**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #51 R51's significant change Minimum Data Set (MDS) dated [DATE], indicated R51 had moderate cognitive impairment with medical diagnoses including type 2 diabetes, communication deficit or difficulties, depression, deformities of the musculoskeletal system and muscle weakness. R51's significant change MDS dated [DATE], indicated he required substantial to maximal assistance to move from lying to sitting to standing, partial to moderate assistance to roll left and was always incontinent of bowel movements. R51's significant change MDS dated [DATE], indicated R51 was at risk for developing pressure ulcers, did not have unhealed pressure ulcers, did not have other ulcers, wounds, or skin conditions of his feet, and did not reject care. The MDS further indicated skin and ulcer treatments included a pressure reducing device for the chair, bed, nutrition, or hydration interventions to manage skin problems, pressure ulcer care and applications of ointments or medications other than to feet. R51's pressure ulcer/injury Care Area Assessment (CAA) dated 10/8/23, indicated R51 had a potential for pressure ulcers with contributing factors identified as frequent bowel (feces) incontinence, activities of daily living (ADL) and mobility impairment. The CAA lacked indication that R51's risk for pressure ulcers would be addressed in the care plan. R51's pressure ulcer/injury CAA dated 12/8/23, indicated R51's risk for developing pressure ulcers was related to ADL impairment and incontinence and identified pain as a risk factor. The CAA indicated a licensed nurse would assess R51's skin weekly and implement appropriate interventions to prevent skin breakdown as needed. Furthermore, the CAA indicated nursing assistants (NA) would report abnormal skin findings during cares and bath days to a licensed nurse. Additionally, the CAA indicated R51's primary care provider (PCP) should be updated with new or abnormal skin findings for treatment order. R51's Braden Scale for Predicting Pressure Sore Risk form dated 12/5/23, indicated R51 had a moderate risk for pressure ulcer development. R51's physician orders included the following: - Skin prep to coccyx area daily at bedtime for preventive, dated 10/19/23 and discontinued 1/24/24. - Apply Mepilex (type of dressing) to coccyx every 3 days on evening shift and as needed if soiled, dated 11/7/23 and discontinued 1/24/24. - Monitor redden/scab area to left heel 3 centimeters (cm) x 3cm until resolved. Place heel protector on foot every shift, dated 12/11/23 and discontinued 1/24/24. - Turn side to side when in bed every shift, dated 10/19/23. - Coccyx wound: clean with wound cleanser, skin prep around wound and apply Mepilex (type of dressing). Change dressing once daily for an unstageable pressure ulcer dated 1/24/24. - Coccyx wound: clean with wound cleanser, skin prep around wound and apply Mepilex (type of dressing). Change dressing every evening as needed for an unstageable pressure ulcer dated 1/24/24. - Ensure there is no pressure on heel when in bed or sitting in wheelchair every shift, dated 1/25/24. R51's electronic health record (EHR) included body audit assessments dated: - 11/16/23, indicated evidence of alteration in skin integrity, heels were firm. - 11/23/23, indicated evidence of alteration in skin integrity, heels were firm. - 12/13/23, indicated evidence of alteration in skin integrity, heels with dark spots or any discoloration. - 1/10/24, indicated a small red and open area to the coccyx and a small scab area to the left heel. - 1/17/24, indicated a red slit like area on the coccyx and soft, spongy heels and discoloration to R51's left heel. -1/24/24, indicated a small open area to the coccyx and discoloration to the left heel. R51's comprehensive skin and positioning evaluation dated 12/5/23, indicated R51 had an open area to his coccyx and identified a turning and repositioning program as an intervention. R51's comprehensive skin and positioning evaluation dated 2/6/24, indicated R51 was incontinent of bowel and bladder and had mobility impairment, placing him at a risk for skin breakdown. Additionally, the evaluation identified R51 had a current pressure ulcer and interventions in place included turning and repositioning and application of nonsurgical dressings (with or without topical medications). R51's skin and wound evaluation dated 1/31/24, indicated R51 had an unstageable (obscured full-thickness skin and tissue loss) wound to his sacrum with slough and/or eschar noted. The evaluation included wound measurements 1.8cm x 1.9cm with an area measurement of 2.8cm-squared. In the measurement boxes for depth, undermining, and tunneling, not applicable was documented. Furthermore, the evaluation indicated the pressure ulcer was in-house acquired. The evaluation lacked documentation of assessment of the wound bed, periwound, exudate (drainage), odor, edema (swelling), induration (hardening of tissues around a wound), temperature, and