**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure a transfer belt to assist with a safe transfers for 1 of 3 residents (R1) reviewed for falls. This resulted in actual harm for R1 who fell when being transferred without a transfer belt, which which resulted in a fall with a pelvic fracture and subdural hematoma (brain bleed) requiring hospitalization. This deficient practice is being cited at past non-compliance related to corrective action taken to ensure proper use of transfer belt prior to the survey. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 had intact cognition with diagnoses of stroke with left sided hemiplegia (paralysis on one side of body) and a history of falling. R1 required extensive assist of one staff with bed mobility, dressing, toileting, and transfers. R1 had functional limitation in range of motion (ROM) on one side of upper and lower extremity and used a walker and wheelchair for mobility. R1 had a history of falls prior to admission. R1's care plan dated 12/18/23, identified R1 was at risk for falls. R1 was able to transfer with an assist of one with a gait belt. R1 needed an assist of one staff with toileting. R1's Fall Risk assessment dated [DATE], identified R1 was at high risk for falls due to having a balance problem while standing and walking, decreased muscular coordination, change in walking pattern when walking through a doorway, jerking and unstable when making turns, and required the use of assistive devices. R1's Incident Audit Report dated 1/11/24, identified a fall occurred at 4:10 a.m. The nursing assistant stated R1 stood up from the toilet, went to leave the bathroom and R1's legs gave out. R1 landed on her bottom and bumped their head on the wall. R1 stated their legs gave out and she went down and bumped their head. R1 was instructed to let staff know if she was feeling weak. R1 had an cut to the right elbow and the care plan was reviewed on 1/22/24. The report did not identify if a transfer belt was in use during the fall. R1's progress note dated 1/11/24, identified at 4:10 a.m. R1 had a witnessed fall in the bathroom and hit the back of R1's head on the wall. There was no bruising. A transfer belt and gripper socks were in use (although, interviews below determined the transfer belt was not in use). R1's Post Fall Huddle Form dated 1/11/24, identified at 4:10 a.m. R1 had a fall while using the walker. Root cause of fall indicated that R1's legs gave out. A new intervention was added for R1 to alert staff if R1 was feeling weak. R1's provider visit dated 1/11/24, indicated R1 sustained a fall that morning and R1 hit their head. R1 was taking a blood thinner after a recent stroke and had a hematoma (a solid swelling of clotted blood within the tissues)present on the back of R1's head. R1's hip was injured and not able to bear weight or pivot due to severe pain. Physical therapy (PT) evaluated R1 with worry that R1 might have a pelvic fracture. Recommendation for R1 to be seen urgently to the emergency department with computed tomography (CT) [an imaging test] of head to rule out intracranial bleed as well as trauma evaluation of hip/pelvis. R1's progress note(s) identified the following: - 1/11/24, at 11:08 a.m. R1 was sent to the emergency department (ED) for evaluation following fall with hematoma to the back of head and pain in the pubic area and unable to bear weight. - 1/11/24, at 11:38 p.m. family member (FM)-A called to give an update that R1 was being placed in observation at the hospital with a small brain bleed. R1's After Visit Summary (AVS) dated 1/16/24, identified R1's hospital stay in the trauma critical care general surgery (TCGS) from 1/11/24 to 1/16/24 for management of trauma related injuries. Final diagnoses sustained from R1's fall included subdural hematoma (bleeding in the brain from a traumatic incident such as a blow to the head), fractured pubic (crack or break in pelvis). During an interview on 1/18/24 at 2:54 p.m., physical therapy assistant (PTA)-A identified R1 was in therapy for strengthening, mobility, transfers, and balance since admission and needed minimal assist with transfers and maximum assist for hygiene and toileting tasks. PTA-A stated it was important to use a transfer belt to stabilize a resident when moving, for balance purposes and recommended that all residents use transfer belt for transfers unless contraindicated. During an interview on 1/18/24 at 2:56 p.m. physical therapist (PT)-A stated on 1/11/24, in the late morning a bump was found to the back of R1's head. PT-A stated R1 was adamant that no gait belt was used during the transfer when R1 fell earlier the morning of 1/11/24. On 1/18/24 at 4:02 p.m., R1 was observed seated in the recliner with legs elevated in R1's room. R1 stated early in the morning on 1/11/24, R1 was helped to the bathroom, using a platform walker (a walker used for patients who can't use both hands). Upon standing up from the toilet, nursing assistant (NA)-E was standing next to R1's left side. R1 did not have a transfer belt on. R1 stated, I would have waited for one, I made it a few steps, lost my balance, and fell right by the shower landing on my butt and hit my head on the wall. R1 noticed a difference in her walking and had an intense level of left sided groin pain. R1 stated the next thing you know I was being hauled to the hospital by an ambulance. During a phone interview on 1/22/24 at 11:49 at a.m., registered nurse (RN)-A identified on 1/11/24 before 6:00 a.m., RN-A was notified by NA-E that R1 fell in the bathroom. RN-A assessed R1 and R1 had no pain or injury that was identified. RN-A walked R1 back to bed. RN-A stated it was a professional standard of practice to use of a transfer belt with a resident who needed extensive assist of one. During a