**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the comprehensive care plan was reviewed and revised for one resident (Resident #8) out of 13 residents reviewed for quality care, resulting in hospitalization for a fracture sustained after a fall from staff use of the incorrect lift device. Findings: Resident #8 (R8) Review of an admission Record reflected R8 admitted to the facility with diagnoses that included generalized osteoarthritis, hemiplegia and hemiparesis (weakness and partial paralysis) of the left non-dominant side following a stroke, history of traumatic brain injury and muscle weakness. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected R8 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14/15. R8 was coded as using a wheelchair for mobility, did NOT walk, and was Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity for sit to stand (the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed) and chair/bed - to- chair transfers. Review of a Discharge assessment - return anticipated MDS dated [DATE] reflected R8 was Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity for sit to stand (the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed) and chair/bed - to- chair transfers. During an observation and interview on 11/18/2024 at 11:23 AM, R8 was sitting up in bed, a sling in place on her left arm. R8 reported her left hip and shoulder were painful due to an accident that occurred at the facility during a transfer, resulting in a broken arm. R8 said that before the accident occurred, she told staff she felt weak and tired from recent low blood pressures and thought she had another urinary tract infection when she slipped out of a sit-to-stand lift. Review of a Fall incident report dated 9/1/2024 reflected Incident Description: This nurse was called to room. Nurse aides were standing around resident (R8) who was sitting on the floor, with an aide behind her. She slipped out of sit-to-stand during a transfer. The report indicated When resident goes outside, she is to be transferred via Hoyer (a full mechanical lift) to bed instead of sit-to-stand. She is tired from being outside and its hard for her to hold on. The report indicated R8 had a left shoulder injury and 10/10 pain level. Details in the report were limited and the complete fall investigation was requested. Review of a Verification of Investigation form dated 9/01/2024 reflected Resident (R8), who is AxOx3 (alert and oriented times 3, person, place, situation), fell when she let go of a sit-to-stand. She was a two person assist, and her CNAs (Certified Nurse Aides) (CNA H and CNA K) both testified that they had taken (R8) to the restroom, and were bringing her back to bed in the EZ sit-to-stand, when (R8) let go of the sling on the left side, and slid down to the floor through the lift sling (she was dragged down by her girth). (R8's) grey dress pullover was pulled up over her head. (R8's) shoulder hit the side of her bed when she went down. (R8) stated I was tired from the day, and I just let go. Current care plan includes a 2 person assist for transfers, and the care plan was followed. The care plan included with the investigation did not address R8's transfer status. A statement from CNA H indicated that R8's left arm was flaccid (limp) and R8 let go of the lift device with her right hand when she fell. Review of a Care Plan initiated on 11/28/2019, revised on 7/03/2024 indicated that R8 was at risk for fall related injury related to history of falls, hemiplegia/paresis left side, TBI (traumatic brain injury), needs assistance with ambulation with use of walker . The goal was that R8 would remain free from injury related to falls. Interventions included Encourage the resident to wear appropriate footwear as needed; ensure gait belt is on for all transfers . This care plan, in place at the time of R8's fall, conflicts with the MDS data which indicate R8 does not ambulate or use a walker for ambulation. Review of a Care Plan initiated 3/15/2024 and in place prior to R8's fall on 9/01/2024 reflects (R8) has a functional ability deficit and requires assistance with self-care/mobility R/T (related to): weakness d/t (due to) CVA (stroke) with left sided weakness, PVD (peripheral vascular disease), GERD (gastro-esophageal reflux disease), seizures, RLS (restless leg syndrome), HTN (high blood pressure), and OA (osteoarthritis). This care plan indicates R8 is unable to walk or ambulate and was dependent on staff for transfers. The care plan does NOT specify the number of staff or assistive devices required to transfer R8. During an interview on 11/20/2024 at 11:31 AM, Physical Therapy Assistant (PTA) L said R8 was on the therapy case load to evaluate R8 due to deconditioning and had been cut from services on 8/30/2024 due to lack of progress prior to being hospitalized after the fall and broken arm on 9/01/2024. PTA L reported that R8 was a max (maximum) assist with a sit-to-stand for transfers and required a Hoyer lift as needed. PTA L said she does not update care plans but gives transfer status recommendations to nursing staff in the form of a communication and education to staff. PTA L said that the intervention Hoyer as needed has been long standing. PTA L emphasized that staff can always use more support than required, but cannot offer less support than what is typical for a resident. The transfer status recommendations and communication forms were requested from PTA L at this time. Review of Therapy Communication Forms dated 3/14/2022 indicated that R8 was to be transferred via EZ-stand for transfers <> (to and from) bed to wheelchair . The recommendation made over two years prior was not found in a comprehensive review of the care plan that was in place prior to R8's fall from the sit-to-stand device. During an interview on 11/20/2024 at 11:47 AM, the Director of Nursing (DON) reviewed the care plan that had been in place prior to R8's fall with fracture on 9/01/2024. The DON said that they were present at the facility on the day R8 fell. R8 had been outside most of the day, coming inside every few hours to be cared for, which likely weakened R8 and contributed to the fall. The DON confirmed that no specific directions pertaining to how R8 was to be transferred was documented in the care plan for self-care/mobility and confirmed that R8 did not walk using a walker anymore. Review of a hospital History of Physical Notes dated 9/2/2024 reflected History of Present Illness: (R8) is a 60 y.o. (year old) female who presents with past medical history notable for hypertension, hyperlipidemia, hemorrhagic CVA with residual left-sided weakness and obstructive sleep apnea who presents to the emergency room after a fall while being transferred from the wheelchair to a bed via a sit and stand device. The patient said that her blood pressures have been low and she apparently passed out briefly. Patient landed on her left side resulting in severe pain in the left arm. She was confirmed to have a fracture at the facility and was brought to the emergency room for evaluation/treatment. In the ED (Emergency Department) the patient was afebrile with low blood pressures documented around 87/68. Nontachycardic (no increased pulse). After IV (intravenous) fluids in the ER blood pressures have improved to systolic blood pressure close to 100. Currently she is asymptomatic but does want to go back to sleep. Further review of hospital records indicated R8 had a CT (computed tomography, an imaging exam) scan of the left shoulder without contrast which showed R8 had a Comminuted (a broken bone that has separated into three or more pieces; usually caused by a severe impact, such as a car accident or a serious fall), displaced, and angulated fracture of the surgical neck of the humerus. The hospital record also revealed R8 was diagnosed with Metabolic Encephalopathy and Sepsis without shock due to a UTI.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to 1.) implement the facility policy for pressure injury/wound management, 2.) ensure pressure injury/wound assessments were comprehensive and accurate, and 3.) ensure treatments were promptly ordered and completed, for 2 of 13 residents (Resident #17 and #1) reviewed for alterations in skin integrity, resulting the development of preventable pressure injuries and the worsening of wounds. Findings: Resident #17 (R17) Review of an admission Record revealed R17 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: chronic respiratory failure, chronic heart failure, and diabetes. R17 was dependent on staff for all activities of daily living. According to the Nurse Notes, R17 was hospitalized from [DATE]-[DATE] for a UTI (urinary tract infection). Review of R17's Care Plan revealed the following concerns and interventions: (a) R17 is at risk for urinary tract infection and catheter-related trauma with the following intervention-Ensure catheter tubing is secured-Initiated: 08/25/2023, (b) R17 is at risk for impaired skin integrity/pressure injury R/T: weakness, mobility issues, low proteins, and incontinence of bowel, presence of catheter and tubing, non ambulatory, COPD, hoyer lift, fragile skin of sacrum r/t previously healed pressure ulcer and MASD (moisture associated skin damage), unable to reposition self with the following interventions-put barrier between skin and catheter tubing to avoid skin irritation and/or abrasion-initiated: 04/05/2024 .turn and reposition every two hours and PRN (as needed)-initiated: 03/26/2021 .Added to the care plan on 11/15/24 was MASD to right buttocks related to incontinence. Review of R17's readmission Nursing Comprehensive Evaluation dated 11/7/24 revealed: groin and perineal area reddened. No measurements were noted. Review of R17's Order Summary revealed that no new order for skin impairment treatment, noted on the admission assessment dated [DATE], were put into place until 11/11/24. Review of R17's Minimum Data Set dated 11/13/24 (completed after returning from the hospital stay 11-3-24 to 11-7-24) revealed R17 did not have one or more unhealed pressure ulcer(s) at Stage 1 or higher and R17 was at risk of developing pressure ulcer. Review of R17's Electronic Medical Record revealed (a) no treatment order for a catheter securement device, (b) no comprehensive wound assessment following the skin breakdown identified on 11/7/24, (c) the guardian was not notified of the skin break down identified on 11/7/24, and (d) the physician was not notified of the skin concerns identified on 11/7/24. Review of R17's provider Progress Note dated 11/12/24, did not reflect a new/worsening pressure injury or skin impairment. Review of R17's Order Summary with a start date of 11/15/24 revealed changes (increased care required) to the order initiated on 11/11/24 for the right buttocks wound care. Review of R17's Electronic Medical Record revealed no comprehensive wound assessment following the identification of the skin breakdown and/or worsening of the skin breakdown which resulted in a treatment order change dated 11/15/24 or guardian and physician notification of the skin breakdown and treatment changes. On 11/21/24 at 12:43 PM, R17's Skin & Wound Evaluation dated 11/17/24 was documented as complete. The wound now measured 0.8 cm (length) x 1.0 cm (width) x 0.1 cm (depth). The surrounding tissue was fragile and at risk for breakdown. It was documented that the guardian and the provider were notified on 11/21/24 of the skin breakdown. During an observation on 11/19/24 at 12:50 PM, R17 was sitting up in a broda chair near the nurses station. R17's heels were resting on the footrest and there were no offloading devices in place behind her left or right side. During an observation on 11/19/24 at 01:07 PM, R17 was sitting up in a broda chair near the nurses station. R17's heels were resting on the footrest and there were no offloading devices in place behind her left or right side. During an observation on 11/19/24 at 02:10 PM, R17 was sitting up in a broda chair near the nurses station. R17's heels were resting on the footrest and there were no offloading devices in place behind her left or right side. During an observation on 11/19/24 at 02:53 PM, R17 was sitting up in a broda chair near the nurses station. R17's heels were resting on the footrest and there were no offloading devices in place behind her left or right side. During an observation on 11/19/24 at 03:41 PM, R17 was sitting up in a broda chair near the nurses station. R17's heels were resting on the footrest and there were no offloading devices in place behind her left or right side. During an observation on 11/19/24 at 03:55 PM, R17 was sitting up in a broda chair near the nurses station. R17's heels were resting on the footrest and there were no offloading devices in place behind her left or right side. During an observation on 11/20/24 at 08:13 AM, R17 was sitting up in a broda chair in the dining room attempting to feed herself. R17's heels were resting on the footrest and there were no offloading devices in place behind her left or right side. During an observation on 11/20/24 at 08:42 AM, R17 was sitting up in a broda chair near the nurses station. R17's heels were resting on the footrest and there were no offloading devices in place behind her left or right side. During an observation on 11/20/24 at 09:26 AM, R17 was sitting up in a broda chair near the nurses station. R17's heels were resting on the footrest and there were no offloading devices in place behind her left or right side. During an observation on 11/20/24 at 10:45 AM, R17 was sitting up in a broda chair in the activity room. R17's heels were resting on the footrest and there were no offloading devices in place behind her left or right side. During an observation on 11/20/24 at 11:58 AM, R17 was sitting up in a broda chair in the activity room. R17's heels were resting on the footrest and there were no offloading devices in place behind her left or right side. During an observation on 11/20/24 at 12:34 PM, R17 was sitting up in a broda chair in the dining room attempting to feed herself. R17's heels were resting on the footrest and there were no offloading devices in place behind her left or right side. During an observation and interview on 11/20/24 at 01:04 PM, Certified Nursing Assistant (CNA) E brought R17 to her room to provide pericare. CNA E reported R17 got up before breakfast but had not provided pericare since that time. During an interview on 11/20/24 at 01:20 PM, R17 reported pain her buttocks. During an observation and interview on 11/20/24 at 01:25 PM, CNA E and CNA F were providing incontinence care for R17. R17 did not have a securement device in place and her urinary catheter tubing was under her thigh/buttocks. R17 was rolled to the left side exposing her buttocks and posterior thighs. On her right groin/upper posterior thigh there were 2 areas of deep ruddy red indentations where the incontinence brief and urinary catheter tubing had been pressing into her skin. CNA F reported R17 should have had a securement device in place for her urinary catheter and did not know how long she had been without it. R17 had dried stool (bowel movement) that was not easily wiped away noted on her buttocks that had contaminated the dressing on R17's right gluteal wound. The dressing border had lifted and there was stool under the dressing. Licensed Practical Nurse (LPN G) entered the room to perform a dressing change and reported she did not know how long R17 had been without the securement device. Review of R17's Skin & Wound Evaluation dated 11/20/24 at 2:11 PM revealed a Medical Device Related Pressure Injury Stage I on the Right Ischial Tuberosity, Medial identified as in-house acquired on identified on 11/20/24. The wound measured 5.5 cm (length) x 1.8 cm (width) . ensure catheter tubing anchor is in place and tubing in proper position . Confirming the presence of a new avoidable pressure injury. Review of R17's contracted wound consultants Progress Note dated 11/20/24 revealed, . is being seen today for evaluation of a new wound site to the right groin/medial Ischial tuberosity, in addition to a follow-up of her right gluteal incontinence-associated dermatitis .On evaluation today after lunch, (R17) was alert. She reported pain at the newly observed wound site without other reports of pain during assessment or other wound interventions .Notes: Pain to groin area where the new wound is located .Indwelling Foley urinary catheter and incontinence brief associated devices appear to have created skin breakdown in the form of a Stage 1, non-blanching, medical device-related pressure wound along the right groin/medial ischial tuberosity. Positive for tenderness on palpation of the wound, erythema and ecchymosis. The wound site measures about 5.5 cm in length by about 1.8 cm in width, but without depth .a 3.5 x 2.5 cm area (without depth) that is red-pink, dermatitis noted to the right gluteus. An area of redness and bruising, 5.5 cm x 1.8 cm, was noted on the right posterior ischium area medially, where the incontinence brief and urinary catheter tubing had been laid onto the skin, showing skin that is reddened and non-blanching, with indentations and bruising in the shape of the incontinence brief edge, and urinary catheter tubing, pressure injury, which is tender on palpation .