pain. The evaluation lacked documentation for goal of wound care, treatment, and wound progress. R51's skin and wound evaluation dated 2/7/24, indicated R51 had a new diabetic wound to his left heel that measured 4.74cm x 6.5cm with an area measurement of 21.32cm-squared. The evaluation indicated this was in-house acquired but lacked documentation where the evaluation asked how long the wound had been present. The evaluation lacked documentation of assessment of the wound bed, periwound, exudate (drainage), odor, edema (swelling), induration (hardening of tissues around a wound), temperature, and pain. The evaluation lacked documentation for goal of wound care and treatment orders. R51's skin and wound evaluation dated 2/7/24, indicated R51 had an unstageable (obscured full-thickness skin and tissue loss) wound to his sacrum with slough and/or eschar noted. The evaluation included wound measurements 1.6cm x 1.8cm with an area measurement of 1.7cm-squared. In the measurement boxes for depth, undermining, and tunneling, not applicable was documented. Furthermore, the evaluation indicated the pressure ulcer was in-house acquired. The evaluation lacked documentation of assessment of exudate (drainage), odor, edema (swelling), induration (hardening of tissues around a wound), temperature, and pain. The evaluation indicated the goal of care of this wound was healable and indicated improving progress. R51's treatment administration record (TAR) from 10/2023 through 2/2024 was reviewed and reflects order to turn resident side to side when in bed signed off as completed by licensed nurse staff. The responses documented in R51's TAR varied between number of times turned, yes or no, refused, or a checkmark for completion. There were six occurrences between 10/1/23 and 2/8/24 with no documentation indicating turning and repositioning occurred. R51's care plan dated 8/15/23, indicated he was at risk for skin impairment related to immobility and incontinence. A goal to participate in repositioning was identified on 12/28/23. Interventions included float or offload heels, encourage repositioning and position changes during rounds, observe skin during cares and report any changes to the nurse, pressure relieving support surfaces in bed and the chair, and weekly skin inspection. R51's care plan dated 1/26/24, identified a goal of no complications related to diabetes with an intervention of monitoring all body parts for breaks in skin and treat promptly. R51's care plan dated 1/26/24, identified a goal to prevent skin alterations due to incontinence with an intervention of encouragement to toilet during rounds. R51's care plan lacked specific interventions for toileting and turn/reposition programs. A facility nursing concern and order form dated 12/10/23 revealed a provider update indicating R51's left heel had a round red area with a scab in the middle with an area measurement of 3cm x 3cm. Staff wrote they applied a hell protector and would continue to monitor. The provider signed and dated the form 12/10/23. A provider progress note dated 10/5/23 indicated R51 and his family member reported sacral pain with sitting. The provider indicated pressure reduction education was provided to both R51 and his family member. A provider progress note dated 10/19/23 indicated R51 reported pain to his bottom when sitting and lying on his back. The provider wrote a recommendation of not lying on his back when in bed and orders included skin prep to his coccyx and turning from side to side in bed. The provider indicated in the note the orders were discussed with nursing staff. A provider progress note dated 11/6/23, indicated R51 had a stage 2 pressure injury of the coccygeal region. The provider indicated R51 reported ongoing buttocks pain and difficulty moving himself in bed. The provider wrote that the pressure injury was newly noted during the exam and photos were take and scanned into his EHR. The provider indicated new orders of applying a Mepilex dressing to the coccyx every 3 days and as needed if soiled and to continue current orders of applying skin prep and barrier cream to the coccyx daily and shifting side to side in bed every shift. R51's EHR lacked documentation of provider updates regarding wounds from 11/6/23 until 1/24/24. A provider progress note dated 1/24/24, indicated a diabetic stage 2 decubitus ulcer (injury to skin and underlying tissue due to prolonged pressure on the skin) of his left heel and an unstageable pressure ulcer of the coccygeal region. The provider indicated new orders to clean the left heel with wound cleanser, apply skin prep around the wound, apply nonstick gauze then wrap with Kerlix once daily and as needed. The provider also ordered no pressure to R51's heels when sitting in the wheelchair or lying in bed. Additionally, new orders for the coccygeal wound included daily wound monitoring, clean with wound cleanser and apply skin prep around the wound, then apply a Mepilex dressing once daily and as