**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure a resident received adequate supervision and assistance to prevent accidents for 1 of 3 residents (R4) reviewed for falls. This resulted in actual harm when R4 fell and suffered a femur fracture. The facility implemented immediate corrective action, so the deficient practice was issued at past non-compliance. Findings include: R4's face sheet dated 5/16/25, identified diagnoses of Parkinson's disease (a disease of the central nervous system that affects movement), depression (persistent sadness), and anxiety (a common human emotion involving feelings of worry, nervousness, or unease). R4's Physical Therapy (PT) evaluation dated 4/22/25, identified that R4 was admitted the facility due to weakness and without further PT she would be at increased risk for falls and functional decline. R4 was modified independence with contact guard assistance (one or two hands on body to support balance or steady body) for transfers. R4's admission Minimum Data Set (MDS) dated [DATE], identified R4 needed supervision or touching assistance for transfers and had moderate cognitive impairment. R4's fall care plan focus dated 4/22/25, identified R4 was at risk for falls due to Parkinson's disease. Goal of will not sustain a fall related injury through review date. With interventions of education on prevention, reduction precautions per facility protocol. R4's care plan did not identify what level of transfer assistance R4 required as per the PT evaluation dated 4/22/25 nor the level of assistance that was identified on the MDS dated [DATE]. R4's nursing assistant care sheet dated 4/22/25, identified R4 was assist x1 with gait belt and walker for transfers. R4's physician note dated 5/1/25, identified R4 was still working with therapy and is not back to her baseline strength or balance and does not feel ready to go home. R4's fall safety event dated 5/10/25 at 1:45 p.m , identified R4 had a witnessed fall in her room during a transfer without assistance. During the transfer R4's feet became entangled in the nightstand, which caused her to lose her balance, fall, and landed on her right hip. R4 had pain in right femur area and was sent to emergency department (ED) for evaluation. R4's emergency department (ED) note dated 5/10/25, identified R4 had been seen in ED following a fall in the nursing home and had subsequent hip pain and unable to bear weight. Imaging showed moderately displaced intertrochanteric fracture of the proximal right femur. R4's hospital operative note dated 5/11/25, identified R4 underwent insertion of intramedullary nail of right femur following a fall in the nursing home. R4's interdisciplinary team (IDT) progress note dated 5/12/25 at 10:12 a.m., identified review of fall on 5/10/25 that R4 was ambulating in room with a staff member present with a gait belt on, however he stepped back as resident was attempting to brush her hair near the nightstand. Staff visualized R4's feet got tangled up in the nightstand when attempting to turn, causing her to lose balance and fall. Staff member was not within close reach to catch R4 from falling. Staff interviews reveal that R4 had a history of ambulating in her room without assistance. R4 was an assist of one with a walker for transfers and ambulation prior to the fall. R4's activities of daily living care plan dated 5/12/25 was revised after her fall on 5/10/25, to include the level of staff assistance R4 required which was, limited assist of one for transfers with a gait belt and walker. R4's progress note dated 5/14/25, identified R4 returned from the hospital and was substantial/maximum assistance for all transfers. During an interview on 5/15/25 at 1:38 p.m., nursing assistant (NA)-B referenced the nursing assistant care sheets as the care plan that gives them direction on how to care for a resident. During an interview on 5/15/25 at 3:55 p.m., nursing assistant (NA)-D stated he was assisting R4 in her room at the time of her fall on 5/10/25. NA-D placed a gait belt on R4 and ambulated her next to the nightstand so she could brush her hair, he then left her at the nightstand and went to get her walker when she must have turned and got her feet tangled on the nightstand and fell to the ground. NA-D stated he was not standing near R4 at that time, and when she lost her balance, he was not able to catch her. During an interview on 5/15/25 at 12:40 p.m., licensed practical nurse (LPN)-C stated R4's nursing assistant care sheet identified R4's transfer status of assist of one staff on admission, however R4's care plan did not identify how she was transferred until 5/12/25 after it was reviewed after the fall. During an interview on 5/15/25 at 4:36 p.m., registered nurse regional director (RNRD) stated her expectation would be for staff to transfer resident per plan of care and ensure adequate supervision is provided during the transfers to maintain safety and that any resident would have their care plans updated in a timely manner. Review of the facility's Integrated Fall Management Policy dated 9/23, identified residents with risk for falling will have interventions implemented through their resident centered plan of care. Additional professionals may be contacted to provide assessment and/or interventions regarding fall risk and prevention, including but not limited to, attending physician/provider, pharmacist, physical therapist, occupational therapist, and speech therapist. The following corrective actions were verified as implemented prior to the survey: 1. A four-point plan of correction was initiated on 5/12/25: a. Specific action taken for identified resident. b. Resident sent to ED for treatment. c. NA suspended pending investigation. d. Updated provider and family. e. Report filed with state agency. f. Interview of NA involved. g. Interviewed therapy. h. Interviewed like residents with no concerns identified. 2. Root cause of R4's fall identified that NA was not following the plan of care and that R4 should have been assist of one with a gait belt. 3. Identified all residents that ambulate with staff assistance may be at risk for the same deficient practice. 4. Educated the NA involved in the incident regarding following plan of care for ambulation status. Education provided to all NA and nurses regarding following plan of care for residents. 5. Ensured all residents had the correct ambulation status on care plan and nursing assistant care sheets. 6. Education of all staff regarding abuse and neglect, reporting policy, expectations including timeframe. 7. Monitoring will be done via audits of direct audit of staff during resident ambulation five times per week x 4 weeks, three times per week x 4 weeks, one time per week for 4 weeks x 4 weeks. Audits will be brought to quality assurance performance improvement (QAPI) to determine ongoing audits. 8. Director of Nursing of designee will be responsible for the compliance of the action plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to provide sufficient staffing to ensure residents received the care and assistance they needed in a timely manner for 4 of 5 residents (R5, R1, R3, & R6) reviewed for call lights. This caused actual harm to R5 when she waited nearly three hours for her call light to be answered causing her to experience increased anxiety, distress, fear, and feelings of worthlessness and helplessness. Findings include: R5 R5's Minimum Data Set (MDS) assessment dated [DATE], indicated she had intact cognition and no behaviors or rejections of care. R5 had diagnoses including multiple sclerosis (chronic disease affecting the central nervous system), anxiety disorder, major depressive disorder, and morbid obesity. R5 was frequently incontinent of bowel and bladder and required substantial staff assistance with toileting hygiene, bathing, dressing, and mobility in bed. R5 was dependent on staff for transfers and used a motorized wheelchair independently. R5's urinary incontinence care plan interventions dated 2/11/25, included keep call light within reach, provide incontinence care after each incontinent episode, toilet per request, and staff to toilet every two hours and as needed with extensive assistance. R5's activities of daily living (ADL) care plan included intervention dated 2/11/25, to discuss with staff how to honor R5's preferences and provide care in a timely manner. R5's psychosocial well-being care plan dated 1/15/25, identified potential for trauma related to history of sexual abuse, physical abuse, and mental abuse. Interventions dated 1/15/25 included observe for signs of adjustment difficulties such as inability to pursue interests or activities or sad or anxious mood. R5's mood state care plan dated 5/26/22 identified R5 was at increased risk for mood issues related to anxiety disorder, suicidal ideations in the setting of delirium, toxic encephalopathy, new an unfamiliar environment, and legal blindness. Intervention dated 5/16/24, noted psychology was to evaluate and treat as needed. R5's psychology provider note by licensed independent clinical social worker (LICSW)-A dated 1/31/25, indicated R5 had diagnoses including major depressive disorder and anxiety disorder. R5's mental status exam noted dysthymic (mild long-lasting depressed) mood, ruminating (persistent negative) thoughts, tearful affect, and tearful behavior. R5 reported an incident of waiting for her brief to be changed after a bowel movement (BM), which she believes contributed to current UTI [urinary tract infection]. Treatment recommendations included it remains of benefit for [R5] to have brief changes after BM's as soon as possible, to reduce risk of developing UTI's which she seems to be prone to. This would aid in decreasing anxiety levels. R5's psychology provider note by LICSW-A dated 2/21/25, indicated R5 presented with anxious and depressed mood of sadness, overwhelmed, grief, stress, difficulty concentrating, and fatigue. R5 reported she had another UTI and endorsed anxiety around this. R5's Long Term Care Social Service assessment dated [DATE], indicated she had mood appropriate to circumstance and mood was affected by diagnoses. She did not have mood symptoms of depression, crying, or withdrawal from activities and her mood was not restless, anxious, or inclusive of complaints. R5 was identified as expressing her feelings openly and coping well. She did not distort or misrepresent events, worry/deny/cry, or display ineffective coping skills such as distancing self, anger, or withdrawal from life at facility. The facility's Grievances Log included a grievance entry dated 4/26/25 voiced by R5. The concern section noted R5 reported on Saturday 4/26/25 around 3:00 p.m. she put on her call light for assistance transferring from chair to commode and waited an hour for a nurse to come in. The nurse said she was going to turn the call light off and then back on and let a nursing assistant (NA) know she was waiting. R5 requested the call light not be turned off as she hadn't been assisted yet. Nurse left call light on and informed a NA who then assisted. The findings section of the log noted The resident's call light was not answered for approximately one hour after activation on Saturday, 4/26, around 3:00 PM. When a nurse eventually responded, she did not provide direct assistance but informed an aide, who later assisted the resident. The nurse initially planned to reset the call light before notifying staff, but the resident requested it remain on until assistance was received. The action section noted Staff were reminded of