(Problem 1) .Skin moisture secondary to chronic urinary incontinence associated dermatitis located to the right gluteus, measuring 3.5 cm x 2.5 cm, no depth .(Note the resident had an indwelling foley catheter at the time of the assessment) .(Problem 2) .Contusion that is pink-red with ecchymosis, no edema or signs of infection noted to the right interior thigh, distal to the groin, appearing to be a medical device associated skin injury from chronic indwelling foley catheter and incontinence brief edge contact with the skin that likely caused friction injury. Nonblanching, the skin remains closed/intact. - Measured 5.5 cm x 1.8 cm, without depth . During an interview on 11/21/2024 at 8:54 AM, Assistant Director of Nursing (ADON) A reported that the provider and guardian should be notified at the time the skin breakdown is identified and documented in the Skin & Wound Evaluation. ADON A reported that the standard of practice was for R17's catheter securement device to be in place at all times. Review of the facility policy Skin Management last revised 8/14/24 revealed, Practice Guidelines (1.) Upon admission/re-admission all residents are evaluated for skin integrity by completing a baseline total body skin evaluation documented in the electronic medical record .(3.) Appropriate preventative measures will be implemented on residents identified at risk and the interventions are documented on the care plan. 4. Residents admitted with any skin impairment will have: (a) Appropriate interventions implemented to promote healing, (b) A physician's order for treatment, and (c) Skin impairment location, measurements and characteristics documented. Review of the facility policy/procedure Indwelling urinary catheter (Foley) care and management last reviewed 11/20/24 revealed, .make sure the catheter is secured properly. Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, Medical device- related pressure injuries (MDRPIs) are injuries that result from the use of devices designed and applied for diagnostic or therapeutic purposes .Pay particular attention to areas located over bony prominence's; next to and around medical devices . Consider adults with medical devices (e.g., tubes, drainage systems, and oxygen devices) to be at risk for pressure injuries. Confirm that devices are not placed directly under an individual who is bedridden or immobile . [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (pgs. 1247-1260). Elsevier Health Sciences. Kindle Edition. Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, Early identification of high-risk patients helps prevent pressure injuries . Interventions aimed at prevention include turning and positioning to relieve pressure. Usually the time that a patient sits uninterrupted in a chair is limited to 1 hour. This interval is shortened in patients who are at very high risk for skin breakdown. Reposition patients frequently because uninterrupted pressure causes skin breakdown. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 845). Elsevier Health Sciences. Kindle Edition. Resident #1 (R1) Review of an admission Record indicates R1 admitted to the facility with diagnoses that included schizoaffective disorder, muscle weakness, dependence on wheelchair, chronic venous insufficiency, peripheral vascular disease, and cerebral palsy. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R1 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 14/15. R1 had Functional Limitation in Range of Motion on one side of the upper extremities and impairment on both lower extremities. R1 needed Substantial/maximal assistance with rolling to the left and right, sitting to lying, lying to sitting and was Dependent-Helper does ALL of the effort. Resident does none of the effort to complete the activity for sitting to standing, chair/bed-to-chair transfer and toileting. Section M - Skin Conditions indicated R1 was at risk of developing pressure ulcers and did not have any pressure ulcers at the time of the assessment. During an interview on 11/19/24 at 2:00 PM, R1 was seated in his wheelchair and reported he had a very sore bottom, and it felt like he sat on a nail. R1 said he would be willing to have his skin observed the next time he got transferred to bed. During an observation and interview on 11/19/24 at 2:19 PM, Certified Nurse Aide (CNA) B and CNA C transferred R1 using a mechanical lift into the bed. CNA B said R1 was last assisted/repositioned prior to lunch at 11:00 AM (three hours prior to the observation). R1's brief was dry, and the resident used the urinal before the CNA's rolled R1 to his right side, exposing his buttocks. Serosanguinous drainage was noted on the brief under R1's right coccygeal area, as well as reddened and blanchable skin. There was no evidence a barrier cream had been applied and CENA B said they would apply A & D ointment because that's all I have. The surveyor requested a nurse observe the wound at this time. During an observation and interview on 11/19/24 at 2:39 PM, the Director of Nursing (DON) assessed the open area and scab on R1's right coccygeal area. The DON verbalized her assessment as blanchable, reddened skin around an open area that measured 2.0 centimeters (cm) x 2.0 cm x 0.1 cm in depth with bloody drainage. The non-blanchable scab measured 0.8 cm x 0.8 cm with no measurable depth. The wound was cleaned with wound cleanser and chalmosyn (a barrier cream) was applied. Review of a Skin & Wound - Total Body Skin Assessment dated 11/03/2024 reflected R1's skin was intact. Review of a Nurses Notes dated 11/9/24 reflects (R1) has a dark scabbed area on right side of coccyx, approx. (approximately) 2.5 x 1 cm (centimeter). No drng (drainage) noted. (Medical Director) faxed, voice mail left for guardian, DON (Director of Nursing) notified. A corresponding Skin & Wound - Total Body Skin Assessment was not associated with the findings. Review of a Total Body Skin Assessment note dated 11/10/2024 reflected Pt (patient) buttocks red with open area noted to right side. Pt. BLE (bilateral lower extremities) are red/dry no open areas noted. Lotion/creams applied, reposition q (every) 2 hours and PRN. Up in w/c wheelchair for meals. Incont (incontinent) of b&b (bowel and bladder), wears briefs. The documentation did not reflect physician and other notifications had been made, measurements, or wound description had been documented upon discovery of an open area. Review of a Skin & Wound - Total Body Skin Assessment dated 11/10/2024 reflected R1 had no new wounds, despite a progress note that indicated R1 had a new open area. Review of a Skin & Wound - Total Body Skin Assessment dated 11/18/2024 reflected Enter the # of New Wounds - 6. New Wounds - yes. The form did not indicate the number of new wounds. Review of R1's November 2024 Treatment Administration Record (TAR) reflected Apply chamosyn (a skin protectant ointment that can be used to treat a variety of skin conditions, including diaper rash, minor burns, and cuts) to coccyx BID (twice a day), monitor site until healed two times a day for wound-Start Date- 11/10/24-D/C (discontinue) Date-11/13/2024. Another order for the same treatment was initiated on 11/13/24 and changed the time from 8 AM and 8 PM to every day and night shift for skin management. Review of a Care Plan initiated 1/27/2020 reflected R1 was at risk for impaired skin integrity/pressure injury related to diagnoses. The Goal of the care plan focus area was to minimize the risk of developing a pressure injury. Interventions included conduct weekly head to toe skin assessments, document and report abnormal findings to the physician; follow facility policies and protocols for the prevention and treatment of impaired skin integrity; observe skin with showers/cares, notify nurse immediately of any new areas of skin breakdown; refer to treatment POC (plan of care); turn and reposition (R1) every 2 hours and PRN (as needed) as allows. The interventions did not address R1's preference for sitting up in his wheelchair for most of the day and the requirement to offload pressure. Further review of the entire Care Plan did not reflect a focus, goals, or interventions related to R1's actual skin impairment/pressure injury identified on 11/09/2024 and 11/10/2024. During an interview on 11/20/24 at 9:50 AM, the Assistant Director of Nursing (ADON) A reported the open area discovered on R1 was classified as a stage 2 pressure ulcer. ADON A reported R1 has a history of stage 2 pressure ulcers, was incontinent and delusional. ADON A said R1 was not on a toileting schedule to address incontinence and did not like to lie down to relieve pressure. ADON A reported there was not a care plan intervention to off-load pressure while up in the wheelchair.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #MI00148210 Based on interview and record review, the facility failed to provide enhanced supervision and assistance to residents with acute medical changes and significant medication changes, for two of five residents (Resident #32 and Resident #16) reviewed, resulting in a fractured left arm and a brain bleed for Resident #32 and a fractured right arm for Resident #16. Findings: Resident #32 (R32) Review of an admission Record revealed R32 was an [AGE] year old female, originally admitted to the facility on [DATE], with pertinent diagnosis of seizure disorder, stroke with impaired speech, congestive heart failure, morbid obesity, impaired vision, muscle weakness, and pain in both knees. R32 required staff assistance for ambulation, bathing, and bed mobility (resident required substantial/maximal assistance x 1 to roll side to side, lying to sitting on side of bed, and sitting to lying), getting dressed, using the bathroom, and to transfer in and out of bed. Review of a Care Plan for R32 reflected the following relevant needs and interventions: (A) R32 is at risk for side effects from pain medications, initiated 03/14/24, with the following interventions: (1) monitor for respiratory depression-obtain respiratory rate, depth, and effort after administration of pain medications, (2) observe for altered mental status .dizziness, sedation, (3) observe for increased risk of falls .(B) R32 is at risk for adverse side effects from diuretic therapy for congestive heart failure, initiated 10/21/24, with the following intervention: (1) may cause dizziness, postural hypotension (a drop in blood pressure when changing positions), fatigue, and increased risk for falls .(C) R32 is at risk for falls and fall related injuries due to encephalopathy (any brain disease or disorder that affects the brain's structure or function. It can be caused by a number of things, including injury, disease, drugs, or chemicals. Encephalopathy can be temporary or permanent, and can lead to serious complications), impaired mobility, muscle weakness, heart failure, morbid obesity, seizure disorder, diuretic and opiod (pain medicine) use, initiated 07/14/22, with the following interventions: (1) anticipate and meet needs as needed and complete fall risk per protocol. Review of a Nursing Comprehensive-Quarterly Fall Assessment for R32, dated 10/11/24, reflected that there was No Risk for falls for this resident. Review of an Electronic Medication Administration Record (Emar) for R32, dated November 2024, revealed the following medications were prescribed: (a) Phenobarbital 97.2 MG (milligrams) at bedtime for seizure disorder (this medication is a hypnotic and causes sedation), (b) Lasix (a diuretic known to cause dizziness and a drop in blood pressure) 40 MG twice daily for swelling due to congestive heart failure (this is an increase from 20 MG twice daily, made on 11/03/24), and (c) Oxycodone (a powerful opiod pain medication) 10 MG twice daily from 11/1/24 to the morning of 11/5/24 and then doubled to 20 MG twice daily from the evening on 11/5/24 until the time of the fall on 11/11/24, as well as an additional order for Oxycodone 5 MG every 6 hours as needed for breakthrough pain, and (d) Clindamycin (antibiotic) 300 MG every 6 hours for infection for 10 days-start date 11/05/24 (This antibiotic can cause dizziness, fainting, or light headedness when getting up .(Mayo clinic Micromedex US L.P. 1973, [DATE]). The same Emar revealed no orders for staff to monitor and check orthostatic blood pressures (used to assess for a drop in blood pressure with position changes), or to monitor for side effects, including dizziness and sedation, following increased doses of Oxycodone and Lasix and the recent start of Clindamycin. Review of a facility Investigation, completed for an unwitnessed fall sustained by R32 on 11/11/24 at approximately 6 AM, revealed that R32 was found by staff on the floor face down in her room, and had sustained a right sided head injury and complained of left shoulder pain. X-rays completed at the facility showed a left upper arm fracture. Review of the last blood pressure obtained before R32's fall the morning of 11/11/24 was 108/80 (obtained 11/10/24 at 3:43 PM). The last recorded blood pressure for R32 with a systolic blood pressure below 110 was recorded on 02/19/24. Per the EHR (electronic health record), following the lower than usual blood pressure reading of 108/80 on 11/10/24 at 3:43 PM, R32 was administered a dose of Oxycodone 20 MG at bedtime and then another dose of Oxycodone 5 MG at 3:54 AM on 11/11/24. No indication of monitoring for side effects following those two doses of Oxycodone could not be located in the EHR. Review of an EMS (emergency medical services) ambulance run record, dated 11/11/24, revealed the following findings regarding R32: (a) EMS arrived at the facility at 1:34 PM, (b) were advised that an earlier x-ray showed a left arm fracture, (c) noted bruising to R32's right side of her face, and (d) was told by facility staff that the staff believed R32 tried to stand up from the bed and fell. Review of an emergency room Record dated 11/11/24 revealed R32 had sustained an acute intraventricular hemorrhage in the right lateral ventricle (a brain bleed) and confirmed the earlier findings of a fractured left arm. Resident #16 (R16) Review of an admission Record revealed R16 was a [AGE] year old female, originally admitted to the facility on [DATE] with pertinent diagnoses of muscle weakness, anxiety disorder, developmental disorder, congestive heart failure, and dementia. Review of a Post Fall Evaluation dated 11/13/24 at 10:15 AM showed R16 fell in her room and fractured her right arm. Resident was weak from pneumonia. Review of an Emar for R16, dated November 2024, revealed the resident was started on Clindamycin (an antibiotic) 300 MG one tab twice daily for pneumonia starting 11/08/24. R16 was also prescribed Invega 3 MG one tab at bedtime and Abilify 15 MG one tab in the morning ( both medications are antipsychotic and can cause blurred vision, confusion, sedation, orthostatic hypotension, and restlessness). Review of a task monitoring form for R16, that documented the amount of staff assistance needed to walk to and from the bathroom, revealed that on 11/7/24 through 11/10/24 R16 was independent to ambulate in her room. Documentation from 11/11/24 through the time of the fall on 11/13/24 showed R16 requested staff assistance to ambulate that ranged from partial to moderate assistance needed to complete dependence on staff. Review of a Provider Encounter Progress Note dated 11/11/24 revealed: Nursing called to report (R16) not getting better as expected. Very pale, lethargic, diminished lung sounds, and oxygen saturations were in the 70's (%) range while receiving 5 liters of oxygen. Review of a Fall Risk Care Plan for R16 reflected that no new safety interventions were put in place once the resident was (a) diagnosed with pneumonia, (b) started on an antibiotic, (c) requested staff assistance to ambulate to and from the bathroom, and (d) was reported to be lethargic and not doing better. During an interview on 11/20/24 at 3:48 PM, Certified Nurse Aide (CENA) H stated that after R16 was diagnosed with pneumonia, R16 had not been doing well, was weak, and was unsteady on her feet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #193 (R193) Review of an admission Record revealed R193 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses which included: tracheostomy (surgical opening into windpipe), traumatic brain injury, and quadriplegia. Prevention Review of R193's Care Plans revealed the following: (R193) is at risk for worsening/new impaired skin integrity. Was admitted with a stage 3 sacral ulcer, and is at risk for new skin impairments related to impaired mobility, vegetative state, and incontinence .Turn/reposition resident every 2 hours and PRN (as needed) Date Initiated: 09/09/2023. (R193) has Actual impairment to skin integrity r/t (related to) stage 3 coccyx wound .Turn and Reposition Date Initiated: 09/09/2023. Review of R193's Hospital Discharge Record dated 11/6/23 revealed, Clinical Impressions as of 10/26/23 .Skin ulcer of sacrum with necrosis of muscle .Wound Services: Asked to see patient regarding coccyx pressure injury. Patient known to wound services .turn pt q 2hr (turn patient every 2 hours) .Wound team to apply vac as ordered . (Vacuum Assisted Wound Closure) . During an observation on 11/08/23 at 08:50 AM, R193 was in bed on his back with no offloading devices in place. During an observation on 11/08/23 at 12:25 PM, R193 was in bed on his back with no offloading devices in place. During an observation on 11/08/23 at 03:18 PM, R193 was in bed on his back with no offloading devices in place. During an observation on 11/09/23 at 08:34 AM, R193 was in bed on his back with no offloading devices in place. During an observation on 11/09/23 at 11:07 AM, R193 was in bed on his back with no offloading devices in place. Review of R193's Wound Care Progress Note dated 11/9/23 revealed, .Patient was discharge to facility with negative wound vacuum therapy. However, based on assessment, this wound-bed has necrotic tissue and yellow adherent slough noted; therefore, negative pressure vacuum therapy is contraindicated. Additionally, this wound has a malodorous smell . During an interview on 11/09/23 at 09:37 AM, Wound Care Provider (WCP) C reported that R193's wound had necrotic tissue with foul smelling drainage. WCP C reported the wound vac had to be discontinued because of the deterioration of the wound. WCP C reported that R193 should have been repositioned at least every 2 hours especially with a wound vac in place. Treatment Review of R193's Wound Care Progress Note dated 9/21/23 revealed, .stage II pressure wound to left iliac crest .2. Left iliac crest stage II .Treatment: Cover with bordered foam for pressure support. Institute offloading from this site . Confirming the presence of a new pressure injury requiring treatment. Review of R193's Treatment Administration Record revealed no documentation that the treatment was ordered or completed. Care Plan Updating Review of R193's Care Plans (all revisions since admission) did not reflect the pressure injury of the iliac crest or the wound providers order to Institute offloading from this site. Review of R193's Care Plans revealed, (R193) has Actual impairment to skin integrity r/t (related to) stage 3 coccyx wound .Cleanse the stage 3 coccyx area with Wound Cleanse, pat dry, apply Medi Honey for autolytic debridement of slough and cover with border foam daily. every day shift for wound management Date Initiated: 09/11/2023 . Review of R193's Order Summary revealed, Sacrum wound- Cleanse site with saline or wound wash. Pat dry. Apply medihoney to wound site. Cover with border foam dressing. Perform daily and as needed if soiled. Label appropriately was discontinued on 9/14/23. Confirming R193's Care Plans were not updated with changes in condition and/or treatment changes. Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, Repositioning (turning) patients is a consistent element of evidence-based pressure injury prevention (EPUAP, NPIAP, PPPIA, 2019a). The twofold aim of repositioning should be to reduce or relieve pressure at the interface between bony prominence and support surface (bed or chair) and to limit the amount of time the tissue is exposed to pressure (Maklebust and [NAME], 2016) .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 (EPUAP, NPIAP, PPPIA, 2019a). A standard turning interval of 1.5 to 2 hours does not always prevent pressure injury development; repositioning intervals are based on patient assessment. Some patients may need more frequent position changes, while other patients can tolerate every-2-hour position changes without tissue injury. When repositioning, use positioning devices to protect bony prominences (WOCN, 2016). [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 1255). Elsevier Health Sciences. Kindle Edition. Based on observation, interview, and record review, the facility failed to prevent facility acquired pressure injuries and provide pressure injury preventative care consistent with professional standards of practice for 3 residents (Resident #94, #37, and #193) reviewed for the risk of and/or the development of pressure injuries, resulting in the development of an avoidable pressure injury, the worsening of a pressure injury, and the potential for skin breakdown and overall deterioration in health status. Findings: Resident #94 (R94) Review of an admission Record reflected R94 was admitted to the facility on [DATE] with diagnoses that included traumatic brain injury, respiratory failure and a urinary tract infection. R94 was identified as having a gastrostomy (tube feeding) and a tracheostomy (breathing tube). Review of a Care Plan initiated on 10/23/2023 reflected that R94 was at risk for impaired skin integrity/pressure injury related to his condition. The goal of the care plan was to minimize risk (of skin impairment/pressure injury) in an effort to reduce the likelihood of pressure injury development .as evidenced by no new pressure injury. Interventions to meet this goal included Conduct weekly head to toe skin assessments, document and report abnormal findings to the physician; follow facility policies/protocols for the prevention/treatment of impaired skin integrity. Further review of the Care Plan reflected that on 11/08/2023 (more than two weeks after R94 admitted to the facility) reflected (R94) was admitted with a stage 2 (intact blister) on coccyx area and red areas on his buttocks. The goal was to heal the pressure injury without complications. The only intervention listed to meet this goal was, Assess skin as needed. Incontinence care promptly after incontinence episodes. Treatments as ordered; nutrition supplements as needed. Additionally, the care plan reflected that on 10/23/23 an incomplete care plan focus area had been initiated as follows: [Preferred Name] (R94's name had not been added to the care plan) has actual impairment to skin integrity r/t (related to). The care plan focus area was incomplete and did not specify contributing factors of R94's skin break down, the location or extent of the skin injury. The interventions listed included Observe location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx (signs/symptoms) of infection, maceration etc. to physician. The care plan and the interventions listed were RESOLVED on 11/08/2023. Review of a Nursing Comprehensive Evaluation dated 10/23/2023 indicated R94 had actual skin impairments to his coccyx/buttock inner coccyx, buttock with redness, fragile non-blanchable. Intact blister noted to left inner buttock. Review of a facility History and Physical dated 10/24/23 documented by Physician (MD) D reflected R94's skin was assessed as Positive: warm, dry, wound, Erythema (redness) and Negative: Rash or bruising. The ASSESSMENTS AND PLANS included in the History and Physical did not include orders for wound care. Review of a Skin& Wound - Total Body Skin Assessment dated 10/30/2023 (one week after admission) reflected R94's skin was intact with no new wounds. Review of Progress Notes - View All accessed from the Electronic Medical Record (physician progress notes, nursing notes, dietary notes, Resident at Risk notes, encounter notes, etc.) for the date range 10/23/23-11/7/23 did not reflect any additional documentation pertaining to R94's wound. Review of the entire October 2023 Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not reflect any orders or treatments had been initiated for R94's pressure injury that had been identified on admission. Review of the entire November 2023 MAR and TAR revealed no treatments had been ordered for R94's pressure injury/skin impairment until 11/8/2023 and 11/9/23. Review of a Skin and Wound Evaluation dated 11/9/2023 reflected R94 had a Stage 3: Full thickness skin loss pressure injury that was present on admission (this assessment conflicts with the original admission assessment documenting R94 with an intact blister/stage 2 pressure injury). The wound measured 2.2 centimeters (cm) in area, by 3.3 cm long by 1.0 cm wide with a depth of 0.6 cm. Absent from the assessment was a description of the wound bed, exudate, the condition of the skin around the wound (periwound), a pain assessment, orders, treatments or provider notification. The assessment indicated R94's wound was stable. During an interview on 11/08/2023 at 2:00 PM, R94's Power of Attorney (POA) reported she was concerned about an area of skin impairment on R94's buttock. During an interview on 11/8/2023 at 4:10 PM, the surveyor requested the opportunity to observe R94's skin. The Director of Nursing (DON), Assistant Director of Nursing (ADON) B and Regional DON E reported the wound care Nurse Practitioner (NP) C would be available to facilitate the observation in the morning on 11/9/2023. The surveyor was assured that the observation of R94 and another resident (R37) would be completed with the surveyor at that time. During an observation and interview on 11/9/2023 at 7:45 AM, R94 was lying in bed. POA F was at R94's bedside and reported NP C and ADON B had already completed the wound assessment and treatment and declined consent to observe the documented stage 3 pressure injury. Direct observation of the wound was not made possible as previously assured. On 11/9/23 at 8:00 AM, ADON B and wound care NP C reported they had already completed the assessment and treatment of R94's pressure injury and wound care. During an interview on 11/9/2023 at 10:02 AM, wound care NP C reported she was first notified of R94's pressure injury was on 11/08/2023 when it was already a stage 3 pressure injury. Resident #37 (R37) Review of an admission Record reflected R37 admitted to the facility on [DATE] with diagnoses that included unspecified dementia with other behavioral disturbances, abnormal posture, alcohol abuse in remission and a history of a traumatic brain injury. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] reflected R37 had short- and long-term memory problems, was not at risk for developing pressure ulcers and was not admitted with any unhealed pressure ulcers or skin alterations. Review of a Nursing Comprehensive Evaluation dated 8/9/2023 reflected that upon admission to the facility R37 was NOT assessed as having any alterations to his coccyx. The assessment noted scabbed areas to R37's right elbow, hand and knee and a scabbed area on the left side of his forehead. The assessment noted a 3cm round purple bruise on R37's left buttock. Review of a Skin & Wound - Total Body Skin Assessment dated 11/01/2023 reflected that there were no skin impairments and no new wounds noted on R37. Review of a Skin & Wound Evaluation dated 11/2/2023 reflected R37 had an abrasion that was discovered on 11/01/23 by nursing staff that measured 1.4 cm 2 (centimeters squared) by 2.5 cm long by 0.9 cm wide with a depth of 0.1 cm. The Notes section of the assessment indicated Identified abrasion on lt (left) inner buttock measuring 2.5 X 0.9 X 0.1 cm. Wound dk (dark) pink with scant amount of bloody drainage. Surrounding skin intact, fragile. Tx (treatment) order in place. Will continue monitoring resident. Notifications were made to the wound care NP, R37's POA and the dietician. Review of a Progress Note dated 11/2/2023 documented by NP C reflected the reason for the evaluation of R37 was Wound Care. The History of Present Illness indicated that R37 was referred to wound care for an area of compromised skin integrity noted by staff that presents as a stage III (3) pressure ulcer to the coccyx. This wound was present on admission to the facility (the presence of the wound was not noted on admission to the facility). The note indicated the wound was 1. Coccyx, Stage III-This wound measures 1.64 (cm) x 1.14 (cm) with a depth of 0.1 (cm). This wound if full thickness. There is a moderate amount of serosanguanious drainage from this area. Wound bed consists of 20% granulation tissue, 10% slough and 70% dermal tissue. Edges are attached and there is no eschar, tunneling, undermining or odor. The surrounding tissue is fragile but without redness, warmth, swelling, pain, induration, or sign of infection. The treatment was Cleanse with wound wash or saline. Pat dry. Apply calcium alginate sheet to site. Cover with gentle optifoam. Perform daily. Label appropriately. Review of November 2023 MAR and TAR did not reflect an order had been entered and treatments were administered to the documented stage 3 pressure injury identified by NP C on 11/2/23. During an interview on 11/8/2023 at 4:10 PM, the surveyor requested the opportunity to observe R37's skin. The Director of Nursing (DON), Assistant Director of Nursing (ADON) B and Regional DON E reported the wound care Nurse Practitioner (NP) C would be available to facilitate the observation in the morning on 11/9/2023. The surveyor was assured that the observation of R37 and another resident (R94) would be completed with the surveyor at that time. On 11/9/23 at 8:00 AM, ADON B and wound care NP C reported they had already completed the assessment and treatment of R37's pressure injury and wound care. R37 was lying in his room in bed and was agreeable to an observation of the wound. The ADON B and wound care NP C positioned R37 and the wound was observed. Wound care NP C described the wound location and stage consistently with the assessment documented from 11/02/2023. During an interview on 11/9/2023 at 10:02 AM, wound care NP C reported she was first notified of R37's pressure injury on 11/02/2023 and staged the area as a stage 3 pressure injury. According to NP C, the location and extent of the injury could not be an abrasion and had to be classified as a stage 3 pressure injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to develop, implement and initiate new interventions in a timely manner for 2 residents (R2 and R26) reviewed for careplans, resulting in unmet and unrecognized care needs, inadequate care and the potential for injury. Findings include: R2 Review of face sheet and electronic medical record for R2 revealed she initially admitted to the facility on [DATE] with diagnosis that included: Huntington's disease, muscle wasting and atrophy, gastrostomy status (feeding tube), depression, anxiety and contractures. R2 was not her own responsible party. On initial tour of the facility on 10/17/22, a sign titled Enhanced Barrier Precautions was viewed on R2's door. On 10/17/22 at 10:45 AM, an interview was completed with the Director of Nursing (DON) regarding the noted precautions on the door of R2 and other residents. The DON stated R2 was on enhanced barrier precautions due to having a feeding tube. The DON stated that while providing direct care to the resident staff should be wearing a gown and gloves. Further review of sign Enhanced Barrier Precautions revealed Providers and Staff Must .wear gloves and a gown for the following High-Contact Resident Care Activities .Device care or use .feeding tube . On 10/17/22 at 11:13 AM, R2 was observed in her room. She was laying in bed and her tube feed was viewed to not be running. An interview was attempted with R2, but she was not understandable. R2 responded with some vocalization and made eye contact but was not able to be understood. On 10/18/22 at approximately 9:00 AM, R2's PEG tube insertion site was viewed. The dressing around the site was dry, but undated. Review of R2's progress notes revealed drainage around the resident's PEG (feeding) tube documented on several occasions as well as notes related to tube malfunction. On 9/17/22: Feeding tube has come apart 3 times during shift. Needs to be taped to stay together; 9/19/22: continued to monitor tube feeding equipment repeated malfunction, notified provider & admin ordered new connector; 9/21/22: Cont. with 200cc bolus feeds q (every) 4 hr until replacement tube put in; 9/25/22: Leaking large amount liquid around feeding tube after bolus feedings. Dressing around tube saturated within 2 hours. Discussed using pump instead of bolus (feedings) with nurse on call .; 09/26/22: No further excessive leaking noted around feeding tube; 10/14/22: resident was found to have completely saturated dressing on PEG tube this morning. Drainage was dark brown/black in color. [Dr E] was notified at 0626 and states, 'keep an eye on it for now.' No further orders received. Scant bloody drainage noted when assessed at 1000; 10/17/22: small amount of brownish drainage noted around peg tube each day over the weekend. Review of physician notes authored by Doctor E revealed a note on 9/20/22 at 8:54 AM that included .There has been a malfunction of her feeding system and replacement parts have been ordered. OK for bollus (bolus) feeding until repairs are completed . The same note was included in a physician note on 10/18/22 at 10:27 AM. There was no notation this this concern was resolved and no corresponding orders were viewed in R2's EMR. It was not clear to what extent Doctor E completed a physical examination of R2 during either visit. Observations were made of R2 on 10/18/22 at approximately 4:00 PM and 10/19/22 at approximately 9:00 AM, she was viewed to be in bed with tube feed running on continuous feed. On 10/19/22 at 9:45 AM an interview was completed with the DON regarding R2. The DON was asked if R2 had a continued malfunction of her PEG tube due to the 9/20/22 and 10/18/22 physician progress notes. The DON reviewed the notes and stated that it looked like Doctor E did not revise his previous note on 10/18/22 and had copied his note from 9/20/22. The DON stated R2 did have a PEG tube malfunction, but it was fixed. The DON stated R2's PEG tube had been popping apart during the tube feeds. The DON was asked when the concern was corrected and she reviewed R2's progress notes. The DON stated she could not find the note where the tubing was fixed, but thought it was fixed around 9/22/22. The DON stated she would try to contact the unit manager who fixed the tubing. The DON stated the unit manager should have entered a progress note when the tube was fixed. On 10/19/22 at 10:05 AM, care was observed for R2. Upon entering the room the Enhanced Barrier Precautions sign was still viewed on the door. There was not a PPE (personal protective equipment) station hanging on the room door. A PPE station was viewed on the outside of the room door along with the Enhanced Barrier Precautions sign on another room on the same hall as R2's room. A PPE station was not immediately located in R2's room. Registered Nurse (RN) D entered the room to provide care for R2 feeding tube and already had gloves with them and was not viewed to obtain the PPE while in R2's room. RN D was observed to flush R2's feeding tube and remove the dressing around R2's feeding tube. RN D was wearing a surgical mask and gloves while providing care and did not don a surgical gown. During care, RN D pushed 50 cc of water into the PEG tube site, RN D was asked if they should push water or use gravity flow. RN D stated it was hard to drain with gravity so she does a gentle push. Review of the PEG tube site revealed a dressing dated 10/18, the dressing was fully saturated with brown liquid. Upon removal, the skin surrounding the insertion of the PEG tube was bright red approximately an inch around the insertion site. R2 was viewed to be uncomfortable as evidenced by her grimacing, squirming and making panicked moaning noises. Per review of the electronic medical record with RN D, it was documented that the dressing was last changed at 12:22 AM on 10/19/22. RN D agreed the amount of drainage on the dressing in less than 10 hours was concerning. RN D was informed that the DON would be alerted to the observations made with R2's PEG tube. On 10/19/22 at 10:15 AM an interview was completed with the DON regarding the concerns with R2's PEG tube. The DON was alarmed to hear there was excessive drainage and excoriation to the skin surrounding R2's PEG tube. The DON reviewed the electronic medical record with the surveyor and reviewed R2 had previously been followed for redness around the PEG tube site, but it was healed at of 08/12/22. The DON stated she would contact Doctor E since he was contacted by staff on 10/14/22 related to the drainage, but gave no new orders. The DON stated they had not yet been able to determine the exact date the PEG tube was fixed in September. She believed it was approximately 9/22/22 but it was not documented. The orders for bolus to continuous feed changed on 9/22/22, so it was likely fixed at that time. The DON stated at the time that the PEG tube malfunctioned they did not have additional equipment in house to immediately rectify the issue, the facility now has 3 lumen tubes in stock if a future malfunction occurs. On 10/19/22 at 11:40 AM an interview with completed with the DON. A review of tube feeding medication policy was completed and the DON confirmed all flushes and meds are given via gravity. The DON was asked if they had a policy or any reason to push the tube feeding flush for R2. The DON confirmed R2 is a gravity flush. The DON also noted doctor E is now treating the excoriated skin at the tube feeding site with antibiotics and they are monitoring the skin breakdown. The DON was not sure if the skin breakdown is related to pushing fluids through tube feed. On 10/19/22 at 02:57 PM a follow up interview was completed with the DON, they spoke to the unit manager and they could not definitely recall when they fixed the peg tube. On 10/19/22 at 3:30 PM a follow up interview was completed with the DON. R2's tube feeding orders were reviewed and it was determined R2's PEG tube orders were changed from 9/20/22-9/22/22 so this was likely when the equipment was on order to fix the malfunction and then it was fixed on 9/22/22 at some point. R22 remained on bolus feeds (a type of feeding where formula is administered directly in a shorter amount of time versus using a gradual pump) until 9/26/22 due to their normal formula not being available until 9/26/22. Review of facility provided policy: Medications Administration- Enteral with a last revised date of 6/24/22 revealed instructions for medication administration for a resident with a feeding tube. The DON indicated this was the only policy they could locate that referred to the process for water flush and gravity flow versus syringe push through a PEG tube. Step 11 of the procedure section included .instill at least 15 ml of water into the tube through the syringe to check for patency via Gravity Flow. If water flows in easily, tube is patent. IF it flows in slowly, raise the syringe to increase pressure. If water does not flow properly, stop the procedure and notify the physician. Review of R2's care plan revealed she is at risk for impaired skin integrity .r/r (related to) .PEG tube. Interventions include weekly head to toe skin assessments, document and report abnormal findings to the physician with a initiated date of 2/5/19. Another need is related to use of a PEG tube, goals include: will remain free of side effects or complications related to tube feeding and will be free of s/sx (signs and symptoms) of infection at insertion site both with an initiated date of 7/26/19. Interventions included: flush tube feed per physician orders, and provide care to tube site as ordered and observe for s/sx of irritation or infection. Report abnormal findings to physician as ordered. Another area of need with a last revised date of 7/20/22 was related to R2 has actual impairment to skin integrity related to MASD (moisture associated skin damage) near PEG Tube insertion site with interventions that included conduct weekly head to toe skin assessments and report new/abnormal findings to physicians as needed, observe for s/sx of infection of area .and report to physician as needed, and treatment per order. R26 Review of face sheet and electronic medical record for R26 revealed he initially admitted to the facility on [DATE] with diagnosis that included: quadriplegia, dementia, traumatic brain injury, diabetes mellitus type 2, anxiety, depression, chronic pain, contractures, pseudobulbar affect (sudden involuntary outbursts of laughing or crying) and symptomatic epilepsy. R26 was not their own responsible party. Per facility provided wound timeline and facility matrix, R26 had a facility acquired Stage IV pressure ulcer that was first discovered on 9/20/21. On 10/17/22 at 10:55 AM an interview was completed with R26 and their responsible party in their room. R26's responsible party confirmed R26 had wounds on his bottom and he was going to a wound clinic. R26 was not viewed to have any pressure offloading pillows or cushions near his trunk area and was laying on his back with his bed slightly inclined. His feet appeared to be up on pillows and were against the foot board. R26's responsible party stated R26 was not a good historian due to a traumatic brain injury and he has very limited short term memory. R26 and R26's responsible party stated he is able to get up into his wheelchair. On 10/18/22 at 10:00 AM a care observation was made with R26 in their room. CNA (certified nursing assistant) H and CNA I turned R26 side to side and did peri care. CNA I stated she turns him with wedges every 4 hours, CNA H said she tries to turn him every 2 hours. The positioning wedges remained on the empty bed next to resident, and they were also observed on the bed next to the resident at 7:00 AM on 10/18/22. There were dressings on both R26's lower legs in their shin area with no date. The CNAs were not sure when these dressings were started. Scabs were viewed on all toes of R26's right foot. There was a large scab on the left forefoot about 1 inch by ¼ inch on a boney area. The CNAs stated the resident is bed bound and has been bed bound for at least 2 months as he would yell when up in his wheelchair. An additional care observation of R26 was made on 10/18/22 at 10:42 AM. R26 was viewed in his bed on his back. R26 was viewed on his back since he was observed at 7:00 AM during a facility tour. The dressing on R26's coccyx was viewed to be dated 10/17/22 and looked soiled at the end of gluteal fold, when removed there was bright red blood, the calcium alginate was soaked with bright red blood. LPN (Licensed Practical Nurse) J removed the dressing and the DON (Director of Nursing) rolled R26 on his right side. LPN J took a photo with the DON's phone that works with the electronic medical record system. A 4x4 inch dressing was viewed on both R26's legs in the mid shin area, the right leg was a dime size wound and on the left leg a quarter size. The dressings were viewed to be soaked with fluid and tissue, fluid was viewed from the outside of dressing. The DON and LPN J stated there were no orders for dressings on the legs and had no idea when they were placed or who placed dressing on both legs. R26 was not aware of when dressings were place or cause. It was also observed R26's right foot had scabbed areas on every toe and his left mid foot anterior side had a 1 inch by 1/8-inch scab. R26 and the DON did not know what caused the scabs/injuries. A request was made for any incident or accident reports related to R26 and they were received by email on 10/18/22 at 3:14 PM. The incidents were reviewed. Review of facility provided Incident and Accident Report for R26 with the date 8/24/22 was revealed to a be a one page handwritten document. The time of day of the injury was not noted, the location was checked as resident room and was an abrasion on the left lower extremity. In the section Describe the nature of the accident/incident and if injuries sustained, location of injuries: a handwritten note was input: left lower extremity- 2 abrasions- top- 1 cm x 2 cm bottom 2 cm x 2 cm. The witness section was marked no. The physician was notified at 1700 (5:00 PM) on 8-24-22 the responsible party was notified on 8-24-22 at 950 (9:50 AM). The interventions implemented were new tx (treatment). The employee signature completing the report appeared to be signed by LPN M and was dated 8-24-22. The NHA (nursing home administrator) and the DON signed the report on 8/26/22. Review of R26's documents in their electronic medical records revealed a note to the physician dated 8/25/22 when they were informed: Guest scraped leg (with?) 1 cm x 2 cm & 3 cm x 2 cm abrasion- new treatment started. Review of wound clinic notes from 8/24/22 revealed the resident was seen by the wound clinic on 8/24/22 at 2:15 PM. There was not any reference to a leg injury. Review of R26's progress notes showed no progress note on 8/24/22. A nurses note on 8/25/22 at 9:47 AM authored by LPN M revealed: called to res room and res noted to have 2 small abrasions on LLE (left lower extremity) top one is 1 cm x 2 cm and bottom is 3 cm x2 cm, dr notified and mom notified, new treatment ordered cleanse with NS wipe, blot dry and apply optifoam and change every 3 days and PRN (as needed). A total body skin assessment is documented on 8/25/22 at 10:15 AM. With the dates and times of these various documents, it is not clear how and when the wound occurred and was initially discovered. Review of facility provided Incident and Accident Report for R26 with the date 9/18/22 was revealed to a be a one page handwritten document. The document revealed at 2100 (11:00 PM) in the resident room R26 sustained an abrasion L (left) 5th toe & top L foot 1 cm (illegible writing). The incident was described a: when rolling resident to change brief, foot scraped on foot board. The interventions implemented revealed: foam dressing applied over wounds and maintenance to look at bed for extender. The employee signature was not legible for who completed it, but was dated 9/19/22. The DON, Administrator and the physician did not sign that they reviewed the document. Review of the electronic medical record progress notes revealed notes regarding the incident as well as notifications. A note from Unit Manager M on 09/19/22 at 9:56 AM revealed Bed cannot accomodate (sp) extenders related to APM and bariatric bed/mattress. New order to pad footboard to protect feet. Review of wound clinic notes from 10/5/22 reveal two additional open wounds both described with original cause of wound was not known. The date acquired was: 9/21/2022. The wound has been in treatment for 2 weeks. Wound #4 is described as Partial thickness wound with etiology of Skin Tear and is located on the Right, Dorsal Foot . and Wound #5 is a Partial Thickness wound with etiology of Skin Tear and is located on the Left, Anterior Lower Leg. Neither of these wounds match the description of the 9/18/22 incident and it is unclear where they came from since the facility provided no further incident reports matching the wound clinic notes injuries. A review of progress notes for R26 shows no note on 9/21/22 and a skin assessment documented on 9/22/22 at 10:15 AM with number of new skin conditions: 0. No other new injury or incident is documented in the progress notes in the date range of 9/21/22. Review of facility provided document dated 10/6/22 at 5:01 AM revealed a computer generated report titled Slid Out of Bed. The incident description revealed: two cenas were changing sheet and rolled guest to side and cena unable to hold him and both cenas lowered to floor. Abrasion to both shins from head board. Red mark to left back shoulder. No other injury. Hoyer (mechanical lift) used to get guest back into bed . The Immediate Action Taken section revealed Full assessment done, no injury except abrasion to shin .Maintenance to check proper functioning and inflation of mattress. Injuries were noted to right lower leg (front) and left lower leg (front). A handwritten Post Fall Evaluation was also included. The date and time of fall was written as 10/5 at 1900 and PM was circled. The description was rolled to floor during bed change. There were several sections of the document not completed including: Re-enactment of fall (to be done if root cause is not determined), Fall Huddle (What was different this time?), Root Cause of this Fall: Review of Contributing Factors (Check all that apply), Describe initial intervention to prevent future falls, and New Interventions after IDT review. The nurse signed the document on 10/5/22 and the section IDT Signatures was blank. Also attached were handwritten witness statements from the two CNAs (certified nursing assistants) involved in the incident with R26. CNA L's statement indicated the incident occurred on [DATE]th at 7:05. The statement was not very detailed and concluded Not sure what happened, but I couldn't stop him from falling. The handwritten statement from CNA K indicated the incident happened on [DATE]th at 7 pm the event account was brief and difficult to read due to incomplete sentences and either misspellings or penmanship. There was also an attached note from Director of Maintenance dated 10-6-22 which stated The Air Mattress on bed [R26's bed] is currently functioning properly and has foam support as well as the air pressure system therefore the mattress should not deflate while on and operating properly. There was no other additional root cause or intervention documented as being explored after the mattress malfunctioning was ruled out. There was no nursing note on 10/5/22 or 10/6/22 regarding the fall. A skin assessment was documented on 10/6/22 at 10:15 AM with no new conditions noted. A progress note on 10/7/22 at 4:06 AM indicated no new injury or pain s/p (status post) lowered to floor from bed. Denies pain. There were two follow up notes on 10/8/22 stating there were no new injuries from being lowered to the floor. There was not another progress note until a skin assessment on 10/13/22 at 10:15 AM which indicated no new skin conditions. The next note was a physician note by Doctor E on 10/18/22 at 10:20 AM. There is no reference to a recent fall or the new injuries. On 10/18/22 at 3:33 PM an email was sent to the DON with questions regarding the incident accident reports: For the 8/24 injury, how did it occur? For the 9/18 injury, was a bed extender obtained, if not how else was this resolved? The 10/6 incident is confusing to me, how was his leg injured on the head board? When the bed was found to be functioning properly, what else was reviewed to find a root cause? On 10/18/22 at 5:53 PM and email was received from the DON: The injury from 8/24/22 was noted by staff upon return from the wound clinic. Guest is transported via [ambulance company] for those appointments. In regards to the incident on 9/19/22 the foot board is to be padded. Maintenance is addressing that tonight. As for the Incident Report on 10/6/22, head board was a documentation error, it should read foot board. His Careplan and [NAME] were updated to reflect that more assistance may be required during linen changes. Therapy is screening Guest for bed mobility, transfers and positioning. A follow up interview was completed with the DON on 10/19/22 at 9:05 AM regarding R26. The injury from 8/24/22 was discussed. The DON stated the injury was reported as soon as R26 returned from the wound clinic. She stated that they did not know if the injury occurred from transport in and out of the ambulance (R26's transportation to the wound clinic) or if it occurred at the wound clinic, but they do know for sure the injury was not there before R26 left the building. The DON was asked if R26 had a full body skin assessment prior to leaving the building on 8/24/22 and the DON reviewed the electronic medical record and stated his last skin assessment was 8/19/22. The DON was asked if she called the wound clinic or the ambulance company to obtain interviews or information about the injury and she stated that was not done to her knowledge. The DON was asked if she could say with certainty how and where the injury occurred, and she stated that she could not. The DON agreed this would be an injury of unknown origin and an investigation should have been initiated by the facility to determine when and how it occurred. The 10/6/22 incident was discussed with the DON, she admitted that the incident report and the witness statements were confusing. The DON stated she completed follow up interviews with the staff involved to get a better understanding of the events. The DON admitted the clarifying follow up interviews were not part of the incident report. The DON stated the event occurred because R26 was not properly centered on the bed when staff were changing his sheets and the staff member could not hold him by themselves when he started to fall. The DON confirmed they have enough staff on day shift and second shift to be able to accommodate more than 2 workers assisting with future sheet changes. The DON stated this intervention had not been added to the care plan but was added as of 10/18/22. On 10/19/22 at 9:15 AM, an observation was made of R26 in his room. R26 was in bed on his back with positioning wedges in place and the foot of his bed was viewed to be padded. During an interview with the NHA (nursing home administrator) on 10/19/22 at 1:00 PM, the absence of a thorough investigation and mode of injury for R26 on 8/24/22 was discussed. The NHA stated the unit manager had called the wound clinic and they confirmed the injuries occurred there. The NHA was informed this was not in the incident report, the medical record and the DON was not aware of this conclusion. The NHA flipped through a personal notebook and stated she wrote herself a note on 8/26/22 that the unit manager had made calls and it happened at the wound clinic. The NHA later followed up on 10/19/22 at approximately 1:45 PM and provided a nurses note from 8/26/22 at 9:41 AM: IDT (interdisciplinary team) team met and reviewed abrasion to LLE (left lower extremity). Per [name of staff], LPN area was noted upon return from appointment on 8/24/2022. Area is due to repositioning and turning on gurney with paramedics. It was noted to the NHA and they admitted the note did not say how and when the information was obtained and does not indicate a complete investigation. During the interview with the NHA on 10/19/22 at 1:00 PM, incident and accident interventions were further discussed. The NHA stated when an incident occurs, the nurse on duty fills out the incident paperwork and then the clinical team reviews it later and ensures everything is in place for interventions. If the incident occurred after regular business hours, a call is made to the DON and the nurse is instructed to put the new information into the resident medical record and put in the interventions immediately. The NHA stated that all nurses are not used to putting in solutions on the spot and they have had to educate nurses to think outside the box for potential solutions. The incident reports received for R26 were not consistent in how they were documented and what forms were used. The NHA admitted there is not a current process in place for the team to circle back an ensure that appropriate and thorough interventions were identified and put in place. It was discussed the incidences with R26 where the 9/19/22 incident intervention had not yet been put into place and the initial potential root cause for the 10/6/22 incident was noted to be there was an issue with bed inflation, but there was not further documentation of an additional area to be addressed when the bed was found to be in proper repair. The NHA stated this would be addressed further with the QAPI (Quality Assurance and Performance Improvement) committee. Review of R26's care plan revealed a need related to them being at risk for impaired skin integrity interventions include: conduct weekly head to toe skin assessments, document and report abnormal findings to the physician; Observe skin with showers/care. Notify nurse immediately of any new areas of skin breakdown .; Provide total assistance to reposition frequently as needed; all with an initiated date on 4/16/2019. An additional intervention with the initiated date of 12/23/2021 is turn/reposition resident every 2 hours and PRN (as needed). An additional need is listed as Bed Mobility Program: [R26 is unable to independently move from a lying position to a sitting position .R/T (related to) quadriplegia, impaired cognition, muscle weakness interventions include: assist resident in repositioning, observe skin integrity when turning guest, report red/open areas to nurse, physical assist of: 2 persons, .turn guest every 2 hours, all with initiated dates of 4/16/2019. Another need is listed as R26 has an actual impaired skin integrity related to Pressure injury on coccyx, Stage IV with an initiated date of 12/23/2021. No additional wounds or skin impairments are noted. An additional need area is listed as an ADL (activities of daily living) deficit and requires total assistance with ADL's, transfers and mobility . with a created date of 4/16/2019. An intervention was added on 10/18/2022 [R26 is to be repositioned between his right side and left side, using positioning wedges, at least every 2 hours. Place positioning wedges above and below his coccyx wound, to offload weight. Avoid positioning [R26] on his back, as he will allow. Review of care plan printed on 10/17/2022 did not reveal this intervention. Another intervention was revised on 10/18/2022 titled BED MOBILITY: Resident requires total assistance of 2-3 staff to reposition and turn in bed. May require increased assistance with linen changes. The care plan printed 10/17/2022 revealed BED MOBILITY: Resident requires total assistance of 1-2 staff to reposition and turn in bed. The care plan was not changed with identified interventions related to the 10/6/22 incident until 10/18/2022. An additional need is listed as R26 had actual impairment to skin integrity r/t [NAME] (sp) pressure ulcer on coccyx .abrasions to left lower extremity with a last revised date of 8/26/2022 by the DON and initiated interventions on that same date: follow facility protocols for treatment of injury yet there were not orders related to the treatment of these injuries in the electronic medical record per interview with the DON on 10/18/22 at 10:42 AM. Review of the task tab in the electronic medical record on 10/18/22 at 12:25 PM revealed a task of Bed mobility: Turn and Reposition every 2 hours and PRN while in bed and up in wheelchair. A look back of the last 30 days revealed only 5 times this task was documented on 9/26/22 for 20 minutes, 9/29/22 for 20 minutes, 9/30/22 for 25 minutes, 10/6/22 for 25 minutes and 10/12/22 for 15 minutes. Review of notes from the wound specialist dated 8/24/2022 reveal: Off-Loading Wound #1 Coccyx .Keep weight off area of wound at all times. Review of facility policy Fall Management with a last revised date of 7/14/21 revealed: The facility will identify hazards and guest/resident risk factors and implement interventions to minimize falls and risk of injury related to falls. Under the section Practice Guidelines: When a fall occurs .a fall huddle will be held to determine the root cause of the fall .The licensed nurse will complete: Incident/Accident Report .Review and/or revise care plan .The IDT will review all guest/resident falls within 24-72 hours .to evaluate/investigate the circumstances and probable cause for the fall, review/modify the plan of care to minimize repeat falls and update the guest/resident [NAME] as needed .A 'Guest/Resident at Risk' meeting will be conducted at least monthly by the Interdisciplinary Team. Guests/residents reviewed during the meeting are as follows: Guests/residents that had a fall since the previous meeting .The DON/designee will document any changes in the care plan and [NAME] at the meeting .The Director of Nursing or designee will print the monthly report .to track and trend falls in the facility. This data .will be analyzed and presented to the QAPI committee for ongoing recommendations .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to prevent the development of a Stage IV pressure ulcer, failed to develop and implement interventions to prevent and heal pressure ulcers and failed to monitor further skin integrity concerns for 1 resident (R26) reviewed for alterations in skin integrity, resulting in the potential for further skin breakdown, delayed wound healing, infection, and overall deterioration in health status. Findings include: Review of face sheet and electronic medical record for R26 revealed he initially admitted to the facility on [DATE] with diagnosis that included: quadriplegia, dementia, traumatic brain injury, diabetes mellitus type 2, anxiety, depression, chronic pain, contractures, pseudobulbar affect (sudden involuntary outbursts of laughing or crying) and symptomatic epilepsy. R26 was not their own responsible party. Per facility provided wound timeline and facility matrix, R26 had a facility acquired Stage IV pressure ulcer that was first discovered on 9/20/21. On 10/17/22 at 10:55 AM an interview was completed with R26 and their responsible party in their room. R26's responsible party confirmed R26 had wounds on his bottom and he was going to a wound clinic. R26 was not viewed to have any pressure offloading pillows or cushions near his trunk area and was laying on his back with his bed slightly inclined. His feet appeared to be up on pillows and were against the foot board. R26's responsible party stated R26 was not a good historian due to a traumatic brain injury and he has very limited short term memory. R26 and R26's responsible party stated he is able to get up into his wheelchair. On 10/18/22 at 10:00 AM a care observation was made with R26 in their room. CNA (certified nursing assistant) H and CNA I turned R26 side to side and did peri care. CNA I stated she turns him with wedges every 4 hours, CNA H said she tries to turn him every 2 hours. The positioning wedges remained on the empty bed next to resident, and they were also observed on the bed next to the resident at 7:00 AM on 10/18/22. There were dressings on both R26's lower legs in their shin area with no date. The CNAs were not sure when these dressings were started. Scabs were viewed on all toes of R26's right foot. There was a large scab on the left forefoot about 1 inch by ¼ inch on a boney area. The CNAs stated the resident is bed bound and has been bed bound for at least 2 months as he would yell when up in his wheelchair. An additional care observation of R26 was made on 10/18/22 at 10:42 AM. R26 was viewed in his bed on his back. R26 was viewed on his back since he was observed at 7:00 AM during a facility tour. The dressing on R26's coccyx was viewed to be dated 10/17/22 and looked soiled at the end of gluteal fold, when removed there was bright red blood, the calcium alginate was soaked with bright red blood. LPN (Licensed Practical Nurse) J removed the dressing and the DON (Director of Nursing) rolled R26 on his right side. LPN J took a photo with the DON's phone that works with the electronic medical record system. A 4x4 inch dressing was viewed on both R26's legs in the mid shin area, the right leg was a dime size wound and on the left leg a quarter size. The dressings were viewed to be soaked with fluid and tissue, fluid was viewed from the outside of dressing. The DON and LPN J stated there were no orders for dressings on the legs and had no idea when they were placed or who placed dressing on both legs. R26 was not aware of when dressings were place or cause. It was also observed R26's right foot had scabbed areas on every toe and his left mid foot anterior side had a 1 inch by 1/8-inch scab. R26 and the DON did not know what caused the scabs/injuries. A request was made for any incident or accident reports related to R26 and they were received by email on 10/18/22 at 3:14 PM. The incidents were reviewed. Review of facility provided Incident and Accident Report for R26 with the date 8/24/22 was revealed to a be a one page handwritten document. The time of day of the injury was not noted, the location was checked as resident room and was an abrasion on the left lower extremity. In the section Describe the nature of the accident/incident and if injuries sustained, location of injuries: a handwritten note was input: left lower extremity- 2 abrasions- top- 1 cm x 2 cm bottom 2 cm x 2 cm. The witness section was marked no. The physician was notified at 1700 (5:00 PM) on 8-24-22 the responsible party was notified on 8-24-22 at 950 (9:50 AM). The interventions implemented were new tx (treatment). The employee signature completing the report appeared to be signed by LPN M and was dated 8-24-22. The NHA (nursing home administrator) and the DON signed the report on 8/26/22. Review of R26's documents in their electronic medical records revealed a note to the physician dated 8/25/22 when they were informed: Guest scraped leg (with?) 1 cm x 2 cm & 3 cm x 2 cm abrasion- new treatment started. Review of wound clinic notes from 8/24/22 revealed the resident was seen by the wound clinic on 8/24/22 at 2:15 PM. There was not any reference to a leg injury. Review of R26's progress notes showed no progress note on 8/24/22. A nurses note on 8/25/22 at 9:47 AM authored by LPN M revealed: called to res room and res noted to have 2 small abrasions on LLE (left lower extremity) top one is 1 cm x 2 cm and bottom is 3 cm x2 cm, dr notified and mom notified, new treatment ordered cleanse with NS wipe, blot dry and apply optifoam and change every 3 days and PRN (as needed). A total body skin assessment is documented on 8/25/22 at 10:15 AM. With the dates and times of these various documents, it is not clear how and when the wound occurred and was initially discovered. Review of facility provided Incident and Accident Report for R26 with the date 9/18/22 was revealed to a be a one page handwritten document. The document revealed at 2100 (11:00 PM) in the resident room R26 sustained an abrasion L (left) 5th toe & top L foot 1 cm (illegible writing). The incident was described a: when rolling resident to change brief, foot scraped on foot board. The interventions implemented revealed: foam dressing applied over wounds and maintenance to look at bed for extender. The employee signature was not legible for who completed it, but was dated 9/19/22. The DON, Administrator and the physician did not sign that they reviewed the document. Review of the electronic medical record progress notes revealed notes regarding the incident as well as notifications. A note from Unit Manager M on 09/19/22 at 9:56 AM revealed Bed cannot accomodate (sp) extenders related to APM and bariatric bed/mattress. New order to pad footboard to protect feet. Review of wound clinic notes from 10/5/22 reveal two additional open wounds both described with original cause of wound was not known. The date acquired was: 9/21/2022. The wound has been in treatment for 2 weeks. Wound #4 is described as Partial thickness wound with etiology of Skin Tear and is located on the Right, Dorsal Foot . and Wound #5 is a Partial Thickness wound with etiology of Skin Tear and is located on the Left, Anterior Lower Leg. Neither of these wounds match the description of the 9/18/22 incident and it is unclear where they came from since the facility provided no further incident reports matching the wound clinic notes injuries. A review of progress notes for R26 shows no note on 9/21/22 and a skin assessment documented on 9/22/22 at 10:15 AM with number of new skin conditions: 0. No other new injury or incident is documented in the progress notes in the date range of 9/21/22. Review of facility provided document dated 10/6/22 at 5:01 AM revealed a computer generated report titled Slid Out of Bed. The incident description revealed: two cenas were changing sheet and rolled guest to side and cena unable to hold him and both cenas lowered to floor. Abrasion to both shins from head board. Red mark to left back shoulder. No other injury. Hoyer (mechanical lift) used to get guest back into bed . The Immediate Action Taken section revealed Full assessment done, no injury except abrasion to shin .Maintenance to check proper functioning and inflation of mattress. Injuries were noted to right lower leg (front) and left lower leg (front). A handwritten Post Fall Evaluation was also included. The date and time of fall was written as 10/5 at 1900 and PM was circled. The description was rolled to floor during bed change. There were several sections of the document not completed including: Re-enactment of fall (to be done if root cause is not determined), Fall Huddle (What was different this time?), Root Cause of this Fall: Review of Contributing Factors (Check all that apply), Describe initial intervention to prevent future falls, and New Interventions after IDT review. The nurse signed the document on 10/5/22 and the section IDT Signatures was blank. Also attached were handwritten witness statements from the two CNAs (certified nursing assistants) involved in the incident with R26. CNA L's statement indicated the incident occurred on [DATE]th at 7:05. The statement was not very detailed and concluded Not sure what happened, but I couldn't stop him from falling. The handwritten statement from CNA K indicated the incident happened on [DATE]th at 7 pm the event account was brief and difficult to read due to incomplete sentences and either misspellings or penmanship. There was also an attached note from Director of Maintenance dated 10-6-22 which stated The Air Mattress on bed [R26's bed] is currently functioning properly and has foam support as well as the air pressure system therefore the mattress should not deflate while on and operating properly. There was no other additional root cause or intervention documented as being explored after the mattress malfunctioning was ruled out. There was no nursing note on 10/5/22 or 10/6/22 regarding the fall. A skin assessment was documented on 10/6/22 at 10:15 AM with no new conditions noted. A progress note on 10/7/22 at 4:06 AM indicated no new injury or pain s/p (status post) lowered to floor from bed. Denies pain. There were two follow up notes on 10/8/22 stating there were no new injuries from being lowered to the floor. There was not another progress note until a skin assessment on 10/13/22 at 10:15 AM which indicated no new skin conditions. The next note was a physician note by Doctor E on 10/18/22 at 10:20 AM. There is no reference to a recent fall or the new injuries. On 10/18/22 at 3:33 PM an email was sent to the DON with questions regarding the incident accident reports: For the 8/24 injury, how did it occur? For the 9/18 injury, was a bed extender obtained, if not how else was this resolved? The 10/6 incident is confusing to me, how was his leg injured on the head board? When the bed was found to be functioning properly, what else was reviewed to find a root cause? On 10/18/22 at 5:53 PM and email was received from the DON: The injury from 8/24/22 was noted by staff upon return from the wound clinic. Guest is transported via [ambulance company] for those appointments. In regards to the incident on 9/19/22 the foot board is to be padded. Maintenance is addressing that tonight. As for the Incident Report on 10/6/22, head board was a documentation error, it should read foot board. His Careplan and [NAME] were updated to reflect that more assistance may be required during linen changes. Therapy is screening Guest for bed mobility, transfers and positioning. A follow up interview was completed with the DON on 10/19/22 at 9:05 AM regarding R26. The injury from 8/24/22 was discussed. The DON stated the injury was reported as soon as R26 returned from the wound clinic. She stated that they did not know if the injury occurred from transport in and out of the ambulance (R26's transportation to the wound clinic) or if it occurred at the wound clinic, but they do know for sure the injury was not there before R26 left the building. The DON was asked if R26 had a full body skin assessment prior to leaving the building on 8/24/22 and the DON reviewed the electronic medical record and stated his last skin assessment was 8/19/22. The DON was asked if she called the wound clinic or the ambulance company to obtain interviews or information about the injury and she stated that was not done to her knowledge. The DON was asked if she could say with certainty how and where the injury occurred, and she stated that she could not. The DON agreed this would be an injury of unknown origin and an investigation should have been initiated by the facility to determine when and how it occurred. The 10/6/22 incident was discussed with the DON, she admitted that the incident report and the witness statements were confusing. The DON stated she completed follow up interviews with the staff involved to get a better understanding of the events. The DON admitted the clarifying follow up interviews were not part of the incident report. The DON stated the event occurred because R26 was not properly centered on the bed when staff were changing his sheets and the staff member could not hold him by themselves when he started to fall. The DON confirmed they have enough staff on day shift and second shift to be able to accommodate more than 2 workers assisting with future sheet changes. The DON stated this intervention had not been added to the care plan but was added as of 10/18/22. On 10/19/22 at 9:15 AM, an observation was made of R26 in his room. R26 was in bed on his back with positioning wedges in place and the foot of his bed was viewed to be padded. During an interview with the NHA (nursing home administrator) on 10/19/22 at 1:00 PM, the absence of a thorough investigation and mode of injury for R26 on 8/24/22 was discussed. The NHA stated the unit manager had called the wound clinic and they confirmed the injuries occurred there. The NHA was informed this was not in the incident report, the medical record and the DON was not aware of this conclusion. The NHA flipped through a personal notebook and stated she wrote herself a note on 8/26/22 that the unit manager had made calls and it happened at the wound clinic. The NHA later followed up on 10/19/22 at approximately 1:45 PM and provided a nurses note from 8/26/22 at 9:41 AM: IDT (interdisciplinary team) team met and reviewed abrasion to LLE (left lower extremity). Per [name of staff], LPN area was noted upon return from appointment on 8/24/2022. Area is due to repositioning and turning on gurney with paramedics. It was noted to the NHA and they admitted the note did not say how and when the information was obtained and does not indicate a complete investigation. During the interview with the NHA on 10/19/22 at 1:00 PM, incident and accident interventions were further discussed. The NHA stated when an incident occurs, the nurse on duty fills out the incident paperwork and then the clinical team reviews it later and ensures everything is in place for interventions. If the incident occurred after regular business hours, a call is made to the DON and the nurse is instructed to put the new information into the resident medical record and put in the interventions immediately. The NHA stated that all nurses are not used to putting in solutions on the spot and they have had to educate nurses to think outside the box for potential solutions. The incident reports received for R26 were not consistent in how they were documented and what forms were used. The NHA admitted there is not a current process in place for the team to circle back an ensure that appropriate and thorough interventions were identified and put in place. It was discussed the incidences with R26 where the 9/19/22 incident intervention had not yet been put into place and the initial potential root cause for the 10/6/22 incident was noted to be there was an issue with bed inflation, but there was not further documentation of an additional area to be addressed when the bed was found to be in proper repair. The NHA stated this would be addressed further with the QAPI (Quality Assurance and Performance Improvement) committee. Review of R26's care plan revealed a need related to them being at risk for impaired skin integrity interventions include: conduct weekly head to toe skin assessments, document and report abnormal findings to the physician; Observe skin with showers/care. Notify nurse immediately of any new areas of skin breakdown .; Provide total assistance to reposition frequently as needed; all with an initiated date on 4/16/2019. An additional intervention with the initiated date of 12/23/2021 is turn/reposition resident every 2 hours and PRN (as needed). An additional need is listed as Bed Mobility Program: [R26 is unable to independently move from a lying position to a sitting position .R/T (related to) quadriplegia, impaired cognition, muscle weakness interventions include: assist resident in repositioning, observe skin integrity when turning guest, report red/open areas to nurse, physical assist of: 2 persons, .turn guest every 2 hours, all with initiated dates of 4/16/2019. Another need is listed as R26 has an actual impaired skin integrity related to Pressure injury on coccyx, Stage IV with an initiated date of 12/23/2021. No additional wounds or skin impairments are noted. An additional need area is listed as an ADL (activities of daily living) deficit and requires total assistance with ADL's, transfers and mobility . with a created date of 4/16/2019. An intervention was added on 10/18/2022 [R26 is to be repositioned between his right side and left side, using positioning wedges, at least every 2 hours. Place positioning wedges above and below his coccyx wound, to offload weight. Avoid positioning [R26] on his back, as he will allow. Review of care plan printed on 10/17/2022 did not reveal this intervention. Another intervention was revised on 10/18/2022 titled BED MOBILITY: Resident requires total assistance of 2-3 staff to reposition and turn in bed. May require increased assistance with linen changes. The care plan printed 10/17/2022 revealed BED MOBILITY: Resident requires total assistance of 1-2 staff to reposition and turn in bed. The care plan was not changed with identified interventions related to the 10/6/22 incident until 10/18/2022. An additional need is listed as R26 had actual impairment to skin integrity r/t [NAME] (sp) pressure ulcer on coccyx .abrasions to left lower extremity with a last revised date of 8/26/2022 by the DON and initiated interventions on that same date: follow facility protocols for treatment of injury yet there were not orders related to the treatment of these injuries in the electronic medical record per interview with the DON on 10/18/22 at 10:42 AM. Review of the task tab in the electronic medical record on 10/18/22 at 12:25 PM revealed a task of Bed mobility: Turn and Reposition every 2 hours and PRN while in bed and up in wheelchair. A look back of the last 30 days revealed only 5 times this task was documented on 9/26/22 for 20 minutes, 9/29/22 for 20 minutes, 9/30/22 for 25 minutes, 10/6/22 for 25 minutes and 10/12/22 for 15 minutes. Review of notes from the wound specialist dated 8/24/2022 reveal: Off-Loading Wound #1 Coccyx .Keep weight off area of wound at all times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R 26 Review of face sheet and electronic medical record for R26 revealed he initially admitted to the facility on [DATE] with diagnosis that included: quadriplegia, dementia, traumatic brain injury, diabetes mellitus type 2, anxiety, depression, chronic pain, contractures, pseudobulbar affect (sudden involuntary outbursts of laughing or crying) and symptomatic epilepsy. R26 was not their own responsible party. Per facility provided wound timeline and facility matrix, R26 had a facility acquired Stage IV pressure ulcer that was first discovered on 9/20/21. On 10/17/22 at 10:55 AM an interview was completed with R26 and their responsible party in their room. R26's responsible party confirmed R26 had wounds on his bottom and he was going to a wound clinic. R26 was not viewed to have any pressure offloading pillows or cushions near his trunk area and was laying on his back with his bed slightly inclined. His feet appeared to be up on pillows and were against the foot board. R26's responsible party stated R26 was not a good historian due to a traumatic brain injury and he has very limited short term memory. R26 and R26's responsible party stated he is able to get up into his wheelchair. On 10/18/22 at 10:00 AM a care observation was made with R26 in their room. CNA (certified nursing assistant) H and CNA I turned R26 side to side and did peri care. CNA I stated she turns him with wedges every 4 hours, CNA H said she tries to turn him every 2 hours. The positioning wedges remained on the empty bed next to resident, and they were also observed on the bed next to the resident at 7:00 AM on 10/18/22. There were dressings on both R26's lower legs in their shin area with no date. The CNAs were not sure when these dressings were started. Scabs were viewed on all toes of R26's right foot. There was a large scab on the left forefoot about 1 inch by ¼ inch on a boney area. The CNAs stated the resident is bed bound and has been bed bound for at least 2 months as he would yell when up in his wheelchair. An additional care observation of R26 was made on 10/18/22 at 10:42 AM. R26 was viewed in his bed on his back. R26 was viewed on his back since he was observed at 7:00 AM during a facility tour. The dressing on R26's coccyx was viewed to be dated 10/17/22 and looked soiled at the end of gluteal fold, when removed there was bright red blood, the calcium alginate was soaked with bright red blood. LPN (Licensed Practical Nurse) J removed the dressing and the DON (Director of Nursing) rolled R26 on his right side. LPN J took a photo with the DON's phone that works with the electronic medical record system. A 4x4 inch dressing was viewed on both R26's legs in the mid shin area, the right leg was a dime size wound and on the left leg a quarter size. The dressings were viewed to be soaked with fluid and tissue, fluid was viewed from the outside of dressing. The DON and LPN J stated there were no orders for dressings on the legs and had no idea when they were placed or who placed dressing on both legs. R26 was not aware of when dressings were place or cause. It was also observed R26's right foot had scabbed areas on every toe and his left mid foot anterior side had a 1 inch by 1/8-inch scab. R26 and the DON did not know what caused the scabs/injuries. A request was made for any incident or accident reports related to R26 and they were received by email on 10/18/22 at 3:14 PM. The incidents were reviewed. Review of facility provided Incident and Accident Report for R26 with the date 8/24/22 was revealed to a be a one page handwritten document. The time of day of the injury was not noted, the location was checked as resident room and was an abrasion on the left lower extremity. In the section Describe the nature of the accident/incident and if injuries sustained, location of injuries: a handwritten note was input: left lower extremity- 2 abrasions- top- 1 cm x 2 cm bottom 2 cm x 2 cm. The witness section was marked no. The physician was notified at 1700 (5:00 PM) on 8-24-22 the responsible party was notified on 8-24-22 at 950 (9:50 AM). The interventions implemented were new tx (treatment). The employee signature completing the report appeared to be signed by LPN M and was dated 8-24-22. The NHA (nursing home administrator) and the DON signed the report on 8/26/22. Review of R26's documents in their electronic medical records revealed a note to the physician dated 8/25/22 when they were informed: Guest scraped leg (with?) 1 cm x 2 cm & 3 cm x 2 cm abrasion- new treatment started. Review of wound clinic notes from 8/24/22 revealed the resident was seen by the wound clinic on 8/24/22 at 2:15 PM. There was not any reference to a leg injury. Review of R26's progress notes showed no progress note on 8/24/22. A nurses note on 8/25/22 at 9:47 AM authored by LPN M revealed: called to res room and res noted to have 2 small abrasions on LLE (left lower extremity) top one is 1 cm x 2 cm and bottom is 3 cm x2 cm, dr notified and mom notified, new treatment ordered cleanse with NS wipe, blot dry and apply optifoam and change every 3 days and PRN (as needed). A total body skin assessment is documented on 8/25/22 at 10:15 AM. With the dates and times of these various documents, it is not clear how and when the wound occurred and was initially discovered. Review of facility provided Incident and Accident Report for R26 with the date 9/18/22 was revealed to a be a one page handwritten document. The document revealed at 2100 (11:00 PM) in the resident room R26 sustained an abrasion L (left) 5th toe & top L foot 1 cm (illegible writing). The incident was described a: when rolling resident to change brief, foot scraped on foot board. The interventions implemented revealed: foam dressing applied over wounds and maintenance to look at bed for extender. The employee signature was not legible for who completed it, but was dated 9/19/22. The DON, Administrator and the physician did not sign that they reviewed the document. Review of the electronic medical record progress notes revealed notes regarding the incident as well as notifications. A note from Unit Manager M on 09/19/22 at 9:56 AM revealed Bed cannot accomodate (sp) extenders related to APM and bariatric bed/mattress. New order to pad footboard to protect feet. Review of wound clinic notes from 10/5/22 reveal two additional open wounds both described with original cause of wound was not known. The date acquired was: 9/21/2022. The wound has been in treatment for 2 weeks. Wound #4 is described as Partial thickness wound with etiology of Skin Tear and is located on the Right, Dorsal Foot . and Wound #5 is a Partial Thickness wound with etiology of Skin Tear and is located on the Left, Anterior Lower Leg. Neither of these wounds match the description of the 9/18/22 incident and it is unclear where they came from since the facility provided no further incident reports matching the wound clinic notes injuries. A review of progress notes for R26 shows no note on 9/21/22 and a skin assessment documented on 9/22/22 at 10:15 AM with number of new skin conditions: 0. No other new injury or incident is documented in the progress notes in the date range of 9/21/22. Review of facility provided document dated 10/6/22 at 5:01 AM revealed a computer generated report titled Slid Out of Bed. The incident description revealed: two cenas were changing sheet and rolled guest to side and cena unable to hold him and both cenas lowered to floor. Abrasion to both shins from head board. Red mark to left back shoulder. No other injury. Hoyer (mechanical lift) used to get guest back into bed . The Immediate Action Taken section revealed Full assessment done, no injury except abrasion to shin .Maintenance to check proper functioning and inflation of mattress. Injuries were noted to right lower leg (front) and left lower leg (front). A handwritten Post Fall Evaluation was also included. The date and time of fall was written as 10/5 at 1900 and PM was circled. The description was rolled to floor during bed change. There were several sections of the document not completed including: Re-enactment of fall (to be done if root cause is not determined), Fall Huddle (What was different this time?), Root Cause of this Fall: Review of Contributing Factors (Check all that apply), Describe initial intervention to prevent future falls, and New Interventions after IDT review. The nurse signed the document on 10/5/22 and the section IDT Signatures was blank. Also attached were handwritten witness statements from the two CNAs (certified nursing assistants) involved in the incident with R26. CNA L's statement indicated the incident occurred on [DATE]th at 7:05. The statement was not very detailed and concluded Not sure what happened, but I couldn't stop him from falling. The handwritten statement from CNA K indicated the incident happened on [DATE]th at 7 pm the event account was brief and difficult to read due to incomplete sentences and either misspellings or penmanship. There was also an attached note from Director of Maintenance dated 10-6-22 which stated The Air Mattress on bed [R26's bed] is currently functioning properly and has foam support as well as the air pressure system therefore the mattress should not deflate while on and operating properly. There was no other additional root cause or intervention documented as being explored after the mattress malfunctioning was ruled out. There was no nursing note on 10/5/22 or 10/6/22 regarding the fall. A skin assessment was documented on 10/6/22 at 10:15 AM with no new conditions noted. A progress note on 10/7/22 at 4:06 AM indicated no new injury or pain s/p (status post) lowered to floor from bed. Denies pain. There were two follow up notes on 10/8/22 stating there were no new injuries from being lowered to the floor. There was not another progress note until a skin assessment on 10/13/22 at 10:15 AM which indicated no new skin conditions. The next note was a physician note by Doctor E on 10/18/22 at 10:20 AM. There is no reference to a recent fall or the new injuries. On 10/18/22 at 3:33 PM an email was sent to the DON with questions regarding the incident accident reports: For the 8/24 injury, how did it occur? For the 9/18 injury, was a bed extender obtained, if not how else was this resolved? The 10/6 incident is confusing to me, how was his leg injured on the head board? When the bed was found to be functioning properly, what else was reviewed to find a root cause? On 10/18/22 at 5:53 PM and email was received from the DON: The injury from 8/24/22 was noted by staff upon return from the wound clinic. Guest is transported via [ambulance company] for those appointments. In regards to the incident on 9/19/22 the foot board is to be padded. Maintenance is addressing that tonight. As for the Incident Report on 10/6/22, head board was a documentation error, it should read foot board. His Careplan and Kardex were updated to reflect that more assistance may be required during linen changes. Therapy is screening Guest for bed mobility, transfers and positioning. A follow up interview was completed with the DON on 10/19/22 at 9:05 AM regarding R26. The injury from 8/24/22 was discussed. The DON stated the injury was reported as soon as R26 returned from the wound clinic. She stated that they did not know if the injury occurred from transport in and out of the ambulance (R26's transportation to the wound clinic) or if it occurred at the wound clinic, but they do know for sure the injury was not there before R26 left the building. The DON was asked if R26 had a full body skin assessment prior to leaving the building on 8/24/22 and the DON reviewed the electronic medical record and stated his last skin assessment was 8/19/22. The DON was asked if she called the wound clinic or the ambulance company to obtain interviews or information about the injury and she stated that was not done to her knowledge. The DON was asked if she could say with certainty how and where the injury occurred, and she stated that she could not. The DON agreed this would be an injury of unknown origin and an investigation should have been initiated by the facility to determine when and how it occurred. The 10/6/22 incident was discussed with the DON, she admitted that the incident report and the witness statements were confusing. The DON stated she completed follow up interviews with the staff involved to get a better understanding of the events. The DON admitted the clarifying follow up interviews were not part of the incident report. The DON stated the event occurred because R26 was not properly centered on the bed when staff were changing his sheets and the staff member could not hold him by themselves when he started to fall. The DON confirmed they have enough staff on day shift and second shift to be able to accommodate more than 2 workers assisting with future sheet changes. The DON stated this intervention had not been added to the care plan but was added as of 10/18/22. On 10/19/22 at 9:15 AM, an observation was made of R26 in his room. R26 was in bed on his back with positioning wedges in place and the foot of his bed was viewed to be padded. During an interview with the NHA (nursing home administrator) on 10/19/22 at 1:00 PM, the absence of a thorough investigation and mode of injury for R26 on 8/24/22 was discussed. The NHA stated the unit manager had called the wound clinic and they confirmed the injuries occurred there. The NHA was informed this was not in the incident report, the medical record and the DON was not aware of this conclusion. The NHA flipped through a personal notebook and stated she wrote herself a note on 8/26/22 that the unit manager had made calls and it happened at the wound clinic. The NHA later followed up on 10/19/22 at approximately 1:45 PM and provided a nurses note from 8/26/22 at 9:41 AM: IDT (interdisciplinary team) team met and reviewed abrasion to LLE (left lower extremity). Per [name of staff], LPN area was noted upon return from appointment on 8/24/2022. Area is due to repositioning and turning on gurney with paramedics. It was noted to the NHA and they admitted the note did not say how and when the information was obtained and does not indicate a complete investigation. During the interview with the NHA on 10/19/22 at 1:00 PM, incident and accident interventions were further discussed. The NHA stated when an incident occurs, the nurse on duty fills out the incident paperwork and then the clinical team reviews it later and ensures everything is in place for interventions. If the incident occurred after regular business hours, a call is made to the DON and the nurse is instructed to put the new information into the resident medical record and put in the interventions immediately. The NHA stated that all nurses are not used to putting in solutions on the spot and they have had to educate nurses to think outside the box for potential solutions. The incident reports received for R26 were not consistent in how they were documented and what forms were used. The NHA admitted there is not a current process in place for the team to circle back an ensure that appropriate and thorough interventions were identified and put in place. It was discussed the incidences with R26 where the 9/19/22 incident intervention had not yet been put into place and the initial potential root cause for the 10/6/22 incident was noted to be there was an issue with bed inflation, but there was not further documentation of an additional area to be addressed when the bed was found to be in proper repair. The NHA stated this would be addressed further with the QAPI (Quality Assurance and Performance Improvement) committee. Review of R26's care plan revealed a need related to them being at risk for impaired skin integrity interventions include: conduct weekly head to toe skin assessments, document and report abnormal findings to the physician; Observe skin with showers/care. Notify nurse immediately of any new areas of skin breakdown .; with an initiated date on 4/16/2019. An additional need is listed as Bed Mobility Program: [R26 is unable to independently move from a lying position to a sitting position .R/T (related to) quadriplegia, impaired cognition, muscle weakness interventions include: assist resident in repositioning, observe skin integrity when turning guest, report red/open areas to nurse, physical assist of: 2 persons, .turn guest every 2 hours, all with initiated dates of 4/16/2019. Another need is listed as R26 has an actual impaired skin integrity related to Pressure injury on coccyx, Stage IV with an initiated date of 12/23/2021. No additional wounds or skin impairments are noted. An additional need area is listed as an ADL (activities of daily living) deficit and requires total assistance with ADL's, transfers and mobility . with a created date of 4/16/2019. Another intervention was revised on 10/18/2022 titled BED MOBILITY: Resident requires total assistance of 2-3 staff to reposition and turn in bed. May require increased assistance with linen changes. The care plan printed 10/17/2022 revealed BED MOBILITY: Resident requires total assistance of 1-2 staff to reposition and turn in bed. The care plan was not changed with identified interventions related to the 10/6/22 incident until 10/18/2022. Review of facility policy Fall Management with a last revised date of 7/14/21 revealed: The facility will identify hazards and guest/resident risk factors and implement interventions to minimize falls and risk of injury related to falls. Under the section Practice Guidelines: When a fall occurs .a fall huddle will be held to determine the root cause of the fall .The licensed nurse will complete: Incident/Accident Report .Review and/or revise care plan .The IDT will review all guest/resident falls within 24-72 hours .to evaluate/investigate the circumstances and probable cause for the fall, review/modify the plan of care to minimize repeat falls and update the guest/resident kardex as needed .A 'Guest/Resident at Risk' meeting will be conducted at least monthly by the Interdisciplinary Team. Guests/residents reviewed during the meeting are as follows: Guests/residents that had a fall since the previous meeting .The DON/designee will document any changes in the care plan and kardex at the meeting .The Director of Nursing or designee will print the monthly report .to track and trend falls in the facility. This data .will be analyzed and presented to the QAPI committee for ongoing recommendations . Based on observations, interviews, and record review, the facility failed to prevent accidents and injuries related to transfers and falls for 3 Residents (R19. R26 and R41) resulting in R19 having multiple falls causing a fracture, bruises/lacerations, R26 sustaining multiple abrasions, and R41 having falls with potential for injury. Findings included: Review of the facility Fall Management policy dated effective 8/18/22, revealed, The facility will identify hazards and guest/resident risk factors and implement interventions to minimize falls and risk of injury related to falls. Overview. Each guest/resident is assisted in attain/maintain his or her highest practical level of function by providing the guest/resident adequate supervision, assistive devices and/or functional programs as appropriate to minimize the risk of falls. Guests/residents will be evaluated by the interdisciplinary team for their risk for falls. A plan of care is developed and implemented based on this evaluation with ongoing review. If a fall occurs, the interdisciplinary team conducts an evaluation to ensure appropriate measures are in place to minimize the risk of future falls. The Director of Nursing/designee is responsible for coordination of an interdisciplinary approach to manage the process for prediction, risk evaluation, treatment, evaluation, and monitoring of guest/residents falls. In the Practice Guideline section 4. The licensed nurse will complete: Incident/Accident Report. Review and/or revise care plan and guest/resident Kardex. Document in the medical record and on the 24-Hour Report/dashboard. Initiate the Post-Fall evaluation. Document in the progress notes for 72-hours follow the fall. 9. The IDT (interdisciplinary team) will assure the Post-Fall Evaluation is competed within 24-72 hours. R19 Review of R19's face sheet revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: unsteady on feet, muscle weakness, chronic pain and vascular dementia. R19 was not her own responsible party. Review of R19's care plan revealed a care plan for Ambulation, R19 unable to ambulate independently R/T (related to): unsteady gait, decreased safety awareness, impaired cognition, needs assistive device, weakness, ataxia (impaired coordination). Initiated 6/11/19 and revision on 6/10/22. Interventions included: ambulate with FWW (front wheeled walker) and 1 person assistance, encourage large, even steps, and limit distractions. Review of R19' care plan revealed a care plan for R19 is at risk for fall related injury and falls R/T (related to): history of falls, HOH (hard of hearing), impaired vision, dementia, guest self-transfers without using call light. Date initiated: 6/10/19 and Revision on 9/24/21. The goal was, Will be free from injury related to falls through the review date: Date Initiated 6/10/19. Target date: 11/20/22. Interventions included: anticipate and meet needs, encourage guest to wear non-skid socks at all times, assist guest as needed 5/25/21, Encourage resident to rest in chair or bed when she appears fatigued 6/21/22, pressure alarms to bed and chair upon return from Hospital, 8/14/22. Review of R19 incident report dated 12/4/21 at 9:45 AM revealed, R19 had an unwitnessed fall and was found on the floor at her bedside. R19 was injured noting a skin tear, hematoma/bruise. The intervention to prevent recurrence was to move her closer to the nurse's station. Review of the Post Fall Evaluation for the fall on 12/4/21 at 9:45 AM revealed, the root cause was R19 got tangled in her bedding. R19 did not use her call light and already had a fall alarm. Review of R19's incident report dated 2/9/22 at 03:00 AM revealed she had an unwitnessed fall in the bathroom when she self-transferred to the bathroom. R19's physician was notified she had a fracture at 12:30 PM. No indication of new intervention place to increase supervision or assistance. Review of R19's progress note dated 2/9/22 at 12:42 PM revealed Radiology report received from (name of company) show acute fracture of left superior pubic ramus. Review of R19's incident report dated 2/13/22 at 5:40 pm, revealed she had a witnessed fall getting out of bed. R19's bed alarm was turned off. The intervention was to turn the alarm on. There was no indication if staff saw the fall or what they attempted to do to prevent the fall. The root cause revealed boxes were checked for mood or mental status, amount of assistance in effect, alarm and footwear. Review of R19's incident report dated 7/7/22, no time, revealed R19 self-transferred and stated she was going to use the bathroom. The note documented R19's fall alarm was sounding. There was no indication the fall was witnessed or how long the alarm was sounding before she was found on the floor. The new interventions were encouraged call light use, and place on 2-hour toilet plan. 2-hour toilet assistance is the standard of care. No increased supervision or assistance was placed after this fall. Review of a Post Fall Evaluation for R19 dated 7/7/22 at 10:07 AM repeated the information found for the incident report date 7/7/22 with no time. There was no indication R19 was provided any increase supervision or assistance after this fall. The root cause area was not completed. The New Interventions after IDT (interdisciplinary team) review was not completed. Review of R19's incident report dated 8/14/22 at 6:00 PM revealed R19 had an unwitnessed fall and was found on the floor next to her bed. Review of a Post Fall Evaluation for R19 dated 8/14/22 at 6:00 PM revealed R19 had an alarm on, and it was sounding at the time of the fall. The root cause and new intervention section of the form were not completed. No indication R19 was provided any increased supervision or assistance. Review of R19's incident report dated 8/28/22 at 2:30 AM revealed R19 was found on the floor after her roommate called for assistance. R19 sustained multiple skin tears and bruises. There was no indication increased supervision or assistance was provided after this fall. Review of a Post Fall Evaluation for R19 date 8/28/22 at 2:30 AM revealed the root cause was footwear. The new intervention was grippy socks. Review of R19 care plan revealed R19 was to have grippy socks in place at all times since 5/21/22. No new interventions for increased supervision or assistance were noted. Review of R19's incident report dated 9/14/22 at 5:00 AM revealed she was found on the floor in her bedroom. R19 was on her way back to bed after using the bathroom. R19 sustained a laceration to her head and a skin tear to her left upper arm and was sent to the emergency room. There was no indication any interventions were placed for increased supervision or assistance. There was no investigation or root cause noted. Review of R19's incident report dated 10/14/22 at 8:15 PM revealed R19 was found on the floor next to her bed. R19's alarm was sounding, and her roommate was calling out. There was no indication how long the alarm was sounding or when the roommate started calling for assistance. There was no indication of any new interventions placed. Review of Post Fall Evaluation for R19 dated 10/14/22 at 8:15 PM revealed the same information in the incident report with the same date and time. The root cause and new intervention section of the form were not completed. No new interventions to increase supervision or assistance was located for this fall. On 10/18/22 at 11:55 AM, R19's 8 falls from 12/4/21 to 10/14/22 were reviewed with the Director of Nursing (DON), the DON did not have any investigation or additional information to provide about the 8 falls. The DON did not have any information that indicated the facility had assessed R19's wake/sleep cycle, toilet needs or times she required additional supervision. The DON confirmed the facility policy was not followed for doing a root cause after each fall. The DON could not locate any information on how often R19 was attempting to self-transfer, or any interventions placed that would have increased R19's supervision and assistance after her last 7 falls. R41 Review of R41's face sheet revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses that included: nontraumatic subarachnoid hemorrhage (brain injury), lack of coordination, unsteady on feet, and cognitive communication deficit. R41 was not his own responsible party. Review of R41's base line care plan dated 10/4/22 provided no indication that R41's fall history was reviewed. Review of R41's care plan for Activities of Daily Living (ADL) dated 9/29/22 revealed he required assistance of 2 people for bed mobility, transfers, bathing and toilet use. He was to use a wheelchair for mobility as he was not able to walk. As of 10/10/22 he was to have his bed against the wall in low position and a mattress with a concave parameter. Review of R41's care plan for falls dated initiated 9/30/22 and revision on 10/10/22 revealed interventions that included: lock wheels on wheelchair prior to transfers, observe for fatigue and unsteadiness and encourage rest periods as need, observe for ineffectiveness and side effects R/T (related to) psychotropic drug use, report abnormal findings, offer to get dressed in morning as allows, put call light in reach, assist and anticipate needs. (no interventions were noted for any times supervision was needed. Review of R41's incident report dated 9/30/22 at 12:43 PM revealed, oriented to person, confused, was ambulating in his room without assistance, was admitted within the last 72 hours and slid to the floor, There was no witness to the event. Review of a Post Fall Evaluation dated 9/30/22 at 12:45 PM revealed he had an unwitnessed fall and was found sitting on the floor facing the window. Prior to being found on the floor he had been in his wheelchair. R41 had been observed 15 minutes prior to being found on the floor. The root cause was environmental factors/items out of reach and mood or mental status. The section for interventions were left blank. Review of R41's progress note dated 10/12/22 at 3:18 PM revealed he was standing as he turned toward his bed, lost his balance. R41 was observed during medication pass. The morning of 10/12/22, R41 was in a gown, and he took himself in his wheelchair to the nurse's station. He was returned to his room to get dressed and brought back out of his room. Review of R41's incident report for 10/12/22 at 2:30 PM revealed he was standing at his closet, turned towards the bed and lost his balance and hit his head on the overbed table. The immediate action taken was to assist R41 with dressing during am care, prior to breakfast as tolerate. The fall was at 2:30 pm and according to the progress note written on 10/12/22 at 3:18 PM he was dressed prior to the fall. Standard care would be to do morning care and assist a resident get dressed. There was no indication of any increased supervision or assistance placed after this fall. No Post Fall Evaluation was provided for this fall. During an interview with Certified Nurse Aide (CNA) A on 10/18/22 at 3:54 PM, CNA A said she routinely cares for R41. CNA A said R41 self-transfers throughout the day. CNA A was questioned as to why he was care planned to need assistance of 2 people if he was strong enough to self-transfer. CNA A said R41 gets physically aggressive with care and 2 staff are needed as he grabs and pinches them. CNA A was asked if the facility had a program or place for residents that do not have any safety awareness and are at risk of falling. CNA A, responded, no we just do our best to do frequent checks. CNA A was asked if she documents R41's self-transfers or unsafe behavior and she said she does not have a place to document that kind of information. During an interview with the DON on 10/18/22 at 4:18 PM the DON was asked if they had any assessments for R41 that would indicate when he was awake/sleeping, needed to use the toilet, times of self-transferring or other means of anticipating his needs for assistance. The DON said they do not document/assess these areas. R41's incident reports were reviewed, and the DON confirmed no increase in assistance or supervision was provided after both falls. R41's care plan was reviewed, and it did not provide any specific information on how to supervise him to prevent falls. R41 was observed on multiple occasions on 10/18/22 (10:49 AM) and 10/19/22 (7:45 A[TRUNCATED]