2. During an observation on 6/5/25 at 7:57 a.m., resident #13 received morning cares from staff members F and K. Resident #13 was lying on her back in the bed. Resident #13 had a wound dressing on her right heel which was left in place. When resident #13 was turned to her right side for incontinence care, an open area was noted on her coccyx. There was no wound dressing in place. Staff member F applied moisture barrier cream, and a new incontinence brief. Resident #13 called out in pain and cried when she was moved in her bed. The crying stopped as soon as the resident was left alone. During an interview on 6/4/25 at 12:47 p.m., staff member G stated the wound nurse had been seeing the resident weekly, otherwise staff did the dressing changes. Review of resident #13's nursing progress notes showed the following: - 3/17/25, bruising to buttocks, present on admission, no measurements documented, - 4/14/25, bruising to buttocks resolved, - 4/21/25, new pressure ulcer on coccyx, scheduled to see the wound nurse on 4/22/25, - 4/22/25, Unstageable pressure ulcer on medial gluteus and coccyx, moisture barrier cream and a dressing, change every three to four days; and, - 5/27/25, Stage III pressure ulcer to medial gluteus, wound border macerated and raised, apply moisture barrier cream after each brief change. Based on observations, interviews, and record review, the facility failed to ensure residents received necessary treatment and services to prevent pressure ulcers and promote healing for 2 (#s 1 and #13) of 7 residents sampled with pressure ulcers. This practice contributed to chronic (>three months) Stage II and Stage III pressure ulcers for resident #1 and a Stage III for resident #13. Findings include: 1. During an observation on 6/2/25 at 2:35 p.m., resident #1 was sleeping on his back in his bed, with the head of the bed elevated to approximately 30 degrees. His head was tilted forward to the left side. A neck pillow/collar was in his wheelchair. During an observation on 6/2/25 at 2:46 p.m., resident #1 was sleeping on his back in his bed, with the head of the bed elevated to approximately 30 degrees. His head was tilted forward and to the left side. Neck pillow/collar was in his wheelchair. During an observation on 6/2/25 at 3:35 p.m., resident #1 was sleeping on his back in his bed, with the head of the bed elevated to approximately 30 degrees. His head was tilted forward to the left side. A neck pillow/collar was in his wheelchair. During an observation on 6/2/25 at 4:43 p.m., resident #1 was sleeping on his back in his bed, with the head of the bed elevated to approximately 30 degrees. His head was tilted forward to the left side. A neck pillow/collar was on his wound supply shelf. During observations on 6/3/25, from 7:45 a.m. to 4:32 p.m., resident #1 was observed every 30 minutes and found to be in the same position in bed. Resident #1 was sleeping on his back in his bed, with the head of the bed elevated to approximately 30 degrees. His head was tilted forward to the left side. The neck pillow/collar was in his wheelchair. During an interview on 6/4/25 at 10:13 a.m., staff member B stated she was aware wound documentation was not being completed and was working on a wound program, including camera use and staging (determining severity) education. Staff member B stated resident #1 was supposed to be up in his wheelchair for 2-3 hours each day for activities. Staff member B stated resident #1 did not get up in the evenings. Staff member B stated resident #1 should be turned and repositioned every two hours and should be checked and changed every two hours. Staff member B stated resident #1 did have a collar pillow to prevent pressure on his neck and ear. Staff member B stated resident #1 had a history of pressure injuries and maceration on his ear and neck area related to his positioning and moisture. During an observation on 6/4/25 at 10:01 a.m., resident #1 was sleeping on his back in his bed, with the head of the bed elevated to approximately 30 degrees. His head was tilted forward to the left side. The neck pillow/collar was in his wheelchair. During an observation on 6/5/25 at 7:10 a.m., resident #1 was in bed sleeping on his back in his bed, with the head of the bed elevated to approximately 30 degrees. His head was tilted forward to the left side. NF1 assessed resident #1's pressure wounds on his buttocks. NF1 stated he had three wound openings with a large area which was a Stage I pressure sore covering 13.5 cm by 8.5 cm on the right buttock and 13.5 cm by 7.0 cm on the left buttock. The openings included: - 1.5 cm by 9.0 cm by 0 cm: Stage I - 1.1 cm by 1.0 cm by 0.1 cm: Stage II - 0.8 cm by 0.5 cm by 0.15 cm: Stage II NF1 stated frequent turning and positioning were critical, along with frequent brief