needed. A provider progress note dated 1/31/24, indicated the left heel would was stable and had no odor or drainage and was open without a dressing on. The provider indicated the unstageable pressure injury of the coccygeal region had increased in size. Review of the nursing assistant (NA) care sheet dated 2/5/24, indicated R51 had a toileting schedule of upon rising, before and after meals, at bedtime and as needed. The NA care sheet indicated R51's heels should be floated but lacked guidance for a turning and repositioning program. During observation on 2/5/24 at 7:09 p.m., R51 was in bed, lying on his back. During observation on 2/6/24 at 8:39 a.m., R51 was in bed, lying on his right side facing the door. Observations at 1:15 p.m. and 2:13 p.m., showed R51 lying on his back in bed with his legs crossed. His heels were not floated or elevated on a pillow and no heel protectors were on. During continuous observation on 2/7/24 between 7:11 a.m. and 9:30 a.m., R51 was lying in his bed on his ride side, no heel protectors on and heels were not elevated on a pillow or floated. At 7:44 a.m., registered nurse (RN)-B entered R51's room to administer his morning medications and elevated his heels on a pillow. No heel protectors were offered or applied. At 8:13 a.m., NA-G and RN-B entered R51's room to provide morning cares. NA-G stated R51 should be on a turning and repositioning schedule but he is often sitting up in the wheelchair. NA-G reported R51 had a sore on his backside that started small but now could be worse, and the nurses were putting a dressing on it. RN-B stated R51 was assisted to turn in bed a couple of times per shift and was not aware of him being on a toileting program. RN-B stated the wound to R51's left heel is improving but was unsure of how long it had been present. At 8:42 a.m., RN-A entered R51's to provide wound cares and RN-B exited the room. RN-A stated the current unstageable wound to R51's coccyx was a different wound than the one the nurse practitioner (NP) diagnosed as a stage 2 pressure injury in October. RN-A removed the Mepilex from R51's coccyx and the wound bed was noted to have pink tissue surrounding it. There were two open areas, one of which RN-A reported was scabbed over now that measured approximately 1-inch x ¾-inch and the other area was open and appeared moist. RN-A photographed the wound before cleansing the wound and apply a new Mepilex dressing. At 8:47 a.m., RN-A removed the Mepilex to R51's left heel that was dated 2/6/24. The gauze portion of the dressing was noted to have a dark, sticky-appearing substance on ¾ of it once removed. The wound was approximately 1 ½-inches x 2-inches and had dark red outer aspects around the border, and the wound bed had tissue of light pink, red, and yellow color. The wound had an approximate depth of 0.2 millimeters (mm). RN-A cleanses the wound and asked NA-G to go find a similar dressing to the one removed. NA-G left the room. RN-A was unaware if R51 was on a turning and repositioning schedule and stated it would be on the care plan. RN-A verified R51 should have heel protectors on when in bed. RN-A stated NAs could find care-planned interventions for R51 on their NA care sheets. RN-A reported being responsible for spot-checking to ensure care-planned interventions are being implemented. NA-G returned to the room two minutes later and was unable to find a similar Mepilex dressing. RN-A used a larger Mepilex to cover the heel and then put on R51's gripper socks and heel protector. At 8:55 a.m., RN-B re-entered the room, removed R51's heel protector and gripper sock, used wound cleanser to loosen the Mepilex and removed the dressing. She repeated wound cleansing for the heel wound and stated R51's current orders for the left heel would is not a Mepilex, rather a nonadhesive dressing then wrap with Kerlix to cover. RN-B stated the Mepilex that was removed from 2/6/24 did not reflect correct orders and was most likely on in error due to not having the correct supplies during wound cares. At 9:30 a.m., R51 was sitting upright in his wheelchair with a left heel protector on. During observation on 2/7/24 at 1:31 p.m., NA-A and NA-G assisted R51 from his wheelchair to the bed. The NAs assisted R51 onto his back in the bed and elevated his heels on a pillow and applied the heel protectors. No offer was made by either NA to turn R51 onto his side before they left his room. At 1:36 p.m., NA-G verified that R51 had not been repositioned or offloaded out of his wheelchair since 9:30 a.m. after morning cares. During interview on 2/7/24 at 9:13 a.m., licensed practical nurse (LPN)-A stated interventions to reduce skin breakdown would be found on the care plan or the NA care sheets. LPN-A is unable to find a turning and repositioning schedule for R51 on the NA care sheet but acknowledged it should be listed on the care sheet. LPN-A stated that R51 does have a task on the TAR for nurses to document his turning in bed. LPN-A verified R51 has intervention listed on the NA care sheet to float his heels, however, stated it did not identify the heel protectors specifically. During interview on 2/7/24 at 10:28 a.m., RN-A reviewed R51's EHR and was unable to determine when his coccyx pressure injury worsened from a stage 2 to an unstageable. RN-A stated NAs were expected to use their care sheets to determine what interventions a resident needed during cares. RN-A verified that R51's care sheet did not include heel protectors or a turning and repositioning schedule. RN-A stated R51's care sheet did include that his heels should be floated. RN-A stated R51 should be on a turn and repositioning schedule and stated his care plan identified he should be turned as he allowed and with rounds. RN-A verified responsibility for updating the NA care sheets and stated there was no way for NAs to electronically chart if they had turned or repositioned R51. During interview on 2/7/24 at 12:09 p.m., the NP verified first seeing the coccyx wound in November and stated it had one open area. The NP stated when the wound was assessed on 1/24/24, there were two areas noted with one containing slough tissue in the wound bed. The NP stated the left heel wound was bothersome due to wound treatment orders not being followed. The NP did not believe order nonadherence contributed to the worsening of the left heel wound, however, the NP stated pressure was a contributing factor. Additionally, the NP stated the photographs of R51's wounds were not routinely reviewed but were assessed when the facility requested. During interview on 2/8/24 at 12:05 p.m., the regional nurse consultant and director of nursing (DON) stated wound management expectations included weekly wound monitoring, skin and wound assessments with pictures, measurements, orders, and progress. The regional nurse consultant and DON stated this was important to ensure wounds were not worsening and to prevent infections. Additionally, they stated the provider was expected to be updated weekly with wound rounds to ensure the correct orders are in place for wound management. They endorsed concern for orders not being followed. The regional nurse consultant and DON identified repositioning as a skin breakdown prevention intervention and stated resident-specific interventions should be on the care plan, orders, and NA care sheets. The regional nurse consultant and DON expected the NA care sheets to be updated as soon as a change was made. The regional health consultant and DON stated R51 should have been on a turning and repositioning schedule. The regional nurse consultant and DON stated the expected standard of care was not followed for R51. A policy, Hand Hygiene (Based Upon the CDC Guideline Hand Hygiene in Healthcare Settings) dated 7/2021, indicated proper hand washing techniques should be used to protect the spread of infection. Cleaning your hands reduces the spread of potentially deadly germs to the resident and reduces the risk of healthcare provider colonization or infection caused by germs acquired from the resident. Hand hygiene may occur multiple times during a single care episode. Additionally, the policy indicated alcohol based hand sanitizer was used after touching a resident or the resident's immediate environment, immediately before putting on gloves and after glove removal. A policy, Skin Management Program dated 9/2022, indicated all residents were assessed for skin integrity alterations or changes in skin conditions upon preadmission screening, admission, daily with POC and weekly with bath. The policy included the following bullets: establish risk for alteration in skin integrity, establish individual interventions needed to promote and or prevent alteration in skin integrity, monitor for healing process of alterations in skin. Documentation of the skin integrity, risk factors and evaluation of individualized interventions shall be done in clear and concise manner per the resident plan of care. A body audit was completed upon admission and weekly and as needed, a comprehensive skin and positioning evaluation was completed upon admission, quarterly, annually, and with changes in condition, weekly skin integrity evaluations were completed in the EMR for all alterations in skin integrity, and an individualized care plan will reflect approaches to stabilize reduce, or remove risk for pressure injury development and or promoting healing of existing alterations in skin. Daily skin wound monitoring will be completed for all residents on a daily basis that have any alterations in skin integrity until resolved. A policy, Person Centered Care Plan dated 12/2022, indicated a comprehensive person centered care plan was reviewed and revised annually, quarterly, with a significant change in status, and as needed. The comprehensive care plan is comprised of but not limited to NAR care plan, MAR, TAR, flow sheets, POC, engage documentation, weekly skin/wound documentation and physician orders. The overall person-centered care plan should be