**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of facility policies, the facility failed to ensure pressure ulcer care treatments were initiated timely and wound assessments were thoroughly completed to prevent the worsening of a pressure ulcer. Actual harm occurred to Resident #12 when the resident was readmitted to the facility with a stage II pressure ulcer (partial-thickness skin loss with exposed dermis) on assessment and no treatment orders were implemented until concerns were voiced by the resident's representative several days later. This resulted in Resident #12's pressure ulcer worsening to a stage III pressure ulcer (full-thickness skin loss) and associated deterioration and drainage. This affected one (#12) of three residents reviewed for pressure ulcers. The facility census was 69. Findings included: Review of the medical record for Resident #12 revealed an admission date of 01/30/24 with diagnoses including diabetes mellitus, osteoarthritis, hypothyroidism, hypertension, atrial fibrillation, and congestive heart failure. Further review of Resident #12's medical record revealed the resident was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. Resident #12 was hospitalized again on 02/06/25 and readmitted to the facility on [DATE]. Review of Resident #12's annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 had moderate cognitive impairment and was dependent on staff for transfers, bed mobility, and toilet hygiene. Review of Resident #12's weekly wound evaluation dated 01/22/25 revealed the resident was readmitted to the facility from the hospital with a stage II pressure ulcer to the coccyx which measured 10.0 millimeters (mm) long by 10.0 mm wide by 4.0 mm deep. Further review revealed the physician and resident representative were notified and a treatment order was given. Review of Resident #12's physician orders revealed no documentation to support an order for wound care treatment on 01/22/25. Review of a nursing progress note dated 01/28/25 at 12:26 P.M. revealed Resident #12's daughter expressed concerns regarding the wound nurse practitioner assessing the open area to Resident #12's coccyx. Further review revealed a nurse requested the physician or wound nurse practitioner see Resident #12 as soon as possible. Review of Resident #12's weekly wound evaluation dated 01/28/25 revealed the pressure ulcer to Resident #12's coccyx had worsened and treatment was ordered. The evaluation did not have documentation to support measurements were completed. Review of a nursing progress note dated 01/29/25 at 1:45 P.M. revealed a new treatment order was received and the wound nurse practitioner would follow Resident #12. Review of Resident #12's physician orders revealed an order dated 01/29/25 to pack the coccyx wound with Vashe soaked gauze and cover with border foam two times per day and as needed. Review of Resident #12's treatment administration record (TAR) for January 2025 revealed no documentation to support treatment to Resident #12's pressure ulcer to coccyx was initiated until 01/29/25. Review of a wound nurse practitioner progress note dated 02/03/25 revealed documentation of an initial visit for Resident #12's coccyx wound with measurements of 2.0 centimeters (cm) long by 2.0 cm wide by 1.4 cm deep. Further review revealed the wound had 40 percent (%) slough (non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture) and a moderate amount of serous drainage (watery, clear, or slightly yellow/tan/pink fluid that has separated from the blood and presents as drainage). Further review of the note indicated new treatments orders were given. Review of Resident #12's physician orders revealed an order dated 02/06/25 to cleanse the coccyx wound with wound cleanser, apply collagen to the wound bed, pack the wound with Vashe soaked gauze, and cover with bordered foam two times per day and as needed. Further review revealed a new treatment order was given 02/25/25 to cleanse the wound with wound cleanser, apply Santyl to the wound bed, pack with Vashe soaked gauze, and cover with bordered foam daily. Review of a wound nurse practitioner progress note dated 02/24/25 revealed Resident #12 continued with a stage III pressure ulcer to the coccyx with measurements of 2.0 cm long by 2.0 cm wide by 2.0 cm deep with 90% slough and a treatment in place. Interview on 03/06/25 at 11:27 A.M. with the Director of Nursing (DON) confirmed the medical record for Resident #12 did not contain documentation to support a wound treatment was initiated on 01/22/25 when Resident #12 was noted to have a stage II pressure ulcer to the coccyx. The DON also confirmed Resident #12's pressure ulcer worsened to a stage III pressure ulcer on 01/28/25 and verified there was no full assessment of the wound between 01/22/25 and 02/03/25 to determine the wound size. Review of the policy titled, Pressure ulcers/skin breakdown - Clinical Protocol, revised April 2018, revealed nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers. In addition, the nurse shall describe and document or report a full assessment of the pressure sore including location, stage, length, width, and depth, presence of exudates or necrotic, pain assessment, resident's mobility status, and current treatments. Further review revealed the physician will order pertinent wound treatments. Review of the policy titled, Wound Care, revised October 2010, revealed the purpose was to provide guidelines for the care of wounds to promote healing. Staff are to verify there is a physician's order for the procedure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of medical records revealed Resident #14's was admitted to the facility on [DATE]. Diagnoses include dementia without behavioral, Alzheimer's disease, hypertension, depression, history of falling, abnormalities of gait and mobility, pain in right knee, pain left knee, and unspecified fall. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 has severe impaired and requires supervision for activities of daily living. Resident #14 also required limited assistance for dressing. The at risk for falls care plan dated 06/08/18 documented Resident #14 is always to wear non-skid socks and shoes. Review of a fall risk assessment dated [DATE] identified Resident #14 scored an 11 indicating the resident was at risk for falls. Observation on 05/15/19 at 2:09 P.M., revealed Resident #14 sleeping in bed. Bed was low and against the wall as in the care plan. Resident #14 had no nonskid socks on her feet. Resident #14 shoes were under the bed, her walker was about two feet away from bed. The call light was not in reach. Call light was about four feet away. Interview on 05/15/19 at 2:47 P.M., revealed Licensed Practical Nurse (LPN) #707 reported the State Tested Nursing Assistants (STNA's) lay out clothes for Resident #14 to wear. LPN #707 stated Resident #14 requires limited assistance getting dressed. Resident #14 goes to the bathroom without any assistance. Interview on 05/15/19 at 2:49 P.M., revealed STNA #863 verified Resident #14 did not have on nonskid socks but second shift makes sure resident has on nonskid socks. Reviewed policy titled Brethren Retirement Community Falls and Fall Risk, Managing revised December 2007 states based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Based on medical record review, review of an incident report, observation, staff interview and policy review, the facility failed to ensure Resident #88's fall interventions were implemented to prevent falls in accordance with the resident's fall risk care plan. This resulted in actual harm when Resident #88's call light was not within reach at the time the resident experienced a fall, the resident was subsequently hospitalized and required surgical intervention for a left hip fracture. In addition, the facility failed to ensure staff implemented a second resident's (#14) fall interventions in accordance with the care plan which did not result in injury. This affected two (#88 and #14) of two residents reviewed for falls and accidents. The facility census was 110. Findings include: 1. Review of Resident #88's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses include dementia with Lewy Bodies, dysphagia, hypertension, major depressive disorder and hyperlipidemia. Review of the care plan start dated 12/14/18, revealed Resident #88 was at risk for falls or injury related to Parkinson's disease with dementia. The goal of the care plan was to achieve optimal level of function in activities of daily living with progressive limitations of cognition. The approaches included to encourage the resident to use the call light for assistance, keep the call light in easy reach, and meet the residents needs promptly. Review of a quarterly minimum data set (MDS) assessment dated [DATE], revealed Resident #88 had moderate cognitive impairment with a Brief Interview for Mental Status of 12 out of 15. The MDS assessment review further revealed the residents speech was clear, the resident was able to make self understood, and had the ability to understand others. Resident #88 required extensive assistance of one person for bed mobility, transfers, and toileting. Review of a fall risk assessment dated [DATE], revealed the resident's assessment score was 24. Further review of the fall risk assessment criteria revealed a score over nine indicates the resident is at risk for falls. Review of a nursing progress note dated 05/04/19 at 9:45 P.M. revealed Resident #88 was found on the floor and noted to have pain in the left hip. Review of the nursing progress note revealed the physician was notified of the fall and a new order was obtained to send the resident to the hospital for evaluation and treatment. Review of a nursing progress note dated 05/04/19 at 10:03 P.M. revealed Resident #88 was being admitted to the hospital for a left hip fracture. Review of an incident details report dated 05/04/19 revealed Resident #88 was found on the floor in his/her room on 05/04/19 at 6:30 P.M. The incident report further documented the resident was on the floor in front of his/her recliner chair. The recliner foot rest was elevated. Resident #88 reported to staff that he/she rolled off of the recliner chair and was having hip and foot pain. Continued review of the incident details report revealed Resident #88's left leg was observed to be short than the right leg and rotated inward. The incident report documented Resident #88's call lights were not within reach of the resident prior to the fall. Review of hospital documentation dated 05/04/19 at 10:38 P.M., revealed Resident #88 was brought to the hospital from the facility after the resident sustained a fall. Resident #88 reported to hospital staff he/she was attempting to get up from the recliner, the foot of the recliner would not go down, and the resident fell. The documentation further revealed radiograph (X-ray) results showed a left femoral neck fracture. The assessment and plan included a left hip fracture, orthopedic consultation and plan for surgery on Monday. Interview on 05/14/19 at 4:39 P.M. with Registered Nurse (RN) #900 revealed this nurse was in Resident #88's room to administer medication on 05/04/19 at approximately 6:20 P.M. RN #900 reported Resident #88 was in his/her recliner when the medications were administered. RN #900 reported on 05/04/19 at approximately 6:30 P.M. State Tested Nursing Assistant (STNA) #800 went to Resident #88's room and found the resident on the floor. RN #900 confirmed Resident #88 was at risk for falls and he/she was capable of using the call light. RN #900 further stated the staff provided Resident #88 with two call lights; however, upon further assessment after Resident #88's fall both call lights were observed on the residents pillow located on the resident's bed. RN #900 confirmed the call lights were not in reach of the resident when the resident was sitting in the recliner chair which is where Resident #88 fell. RN #900 revealed an investigation of the fall was completed. The investigation revealed the resident was not assisted in the recliner by facility staff and the call lights were not given to the resident because staff did not assist the resident to the chair. RN #900 verified on 05/04/19 at 6:20 P.M., 10 minutes prior to Resident #88 being found on the floor, RN #900 was in the residents room to administer medications and the resident was observed in the recliner chair at that time. RN #900 further verified Resident #88's call light placement was not checked by on 05/04/19 when she administered his/her medications because the resident appeared to be comfortable. Interview on 05/16/19 at 3:16 P.M. with STNA #800 revealed he/she entered Resident #88's room on 05/04/19 at 6:30 A.M. and the resident was observed sitting on the floor in front of his/her recliner chair. The foot rest of the recliner was elevated. STNA #800 stated Resident #88 had propelled himself/herself back to the room after supper. STNA #800 reported Resident #88 would sometimes transfer himself/herself, even though the resident required staff assistance for transfers. STNA #800 reported, Resident #88 was often given education from the staff for use of the call light and getting staff assistance for transfers. STNA #88 revealed Resident #88 had two call lights in his/her room but could not verify the location of either call light at the time of the fall. STNA #88 revealed when the resident was observed sitting on the floor, the STNA immediately went to notify the nurse and did not check for call light placement.