the importance of promptly responding to call lights to ensure residents receive timely assistance. Nursing staff were specifically instructed not to reset a call light until the resident's needs have been fully addressed. The situation was reviewed with the care team to reinforce effective communication practices and appropriate procedures for escalating any delays in care. The resident was informed of the concern and the steps being taken to address it. R5's Device Activity Report (call light log) dated 4/12/25 through 5/14/25, included but was not limited to the following reset times (time from when light is activated to when it is cleared): - 4/12/25 at 7:27 p.m., 20 minutes and 46 seconds - 4/12/25 at 10:40 p.m., 25 minutes and 48 seconds - 4/13/25 at 7:57 a.m., 100 minutes and 22 seconds - 4/15/25 at 2:09 p.m., 21 minutes and 35 seconds - 4/16/25 at 5:05 p.m., 29 minutes and 19 seconds - 4/17/25 at 3:37 p.m., 24 minutes and 32 seconds - 4/19/25 at 7:57 a.m., 23 minutes and 7 seconds - 4/20/25 at 8:50 a.m., 43 minutes and 48 seconds - 4/20/25 at 12:58 p.m., 61 minutes and 51 seconds - 4/20/25 at 9:45 p.m., 22 minutes and 36 seconds - 4/22/25 at 7:38 a.m., 34 minutes and 54 seconds - 4/22/25 at 1:18 p.m., 49 minutes and 30 seconds - 4/22/25 at 9:54 p.m., 28 minutes and 3 seconds - 4/25/25 at 1:16 p.m., 26 minutes and 8 seconds - 4/26/25 at 7:13 a.m., 202 minutes and 18 seconds - 4/26/25 at 3:38 p.m., 64 minutes and 31 seconds - 4/26/25 at 5:50 p.m., 20 minutes and 30 seconds - 4/27/25 at 5:40 p.m., 30 minutes and 14 seconds - 4/28/25 at 6:01 p.m., 32 minutes and 32 seconds - 5/3/25 at 1:03 p.m., 22 minutes and 52 seconds - 5/6/25 at 7:41 a.m., 57 minutes and 32 seconds - 5/6/25 at 1:00 p.m., 43 minutes and 42 seconds - 5/6/25 at 5:20 p.m., 26 minutes and 2 seconds - 5/7/25 at 7:34 a.m., 24 minutes and 35 seconds - 5/7/25 at 5:57 p.m., 31 minutes and 49 seconds - 5/10/25 at 12:12 p.m., 174 minutes and 8 seconds - 5/11/25 at 12:58 a.m., 20 minutes and 55 seconds - 5/11/25 at 2:12 p.m., 59 minutes and 19 seconds - 5/11/25 at 7:17 p.m., 26 minutes and 51 seconds - 5/12/25 at 3:16 p.m., 31 minutes and 41 seconds - 5/13/25 at 3:24 p.m., 18 minutes and 14 seconds - 5/13/25 at 5:52 p.m., 29 minutes and 34 seconds During an interview on 5/14/25 at 2:19 p.m., R5 stated there are huge issues with call lights. R5 stated at night sometimes nobody would answer her call light so she would have to use a telephone to call the nursing station on her unit and another unit to request assistance. R5 explained on a good day call lights are answered in 15 minutes, on a bad day anytime between half an hour and 45 minutes, and on a real bad day a lot longer. R5 noted there were occasions she had to wait marathon times with the most recent incident on Saturday 5/10/25. R5 stated a nursing assistant (NA) got her up and dressed in the morning and told her the NA assigned to her had left sick an hour into the day shift. The NA who had helped her was then pulled and put on a medication cart to work as a medication aide because they were short a nurse, leaving one NA working the whole floor. R5 stated around 12:15 p.m. she turned her call light on because she needed to have her brief changed. She was sitting in her recliner, it was nice out, and she wanted to go outside. She turned on the light to have her brief changed and transfer to her electric wheelchair to go outside. R5 stated, no one came until 3:15 in the afternoon, nobody came, not one person to check on me. Review of R5's call light log identified her call light was activated on 5/10/25 at 12:12 p.m. and was not reset for 2 hours 54 minutes and 8 seconds. R5 stated the evening shift NA stopped in her room while orienting another NA who was agency staff and they were not aware her light was on when they came by, but R5 told them what she needed. R5 stated she was a mell of a [NAME] [sic] by this point, I was angry at being ignored, I was terrified that here I am again, and grateful I wasn't in serious physical danger. R5 noted this could have been fatal to somebody so yeah, I'm grateful for that, but I'm afraid, it makes me afraid about being here. I'm never safe here. After she was assisted to the commode she had NAs put her in bed. R5 was afraid by that time, she didn't know who was going to be working that night. She didn't feel comfortable enough to be in her wheelchair and go outside. I thought just put me in my bed so I can be as safe as possible. R5 noted the facility had been staggering nurses and instead of two nurses starting at 3:00 p.m. they had one start at 3:00 p.m. and one start at 5:00 p.m. which made R5 not feel secure and safe. R5 stated I don't think emotionally I have recovered R5 did not feel safe in the late afternoon or early morning because staff don't help. R5 explained another recent instance where she waited an extended time for assistance. R5 had a large BM and had BM all over herself. She informed an NA that she needed assistance because I know I needed to be changed, and I needed to be changed fast because I didn't want to have another UTI. R5 indicated the NA told her he needed to finish passing out lunch trays and collecting them and would then get to her. R5 then went to the nursing station and informed staff she needed to be changed now, went back to her room, and turned on her call light. After 15 to 20 minutes, she left her room in her wheelchair to find the NA, told him she needed to be changed now, he stated he had to do something else first, and she returned to her room. After waiting another 15 to 20 minutes she went looking for him again, and he again said he had to go do something in another room. After 15 to 20 more minutes, she found him again and he did it again a third time. R5 stated she lost it and went back to my room and she wept and wailed. After about five minutes, the NA arrived and asked why she was crying and she said because you won't change me. The NA got a second NA and the two then assisted with cleaning her up. R5 stated she was very upset by this incident. During an interview on 5/15/25 at 12:05 p.m., trained medication aide (TMA)-A stated aides answer call lights and other staff don't answer call lights, but they should. TMA-A noted it was hard to answer call lights with three aides and sometimes two working. TMA-A stated ten minutes was too long to take to answer a call light and if somebody needs to go to the bathroom they can't wait, we don't have enough staff to do that. TMA-A stated with two aides it is a struggle. If we had more staff it would be helpful with call lights. TMA-A noted R5 used the call light when she needed to use the commode or wanted to come out of her room and staff did not have time because two people were needed to transfer R5. TMA-A stated, R5 did get upset about the call light after waiting, her face changes, she is mad. During an interview on 5/15/25 at 12:26 p.m., registered nurse (RN)-C stated there were not enough staff to do what needed to be done for the residents and answer call lights like we should. RN-C stated she thought the recent instance when R5 had to wait approximately three hours for her call light to be answered was sad and it's obvious how you would feel, neglected, afraid. RN-C explained there should be three aides at all times and noted call lights were more of a problem when there were less than three NA's working on the unit. During an interview on 5/15/25 at 9:50 a.m., staffing coordinator (SC) reviewed the schedule from Saturday 5/10/25 for R5's unit. She noted the day shift had two nurses, an RN from 6:30 a.m. to 1:00 p.m. and an LPN from 6:30 a.m. to 3:00 p.m. The day shift had three NA's working, with two scheduled from 6:30 a.m. to 2:45 p.m. and one scheduled from 6:30 a.m. to 3:00 p.m. The NA scheduled to work until 3:00 p.m. came in for about an hour in the morning, became sick and left, and another NA came in to replace her. The evening shift had two nurses and two NA's. One LPN was scheduled from 3:00 p.m. to 8:00 p.m. and the second LPN scheduled from 4:00 to 11:00 p.m. called out and was replaced by an RN pulled from a different unit. Three NA's were scheduled to work: one from 2:30 p.m. to 11:00 p.m., one from 3:00 p.m. to 11:00 p.m., and one from 3:00 p.m. to 9:00 p.m. Two NA's worked the evening shift as the third was pulled to a different unit to work as a TMA. The SC stated one of the aides from another unit was probably floating between their assigned unit and R5's unit. During an interview on 5/15/25 at 4:33 p.m., the nurse manager for R5's unit, RN-D, stated she didn't know what was going on with call lights, we need to work on getting those lights. Call lights should be answered in no more than five minutes. If a light was not answered timely a resident would may not feel good about it or disappointed, RN-D noted she wouldn't be happy. RN-D recalled the instance on 4/26/25 when R5 had to wait an hour for her call light to be answered and thought it was because an aide had been sick and left early. RN-D stated she talked to R5 about this and she was not happy. Whoever saw the light should have answered right away and it was unacceptable. RN-D had also spoken with R5 about the instance on 5/10/25 when she waited approximately three hours for her call light to be answered and R5 wasn't happy. Long call lights had a negative effect on residents when they had to wait that long for assistance and it was definitely something we need to work on with the call lights, whether it is a weekend or not. Regarding how long call light times affected R5, RN-D stated she knew for sure R5 did get anxious and worried because R5 had told as much. RN-D stated she had not looked into how call light logs compared to staffing and hadn't heard from her staff that they were related. During an interview on 5/15/25 at 4:00 p.m., the director of social services (DSS) stated long call light wait times are negative towards people's psychosocial well-being and could make residents not trust our staff, could impact how people feel about being safe here. The DSS noted some residents could get a lot more anxious if their call lights were not being answered, especially if they already have anxiety. An increase in anxiety would be considered a negative impact to psychosocial well-being. The DSS reviewed her concerns (grievances) database and noted a concern from R5 on 5/10/25 that her call light was on for three hours and noted staff were still looking into this with nurse manager RN-D assigned to investigate. She identified an additional concern from R5 dated 4/26/25 when she waited for over an hour for her light to be answered which was confirmed when staff reviewed call light logs. The DSS assumed this impacted R5 negatively, could be harmful, and probably increased her anxiety levels. The DSS noted waiting one or three hours for a call light to be answered could impact a resident's sense of dignity or self-worth. She expected call lights to be answered no later than 20 minutes and long call light wait times wouldn't feel good. During a return phone call interview on 5/19/25 at 4:45 p.m., licensed independent clinical social worker (LICSW)-A stated she had been seeing R5 since she admitted to the facility and saw R5 for her depression, chronic adjustment distress, anxiety, and post-traumatic stress symptoms. LICSW-A was aware of R5's long call light times, including the one that took staff three hours to answer. LICSW-A noted in response to the long call light times it made R5 feel helpless, a lack of control, and like her needs don't matter. R5 was reliant