orientated towards: preventing avoidable declines, managing risk factors, include specific care goals, interventions should be individualized to the resident avoiding vague/non specific information such as offer preferred foods, offer activities etc. A PressureGuard Custom Care Convertible Owner's Manual undated, indicated the Custom Care Convertible is a non powered treatment surface featuring a patented air therapy design that automatically adjusts a network of interconnected air cylinders and elasticized reservoirs to the appropriate, therapeutic level, regardless of the user's weight or position. It is intended for use as a non-powered reactive therapy surface, or as a powered active therapy surface via the addition of a powered air control unit. The system consists of a foam shell with a high density zoned foam topper serving as the support surface underneath the patient. The foam shell also includes contoured foam bolsters at the sides and ends of the mattress, providing added patient stability and positioning. Within the foam shell is housed the inflation system, consisting of air cylinders which run lengthwise within the mattress. The optional, add on powered control unit connects to the mattress at the patient foot end and provides alternating pressure and rotation therapy modes. Custom care Convertible models are intended for the prevention and treatment of pressure ulcers. Powered modes are intended for active wound treatment, and may be indicated for use as a preventive tool against further complications associated with critically ill patients or immobility. Under the heading Control unit Functions: On/Off: Ensure On/Off switch is Off. Plug power cord into wall outlet. On/Off indicator light will illuminate in amber, indicating that the unit is drawing current but not yet powered up. Press on/off switch to ON. Indicator light will change to green, along with additional lights on control panel, indicating that the unit is powered up. Unit will resume the settings it was in when last powered down. Based on observation, interview, and document review, the facility failed to perform timely and accurate comprehensive skin assessments, follow prescribed wound care orders and implement interventions to promote healing for 2 of 3 residents (R2, and R51) who were admitted to the facility without pressure ulcers. This resulted in harm for R2 and R51 when R2 developed a pressure ulcer and the pressure ulcer worsened and R51 developed an unstageable pressure ulcer. Findings include: A stage one pressure injury is intact skin with a localized area of redness that is non-blanchable (does not turn white when pressed). A stage two pressure ulcer is partial thickness loss of the skin with exposed dermis, presenting as a shallow open ulcer. A stage three pressure ulcer is full thickness loss of the skin in which subcutaneous fat may be visible. Additionally, slough (non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture) or eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like) may be visible but does not obscure the depth of the tissue loss. A stage four pressure ulcer is full thickness loss of the skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and or eschar may be visible on some parts of the wound bed. Undermining and or tunneling often occur. If slough or eschar obscures the wound bed, it is an unstageable pressure ulcer. An unstageable pressure ulcer is obscured full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. If slough or eschar is removed, a stage three or stage four pressure ulcer will be revealed. If the anatomical depth of the tissue damage involved can be determined, then reclassified stage should be assigned. R2's Diagnosis form indicated the following diagnoses: other displaced fracture of upper end of right humerus (upper arm), chronic combined systolic congestive and diastolic congestive heart failure, unspecified dementia, chronic kidney stage 3, and postural kyphosis (an excessive forward curve of the spine). R2's admission Minimum Data Set (MDS) Optional State Assessment (OSA) dated 10/8/23, indicated R2 required extensive assist for bed mobility, transfers, eating, and toileting. R2's admission MDS dated [DATE], indicated R2 was at risk of developing pressure ulcers, had hallucinations, did not reject care, and did not have unhealed pressure ulcers. R2's significant change MDS OSA dated 12/5/23, required extensive assistance with bed mobility, transfers, and toileting. R2's significant change MDS dated [DATE], indicated R2 had moderate cognitive impairment, rejected cares 1 to 3 days, had one stage three pressure ulcer. The MDS further indicated skin and ulcer treatments included a pressure reducing device for the chair, bed, nutrition or hydration interventions to manage skin problems, pressure ulcer care and applications of ointments or medications other than to feet. R2's Braden Scale for Predicting Pressure Sore Risk form dated 12/1/23, indicated a score of 15, indicating R2 had a