**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #40 revealed an admission date of 10/04/19. Diagnoses included chronic respiratory failure, peripheral vascular disease, tracheostomy, dependence on respirator, atrial fibrillation, and neuromuscular dysfunction of the bladder. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #40 was cognitively impaired, was dependent on staff for activities of daily living and mobility, had an indwelling urinary catheter, was always incontinent of bowel, and was risk for pressure ulcer with no unhealed pressure ulcer present. Review of the care plan initiated on 09/06/23 revealed Resident #40 was at risk for impaired skin integrity related to respiratory failure, seizures, encephalopathy, peripheral vascular disease, atrial fibrillation, neurogenic bladder, anemia, vegetative state, and hypertension. Interventions included the administration of medications as ordered, the application of protective barrier with each incontinence episode, assistance with turning and reposition as needed, completing a Braden scale as needed, providing dietary supplements as ordered, elevation of heels off the mattress as tolerated, and to notify the nurse of any new skin areas of skin impairment during bathing or daily care, as well as notification to the provider of any new skin impairment. Resident #40 was also to have a pressure redistribution device to chair, specialty air mattress to bed with bilateral bolster, preventive treatments provided as ordered, and incontinence care as needed. The care plan was revised on 07/31/24 to reflect a stage III pressure ulcer to the coccyx with interventions to include monitoring the dressing every shift and change as needed. Review of the weekly skin assessments revealed Resident #40 had a pressure ulcer to the coccyx which was resolved on 04/17/24. From 04/17/24 to 07/15/24, Resident #40 had no abnormal skin areas. Resident #40 was sent out to the hospital for evaluation of shortness of breath on 07/16/24 and returned to the facility on [DATE]. Review of the hospital record revealed a wound care consult dated 07/18/24 for moisture associated skin damage (MASD) to the sacrum on 07/18/24. The wound care noted a sacral wound, history of a stage IV pressure ulcer in 2022. The wound assessment revealed a denudation to the buttocks and a linear area of erosion in gluteal cleft. Hospital staff did apply fecal pouch, as patient was having multiple loose stools overnight. A protective foam dressing in place over the gluteal cleft at time assessment, which was trapping a lot of moisture in gluteal cleft. Wound care recommendation was for triad cream twice a day and when incontinent after the area was cleansed with soap and water and patted dry. Additionally, Resident #40 was to be turned and repositioned every two hours while in bed, heels floated off the bed with pillows under calves, and a single layer moisture wicking under pad under the resident. Review of the continuation of care paperwork printed 07/20/24 at 10:11 A.M. revealed Resident #40's buttocks were to be cleaned with soap and water, patted dry, followed by the application of triad cream twice a day and as needed when incontinent. There was no physician order at the facility implemented for this skin treatment to continue as the hospital recommended. Review of the nursing readmission evaluation dated 07/20/24 and timed 3:27 P.M. Resident #40 was noted to have MASD of the coccyx. There was no mention of an open area to the coccyx. There were no weekly skin assessments completed from 07/21/24 to 07/30/24. There were no physician orders for a foam dressing to be in place until 07/31/24. There was no treatment for a foam dressing noted in the treatment administration record. Interview with Resident #40's family member on 07/30/24 at 3:15 P.M. revealed concerns related to the timeliness of care including suctioning, repositioning and incontinence care. The family member stated there was now a camera in the resident's room and if family member notices more than two and half hours have gone by without Resident #40 being checked, changed and repositioned, she called the facility to get someone into the room to provide the care. The family member verbalized concern over Resident #40's skin due to a pressure ulcer Resident #40 on the coccyx that took over two years to heal. There was no mention of an open area to Resident #40's coccyx until 07/31/24. Observation of incontinence care on 07/31/24 at 7:30 A.M. for Resident #40 completed by State Tested Nursing Assistant (STNA) #423 and #463 revealed Resident #40 had a foam dressing on the coccyx dated 07/31/24 and timed 2:40 A.M., the foam dressing was loose and soiled with stool. STNA #463 removed the foam dressing