on staff to use the bathroom or get transferred. Long call light wait times certainly impacts her [R5's] anxiety levels. R5's reported three-hour wait time was a long wait time, I would expect that most people would feel pretty distressed by that. LICSW-A felt R5's distress level and response is completely understandable and appropriate to the situation. LICSW-A also noted R5 had brought up call light wait times with her previously. LICSW-A believed it did impact R5's mood and feeling of lack of being in control of her situation. Additionally, feeling of helplessness that R5 requested help and not only has it not arrived, but then she has had to wait for that long amount of time. LICSW-A stated for R5 it kind of filters into her thought of do my needs matter?' and when her call light was not answered timely she feels depressed. R5 was angry and tearful when talking about this experience. LICSW-A stated for her to wait that long, that is harmful to her. R5 had filed multiple complaints and grievances and spoken with facility staff and the ombudsman, but there has not been any improvement so she worries. LICSW-A noted R5 had expressed fears about what could happen to her in the time frame while she was waiting for a call light to be answered, and the worry had been kind of steady. LICSW-A noted adjusting to the facility has been very difficult for her [R5] and long call light wait times doesn't help. LICSW-A noted R5 had been better adjusted over the last year and a half but then if a circumstance like this comes up it brings her back to some of those feelings. R1 R1's MDS assessment dated [DATE], indicated she had intact cognition and no behaviors or rejections of care. R1 had diagnoses including Parkinson's disease, acute pain due to trauma, back pain, and abnormalities of gait and mobility. She was occasionally incontinent of urine, and required substantial staff assistance with toileting, bathing, bed mobility, and transfers. R1's mobility care plan dated 3/1/25, identified she needed staff assistance with bed mobility, transfers, ambulation, and locomotion due to immobility. Intervention dated 5/12/25, directed staff to ensure the call light was in reach and encourage R1 to use it to make needs known. R1's urinary care plan with interventions dated 2/11/25, directed staff to keep call light in reach, toilet every two to three hours and as needed, and toilet per request. Her communication care plan dated 2/11/25, identified R1 preferred to have her call light on the table in her room and would also like to have a bell to ring if she needed assistance. Intervention dated 2/11/25, directed to discuss with staff how to honor preferences and provide care in a timely manner. R1's call light log dated 4/12/25 through 5/14/25, included but was not limited to the following reset times: - 4/12/25 at 11:05 a.m., 28 minutes and 46 seconds - 4/12/25 at 5:32 p.m., 33 minutes and 39 seconds - 4/12/25 at 8:24 p.m., 26 minutes and 58 seconds - 4/13/25 at 8:27 a.m., 25 minutes and 25 seconds - 4/13/25 at 9:17 a.m., 32 minutes and 59 seconds - 4/13/25 at 12:37 p.m., 34 minutes and 42 seconds - 4/15/25 at 12:21 p.m., 21 minutes and 39 seconds - 4/16/25 at 10:57 a.m., 18 minutes and 41 seconds - 4/16/25 at 12:20 p.m., 31 minutes and 20 seconds - 4/16/25 at 5:20 p.m., 24 minutes and 22 seconds - 4/16/25 at 7:32 p.m., 32 minutes and 38 seconds - 4/19/25 at 1:38 a.m., 26 minutes and 51 seconds - 4/20/25 at 11:12 a.m., 29 minutes and 16 seconds - 4/20/25 at 3:56 p.m., 23 minutes and 32 seconds - 4/20/25 at 7:41 p.m., 36 minutes and 34 seconds - 4/21/25 at 10:01 a.m., 36 minutes and 51 seconds - 4/22/25 at 12:28 p.m., 24 minutes and 18 seconds - 4/24/25 at 9:13 a.m., 265 minutes and 5 seconds - 4/24/25 at 1:40 p.m., 29 minutes and 14 seconds - 4/20/25 at 10:38 a.m., 22 minutes and 34 seconds - 5/3/25 at 10:52 a.m., 46 minutes and 44 seconds - 5/4/25 at 1:54 p.m., 53 minutes and 24 seconds - 5/5/25 at 6:09 p.m., 19 minutes and 12 seconds - 5/6/25 at 11:47 a.m., 24 minutes and 4 seconds - 5/6/25 at 5:39 p.m., 31 minutes and 19 seconds - 5/7/25 at 9:56 a.m., 22 minutes at 24 seconds - 5/7/25 at 5:56 p.m., 26 minutes and 44 seconds - 5/7/25 at 9:46 p.m., 49 minutes and 43 seconds - 5/10/25 at 8:06 a.m., 67 minutes and 58 seconds - 5/10/25 at 9:40 a.m., 21 minutes and 56 seconds - 5/10/25 at 5:27 p.m., 31 minutes and 21 seconds - 5/10/25 at 6:03 p.m., 21 minutes and 49 seconds - 5/11/25 at 10:22 a.m., 24 minutes and 52 seconds - 5/11/25 at 1:32 p.m., 30 minutes and 56 seconds - 5/12/25 at 7:56 p.m., 27 minutes and 33 seconds During an interview on 5/12/25 at 3:08 p.m., R1 stated things aren't going well. Staff would not answer the light. R1 had a bell that one of the nurses gave him and directed R1 that if staff did not answer the call light in a reasonable time, to use the bell. R1 stated I do scream and staff would tell R1 to quit it. Staff would not answer the bell either, so R1 gave it away. R1 stated she would press her call light and wait so long that she turned it off because staff didn't answer. R1 stated she had fallen recently while trying to organize laundry in her room and staff told her to use her call light for assistance, but that was a joke because staff don't answer her light and have said they are shorthanded. R1 stated she used her call light when she needed to use the bathroom but staff don't answer, so I end up going in my pull-ups because she couldn't hold it for that long. R1 stated she felt helpless, and it sometimes took one or two hours for her call light to be answered. She stated, I am bitter because I had to mess myself because she could not get staff to come help her. On 5/12/25 at 5:18 p.m., a call light digital alarm board in the hallway displayed displayed alarm [R1's room number] 15 minutes and was flashing. NA-C entered R1's room. R1's call light log indicated her light was activated on 5/12/25 at 5:00 p.m. and was not cleared for 17 minutes and 58 seconds. Upon exiting, NA-C stated R1 wanted to go to the bathroom and usually if her call light is on it is because she wanted water or to go to the bathroom. NA-C stated she had taken R1 to the bathroom and cleaned her up after toileting. During an interview on 5/13/25 at 9:23 a.m., R1's friend and power of attorney (POA)-A stated R1 had called her crying before, stating she's uncomfortable, needed to get up, needed to go to the bathroom, and needed pain medication. POA-A told R1 to ring her bell while still on the phone to see if staff come in and she's ringing the bell, and nothing happens. POA-A stated this was not okay. R3 R3's MDS assessment dated [DATE], indicated she had intact cognition and no behaviors or rejections of care. R3 had diagnoses including stage four pressure ulcer of the sacral region (wound with full thickness tissue loss and exposed bone, tendon, or muscle over the tailbone area), low back pain, heart failure, non-Alzheimer's dementia, and depression. She was occasionally incontinent of bowel and bladder and required supervisory staff assistance with toileting hygiene and bathing, and partial assistance with footwear and walking. R3's urinary care plan included interventions dated 2/13/25, including keep call light within reach, staff to toilet every two to three hours and as needed with assist of one staff, and toilet per request. R3's routines care plan included intervention dated 2/13/25, directing discuss with staff how to honor my preferences and provide care in a timely manner. R3's activities of daily living care plan included interventions dated 8/9/24, I can verbally ask for assistance, I need assistance to help me remain free from skin breakdown and respect my dignity. Her pain care plan included a goal dated 5/3/25, to be comfortable. Intervention dated 9/5/24, noted interventions for pain included prescribed medications, relaxation, and distraction. R3's call light log dated 4/12/25 through 5/14/25, included the following reset times: - 4/12/25 at 5:20 p.m., 40 minutes and 21 seconds - 4/20/25 at 12:21 p.m., 26 minutes and 36 seconds - 4/21/25 at 12:11 p.m., 49 minutes and 11 seconds - 4/21/25 at 3:45 p.m., 36 minutes and 22 seconds - 4/26/25 at 8:53 a.m., 106 minutes and 54 seconds - 4/28/25 at 7:04 p.m., 44 minutes and 12 seconds - 4/30/25 at 8:41 a.m., 17 minutes and 2 seconds - 5/1/25 at 8:46 a.m., 51 minutes and 35 seconds - 5/4/25 at 12:21 p.m., 17 minutes and 43 seconds - 5/5/25 at 9:10 a.m., 124 minutes and 52 seconds - 5/5/25 at 12:52 p.m., 45 minutes and 40 seconds - 5/5/25 at 2:54 p.m., 33 minutes and 14 seconds - 5/7/25 at 7:36 a.m., 114 minutes and 47 seconds - 5/7/25 at 12:56 p.m., 32 minutes and 41 seconds - 5/8/25 at 1:15 p.m., 56 minutes and 11 seconds - 5/10/25 at 9:47 a.m., 105 minutes and 27 seconds - 5/10/25 at 6:34 p.m., 75 minutes at 14 seconds - 5/11/24 at 9:02 a.m., 119 minutes and 15 seconds - 5/13/25 at 11:01 a.m., 24 minutes 35 seconds - 5/14/25 at 8:38 p.m., 38 minutes and 14 seconds On 5/13/25 at 11:04 a.m., NA-A stated staffing was short sometimes, and they could use a little help. NA-A noted call lights should be answered in either eight to 10 minutes or five to eight minutes, she couldn't remember. NA-A noted she would usually turn call lights off right away and then go look for someone to help her if she was unable to provide the needed assistance. She stated answering call lights can be a challenge and lights were usually on for thirty minutes plus which was pretty bad and a long time. NA-A noted she wouldn't like this if it was her family member. At 11:24 a.m., a call light digital alarm board in the hallway displayed alarm [R3's room number] 20 minutes and was flashing. NA-A entered R3's room and stated she was there because R3's call light was on and confirmed it had been on for 20 minutes. During an interview on 5/13/25 at 11:24 a.m., R3 stated it had been a while since she pressed her call light. R3 asked NA-A for as needed pain medication for back pain rated six out of 10. R3 thought nursing staff all went on break every hour because it sometimes took a long time for call lights to be answered. R3 noted call light wait times were not timely around mealtimes, as staff were busy preparing and serving meals and passing trays. R3 stated she realized staff were busy and she just had to be patient, but sometimes staff got mad and then they ignore you. R6 R6's MDS assessment dated [DATE], indicated she had intact cognition and no behaviors or rejections of care. R6 had diagnoses including encephalopathy (disturbance in brain's function), sclerosis, anxiety, depression, and functional quadriplegia (complete inability to move all four limbs due to extreme debility or frailty). She was frequently incontinent of bowel and had an indwelling urinary catheter. R2 was dependent on staff for assistance with all cares, activities of daily living, and mobility. R6's mobility care plan dated 2/13/25, identified she needed assistance due to functional quadriplegia. Intervention dated 5/7/26, directed staff to ensure call light is in resident's reach while in room and encourage to use it to make needs known. R6's communication care plan dated 4/24/25, noted she used a specialized call light she accessed with her face/chin. R6's urinary care plan included interventions dated 2/13/25, including keep call light within reach, staff to toilet every two to three hours and as needed, and toilet per request. R6's call light log dated 4/12/25 through 5/14/25, included the following reset times: - 4/13/25 at 8:56 a.m., 58 minutes and 55 seconds - 4/18/25 at 2:38 p.m., 18 minutes and 4 