changes related to incontinence. Staff member L entered to assist NF1 during the dressing change. Staff member L stated the neck pillow was only used during times resident #1 was in his wheelchair. NF1 stated the pressure sores on resident #1's buttocks have waxed and waned, but the wounds were worse than the last time she evaluated them. NF1 stated it was hard to achieve compliance with turning and positioning with all the travel staff used by the building. During an observation on 6/5/25 at 9:20 a.m., resident #1 was sleeping on his back in his bed, with the head of the bed elevated to approximately 30 degrees. His head was tilted forward to the left side. Review of resident #1's Nursing Care Plan, with a revision date of 4/22/25, reflected: - . Use soft cervical collar-type pillow to prevent left ear from resting on shoulder. Pillow should be on left side only with no pressure to ear. Ask for assist to properly position as needed. Check collar frequently to monitor for positioning, pressure areas, and to insure breathing and circulation are not compromised. [sic] - . [Resident #1] needs total assistance to REPOSITION ROUTINELY THROUGHOUT THE DAY/NIGHT; use turn sheet when he is in bed to prevent shearing. 2-3 hours maximum time in w/c and reposition every 2 hours in bed. Review of resident #1's EHR nursing progress note, dated 1/6/25 reflected resident #1 developed a new pressure wound on his buttocks. No measurements were available. Review of the facility provided tracker, Treatment/Svcs to prevent/heal pressure sores, dated 1/7/25 through 6/3/25, reflected: - On 1/7/25 the report showed: . 6.8 x 5 x 0.01 increased significantly in size from previous measurement 12/13 of 4.8 x 3.6 *requested air mattress overlay for bed - On 1/14/25 the report showed: . Air mattress overlay placed 1/7/25 measurements have increased to 7.9 x 6.4 x 0.01 - On 3/11/25 the report showed: .Wound 1.5 x 2.5 x 0.1 - On 4/8/25 the report showed: . 3 x 3.5 x 0.01, scattered wounds - On 5/13/25 the report showed: . scattered wounds - On 6/3/25 the report showed: . scattered wounds-improving Refer to observation on 6/5/25 at 7:10 a.m. for the most current measurements. Review of resident #1's Braden Scale, dated 10/15/24, reflected resident #1 was at high risk for pressure ulcers with a score of 10. A score of 12 or less reflects a High Risk.

Based on interview and record review, the facility failed to maintain scale equipment, resulting in a fall with an injury, for 1 (#28) of 2 sampled residents. Findings include: Review of an incident for resident #28, dated 2/21/23, showed, Upon entry into room resident was on all fours on the floor with a pool of blood near left leg .Was in the chair scale and fell out when a wheel fell off, Resident thinks she hit her head . [sic]. During an interview on 6/7/23 at 10:16 a.m., staff member F stated resident #28 required assistance with transfers and had a history of falls. During an interview on 6/7/23 at 10:58 a.m., staff member A stated the facility did not have maintenance records for the chair scale, and staff member A did not know why staff did not notify maintenance of any previous issues with the chair, before resident #28's fall on 2/21/23. Staff member A stated maintenance fixed items as needed in the facility. During an interview on 6/7/23 at 12:38 p.m., staff member G stated she recalled the incident with resident #28's fall from the scale chair. Staff member G stated the wheel came off the leg of the chair, and she fell out. Staff member G stated if something was wrong with a piece of equipment in the facility, work orders were given to staff member E. During an interview on 6/7/23 at 12:40 p.m., staff member E stated the chair scale was not checked or maintained annually, and there was not a schedule to check the chair's function. Staff member E stated he was called to fix the chair scale after the incident with resident #28 on 2/21/23, and the wheel had come loose. There was no schedule for maintenance created for the chair after the incident. During an interview on 6/8/23 at 8:02 a.m., staff member A stated she did not know if resident #28's fall on 2/21/23 was a QAPI discussion, as it was viewed as a fluke. Staff member A stated she thought an informal education was done for staff to check equipment moving forward, but nothing was documented. Review of resident #28's Emergency Department Provider Notes, dated 2/21/23, showed the resident had the following injury from the fall from the chair scale: Complex 12 cm laceration overlying the left lower leg. This penetrates into the subcutaneous tissue .Repair method: Sutures .Number of sutures: 20. A review of the facility's policy, Preventative Maintenance Program, dated 8/19/22, showed, 1. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner.