Based on observation, interview, and record review, the facility failed to prevent and correctly identify pressure ulcers for two out of seven residents (Residents 101, and 108) resulting in misidentifying of pressure ulcers, and worsening of pressure ulcers. Findings Included: Resident #101 (R101): Per the facility face sheet R101 had resided at the facility since 4/4/2023. Diagnoses included spinal cord injury, contractures of both hands and fingers, and muscle contractures. Review of a photo dated 12/17/24, of R101's buttocks area reveal moisture associated skin damage (MASD-damage of the skin caused by being constantly moist from things such as urine), and a stage III pressure ulcer (PU) (full thickness tissue loss, fat may be visible). The photo also had an assessment documented which revealed the PU was a stage III (3) in-house acquired PU. The PU was located on R101's right buttocks and the facility documented it as new on 12/17/2024. The facility also documented that the PU had granulation, per the assessment, in 100% of the wound. There was no granulation observed in the picture of the wound, but rather beefy bloody red tissue. In an observation on 3/26/2025 at 3:02 PM of R101's buttocks wounds, R101 had MASD, and an open approximately 3 centimeter (cm) wound located in the same place as the stage 3 wound identified on 12/17/2024. Observation of the wound revealed it to be stage III with a beefy red bed, and no dressing noted to be in place. Review of the photos dated 12/17, 12/18/2024, and 1/7/2024 revealed R101 had MASD in each photo, and also at the time of the observation on 3/26/2025. No other photos or assessments were found to have been completed, nor in R101's electronic medical record (EMR). Review of R101's skin assessments provided by Administrator A revealed that the only skin assessments R101 had conducted were on 2/2, 2/12, 2/19, 3/5, 3/12, 3/19, and 3/26/2025. The Administrator did not provide any further skin assessments. The facility did not provide any skin assessments showing they completed any for the months of November and December 2024, and January 2025, and the skin assessments provided did not identify or have documented any new wounds. Review of R101's care plan revealed a care plan was in place for R101 being at risk for impaired skin integrity, dated 4/4/2023, and last revised on 6/11/2024. The last intervention revision was on 1/4/2025, and that was to turn and reposition R101 from side to side as tolerated or will allow. No care plan was in place for R101's MASD or stage III PU. In an interview on 3/27/2025 at 2:50 PM, Licensed Practical Nurse (LPN) K stated R101 did not have a wound, but had MASD. LPN K said R101 did have a wound on his buttocks at one time. LPN K said R101's MASD had not resolved because he refused everything. LPN K said it was hit or miss with R101 because he had refused a low air loss mattress and ROHO (air mattress) mattress, it was hit or miss with turning him, he refused to eat, refused care, refused splints, refused heel boots at times because he is angry with his situation. LPN K did not state any possible staff concerns for the reason R101 had continuous MASD. Furthermore, LPN K was not aware that R101 had an open area to his buttocks as observed on 3/26/2025. Resident #108 (R108): Review of the facility face sheet revealed R108 had resided at the facility since 10/18/2024. During an interview on 3/24/2025 at 11:05 AM, R108 stated she had a PU on her right foot on the ball of her foot. R108 removed her shoe and sock and allowed observation of the wound. The wound observed to be approximately a 2 x 2 cm scab and was unstageable (U). R108 stated that it was very painful. R108 also stated that she had another PU on her buttock, but stated she did not know when that one occurred. R108 was in her wheelchair during the interview and observed to attend to her own needs at will. R108 stated that she was able to use the bathroom if someone would assist her. In an interview and observation on 3/24/2025 at 11:13 AM, R108 had a catheter. R108 stated she stated did not know why she had a catheter, and she wanted it taken out. R108 said she had asked to have it removed but staff did not provide an answer as to when the catheter could come out. R108 stated she used the bathroom before staff placed the catheter and wanted to use the bathroom now to urinate and have bowel movements. R108 stated it was humiliating because she also had to wear what R108 called a diaper. Review of a Physician's order dated 2/3/2025, revealed an order for R108 to have a catheter placed related to an unstageable sacral wound, and end of life care. In another interview on 3/27/2025 at 12:26 AM, R108 stated again that she wanted the catheter out, and again said she asked Hospice about having it removed but received no real answer. Record review of R108's skin assessments that staff provided upon request revealed that the only skin assessments that staff conducted were on 2/5, 2/12, 2/27, 3/6, 3/13, and 3/20/2025, and the skin assessments did not identify or have documented any new wounds. Review of a Clinically Unavoidable Pressure Injury-V2 document revealed the facility assessed R108 to have a PU that was a DTI (deep tissue injury-appears as a purple/dark area on the skin that is not open) on her right foot and sacrum (buttocks area). The document revealed the DTI developed on 1/15/2025 and was determined to be unavoidable on 2/6/2025, 22 days later. The document revealed that R108's PU's were clinically unavoidable due to malnutrition, terminal diagnosis, poor food intake, and revealed R108's Braden score (score that determines the likelihood of skin breakdown) was an 11 (indicating high risk), and that Hospice services were providing cares for R108. Further review of the Clinically Unavoidable Pressure Injury-V2 document revealed that the interventions in place were barrier cream (cream placed on the skin), a pressure-reducing mattress on the bed, off-loading bony prominences (not allowing bone areas of the body to rest on the bed mattress), and other positioning devices. However, interventions that were listed on the document but were not checked as interventions in place were, Turn q (every) 1 hour, turn q 2 hours, RD (Registered Dietician) consult, Draw-sheet (used to pull resident up in bed to prevent friction), Trapeze (a bar above the resident's bed so resident can move self around), Pressure Reducing Equipment in Chair, Resident/Guest/Family Education, and would also address R108's clinical reasons for skin breakdown. Review of a Skin & Wound Evaluation V7.0 dated 1/28/2025 revealed R108 to have a pressure ulcer to her sacrum on 1/15/2025. The document showed the pressure ulcer to be unstageable and acquired at the facility. The evaluation revealed that the wound was 50% filled with granulation tissue (new good tissue that forms on the wound during the healing process), and 50% filled with slough (dead dark tissue). The wound measured 7.2 x 3.3 x 2.9 x 1.2 cm (area, length, width, and depth) with 5.0 am of undermining (an unattached area under the edges of the wound). The evaluation revealed the PU was deteriorating. Upon review of the photograph of the pressure ulcer dated 1/28/2025, to R108's sacrum it was revealed that the wound was a stage IV (4) wound with undermining, red edges, and a visible wound bed at the deepest point. Record review of a Skin & Wound Evaluation V7.0 dated 2/5/2025, revealed R108 had a documented PU to be unstageable due to slough and/or eschar (hard, dry, black or brown dead tissue scab like covering) on her sacrum. The evaluation revealed the wound was a facility acquired. The exact date of the wound was 1/15/2025. The wound measured 8.9 x 3.5 x 3.0 x 1.5 cm with 2.4 cm of undermining. The evaluation also revealed that the wound was 80% filled with granulation, with 20% filled with slough. The evaluation revealed that the interventions were incontinence management, moisture control, nutrition supplementation, and repositioning devices. Review of the photograph of R108's wound to her sacrum dated 2/5/2025 revealed a stage IV wound that was not unstageable due to the deepest part of the wound bed was clearly visible and not obscured. The wound bed revealed beefy red exposed muscle, and some slough present. Review of a Skin & Wound Evaluation V7.0 dated 3/26/2025, revealed staff continued to document R108's sacral PU as an unstageable wound. The evaluation did not have any dressing treatment documented. Review of the photograph of R108's sacral wound dated 3/26/2025, revealed a stage IV beefy red wound bed that was visible at the deepest depth, and therefore was stageable. Record review of R108's care plans revealed a care plan was in place that had a Focus of (R108) is at risk for impaired skin integrity related to fragile skin. I (R108) am on Hospice. I frequently refuse to reposition and prefer to lay on my left side, dated 1/31/2025, and last revised on 2/25/2025. The care plan did not have an intervention that addressed R108's refusals to reposition, nor did the care plan have an intervention listed on how to approach or encourage R108 when R108 refused to reposition due to impaired skin integrity. The care plan also did not list an intervention on coordinating care with Hospice regarding R108's increased risk for impaired skin integrity. Review of a care plan dated 1/15/2025 and revised on 3/13/2025, revealed R108 have a Focus area of (R108) has an Actual impairment to skin integrity r/t (related to) 1) unstageable pressure injury to medical sacrum. 2) R (right) plantar (sole of the foot) foot DTI. The Focus also revealed, (R108) frequently refuse to reposition and prefer to lay on my left side. Further review of the care plan revealed that there were no interventions listed on R108's Actual impairment to skin integrity care plan that addressed R108's refusals to reposition and preferences to lay on her left side. There were no interventions to re-approach, attempt to understand R108's comfort levels, pain levels, no interventions to turn or reposition R108, no interventions to offer R108 to get out of bed to chair, no interventions to prop R108 off of bony prominences to relieve pressure areas, and there were no interventions to coordinate with Hospice any needs R108 may have with her pressure ulcers and interventions. In an observation and interview on 3/27/2025 at 12:26 PM, Licensed Practical Nurse (LPN) K, who was the wound care nurse, performed wound care on R108's sacral wound. The wound was a stage IV PU, with a beefy red wound bed not obscured by any slough/eschar or granulation tissue. Upon asking what stage the PU was, LPN K stated R108's sacral wound was unstageable. LPN K said the PU was unstageable because that was the highest stage the wound was ever staged at, so that was the stage the wound would always be staged as. Per the Resident Assessment Instrument (RAI) manual 3.0 Version 1.1.9.1 dated October 2024, on page M-24, pressure ulcers covered with slough and/or eschar with a wound bed that cannot be visualized, should be coded (or identified) as unstageable because the true anatomic depth of the soft tissue damage cannot be determined. The manual further revealed that when enough slough and/or eschar is removed to expose the anatomic depth of soft tissue damage involved, the stage of the can then be determined. In an interview on 3/27/2025 at 3:01 PM, LPN K stated that she did not perform a root cause analysis to determine why R101 and R108 had developed PU's at the facility. LPN K stated that she talks about the resident's wounds and only verbally discusses resident's wounds in the Quality Assurance Performance Improvement (QAPI) meetings, but stated she had no documentation of that. LPN K stated that no meetings occurred with Director of Nursing (DON) B to discuss PU's, the root causes, or to put a plan into place for further prevention of PU's. In a further interview with Registered Nurse (RN) M, who was also a wound care nurse, RN M stated that she learned that whatever stage a wound was staged at for the very first time was where the wound was to always be stage at up until the wound closed. In an interview on 3/31/2025 at 2:06 PM, DON B stated that with the wounds she just assists LPN K and RN M in getting the equipment needed for residents with wounds, such as mattresses, cushions, and to coordinate with the dietician or therapy. DON B stated that she met weekly with LPN K and RN M to go over the resident's wounds, and that was when she would find out what equipment or coordination, they needed from her. DON B stated she had not performed any audits, root cause analysis or put a plan into place to ensure healing of current wounds or prevent the occurrence of further wounds.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake: MI00145821 Based on observation, interview and record review the facility failed to: 1.) ensure the safety, 2.) implement care-planned interventions, 3.) ensure that those interventions were functional and in place; and 4.) provide timely assessment and treatment for 1 of 3 sampled residents (R104) reviewed for supervision from a total sample of 4 residents, resulting in actual harm for R104's fall with left femur fracture on 6/7/24, delay in assessment, pain and transfer to the hospital. Findings include: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R104 was a [AGE] year old female admitted to the facility on [DATE], with re-admission post hospital transfer 6/11/24 following displaced transverse fracture left femur with other diagnoses that included cerebral vascular accident with left side paralysis, spastic hemiplegia left side, hypertension (high blood pressure), lupus, cervical disc disorder, anxiety, and depression. The MDS reflected R104 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact. Review of the complaint intake reflected concerns that included resident supervision, staff assistance with activities of daily living, and monitoring and assessing residents. Review of the facility provided Resident Matrix, dated 7/30/24, reflected R104 had a fall with major injury. Review of R104 Nursing Progress Notes, dated 6/7/2024 at 6:00 p.m., reflected, Writer and charge nurse alerted by CNA that resident slid out of her shower chair with the assistance of CNA. Resident was assisted to the floor, next to the right side of her bed, shower chair was near the foot of the bed. Resident assisted back into her shower chair, shower provided. When resident was placed back into her bed she was c/o pain in left knee and left elbow. Left knee swollen and left antecubital swollen. Resident stated she began to slide out of her shower chair when she leaned forward to look at vaginal discharge and CNA assisted her to the floor. Resident states her left knee began hurting when she was placed back into her bed from the shower chair .NP notified .Resident's emergency contact present at bedside .DON .notified. Xray ordered of left knee and left elbow due to pain/ swelling. Neuro checks x 24 hours. Review of R104 Nursing Progress Note, dated 6/11/2024 3:07 p.m., reflected, patient returned 1410 via [named transport] on stretcher alert to baseline and in no apparent distress. patient seen and treated at [named hospital] s/p fall for left distal femur fracture. spouse, CN and physician notified. no med changes. full code. general diet. Review of R104 Nursing Summary Note, dated 6/11/2024 3:36 p.m., reflected, patient returned from hospital s/p fall with dx left distal femur fx. currently she denies pain and she has a full leg immobilizer in place. Review of R104 hospital Discharge summary, dated [DATE], reflected principle diagnosis included closed bicondylar fracture of distal femur. During an observation and interview on 7/31/24 at 1:00 p.m., R104 was laying in bed and appeared calm pleasant and able to answer questions without difficulty. R104 reported had a fall 6/7/24 in room after staff assisted her to shower chair from her bed with one person assist pivot transfer. R104 reported aid was unable to position R104 far enough back in shower chair and stepped to doorway to get assistance from other staff. R104 reported she started to slip forward out of shower chair and fell on left side. R104 reported two staff members positioned R104 back in shower chair and completed the shower and the same aid transferred R104 from the shower chair to bed with pivot transfer. R104 reported developed left knee pain that was not controlled by medication and was transferred to the hospital. R104 reported she fractured left upper leg and chose not to have surgical intervention and was discharged back to facility after couple of days with immobilizer. R104 reported had fear of showers since fall but would prefer showers over bed baths. R104 reported has been getting bed baths and reported forgot she could use shower bed instead of chair and reported staff had not offered shower bed. R104 reported after fall remained in bed because of non-removeable immobillizer and pain for several weeks. R104 reported prior to fall had generalized pain controled with once daily medications at 5/10 pain level. R104 reported after the fall with fracture during staff assisted transfer had increased pain with need for two to three doses of narcotic pain medications daily with pain up to 8/10 on scale with 10 being worst pain. Reported also now has constipation. R104 reported is hesitant to get out of bed related to fear of another fall. Request for all of R104 incident/accident reports for past three months with complete investigation send by email request on 7/31/24 at 12:49 p.m. Received one Incident/Accident(IA) Report for R104 for the past three months, dated 6/7/24 at 6:00 p.m., on 7/31/24 at 2:20 p.m., with no evidence of investigation noted. The IA was titled, Slid out of Wheelchair and included description, Writer and charge nurse alerted by CNA that resident slid out of her shower chair with the assistance of CNA. Resident was assisted to the floor, next to the right side of her bed, shower chair was near the foot of the bed. Resident assisted back into her shower chair, shower provided. When resident was placed back into her bed she was c/o pain in left knee and left elbow. Left knee swollen and left antecubital swollen. The report reflected injuries observed at the time of the incident included hematoma to left knee and antecubital(elbow) area. Continued review of the report reflected R104 was alert and oriented with predisposing physiological factors that included mood/behavior, weakness/fainted, and gait imbalance. Continued review reflected incomplete form as evidenced by no documentation under predisposing situation factors or predisposing environmental factors. Review of the provided Post Fall Evaluation reflected R104 had an observed fall on 6/7/24 at 6:00 p.m. The Post Fall Evaluation reflected R104 was receiving assistance from staff per care plan. The evaluation included, Re-Creation of Last 3 Hours Before Fall, with instructions, Below, the primary nursing assistant who observed and/or assisted the guest/resident during the three hours prior to the fall was interviewed and described the life of the guest/resident before the fall . The information reflected, Pt[patient] taken to bathroom in shower chair and showered. Staff turned for moment to get supplies. Pt leaned forward and began to fall. Staff intervened and lowered patient to floor. The evaluation reflected fall huddle with no changes in fall details and root cause of fall included environmental factors/items out of reach. The Post Fall Evaluation was completed by LPN C and signed by the Interdisciplinary team. Review of R104 Care Plans, dated 10/20/23, reflected, I am at risk for fall related injury and falls R/T: Hx of CVA with L. sided weakness, chronic back pain, Lupus, Osteoarthritis, recent L. distal closed Femur Fracture with routine healing, Non ambulatory status Date Initiated: 06/11/2024 Created on: 10/20/2023 .Hoyer Lift with 2 assists for all transfers. Date Initiated: 10/27/2023 . Review of R104 Medication Administration Record(MAR), dated 6/1/24 through 6/30/24, reflected once daily use of Oxycodone 10mg 6/1/24 through 6/7/24 with pain levels less than 6/10 on scale. Continued review of MAR reflected R104 pain level 8/10 on pain scale of several occasions with use of Oxycodone 10mg two to three times daily after return from hospital on 6/11/24 post fall with fracture during staff assisted transfer without following Care Planned interventions for transfer status. Review of the Functional Abilities and Goals assessment, dated 4/23/24 and 6/12/24, reflected decline in overall activities of daily living including eating, oral hygiene, toileting, bathing, dressing, and personal hygiene. The assessment reflected decline in overall mobility. The decline was a direct result of R104's fall with fracture during staff assisted transfer without following Care planned safetly interventions on 6/7/24. Received witness statements from R104 fall on 6/7/24, after second request for complete investigation, on 7/31/24 at 3:07 p.m. Review of the, Quality Assurance Interview Summary, with first interview on document, dated 6/13/24 (six days after fall), for R104. The interview reflected, CNA sat me on the shower chair and walked away to get help because wasn't fully sitting back. Toppled to the floor onto left side. CNA came back with help to put me back in shower chair. Took me into shower then was helped back to bed. Pain started to left knee after back in bed. Review of the next interview for CNA D, dated 6/10/24 (three days after fall), reflected, Went in room to get [named R104] ready for a shower. Transferred [named R104] to the shower chair. She wasn't fully sitting back in chair. Went behind chair and tried to pull resident back in chair under her arms. [named R104] didn't fully scoot back into chair. Told resident to stay here and went to doorway to get co-worker to help. When turned around to head back in room seen [named R104] leaning forward. Ran over to resident and grabbed resident under her arms from behind as she was falling forward lowering [named R104] to the floor. She was laying on her left side with legs bent up and under her. Co-worker [named CNA J] entered the room and assisted with getting resident back into the shower chair. Took resident into shower room and gave her a shower. After shower assisted [named R104] back to bed. Little while later [named R104] began complaining of pain to left knee. While placing a pillow under her knee noticed her knee was swollen. Nurse notified of pain and that resident had been lowered to the floor. Review of the next interview for CNA J, dated 6/10/24, reflected, Entered doorway after [named CNA D] called out for help with [named R104]. Upon entering room resident noted to be laying on her left side with legs bent, shower chair positioned at the head of the resident. Assisted [named CNA D] with picking [named R104] up off the floor and getting her back in shower chair then left the room. Review of the next witness statement on the page for LPN C, dated 6/11/24(five days after fall), reflected, [named R104] husband came out in hallway stating [named R104] was having pain. Went into speak with [named R104]. She told me she had ended up on the floor. Assessed resident noted swelling to left knee. Medication provided for pain, nurse manager [named Nurse Manager K] notified of fall. X-rays ordered. Review of the Neurological Assessment, dated 6/7/24 at 6:00 p.m., reflected the assessments 6:00 p.m. through 8:15 p.m. with no signature for day shift staff 6/7/24. The form appeared to have same writing for 6/7/24 for both day shift and night shift assessments. Review of R104 einteract Change of Condition Evaluation, dated 6/8/24 3:48 p.m., reflected R104 fall and uncontrolled pain with note that reflected, resident complained of pain 10/10 not relieved by Oxy or Tylenol. resident requested to go to the hospital. On call provider notified. DON notified. Husband was here and also requested resident go to the hospital. resident had a fall at 1800 on 06/07/2024. During an interview on 8/1/24 at 9:37 a.m., Licensed Practical Nurse(LPN) C reported was R104 nurse on 6/7/24. LPN D reported was first aware of R104 fall on 6/7/24 when R104's husband came to LPN C about two hours after the fall around 6:00 p.m. and reported R104 was having pain related to fall earlier that day. LPN C reported spoke with R104 and completed assessment and was informed by R104 had fall during a staff assisted transfer prior to shower that day out of shower chair and was currently having pain to left leg. LPN C reported then spoke Certified Nurse Aid(CNA) D who informed LPN C that prior to R104 shower that day around 4:00 p.m. R104 slid out of shower chair and CNA D lowered R104 to the floor. LPN C reported CNA D reported R104 was placed back in shower chair with another staff assist, shower completed and R104 was transferred back to bed and then complained of pain to left leg. LPN C reported thought R104 was required hoyer lift assistance with transfers at the time of the fall. LPN C reported staff are expected to follow transfer status according to care plan and [NAME]. LPN C reported R104 had swelling in left knee area and complained of pain in left knee and hip area. During the interview on 8/1/24 at 9:37am, LPN C reported did not complete any neurological assessments for R104 after reported fall and was not aware of R104 fall until about two hours after event. LPN C reported staff are expected to notify nurse of all falls and not to move residents until assessed by nurse. During an interview on 8/1/24 at 9:51 a.m., CNA E reported facility process for resident falls required staff to assure resident is safe, notify nurse immediately if fall is suspected or witnessed and nurse to complete assessment prior to moving resident. CNA E reported aware of resident transfer status by reviewing the [NAME]. CNA E reported was not present for R104 fall on 6/7/24, however all staff received education after fall related to importance of following [NAME] interventions including transfer status and definitions of falls and fall policy. CNA E reported staff educated to report all falls to nurse immediately and not to move resident. During an interview on 8/1/24 at 10:03 a.m., CNA F reported had worked at the facility for over seven years and reported aware of resident needs by review of [NAME] including transfer status. CNA F reported if resident fall is suspected or observed staff expected to make sure resident is safe, notify nurse and not to move resident for any reason prior to notification of the nurse. During an interview and record review on 8/1/24 at 10:15 a.m., LPN G reported would expect staff to report all falls to her immediately prior to moving residents. LPN G reported all staff received fall re-education within past 2 months and resident alerts were updated in binder observed at nurse stations that included residents at risk for falls. LPN G reported staff expected to follow resident [NAME] including transfer status needs During an interview on 8/1/24 at 10:20 a.m., CNA H reported had worked at the facility for over 9 years. CNA H reported staff expected to report to nurse immediately if fall suspected or observed and not to move resident and follow resident [NAME] care interventions. During an interview on 8/1/24 at 10:46 a.m., NHA A was asked (for the third time) if this surveyor had been provided with R104 complete fall investigation from 7/6/24. NHA A stated, No, we have a past non-compliance. Surveyor again requested complete investigation first requested 7/31/24 at 12:39 p.m. NHA A reported completed staff education along with past survey that exited 6/5/24 with concerns with fall supervision. This surveyor requested residents with falls in from June and July 2024. During an interview and record review on 8/1/24 at 11:01 a.m., NHA A reported had not provided this surveyor with the supporting documentation of compliance yet because she was attempting to combine the recent Plan of Correction, with exit date 6/5/24 and requested Past Non-Compliance documents. NHA A reported was informed by corporate staff could provide named resident accident reports. Residents with facility falls, dated 6/1/24 through 7/19/24, reflected 38 resident falls at the facility. During a telephone interview on 8/1/24 at 11:07 a.m., CNA D reported was R104 CNA on 6/7/24 at the time of the fall between 4:00 p.m and 5:00 p.m. and had worked a double shift that day. CNA D verified witness statement and reported transferred R104 from the bed the the shower chair with one person assistance with pivot transfer. CNA D reported was unable to position R104 in shower chair correctly on own and went to bedroom door and asked CNA J to assist. CNA D reported turned around saw R104 lean foreword and ran toward R104 because she was coming out of chair and caught her under her arms and lowered R104 to floor. CNA D reported she assessed R104 by asking if she had pain and observing and CNA J assisted her transfer R104 off the floor back into the wheelchair with two person manual assist. CNA D reported proceeded to take R104 to shower room and completed shower. CNA D then reported transferred R104 from the shower chair into bed with one person pivot assist. CNA D reported was approach by LPN C who asked what had happened with R104. CNA D reported after R104 fall and shower was called to Nursing Home Administrator (NHA) A office for another resident investigation and was met by LPN C when returned to the unit to report R104 fall around 5:00 p.m. CNA D reported was suspended pending investigation. CNA D reported knows resident care needs including transfer status by asking residents and staff report and [NAME]. CNA D reported had been transferring R104 with one person assist for several weeks. CNA D reported should have reviewed the [NAME] and used hoyer lift per the [NAME]. CNA D' reported did not think at first R104 fall on 6/7/24 was an actual fall because she was lowered to the floor so did not notify nurse prior to transferring R104 from the floor back to the shower chair with 2 person physical assist. CNA D reported was informed was terminated over a week later. During an interview and record review on 8/1/24 at 12:15 p.m., NHA A reported each fall was discussed at Quality Assurance and Performance Improvement (QAPI) meetings on 6/20/24 and 7/30/24. Review of the meeting notes, dated 6/20/24, reflected no evidence R104 fall concerns were discussed. NHA A reported completed Past Non-Compliance for R104 fall because fall was not immediately reported to the nurse and CNA staff moved resident post fall prior to nurse assessment. NHA A reported fall trends discussed at QA meetings and verified R104 fall on 6/7/24 was not issue of trending. During an interview on 8/1/24 at 12:30 p.m., Director of Nursing (DON) B reported was unable to verifiy that falls were reviewed at 6/20/24 QAPI meeting. DON B verified neurological checks completed and appeared all same writing covering more than one shift. DON B verified 6/7/24 day nurse did not sign it and reported was unsure who completed form. During an interview on 8/1/24 at 12:45 p.m., Registered Nurse (RN) K reported completed R104 incident accident report on 6/7/24 to assist floor nurse related to busy day. RN K reported was informed by CNA D that R104 was lowered to the floor and did not consider that a fall. RN K reported any change in elevation was fall and reported R104 fall should have been reported immediately to the nurse. During a telephone interview on 8/1/24 at 2:58 p.m., LPN L report worked 6/7/24 on R104 hall after fall on night shift that started at 6:45 P.m. Received in report that R104 had fallen during the day and the nurse had not been notified until around 6:00 p.m. LPN L reported when husband arrived to the facility requested resident be sent to the hospital related to unrelieved left leg pain post fall. LPN L reported assessed R104 who continued to have elevated pain in left leg and both husband and R104 requested to be transferred to the hospital. LPN L reported called 911 services, DON B and on call provider and resident sent out. LPN L reported day nurse completed one set of neurological assessments and she completed remaining until transferred out and reported she added day shift assessment to new form. During an interview and record review on 8/1/24 at 4:10 p.m., DON B reported R104 fall on 6/7/24 was not reported immediately and when reported and R104 complained of elevated pain sent to the hospital. DON B reported started asking everyone after notified R104 had left femur fracture. DON B reported would expect staff to follow [NAME] including transfer status and call nurse prior to moving resident off the floor. DON B reported the facility completed investigation that included final summary and verified was part of R104 fall investigation. Informed DON B this surveyor had not yet received R104 fall summary for 6/7/24 after three requests from to the NHA A for the complete investigation. DON B left the area and returned with a typed fall summary for R104 dated 6/7/24.(over 24 hours after request for complete investigation). DON B reported were unable to determine when fall occurred even though documented on incident/accident report at 6:00 p.m. DON B reported knows fall occurred earlier in day and reported R104 shower was documented as given at 2:58 p.m.(not part of investigation). DON B reported wound expect staff to follow facility Fall Policy. DON B verified the Post Fall investigation was completed by the day nurse on 6/7/24 who was confused about where the fall took place and verified had indicated was in shower room but did occur in resident room. Continued review of R104 fall summary included, In Conclusion: Action Taken: Resident was assessed, The resident MD and RP were notified of the resident occurrence, X-ray ordered, Pain Medication offered, Care plan updated. No mention that R104 Care Plan and [NAME] were not followed related transfer status of Hoyer lift of three staff assisted transfers and no mention of staff moving resident post fall without notifying nurse or delay in notification. As a direct result of R104 staff assisted transfer with fall and fracture on 6/7/24 R104 has increased pain and need for increase in pain medications with increased likelihood of constipation, decrease in activity related to fear of transfers and overall increased likelihood of worsening depressing. Review of the Fall Management Policy, dated 9/22/23, reflected, Fall Defined: Fall refers to unintentionally coming to rest on the ground .When a fall occurs, the licensed nurse will evaluate the resident for injury. Do not move the individual until he/she had been examined by a nurse. The first responder (first person to identify that the resident has fallen) will summon a nurse after ensuring the resident is safe, and then ask the resident what they were attempting to do. A hall huddle will be held to determine the root cause of the fall .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review facility failed to: 1) accurately assess, monitor, treat and prevent the development of pressure ulcers consistent with professional standards of practice to prevent avoidable pressure ulcers; and 2) implement care-planned and non-care-planned interventions for one Resident (R38) of three reviewed for pressure ulcers, resulting in facility acquired stage 4(full thickness skin and tissue loss), and the increased likelihood for delayed wound healing and/or worsening of wounds and overall deterioration in health status. Findings include: Resident #38(R38) Review of the Face Sheet and Minimum Data Set (MDS) with ARD date [DATE], reflected R38 was a [AGE] year old female admitted to the facility on [DATE] related to chronic obstructive pulmonary disease, stage 4 facility acquired pressure ulcer with chronic osteomyelitis, hypertension (high blood pressure), diabetes mellitus, cerebral vascular infarction with left non-dominant hemiparesis, anxiety, and depression. The MDS reflected R38 had a BIM (assessment tool) which reflected moderately impaired. The MDS assessment reflected R38 had no behaviors related to rejection of care. During an observation and interview on [DATE] at 11:03 AM, R38 was observed laying flat on back in bed with call light out of reach, draped over wall unit, about 3 feet from R38 reach. R38 appeared able to answer questions without difficulty. R38 reported wanted to get out of bed because she was not comfortable and could not get staff attention. R38 reported staff was last in room around at breakfast time but not since. When R38 quarried, how she got staff attention, R38 reported by yelling. R38 reported had wound on bottom and staff do not reposition her every two hours. During an interview on [DATE] at 1:45 PM, Licensed Practical Nurse (LPN) QQ reported was R38 nurse. LPN QQ reported wound rounds were every Tuesday with Nurse Practitioner and Assistant Director of Nursing(ADON) I. LPN QQ reported R38's daily wound treatments had been completed that day between 7:00am and 8:00am. LPN QQ reported floor nurses complete daily wound treatments on other days. Review of R38's Provider Note, dated [DATE], reflected, There is improvement in the depth of the tunnel this week. Continue treatment with Dakins soaked packing strip. Wound shows slight improvement. Continue current treatment .Stage 4 sacral ulcer -this wound measures 0.5 x 0.4 cm with a depth of 3.3 cm. There is a 4.8 cm tunnel at 10 o'clock. This is a full thickness wound. There is a moderate amount of serosangeous drainage from this area. Wound bed consists of 100% granulation tissue. Edges are attached and there is no slough, eschar, undermining, or odor. Surrounding tissue is fragile but without redness,warmth, swelling, pain, induration or sign of infection. This area can be cleaned daily and PRN if dressing becomes soiled or dislodged with wound cleanser and treated with Dakins soaked packing strip for 14 days packed to the depth of the tunnel. Wound should be covered with a border gauze .Continue supportive care. Patient should be repositioned frequently. Patient should be supported with pillows or wedges to prevent pressure on wound. Continue preventative measures and pressure relief. Elevate bilateral lower extremities, float heels, apply soft heel lift boots. Continue proper nutrition and hydration to support wound healing. Review of R38's Wound Clinic Consult Note, dated [DATE], reflected R38 was seen for debridement for chronic osteomyelitis of sacrum, stage 4 skin ulcer of sacral region. The consult note was date stamped as received by medical records [DATE]. The consult note reflected, Instructions Details .Wound 1 (Coccyx): In clinic and at facility wound management- wash wound with wound wash, triad cream or zinc oxide to all surrounding skin, ten pack wound with Aquacel Ag, cover with 4 fluffed 4x4 gauze and cover with 8x10 ABD pad .Follow up Appointment: 6 weeks with NP . Review of the facility Wound Care Provider Note, dated [DATE]. The Provider Note reflected, Stage 4 sacral ulcer -this wound measures 0.6 x 0.6 cm with a depth of 2.8 cm. There is a 5.0 cm tunnel at 10 o'clock. This is a full thickness wound. There is a moderate amount of serosangeous drainage from this area . Review of the facility Skin and Wound Evaluation, dated [DATE], reflected R38's had a facility acquired stage 4 pressure ulcer that was identified on [DATE] that measured 0.9cm length by 0.7cm width with 2.1cm depth with no tunneling. Review of the facility Wound Care Provider Note, dated [DATE], reflected, Wound is stable. Treatment was changed to Dakins soaked packing strip to reduce any possible bioburden in the wound tunnel to promote reduction in depth. Will continue this treatment an additional 7days and monitor progress .Stage 4 sacral ulcer -this wound measures 0.9 x 0.7 cm with a depth of 2.8 cm. There is a 6.3 cm tunnel at 11o'clock. This is a full thickness wound.There is a moderate amount of serosangeous drainage from this area. (wound decline compared to [DATE]). Review of the facility Skin and Wound Evaluation, dated [DATE], reflected R38 coccyx wound had tunnel that measured 5.2cm.(compared to one year later at 6.3cm on [DATE]). Review of R38's Physician Orders, dated [DATE] to current([DATE]), reflected, Irrigate sacrum with NS. Pat Dry. Dab with skin prep. Pack wound lightly with 1 continuous strip of Dakins moistened packing strip, Cover with border gauze every day shift for wound care. Continued review of the physician orders reflected no evidence of treatment order changes after R38's wound clinic visit on [DATE] with orders to change wound treatments. During an observation and interview on [DATE] at 12:27 PM, LPN G collected wound care supplies from the treatment cart including, opened, undated Dakins quarter solution with manufacture expiration date of 1/2024, skin prep, 1/2 pack strip, border gauze, 4x4 gauze, and normal saline. LPN G entered R38 room at 12:30 PM with treatment supplies. R38 was in bed and was observed to have a urine soaked brief in place with small amount of stool as well. LPN G pulled down the soiled brief and exposed R38's coccyx area with no old dressing noted. LPN G cleaned the wound area with normal saline. The wound appeared to have an opening about the diameter of a nickel and unable to visualize base of wound. LPN G packed expired Dakins solution lodofrm strip into tunnel area. R38 stated, ouch, ouch with packing. LPN G requested assistance from Certified Nurse Assistant, who had been assisting another resident, to removed scissors form LPN G uniform pocket. LPN G used scissors to trim packing strip to leave short tail. LPN G applied border gauze over wound after applying skin prep to peri wound. LPN G then removed soiled brief and cleaned stool from R38 and applied clean brief without wiping urine from skin. LPN G reported was unsure why R38 did not have a wound dressing in place and reported R38 had just returned to bed from the wheelchair prior to the dressing change and had been up in wheelchair since start of shift at 6:00a.m. LPN G reported CNA staff are expected to notify nurse of dressing becomes soiled during incontinence care so as need wound care can by performed. LPN G reported was no informed dressing had been removed since start of shift at 6:00a.m. During an interview on [DATE] 03:40 PM, Unit Manager LPN J unlocked the 200 hall treatment cart and verified Dakins solution, used for R38 wound care had a manufacture expiration date of 1/2024 and reported plan to discard and reported should have been disposed of prior to expiration date and not used for R38 wound treatment. Review of R38 Electronic Medical Record(EMR), dated [DATE] through current ([DATE]), reflected no evidence facility staff communicated with R38 provider related to wound clinic treatment orders changes dated [DATE]. Review of R38's wound Care Plan, dated [DATE], Administer treatments as ordered and observe effectiveness. Continued review of skin care plan reflected, Provide incontinence care as needed and apply moisture barrier cream/ointment per facility policy/orders . During an interview on observation on [DATE] at 12:26 PM, Central Supply staff Y reported Dakins solution disposed of in central supply [DATE] because were all expired and new order was placed and received shipment [DATE] for Dakins quarter strength solution. Observed several bottles on shelf. During an interview on [DATE] at 1:20 PM, Wound Nurse/Assistant Director of Nursing(WN) I reported would expect nursing staff to follow physician orders including for wound care. WN I reported would expect CNA staff to notify nurse of wound dressings become loose or soiled during incontinence care. WN I reported R38 wound healing had stalled and had show minimal changes over several weeks. WN I reported recent change in facility wound care provider with treatment changes and reported provider believes R38 needs surgical intervention. During a second interview on [DATE] 02:30 PM, WN I reported unsure when R38 was last seen by wound clinic. WN I reported would expect nurse on duty at the time of return from clinic to review visit notes and contact physician to review clinic orders and add to physician orders to EMR. WN I reported was not aware of R38 wound clinic recommendations to change treatment orders on [DATE] and verified had been scanned into medical record and verified orders were not updated per physician orders on [DATE]. WN I reported was not aware of R38's need for next follow up appointment until review of notes at that time. WN I reported facility Providers usually follows wound clinic recommendation and if not WN I would expect to see documentation reflected in the EMR. During an interview on [DATE] at 3:15 PM, Director of Nursing B reported would expect nurse on duty to review consult notes post wound clinic appointments, contact facility provider add orders to EMR. DON B reported would expect CNA staff to notify nurse immediately if wound dressing removed during incontinence care and nurse to replaced as needed. DON B reported would expect nurse to follow physician orders and verify treatment supplies were not expired prior to use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #79 Review of an admission Record revealed Resident #79 (R79) admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included pneumonitis due to inhalation of food and vomit, major depressive disorder, nausea, syncope and collapse, and difficulty in walking. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/5/24, reflected R79 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The Care Plan reflected R79 did not ambulate and required one person for bed mobility. On 02/26/24 at 10:33 AM, R79 was observed in bed resting. R79 stated that he had a fall when he resided in a different room at the facility. R79 reported that he tumbled off the bed during a brief change. He was sent out to the hospital a few hours later but reported aside from some knee pain, he was uninjured. Review of a Nursing Note dated 1/24/2024 at 09:55 revealed Pt (patient) had a fall from his bed this morning at approximately 0620 [AM] while turning in bed, performing peri-care. Pt fell out of bed onto his right side and is complaining of pain to his right side of forehead (with some bruising) right shoulder and arm area and right knee and leg. PRN (as needed) Tylenol administered at 0630 [AM] by nurse. NP (Nurse Practitioner) ordered transfer to ER for evaluation . Review of a Resident at Risk note dated 1/24/24 at 11:59 AM revealed Resident experienced a recent fall occurrence [sic] from bed during provision of care. It was noted that the mattress was ill fitted on the frame and as the resident turned he was unable to brace himself and slid off the side of the mattress. The resident will be provided with a wide bed with a secured mattress . In an interview on 03/05/24 at 10:22 AM, Licensed Practical Nurse (LPN) V confirmed she was working the night that R79 experienced the fall. LPN V reported that R79 was in bed being assisted with a brief change by Certified Nursing Assistant (CNA) W. When CNA W rolled R79 over in bed, R79 fell out of bed and onto the floor. LPN V stated that the mattress on the bed was not the correct size mattress for the bed frame. In an interview on 03/05/24 at 10:39 AM, CNA W confirmed that he was present at the time of the fall. CNA W stated that the mattress that R79 had on his bed was too big for his bed and the mattress hung over the bed frame about 4 inches on each side of the bed. CNA W was unaware that the mattress did not have a frame underneath of it to help support the weight of R79. CNA W also stated that the side of the bed frame had additional support on each side that maintenance can pull out and lock to give the mattress support, but this was not done, and CNA W was not aware. Review of the Incident Report dated 1/24/24 revealed Resident rolled out of bed onto the floor in between the bed and the bedside dresser While Aide was giving care. The resident landed on his right side. Resident Description: The resident stated that he rolled out of bed during a brief change onto the floor and that he hit his head on the table. Review of the Post Fall Evaluation dated 1/24/24 revealed that the intervention for R79's fall included providing R79 with a wide bed and a secured mattress. In an interview on 03/05/24 at 2:52 PM, Director of Nursing (DON) B reported that the fall was reviewed by the Interdisciplinary Team. Regarding R79's fall, the Certified Nursing Assistant was providing care and when the Certified Nursing Assistant turned R79, the mattress shifted and R79 fell onto the floor. When asked why the bed was not widened to support the mattress, DON B stated she was unsure what caused the bed frame malfunction. Resident #89 Review of an admission Record revealed Resident #89 (R89) admitted to the facility on [DATE] with diagnoses which included repeated falls, major depressive disorder, schizophrenia, and sensorineural hearing loss. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/19/24, reflected R89 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The Care Plan reflected R89 was independent with ambulation with the use of his walker. Review of the Medical Record revealed that R89 had a court appointed guardian. In a screening interview on 02/25/24 at 12:41 PM, R53 who was easily conversant and understood, reported that the code to the door used to exit the building to smoke cigarettes had recently been changed because some people learned the code and have been getting out. When queried, R53 further explained that occasionally a non-smoking resident had joined the group of residents that sat outside to smoke. One on occasion recently, the resident that does not smoke was outside and got up and walked off. R53 stated that there was an employee present at the time, but no one seemed to observe the resident walk off the facility property because staff panicked and ran off attempting to locate the resident. In an observation and interview on 02/25/24 at 12:15 PM, R89 was observed dressed appropriately and lying in bed. R89 was easily conversant and understood questioning. A wander guard was observed on his right ankle. R89 reported no concerns and explained that he enjoys walking the hall and attending activities. In a screening interview on 02/26/24 at 10:12 AM, R317 who was easily conversant and understood, reported that his roommate (R89) had informed him that he walked away from the facility recently. R317 stated that R89 had been struggling with ideas that a motorcycle gang was going to harm his family and R89 had been increasingly anxious about wanting to go home to deal with these matters. In an observation and interview on 02/28/24 at 09:54 AM, R89 was observed in his room having a conversation with a case manager from outside of the facility. Case manager (CM) AA was explaining the process of transitioning to the community to R89. R89 was overheard stating to CM AA that he did not belong here (the facility) and that he was trying to get out. R89 reported to CM AA that he was thrown in here and someone took all of his stuff. Upon exit of R89's room, CM AA explained that she was escorting R89 down to the social worker office to assist her in explaining the process of transitioning to the community. In an interview on 02/28/24 at 12:33 PM, a confidential staff member (SM) reported that she was aware that R89 had walked away from the facility. SM CC stated that R89 told her that his intention was to leave the facility and go live in the woods. In an interview on 02/28/24 at 1:07 PM, Registered Nurse (RN) S stated that she heard from other residents and staff members that R89 had unknowingly walked away from the facility. RN S stated that R89 did not have an updated care plan after the elopement and was unsure if he had a wander guard after the elopement. In an observation and interview on 02/28/24 at 2:09 PM, R89 was observed in his room, laying in bed. There was no longer a wander guard present on the ankle of R89. R89 reported that he had recently arrived back to the facility from an outing with activity staff members. When queried about walking off the facility property, R89 explained that he really wanted to go home. Prior to living at the facility, R89 stated he was independent, managed his own finances, did his own shopping, and mowed his own lawn. R89 was unsure how he got to the facility and why he had a guardian. R89 recalled the day that he walked off. He stated that he had gone outside with the smoking group to get some fresh air. R89 said he made it to the edge of the property and after realizing that no one had noticed, he started walking down the sidewalk. R89 recalled seeing cars slowing down as they went past him, however, a blonde lady from activities stopped and had him get into her vehicle. R89 stated that he was educated on leaving the facility and had to wear a tether (wander guard). When asked what happened to the wander guard, R89 explained that it was removed yesterday. A telephone call was placed to the guardian of R89 but was not returned. In an interview 02/28/24 at 02:19 PM, Certified Nursing Assistant (CNA) EE reported that she had heard that R89 had eloped from the facility and that staffing had received education regarding the incident. Review of the most recent Elopement Risk assessment dated [DATE] reflected that R89 was categorized as no risk for elopement. Review of R89's Care Plan revealed no Care Plan for Elopement Risk. Review of the Physician Order's for R89 revealed no order for the wander guard. Review of the Elopement Book located behind the Nursing Desk of the unit that R89 resided on revealed that R89 was not listed as an elopement risk in the book. No Incident Reports were located for R89. Review of a Resident/Family Education Record dated 2/19/24 revealed that R89 received education from the Nursing Home Administrator regarding the Leave of Absence process. The Specific Education section of the form revealed talked with resident that if he wishes to leave the property, activity staff can assist him in arranging in outing in addition to going out with smoking group and additional time he requests to go outside. In an interview on 03/05/24 at 3:19 PM, Activities Aide (AA) Z reported she was working and present at the time when R89 walked away from the facility. AA Z stated that her and a coworker were taking the smoking group outside and R89 wanted to join. AA Z and the coworker were distributing smoking supplies and lighting cigarettes for the residents and when they looked up, R89 was gone. AA Z and the coworker stated, where is [R89] and they both went around the building to see if they could locate him, with no avail. AA Z stated that her co-worker got into her personal vehicle and exited the facility parking lot to find R89. R89 was located at a neighboring business a few doors down, got into the vehicle with the co-worker, and was returned to the facility. AA Z stated that the facility was re-educated after the incident and was stressed the importance of being careful when taking residents out of the building. A telephone call was placed to the co-worker and was not returned. In an interview on 03/05/24 at 2:59 PM, Director of Nursing (DON) B stated that residents are assessed quarterly to determine if they are an elopement risk. If the risk is present, interventions are implemented such as moving the resident to the secured unit, applying a wander guard bracelet, care planning to inform the staff, and adding the resident to the Elopement Book. Regarding the elopement for R89, DON B stated that she has heard that he was out in the smoking area with members of the activity department when he decided he wanted to go home, he felt the place was too restrictive. DON B stated that one of the activity staff members had gone out and retrieved him. Nuring Home Aminstrator A had a meeting with R89 and explained to him that he cannot walk off the property without going through the proper channels which including requesting permission from the guardian and following the leave of absence process. In an interview on 03/05/24 at 3:10 PM, Assistant Nursing Home Administrator stated that when R89 exited the property, it was not considered an elopement because staff had eyes on him the entire time. This citation pertains to intake MI00142988. Based on interview and record review, the facility failed to thoroughly supervise, assess and investigate incident and accidents in three of five residents reviewed for accidents (Resident #77, #79 & #89), resulting in a change of condition, transfer to the hospital followed by death (R77), and avoidable accident (Resident #79) and safety risks with elopement (Resident #89). Findings include: Resident #77 (R77) R77's admission Minimum Data Set (MDS) assessment dated [DATE], revealed he admitted to the nursing home on 2/09/24, had severely impaired cognition, difficulty with focusing attention, and disorganized thinking. The same MDS assessment indicated R77 did not wander or have any physical, verbal or other behavioral symptoms during the 7-day look-back period. Fall risk assessment dated [DATE] revealed R77 was at risk for falls. Progress note dated 2/20/24 at 9:33 PM indicated R77 would not sleep or stay in his room, he was wandering into other residents' rooms all night and even getting in bed with two female residents. The same note indicated R77 received Ativan for anxiety symptoms. R77's [NAME] care plan dated as of 2/24/24, indicated he required supervision or touching assistance of one helper with transfers. Incident report dated 2/24/24 at 5:44 PM indicated R77 had an unwitnessed fall at the bedside, observed lying down on the floor with his sheet, no injuries, vital signs stable. The same report did not indicate R77's responsible party was notified of the incident. Post Fall Evaluation dated 2/24/24 indicated the time of R77's fall was at 5:00 PM. The form instructed to check a blood sugar if the resident was diabetic, no blood sugar was checked and not applicable was checked; R77's diagnosis list in the electronic medical record (EMR) indicated he had type 2 diabetes mellitus. R77's EMR revealed his blood sugar was 280, on 2/25/24 at 4:51 AM and 4:53 AM, over 11 hours after the incident. The same form instructed to check orthostatic blood pressures if fall was within 5 feet of transfer surface; no orthostatic blood pressures were documented on the form or in his EMR. R77's February 2024 physician orders revealed orders for Seroquel (antipsychotic) medication for the diagnosis of depression and Lopressor for the diagnosis of high blood pressure. Drugs.com website indicated Seroquel and Lopressor could cause orthostatic hypotension (form of low blood pressure that occurred moving from sitting or standing positions and could cause dizziness). Licensed Practical Nurse (LPN) P was interviewed on 2/28/24 at 3:49 PM and