seconds - 4/20/25 at 5:10 a.m., 28 minutes and 8 seconds - 4/20/25 at 7:04 a.m., 37 minutes and 0 seconds - 4/20/25 at 9:26 a.m., 30 minutes and 55 seconds - 4/20/25 at 11:00 a.m., 55 minutes and 37 seconds - 4/20/25 at 12:56 p.m., 51 minutes and 14 seconds - 4/21/25 at 9:20 a.m., 22 minutes and 45 seconds - 4/21/25 at 10:10 a.m., 43 minutes and 0 seconds - 4/21/25 at 1:31 p.m., 25 minutes and 3 seconds - 4/21/25 at 7:13 p.m., 23 minutes and 59 seconds - 4/22/25 at 5:22 a.m., 20 minutes and 4 seconds - 4/22/25 at 7:39 a.m., 30 minutes and 28 seconds - 4/22/25 at 9:16 a.m., 36 minutes and 43 seconds - 4/22/25 at 10:02 a.m., 20 minutes and 31 seconds - 4/24/25 at 11:22 a.m., 20 minutes and 36 seconds - 4/24/25 at 5:01 p.m., 18 minutes and 47 seconds - 4/25/25 at 2:08 p.m., 19 minutes and 55 seconds - 4/25/25 at 2:35 p.m., 18 minutes and 50 seconds - 4/26/25 at 5:11 a.m., 60 minutes and 40 seconds - 4/26/25 at 6:41 a.m., 96 minutes and 29 seconds - 4/26/25 at 9:32 a.m., 55 minutes and 11 seconds - 4/26/25 at 10:54 a.m., 61 minutes and 9 seconds - 4/26/25 at 12:21 p.m., 34 minutes and 50 seconds - 4/26/25 at 2:26 p.m., 18 minutes and 4 seconds - 4/26/25 at 3:27 p.m., 31 minutes and 45 seconds - 4/27/25 at 2:34 p.m., 18 minutes and 50 seconds - 4/27/25 at 3:36 p.m., 36 minutes and 5 seconds - 4/27/25 at 5:30 p.m., 22 minutes and 24 seconds - 4/27/25 at 10:07 p.m., 50 minutes and 2 seconds - 4/28.25 at 5:25 a.m., 19 minutes and 3 seconds - 4/28/25 at 10:46 a.m., 48 minutes and 21 seconds - 4/29/25 at 7:50 a.m., 21 minutes and 13 seconds - 4/30/25 at 2:24 p.m., 23 minutes and 32 seconds - 5/1/25 at 10:56 a.m., 18 minutes and 32 seconds - 5/2/25 at 6:30 a.m., 28 minutes and 24 seconds - 5/2/25 at 7:09 a.m., 51 minutes and 11 seconds - 5/2/25 at 11:41 a.m., 36 minutes and 59 seconds - 5/4/25 at 5:40 a.m., 37 minutes and 11 seconds - 5/4/25 at 12:08 p.m., 29 minutes and 32 seconds - 5/4/25 at 1:49 p.m., 27 minutes and 39 seconds - 5/4/25 at 1:18 p.m., 21 minutes and 34 seconds - 5/5/25 at 5:28 a.m., 29 minutes and 18 seconds - 5/5/25 at 8:37 a.m., 28 minutes and 18 seconds - 5/5/25 at 10:43 a.m., 20 minutes and 1 second - 5/5/25 at 1:49 p.m., 22 minutes and 15 seconds - 5/5/25 at 2:38 p.m., 54 minutes and 56 seconds - 5/5/25 at 6:58 p.m., 71 minutes and 0 seconds - 5/6/25 at 12:04 p.m., 26 minutes and 50 seconds - 5/7/25 at 4:17 p.m., 25 minutes and 59 seconds - 5/10/25 at 7:28 a.m., 45 minutes and 41 seconds - 5/10/25 at 9:53 a.m., 63 minutes and 46 seconds - 5/10/25 at 12:58 p.m., 106 minutes and 44 seconds - 5/10/25 at 2:46 p.m., 81 minutes and 29 seconds - 5/10/25 at 5:43 p.m., 72 minutes and 11 seconds - 5/10/25 at 7:26 p.m., 29 minutes and 53 seconds - 5/10/25 at 10:18 p.m., 32 minutes and 12 seconds - 5/11/25 at 3:47 a.m., 27 minutes and 26 seconds - 5/11/25 at 9:19 a.m., 92 minutes and 53 seconds - 5/11/25 at 7:13 p.m., 19 minutes and 51 seconds - 5/11/25 at 7:40 p.m., 20 minutes and 37 seconds - 5/11/25 at 10:00 p.m., 43 minutes and 56 seconds - 5/12/25 at 12:13 p.m., 36 minutes and 55 seconds - 5/12/25 at 3:23 p.m., 26 minutes and 10 seconds - 5/13/25 at 7:33 a.m., 44 minutes and 6 seconds - 5/14/25 at 9:32 a.m., 37 minutes and 47 seconds During an interview on 5/14/25 at 3:05 p.m., R6 stated she used her chin to press her specialized call light. R6 stated that when she used her call light staff sometimes came right away and sometimes who knows when they would come. R6 stated it pissed her off when staff didn't answer her call light in a timely

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to comprehensively assess and follow the hospital discharge orders to keep a cast completely dry for 1 of 3 residents (R1) reviewed for orders. R1 was harmed when he was admitted to the facility with a post-surgical cast covering his right leg with orders that the cast must remain dry, and the facility failed to keep the cast dry. R1 was sent to the hospital where the cast was found to be soiled with urine and feces, contributing to continuous infections. Findings include: R1's hospital discharge information to the facility dated 6/25/24 indicated R1 was medically complicated. R1 had a right knee open reduction dislocated hinged total knee arthroplasty revision on 6/20/24 with confirmation of infectious bacteria: staphylococcus aureus and pseudomonas aeruginosa. Following the lab results R1 underwent placement of a peripherally inserted central catheter (PICC) line to directly treat the bacteria infections with antibiotics. R1 had a history chronic and multiple episodes of bacteremia: methicillin-susceptible staphylococcus aureus (MSSA), group B strep, pseudomonas aeruginosa, corynebacterium, and s. epidermidis. of the right infected total knee prosthesis dating back to 2020. R1's active problem list also included atrial fibrillation, cardiomyopathy ischemic, coronary artery disease, chronic kidney disease stage 4, obesity, presence of automatic cardiac defibrillator with pacemaker, declined functional status, delirium, history of right fractured ankle with open reduction and internal fixation (ORIF) 2021 and left knee arthroplasty total knee replacement 2021, history of left shoulder arthroscopy date unknown with a current views on 6/19/24 indicating the surgical components appeared intact. R1 had history of falling, deep vein thrombosis, anemia, anxiety, obstructive sleep apnea. R1's hospital after visit summary dated 6/26/24 indicated R1's knee incision was covered by a long leg cast. Do not put anything under the cast. Keep the cast completely dry. R1 was to maintain the long leg cast until a return appointment on 7/9/24. Do not let cast get wet, if does get wet, notify the orthopedic surgeon immediately. R1's skin assessment dated [DATE] at 7:10 p.m. indicated R1 was always continent of bowel. No intervention of bowel care was initiated on the care plan. R1's admission nursing progress note dated 6/26/24 at 10:37 p.m. indicated R1 arrived from the hospital and had knee replacement surgery. R1 had a cast on his right leg. R1 had a PICC line on his upper left chest area. R1 had some IV bruises on his right arm and wounds on his left foot 2nd and 3rd toe. R1 had a slight rash on his bottom and some blood. He had a spot near top of his cast. [sic] R1's care plan dated 6/27/24 indicated R1 had an infection in his right knee wound culture results were Staphylococcus Aureus and Pseudomonas. R1's risk factors were a history of Pseudomonas in wounds and inadequate fluid intake. R1 admitted with an infection, abnormal wound drainage, abnormal labs, and abnormal x-ray results. R1's goal was to resolve the infection without signs or symptoms of complications of antibiotics. R1's approaches were: -Antibiotics per medical provider, monitor for effectiveness and side effects -Assess for pain: nature, intensity, location, and duration -Encourage periods of rest -Encourage high protein/high carbohydrate foods/fluids when indicated -Encourage oral fluid intake -Explore with resident potential etiological factors, which potentiate infection and include appropriate health teaching. -Isolation precautions per policy - Enhanced barrier precautions -IV as ordered, IV dressing change and site care as ordered -Labs as ordered -Meds as ordered -Monitor for signs and symptoms of worsening infection -Monitor vital signs every shift for duration of antibiotic therapy -Observe for any complications with IV therapy: signs of infection around site, infiltration -Update family and medical provider as needed. -Wound team to follow on weekly rounds. R1's care plan failed to document problem, goals, and an approach for R1's toileting, transferring, and what assistance was required for activities of daily living. R1's care plan failed to assess whether R1 was to wear an incontinent pad or not or if he were to use the urinal by himself. In addition, R1's care plan did not identify that R1's cast was to kept dry and methods to keep it dry. R1's admission Minimum Data Set (MDS) dated [DATE] indicated R1 had a Brief Interview for Mental Status (BIMs) score of 15 indicating R1 was cognitively intact. R1 required extensive assistant for bed mobility, transferring, eating and toilet use. The MDS indicated R1 had no unhealed pressure ulcers or injuries. R1 was occasionally incontinent of urine and frequently incontinent of bowel. R1 had a surgical wound. His skin treatments were pressure reducing device for chair and bed and applications of ointments. The MDS did not indicate turning/repositioning program, nutrition or hydration interventions or pressure ulcer care. R1's pertinent diagnoses were Methicillin susceptible Staphylococcus aureus infection, Pseudomonas, presence of right artificial knee joint, lymphedema (swelling caused by lymphatic blockage), atopic dermatitis (itchy inflammation of the skin), pain in right knee, infection, and inflammatory reaction due to internal right knee prosthesis. Progress note dated 7/5/24 at 8:58 a.m. indicated: R1 had a covered cast on his right knee, no drainage noted. R1 had dull pain of his right knee. R1's toileting was dependent. R1's skin condition was not assessed. emergency room encounter 7/7/24 at 8:51 p.m. indicated R1 was an [AGE] year-old male with multiple medical problems from a facility with failure to thrive, decreased mental status and fatigue. Recently R1 was discharged from another hospital after he was found to have an infected right total knee replacement. R1's groin was red and irritated with no signs of Fournier's gangrene. His cast was soaked in the upper and half due to urine. His left lower extremity was all bandaged and specifically a dorsal wound of the third toe which appears to be infected. Posteriorly R1 had Stage II (partial loss of skin, but no deeper than the dermis) pressure ulceration on his essentially backside from the mid-thigh through the mid lumbosacral (five large vertebrae that make-up the lumbar portion of the spine) region. R1 will be sent to larger hospital where he had surgery for further care as well as treatment. emergency room nursing note dated 7/7/24 at 11:48 p.m. R1 came in looking red, flush, and complaining of pain. Upon skin assessment staff noticed the following: -Red, swollen skin to the scrotum, penis and peri-area, penis had a large amount of smegma (thick cheesy secretion around genital that collects when not washed regularly). -Skin around R1's cast on the right leg was excoriated, red and non-blanchable and cast was noted to have a strong odor to it along with being saturated with urine and stool. -Left arm had a cast stocking on it from the hand to midway past the elbow, damp and visually soiled. Hospital admission note dated 07/08/24 at 12:00 p.m. indicated R1 presented with septic shock secondary from infected right knee on 7/8/24. His dressing was removed by orthopedics and noted significant soiling of the dressing with concern for infection of the knee. R1 was transferred to the intensive care unit (ICU) for continuing care on 7/9/24. Orthopedic surgeon was planning a washout vs. amputation of R1's right leg. Infectious disease summary 7/8/24 indicated on admission R1 was found to have fecal and urine contamination of his right knee incisions under the cast. His incisions were noted to be macerated (a softening and breaking down of skin resulting from prolonged exposure to moisture) and dehiscence (separation of wound edges). He was also noted to have foul smelling drainage. Upon interview on 7/10/24 at 10:41 a.m. nursing assistant, (NA)-A stated, stated R1 was incontinent of bowel and bladder and often had diarrhea. R1's urinal