phone interview on 1/22/24 at 12:06 p.m., NA-E stated on 1/11/24 around 4:00 a.m., NA-E walked R1 to the toilet without a transfer belt as the transfer belt could not be found. R1 stood up from the toilet took two steps and R1 stated, I feel like my legs are spaghetti. R1 had the walker and NA-E stood to R1's left side. Then boom down R1 went. R1 hit her head and sustained a skin tear to the left elbow. R1 was assisted to the wheelchair and pivot transferred back to bed with the transfer belt. Although RN-A stated RN-A had walked R1 back to bed During an interview on 1/22/24 at 12:24 p.m., director of nursing (DON) identified R1 had a fall on 1/11/24. NA-E assisted R1 off the toilet without a transfer belt and when R1 got weak R1 fell resulting in a head strike. The use of the transfer belt with extensive assist of one staff would be a professional standard of practice. R1 fell because there was not transfer belt in use when R1's legs gave out. The facility started education with staff about the importance of transfer belt use and will be getting command hooks to put up in the bathroom where a gait belt would be available for all staff to use so there is a transfer belt always available. They had a plan in place to ensure all staff were educated on the use of transfer belts. During an interview on 1/23/24 at 9:34 am licensed practical nurse (LPN)-A any resident who is extensive assist with transfers we would use a transfer belt for safety. If a resident was weak or start to fall staff would have something to hang on to. During an interview on 1/23/24 at 9:37 a.m. occupational therapist (OT)-A identified staff should be using a transfer belt with all residents as long as they were not independent. The facility started writing on the resident whiteboards to use a transfer belt along with the residents transfer status as a cue to staff. The use of a transfer belt is our expectation. During an interview on 1/23/24 at 9:38 a.m. trained medication aide (TMA)-A stated a transfer belt should always be used for any resident who required extensive assist, because they could have problems with their balance. During an interview on 1/23/24 at 9:43 a.m. (NA)-F stated when someone required extensive assist with transfers you would always use a transfer belt. A transfer belt was used for stability and safety in case the resident got weak and fell. . During an interview on 1/23/24 at 9:47 a.m. NA-A stated a transfer belt should always be used when a resident required extensive assist with transfers. NA-A would use a transfer belt with anyone so if they get weak you have something to hang onto, it can help prevent a fall, if a resident refused the gait belt NA-A would go get the nurse. During an interview on 1/23/24 at 9:48 a.m. NA-G stated a transfer belt should be used when a resident required extensive assist with transfers. Using the transfer belt gave more support and safety, if someone's leg gives out you, have a better chance of keeping them safe. During an interview on 1/23/24 at 9:49 a.m., NA-H stated that transfer belt requirements are located in the care plan or [NAME]. NA-H stated that use of a transfer belts were promoted at the facility. The facility provided undated [NAME] included direction that R1 was able to ambulate short distances in R1's room with assistance of one staff, walker and transfer belt. During an interview on 1/23/24 at 9:50 a.m., NA-I stated that a transfer belt was used for any resident that does not use a machine lift. A transfer belt was used when walking residents and if a resident refused the gait belt education would be provided on transfer belt safety for the resident. During the survey resident observations and resident and staff interviews identified the facility was using transfer belts during all non-mechanical transfer that required staff assistance and the facility had corrected the non-compliance of not transferring residents without a transfer belt who required the use of a transfer belt prior to entrance on 1/17/24, prior to survey entrance. The facility policy Fall Prevention and Reduction Policy revised 8/2023, identified individual fall precautions and interventions would be developed for all residents who admit to the facility. The facility would implement appropriate gall interventions and precautions. A transfer belt policy was requested and not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R44 According to R44's electronic health record (EHR) admission record/face sheet included diagnosis of chronic congestive heart failure, cardiomyopathy (damaged heart muscle), high blood pressure, chronic obstructive pulmonary disease, shortness of breath, a dependence on supplemental oxygen and a history of pleural effusion (fluid in lungs). R44's quarterly Minimum Data Set (MDS) assessment dated [DATE], R44's primary medical condition was considered to be a medically complex condition. R44's physician orders instructed nursing staff to monitor and evaluate R44 for fluid overload and reduce the risk of fluid overload. The following orders included: 2 L (liters) fluid restriction-document total consumed each shift. NOC (night shift) will total every day shift, Document progress note with total 24 hour fluids consumed; Daily weights-->notify provider if >189 lbs in the morning; Document progress note on edema location, pitting edema noted, skin intact (fluid weeping) lung sounds, weight, CNP [certified nurse practitioner] followed up on 8/13/21 and increased torsemide [diuretic]. Edema to BLE [bilateral lower extremities]. Every evening shift until resolved, Wrap legs daily with ACE bandages on in am and off at HS [bedtime]. R44's orders also included medications to control heart, blood pressure and to relieve edema: Metoprolol succinate capsule ER 24 hour sprinkle 