing changes on 6/21/25 related to saturated dressings. LPN F reported R106 had compression dressings that were not available. LPN F reported R106 never refused treatments and stated, in fact, [named R106] wanted to heal wounds. LPN F reported was unsure why she would have documented R106 refused treatment on 6/22/25 unless she documented on wrong resident and verified R106 definitely did not refuse treatment. LPN F reported placed black plastic bags on R106 bilateral legs around 1:15 p.m. and reported was unsure what day, because of copious amount of drainage and did not remove prior to end of shift. LPN M reported informed next shift nurse but could not recall name. LPN F reported plastic bags were not ordered by physician and was unsure if R106 change of condition on 6/21/25 had been reported to the physician, but if so, documented would be in Progress Notes. (Verified no mention of physician notification of change). LPN F reported received verbal education from DON B because physician orders were no followed. During a telephone interview on 10/2/25 at 10:09 a.m., the facility Wound Nurse Practitioner U reported LPN D and WN M asked her to see R106 related to wounds that went from cluster wounds to entire lower legs. Practitioner U reported R106 first observed on 6/25/25 and determined to have cellulitis and antibiotics were ordered. Practitioner U reported was informed by WN M that R106 was found to have plastic bags over dressings prior to consult. Practitioner stated, not appropriate treatment, definitely not. During an interview on 10/2/25 at 11:56 a.m., DON B reported was informed that R106 was found to have black plastic bags over dressings on bilateral lower legs on 6/23/25. DON B' reported that was not appropriate and/or physician ordered treatment because keeps heat in. DON B reported R106 legs were twice as bad after removing bags and saturated dressing on 6/23/25 when observed with WN M with copious amounts of drainage. DON B reported R106 was alert and oriented times three and her own responsible party. DON B reported she questioned LPN F about placing plastic bags on R106 legs and LPN F reported, yes, she had done that. DON B reported was unsure when the bags were placed on R106 legs. DON B reported placing plastic bags over dressings was not an acceptable practice and would expect the nurse to follow physician orders and contact physician with change of condition. DON B verified LPN M did not follow the physician orders or contact physician with change of condition on 6/21/25 and was given education after the incident. DON B reported R106 was started on antibiotic treatment for cellulitis on 6/26/25 and investigation was completed, however, did not complete Incident/Accident report related to event. DON B verified R106 was admitted to the hospital for NSTEMI, sepsis and cellulitis and returned to facility on hospice services and passed 7/18/25. During an interview on 10/2/25 at 1:10 p.m., DON B provided file for R106 skin investigation with no evidence of Incident/Accident report and revealed DON B had also provided education to another staff member nurse supervisor Z. DON B verified nurse supervisor Z responded to written education and was not present at time of event and DON B verified after review of nurse schedules. (Evidence that investigation was not through or complete). Review of the provided file for R106 included written statement by DON B, dated 6/23/25. The statement included, [named LPN D] mentioned that [named LPN F] had applied a plastic bag because it was seeping continuously. The file included, Counseling Notification, oral warning, dated 6/23/25, that reflected, Subject: Improper Treatment in Place.Education Provided: Follow treatment exactly as ordered. Notify Doctor with change of Condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to: 1.) ensure the safety of resident during staff assisted transfer, and 2.) implement care-planned interventions for 1 of 4 sampled residents (R6) reviewed for accidents, resulting in actual harm for R6's fall during staff assisted transfer with bilateral pelvic fractures, a fractured left elbow, and a non displaced fracture near her left total hip site on 3/10/24 and 10/21/24 that required transfer to the hospital. Findings include: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R6 was a [AGE] year old female admitted to the facility on [DATE], with re-admission post hospital admission 3/12/24 following left pelvic fractures, a fractured left elbow, and a non displaced fracture near her left total hip site, and 10/23/24 post fall with a left lesser trochanter fracture which is non-operable with other diagnoses that included history left hip replacement, heart failure, hypertension(high blood pressure), diabetic, Osteoarthritis, heart disease, chronic lung disease, anxiety and depression. The MDS reflected R6 had a BIM (assessment tool) score of 13 which indicated her ability to make daily decisions was cognitively intact with no behaviors including rejection of care. Continued review of the significant change MDS, dated [DATE], reflected R6 was now bed bound and was dependant on staff for all activities of daily living. During an observation and interview on 12/03/24 at 9:14 AM, R6 door was closed. R6 was laying in bed wearing a hospital gown, call light out of reach resting on oxygen concentrator about three feet from bed. R6's fitted sheet was under R6 but not over edges of air mattress with odor of BM(bowel movement) in room. R6 appeared able to answer questions without difficulty and reported would use call light to get staff assistance if needed. During an observation on 12/03/24 at 10:20 AM, R6 door closed and call light continued to be out of reach, now on the floor under resident bed. R6 eyes closed laying in bed. During an observation and interview on 12/03/24 at 12:15 PM, R6 door was open and family was R6's daughter DD was present with call light on and within reach. R6 daughter DD reported call light was on because R6 needed assistance with bowel incontinence care. R6 daughter DD reported R6 had foley catheter in place related to since most recent fall with left hip fracture related to Orthopedic