would spill under him because he would leave I between his legs and fall asleep. Staff checked on him every two hours, but when he was finished using the urinal, he would not press the call light when he was finished with the urinal. NA-A stated no other means of toileting was attempted. Upon interview on 7/10/24 at 3:23 p.m. Family member (FM)-A stated R1 arrived at the large regional hospital and was awaiting amputation of his right leg. She stated at the emergency room (ER) R1's cast was cut off due to the odor and then staff found the entire cast was seeping with urine and feces. FM-A stated the ER noticed the infected surgical knee sight and immediately notified the hospital where he had surgery and wanted him sent back due to their ability to handle infections of that level. FM-A stated she noted the smell of urine and feces in his room and noticed the top cloth portion of the cast was yellow with urine. She stated the facility did not speak with her about interventions other than a urinal to keep him dry. The facility did not drape anything over the cast, discuss a catheter or make an attempt to stop his diarrhea. Upon interview on 7/10/24 at 4:01 p.m. occupation therapist, (OT)-A stated she was only saw R1 on one occasion and that was the day after his admission when she completed her assessment. She stated she attempted to sit R1 at the edge of his bed and he became incontinent of very runny stool. Cleaning him required the assistance of the nursing assistants. She stated she does not recall the stool getting on his cast, but did not see how it could not, as he had to be laid down in bed and rolled to be cleaned. She stated she was aware that R1 used a urinal for urination and stated it was right of the family to choose the method they prefer. She stated occupation therapist assistant (OTA)-A told her R1 frequently had his urinal between his legs, and it would spill. OT-A stated she did not do another assessment on R1's safe use of a urinal. She stated nursing would be more likely to do that as they do the bowel and bladder assessment. OT-A stated R1 had been incontinent of bowel and bladder since his day of admission to the facility. Upon interview on 7/10/24 at 4:41 p.m. R1's orthopedic surgeon stated, in a few moments R1 was going to have his right leg amputated above his knee. He stated, I can't say 100% that the urine and feces filled cast caused the infection requiring amputation, but it certainly had a contributing factor. Upon interview on 7/11/24 at 10:43 a.m. R1's nurse practitioner (NP) stated she did not notice any odor or urine on R1's cast. She stated that the facility did not reach out to her and ask for a catheter or any other invention, such as a barrier cover. She stated having R1 use a urinal with a cast within inches of R1's right groin and a dislocated left shoulder was not a good plan for a cast needing to stay dry. She stated she was not aware R1 was having diarrhea therefor no interventions were ordered. Upon interview on 7/11/24 at 11:10 a.m. R1's occupation therapy aide (OTA)-A stated she did notice frequently when she went to work with R1 that he had a urinal between his legs and his bedding was soiled. She stated she did not notice the cast was soiled. She stated on the 7/7/24 she assisted the nursing assistants with cleaning R1 after an episode of diarrhea. She stated that the feces did get on the cast and cast was yellow tingled from urine. Upon interview on 7/11/24 at 11:53 a.m. RN-A the unit manager stated that she was aware that R1 used a urinal, she was not aware of any spillage from the use. She denied staff ever reporting that the cast had gotten soiled if it did the surgeon would have been called immediately. Upon interview on 7/11/24 at 3:42 p.m. the director of nursing, (DON) stated her expectation of staff would be for the NAs to report any skin concerns to the nurses. She stated she expected nursing staff who are assessing and treating the residents to follow the resident's orders. Upon interview on 7/11/24 at 3:55 p.m. the Administrator stated her expectation would be for the resident assessment instrument (RAI) tool to be accurate, leading to an accurate care plan for the residents and finally proper care being implemented for the residents. A facility policy titled Abuse Prevention Plan Prevention dated 2017 indicated neglect is the failure of the facility, its employees, or services providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure 1 of 3 residents (R1) reviewed for pressure ulcers received care consistent with professional standards of practice to prevent pressure or worsening of pre-admission pressure ulcers. R1 was harmed when the facility failed to promote healing of current pressure ulcers and prevent new ulcers from developing. R1 was admitted with two pressure ulcers, and a shearing wound on 6/26/26. R1 discharged from the facility on 7/7/14 with three pressure ulcers and the shearing wound turned into stage II pressure ulcers in multiple areas from his thigh to his mid-dorsal back. R1's hospital discharge information to the facility dated 6/25/24 indicated R1 was medically complicated. R1 had a right knee open reduction dislocated hinged total knee arthroplasty revision on 6/20/24 with confirmation of infectious bacteria: staphylococcus aureus and pseudomonas aeruginosa. Following the lab results R1 underwent placement of a peripherally inserted central catheter (PICC) line to directly treat the bacteria infections with antibiotics. R1 had a history chronic and multiple episodes of bacteremia: methicillin-susceptible staphylococcus aureus (MSSA), group B strep, pseudomonas aeruginosa, corynebacterium, and s. epidermidis. of the right infected total knee prosthesis dating back to 2020. R1's active problem list also included atrial fibrillation, cardiomyopathy ischemic, coronary artery disease, chronic kidney disease stage 4, obesity, presence of automatic cardiac defibrillator with pacemaker, declined functional status, delirium, history of right fractured ankle with open reduction and internal fixation (ORIF) 2021 and left knee arthroplasty total knee replacement 2021, history of left shoulder arthroscopy date unknown with a current views on 6/19/24 indicating the surgical components appeared intact. R1 had history of falling, deep vein thrombosis, anemia, anxiety, obstructive sleep apnea. R1's hospital discharge orders dated 6/25/24 indicated R1 had: -A Stage 3 (an injury that extends through the skin into deeper skin and fat but does not reach muscle tendon or bone) pressure ulcer on the dorsum (upper surface) of his second right toe. R1 had this pressure injury since 1/6/23. -A dermatologic condition of his right foot since 1/6/23 -Incision on the anterior portion of his right knee since 6/20/24 -A Stage 4 (an injury that extends to the muscle, tendon, and bone) pressure injury on the dorsum of his third right toe since 6/21/24. -A dermatologic condition of generalized rash and pruritis since 6/21/24 -A Shearing wound to his buttocks bilaterally from friction and adhesive from sacral Mepilex (a wound dressing) since 6/21/24. -A deep tissue pressure injury (when there is not an open wound, but the tissues beneath surface have been damaged the skin may appear purple or dark red) to R1's right thigh since 6/24/24. -A Peripheral inserted central catheter (PICC) single lumen permanent tunneled and implanted to his left chest placement 6/25/25. R1's after visit summary dated 6/26/24 indicated on 10/27/22 - present for R1's dermatitis perianal was to include acetic acid soaks for 15 minutes followed by zinc oxide keeping the area open and dry. R1's skin assessment dated [DATE] at 7:10 p.m. indicated R1 was always continent of bowel. R1 had a rash in his peri-care, no description documented. The assessment indicated R1 did not have one more unhealed pressure injuries at a Stage 1 or higher. R1 did have an open lesion on his foot and a surgical wound, no description documented. R1's admission nursing progress note dated 6/26/24 at 10:37 p.m. indicated R1 arrived from the hospital and had knee replacement surgery. R1 had a cast on his right leg. R1 had a PICC line on his upper left chest area. R1 had some IV bruises on his right arm and wounds on his left foot 2nd and 3rd toe. R1 had a slight rash on his bottom and some blood. He had a spot near top of his cast. [sic] R1's care plan dated 6/27/24 indicated R1 had an infection in his right knee wound culture results were Staphylococcus Aureus and Pseudomonas. R1's risk factors were a history of Pseudomonas in wounds and inadequate fluid intake. R1 admitted with an infection, abnormal wound drainage, abnormal labs, and abnormal x-ray results. R1's goal was to resolve the infection without signs or symptoms of complications of antibiotics. R1's approaches were: -Antibiotics per medical provider, monitor for effectiveness and side effects -Assess for pain: nature, intensity, location, and duration -Encourage periods of rest -Encourage high protein/high carbohydrate foods/fluids when indicated -Encourage oral fluid intake -Explore with resident potential etiological factors, which potentiate infection and include appropriate health teaching. -Isolation precautions per policy - Enhanced barrier precautions -IV as ordered, IV dressing change and site care as ordered -Labs as ordered -Meds as ordered -Monitor for signs and symptoms of worsening infection -Monitor vital signs every shift for duration of antibiotic therapy -Observe for any complications with IV therapy: signs of infection around site, infiltration -Update family and medical provider as needed. -Wound team to follow on weekly rounds. R1's care plan dated 6/27/24 did not indicate R1 had any pressure ulcers. In addition, R1's care plan failed to document problem, goals, and an approach for R1's pressure ulcers of the toes, potential for pressure ulcers per Braden assessment, turning and reposition and how R1 was to toilet, transfer, and what assistance was required for activities of daily living. R1's care plan failed to assess whether R1 was to wear an incontinent pad or not or if he were to use the urinal by himself. R1's Braden Scale for Prediction of Pressure Sore Risk dated 7/1/24 indicated: -R1's sensory perception was completely limited, R1 was unresponsive to painful stimuli. -R1 was constantly moist - skin is kept moist constantly by perspiration, urine etc. Dampness is detected every time resident is moved or turned. -R1 was chairfast. -R1 was completely immobile - does not make slight changes in body or extremity position without assistance. -R1's nutrition was probably inadequate. -R1 had a problem with friction and shearing - He required moderate to maximum assistance in moving. R1's Braden score was eight. Indicated very high risk for pressure ulcers. R1's interventions were: -Pressure reducing device for chair and bed. -Turning/repositioning program. -Nutrition for hydration intervention to manage skin problems. The assessment failed to provide interventions for pressure ulcer care, application of nonsurgical dressings, application of ointments or applications of dressing. No other measures were taken, and the care plan was not updated. R1's admission Minimum Data Set (MDS) dated [DATE] indicated R1 had a Brief Interview for Mental Status (BIMs) score of 15 indicating R1 was cognitively intact. R1 required extensive assistant for bed mobility, transferring, eating and toilet use. The MDS indicated R1 had no unhealed pressure ulcers or injuries. R1 was occasionally incontinent of urine and frequently