25 mg, give 12.5 by mouth in the morning, Spironolactone tablet, give 50 mg by mouth one time a day, Torsemide tablet 20 mg, give 40 mg by mouth two times a day. R44's Torsemide dose had increased on 8/13/21 from 20 mg to 40 mg and increased again on 8/16/21 to be taken twice a day instead of once per day. A review of R44's daily weight was not recorded on 9/3, 9/5, 9/10 or 9/11. On 9/12, 9/13 and 9/14 his weight exceeded 189 pounds. A physician order dated 8/14/21 included instructions for a progress note to be written daily on R44's edema location, pitting edema noted, skin intact (fluid weeping), lung sounds and weight. A review of R44's record for September identified missing progress notes for 9/9/21-9/11/21 no note related to edema, weight, or lung sounds 9/12/21-weight was taken after lunch. Will reweight [sic] tomorrow and reassess. Resident is asymptomatic. No additional information related to edema or lung sounds. 9/13/21-no note related to edema, weight, or lung sounds 9/14/21 at 3:42 p.m. assessment conducted: resident is alert and oriented x3, oxygen levels 92-93% on 1 L, wheezing auscultated bilaterally, 4+ edema of R and L extremities. Weight for today 190.2 lb. Nurse manger notified of change in weight, ACE wrap applied, resident left building for scheduled appointment. On 9/14/21, at 8:19 a.m. R44 was observed lying in bed in his room, resting. His facial appearance and limbs was red and flushed. A one liter jug of ice water was noted to be sitting at his bedside. An oxygen concentrator was beside the bed and was running, but R44 did not have a nasal cannula in his nose. On 9/14/21, at 8:43 a.m. R44 was observed sitting on the side of his bed. His legs were bare and swollen from the knees down. R44 had difficulty speaking, but was able to communicate through short phrases, gestures, some writing and answering yes, no questions. He indicated he had noticed his legs were swollen and gestured to show they were getting bigger. He also tapped on his abdomen. He indicated his legs should be wrapped. His hands were slightly swollen and he held them up to be seen. On 9/14/21, 12:03 p.m. R44 was observed to be lying in bed with his legs bare. Registered nurse (RN)-C entered the room with two elastic compression wraps and informed R44 he should have his legs wrapped before going out for the day. RN-C started wrapping R44's right leg at the toes and performed a figure eight wrap. He asked, do you like it tight? No, just a little loose? After reaching R44's knee, there was a considerable amount of wrap still on the roll, so RN-C proceeded to wrap the leg back down to the ankle. Following the right leg, RN-C wrapped the left leg in the same manner. RN-C stated the wraps were too long, and that he should have gone to find different wraps; however, RN-C did not go find any other wrap. At 9/14/21, 12:15 p.m. R44 indicated he had not been weighed. RN-C stated R44 was to be weighed every day. RN-C called to a passing nursing assistant (NA-F) who said R44 had not been weighed. Another nursing assistant, NA-C stated daily weights were to be done every morning as soon as possible, before eating and confirmed that R44 had not yet been weighed for unknown reasons. NA-C weighed R44 and reported a weight of 195 lbs. During an interview on 9/14/21 at 12:17p.m. RN-C confirmed that R44 had an order to monitor edema. He stated the best way to assess edema was to squeeze the feet and watch how much indent would occur and confirmed he had not done this but would do it later. RN-C noted R44's weight should be re-checked because it was more than the day before. RN-C confirmed he had been working the day before and had documented a weight of 191.6, but had not called the medical provider, stating he had not seen the order to call the provider for a weight greater than 189 lbs. RN-C stated an increase in weight and edema indicated a possible fluid overload. According to an interview 9/14/21, 12:42 p.m. the nurse manager for the unit, RN-D, said a daily weight was to be done before breakfast, and edema monitoring and compression wraps should also be done early in the morning. Edema monitoring, RN-D confirmed, should be accomplished prior to the application of the compression wraps. RN-D stated a nurse should find a shorter set of compression wraps if the ones they had were too long. RN-D said a nurse should notify medical providers when a resident has a change in condition or when an order was left for notifications to be done. The expectation for notification method would be to write out an SBAR (situation, baseline, assessment, result/request) form and send it to the provider immediately, but any nurse should also be able to call a provider with a report. RN-D was not aware of any guidelines saying it must be the nurse manger to call. RN-D confirmed that R44 had an order for a daily weight to be done, but upon review of his EHR stated, it has not been done daily. RN-D stated an expectation of nurses to document on R44's condition in a daily progress note as outlined in his orders with lung sounds, edema, changes in weight, but confirmed that this information was not done daily, saying, it looks like there is no documentation since the 12th. According to an interview 9/14/21, 12:57 p.m. with the director of nursing (DON) the DON stated an expectation that daily weights be done at the same time each day, preferably right away upon rising before breakfast. DON also stated an expectation for compression wraps to be applied before getting up for the day. In relation to monitoring edema, DON stated some physicians like to have edema checked later in the day, such as in the afternoon, to see if the condition progresses when the resident is up, but in general, edema monitoring should be done in the morning prior to the