order for bed rest and stage 3 pressure wound to sacral area. R6 reported had fall about 6 months ago with several fractures during a staff assisted transfer then an additional fall about two months ago during staff assisted transfer with fracture of left hip. R6 reported pressure wound started at the facility. During an observation on 12/04/24 at 8:45 AM, R6 door was open, resident was sitting upright in bed eating independently dressed in hospital gown with call light out of each under the bed. Review of the Nursing Progress note, dated 3/10/2024 at 8:00p.m., reflected, Secure Conversations Messages: Subject: FALL[2024-03-10 19:37:24 EDT] .Resident fell outside bathroom door, witnessed as CNA[Certified Nursing Assistance] was assisting resident. Complains of left hip pain including with ROM[range of motion]. Dr phoned and order to send out to ER for further eval and tx[treatment]. Small hematoma to left side of forehead and bruise to left top of hand . Review of the Nursing Progress note, dated 3/11/2024 at 4:54a.m., reflected, Telephoned [named] Hospital ER[Emergency Room] and was notified that resident was admitted with hip fracture . Review of the Nursing Progress note, dated 6/22/202 at 2:27 p.m., reflected, Resident observed sitting on the floor in front of her dresser beside her PC[personal chair] leaning back on the dresser, Code 99 called. Assessed resident, no injuries noted. Resident did state,My butt hurts from sitting on the floor. Resident's oxygen was off spo2[oxygen saturation] was 83% on RA[room air], re-applied oxygen immediately before assessing her and spo2 increased to 91% on 2.5 LPM[liters per minute] o2via NC[nasal canula]. Resident assisted in PC via maxi-lift. CNA stated, I was walking resident back from the bathroom and she was off balance so I lowered her to the floor. Resident did not hit her head. CNA did not have F/U[follow up] w/c[wheelchair]behind resident as ordered when ambulating. CNA was given a written verbal warning for resident not having o2[oxygen] on and for not using F/U w/c while ambulating as ordered . Review of the Nursing Progress note, dated 10/21/2024 at 6:39 p.m., reflected, At 1450p[2:50 p.m.] Resident was being transferred from her motor-chair to her personal chair with gait belt on and 2ww[two wheel walker], by this writer, resident lost her balance, and resident fell backwards to the floor. Code 99 called. Upon assessment resident complained of left hip pain, resident not moved and 911 called, resident left by ambulance at 1515pm[3:15 p.m.]. Review of the Nursing Progress note, dated 10/23/2024 at 2:51 p.m., reflected, admission Summary Note Text: Resident arrived back at facility at 1323[1:23 p.m.] via stretcher accompanied by 2 EMTs[emergency medical technicians] after a fall. Resident has a Left lessor trochanter FX[fracture]. Resident is non-wt bearing, has a 16 Fr Foley catheter. Resident's pain level now is a #7 of 10, Percocet 7.5/325mg tab given at 1357[1:57 p.m.]. Resident has a stage 3 pressure wound to coccyx that is covered by border foam . Review of the Incident/Accident(I/A) reports provided 12/04/24 at 1:10 PM, revealed R6 had fall with several fractures on 3/10/24 during staff assisted transfer without following interventions including the use of a gait belt. Fall on 6/22/24 during staff assisted transfer without following ordered interventions. Fall on 10/21/24 during staff assisted transfer with left lessor trochanter fracture. Continued review of the I/A reports reflected no witness statements. Director of Nursing (DON) B reported would provided complete investigations. Review of the Fall Assessment, dated 1/21/24, reflected R6 was at high risk for falls with score of 55. Continued review of the Fall Assessment, dated 9/12/24, reflected R6 was at high risk for falls with score of 70. Review of R6 Care Plan, dated 10/8/2019 to current 12/10/24, reflected, The resident is high risk for falls r/t cardiac issues/anxiety/COPD/muscle weakness/prior history of falls, Macular Degeneration. The Care Plan had interventions that included, Be sure The resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Date Initiated: 12/08/2019 . During a telephone interview on 12/05/24 at 10:37 AM, Certified Nurse Aid (CNA) EE reported was transferring R6 on 3/10/24 when she fell in bathroom. CNA EE reported R6 used walker with one person assist for transfers with gait belt. CNA EE reported R6 did not have gait belt on at the time of the fall because R6 did not like it. CNA EE reported R6 fell hard on left hip and left elbow the hit left side of face on floor just inside bathroom door when R6 insisted CNA EE pick up personal item from the floor. CNA EE reported R6 was in visual pain as evidenced by wincing and guarding and reported pain in left hip and told EMS left elbow. CNA EE reported called for nurse who was just outside R6 door and reported remained with R6 on the floor until EMS arrived 30 minutes to one hour later. CNA EE reported received education after fall to always use gait belt during transfers and if residents refuse to notify nurse prior to transfer. CNA EE reported after 3/10/24 fall R6 transfer status was maxi lift(hoyer) with 2 assist, then to 1 assist with 4ww and gait belt. CNA EE reported R6 was making good recovery after fall and had additional fall with nurse assist about 2 months ago. During a telephone interview on 12/05/24 at 2:39 PM, Licensed Practical Nurse (LPN) FF reported was transferring R6 on 10/21/24 from motorchair to personal chair in room when R6 lost balance and fell backwards on floor. LPN FF reported she was standing beside R6 with gait belt in place and walker in front of R6 when R6 lost balance fell on back on floor. LPN FF reported was unsure if she was holding R6 gait belt by side of the back. LPN FF reported R6 reported severe pain to left leg and could not even stand for left leg to be touched. During a telephone interview on 12/06/24 at 5:06 PM, CNA GG reported was working 3/10/24 when R6 fell. CNA GG reported was the first extra staff to respond to the code 99(fall code). CNA GG reported R6 was laying in doorway of bathroom in room and did not have a gait belt on. CNA GG reported gait