incontinent of bowel. R1 had a surgical wound. His skin treatments were pressure reducing device for chair and bed and applications of ointments. The MDS did not indicate turning/repositioning program, nutrition or hydration interventions or pressure ulcer care. R1's pertinent diagnoses were Methicillin susceptible Staphylococcus aureus infection, Pseudomonas, presence of right artificial knee joint, lymphedema (swelling caused by lymphatic blockage), atopic dermatitis (itchy inflammation of the skin), pain in right knee, infection, and inflammatory reaction due to internal right knee prosthesis. Progress note dated 7/5/24 at 8:58 a.m. indicated: R1 had a covered cast on his right knee, no drainage noted. R1 had dull pain of his right knee. R1's toileting was dependent. R1's skin condition was not assessed. R1's nursing progress note dated 7/5/25 at 10:17 a.m. R1's family member (FM)-A was in the facility taking pictures of R1's skin. FM-A started placing acetic acid to skin on R1's buttocks and told the NA she was going to leave it on for 1 hour. FM-A stated this was the order that the hospital was performing. LPN-A attempted to education FM-A that an hour was too long. FM-A stated this is the only way the redness will improved. FM-A stated that R1's bottom was very red, sore, and bleeding in areas where the skin is excoriated or split open. LPN-A observed the skin the prior day and the skin was red and intact. FM-A also asked when R1 had his last oxycodone (a narcotic pain medication) as FM-A felt R1 was too sedated. R1 had not received any oxycodone since 7/2/24 at 2:00 p.m. FM-A did not want R1 to receive any more oxycodone, but also stated R1 was in so much pain because of his bottom hurt him. LPN-A explained R1 will not lay in bed on his side, he sits in a chair or lies on his back and the skin does not get any relief. FM-A stated that the staff are not making him lie on his side. LPN-A stated the staff cannot make him change position. LPN-A called the primary care clinic triage and left a message for the NP regarding pain management and informed her that FM-A was doing acetic acid treatments and leaving on the skin for a longer period that was order. The progress note did not indicate a description of R1's skin on 7/5/25 just the prior day observation or what the facility was doing for the R1's skin. emergency room encounter 7/7/24 at 8:51 p.m. indicated R1 was an [AGE] year-old male with multiple medical problems from a facility with failure to thrive, decreased mental status and fatigue. Recently R1 was discharged from a regional hospital after he was found to have an infected right total knee replacement. R1's groin was red and irritated with no signs of Fournier's gangrene. His cast was soaked in the upper and half due to urine. His left lower extremity was all bandaged and specifically a dorsal wound of the third toe which appears to be infected. Posteriorly R1 had Stage II (partial loss of skin, but no deeper than the dermis) pressure ulceration on his essentially backside from the mid-thigh through the mid lumbosacral (five large vertebrae that make-up the lumbar portion of the spine) region. R1 will be sent back to the [NAME] larger hospital where he had surgery for further care as well as treatment. emergency room nursing note dated 7/7/24 at 11:48 p.m. R1 came in looking red, flush, and complaining of pain. Upon skin assessment staff noticed the following: -Red, non-blanchable, grossly excoriated, bleeding skin of the gluteus maximus, gluteus Medius, and gluteus minimus. -Red, swollen skin to the scrotum, penis and peri-area, penis had a large amount of smegma (thick cheesy secretion around genital that collects when not washed regularly). -Red excoriated skin to the right abdominal folds and right axillary. -Skin around R1's cast on the right leg was excoriated, red and non-blanchable and cast was noted to have a strong odor to it along with being saturated with urine and stool. -Left thigh, knee and shin aberrations from leg rubbing on the cast. -Left arm had a cast stocking on it from the hand to midway past the elbow, damp and visually soiled. -Left top of foot had an open sore weeping serosanguinous drainage. Hospital admission note dated 07/08/24 at 12:00 p.m. indicated: #1 Wound 07/08/24 Incontinence Associated Dermatitis Buttocks and posterior thighs. Date First Assessed: 07/08/24 Present on Original admission: Yes, Primary Wound Type: Incontinence Associated Dermatitis Location: Buttocks Wound Description (Comments): and posterior thighs Shape Irregular *Wound Bed Open; Red; Shiny Tissue Exposed None Odor None Exudate Amount Small Drainage Description Serosanguineous Peri-wound Assessment Fragile ;Friable; Painful; Rash #2 Wound 07/08/24 Incontinence Associated Dermatitis Groin Bilateral and thighs. Date First Assessed: 07/08/24 Present on Original admission: Yes, Primary Wound Type: Incontinence Associated Dermatitis Location: Groin Wound Location Orientation: Bilateral Wound Description: and thighs Shape Irregular *Wound Bed Closed; Red; Shiny Odor None Exudate Amount Scant Drainage Description Serous Peri-wound Assessment Friable; Painful; Red; Rash #3 Wound 07/08/24 Intertriginous Dermatitis Pannus Right Date First Assessed: 07/08/24 Present on Original admission: Yes, Primary Wound Type: Intertriginous Dermatitis Location: Pannus Wound Location Orientation: Right Shape Irregular *Wound Bed Closed; Red; Shiny Odor None Exudate Amount Scant Drainage Description Serous Peri-wound Assessment Fragile; Red; Rash #4 Wound 07/08/24 Intertriginous Dermatitis Axilla Bilateral Date First Assessed: 07/08/24 Present on Original admission: Yes, Primary Wound Type: Intertriginous Dermatitis Location: Axilla Wound Location Orientation: Bilateral Shape Irregular *Wound Bed Closed; Red; Shiny Exudate Amount Scant Drainage Description Serous Peri-wound Assessment Maceration; Rash #5 Wound 06/21/24 Pressure Injury Stage 4 Toe Third Left; Dorsum Date First Assessed/Time First Assessed: 06/21/24 1020 Primary Wound Type: Pressure Injury Pressure Injury Staging: Stage 4 Location: Toe Third Wound Location Orientation: Left; Dorsum Shape Round / oval *Wound Bed Full thickness; Red; Yellow Tissue Exposed Bone Odor None Exudate Amount Small Drainage Description Sanguineous Peri-wound Assessment Intact #6 Wound 01/06/23 Pressure Injury Stage 3 Toe 2nd Right; Dorsum Date First Assessed/Time First Assessed: 01/06/23 1315 Primary Wound Type: Pressure Injury Pressure Injury Staging: Stage 3 Location: Toe 2nd Wound Location Orientation: Right; Dorsum Shape Irregular *Wound Bed Red; Pink; Open Odor None Exudate Amount Scant Drainage Description Serosanguineous Peri-wound Assessment Maceration Wound 07/08/24 Pressure Injury Deep Tissue Heel Right #7 wound Date First Assessed: 07/08/24 Present on Original admission: Yes, Primary Wound Type: Pressure Injury Pressure Injury Staging: Deep tissue Location: Heel Wound Location Orientation: Right Shape Round / oval *Wound Bed Black; Brown; Pink (mixed wound bed, evolving purple discoloration with sloughing edges revealing pink tissue) Tissue Exposed None Odor None Exudate Amount Scant Drainage Description Serosanguineous Peri-wound Assessment Fragile Upon interview on 7/10/24 at 10:41 a.m. nursing assistant, (NA)-A stated, his skin was not good. She stated R1 was incontinent of bowel and bladder and often had diarrhea, making R1's skin red, raw, and bleeding on his buttocks. Sometimes he would have an incontinence pad on and sometimes he would not, if he were having frequent diarrhea, staff would put an incontinent pad on and if not, staff would let him sit without an incontinence pad. She stated she believed the nursing staff was aware of R1's skin concerns because he had a zinc treatment the nursing assistants were applying to his back and buttocks. NA-A stated she recalled R1 had some kind of dressing on his toes but was not aware whether nursing was doing a treatment or not. R1 used the urinal on his own and with staff assistance. The urinal would spill under R1 as he would leave the urinal between his legs and fall asleep. The urine would spill on his skin and his cast. Staff checked on him every two hours, but when he was finished using the urinal, he would not press the call light for assistance. Upon interview on 7/10/24 at 3:23 p.m. FM-A stated she visited R1 almost daily and she would find him incontinent of urine or stool. She stated R1 was not to have an incontinent pad on because his skin was to be open to air and she would often find him wearing one. She stated she left notes all over R1's room for what staff was to do for his skin care. She stated the staff was supposed to be doing an acetic acid treatment on his buttock and back. The facility told FM-A they did not have an order. FM-A called the nurse practitioner (NP) and told her R1's skin was getting worse, and she wanted the staff to follow the hospital recommendations. FM-A did not receive a response from the NP. She stated she took the acetic acid that he that hospital staff had used and started doing the cares herself. FM-A stated R1 was difficult to reposition, because of the dislocation to his left shoulder. She stated she would perform his repositioning by shifting him slightly with a pillow under one side of his buttocks to relieve pressure. She stated she asked staff to reposition him that way multiple times with no avail. FM-A asked an unidentified nursing assistant why R1 was wearing a pad and to please remove it and clean him as the pad was wet. The response FM-A received was, if he is wet, he did not need to be changed until the line on the pad turned blue. FM-A removed the pad herself and cleaned R1. Upon interview on 7/10/24 at 4:15 p.m. NA-C stated R1 had diarrhea often and his bottom and back had rashes all over that were bleeding from multiple open areas. She stated that the nursing department was aware because they would assist NA-C to change R1 and clean him when he was incontinent. R1 would cry whenever the skin on his back was touched. NA-C would sometimes find R1 in an incontinent brief and sometimes not she stated there were not specific instructions on that. She stated if staff did not put an incontinent brief on R1 they would have entire bed changes due to either urine or feces. Upon interview on 7/10/24 at 4:41 p.m. R1's orthopedic surgeon stated, the condition of R1's skin when he returned to the hospital from the facility was neglect. He stated please read all the hospital wound notes from his hospital discharge summary on 6/26/24 to his re-admission note on 7/8/24. Upon interview on 7/11/24 at 10:43 a.m. R1's nurse practitioner (NP) stated she was not aware R1 had any wounds. She stated the nursing manager had mentioned R1 had some yeast in his groin and asked for Nystatin powder and the order was given. She stated R1's family member, (FM)-A had called her and spoke with her about the groin rash and about his back. FM-A was asking if an acetic acid treatment that the hospital did, with good results, could be implemented for the rash and sores on R1's back. The NP told FM-A she would investigate that treatment. FM-A also inquired with the NP about using a hydrocortisone cream on his skin. The NP stated that the daughter wanted hydrocortisone applied to his entire body for itching. The NP ordered hydrocortisone to be used on itching areas, she was not aware where R1's itchy areas were. The NP denied ever observing R1's skin stating the facility staff makes observations and reports concerns to her or refers the residents directly to the wound care. Upon interview on 7/11/24 at 11:53 a.m. RN-A the unit manager stated R1 did not admit with any wounds. She stated a few days after admission R1's daughter was asking about using acetic acid on his back however he did not have any rash or redness. RN-C stated she was not aware of the documented wounds on the hospital discharge. Acetic acid was listed on the discharge medication list and RN-A stated she thought that was maybe from a catheter he may have had. RN-A did not find out exactly what the acetic acid was recommended for. She stated the wounds were more than likely overlooked because there were no orders attached to them. RN-C was uncertain why R1's care plan indicated wound care to see R1 weekly since he did not have wounds. RN-A stated he was not seen by wound care because the provider was on vacation on 7/3/24 and the provider the agency sent out, did not seen R1 on that date and R1 was discharged on 7/8/24. RN-A did not observe R1's skin directly during his stay. Upon interview on 7/11/24 at 3:30 p.m. RN-C stated he completed R1's admission skin assessment. He stated he recalled R1 had what appeared to be a couple of open blisters that had popped on two of R1's toes. He stated due to shoulder pain and inability to turn RN-C was unable to assess R1's backside to assess. Upon interview on 7/11/24 at 3:42 p.m. the director of nursing, (DON) stated her expectation of staff would be for the NAs to report any skin concerns to the nurses. She stated she expected nursing staff who are assessing to observe the patient and if a nurse can assess a resident fully to notify the manager so the staff can get an accurate assessment later. Upon interview on 7/11/24 at 3:55 p.m. the Administrator stated her expectation would be for the RAI tool to be accurate, leading to an accurate care plan for the residents and finally proper care being implemented for the residents. A facility policy titled Prevention and treatment of skin breakdown dated 2018 indicated resident skin integrity is assessed upon admission and weekly thereafter. A skin risk assessment is completed upon admission and weekly for 4 weeks upon significant change, and quarterly thereafter. Those residents at an increased risk for impaired skin integrity are provided preventative measures to reduce the potential for skin breakdown. Those residents' who experience a break in skin integrity or wounds are provided care and service to heal the skin according to professional standards of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Findings include: Stage II pressure ulcer: partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. Stage III pressure ulcer: full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. Stage IV pressure ulcer: full-thickness 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. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. Unstageable pressure injury: obscured full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage III or Stage IV pressure injury will be revealed. R59's significant change Minimum Data Set (MDS) dated [DATE], identified R59 had severe cognitive impairment and required extensive assistance for bed mobility, transfers, dressing, eating, and personal hygiene. R59 had not walked. R59 required total assistance with toileting. R59 had diagnoses of dementia and diabetes. Further, the MDS outlined R59 was at risk for developing pressure ulcers, however, had no current pressure ulcers or injury. R59's care plan reviewed/revised 2/14/23, indicated R59 was at risk for pressure ulcer due to friction, shear, nutrition, bedfast/ mobility and impaired sensory perception. The interventions included elevate heels off bed or use heel protectors, encourage family to bring in favorite food, monitor for infection, nutritional consult, offer small frequent meals, provide nutritional supplement as ordered, teach patient to do frequent small shifts of body weight if able, treatment as ordered, weekly wound rounds scheduled, wound vac to sacrum in place as ordered, air mattress in place, repositioning patient every 2-3 hours, minimum of two people plus draw sheet to lift resident while in bed, and skin inspection every incontinence care with close attention to heels and other pressure areas. R59's Skin Risk Assessment with Braden Scale dated 10/19/22, indicated R59 was at risk due to diabetes, incontinence of bowel and bladder, slightly limited sensory perception, chairfast, slightly limited mobility, and friction and shearing being a potential problem. The assessment lacked any interventions. On 11/28/22 R59's Braden score was 13 the interventions were to apply barrier cream and to turn and reposition. With a Braden score of 13 and the interventions to apply barrier cream and to turn and reposition the facility increased the risk for R59 to develop pressure areas. R59's admission Body Audit: Skin Condition dated 10/19/22, indicated all skin was intact. R59's Weekly Bath Day Body Audit Form dated 10/25/22, indicated all skin was intact. R59's Weekly Bath Day Body Audit Form dated 11/16/22, indicated all skin was intact. R59's Weekly Bath Day Body Audit Form dated 1/11/23, indicated no new skin issues, had non-verbal pain indicators, cause was from R59's buttocks. R59's Weekly Bath Day Body Audit Form dated 1/31/23, indicated a scar on right ankle measuring 2 centimeters (cm) x 2 cm, a scab on left ankle measuring 2 cm x 1.5 cm, a pressure ulcer on left heel measuring 3 cm x 3.5 cm, and a pressure ulcer on sacrum measuring 10 cm x 9 cm. R59's Weekly Bath Day Body Audit Form dated 2/15/23, indicated no new skin issues noted except dry skin on her lower extremities. There was no evidence in R59's electronic medical record (EMR) that weekly skin audits had been completed between 11/17/22 through 1/10/23. R59's progress note dated 12/20/22, indicated purplish blister on her left heel measuring 4.5 cm x 4 cm, with necrotic (death of body tissue) wound on left ankle measuring 2 cm x 2 cm and on left outer foot which is 1 cm x 1 cm. Wound on right ankle is 1.5 cm x 1.5 cm. R59's progress note dated 1/1/23, indicated an open area on the sacrum measuring 3 cm x 2 cm. R59's Physician Order Report dated 2/16/23, included the following orders: - 1/31/23, zosyn in dextrose 3.375 milligram/50 milliliter intravenously every 6 hours. - 1/31/23, wound vac to sacrum: Negative pressure on the pump is 125 millimeters of mercury continuous. Supplies needed for wound vac dressing change are medium black granuform. The pump must be delivering this amount of negative pressure for at least 22 out of 24 hours. If the pump alarms that pressure is not correct the warning LEAK DETECTED will show on the pump. If this occurs, please try to locate the leak by listening, and patch the air leak with clear tegaderm. If the seal cannot maintain for two hours, then the wound vac dressing will need to be removed and replaced with normal saline wet to moist dressing and notify medical director MD. - 2/2/23, Wound care (bilateral lateral ankles and left foot): Cleanse wound with normal saline and pat dry, skin prep to scabs, no dressing needed. - 2/2/23, Wound care (left heel): Cleanse wound with normal saline and pat dry, apply xeroform, cover with 4x4 mepilex. R59's Wound Evaluation and Management Summary physician notes identified the following: - 1/4/23, Right lateral ankle stage II pressure area measuring 1.5 cm x 2 cm, scabbed over, duration greater than 18 days. Unstageable deep tissue injury to left ankle measuring 2 cm x 1.7 cm, duration greater than 18 days. Unstageable deep tissue injury to left lateral foot measuring 1 cm x 0.9 cm, duration greater than 18 days. Unstageable due to necrosis of left heel pressure area measuring 5 cm x 3.2 cm, duration greater than 18 days. Stage III pressure wound to sacrum measuring 1.8 cm x 1.3 cm x 0.1 cm, duration greater than 10 days. Recommendations for all wounds was to off-load wounds, reposition per facility protocol, float heels in bed, sponge boot. - 1/18/23, Right lateral ankle pressure area unstageable due to necrosis measuring 1.8 cm x 1.8 cm eschar/scab is dry with no signs of infection. Left ankle unstageable pressure area due to necrosis measuring 2.2 cm x 2 cm scab/eschar (dead tissue) is dry and intact. Left lateral foot unstageable deep tissue injury measuring 1 cm x 0.8 cm with intact skin. Left heel unstageable pressure area due to necrosis measuring 3.5 cm x 3.7 cm. Sacrum unstageable pressure area due to necrosis measuring 6 cm x 8.2 cm, given the increase in size and new odor, recommended transfer to emergency department. - 2/1/23, Right lateral ankle pressure area unstageable due to necrosis measuring 1.8 cm x 2 cm scab. Left ankle unstageable pressure area due to necrosis measuring 2.6 cm x 2 cm. Left lateral foot unstageable deep tissue injury measuring 0.8 cm x 1 cm with intact skin. Left heel unstageable pressure area due to necrosis measuring 3.2 cm x 3.7 cm x 0.2 cm. Sacrum stage IV pressure ulcer measuring 10 cm x 6.5 cm x 1 cm. - 2/8/23, Right lateral ankle pressure area unstageable due to necrosis measuring 1.2 cm x 1.2 cm scab. Left ankle unstageable pressure area due to necrosis measuring 0.4 cm x 0.3 cm. Left lateral foot unstageable deep tissue injury measuring 1 cm x 1 cm with intact skin. Left heel stage III pressure area measuring 3.2 cm x 3 cm x 0.2 cm. Sacrum stage IV pressure ulcer measuring 8.1 cm x 7.5 cm x 1.3 cm. During an observation on 2/14/23, at 03:55p.m. R59 was noted to have heel boots in place on bilateral feet. R59 had a pillow wedge under her right side. Wound vac noted to be intact with no soiling on wound vac. R59 was noted to have an air mattress. During an interview on 2/15/23, at 12:42p.m. the medical doctor (MD)-A stated the facility could have caught the pressure ulcers earlier if they would have been doing skin inspections weekly but would not have prevented the pressure areas from occurring. On 2/16/23, at 8:58a.m. RN-D stated the facility staff does body audits twice a week and then they are uploaded in the system. If staff find any skin concerns, they would call the on-call for the facility and they would direct us on what to do. The nurse manager is the one who puts interventions into place. On 2/16/23, at 9:09a.m. registered nurse (RN)-B stated the facility staff do body audits on the fourth floor twice a week and then they are uploaded into the system. RN-B stated she was unable to find any other body audits for R59 other then what was already in the EMR. On 2/16/23, at 10:08a.m. the director of nursing (DON) stated the staff are expected to complete a skin assessment upon admission and once or twice weekly for each resident. The DON stated the facility changed the process this week as the paper body audits were not being completed. R59's wounds might have been caught sooner if staff were doing body audits but it is hard to say. The DON confirmed the expectation for nurses is to do weekly skin assessments on all residents. On 2/16/23, at 3:04p.m. the Medical Director stated he felt the preventable and avoidable pressure injuries to the bilateral lower extremities and the sacrum developed between 12/7/22 and 12/20/22. R73's quarterly MDS dated [DATE], indicated R73 had intact cognition and diagnoses of fracture of unspecified part of neck of left femur, pressure ulcer of sacral region (stage IV), muscle weakness, and need for asssitance with personal care. It further indicated R73 required extensive assistance with bed mobility (2 staff) and transfers and ambulation did not occur. R73 was at risk for developing a pressure ulcer, had (1) stage IV pressure ulcer (sacral region), and had an intervention of a turning/repositioning program. R73's care plan dated 9/5/22, include R73 was at risk for alteration of skin status due to fracture of unspecified part of neck of left femur with routine healing, cognitive communication deficit, diabetes mellitus type II, unspecified severe protein- calorie malnutrition, metabolic encephalopathy (neurological disorder resulted from systemic illness such as diabetes or organ failure and which can be reversed if treated), and pressure ulcer of sacral region, with an intervention of a turning and positioning program due to decreased mobility with assist of two. R73 prefers to be repositioned every three hours and requires special attention when positioning related to pressure ulcer of sacral region. R73's nursing assistant care sheet (undated), indicated R73 should be repositioned every 2-3 hours. During continuous observation on 2/14/23, from 1:40 p.m. to 4:47 p.m. R73 was not repositioned timely. R73 was laying in bed on her back and remained in that position throughout the entire observation. At 3:08 p.m. NA-C entered R73's room with a vital signs machine and exited at 3:09 p.m. NA-C stated she took R73's vital signs and did not re-position her or offer to do so. No other staff entered R73's room. During interview on 2/14/23, at 4:45 p.m. NA-C stated R73 should be repositioned every two hours and the last time R73 was repositioned was at 2:30 p.m. by the girl who worked the day shift. NA-C did not know the name of the staff. R73's medical record lacked any documentation R73 had been repositioned, offered to be repositioned, or refused to be repositioned. During interview on 2/16/23, at 2:50 p.m. the director of nursing (DON) stated staff should be repositioning R73 according to her care plan and even if R73 refused, staff should still be offering. The DON also stated staff should be documenting refusals. The facility policy titled Prevention and Treatment of Skin Breakdown/Pressure Injury undated, indicated weekly skin audits would be performed by a licensed nurse. The policy also indicated the treatment for a pressure injury would include a weekly measurement, exam, and staging of the area. R43's quarterly MDS dated [DATE], identified R43 had moderately impaired cognition and no rejection of care assessed. R43 was totally dependent on staff for bed mobility and transfers and had not walked. R43 required extensive assistance with dressing. R43 had no functional limitation in range of motion to his upper extremities and impairment on both sides of lower extremities. R43 had diagnoses of encephalopathy (altered mental state and confusion), diabetes, malnutrition and schizophrenia. R43 was at risk for pressure ulcer or pressure injury, however did not have a pressure ulcer or injury at the time of the assessment. Interventions included pressure relieving device for chair and bed and a turning and repositioning schedule. R43's Pressure Ulcer Significant Change Care Area Assessment (CAA) dated 5/12/22, identified R43 was admitted with no major skin concerns but was at risk for skin breakdown related to reduced mobility, reduced skin integrity, reduced strength, incontinence, and risk for shearing during transfers or repositioning. Resident had a pressure reducing device for chair and bed, and turning/repositioning program. R43 completed therapies with no new referrals and to continue care plan. R43's care plan dated 7/5/22, identified R43 was at risk for pressure ulcers due to a fracture of right patella, staphylococcus arthritis, schizophrenia, cognitive impairment, type two diabetes, encephalopathy, incontinence, catheter and dependence on mechanical lift for transfers. Interventions included monitor skin daily with cares and conduct systematic skin inspection weekly, remove immobilizer from knee and perform skin check twice daily. The care plan lacked intervention to address proper foot wear or other protective and preventative measures for R43's feet. R43's Skin Risk Assessment with Braden Scale dated 1/23/23, identified he was at moderate risk due to cardiovascular disease, contractures, diabetes, hemiplegia, and catheter. History of or refusal of care was not checked on the assessment form. R43 had no pressure ulcers at the time of the assessment. R43 had a cast/brace/splint checked and elevated head of bed due to medical necessity. R43 had slightly limited sensory perception that would affect his ability to respond meaningfully to pressure related discomfort, pressure relieving device for chair, bed and was on a turning and repositioning schedule. The assessment lacked intervention to address proper foot wear or other protective and preventative measures for R43's feet. R43's Physician Order Report dated 1/16/23 - 2/16/23, included the following orders: -1/24/23: occupational therapy (OT) to eval and treat due to wound on the right sole of foot, cushion may be needed for the foot rest -1/25/23: right foot cleanse wound daily with wound cleanser and pat dry. Apply calcium alginate to open wound bed, wrap with kerlix and tape. R43's care plan dated 1/25/23, identified R43 had a stage II pressure ulcer located on the bottom of his right foot plantar (bottom of foot) region. R43 was at risk for increased skin integrity as indicated by the Braden score and comorbidities. Interventions included to wear heel protectors to protect heels while in bed and would be monitored for properly fitting footwear and pressure reduction to the heels. R43's OT Evaluation and Plan of Treatment dated 1/26/23, identified R43's right lower extremity hung off the foot rest at each arch point of foot where there was now a wound. R43 required a different wheelchair and adaptive equipment to prevent skin breakdown to his lower extremeties. R43's Wound Evaluation and Management Summary physician notes identified the following: -1/11/23, treatment to a post surgical wound of the right knee and other wound to the leg was provided. There were no pressure sores identified on R43's foot -1/25/23, a stage II pressure wound of the right plantar foot was identified which measured 4.5 x 2.3 x 0.2 cm and treatments provided. Recommendations included offload the wound and sponge boots -2/1/23, the stage II pressure wound of the right plantar foot had deteriorated to a stage III pressure wound measuring 5 x 4.5 x 0.2 cm, the wound was debrided (removal of dead skin) and treatments provided -2/8/23, the stage III pressure wound of the right plantar foot had deteriorated and measured 5.5 x 6 x 0.4 cm and treatments provided. Redness was noted and antibiotics were ordered. During observations on 2/13/23, at 1:00 p.m., 2/14/23, at 9:00 a.m. and 2/15/23, at 9:00 a.m. R43 was observed to be able to self propel in his wheelchair using his hands. R43's legs were elevated on foot rests attached to the wheelchair. R43 had foam boots on both feet. During an interview on 2/14/23, at 3:07 p.m. NA-B stated she had worked with R43 frequently. R43 relied on staff to dress him. R43 had not worn shoes before he developed this current pressure ulcer on the bottom of his foot. NA-B was unsure if R43 had shoes. NA-B stated R43 would self propel his wheel chair with his unprotected feet pushing on the foot rests. NA-B also stated R43's right foot curved over the foot rest so more pressure was on the foot rest. NA-B stated R43's knee immobilizer was discontinued after the wound developed so he could move his leg more. During an interview on 2/15/23, at 1:04 p.m. NA-A stated she worked regularly on the unit R43 resided on. NA-A stated R43 had not worn shoes probably due to a personal preference, she had not asked why R43 didn't have shoes on. NA-A stated R43 would self propel in his wheelchair with his legs up on the foot rests. NA-A stated the knee immobilizer made it harder for R43 to move his right leg and the pressure from the wheelchair foot rest lined up with the new pressure sore on the bottom of his foot. NA-A stated the knee immobilizer was now discontinued. During an observation on 2/15/23, at 2:08 p.m. with RN-A, RN-B, and MD-A wound treatment was provided to the right plantar pressure sore. MD-A measured the wound to be 5.5 x 4.7 x 0.4 cm which was slightly improved from the previous week. MD-A told R43 she wanted to remove more dead tissue but R43 declined and said yes when MD-A asked if the wound hurt while she worked on it. MD-A stated she would order a pain medication to be given prior to the treatment the next time she came and R43 agreed to reschedule the dead tissue removal next week. During an interview on 2/15/23, at 2:13 p.m. with RN-A, RN-B and MD-A together after wound care was provided, RN-A stated the cause of the pressure sore was R43's foot putting pressure on his wheelchair foot rest and that R43 was at higher risk for pressure sores to the way his right foot dropped (weak in the front of the foot). Next, RN-B stated R43 had a diagnosis of being malnourished and this could contribute to R43's risk for pressure ulcers. MD-A then stated the wound was caught early, however she was unsure why the wound had deteriorated. MD-A stated a wound like this on R43 could develop in as little as two hours, and less than a day. MD-A stated pressure on R43's unprotected foot from the wheelchair foot rests while he self-propelled was the likely cause of the pressure sore. MD-A stated protection of the foot such as a shoe, something more than socks, could have prevented the pressure sore. During an interview on 2/15/23, at 2:20 p.m. RN-A stated R43 was at risk for pressure ulcers and his skin was monitored, however, the bottoms of his feet were not identified as a high risk area even though R43 had not worn shoes, had limited mobility to offload due to the knee immobilizer, his feet rested often on the wheelchair foot rests and R43 lacked protection to the bottom of his feet. During an interview on 2/16/23, at 9:14 a.m. the OT-A stated she had worked with R43 prior to and after the development of the pressure ulcer on the bottom of his foot. OT-A stated the wound developed on the arch of R43's foot which lined up with the wheelchair foot rests. Once the wound developed and then the leg brace was discontinued R43 could move his foot more to offload pressure. OT-A stated R43 only wore socks and was not able to move his foot off the wheelchair foot rest. OT-A stated they were now trying to find a new wheelchair so he could self-propel and protect his feet. OT-A stated the pressure from the foot rest on R43's unprotected foot was the cause of the pressure ulcer and could have been prevented. During an interview on 2/16/23, at 10:24 a.m. the DON reviewed R43's record and agreed with the Braden assessment that he was at moderate risk for developing pressure ulcers. The DON reviewed R43's care plan and agreed foot wear or foot protection was not addressed in the care plan prior to the development of the pressure ulcer on the bottom of his foot. The DON agreed that the pressure sore on the bottom of R43's foot could have been prevented if the foot had been identified as a higher risk area. Based on observation, interview and document review, the facility failed to comprehensively assess and implement pressure ulcer interventions for 3 of 5 residents (R59, R43, R73) identified at risk for pressure ulcers. This resulted in actual harm when R59 developed three unstageable pressure areas, one stage III pressure area and one stage IV pressure area after admission and actual harm when R43 developed a stage III pressure ulcer after admission.