mild risk for pressure ulcer development. R2's pressure ulcer/injury Care Area Assessment (CAA) dated 10/8/23, indicated R2 had a potential for pressure ulcers and contributing factors included activities of daily living (ADL) and mobility impairment, and incontinence. Further, nurses assess skin weekly and initiated proper interventions to prevent skin breakdown if needed and the care plan would be reviewed to decrease the risk for pressure ulcers. R2's pressure ulcer/injury CAA dated 12/19/23, indicated pressure ulcer objective was for improvement, due to an actual pressure ulcer and contributing factors included ADL and mobility impairment, cognitive loss, incontinence, and pain. A licensed nurse assesses skin each week and skin was also assessed by caregivers with each bath and each time the resident was dressed. Caregivers assist with repositioning at least every two hours and as needed for comfort and a care plan would be initiated to improve actual pressure ulcer by decreased size and condition and decrease further pressure ulcer risk. R2's Dashboard in the electronic medical record (EMR) indicated R2 was 69 inches tall and weighed 130.2 pounds on 1/9/24. R2's care sheet dated 2/2/24, indicated R2 required assist of two for bed mobility, repositioning, had an air mattress, and a Tilt N Space wheelchair, was incontinent and was to be toileted upon rising, before and after meals, at bedtime and as needed. The care sheet lacked information that resident had a pressure ulcer on her sacrum and lacked interventions how to reposition, and how often to reposition and offload when in the wheelchair. Additionally, the care sheet lacked information on how to determine whether the air mattress was on. R2's care plan revised 12/5/23, indicated R2 refused repositioning, cares, and medications and an intervention included to attempt redirection. R2's care plan revised on 1/24/24, indicated R2 required partial to moderate assistance of 1 for bed mobility to roll left and right. R2's care plan revised on 1/24/24, indicated R2 had a stage three pressure injury to the coccyx (tailbone). Interventions included keeping linens dry, observing skin during cares and reporting changes to the nurse, pressure relieving support surfaces in bed and chair, air mattress on the bed alternating, and weekly skin inspections. Interventions were later added on 2/6/24, that included: attempt to reposition off area and not position on area when possible, daily wound monitoring in place, educate, cue and assist with repositioning and offloading, see skin and wound tab for current skin measurements and interventions. Additionally, an intervention was later added on 2/7/24, to ensure the alternating air mattress was plugged in and in working order and report to the nurse if it was not working. R2's Air Mattress task form obtained 2/8/24, indicated staff were to ensure an alternating air mattress was plugged in and in working order and report to the nurse if not working. During a 30 day look back period, no data was found to indicate staff were checking the air mattress. R2's Behaviors task form obtained on 2/6/24, from 1/8/24, to 2/6/24, indicated R2 did not have any behaviors of refusals, or rejection of care or treatments in the last 30 days. R2's Bed Mobility Self Performance task form obtained on 2/6/24, indicated from 1/8/24, to 2/6/24, R2 required mostly extensive assist with bed mobility, but did not refuse. R2's Skin Observation form from 1/8/24 to 2/6/24, indicated R2 did not refuse. R2's Transfer Support Provided form from 1/9/24 to 2/7/24, indicated R2 did not refuse transfers and mostly required two person physical assist. R2's Amount Eaten form from 1/8/24 to 2/6/24, indicated R2 mostly ate 51 to 75% of meals. Nurse practitioner's (NP)-A's nursing home regulatory progress note dated 12/6/23, indicated R2 had a stage two pressure injury to the sacral region that was improving per staff reports and approved an order for an air mattress. Medical director's (MD) progress note dated 1/15/24, indicated R2's pressure injury had increased in size per nursing report, and under the heading, Exam indicated a large wound over the buttock just behind anal canal, soiled with watery stool. There was a thick band of necrotic tissue attached at 1 o' clock. The wound base had good granulation tissue. The progress note further indicated the wound was a stage three pressure wound over the sacral area and oxycodone (a narcotic used to treat pain) 2.5 mg was ordered prior to wound change due to unbearable pain. NP-A's nursing home progress note dated 1/24/24, indicated R2 had a stage three pressure injury and did not see the wound the week prior. Additionally, the note indicated NP-A had ordered Vashe (a wound cleanser that inhibits microbial contamination, loosens exudate, slough, and other foreign materials from the wound bed) for the wound but was not available per the nurse and had also ordered Iodoform (used to drain exudate from tunneling wounds that are open and or infected) to pack the wound, which was also not available. The wound had a moderate amount of foul smelling drainage present on the wound and R2 could benefit from calcium alginate and planned to continue with a wet to dry dressing and change twice daily and may need to increase the frequency of the dressing changes. NP-A's progress note indicated R2 should off load as much as possible. R2's physician's orders dated 11/28/23, indicated a body audit was completed every week on Tuesdays. Additionally, physician orders on 1/18/24, indicated the following wound care orders for R2's coccyx wound: clean wound with Vashe, wet to dry dressing with normal saline, Iodoform gauze in areas of tunneling, then gauze, then ABD (abdominal gauze pad) and apply skin prep around wound change twice daily. R2's Comprehensive Skin and Positioning Evaluation note dated 12/1/23, indicated R2 had immobility/contractures and was confined to her bed or the chair all or most of the day and had a pressure reducing device for the chair and bed and application of ointments or medications other than to feet. R2's Comprehensive Skin and Positioning Evaluation form dated 2/6/24, indicated R2 had immobility/contractures, refused cares and or treatments, was confined to the bed or chair all or most of the day, was on an antidepressant, narcotics, and opioids, had a pressure ulcer over a bony prominence, had thin fragile skin, and approaches included: a pressure reducing device for the chair, turning and repositioning program, pressure ulcer injury care, and application of a nonsurgical dressing other than to feet. R2's Occupational Therapy (OT) note dated 1/24/24, indicated the followi[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to reduce the risk of accidents to prevent falls for one of one resident (R1) reviewed for falls with injuries. The facility failed to assess and add interventions following a positive Covid diagnosis with symptoms increasing the potential R1's risk for falls and did not comprehensively analyze and update the care plan with appropriate interventions following a fall that resulted in new fractures. Findings include: R1's progress noted dated 11/21/23 indicated R1 was admitted to the facility from a hospital 11/21/23 with a primary diagnosis of a spinal surgery following a fracture in his back in the 11th and 12th lumbar vertebra that resulted from a fall at home. R1's admission Minimum Data Set (MDS) dated [DATE] indicated R1 had a Brief Inventory of Mental Status (BIMs) score of 11 indicating R1 had moderate cognitive impairment. R1 required moderate assist with toileting, upper body dressing and transferring. R1 required maximum assistance with showering, and lower body dressing and putting on shoes. R1's progress note dated 11/29/23 at 1:09 p.m. indicated R1 tested positive for Covid-19. R1's progress note dated 11/30/23 at 5:25 a.m. indicated R1 was having dry heaves and later had emesis. R1 had a nonproductive cough and a light pink color in his urinal. R1's progress note dated 11/30/23 at 9:21 a.m. indicated R1's oxygen saturation rate was 93% on room air. R1 exhibited a cough and gastrointestinal symptoms. R1's progress note dated 12/1/23 at 5:25 a.m. indicated R1's oxygen saturate rate was 90% on room air. R1 gastrointestinal symptoms and a cough. R1's progress note dated 12/2/23 at 4:53 a.m. indicated R1's rate was 90% on room air and R1 continued to exhibit a cough and body aches. R1's progress note dated 12/3/23 at 1:37 p.m. indicated R1 complained of pain with movement, repositioning and transfers. R1's incident report dated 12/4/23 at 4:41 indicated R1 was heard yelling down the hallway, R1 was found on the floor in his room lying on the floor next to his bed. R1 was confused, making groaning sounds and complaining of lower abdominal pain. The note indicated R1 was mechanically lifted to bed and assessed for injury. At that point he did not complain of pain. He had full range of mouth in his neck, arms, and legs. R1's temperature was 100.6 with all other vital signs stable. R1 was not sent to the hospital. He had a head strike with a laceration on the back of his head. In addition, the incident report indicated R1's room had poor lighting, R1 had a recent change in condition, was confused and had a recent illness. R1 was ambulating without assistance. The incident report did not indicate any new fall prevention interventions. R1's progress note dated 12/4/23 at 4:41 a.m. (a late entry) indicated R1 had an unwitnessed fall. R1 was witnessed to have hit his head with a laceration. There were no further notes on the laceration. R1's mental staff was oriented to person, place, and time. R1 was attempting to transfer without using his call light. There were no recent changes to may have contributed to the fall. No new interventions were put into place and no potential of root cause was identified. A Post Fall Data Collection document dated 12/4/23 indicated that R1 fell and was found on the floor in his room with a laceration to the back of the head. It was indicated that R1 did not activate his call light for assistance, and R1 was capable and had historically used the call light. The report indicated that R1 was not transferred to the hospital. The Post Fall Data Collection Assessment did not indicate or include any environmental factors that may have contributed to the fall, vital signs, blood sugars, or last urination/bowel movement. The interventions that were indicated was for R1 to always have gripper socks on, and other fall interventions but was not specified on the report. The report indicates that the care plan and nursing care sheets were reviewed, and no changes were indicated. R1's progress note dated 12/4/23 at 9:43 a.m. indicated R1 was transferred to the hospital. There was no documentation as to the reason he was sent to the emergency department. R1's progress note dated 12/4/23 indicated the hospital called and stated R1 was being admitted with Covid and a fracture of the 5th vertebra. R1's hospital discharge date d 12/7/23 indicated R1 reported he was trying to transfer from his wheelchair to another chair and fell to the floor hitting his head. Spine imagining identified a fracture at through L4 and L5. In addition, R1 was admitted for hypoxia secondary to Covid, with suspected superimposed bacterial pneumonia and borderline/early sepsis. R1's care plan dated 12/7/23 did not indicate any indications on how R1 was to be transferred. In addition, the care plan did not indicate R1 was positive for Covid with any interventions and did not indicate any fall preventions prior to or to the recent fall on 12/4/23 with the new fracture. R1's Post Fall Data report dated 12/17/23 indicated that R1 fell and was found on the floor in his room. The report stated that R1 lost his balance while trying to reach for his pillow that fell on the floor. The report indicated no apparent injuries. The report indicated R1 had an overall decline in his health in the past few months. R1 was not transported to the hospital. The specified intervention was to remind R1 to use his call light. The report indicated the care plan and nursing care sheets were reviewed and no changes indicated. R1's fall report dated 12/17/23 indicated the immediate intervention was to ensure items are within reach for R1. R1's progress note dated 12/17/23 at 11:56 p.m., indicated that R1 had a fall and to see the care plan for interventions put into place. R1's care plan dated 1/9/24 did not indicate that R1 had recent falls or that R1 should be always wearing gripper socks, to keep items within reach or how to transfer R1. During an on 1/10/24 at 9:57 a.m. Physical Therapist (PT)-A the director of rehabilitation services stated that when a resident falls the staff will reach out to him for interventions during the interdisciplinary team (IDT) meeting and ask if he has any suggestions on interventions. He stated he did not recall what interventions were put into place after R1 had his fall on 12/4/23 or 12/17/23. PT-A denied reassessing R1 following his Covid diagnosis for any increased interventions due to the pain, gastrointestinal symptoms, and weakness. During an interview on 1/10/24 at 11:30 a.m., RN-D stated that after R1 fell on [DATE] she had sent him to the hospital for further evaluation. RN-D stated that PT and Occupation Therapy (OT) did not give the nursing staff any interventions for R1 and stated she was uncertain how R1 was to have been transferred. She was unaware that R1 had another all on 12/17/23. During an interview on 1/10/24 at 12:19 p.m., LPN-D stated that she did not know of any interventions that were in place after R1's fall on 12/4/23. LPN-D stated that she does not remember anyone telling her about R1's fall from 12/4/23 or 12/17/23. During an interview on 1/10/24 at 2:33 p.m., the director or nursing DON stated that when a resident falls, she will be notified by the nurse on duty, or the on-call nurse and they will then put add new interventions following an assessment to the care plan. The DON stated that it is ultimately the responsibility of the nurse on duty or the nurse manager to put the interventions into the residents' care plans. She stated after a fall a new intervention should always be placed on the resident. The DON stated she was uncertain of any increased interventions were set in place for R1 following the Covid-19 diagnosis. A policy provided by the facility called Fall Risk and Prevention Policy and Procedure effective 11/2014 and revised on 8/2022 indicated it is the responsibility of the director of nursing services (DNS)/ director of health services (DHS) and/or delegate to monitor these preventative measures to assure they are in place. The policy indicates that all interventions are to be listed on the skilled nursing facility (SNF) Care Plan and the NAR Care Plan/home health aide (HHA) Care Plan. The policy indicates an immediate action post fall procedure is that post fall interventions are implemented.