belt should always be used during staff assisted transfer and reported had informed nurse manager was not in place. CNA GG reported CNA EE received education after R6 fall related to use of gait belt at all times. During an interview on 12/06/24 at 9:25 AM, Therapy staff HH verified R6 transfer status was one assist with use of walker and gait belt at the time of the 3/10/24 and 10/21/24 fall. During an interview on 12/06/24 at 11:39 AM, LPN II reported was R6 nurse on 3/10/24 and reported had medication cart just outside R6 when she heard crash in R6's room and heard CNA FF say R6 was on the floor. LPN II reported R6 was on the floor, in the bathroom doorway, laying on her back and called code 99. LPN II reported R6 complained on 10/10 pain left hip with externally rotated ankle. LPN II reported CNA EE remained with R6 on floor until EMR arrived after about 20 minutes. LPN II reported R6 transfer status prior to fall was staff assist of 1 with use of gait belt and walker and verified gait belt was no in place. During an interview on 12/10/24 at 12:30 PM, DON B reported would expect staff to use gait belt with all resident transfers and follow care plans. DON B reported R6 had history of refusing gait belt. DON B reported staff was re-educated on use of gait belt with resident transfers. Review of the provided education reflected staff sign in with no topic of education or date. Review of the facility, Transfer with a Gait Belt policy, undated, reflected, The resident will be assessed by professional therapies for the safest transfer option to provide the resident and staff with the utmost safety .Put on the resident's stockings/socks, shoes and gait belt .Face the resident .Grasp the gait belt on each side of the waist-with your fingers inserted up through eh bottom of the belt. Flex your knees and hips deeply, supporting the resident's knees with yours. Straighten your knees and hips, lifting the resident to a standing position at the same time. Pivot the resident so that the back of their legs are close to the chair, your hands still in position in the gait belt. Tell the resident that the chair is behind them and that you are going to lower them into the chair seat .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #3 (R3) Review of the medical record revealed Resident #3 (R3) was initially admitted to the facility on [DATE] with diagnoses that included encounter for orthopedic aftercare following surgical amputation, peripheral vascular disease, atherosclerosis of native arteries of extremities, with rest pain, right leg, chronic obstructive pulmonary disease, and diabetes 2. According to Resident #3 (R3)'s Minimum Data Set (MDS) dated [DATE], revealed R3 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and had no behaviors. R#3's Braden scale results were a score of 13, showing R3 was at moderate risk for skin breakdown. Record review revealed the admission assessment of the wounds on R3. Coccyx pressure ulcer 0.5cm x0.3cm x0.1cm, Stage 2. Right heel pressure ulcer 5.0cm x5.0cmx0.0cm suspected deep tissue injury (Record review revealed the admission assessment of the wounds on R3. Coccyx pressure ulcer 0.5cm x0.3cm x0.1cm, Stage 2. Right heel pressure ulcer 5.0cm x5.0cmx0.0cm suspected deep tissue injury (Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration, or epidermal separation revealing a dark wound bed or blood-filled blister. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue). A second skin assessment dated [DATE] describes the heel pressure ulcer with no measurements and wound bed is filled with 100% eschar. Right toe pressure ulcer 0.5cm x0.5cm x0.0cm suspected deep tissue injury. Right dorsum foot pressure ulcer stage 1, no measurements. Left elbow other type of wound 1.0cm x1.0cm x0.0cm. Left knee, surgical incision, 19cm. Minimum Data Set (MDS) for admission assessment documented R3 had 1 stage 1 pressure ulcer, 1 stage 2 pressure ulcer, and 2 unstageable pressure ulcers under section MO300 current number unhealed pressure ulcers/injuries at each stage. Record review of 11/01/23 revealed a skin/wound assessment. Left lower leg amputation surgical site with 21 staples, was stable with a small amount of blood on the dressing covering it. Coccyx pressure ulcer 0.5x0.3x0.1. Right heel pressure ulcer 5.0x5.0x0.0 suspected deep tissue injury. Right toe pressure ulcer is unstageable due to eschar. Marked as deteriorating. Right dorsum foot pressure ulcer stage 1, no measurements. Left elbow other type of wound 1.0cm x1.0cm x0.0cm. Left knee, surgical incision, 19cm. No documentation to support a provider oversight of the wound/pressure ulcer program. Record review revealed no weekly skin/wound assessment on 11/08/23 was completed on the right heel, right dorsal foot, right anterior foot, coccyx, left elbow or surgical site for the left lower leg amputation site. Record review revealed on 11/10/23 in the nursing progress notes that the nurse called the vascular surgeons office with concerning areas on the right foot. New order received to not wrap the right foot. Record review revealed on 11/13/23 in the nursing progress notes that the nurse identified the right heel with a dark unstageable area on the heel, removed protective dressing and heel is soft and looks like it a blood blister about the size of a half a dollar, left message for wound care to assess. Record review revealed on 11/14/23 at 10:41 in the nursing progress notes documented the wound care nurse assessed areas. Right heel with dark area and dark unstageable area also on middle toe have become soft and developed what looks like a blister. Record review of 11/14/23 revealed a skin/wound assessment. Left lower amputation surgical site with 21 staples, was stable with a dressing covering it. Coccyx pressure ulcer, no assessment completed. Right heel pressure ulcer 5.0cm x5.0cm x0.0cm suspected deep tissue injury, no assessment completed. Right toe pressure ulcer is unstageable due to eschar. Measurements of 0.5 cm2x1.0x0.7cm, then marked dark purple. Right dorsum foot pressure ulcer stage 1, no measurements. Left elbow other type of wound 1.0x1.0x0.0. No documentation to support a provider oversight of the wound/pressure ulcer program. Record review of 11/21/23 revealed a skin/wound assessment. Left lower amputation surgical site with 21 staples, was stable with a dressing covering it. Coccyx pressure ulcer. No assessment completed. Right heel pressure ulcer suspected deep tissue injury. Assessment stated R3 had a fever, no measurements taken, called it a hematoma. The rest of the assessment was blank, marked stable. No documentation that the physician was notified of the fever. Right toe pressure ulcer is unstageable due to eschar. No assessment completed. Right dorsum foot pressure ulcer stage 1. No assessment completed. Left elbow other type of wound 1.0cm x1.0cm x0.0cm. No assessment completed. Right Lateral Foot stage 1 pressure ulcer, in house acquired, marked new, no measurements. No documentation to support a provider oversight of the wound/pressure ulcer program. Record review of 11/28/23 revealed a skin/wound assessment. left lower leg amputation site with 21 staples were stable and covered with a dressing. No assessment was completed on the right heel, right dorsal foot, right anterior foot, right foot second toe, coccyx, or left elbow. No documentation to support a provider oversight of the wound/pressure ulcer program. Record review of 12/05/23 revealed a skin/wound assessment. Coccyx pressure ulcer. No assessment completed. Right heel pressure ulcer suspected deep tissue injury. Assessment started but not completed. Right toe pressure ulcer is unstageable due to eschar. Assessment started but not completed. Right dorsum foot pressure ulcer stage 1. Assessment started but not completed. Left elbow other type of wound 1.0cm x1.0cm x0.0cm. No assessment completed. Right Lateral Foot stage 1 pressure ulcer, in house acquired, marked new, no measurements. No documentation to support a provider oversight of the wound/pressure ulcer program. Record review revealed that R3 did not have a skin/wound assessment the week of 12/11/23. No assessment was completed on the right heel, right dorsal foot, right anterior foot, right foot second toe, coccyx or left elbow. Record review of 12/14/23 revealed R3 went to the wound clinic. Severe PAD, right lower extremity arterial ulcers x 3. 2nd opinion with vascular specialist. Follow up in 1 week. No new orders. Record review of 12/18/23 revealed R3 went to the wound clinic. Right heel ulcer with toe ulceration. Very complex disease in right lower extremity with multiple areas of ulceration. Diagnosis with gangrene with .occlusion. Record review revealed that R3 did not have a skin/wound assessment the week of 12/18/23. No assessment was completed on the right heel, right dorsal foot, right anterior foot, right foot second toe, coccyx or left elbow. Record review revealed that R3 did not have a skin/wound assessment the week of 12/25/23. No assessment was completed on the right heel, right dorsal foot, right anterior foot, right foot second toe, coccyx or left elbow. Record review of 12/29/23 revealed R3 went to the wound clinic. No new orders. Record review of 01/02/24 revealed a skin/wound assessment. Right heel pressure ulcer still marked suspected deep tissue injury. Assessment started but not completed, stated wound bed was full of eschar and the peri wound now has rolled edge. Pressure ulcer was marked stable even though it was gangrene. Right Lateral Foot stage 1 pressure ulcer, assessment started not completed. Left elbow other type of wound 1.0cm x1.0cm x0.0cm. No assessment completed. Right toe pressure ulcer is unstageable due to eschar. Assessment started but not completed. No documentation to support a provider oversight of the wound/pressure ulcer program. Record review revealed that R3 did not have a skin/wound assessment the week of 01/08/23. No assessment was completed on the right heel, right dorsal foot, right anterior foot, right foot second toe, coccyx or left elbow. Record review revealed in the nursing progress notes dated 01/10/24 at 11:38, RN peeled skin off of toes to reveal no open areas. One small dark red area on lateral side of 2nd toe remains. Resident denies pain in foot, but states he has pain in leg. Record review revealed that R3 did not have a skin/wound assessment the week of 01/15/24. No assessment was completed on the right heel, right dorsal foot, right anterior foot, right foot second toe, coccyx or left elbow. Record review revealed that R3 did not have a skin/wound assessment the week of 01/22/24. No assessment was completed on the right heel, right dorsal foot, right anterior foot, right foot second toe, coccyx or left elbow. Record review revealed that R3 went to the wound clinic on 01/25/24. New orders given. Record review of 01/30/24 revealed a skin/wound assessment. Right heel pressure ulcer now marked arterial wound. Measurements include 4.6cm x3.4cm, depth NA. Wound bed 100% eschar. Under other marked as a deep tissue injury. Surrounding tissue dry and flaky. Right Lateral Foot stage 1 pressure ulcer, no assessment completed. Left elbow other type of wound 1.0cm x1.0cm x0.0cm. No assessment completed. Right toe pressure ulcer is unstageable due to eschar. Now marked arterial. Assessment started but not completed. Coccyx pressure ulcer. Assessment started on 01/31/24 but not completed. Left lower leg amputation site with 21 staples were stable and covered with a dressing. No documentation to support a provider oversight of the wound/pressure ulcer program. Record review of 02/08/24 revealed a skin/wound assessment. Right heel pressure ulcer now marked arterial wound. Measurements include 4.6cm x3.4cm, depth NA. Wound bed 100% eschar. Under other still marked as a deep tissue injury. Surrounding tissue dry, flaky and calloused. Right Lateral Foot stage 1 pressure ulcer, no assessment completed. Left elbow other type of wound 1.0cm x1.0cm x0.0cm. No assessment completed. Right toe pressure ulcer is unstageable due to eschar. Now marked arterial. Measurements of 0.7cm x1.1cm. Depth is marked NA. Assessment started but not completed. Coccyx pressure ulcer. No assessment completed. Left lower leg amputation site with 21 staples were stable and covered with a dressing. New skin opening of groin and chest incision not addressed for 02/05/24. No documentation to support a provider oversight of the wound/pressure ulcer program. Record review of 02/08/24 revealed R3 went to the wound clinic. Record review of 02/12/24 revealed a skin/wound assessment. Right heel pressure ulcer/arterial wound. Assessment started, not completed. Right Lateral Foot stage 1 pressure ulcer, no assessment completed. Left elbow other type of wound, no assessment completed. Right toe pressure ulcer/arterial ulcer is unstageable due to eschar. Assessment started but not completed. Coccyx pressure ulcer, no assessment completed. Left lower leg amputation site with 21 staples were stable and covered with a dressing. No documentation to support a provider oversight of the wound/pressure ulcer program. Record review revealed R3 went to the wound clinic on 02/15/24. Right heel 4.7cm x4cmx0.1cm. Right shin 2.7cm x1.5cm x0.3cm. Right dorsal foot 2cm x1.9cm x0.3cm. Record review of 02/20/24 revealed a skin/wound assessment. Right toe pressure ulcer/arterial ulcer is unstageable due to eschar. Assessment started but not completed. Measurements of 2.3cm x1.0cm. Depth marked NA. Right heel pressure ulcer/arterial wound. Assessment started, not completed. Measurements of 4.1cm x3.2cm. Depth marked NA. No documentation to support a provider oversight of the wound/pressure ulcer program. Record review revealed R3 went to the wound clinic on 02/21/24. Record review revealed that R3 did not have a skin/wound assessment the week of 02/26/24. No assessment was completed on the right heel, right dorsal foot, right anterior foot, right foot second toe, coccyx or left elbow. Record review of 02/28/24 revealed R3 went to the wound clinic. Right foot and ankle ulcers x3 with increased edema and erythema (swelling and redness). Superficial debridement (removing dead tissue or infected tissue) done. Culture and sensitivity done to distal ankle wound. Follow up in 1 week. Record review revealed that R3 did not have a skin/wound assessment the week of 03/04/24. No assessment was completed on the right heel, right dorsal foot, right anterior foot, right foot second toe, coccyx or left elbow. Record review of 03/06/24 revealed R3 went to the wound clinic. Reported right anterior foot/ankle debridement done with subcutaneous tissue removed. Right heel also debrided with subcutaneous tissue removed as well. Patient still on antibiotics as prescribed. Awaiting procedure for vascular intervention. Record review revealed R3 received wound care to R foot, tan colored drainage (sign of infection) slightly larger than wounds on dressing, slight odor (sign of infection), pedal and front of ankle slightly red, continues ABX for wound infection. No documentation found to support the physician was notified of the wound changes. Levaquin oral tab 500mg, give 1 tab by mouth at bedtime for wound infection for 10 days. Ordered 03/03/24 completed 03/13/24 for culture results of Isolate 1 Morganella morganii Moderate (bacteria in the environment). Isolate 2 Staphylococcus aureus Rare (MRSA), susceptible to oxacillin. Bactrim DS oral tab 800-160mg. Give 1 tab by mouth 2 times a day for wound infection for 10 days. Ordered 03/13/24 completed on 03/13/24 24 for culture results of Isolate 1 Morganella morganii Moderate. Isolate 2 Staphylococcus aureus Rare, susceptible to oxacillin. Record review of 03/14/24 revealed a skin/wound assessment. Right heel pressure ulcer. Assessment started, not completed. Reported that wound bed was 100% slough, not 100% eschar. Measurements of 1.7cm x1.2cm. Depth NA. Right Lateral Foot stage 1 pressure ulcer, no assessment completed. Right toe pressure ulcer/arterial ulcer is unstageable due to eschar. No assessment completed. No documentation to support a provider oversight of the wound/pressure ulcer program. Record review of 03/20/24 revealed R3 went to the wound clinic. Superficial debriding done. Right lower extremities, ankle x 2 wounds and right heel. Follow up in 2 weeks. No new orders. Record review of 03/25/24 revealed a skin/wound assessment. Right heel pressure ulcer. Assessment started, not completed. Reported that wound bed was 100% slough, not 100% eschar. No measurements. No assessment was completed on right dorsal foot, right anterior foot, right foot second toe, coccyx or left elbow. No documentation to support a provider oversight of the wound/pressure ulcer program. Record review of 04/02/24 revealed a skin/wound assessment. Right heel pressure ulcer. Assessment started, not completed. Measurements of 3.1cm x4.4cm. Depth NA. No assessment was completed on the right dorsal foot, right anterior foot, right foot second toe, coccyx or left elbow. No documentation to support a provider oversight of the wound/pressure ulcer program. Record review of 04/03/24 revealed R3 went to the wound clinic. Right foot and ankle wounds x 3. Debridement done. Had re-vascular done last week. Wound vac (vacuum placed on wound that drains fluids and promotes blood flow to the wound) to heel wound. Record review revealed R3 went to the wound clinic on 04/10/24. Right heel 4.2cm x3.9cm x1.1cm. Right anterior ankle 3.9cm x1.6cm x0.5cm. Right dorsal foot 2.1cm x1.9cm x0.8cm. Record review revealed that R3 had his dressing changed at 13:29 on 04/10/24 to the right dorsal foot and heel with moderate amount of drainage and a slight odor (sign of infection). No documentation to support the physician was notified. Record review of 04/11/24 revealed a skin/wound assessment: Right heel pressure ulcer. Assessment started, not completed. Measurements of 3.6cm x2.9cm. Depth marked NA. No assessment was completed on the right dorsal foot, right anterior foot, right foot second toe, coccyx or left elbow. No documentation to support a provider oversight of the wound/pressure ulcer program. Record review revealed that R3 went to the wound clinic on of 04/17/24. Right heel: 4cm x3cm x0.9cm. Right anterior ankle: 4cm x1.5cm x0.8cm. Right dorsal foot: 2cm x1.6cm x2.2cm. Cultures (test for infection) taken of right ankle and dorsal foot. X-rays (detect bone infection, osteomyelitis) ordered needs completed on Right foot and ankle. During an interview and observation on 04/16/24 at 1:50 PM with R3 and his wife. R3 stated he had 2 sores on his right foot, and one on his heel. R3 stated that the dressing was changed this morning by the floor nurse. Observation with today's date and time written on the outside of the dressing. Wife stated the facility doctor has never seen the wounds. Wife also stated that the doctor has come in the room to talk to R3, but not look at the wounds. Wife stated R3 had a pressure ulcer on his coccyx but that was healing. Wife added R3 got the pressure ulcer from sitting in wet briefs. Writer asked how often the staff come in to check and change him. Wife stated she is there with the resident every day. Added the day shift is better at it than the other shifts. R3 stated they had to use a mechanical lift to get him transferred from the bed to his wheelchair and back to bed. R3 stated the staff leave the mechanical lift sling under him to make it easier for them, but he sits on it all day while up in his wheelchair. Writer educated R3 on the increased risk of breakdown by having that under him. The mechanical lift sling added extra pressure on his coccyx and left leg stump. R3 also stated he goes to the wound clinic, and they wanted to put on a wound vac and the nurses here told him he wasn't a candidate for a wound vac. R3's wife stated R3 brings back the documentation from the wound clinic and the nurse will read the documentation, then calls the wound clinic and tell them that not what the facility wants to do. R3's wife also stated there was another resident in the facility that had a wound vac, why can't he? During an interview on 04/17/24 at 09:00 AM, RN C and RN D stated the wound care nurse is off work due to medical reason. RN C also stated that those two nurses were asked to come back to help with wounds while the wound nurse was off. RN C stated R3's wounds are chronic, wound clinic does the measuring of the wounds and the facility scans them into his chart. RN C added that the facility does not measure the wounds. Writer asked RN C what they do with the new orders from the wound clinic for R3. RN C stated they are read by the house supervisor or unit manager, notify the covering physician, and it he agrees with the orders, they are put in the electronic medical record. If not, then he will write his own orders. Writer asked who does the weekly skin/wound assessments. RN C stated she and the other nurse have started doing that. Writer asked [NAME] often does the provider round with them when they are providing care and assessing. RN C stated he had not made any rounds with them during the last two weeks that they had taken over the wound program. During this same interview with RN C and RN D she stated R3 goes to the wound clinic for the heel wound. Also stated that R3 was admitted with the pressure ulcer on his right heel. Writer asked about the order from the wound clinic for the wound vac ordered for R3's heel on 04/03/24 and why it had not been followed. RN D stated the wound care nurse addressed the order. RN D added there was a concern about the wound clinic not debriding the heel enough to use a wound vac. Writer asked if R3 had the wound vac on yet. RN C stated no. During an interview and observation of RN C and RN D performing wound care on R3. R3 stated that the wound clinic scrapped all 3 of his wounds. Observation of the heel revealed beefy red tissue with slough. R3 stated they cultured his wounds but wasn't sure why. RN C stated his wounds look better today than they did last week. No provider present at this dressing change for oversight as required. During an interview on 04/18/24 at 11:14 AM RN C and RN D stated that the wound care nurse needed to collaborate with the physician to get a history, diagnosis of the correct wounds. Wound care and dressings are used for different wounds as well as the amount of drainage. RN C stated the facility has standard wound care orders, but if the nurse wants to use something else, they need to call the physician first. RN D stated they use the weekly skin/wound assessments and pictures to show changes week to week. So, if the wound is getting worse, you need to call the physician. RN C stated the physician comes into the facility weekly but does not know if he looks at the wounds. Adding at this time, there is no oversight be the physician or facility nurse practitioner. RN C stated they used to have an NP that made rounds with the wound care nurse about a year ago. RN C stated the expectation would be for the nurses to notify the physician on any wound changes. During an interview on 04/18/24 at 11:53 AM, RN C and RN D stated they had been working with the wounds in the facility and voiced they had discovered some areas of concern. RN C stated she had concerns about the wounds that became infected, lack of skin/wound assessments being completed. Also stated they noticed wounds that had not been resolved or remain open. RN D stated they had decided to do a sweep of every resident with and without wounds and re-assess the residents with pressure ulcers. RN C stated they had found the same concerns that the writer did. RN C stated they talked to the Director of Nursing (DON) B the end of last week once they could share their findings with her. RN C stated they didn't just discuss the stage 4 pressure ulcers but the lack of documentation and weekly assessments being done. RN D stated the wounds are scattered throughout the facility, not on one single unit. During an interview on 04/18/24 at 2:00 PM, RN F stated she did have concerns with the infected wounds. RN F also stated she tracks all symptoms, use of antibiotics, current infections and resolved infections. Added she used the McGeers criteria with the antibiotics. RN F stated she follows all wounds regardless of type. RN F stated the facility will refer residents to the wound clinic for their professional opinion when they cannot get a wound to heal or worsens. The wound clinic will send back their recommendations, the supervisors/unit managers review them, discuss with the DON, orders are then put into the electronic medical record. RN F stated she had put Enhanced Based Precautions (EBP) over a year ago, audits staff using personal protective equipment (PPE) at hiring of staff, monthly meetings, in-services as well as other ongoing education. RN F stated she presents this information monthly at the QAPI meetings. RN F also stated this process has been in place well over a year, so the DON and physician have been aware of this concern. RN F also stated she tracks and trends the peaks and valleys with the wounds/infections concerns. RN F stated that this information had been presented for some time now, so it should not come as a surprise to anyone. During an interview on 04/18/24 at 2:20 PM, LPN G stated she does the weekly skin assessments. LPN G stated she tries to follow the residents in the shower on the shower days because it is easy to do a head-to-toe assessment. LPN G also stated if she can not make it in the shower to do it, then she does in sometime during the day. During an interview on 04/19/24 at 09:27 AM, RN E stated she was hired as a wound care nurse about 1.5 years ago. RN E stated she did not have any formal training; the former supervisor taught her how to take pictures of the wounds but no other training. RN E stated she had home care experience and took care of wounds. RN E also stated she knew how to measure wounds from previous experience. RN E stated however, she had not been taught to measure tunneling and undermining. RN E stated that when she started here as a wound care nurse, there was an NP that made rounds with her for a couple of months. But nobody had made rounds with her after that. RN E stated it would have been nice to have someone make rounds with her to consult with, review orders and dressings appropriate for the wounds. RN E also stated that if a wound got worse, she would send them to the wound clinic after monitoring them for days or weeks. RN E stated she did all the daily dressings herself. RN E added that if the stage 2 or stage 3 pressure ulcers/wounds looked infected or had an odor or drainage, she would discuss the wounds with the unit manager or physician. RN E stated that she would wait a couple of days, scrub it really good to see if that helped. RN E stated she is much more effective cleaning these wounds than other nurses. RN E also stated the floor nurses watch her do the dressing changes and then they are competent from watching her process. RN E stated again, she is confident in her care. During this same interview with RN E, writer asked RN E about R3's wounds. RN E stated there was some confusion if the wounds were pressure or vascular. RN E stated she wasn't sure of that outcome since R3 saw both the vascular surgeon and the wound clinic. RN E stated that the wound clinic would give their orders/recommendations, she would talk to the physician who did not always agree with their recommendations. If the wound clinic NP did not agree with what the physician's order, she would call the facility with her rational. RN E stated she questioned the rational of using products together and questioned the wound clinic NP's education and background. RN E her treatments were not always appropriate. RN E also stated that sometimes she did not follow the clinic NP's orders, she would change them. Writer asked RN E how she knew what dressing/treatment she should be using. RN E stated she used an outside vendor to gain information and education on wounds, staging and use their products. RN E also stated she could have gone to DON B as needed but added the DON B didn't have any wound care background knowledge either. RN E stated that she did not have any support internally until the outside vendor was brought onboard. Writer asked RN E if she knew anything about pressure ulcer regulations, and RN E stated no. RN E stated she had no idea what the regulations were for pressure ulcers. RN E also added that she currently doesn't have any up-to-date manuals to use so she calls an NP for advice. During this same interview with RN E, writer asked RN E why R3 did not get the wound vac applied to his right heel as ordered from the wound clinic. RN E stated well if the wound was appropriate, then it should have been put on, but if the wound is infected, then she was not sure it should be used. RN E also stated she would have called her NP friend and asked her. During an interview on 04/18/24 at 11:00 AM, RN E stated she did not have wound vac competencies upon hire. RN E stated again that she would review orders with physician through a bubble/text feature in the nursing progress notes or text messaging from her personal phone. Physician would agree or disagree to the order, and she would put it in the electronic medial records. When asked by writer what was her process if she did not like the recommendations from the wound clinic. RN E stated she notify the physician, describe the wound to him and let him make recommendations. When asked what the time frame was for getting these new orders into the electronic medical record, RN E stated she was not aware of any timeframe. When asked by writer if the physician ever made rounds with her while doing weekly skin/wound assessments, measurements, or pictures. RN E stated no. RN E stated that the physician liked her to give him her recommendations, stating she did not have resources to use, she would go off her experience. During this same interview writer asked RN E if she worked with the infection Preventionist RN with the wounds. RN E stated she talks to her, monitors the wounds, had audits that showed that staff were not washing their hands enough between care. RN E also stated she had to show the certified nursing assistants (CNA) how to wash with soap and water. RN E stated again that she applied santyl (used to remove damaged tissue) to a moist gauze then placed it in the wound bed, instead of applying it to the wound bed as ordered and recommendation by the manufacturer. RN E also stated that these wounds needed debriding before they could be cultured, or you are just culturing dead tissue. Writer asked RN E again about including the DON in the lack of proving wound care to these residents. RN E stated she did not feel the DON B knew much about wounds so she did not