application of the compression wraps. DON said that when monitoring a resident for problems with fluid excess it was expected that nurses would do daily weights, monitor lung sounds, vital signs and sometimes abdominal girth if ordered. DON stated any orders should be initialed as being completed in the treatment administration record (TAR), but a progress note should be written as well. During an interview 9/15/21, 8:46 a.m. with the facility medical director (MD-A), he stated he was watching R44's condition closely as he had a perplexing presentation, their interventions had not been fully successful and R44's clinical trajectory continues to decline. MD-A stated unchecked fluid intake would be problematic, although he was currently stable. The primary concern for R44, according to MD-A was an exacerbation of his heart failure. A request was made of the facility for a policy on fluid/edema management and monitoring, but this was not provided. The Heart Failure-Clinical Protocol policy revised November 2018 covered only expectations of physicians and did not address nursing care. Based on observation, interview, and document review, the facility failed to ensure appropriate assessment, monitoring and physician notification were completed for 3 of 3 residents (R48, R36, R44). This resulted in actual harm when R48 required re-hospitalization with fluid overload resulting in respiratory failure and acute on chronic congestive heart failure. Findings include: R48's facility face sheet identified R48 was admitted to the facility on [DATE], with diagnoses of heart failure, chronic obstructive pulmonary disease, and hypercapnic respiratory failure. R48's physician visit dated 7/30/21, included R48 had leg swelling and his weight was 333.8 lbs. (pounds). Plan was to continue Lasix 40 milligrams [mg], will adjust if needed, nursing to monitor weight, Check daily weight notify provider if gain 2 lbs. in a day or 5 lb. in a week. R48's physician orders reviewed, included the following -Daily weights, notify physician for weight gain over 2 lbs. (pounds) in a day OR 5 lbs. in a week (start date 8/2/21) -Lasix 40 mg (milligrams) one time a day for congestive heart failure (start date 7/31/21) -Occupational therapy wrap bilateral lower extremities Monday through Friday (start date 8/6/21) R48's admission assessment dated [DATE], indicated R48 had +3 pitting edema in both lower extremities; location in the lower extremities was not identified. R48's admission Minimum Data Set (MDS) dated [DATE], identified R48 did not have cognitive impairment, required extensive assistance of two or more staff members for activities of daily living that involved mobility and extensive assist of one staff for personal hygiene and dressing. The MDS indicated R48 was administered diuretic medications. R48's care plan dated 8/6/21, indicated R48 had a diagnoses of congestive heart failure with corresponding interventions, compression stockings on in the morning off and night, physician to assess medication program periodically, medications as ordered, staff to observe for signs and symptoms of increased edema, significant weight changes, increase shortness of breath/new shortness of breath, and notify physician as needed, and weight at least weekly, or as ordered by physician, notify physician of significant weight gain. R48's record indicated on 8/6/21, physician ordered a chest X-ray to rule out tuberculosis. R48's chest X-ray results on 8/11/21, indicated R48 had patching opacification (air in lungs replaced with other material such as fluid or bacteria) in the right lower lobe, and small pleural effusion (water on the lungs). The report also included Patchy right lower lobe infiltrate is seen, follow up exam recommended). R48's weight record identified over 2 lb. weight gain in a day without evidence of physician notification per physician order. -On 8/3/21, weight was 330.4 lbs. -on 8/4/21, weight was 334.2 lbs. -On 8/5/21, weight was 339.0 lbs. -On 8/7/21, weight was 343.0 lbs. -On 8/9/21, weight was 343.0 lbs. R48's record lacked evidence of daily weights on 8/10/21, 8/11/21, 8/12/21, and 8/13/21. R48's progress note dated 8/13/21, at 7:39 a.m. included, Resident had a sudden onset of shortness of breath around 4:00 a.m. Resident appeared pale/cyanotic. Resident initially had head of bed elevated, and oxygen increased to 3 liters per minute (LPM). Lung sounds clear/diminished. Vital signs: blood pressure 146/85, Pulse of 90, respirations 28, and oxygen saturations 80%. Resident requested to be placed in a tripod position, fellow nurse assisted to position, and one on one supervision initiated. Resident refused ambulance services. Symptoms resolved approximately 30 minutes after onset. Resident requested to be put back to bed with head of bed elevated. Every one-hour checks initiated, morning staff notified of incident and sent physician notification. R48's progress note dated 8/13/21, at 10:30 a.m. indicated R48 was transferred to the hospital via ambulance related to shortness of breath and low oxygen saturations. R48's Discharge summary dated [DATE], indicated primary diagnosis for admission was hypercarbic (increase in carbon dioxide in the bloodstream)respiratory failure and acute on chronic congestive heart failure. The summary indicated between hospital discharge on [DATE] and hospital admission on [DATE], R48 had an 8.8 lb. weight gain. The summary indicated 1.5 liters of fluid was removed from R48's lungs. The discharge summary included new orders to change diuretic from Lasix to Torsemide and add 2-liter fluid restriction. R48's physician orders between 8/25/21 to 9/13/21 included: -Daily weights, notify physician for weight gain over 2 lbs. in a day OR 5 lbs. in a week (start date 8/25/21) -Fluid Restriction: 2 Liter-Document in progress note with total 24-hour fluids consumed (Start Date 8/25/21) -Torsemide 60 mg one time a day related to heart failure (start date 8/25/21) -Compression Stockings: Donn in a.m. prior to getting out of bed. Remove in evening once in bed (start date 8/25/21) R48's weight record was reviewed from 8/25/21 to 9/13/21; record lacked physician notification in accordance with physician orders until 9/7/21. -On 8/25/21, weight was 303.0 lbs. -On 8/26/21, weight was 308 lbs. -On 8/28/21, weight was 307.2 lbs. -On 9/2/21, weight was 310.0 lbs. -On 9/3/21, weight was 312.6 lbs. -no weight was recorded on 9/4/21 according to physician's orders -On 9/5/21, weight was 315.0 lbs. -On 9/7/21, weight was 315.0 lbs. R48's physician notification dated 9/7/21, indicated R48 had a 13 lb. weight increase since 8/31/21 with no other symptoms. The note indicated R48 had +2 pitting edema to both lower extremities. The note also included, He does have some complaints of shortness of breath with exertion but is able to catch his breath when at rest. Lungs are clear bilaterally anterior and posterior. R48's fluid intake record was reviewed along with nursing progress notes for the 24-hour fluid intake evaluation. Fluid intake was not consistently documented every shift; with the lack of documented intake on the 24-hour fluid intake it could not be calculated/reviewed in accordance to the fluid restriction. R48's record identified between 9 different shift when R48's fluid was not monitored or documented from 8/25/21 to 9/13/21. During an observation and interview on 9/13/21, at 1:43 p.m. R48 sat up in his wheelchair. R48 stated he was in the hospital a couple of weeks ago for fluid overload and they had removed 24 liters of fluid. R48 stated when he got back from the hospital, he weighed 303 lbs. but was back up again to 315 lbs. R48 stated before he went to the hospital, he had been around 330 to 335 lbs. R48 stated he had felt so much better after all the fluid was removed, and thought it had steadily progressing over time, and indicated he would have to pay closer attention to his weight gains. During an interview on 9/15/21, at 8:24 a.m. medical director stated there were clear expectations nursing notify the physician when there was a weight gain in accordance with physician order. Medical director indicated the most objective measurement for fluid volume monitoring is weight gain. Medical director stated nursing needed to be monitoring/evaluating edema for the effectiveness of the treatments and medications. During an interview on 9/15/21, director of nursing (DON) stated she expected the physician be notified of weight gain in accordance with physician orders. DON stated the expectation of monitoring edema daily and findings documented accurately. DON stated if there was a weight gain, an evaluation needed to be done to determine if the weight gain was related to fluid, the evaluation should include a complete respiratory assessment, resident interview, and assessing for edema in extremities, hips, and abdomen. DON indicated if there was a change the physician needed to be notified. DON stated the episode of shortness of breath should have been documented in its entirety with a complete assessment and passed along in shift report for continual monitoring. R36 R36's face sheet indicated R36 was admitted to the facility on [DATE], with diagnoses of congestive heart failure, chronic kidney disease stage 4, and hyperkalemia. R36's hospital Discharge summary dated [DATE], indicated R36 was admitted in part related to fluid overload with a primary diagnosis of hyperkalemia (high potassium) and had a history of hospitalization for heart failure exacerbation with the last visit in May 2021. The discharge summary included, would recommend short term rehab to allow for closer monitoring of his weights/fluid status to determine appropriate dosing of diuretic in the outpatient setting. The summary indicated R36's dry weight of 303.6 lbs. The discharge summary also included an order for daily weights with close monitoring. R36's physician orders included: -Daily weights notify physician for weight gain of over 2 lbs. in a day or over 5 lbs. in a week (start date 7/23/21). -Lasix (diuretic medication) 10 mg (milligrams) in the morning for fluid retention's (start date 7/23/21). R36's care plan dated 7/25/21, identified R36's diagnosis of congestive heart failure. Associated interventions included, elevate feet when sitting up in chair to help prevent dependent edema, monitor for signs and symptoms of hypovolemia/hypervolemia [medical condition when you have too little/too much fluid in your body], monitor/document/report to MD as needed the following signs/symptoms: Edema; weight gain of over 2 lbs. a day; neck vein distention; difficulty breathing; increased heart rate; elevated blood pressure; skin temperatures; monitor breath sounds for crackles. R36's physician visit dated 8/27/21, indicated R36's weight was stable on low dose of Lasix; weight was 299.6 lbs. and on admit on 7/20/21 was 298 lbs. R36's weight record reviewed between 8/27/21 and 9/13/21, identified an increase in weight over 2 lbs. in a day or over 5 lbs in a week; record lacked evidence of physician notification. R36's weights included: -On 8/28/21, weight was 302.2 lbs. -On 8/30/21, weight was 302.8 lbs. -On 8/31/21, weight was 304.2 lbs. -On 9/3/21, weight was 306.6 lbs. -On 9/4/21, weight was 308.0 lbs. -On 9/6/21, weight was 308.4 lbs. -On 9/7/21, weight was 310.0 lbs. -On 9/9/21, weight was 313.4 lbs. -On 9/11/21, weight was 315.0 lbs. -On 9/12/21, weight was 315.4 lbs. -On 9/13/21, weight was 314.2 lbs. During an observation on 9/13/21, at 3:21 p.m. R36 sat in his wheelchair with his feet down on the floor. R36 was wearing