stated she did not usually work on the dementia unit, where R77 lived, and was assigned to the unit on 2/24/24 on day shift for twelve hours. LPN P stated on 2/24/24 at 5:00 PM, a certified nurse assistant (CNA) reported R77 had been found lying on the floor in his room. LPN P stated when she went into R77's room, he was found in bed, and that his CNA had transferred him to his bed. LPN P stated R77 did not have injuries from his fall on 2/24/24 at 5:00 PM; R77 had an injury on his head that was observed prior to his fall, and he may have fallen prior to the start of her shift on 2/24/24. LPN P stated she had written the name of R77's roommate on the neurological assessment form, and then drawn a line through the roommate's name and printed R77's name above. The neurological assessment form was presented to this writer with white-out covering the roommates name on 2/28/24. LPN P stated she was confident that the neurological assessments were pertaining to R77 and not his roommate. CNA Q was interviewed on 3/05/24 at 8:43 AM and stated he did not usually work on day shift but had worked a split shift that day. CNA Q stated when R77 was observed on the floor, he looked like he had just laid down on the floor, on his back to sleep. CNA Q stated he took R77's vital signs and was assessed by the nurse after R77 was transferred into his bed. CNA Q stated R77's head wound looked old and there was no fresh bleeding. Director of Nursing (DON) B was interviewed on 3/05/24 at 9:31 AM and stated R77's fall was investigated by the interdisciplinary team (IDT) on 2/26/24. DON B stated the IDT doesn't always review residents that transfer to the hospital following a change of condition. DON B stated she did not know how or when R77 obtained the injury on the right side of his head and was not investigated. DON B stated she would expect staff to not move a resident from the floor until after the resident was assessed by a nurse. DON B was not able to confirm R77's family/responsible party were notified of the fall on 2/24/24. DON B stated she did not have an answer as to why vital signs/neurological assessment post fall were not included in the transfer notice or physician notification. DON B stated the IDT team did not discuss R77 getting into bed with female residents documented on 2/20/24; and confirmed behavior was not on R77's care plan. CNA R was interviewed on 3/05/24 at 9:53 AM and stated she worked on 2/24/24 and did not work on the dementia unit often. CNA R stated she did not recall R77 having an injury on his head but did recall he didn't eat much for dinner that evening. CNA R stated R77 had been observed prior to 2/24/24 getting into two other female residents' beds. CNA R stated prior to 2/24/24, one female resident started screaming at R77 to get out, and R77 was combative with staff when they attempted to re-direct him from the other residents' room. Social Worker (SW) D was interviewed on 3/05/24 at 12:15 PM and stated there was a period of time the IDT team were not having at risk meetings to address behaviors due to lack of staff. SW D stated she was not aware R77 had been combative when staff attempted to re-direct from other residents' rooms. CNA T was interviewed on 3/05/24 at 1:21 PM and stated she had noticed R77 had been wandering more just prior to his transfer to the hospital. CNA T stated she had heard R77 was combative with other staff. Activities Assistant (AA) U was interviewed on 3/05/24 at 2:55 PM and stated she worked on 2/24/24 from 9:30 AM to 6:00 PM. AA U stated she found R77 lying on his back, on the floor in his room, parallel with the bed that was near the door on 2/24/24 right before dinner. R77 had a plaid flannel shirt bundled up under his head. AA U stated she did not think R77 had an injury, but noted his breathing looked labored, he wasn't wearing his shirt and was using his upper chest muscles to breathe. AA U stated she reported to the CNA that R77 was on the floor and stepped out of the room after that. AA U stated she noted he slept a lot during the day. R77's Change of Condition form dated 2/24/24 at 5:50 PM revealed a question if the vital signs were the most recent vital signs taken, the form indicated yes; the temperature, pulse, respirations, and blood pressure was documented as obtained on 2/24/24 at 9:06 AM, approximately 8 hours prior to R77's fall. R77's oxygen saturation level was obtained on 2/23/24 at 12:27 PM. Neurological Assessment form dated 2/24/24 indicated R77's blood pressure at 5:00 PM was 124/78 following the incident and dropped to 95/60 at 11:45 PM. Progress Note dated 2/25/24 at 4:37 AM revealed R77 was lethargic, opened his eyes and mumbled. R77's color was dusky, blood saturation was 87 percent (%, normal greater than 95 %), respirations were at 20 breaths per minute and shallow, his blood pressure dropped to 93/60 at 3:40 AM. Oxygen per mask was initiated at four liters. Emergency Medical Services were called and arrived at the facility at 4:10 AM and transferred to the hospital at 4:20 AM. Transfer Form dated 2/25/24 at 4:48 AM revealed the reason for R77's transfer to the hospital was lethargy and change in vital signs. The same form indicated R77 had an abrasion with swelling and bruising on the right side of his forehead. R77's Emergency Services Evaluation dated 2/25/24 at 4:48 AM revealed triage chief concern was fall and trauma. Emergency services reported R77 fell on 2/24/24 around 4:00 to 5:00 PM and around 3:00 AM he was found down and unresponsive. Blood pressure was 70/40, had minimal respirations with oxygen saturation was 70 % on a non-rebreather mask. R77 had a Glasgow scale (neurological scale to measure consciousness, scoring of 3 to 15), score of 7; a score of 3 to 8 indicated a severe traumatic brain injury. R77 had a 1-centimeter (cm) abrasion to his right forehead and had a significant amount of vomitus in his throat. The same Emergency Services Evaluation dated 2/25/24 at 4:48 AM note indicated at triage R77's physical examination indicated he was largely unresponsive and critically ill appearing. R77 had a right forehead abrasion that appeared several days old with granulation tissue (development of new tissue and blood vessels in a wound during the healing process) and no active bleeding. Vomitus and blood were noted in R77's throat and his mucus membranes were dry. R77's heart rate was 122 (normal at rest 60 to 80 beats per minute), respirations were 44 (normal at rest 12 to 16 breaths per minute), and oxygen saturation was 85 %. The same document revealed R77 had a history of atrial fibrillation (A-Fib, irregular heartbeat) not on anticoagulation medication, diabetes, lung disease, dementia, and heart failure. Medical Decision-Making and Emergency Department course after sign out document, dated 2/25/24 revealed R77 was found to have a spleen laceration, pulmonary embolism (blood clot in both lungs) and significant aspiration pneumonia (food or liquid breathed into the lungs instead of swallowed). This presented a difficult situation where heparinizing (anticoagulation) for pulmonary embolism would cause potentially fatal bleeding from splenic laceration. The trauma team felt that R77 would not tolerate surgery to address his splenic laceration in the setting of his severe pulmonary embolism. After several discussions, family decided to make R77 comfort care, he was taken off of pressor support (medications to raise blood pressure and increase cardiac output) and expired shortly thereafter on 2/25/24 at 11:40 AM. Progress Note dated 2/26/24 at 10:32 AM revealed the interdisciplinary team (IDT) reviewed R77's incident from 2/24/24 at 5:00 PM and concluded R77 was impulsive with poor safety awareness and may had lost his balance or slipped from bed. The same note didn't address the origin of R77's head injury or recent behaviors. The same note didn't indicate R77 was observed lying next to his roommate's bed or that the activity aide that first observed R77 on the floor was interviewed. DON B was interviewed on 03/05/24 at 3:25 PM and stated she had not been able to determine how R77 injured his head and did not have any additional information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pain management service of Botox injections in one of three residents (Resident #317) reviewed for pain, resulting in unrelieved pain. Findings include: Review of an admission Record revealed Resident #317 (R317) admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included fracture of neck, traumatic subarachnoid hemorrhage with loss of consciousness, need for assistance with personal care, disorder of the autonomic nervous system, and cellulitis of toe. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/9/23, reflected R317 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The Care Plan reflected R317 was dependent on staff for all activities of daily living. In an observation and interview on 02/25/24 at 12:15 PM, R317 was observed in bed dressed in a gown. R317's hands and wrists were exposed which revealed to be severely contracted. R317's left wrist was extended at an uncomfortable appearing angle. When queried if R317 has any pain from his bilateral hand and wrist contractures, R317 stated that he has spasms in his hands and wrist which causes him to have severe pain. R317 described it as his brain was telling him to move his hands but when he tries, they spasm out of control. R317 denied wearing braces or having any regular restorative nursing services to assist with his range of motion for his hands and wrist. R317 stated that his range of motion in his hands used to be better but since not having any services, the function in both limbs declined. R317 reported that he was followed by outside services for the management of his contractures and that he was prescribed pain medication and muscle relaxers to aid in pain relief. Review of the Physician Order set revealed that R317 was prescribed medication for pain control and was regularly receiving the prescribed medication. Review of a Progress Note dated 11/22/2023 at 00:00 revealed R317 was seen my Physical Medicine for rehabilitation for his spasms and pain. R317 was advised to have a Botox injection on both hands for spasm. Review of a Progress Note dated 12/5/2023 at 00:00 revealed R317 was seen by physiatrist for his muscle spasm in the wrist drop, was recommended to wear the hand braces and also schedule baclofen (used to treat muscle spasms) 3 times a day. We will continue monitor his spasm conditions . Review of a History and Physical Note dated 2/20/2024 at 00:00 revealed that his feet are having quite a bit of pain as well as his left wrist contracture area. Will change as needed Tylenol to schedule 650 mg [milligram] every six hours along with tramadol (pain reliever) one tablet every six hours . patient was quite irritable in his mood. Patient said he was having seven out of 10 pain in his left wrist at or above the same in his right . Review of an After Visit Summary dated 2/20/24 revealed R317 had an upcoming appoint on 2/21/24 at 10:00 AM at a local physical medicine rehabilitation center for the Botox injections to assist with his pain relief. The Appointment Book behind the nurses station on the unit R317 resided on was observed on 3/5/24 at 10:01 AM. Appointment dates ranged from current back to November 2023. There was no appointment for R317 in the appointment book for 2/21/24. In an interview on 3/05/24 at 10:09 AM, Licensed Practical Nurse E confirmed he was aware of R317 care needs. When queried if R317 had attended his appointment for Botox injections, LPN E was unsure but stated R317 would know if asked. In an observation and interview on 3/05/24 at 10:59 AM, R317 was seen resting in bed. R317 stated that he was currently experiencing pain in hands and wrist and stated that he had not gone out to any appointments recently and had not received the Botox injections. In an interview on 03/05/24 01:51 PM, Medical Records/Appointment Scheduler employee (MR) H stated that she was not aware of R317 going out to any appointments in the month of February and did not have him on the list for any future schedule appointments or appointment requests. In an interview on 03/05/24 at 2:59 PM, Director of Nursing (DON) B stated that she was unsure if R317 had received the Botox injections and would follow up regarding any upcoming appointments for R317. At the time of survey exit, no information was provided regarding R317's Botox injections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #21 (R21): R21 was an eighty-nine-year-old admitted to facility 2/18/20 with diagnoses including major depressive disorder, anxiety disorder, and unspecified dementia. Review of Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/18/22 revealed Brief Interview for Mental Status (BIMS) score of three (severely impaired cognition). Section G of MDS revealed that R21 required limited assist of one for bed mobility, transfers, and toileting. Section H of MDS reflected that R21 was frequently incontinent of bladder and always incontinent of bowel. Resident # 466 (R466): R466 was an eighty-two-year-old initially admitted to facility 3/23/22 and readmitted on [DATE] with diagnoses including Alzheimer's disease and major depressive disorder. Review of Minimum Date Set (MDS) with an Assessment Reference Date (ARD) of 9/24/22 revealed that resident was usually understood and understands with Brief Interview for Mental Status (BIMS) score of three (severely impaired cognition). Section D of MDS reflected Resident Mood Interview (PHQ-9) score of zero (no depression). Section E, physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) and verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others), of MDS indicated that Behavior of this type occurred 1 to 3 days during 7 day look back period. Activities of Daily Living Assistance revealed that R466 required supervision of one person assist for bed mobility and transfers, was independent with walking in room with supervision required in corridor and on unit. Limited assist of one person required for toilet use. Section H of MDS indicated that resident was occasionally incontinent of bladder and bowel. On 11/04/22 at 8:54 AM, R21 was observed laying in bed, on left side, dressed in facility gown. According to the facility reported incident dated 7/29/22 at 10:35 AM, Housekeeper C heard yelling in the hallway coming from room [ROOM NUMBER]. Housekeeper C entered the room, heard R21 yelling at R466, and observed R466 to have a hold of R21's left wrist and was hitting her on the left arm and left side of the face with his right hand. The report indicated that Housekeeper C intervened, separated the residents at which time R466 grabbed and dumped the water pitcher onto R21 and then proceeded to hit housekeeper C on left upper arm. Housekeeper C separated the residents, helped R466 out of room [ROOM NUMBER], and notified RN M. The facility investigation included a statement from Housekeeper C, which reflected that she heard yelling from the hallway, entered room [ROOM NUMBER], observed R466 to have a hold of R21's left wrist and was hitting her on the left arm and left side of face with his right hand. Housekeeper C separated the residents at which time R466 grabbed and dumped the water pitcher onto R21 and then proceeded to hit housekeeper C on left upper arm. Housekeeper C separated the residents, helped R466 out of room [ROOM NUMBER] and notified RN M. In an interview on 11/17/22 at 9:29 AM, housekeeper C stated that on 7/29/22 when she approached room [ROOM NUMBER] from hallway, she heard R21 scream. Housekeeper C stated that upon entering room [ROOM NUMBER], she saw R466 hit R21 twice with a closed fist, once on the arm and once on the face. Per Housekeeper C, she separated the residents and then ran to the nurses' station to notify the nurse as she did not see staff in the hallway. Housekeeper C stated she heard R21 scream but stated that was usual behavior for her if someone entered her room, thus did think it was urgent. In an interview on 11/17/22 at 11:15 AM, Social Worker (SW) R stated that R21 had dementia, was protective of her space and did not like other residents coming into her room or near her. Per SW R, R21 would yell get out of here or get away from me at other residents that entered her room. SW R stated that R466 was confused, did not engage a lot, and would wander into other residents' rooms and would be noted to rummage through their belongings requiring redirection. SW R stated that she was not surprised that R21 had yelled at R466 when he entered her room. SW R stated that R466 was known to be aggressive toward staff but, to her knowledge, had never been noted to be so with other residents prior to 7/29/22 incident. Review of facility policy titled Abuse Prohibition Policy with 9/9/2022 revision date indicated that Each guest/resident shall be free from abuse, neglect, mistreatment .To assure guests/resident are free from abuse .the facility shall monitor guest/resident care and treatments on an on-going basis. It is the responsibility of all staff to provide a safe environment for the guests/residents .Physical abuse includes hitting, slapping, pinching, and kicking. This citation pertains to intakes MI00129193 and MI00130754. Based on observation, interview and record review, the facility failed to 1) protect the resident's right to be free from sexual abuse for one (Resident #54) by Resident #20 and; 2) protect the resident's right to be free from physical abuse for one (Resident #21) by Resident #466 of four reviewed for abuse, resulting in resident to resident sexual and physical abuse. Using the Reasonable Person Concept, findings could include fear, anxiety, trauma and withdrawal. Findings include: Resident #20 (R20): Review of the medical record reflected R20 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included diabetes, paranoid schizophrenia and other frontotemporal neurocognitive disorder. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/23/22, reflected R20 had short-term and long-term memory problems. The same MDS reflected R20 performed activities of daily living with independence to extensive assistance of one person. Resident #54 (R54): Review of the medical record reflected R54 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included traumatic subdural hemorrhage without loss of consciousness, unspecified dementia, schizoaffective disorder, muscle weakness, difficulty walking, major depressive disorder, and anxiety. The Quarterly MDS, with an ARD of 8/25/22, reflected R54 had short-term and long-term memory problems. The same MDS reflected R54 performed activities of daily living with independence to extensive assistance of one to two or more people. On 11/15/22 at 11:45 AM, R20 was observed lying in bed, facing the door. His room door was observed to be open, and his room was located directly next door to R54's room. During an interview on 11/10/22 at 10:45 AM, Housekeeper C reported that on 5/28/22, she was in the hallway, coming out of a room that she had just cleaned. R54 was asleep in a dining chair in the hallway. When she came out of the room that she had cleaned, R20 was in front of R54. R20 stood in front of R54, raised R54's head and tried to force. There was nobody else in hallway, according to Housekeeper C. She tried to have R20 step back, and he would not. Housekeeper C reported she could see R54's whole face, and she could see R20 trying to insert his penis into R54's mouth, while holding her head up. R20 could not get R54's mouth open, according to Housekeeper C. She reported R20's penis was on R54's mouth. R20 swung at Housekeeper C as she attempted to separate the residents. Housekeeper C reported that was the first incident she had knowledge of, and she was not aware of anything happening since. Housekeeper C reported that when she went in to clean the room, which took at least ten minutes, R20 was walking in the hallway, and R54 was sitting in a chair in the hallway. When she was unable to separate the two residents, she went to get the nurse. During that time, R20 was still attempting to put his penis in R54's mouth, according to Housekeeper C. She reported it took about ten to 15 seconds to get the nurse, who was in the dining room. R20 was then taken to his room, per her report. Review of the facility's investigation reflected an Incident and Accident Investigation Form, which indicated an incident occurred on 5/28/22 at 12:30 PM and was reported to the Director of Nursing (DON) and Nursing Home Administrator (NHA) on 5/28/22 at 1:30 PM. The occurrence was observed by Housekeeper C and was reported to the nurse. The Investigation section reflected, .Was the site of the alleged incident examined? was marked Not necessary or feasible. The investigation included a Progress Note for R54, dated 5/28/22 at 1:55 PM and created by Licensed Practical Nurse (LPN) E on 5/29/22 at 1:58 PM, which reflected .Resident observed asleep siting [sic] in a chair in the hallway. Resident peer .was noted standing in front of resident attempting to engage with her in an inappropriate manner. Residents were separated and resident was assessed. No injuries noted. Resident seemed to be unaware of the actions of her peer as she was asleep at the time .15 minute checks initiated. The facility investigation included a statement from LPN E, which reflected she was notified by Housekeeper C that R54 was sitting in the hallway, sleeping with her head down. R20 walked up to R54, tilted her head up with his hand and touched his penis to her lips. R20 had clothing on with his genitals out of his pants. The statement reflected that the nurse reported to the unit and observed R20 sitting in a chair in the hallway and R54 walking in the hall. R54 stopped in front of R20 and took his hand. They chatted for a moment, very friendly, then she let go of his hand and continued to walk in the hallway. R20 was assisted to the day room and placed on 15 minute checks. Housekeeper C's statement reflected that around 11:00 AM, she was in the hallway at her cart. She noticed R54 sitting in a chair in the hallway, asleep, with her head down. She noted that R20 was standing in front of R54 with his back to her (Housekeeper C). Housekeeper C walked over to them and observed R20 with his penis out of his pants, putting it on R54's lips. R20 had R54's head tilted back with his hand, while R54 remained asleep. Housekeeper C addressed R20, told him his actions were inappropriate and stated, Let's go to him, as she took hold of his arm to redirect him. R20 hit the Housekeeper C on the arm with his hand. Housekeeper C obtained the assistance of the Certified Nurse Aide (CNA) on the unit to separate the residents. The CNA took R54 to her room, away from R20. The occurrence was reported to the nurse. A statement from LPN G reflected she came out of the bathroom and Housekeeper C reported that R20 walked up to R54, wanting to put his genitals in her mouth. LPN G went out into the hall and observed R20 walking away from R54, then up and down the hallway. According to the statement, the Housekeeper tried to redirect R20, and he hit her (Housekeeper). The Housekeeper reported to a CNA for assistance. A statement from CNA H included that he was assisting a peer to provide care to a resident. The Housekeeper entered the room and called for assistance, relaying that R20 was attempting to place his genitals on R54. When CNA H went into the hall to assist, R20 was observed walking in the hallway. R54 was sitting in a chair in the hall. The Description of the occurrence in the facility's investigation reflected that per the Social Worker, R20 denied having any inappropriate contact with his peer. He was advised that he could not touch his peers. Additionally, if he needed to pleasure himself, he should go to his room and do so in private. R20 verbalized understanding, according to the document. A Progress Note in R20's medical record, dated 8/17/22 at 11:05 AM, reflected R20 was observed holding R54 from behind. R20 had his penis out, masturbating and touched R54 with his penis. The Nursing Home Administrator (NHA) was notified, and the police were called, according to the note. An additional Progress Note in R20's medical record, dated 8/17/22 at 11:36 AM, reflected R20 approached R54 from behind. R20 took hold of R54's arm from behind, while he (R20) had his penis exposed and masturbating, as he pressed his penis against her (R54). The note reflected staff separated the individuals immediately. The NHA, Physician and police notified, according to the note. A Progress Note in R20's medical record, dated 8/17/22 at 11:37 AM, reflected R20 was approaching staff, wanting them to accompany him back to his room. When asked why, R20 stated, so you can suck my [d***]. According to the note, R20 was making the request to both male and female staff, while exposing his penis. A Progress Note in R20's medical record, dated 8/19/22 at 12:59 PM, reflected R20 was standing in the hallway, exposing himself while masturbating. R20 was stating he wanted someone to orally satisfy him and was redirected back to his room. A Progress Note in R20's medical record, dated 8/23/22 at 11:54 AM, reflected R20 was sexually inappropriate throughout the day 8/22, exposing himself and masturbating. He was redirected to his room multiple times. During an interview on 11/15/22 at 1:59 PM, CNA O reported they had worked on the dementia unit on and off for about one year. According to CNA O, R20 pretty much kept to himself and was more withdrawn, mostly staying in his room. CNA O denied knowledge of R20 having sexual behaviors or any inappropriate interactions between him and other residents. During an interview on 11/15/22 at 3:19 PM, NHA A denied that the facility had any surveillance footage. He reported the facility had cameras, but they pointed at the exits and captured live video stream only. Review of a facility investigation for R54 and R20 for an incident on 8/17/22 reflected the CNA reported to the nurse that she exited a room and noticed R20 standing behind R54 in the hall, near the shower room. Both residents were facing the CNA. R54 was smiling and giggling. The CNA approached the residents to redirect their proximity and noted R20 had his penis exposed, holding it in his hand and touching it to R54's clothing, near her lower back. The CNA redirected R20 to his room and brought R54 to the nurse to report the situation. A facility investigation statement from CNA F reflected she came out into the hall from a room and observed R20 in the hall, standing directly behind R54. Both residents were facing the CNA. When she approached to redirect their proximity, she observed that R20 had his penis out of his clothes, holding it in his hand and touching it to the back of R54's clothing, near the sacrum. R20's other hand was on R54's waist. The residents were immediately separated. R20 was taken to his room, and R54 was taken to the day room to report to the nurse. During an interview on 11/10/22 at 2:36 PM, LPN D reported R54 paced up and down the hall and sometimes went into other resident rooms. She sometimes sat on the bed if there was another resident in the room. LPN D reported the facility began having sexual incidents involving R20 about four months prior. He went out (to the hospital), and his medications were adjusted. LPN D reported hearing of an incident in the hall, between R54 and R20, when R20 had his penis out. They began paying more attention to R20 after that. That was the first time he had knowledge of an incident of that nature with another resident. During an interview on 11/15/22 at 2:20 PM, Registered Nurse (RN) L reported she did not know the specifics of any resident to resident incidents or encounters between R54 and other residents. She reported there was some sexual exposure between R54 and R20 that she heard of a couple months prior. There had not been anything recently or when she was on duty, per her report. A Progress Note in R20's medical record, dated 9/4/22 at 2:26 PM, reflected that at 10:45 AM, R20 was observed in another resident room, in close proximity to R54. R20 had his penis exposed. The note reflected no contact was made. According to the note, the NHA and Director of Nursing (DON) were notified. A Progress Notes in R20's medical record, dated 9/7/22 at 5:58 AM, reflected R20 was standing in the doorway of his room, attempting to coax R54 into his room. R20's medical record reflect he was sent to the hospital on 9/7/22 and returned to the facility on 9/20/22. During a phone interview on 11/16/22 at 11:45 AM, Registered Nurse (RN) J reported (on 9/4/22) from the nurse's station in the day room, she observed R54 in bed two of a room (which was not R54's room), and there was a male resident in bed one. She happened to look up and observed R20 in the room, at the foot of the bed that R54 was lying in. When asked if R20 was exposed in any way, RN J stated it had been a while. She believed R20's zipper was down, and he was not that close to R54. RN J was unaware of any incidents between R20 and R54 prior to that. According to the facility's Abuse Prohibition Policy, with a revision date of 9/9/22, .Each guest/resident shall be free from abuse .To assure guests/residents are free from abuse .the facility shall monitor guest/resident care and treatments on an on-going basis. It is the responsibility of all staff to provide a safe environment for the guests/residents .Sexual Abuse is a non-consensual sexual contact of any type with a guest/resident .Sexual abuse includes, but is not limited to: unwanted intimate touching of any kind especially of breasts or perineal area; all types of sexual assault or battery, such as rape, sodomy, fondling and/or intercourse or coerced nudity; forced observation of masturbation .Guests/residents have the right to engage in consensual sexual activity. If at anytime the facility has reason to suspect the guest/resident does not have the capacity to consent to sexual activity the facility should evaluate whether the guest/resident has the capacity to consent .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement pressure injury interventions for two (Resident #52 and Resident #97) of five residents reviewed for pressure injuries resulting in the development of facility acquired pressure injuries with the potential for delayed healing, wound deterioration, and formation of additional pressure injuries. Findings include: Resident #52 (R52): R52 was an eighty-nine-year-old initially admitted to facility 12/21/2018 with most recent readmission on [DATE] with diagnoses including acquired absence of left toe, unspecified dementia, atrial flutter, type 2 diabetes mellitus, peripheral vascular disease. Review of Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 11/1/22 indicated that resident with Brief Interview for Mental Status (BIMS) score of 5 (severely impaired cognition). Section G of MDS revealed that R52 required extensive assist of one for bed mobility and two-person dependent assist for transfer. Section H of MDS reflected that R52 was frequently incontinent of bladder and always incontinent of bowel. Section M of MDS indicated that R52 had one Stage 4 pressure ulcer, an infection of the foot, a surgical wound and that resident was not on a turning/repositioning program. The MDS dated [DATE] revealed R52 had one venous/arterial ulcer, was at risk for developing pressure ulcers and was on a turning/repositioning program. The MDS dated [DATE] indicated R52 had one Stage 3 pressure ulcer, was at risk for developing pressure ulcers and was on a turning/repositioning program. The MDS dated [DATE] indicated that R52 had one Stage 2 pressure ulcer, was at risk for developing pressure ulcers and was on a turning/repositioning program. The MDS dated [DATE] indicated that R52 had one Stage 4 pressure ulcer and 2 unstageable pressure ulcers, was at risk for developing pressure ulcers and was not on a turning/repositioning program. The MDS dated [DATE] indicated that R52 had one Stage 4 pressure ulcer and 2 unstageable pressure ulcers, was at risk for developing pressure ulcers and was not on a turning/repositioning program. The MDS dated [DATE] indicated that R52 had one Stage 4 pressure ulcer, an infection of the foot, a surgical wound and was not on a turning/repositioning program. The MDS dated [DATE] indicated that R52 had one Stage 4 pressure ulcer, an infection of the foot, a surgical wound and was not on a turning/repositioning program. On 11/04/22 at 10:05 AM, R52 was observed laying in bed, in facility gown, positioned on back with head of bed elevated to approximately seventy-five degrees. Oxygen noted to be in place at 2 liters per minute via nasal cannula. R52 observed with yellow gripper socks to bilateral lower extremities with visible gauze wraps noted beneath socks at bilateral ankles/heels. Bilateral heels in direct contact with standard mattress. Clear plastic bag noted on floor labeled personal belongings with two black foam boots noted to be inside bag. On 11/04/22 at 11:29 AM, R52 was observed laying in bed, on back, with head of bed at approximately 30 degrees. Headphones noted to be in place with resident observed to be watching television. Lower extremities observed to be bent at knees with bilateral heels noted to be in direct contact with mattress. On 11/10/22 at 9:30 AM, R52 was observed laying in bed, on back, with head of bed at approximately 30 degrees. Headphones noted to be in place with television observed to be on. Left leg noted to be bent slightly at knee and right leg observed to be straight with both heels in direct contact with mattress. No footwear in place with gauze wrap noted to left foot/heel. No dressing noted to right foot/heel. Two black foam boots noted to be in wheelchair positioned at resident bedside. On 11/10/22 at 12:47 PM, R52 was observed laying in bed, on back, with head of bed at approximately 45 degrees. Left leg noted to be bent slightly at knee and right leg observed to be straight with bilateral heels in direct contact with mattress. No footwear in place with gauze wrap noted to left heel/foot. No dressing noted to right foot/heel. In an interview on 11/10/22 at 12:51 PM, Certified Nurse Aide (CNA) Z stated that she had not assisted R52 as CNA X was assigned to him. CNA Z confirmed that she was familiar with R52 and stated that he required total care which included assist with grooming, bathing, dressing and that he was incontinent of bowel and bladder. She stated that when assigned to R52, she would reposition him in bed approximately every two hours, would generally position a pillow between his legs, put his legs up on a pillow and would put boots on his heels. CNA Z stated, When I have him, I definitely put the boots on his heels as he has breakdown. CNA Z stated that she did not know the wearing schedule for the boots and upon checking the [NAME] stated It doesn't say anything about the boots, but I know we put them on him when he gets up too. In an interview on 11/10/22 at 1:45 PM, CNA X stated that she had not assisted R52 as CNA Z was assigned to him. CNA X stated that she was familiar with R52 and that he required total assist with grooming, bathing, dressing and was incontinent of bowel and bladder. CNA X stated that she believed that R52 had wounds on his legs or feet and that she had seen him with the heel boots on. CNA X stated that she tried to look at each resident's [NAME] daily but that sometimes relied on the nurse for resident updates as did not have time to check every [NAME] daily. In an interview on 11/10/22 at 1:59 PM, CNA Y confirmed that she was assigned to R52. CNA Y stated that R52 was incontinent of bowel and bladder and that she tried to complete a check and change twice a shift (after breakfast between 9 to10 AM and after lunch between 1:30 to 2 PM). CNA Y stated that R52 required total assist for grooming, bathing, and dressing but that he repositioned himself and that she generally did not need to assist him with that as he rolls to the side a little and moves his legs up and down. CNA Y stated that R52 had sores on his feet and that she used a wedge cushion, at times, to position his legs but that he really didn't like things by his feet and would sometimes kick it off. On 11/10/22 at 2:30 PM, observed completion of R52 wound care by Licensed Practical Nurse (LPN) U. LPN U washed hands, applied gloves, and then was observed to remove gauze wrap from left ankle and foot and gauze dressing from dorsal left foot and left toes. Wound at left dorsal foot presented as oval shaped area with wound base covered by adherent dry, black tissue. In reference to left dorsal foot wound, LPN U stated There is no treatment order for that, but I clearly removed a dressing. Left third toe amputation site presented with open wound with visible depth and beefy red tissue in wound base. LPN U washed hands, applied gloves, and then cleansed left toe amputation site with normal saline, applied medicated gauze wound dressing, covered wound with 5inch (in) by 9in absorbent dressing (to cover left dorsal foot wound as well) and wrapped toe and foot with gauze wrap. In reference to the right foot/heel, LPN U stated As you can see there is no dressing on the right foot like there is supposed to be. Tissue observed to be intact to right dorsal foot and presented with deep purple and maroon discoloration. LPN U stated That was open, but it is healed now. LPN U stated that she believed the treatment ordered to the right dorsal foot wound was intended for the left dorsal foot wound and did not complete the ordered right dorsal foot wound treatment. LPN U stated that she would follow up with the wound nurse regarding wound presentation and treatments. Right heel presented with open wound with visible depth. Dark pink tissue noted in majority of wound base with minimal adherent white tissue observed at distal wound aspect. LPN U washed hands, applied gloves, cleansed wound with normal saline, patted dry, applied medicated gauze wound dressing, covered with 5in by 9in absorbent dressing, and wrapped heel with gauze wrap. Upon wound treatment completion, LPN U stated that she would put R52's bilateral heel boots back on sometime after treatment completion and prior to the end of her shift. LPN U confirmed R52 to spend most of the day in bed as stated that he was more restless when up in wheelchair and tried to transfer back to bed independently. LPN U stated that R52 was pretty still when in bed and didn't move around much. In an interview on 11/10/22 at 2:52 PM, Registered Nurse (RN) M confirmed that she was familiar with R52 and stated that she completed his weekly wound assessments with Nurse Practitioner (NP). RN M stated that R52 had an active Stage 4 pressure ulcer at right heel, a deep tissue injury at right dorsal foot, and an open wound at left toes from surgical removal of the left second and third toes. RN M denied knowledge of events that lead to right heel wound deterioration from original Stage 2 to current Stage 4 as stated, I started at facility when it was a Stage 4. RN M stated that the goal was to maintain right heel wound stability via prophylactic antibiotic use and routine wound care which included pressure relief. RN M stated that heel boots were ordered and were being used until new wound was noted to right dorsal foot. Per RN M, heel boots were discontinued at approximately end of August or beginning of September as the straps of the boots correlated to the formation of the right dorsal foot wound. RN M stated that a wedge was trialed next but as it did not work well have transitioned to float R52's heels with a pillow. RN M denied prior knowledge of wound at left dorsal foot and stated that there was no current treatment order in place as was not aware that wound was present until she was informed by assigned nurse earlier that day. During same interview, RN M acknowledged ongoing staff usage of heel boots to offload R52's heels stating, I did pull them out of his room this morning because the aides are not supposed to be using them as boot usage correlated to the formation of the right dorsal foot wound. RN M verbalized that as she had not yet assessed left dorsal foot wound, she could not discuss correlation of ongoing boot usage to new left dorsal foot wound. RN M stated that either she or the assigned floor nurse would have discontinued the order for the heel boots as she recalled that this change in R52's plan of care was discussed with the assigned floor nurse at the time of the boot discontinuation. RN M stated that as the assigned floor nurse was aware of the boot discontinuation, the expectation would have been that this information was passed on by staff through the daily 24-hour report and that the boot usage was stopped at the time the order was discontinued. RN M further stated that as R52 cannot independently move in bed enough for effective pressure reduction, the expectation would be that the CNAs assist R52 to be repositioned every two hours. Additionally, RN M stated that she believed R52 had a roho mattress but after further evaluation confirmed that he had a standard foam, raised edge mattress but acknowledged that he would benefit from enhanced pressure redistribution. On 11/15/22 at 11:23 AM, R52 was observed laying in bed, on back, dressed in facility gown. Two pillows noted to be positioned under bilateral lower extremities at knees with bilateral heels resting on standard mattress. In an interview on 11/15/22 at 12:10 PM, RN M confirmed that R52's heel boots were discontinued 9/22/22 and stated that it's possible that the care plan was not revised at the time of the boot discontinuation. RN M confirmed during same interview that the care plan was revised in early November to reflect heel boot discontinuation and the initiation of pillows for offloading of heels. RN M stated that the floor nurses, MDS nurses, unit managers all update care plans and that care plan updates was everyone's responsibility. RN M also clarified that R52 never did have a roho mattress and when questioned regarding weekly skin assessments as reflected mattress w/ pump stated Yes. Because I thought he did. That was my mistake. R52 record review complete on 11/10/22 with the following findings noted: 11/9/22 Skin & Wound Evaluation form reflected right heel pressure injury acquired in house on 2/8/22. Wound was documented as a Stage 4 pressure injury measuring 1.7centimeters (cm) by 1.4cm by 0.4cm. 11/1/22 Skin & Wound Evaluation form indicated Stage 4 pressure injury to right heel measuring 2.4cm by 1.2cm by 0.2cm. Wound bed indicated to present with 20% granulation tissue and 80% slough. Review of Section H (Treatment) of same assessment reflected heel suspension/protection device and mattress with pump neither of which noted to be used by R52 throughout survey. 10/25/22 Skin & Wound Evaluation form indicated Stage 4 pressure injury to right heel measuring 2.7cm by 2.6cm by 0.4cm. Wound base indicated to present with 70% granulation tissue and 30% slough. Review of Section H (Treatment) of same assessment reflected heel suspension/protection device and mattress with pump. 10/18/22 Skin & Wound Evaluation form indicated Stage 4 pressure injury to right heel measuring 2.2cm by 1.7cm by 0.1cm. Wound base indicated to present with 70% granulation tissue and 30% slough. Review of Section H (Treatment) of same assessment reflected mattress with pump. 10/11/22 Skin & Wound Evaluation form indicated Stage 4 pressure injury to right heel measuring 1.8cm x 1.9cm x 0.7cm. Wound base indicated as 80% granulation tissue and 20% slough. Review of Section H (Treatment) of same assessment reflected heel suspension/protection device and mattress with pump. 2/9/22 Skin & Wound Evaluation form reflected right heel pressure injury acquired in house on 2/8/22. Wound was documented as a Stage 2 pressure injury measuring 2.4cm by 2.0cm by 0.2cm with wound base indicated to present with 100% granulation tissue. Review of Section H (Treatment) of same assessment reflected heel suspension/protection device and mattress with pump. 2/8/22 12:34 AM PCC Skin & Wound - Total Body Skin Assessment indicated no new wounds. 2/8/22 6:52 AM Nurses Notes indicated Open area noted on pt's right heel. Area cleansed with NS, wet to dry gauze applied, and dry dressing intact. 2/16/22 5:03 PM Physician Note reviewed with no noted indication of right heel wound although note indicated no evidence of acute cellulitis infection or gangrene on the foot noted. 11/9/22 Skin & Wound Evaluation form indicated pressure injury to the dorsum of right foot acquired in house on 8/30/22. Wound was documented as a Deep Tissue Injury (DTI) measuring 2.2cm by 0.5cm with depth not applicable. 11/1/22 Skin & Wound Evaluation form indicated Deep Tissue Pressure Injury to dorsum of right foot measuring 3.4cm by 1.7cm with depth not applicable. Wound bed indicated to present with 100% epithelial tissue. Review of section H (Treatment) of same assessment reflected heel suspension/protection device and mattress with pump neither of which noted to be in use by R52 throughout survey. 8/30/22 Skin & Wound Evaluation form indicated Deep Tissue Pressure Injury to dorsum of right foot acquired in house on 8/3022. Wound indicated to measure 3.8cm by 2.8cm with depth not applicable and wound base indicated to present with 100% epithelial tissue. Review of section H (Treatment) of same assessment reflected heel suspension/protection device and mattress with pump. 8/25/22 PCC Skin & Wound - Total Body Skin Assessment indicated no new wounds. 9/1/22 PCC Skin & Wound - Total Body Skin Assessment indicated no new wounds. 8/30/22 Wound Care Note completed by Nurse Practitioner (NP) indicated Right foot-cleanse area with normal saline, apply betadine, cover with dry dressing for protection to prevent further skin breakdown and Continue supportive care. Patient should be turned every 2 hours. Patent should be supported with pillows or wedges to prevent pressure on wound Elevate bilateral lower extremities, float heels, apply soft heel lift [NAME]. 11/1/22 Progress Note completed by NP indicated Dorsum Right Foot-area previously noted as resolved, reoccurring DTI over a bony area and to Continue preventative measures and pressure relief. Frequent repositioning, elevate bilateral lower extremities, apply soft heel lift boots. Review of R52 Braden Scale for Predicting Pressure Sore Risk complete with findings as follows: 11/3/22 = 13 (moderate risk) 10/26/22 = 13 10/19/22 = 14 (moderate risk) 10/12 = 13 6/9/22 = 14 3/4/22 = 16 11/30/21 = 16 (low risk) Review of R52 Care Plan risk for impaired skin integrity/pressure injury complete with noted intervention created 1/2/19 and revised 11/9/22 to reflect Encourage and assist me to float my heels while in bed as tolerated and an intervention to Encourage and assist me to turn/reposition as resident allows while in bed as tolerated with 1/2/19 creation and 10/5/22 revision date. An intervention created 5/25/19 and revised 11/9/22 indicated to provide extensive assistance of one to reposition frequently and as needed. Review of R52 Care Plan actual impaired skin integrity complete with intervention created on 4/9/21 and revised on 11/9/22 to reflect elevate heels on pillow while in bed as resident tolerates. An intervention for Heel boots on when in bed with 3/9/21 creation date was noted to be canceled on 11/9/22. Resident # 97 (R97): R97 was an eighty-one-year-old admitted to facility 9/8/22 with diagnoses including congestive heart failure, paroxysmal atrial fibrillation, essential hypertension, hyperlipidemia, mild cognitive impairment, benign prostatic hyperplasia, major depressive disorder, iron deficiency anemia, unspecified osteoarthritis, type 2 diabetes mellitus, benign neoplasm of spinal meninges. Review of Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/14/22 revealed that R97 was understood and understands with a Brief Interview for Mental Status (BIMS) score of 12 (moderately impaired cognition). Section G of MDS revealed that R97 required extensive assist of two for bed mobility, total dependent assist of two for transfers, and extensive assist of two for toileting. Section H of MDS reflected that R97 was frequently incontinent of both bowel and bladder. Section M of MDS indicated that resident did not have a pressure ulcer/injury, was at risk for developing pressure ulcers, and that resident was not on a turning/repositioning program. On 11/04/22 at 9:35 AM, R97 was observed laying in bed, on his back, with head of bed at approximately forty-five degrees and breakfast tray on over the bed table positioned in front of him. At time of observation, R97 stated that he had a sore spot at his tailbone that started to hurt after he sat up in wheelchair for too long. R97 did not recall a routine treatment to area but stated that the staff would put cream on it if he requested them to do so. Per R97, staff assisted him with repositioning off and on but stated that generally staff just instructed him to turn on your side and the pain will lesson. R97 stated that he could turn a little tiny bit onto side and the pain would lesson but that that when staff helped, he could turn onto his side more. R97 stated that he had sat in the wheelchair up to five hours as staff stated that We are in the middle of lunch. You will have to wait before being assisted back to bed. R97 stated that he normally remained up in the wheelchair from two to three hours before being assisted back to bed. During same interaction, R97 Stated I have a hole in my heel that I got here with gauze wrap noted to right ankle dated 11/2/22. R97 stated that he believed that the wound was gradually getting better and that the staff completed a treatment every other day. Resident noted with standard mattress on bed with bilateral heels in direct contact with mattress. Resident stated that staff sometimes put a boot on the right foot when he was in bed and stated The other day I woke up and the boot was on the wrong foot. It was on the left foot. One soft black boot was noted in chair at resident bedside. On 11/04/22 at 11:33 AM, R97 observed laying in bed, positioned on back with head of bed elevated at approximately thirty degrees. Bilateral lower extremities noted to be straight with both heels observed to be in direct contact with mattress. On 11/10/22 at 1:12 PM, observed completion of R97 wound care by Licensed Practical Nurse (LPN) U. LPN U washed hands, applied gloves, removed soft black boot from right lower extremity, and then removed undated gauze wrap at right heel. Right lateral heel wound noted to present with adherent dry tan to dark brown tissue covering wound base with intact pink tissue surrounding. LPN U washed hands, applied gloves, cleansed wound with normal saline, applied yellow ointment to wound base with tongue depressor, placed dry gauze and then wrapped heel with gauze wrap. R97 confirmed usage of black boot to right lower extremity when staff remember to put it on. In an interview on 11/10/22 at 1:33 PM, Certified Nurse Aide (CNA) X confirmed that she was assigned to R97. CNA X stated that she had delivered and set up both breakfast and lunch for R97 but that He doesn't ask for much. CNA X stated R97 had not asked for any assistance yet that shift and that he denied needing anything when he was asked. CNA X stated that R97 was continent of both bowel and bladder and had not checked him or assisted him with toileting needs that day. CNA stated he is fine just the way he is as he was comfortable positioned on back and denied knowledge of any skin concerns or use of any devices or splints. On 11/10/22 at 2:19 PM, CNA X observed exiting R97's room with clear plastic bag with brief noted to be inside. CNA stated that she had just checked R97 and as he was noted to be incontinent of both bowel and bladder had provided incontinence care. As resident reported sore spot on my bottom, coccyx/ buttocks visualized in presence of CNA X with intact skin and mild erythema and dry/flakey skin noted to area. In an interview on 11/10/22 at 3:00 PM, RN M confirmed that she was familiar with R97, stated that she completed his weekly wound assessments with NP, and stated that R97 had a facility acquired unstageable pressure ulcer at right heel. RN M then verbalized the need to review R97 record prior to any further discussion. On 11/15/22 at 11:18 AM, R97 observed laying in bed, on back, with head of bed at approximately thirty degrees. Bilateral lower extremities noted to be extended straight out with heel boot noted on right lower extremity. Left heel in direct contact with mattress. In an interview on 11/15/22 at 12:14 PM, RN M stated that R97 had order for bilateral heel boots to offload both heels so that we don't create anything else. As weekly Skin & Wound Evaluation form reflected mattress with pump within Treatment section, RN M stated it might be something that we talked about and didn't have in the building .I'm not exactly sure. RN M stated that she would follow-up with rationale after reviewing notes. In a follow-up interview on 11/15/22 at 12:44 PM, RN M stated He does not have a roho mattress so that was my mistake in indicating that on his weekly assessments in reference to the indication of mattress with pump within Treatment section on weekly Skin & Wound Evaluation form. RN confirmed R97 to still have a standard mattress in place on bed. R97 record review complete on 11/15/22 with the following findings noted: 9/29/22 PCC Skin & Wound - Total Body Skin Assessment indicated 1 new wound 9/29 Physician Progress Note indicated Nursing noted that patient had a wound on his right heel today and it appears to be where his posterior lateral heel rests on the bed chronically and we will have nursing and wound service fully assess this wound. Patient is having no pain in his feet. I spoke with DON and ADON and they will get pressure off of his heel and apply appropriate dressing. 10/4/22 Skin & Wound Evaluation form reflected right heel pressure ulcer acquired in house on 10/4/22. Wound was documented as an Unstageable Pressure Ulcer measuring 1.8centimeters (cm) by 2.0cm with wound depth not applicable. Wound base indicated to present with 100% eschar. Review of Section H (Treatment) of same assessment reflected heel suspension/protection device. 10/11/22 Skin & Wound Evaluation form reflected Unstageable right heel pressure ulcer measuring 1.7cm by 1.1cm with wound depth not applicable. Wound base indicated to present with 10% granulation tissue, 10% slough, 80% eschar. Review of Section H (Treatment) of same assessment reflected heel suspension/protection device and mattress with pump. 10/18/22 Skin & Wound Evaluation form reflected Unstageable pressure ulcer measuring 1.5cm by 1.2cm with wound depth not applicable. Wound base indicated to present with 100% eschar. Review of Section H (Treatment) of same assessment reflected heel suspension/protection device and mattress with pump. 10/25/22 Skin & Wound Evaluation form reflected Unstageable pressure ulcer measuring 1.8cm by 1.8cm by 0.6cm. Wound base indicated to present with 10% granulation tissue, 10% slough, 80% eschar. Review of Section H (Treatment) of same assessment reflected heel suspension/protection device and mattress with pump. 11/1/22 Skin & Wound Evaluation form reflected Unstageable pressure ulcer measuring 1.0cm by 1.4cm with depth not applicable. Wound base indicated to present with 70% slough and 30% eschar. Review of Section H (Treatment) of same assessment reflected heel suspension/protection device and mattress with pump. 11/8/22 Skin & Wound Evaluation form reflected Unstageable pressure ulcer measuring 1.2cm by 1.3cm with depth not applicable. Wound base indicated to present with 100% slough. Review of Section H (Treatment) of same assessment reflected heel suspension/protection device and mattress with pump. Review of R97 Treatment Administration Record for September through November complete with orders noted as follows: 9/30 order noted for Protective foam until new order, one time a day for wound care 10/1 order noted to Cleanse heel with NS, pat dry, apply medihoney and wrap it with kerlix. Change dressing daily for right heel 10/13/22 order noted to Cleanse heel with NS, pat dry, apply medihoney and wrap it with kerlix. Change dressing every other day for right heel 11/10/22 order noted for Santyl Ointment-Apply to right heel topically every day shift for pressure wound. Cleanse with NS, Pat dry, apply thin layer santyl to wound bed, cover with dry dressing Order dated 10/2/2022 at 3:58 AM reflected heel boots bilaterally as tolerated Review of R97 Braden Scale for Predicting Pressure Sore Risk complete with findings as follows: 9/9 = 18 (low risk) 9/16 = 21 (low risk) 9/26 = 16 (low risk) 10/3 = 21 (low risk) Review of R97 Care Plan I am at risk for impaired skin integrity/pressure injury complete with interventions noted to Encourage to float heels while in bed and assist as needed created on 9/9/2022, Pressure reduction mattress to bed created on 10/28/22, and Observe for sliding down in the chair and assist to reposition in chair as needed created 9/9/22. Review of R97 Care Plan Actual impaired skin integrity related to pressure injury. Site: right heel created 10/2/22 with intervention noted for heel boots bilaterally as tolerated created 10/2/2022. Review of R97 Care Plan I am incontinent of bladder and bowel created 9/8/22 with intervention noted for BRIEF USAGE: I use disposable briefs. Check and Change every 2 hours and as needed created 9/8/22. Review of R97 [NAME] complete and noted to reflect Heel boots bilaterally as tolerated and Encourage to float heels while in bed and assist as needed listed under Skin interventions. Within [NAME] under Bladder/Bowel/Toileting interventions BRIEF USAGE: I use disposable briefs, Check and Change every 2 hours and as needed and Check q 2hr and prn for incontinence. Wash, rinse, and dry perineum. Apply moisture barrier. Review of facility policy titled Care Planning with 6/24/2021 revision date indicated that the purpose of the policy was to ensure Every resident in the facility will have a person-centered Plan of Care developed and implemented that is consistent with the resident rights, based on the comprehensive assessment. The procedure indicated The care plan and resident [NAME] will be updated on Admission, Quarterly, Annually and with significant changes. This includes adding new focuses, goals, and interventions and resolving ones that are no longer applicable. Review of facility policy titled Skin Management with 7/24/2021 revision date indicated that It is the policy that the facility should identify and implement interventions to prevent development of clinically unavoidable pressure injuries. and that Appropriate preventative measures will be implemented on guests/residents identified at risk and the interventions are documented on the care plan.