go to her, she would call her NP friend. Writer asked RN E if anyone like the NP or physician had ever watched her do a skin/wound assessment, measurements or pictures and RN E stated no. Writer asked RN E if she realized that by not doing the weekly skin/wound assessments, these wounds had deteriorated to the point of causing harm. RN E stated she did the best she could do. During an interview on 04/19/24 at 12:30 PM, DON B stated she did not have a background in wound care nor was wound care certified. Writer asked if RN E was wound care certified, DON B stated no. DON B also stated that RN E was signed up for the class but did not finish it. Writer asked DON B if RN E dropped out or failed the class, DON B stated she did not know but she did not complete it. Writer asked DON B if RN E would be finishing it and DON B stated probably not. DON B was asked when she became aware of a concern with the wound care program. DON B stated she became aware in January 2024. Asked how she became aware. DON B stated the documentation was not being completed. Writer asked DON B what she did about the concern. DON B stated she formed a group including infection control, wound care nurses filling in, and a seasoned licensed practical nurse (LPN). DON B also stated she gave them task to check all the wound care orders and make sure they in the electronic medical record. DON B stated they did find orders that were overlapping, some orders were not discontinued, and wound clinic orders were never put in the electronic medical record. During this same interview DON B was asked what her expectations were for the wound care program. DON B stated she expected the weekly skin/wound assessments to be completed with measurements, descriptions, and pictures. Expected the wounds to be properly identified and staged. DON B added that any changes in the wounds/pressure ulcers should have been reported to the physician immediately. DON B stated she was [NAME][TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent falls in one of three residents reviewed for falls (Resident #4), resulting in a fracture. Findings Include: Resident #4 (R4) On 10/02/23 at 1:16 PM R4 was observed sitting in her wheelchair with an alarm on the back of her chair. R4's Minimum Data Set (MDS) dated [DATE] revealed she was admitted to the facility on [DATE], had a Brief Interview for Mental Status (BIMS) score of 03 (00-07 Severely Impaired); her transfer status at that time was extensive assist and used a wheelchair and walker for mobility. R4 had the diagnoses of Alzheimer's, Multiple Sclerosis, and Chronic Obstructive Pulmonary Disease (COPD, lung disease). Incident Report dated 3/17/23 at 11:20 AM revealed the nurse was in the hallway and hear a thud like sound, R4 was observed on her right knee and lowered herself to her left side. The same report indicated the alarm was not sounding and R4 reported she was trying to pick up her pen that she had dropped on the floor. R4 was transferred to the hospital. Operative Report dated 3/20/23 revealed R4 had a fractured right femur (thigh bone of leg articulating at the hip and knee) and underwent surgery. The same report indicated R4 would be non-weight bearing for six weeks. Nurses note dated 3/22/23 at 6:29 AM revealed the post fall investigation was completed and R4 had orders to not be left unattended in her wheelchair in her room, foot pedal be on her wheelchair, and therapy evaluation. The same note indicated questioning if R4's alarm was on at the time of the incident, when checked after the incident it was functioning appropriately. R4's electronic medical record revealed she returned to the facility on 3/22/23 at 8:30 PM. R4's Significant Change MDS assessment dated [DATE] revealed she was totally dependent on staff for transfers and used a wheelchair only for mobility. Fall risk assessment dated [DATE] at 12:54 PM revealed R4 was at high risk of falling, had previous falls, and overestimated or forgets limits. Risk Manager/Licensed Practical Nurse (LPN) H was interviewed on 10/04/23 at 11:39 AM and stated she investigated R4's fall on 3/17/23 and was not able to confirm the alarm had been turned on prior to R4's fall. LPN H stated she did not know what time R4's alarm was last checked for proper functioning, or how long R4 had been sitting in her wheelchair prior to the fall. LPN H stated staff should have checked the functioning of R4's alarm every two hours. LPN H stated she had only had a couple days of training in the risk management role. LPN H stated following R4's fall she educated all staff on making sure alarms were turned on and functioning correctly. Registered Nurse (RN) I was interviewed on 10/04/23 at 12:36 PM and stated she was near R4's room in the hallway and was passing medications when she heard a boom noise. RN I stated R4's alarm did not sound. RN I stated a nurse had sat on the alarm pad, stood up and it functioned correctly in alarming. RN I stated she did not recall how long she had been sitting in her wheelchair prior to her fall. Certified Nurse Assistant (CNA) J was interviewed on 10/04/23 at 1:45 PM and stated she was assigned to R4 on 3/17/23 and did not recall what time she got up and into her wheelchair. CNA J stated she had not had a chance to check on her prior to the incident, that she had just started working that day. CNA J stated R4 had tried to pick up a pen on the floor prior to her fall and had reached for things on the floor prior to the incident on 3/17/23. CNA J stated she was not sure if R4 had a reacher/grabber pick up tool to assist her in picking up items. R4's Fall Risk care plan dated 11/03/19 indicated she was at high risk of falls due to altered gait, balance, safety judgement, muscle weakness and history of falls. R4's goal was to be free of injury of falls. The same care plan indicated she had a pressure sensor alarm in her bed and wheelchair, initiated on 11/03/19. There was no intervention for a reacher/grabber pick up tool on R4's fall risk care plan. DON B was interviewed on 10/04/23 at 1:56 AM and stated a reacher/grabber pick up tool would be a good intervention for R4, since she was reaching for something when she fell.