regular cotton socks and was observed to have edema from ankle to just below the knee. R36 stated he had a history of congestive heart failure and had been in the hospital for it. During an observation and interview on 9/14/21, at 8:13 a.m. R36 sat in his recliner with his feet elevated. R36 was observed to have edema in both legs from ankle to just below the knee. R36 stated that he had not slept very well last night, he woke up short of breath and indicated he called for staff to assist him to his recliner. R36 stated the shortness of breath resolved once he was sitting up. R36 stated, according to my doctor the fluid in my legs is making it hard for me to breath. R36's progress note dated 9/14/21, at 3:56 a.m. did not address R36's episode of shortness of breath and indicated R36 did not have edema present. R36's documented oxygen saturations were 90% on room air, which was below R36's average of 93-98%. During an interview on 9/14/21, at 12:05 p.m. licensed practical nurse (LPN)-D was asked, how often do you measure edema, LPN-D stated he had never measured edema while working at this facility, stated he would only measure the edema if the resident had ace wraps or if physical therapy had reported concerns of edema. During an observation and interview on 9/14/21, at 12:11 p.m. LPN-D entered R36's room, R36 was sitting in his wheelchair with his feet down on the floor. LPN-D requested permission to evaluate edema; R36 consented. LPN-D stated R36 had 2+ pitting edema around both right and left ankles and 3+ to 4+ edema from lower shin to just below the knee on both legs. Although, R36's progress note dated 9/14/21, at 12:32 p.m. entered by LPN-D, reflected R36 had No edema present even though LPN-D had evaluated the edema at 12:11 p.m. in the presence of the surveyor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review the facility failed to comprehensively assess risk for pressure ulcers, and develop and implement interventions to prevent pressure ulcer injuries for 1 of 2 residents (R175). The facility's failures resulted in harm when R175 developed a stage 2 pressure ulcer and a deep tissue pressure ulcer. In addition, the facility failed to complete comprehensive assessments for pressure ulcers and failed to follow physician orders for 1 of 4 residents (R61) reviewed for pressure ulcers. Findings include R175's face sheet dated 9/16/21, included diagnoses of dementia with behavioral disturbance and congestive heart failure. R175's significant change minimum data set (MDS) assessment dated [DATE], indicated R175 had severe cognitive impairment. The MDS identified R175 required extensive assistance from two or more staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. The MDS indicated R175 was occasionally incontinent of urine and bowel. The MDS identified R175 was at risk for pressure ulcers and did not have pressure ulcers or moisture associated skin damage at the time of the assessment. The MDS indicated pressure reducing device for chair was not used for chair however a pressure reducing device was used for bed and identified R175 did not have a turning and repositioning program. R175's record lacked a comprehensive assessment for risk of skin breakdown after R175 became dependent on staff for mobility. R175's care plan did not identify the level of assistance in accordance with the MDS. R175's toileting care plan dated 9/1/20, directed staff to toilet R175 upon rising, after breakfast, before and [after] all other meals, at bedtime, on night rounds, and as needed. R175's skin care plan dated 10/17/2019, indicated R175 has the potential for pressure ulcer development r/t [related to] immobility. [R175] has thin, fragile skin prone to bruising, skin tears, and age related petechiae (pinpoint, round spots that appear on the skin as a result of bleeding). Associated interventions included follow facility policies/protocols for the prevention of skin breakdown R175's Skin Only Evaluation dated 9/10/21, at 11:44 p.m. indicated skin warm and dry, normal color, turgor normal, and had a skin tag on right upper abdomen. During an observation on 9/13/21, at 7:40 p.m. R175 laid on her back in bed. R175's room smelled of urine. RN-H and nursing assistant (NA)-H were at bedside encouraging R175 to roll over to allow them to change her saturated incontinent garment. R175's mattress protectors was observed to also be urine soaked. R175's behavior progress note dated 9/13/21, at 10:41 p.m. included tonight nurse and nursing assistant got R175 out of bed. Pain medication was offered at the beginning of the process, she did not understand. It was attempted to roll R175 she yelled out in pain and started hitting. The morphine was given and more communication about the process was provided. After several attempts to motivate the patient we rolled her on her side, washed and laid new pads down. During an observation on 9/14/21, at 7:00 a.m. R175 sat in her wheelchair in a hospital gown. At 7:50 a.m. licensed practical nurse (LPN)-D stated R175 had been in the wheelchair all night because she had been restless, stated an unawareness of the last time R175 had been toileted or changed. During an observation on 9/14/21, at 8:50 a.m. R175 was given her breakfast tray. At 9:27 a.m. R175 continued to sit in her wheelchair by the nursing station with her breakfast in front of her. During an observation and interview on 9/14/21, at 12:04 p.m. R175 continued to sit in her wheelchair by the nursing station. Licensed practical nurse (LPN)-D stated R175 had been sitting there since he got there this morning, and stated he was not aware if NAs had checked her incontinent brief or repositioned her. LPN-D stated R175 had nodded off for an hour maybe two in her chair. During an observation on 9/14/21, at 12:20 p.m. R175 remained by the nursing station. At 12:32 NA-A asked LPN-D how R175 transferred. LPN-D stated an unawareness and stated he would call therapy. NA-A was asked when R175 had last been toileted, NA-A stated the last time was between 6:00 a.m. and 7:00 a.m. when she assisted the night shift aide. At 12:49 p.m. R175 was transferred via full body mechanical lift to her bed by NA-A and NA-B. When NAs removed R175's incontinent garment, it was observed to be heavily saturated with urine. When R175 rolled onto her right side, a dark purple/blue area with a small wound that was bleeding was observed on her lower left buttock and small reddened area was observed on her right lower buttock. NA-A exited the room to get registered nurse (RN)-D. RN-D entered the room, RN-D observed the impaired skin integrity, and indicated R175 had a stage 1 pressure ulcer to the right buttock and the left buttock wound was a stage 2 and would have to do further evaluation if the wound was a deep tissue injury. RN-D stated the left buttock had more redness than the right and appeared irritated. R175 was very cooperative with RN-D during the assessment and with application of new brief. During an interview on 9/14/21, at 3:38 p.m. RN-D stated the wound on her left buttock was a deep tissue injury, with an open stage 2 pressure injury. RN-D stated she had conversed with family member who thought that R175 had a history of a pressure ulcer to the same area. RN-D stated within the last several weeks R175 had an increased need to for assistance; she used to be independent with bed mobility and positioning herself. RN-D reviewed R175's care plan and verified the care plan was not consistent with the level of care R175 required and the MDS assessment. RN-D confirmed the care plan did not identify how often R175 needed to be turned and repositioned and an assessment to determine tissue response to pressure over time had not been completed after R175's change in condition. RN-D stated the nurse should have questioned/prompted or directed NAs to reposition R175 if there was a question of how long R175 was sitting in her chair next to the nursing desk. RN-D stated if R175 was refusing care then, it was expected the NA's reattempt or get someone else to attempt, report to the nurse on the floor, nurse should then attempt and notify the charge nurse of continued refusals. RN-D indicated, if necessary, the physician should be contacted for further medical management if interventions were unsuccessful. RN-D stated the refusals with interventions and the effectiveness of the interventions needed to be documented. R175's progress note dated 9/14/21, 9:24 p.m. identified R175 had left buttock stage 2 deep tissue injury 2 centimeters (cm) x 0.9 cm. Injury is purple/blue in color, small tear which had fresh red blood around the edges, less than 0.5 cm in diameter of fresh red blood in center of injury. The evaluation indicated dietary would be consulted, and care plan revised to include repositioning schedule and behavior plan for increased need in cares including barrier cream and hydrating lotion for dry skin for comfort. During an interview on 9/15/21, at 8:24 a.m. medical director stated a familiarity with R175 and indicated R175 had worsening heart failure and advancing dementia; goals of care were conservative. Medical director indicated an awareness of R175's behaviors of rejection/refusals of medications and compression management for edema, however, was not aware of rejection/refusals for repositioning/toileting. Medical director indicated an expectation of routine skin assessments and a repositioning plan be in place for the prevention of pressure ulcers. Medical director stated if a resident demonstrated self-neglecting behaviors the physician (or hospice) needed to be notified; residents can't sit in their own urine, it would need further evaluation. When asked if the duration of time R175 sat in her wheelchair without positioning or changing incontinent brief contributed to the pressure ulcers, medical director stated Yes, that would be the definition of a pressure ulcer. During an interview on 9/15/21, at 11:34 a.m. director of nursing (DON) indicated R175 should have been assessed for a turning and repositioning program after her mobility declined. DON stated the expectation residents were toileted in accordance with their care plan. DON stated if residents refused, the expectation was the nurse be notified, and ultimately the physician if necessary for further medical intervention. R61 R61's hospital Discharge summary dated [DATE], indicated R61 had a left buttock stage 2 pressure ulcer that had been identified on 7/16/21; plan for treatment included cleanse skin with wound cleanser, pat dry, and cover with foam boarder dressing, change dressing daily and as needed. The discharge summary also identified an unstageable pressure ulcer on a leg with orders for wound care. R61's admission skin assessment dated [DATE], did not identify presence of pressure ulcers. The note indicated resident refused with no further information or interventions for refusal. R61's physician order dated 8/11/21, identified the left buttock pressure ulcer as outlined by the hospital discharge summary, however had a stop date of 9/2/21. R61's physician order dated 8/11/21 included: Leg Pressure Injury Treatment: Cleanse affected area daily with normal saline and gauze, apply nickel thick layer of Santyl covering entire wound bed (soft black eschar), cover with mepilex border (sacral or large size). R61's physician order dated 8/14/21 included: Daily skin monitoring. If changes, document in skin alterations and wounds progress note. Wound: pressure injury to left lower extremity-unstageable, left buttock pressure stage 2. R61's record identified the left lower extremity pressure ulcer was not comprehensively assessed until 8/16/21, even though there were physician orders upon admission. In addition, the record lacked evidence R61's left buttock pressure ulcer had not been comprehensively assessed after facility admission, even though there was a physician ordered treatment for the wound upon admission and an order that directed both pressure ulcers be monitored daily. R61's skin evaluation dated 8/16/21, indicated R61 had an unstageable pressure ulcer on the left lower extremity (location on extremity was not identified) that measured 1.5 cm (centimeters) x 0.9 cm. The skin evaluation did not identify the presence of a stage 2 pressure ulcer. R61's admission Minimum Data Set (MDS) assessment dated [DATE], identified R61 had one stage 2 pressure ulcer and one unstageable pressure ulcer. R61's skin evaluation dated 8/23/21 and 8/31/21, did not identify the stage 2 pressure ulcer. R61's record did not indicate why the physician ordered treatment to the left buttock was discontinued on 9/2/21. R61's skin evaluations dated 9/7/21 and 9/8/21, did not identify the left buttock pressure ulcer. R61's physician order dated 9/13/21, included, Leg Buttocks Pressure Injury Treatment: Cleanse affected area daily with normal saline and gauze, apply nickel thick layer of Santyl covering entire wound bed (black soft eschar), cover with mepilex border (sacral or large size). During an interview on 9/14/21, at 9:15 a.m. licensed practical nurse (LPN)-D indicated R61 only had one wound treatment to complete; the unstageable ulcer on the left calf. During an observation on 9/14/21, at 9:21 a.m. licensed practical nurse (LPN)-D explained to R61 he was going to complete the dressing change on his left calf; R61 gave consent. LPN-D donned gloves, removed the dressing, disposed of the dressing, then removed gloves. LPN-D then used a pen to write the date on the new dressing and donned new gloves without performing hand hygiene. LPN-D completed the dressing change per physician orders, removed gloves, and washed hands. During an interview on 9/14/21, at 9:26 a.m. LPN-D stated he should have done hand hygiene between glove changes. During an observation on 9/15/21, at 1:16 p.m. RN-B explained to R61 he was going to change the dressings on his left calf and left buttock; R61 gave consent. RN-B washed his hands and donned gloves, RN-B then removed R61's wound dressing from the left calf and through the dressings on the floor. RN-B then removed the cap from the saline bottle, put the ointments for the wound in the cap, opened a tongue depressor, and stirred the ointments together. RN-B then removed scissors from his left pocket and cut the non-stick dressing to the size of the wound. RN-B then used a Q-tip to spread the mixture of ointments onto the wound and applied the cover dressings. RN-B had the same gloves on throughout the procedure, in addition RN-B had not disinfected the scissors prior to or after the completion of the dressing change. RN-B then picked up the soiled dressings from the floor, took off gloves, and sanitized his hands. RN-B then informed R61 of the next dressing change on his left buttock. RN-B donned gloves and undid R61's incontinent brief, R61 was incontinent of stool, RN-B performed incontinent care (a dressing was not observed on R61's left buttock where there was a nickel sized superficial wound that was reddened), used an incontinent wipe to clean his gloves, walked to the bathroom and donned another pair of gloves (without disinfecting) over the gloves he already had on and applied the left buttock dressing per physician order. During an interview on 9/15/21, at 2:13 p.m. RN-B confirmed there was not a dressing to the buttock wound and there should have been, RN-B stated if the wound had been resolved it's not anymore. RN-B stated he should have changed his gloves and performed hand hygiene after taking off the old dressing. RN-B stated an unawareness if double gloving was appropriate for the procedure. During an interview on 9/16/21, at 11:44 p.m. director of nursing (DON) stated an expectation that pressure ulcers were comprehensively assessed upon admission, weekly thereafter and as need, should be monitored for improvement or worsening daily with dressing changes. DON stated the expectation dressings were applied according to physician order. DON indicated appropriate hand hygiene was expected during dressing changes, gloves should be removed after dressing and removal and cleansing the wound, hand hygiene should be performed after each glove change. DON stated soiled dressings need to go into a garbage can and not on the floor, and scissors should be disinfected prior to using on a clean dressing. Facility policy Pressure Injury Risk assessment dated 3/2020, included 1) The purpose of pressure injury risk assessment is to identify all risk factors and then determine which can be modified and which cannot, or which can be immediately addressed, and which will take time to modify. 2) Risk factors that increase a resident's susceptibility to develop or to not heal PU's include b) impaired/decreased mobility and decreased functional ability, the presence of previously healed PU, exposure to urinary and fecal incontinence or other source of moisture, altered skin status over pressure points, and cognitive impairment 6) once the assessment is conducted and risk factors are identified and characterized, a resident centered care plan can be created to address the modifiable risks for pressure injuries. Facility policy Pressure Ulcers/Skin Breakdown-Clinical Protocol dated 4/2018, did not identify frequency of monitoring or completing comprehensive wound assessments. The protocol indicated a skin examine would be completed upon admission