and alerted the nurse of the dressing needing to be replaced. Observation of Resident #40's skin when the dressing was removed revealed an open reddened area of skin approximately 2.0 cm long by 2.0 cm wide in the upper gluteal cleft. Skin care was completed with soap and water, and the area was patted dry. Registered Nurse (RN) #515 entered the room at 7:40 A.M. and placed a new clean foam dressing over the open area on the coccyx. Interview on 07/31/24 at 7:45 A.M. with RN #515 verified Resident #40 had an open area and further verified the foam dressing was in place to protect to the area. Interview on 07/31/24 at 12:30 P.M. with the Director of Nursing (DON) revealed no knowledge of Resident #40 having an open area to the coccyx. Review of the skin and wound evaluation dated 07/31/24 at 3:14 P.M. revealed Resident #40 had a stage three pressure ulcer to the coccyx, measuring 1.9 centimeters (cm) long by 0.9 cm side by 0.1 cm deep with 100 percent of wound filled. The physician was notified, and an order was received on 07/31/24 to cleanse the coccyx with in-house wound cleaner, pat dry, apply collagen and cover with foam dressing every day and as needed. Review of the nursing progress note revealed a note dated 07/31/24 at 3:31 P.M. revealed a small open area on coccyx, area cleansed with soap and water and a foam dressing applied. Interview on 08/01/24 at 7:33 A.M. with the Assistant Director of Nursing (ADON) #510 verified Resident #40 had a stage III pressure ulcer to the coccyx, the physician was notified with treatment orders obtained and family was updated. ADON #510 verified the medical record for Resident #40 contained no evidence of the open area to the coccyx of Resident #40 prior to 07/31/24. 3. Review of the medical record for Resident #184 revealed an admission date of 07/24/24. Diagnoses included acute respiratory failure, chronic obstructive pulmonary disease, type II diabetes mellitus, end stage renal disease, dependence on dialysis, major depressive disorder, tracheostomy, and atrial fibrillation. Review of the continuation of care paperwork dated 07/24/24 revealed Resident #184 had a traumatic injury wound to the left anterior foot with a measurement of 1.2 centimeters (cm) long by 4.5 cm wide, an unstageable pressure ulcer to the left proximal dorsal thigh with a measurement of 3.1 cm long by 6.6 cm wide by 0.2 cm deep, an unstageable pressure ulcer to the sacrum, measurements 7.1 cm long by 6.9 cm wide by 0.1 cm deep, and a deep tissue injury (DTI) to the right heel with measurements of 2.5 cm long by 2.5 cm wide. Resident #184 was also noted to have redness to the left cheek and dry skin to the left abdomen. Review of the nursing admission evaluation completed on 07/25/24 at 12:11 A.M. revealed Resident #184 did not have any identified skin conditions. Review of the physician orders dated 07/25/24 revealed an order for protective cream to buttocks after episode of incontinence and to complete weekly skin assessments. There were no treatments in place to the unstageable pressure ulcers on the left proximal dorsal thigh and sacrum, or DTI to the right heel. Review of the care plan dated 07/25/24 revealed Resident #184 was identified at risk for impaired skin integrity. Interventions included to administer medications as ordered, apply protective barrier cream after incontinence episodes, completed Braden scale as needed, dietary supplements as ordered, pressure/redistribution mattress to bed/chair, report any new areas of skin impairment noted during bathing or daily care. Review of the Braden scale for predicting pressure sore risk completed on 07/25/24 at 12:10 A.M. revealed Resident #184 was at moderate risk for developing pressure ulcers. Resident #184 was identified as being unresponsive, with usually dry skin, was confined to bed with very limited mobility, had adequate nutrition and had no apparent problem with friction or shear as the resident moves in the bed and chair independently. Review of the physician history and physical completed on 07/25/24 revealed there was not a skin assessment completed for Resident #184. Review of the skilled nursing assessment completed on 07/26/24 at 12:23 P.M., on 07/28/24 at 12:46 A.M. and 3:13 P.M. revealed Resident #184 had no abnormal skin conditions. The skilled nursing assessment completed on 07/30/24 at 12:11 A.M. revealed Resident #184 had abnormal skin conditions. Review of the pulmonary nurse practitioner note dated 07/26/24 revealed Resident #184 had multiple wounds covered with dressings. Review of the nutritional note dated 07/29/24 and timed 8:18 A.M. revealed Resident #184 had intact skin. Review of the nursing progress notes revealed a note dated 07/30/24 at 7:10 P.M. revealed the day shift nurse reported Resident #184 had a necrotic area to the coccyx with Resident #184 requiring total care and repositioned on the right side. A progress note dated 07/30/24 at 9:00 P.M. stated Resident #184 was transported to the hospital with family updates provided. Observation on 07/30/24 at 4:30 P.M. revealed staff moving quickly into Resident #184's room, followed by the door being closed. Interview on 07/30/24 at 4:45 P.M. with Licensed Practical Nurse (LPN) #650 revealed Resident #184 had a wound to the coccyx that appeared to be necrotic. LPN #650 believes in contributing to a change in condition for Resident #184 as Resident #184 had been clammy all day. LPN #650 stated Resident #184 was going to be sent out to the hospital for evaluation. Interview on 07/30/24 at 5:15 P.M. with State Tested Nursing Assistant (STNA) #503 at the bedside of Resident #184 verified Resident #184 had a necrotic area to the coccyx and after cleaning Resident #184 the resident was repositioned off his back. STNA #503 added she was remaining with Resident #184 until the nurse returned. Review of the Emergency Department record dated 07/30/24 revealed Resident #184 was sent to the emergency department for an evaluation of wounds with facility concerns about a decubitus ulcer on Resident #184's buttocks and developing wounds on the lower legs. Review of Resident #184's emergency department assessment revealed a wound of the left foot measured 0.5 cm long by 1.5 cm wide that goes down to the subcutaneous fascia, a coccyx wound, a right heel wound, and wounds to the left upper chest and face. left dorsal foot, right lateral calf, and right arm. Resident #184 was admitted to the hospital on [DATE] at 2:10 A.M. with a decubitus pressure injury of the sacral region, sepsis and respiratory failure. Interview on 08/05/24 at 3:30 P.M. with the Director of Nursing denied knowledge of Resident #184 having any wounds and further verified the medical record for Resident #184 was silent for wound treatment orders and the care and treatment of any wounds since Resident #184's admission on [DATE]. Review of the facility's Pressure Ulcer/Skin Breakdown Clinical Protocol last revised 01/01/22 revealed because a resident at risk can develop a pressure ulcers/pressure injuries (PU/PI) within hours of onset of pressure, the at-risk resident needs to be identified and have interventions implemented promptly to attempt to prevent PU/PI. The interdisciplinary team will assess and document and individual's significant risk factors for developing PU/PI; for example, immobility, recent weight loss, history of PU/PI, modifiable and non-modifiable risk factors. The plan of care for prevention and/or treatment of PU/PIs will be developed based on the assessments. A resident with current PU/PI's is evaluated/assessed by the licensed nurse at each treatment and as needed. Review of the NPUAP guidelines dated 2014 revealed facilities should educate health professionals on how to undertake a comprehensive skin assessment that includes the techniques for identifying blanching response, localized heat, edema, and induration. Ongoing assessment of the skin was necessary to detect early signs of pressure damage. Visual assessment for erythema (redness of the skin) was the first component of every skin inspection. Skin redness and tissue edema resulting from capillary occlusion was a response to pressure, especially over bony prominences. Staff should conduct a head-to-toe assessment with particular focus on skin overlying bony prominences including the sacrum, ischial tuberosities, greater trochanters and heels and each time the patient was repositioned was an opportunity to conduct a brief skin assessment. This deficiency represents non-compliance investigated under Master Complaint Number OH00156481, Complaint Number OH00156247, and Complaint Number OH00155863. AMENDED 08/27/24 Based on observation, medical record review, family and staff interview, and review of the facility's Pressure Ulcer/Skin Breakdown Clinical Protocol, and review of the guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to accurately assess wounds, provide timely interventions to prevent the development of pressure ulcers or healing of existing pressure ulcers, failed to obtain timely treatments of existing wounds, and failed to timely identify the resident's pressure ulcers until it reached an advanced stage. This resulted in Actual Harm to Residents #79 and #40 who were at risk for pressure ulcers and the facility found Resident #79's pressure ulcer as an unstageable pressure ulcer (Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar) and Resident #40's pressure ulcer as a stage III pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed). Actual Harm occurred to Resident #184 when the resident was admitted with two unstageable pressure ulcers, and a deep tissue injury (purple or maroon area of discolored intact skin due to damage of underlying soft tissue) and did not have any treatments in place while residing in the facility for six days. Resident #184 was sent to the emergency room on the sixth day due to decubitus pressure injury of the sacral region, sepsis and respiratory failure. This affected three (#40, #79, and #184) of six residents reviewed with pressure ulcers. The facility census was 74. Findings include: 1. Closed medical record review revealed Resident #79 was admitted to the facility on [DATE] with the diagnoses included cerebral infarction, cerebral aneurysm, type II diabetes mellitus, coronary artery disease, congestive heart failure, anemia, osteoarthritis, seizure disorder, dysphagia, chronic inflammatory disease of uterus, and anxiety disorder. Review of the physician order dated 01/26/23 revealed an order for the application of protective cream to buttocks each shift and as needed (PRN). On 03/02/23, an order for a frozen nutritional treat (or equivalent) (high calorie) one time a day with dinner related to weakness. Review of the nursing care plan dated 08/21/23 revealed Resident #79 was at risk for impaired skin integrity related to cerebral vascular accident with left sided weakness, diabetes, coronary artery disease, congestive heart failure, osteoarthritis, and weakness. Interventions were implemented on the following dates: on 08/21/23, an air mattress with bed bolsters to establish safe parameters, apply protective barrier cream after incontinent episodes, assist the resident with turning and repositioning as needed, encourage the resident to reposition self if able, notify nurse of any new areas of skin impairment noted during bathing or daily care (e.g. redness, blisters, bruises, discoloration), notify Physician/Physician Assistant/Nurse Practitioner of any new areas of skin impairment, preventive treatments per orders, complete skin inspection weekly and as needed, consult dietitian as needed, dietary supplements as ordered, encourage good nutrition and hydration. Assist as needed. Provide a non-irritating surface to reduce friction or shearing forces. Provide incontinence care as needed. On 08/29/23, a pressure redistribution device was placed in chair. On 03/19/24, monitor dressings each shift and change as ordered. Further review of the medical record revealed it lacked documentation indicating an air mattress with bed bolsters was applied to the bed, pressure redistribution device was placed to the chair, or turning and repositioning was provided consistently. Review of the skin risk assessment dated [DATE] revealed Resident #79 was at moderate risk for pressure ulcer development. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #79 was assessed with moderate cognitive impairment and had no behaviors of refusal of care during the review period. Resident #79 was dependent on staff for the completion of activities of daily living, which included with bed mobility and transfers. Resident #79 utilized a wheelchair for mobility. Resident #79 was incontinent of bowel and bladder, had no reports of pain during the assessment period, no weight loss, received a mechanically altered and therapeutic diet, at risk for pressure ulcer development with no skin breakdown identified. Review of the Task Documentation Survey Report for tracking turning and repositioning per the care plan revealed it lacked documentation during May 2024 of every two hour turn and repositioning. The documentation noted repositioning was provided on 05/06/24 at 12:16 A.M., 05/11/24 and 05/19/24 between 12:00 A.M. and 6:00 A.M., 05/25/24 between 12:00 A.M. and 2:00 A.M. No further repositioning was documented between 12:00 A.M. and 6:00 A.M. during May 2024. Additional review of two hour turns and repositioning documentation revealed on 05/27/24 between 9:24 P.M. and 05/28/24 at 2:00 P.M., and 05/28/24 between 9:24 P.M. and 05/29/24 at 2:00 P.M., no repositioning was recorded in the medical record. The medical record lacked consistent documentation recording turning and repositioning every two hours through 06/18/24. Review of the skin assessment dated [DATE] at 5:21 P.M. revealed an abnormal skin area was identified to the sacrum. The area was described as moisture associated skin damage (MASD). No measurement or evaluation of the impaired skin was documented. No further assessment was contained in the medical record regarding the sacral MASD. On 05/29/24 at 2:25 P.M., a physician order was obtained by Licensed Practical Nurse (LPN) #455 for a treatment to Resident #79's coccyx. The order included to flush wound with normal saline, pack with Iodoform, cover with foam dressing everyday shift for open area. Review of the Incident Description New Pressure Ulcer documentation revealed on 05/29/24 at 5:15 P.M., LPN #455 was notified by care staff Resident #79 was discovered with an open area to coccyx. Resident stated her buttocks hurt. LPN #455 documented unaware Resident #79 had an open area. A treatment was applied to the area. The nursing note dated 05/29/24 at 5:19 P.M., revealed LPN #455 documented during care a staff member noticed open area to resident's coccyx and reported to nurse whom further evaluated. The skin assessment dated [DATE] at 5:26 P.M. revealed a pressure area to the coccyx. No documentation indicated wound measurements were obtained or an evaluation of the area was noted. The medical record was silent to wound measurements, descriptions, or additional interventions being implemented on 05/29/24. The initial wound description was completed on 05/30/24 and identified a right gluteal wound was evaluated as in-house acquired with origin date of 05/29/24. The wound descriptions noted it was an unstageable pressure ulcer to the right gluteal with 100% slough and moderate amount of serosanguineous (blood tinged) exudates (drainage). Measurements were noted 0.67 centimeters (cm) length by (x) 0.96 cm width x 0.2 cm depth, undermining was recorded 0.5 cm from 12 to 12 o'clock. The right gluteal dressing treatment was changed by the physician on 05/30/24 to include Santyl External Ointment (debriding agent) 250 unit/gram (gm) (Collagenase). Apply to right gluteus topically as needed for wound care, cleanse wound with in-house wound cleanser, pat dry, apply nickel thick layer of Santyl to wound bed, lightly pack with saline moisten gauze, and cover with dry dressing. The physician orders dated 05/30/24 included the application of an air mattress with bed bolsters to the bed and monitor dressing(s) every shift to ensure they were clean, dry, and intact. If not, replace dressing to be completed every day and night shift. On 06/06/24, the wound measurements and descriptions contained in the medical record noted the right gluteal wound measured 3.19 cm long x 2.43 cm wide x 0.2 cm deep. The wound bed was assessed with 20% granulation, 60% slough, 20% eschar, and moderate amount of serosanguineous drainage. The physician was notified on 06/06/24 and modified the order to the wound to include the application of Santyl External Ointment 250 unit/gm (Collagenase) to apply to right gluteus topically as needed for wound care, cleanse wound with in-house wound cleanser, pat dry, apply nickel thick layer of Santyl to wound bed, lightly pack with Dankin's moisten gauze, and cover with dry dressing every day shift for wound care. On 06/13/24, the right gluteal wound was documented with measurements 3.92 cm long x 5.48 cm wide x 0.5 cm deep and undermining of 0.3 cm from five to nine o'clock. Wound bed was described with 20% granulation, 40% slough, 40% eschar, and moderate amount of serosanguineous drainage. On 06/14/24, the physician ordered Santyl External Ointment 250 unit/gm (Collagenase) to apply to right gluteus topically as needed for wound care, cleanse wound with in-house wound cleanser, pat dry, apply nickel thick layer of Santyl to wound bed, lightly pack with calcium alginate, and cover with dry dressing. On 06/17/24, the physician ordered a referral to wound care for an unstageable pressure ulcer to the right gluteus. However, Resident #79 was not evaluated by the wound care specialist and was discharged to the hospital on [DATE]. Resident #79 did not return to the facility. Interview on 07/31/24 at 7:55 A.M. with LPN #455 confirmed on 05/29/24, she was notified by care staff that Resident #79 had an area of skin breakdown to the right gluteal. LPN #455 was not informed the resident had an open area prior to assuming care of the resident. LPN #455 observed the wound and stated was open and draining. LPN #455 indicated she was unaware why the wound was not discovered before it was found to be open and draining blood-tinged exudates. LPN #455 verified Resident #79 was dependent on staff for repositioning and had a standard pressure relief mattress in place without an air mattress. The physician and family were notified, and a treatment was implemented. LPN #455 verified she did not obtain wound measurements, document wound description, or implement any additional interventions on 05/29/24. Interview on 07/31/24 at 8:06 A.M. with Unit Manager (UM) #422 revealed she was informed via incident report completed 05/29/24 that Resident #79 was discovered with a pressure ulcer to the right gluteus. On 05/29/24, LPN #455 completed an incident report with notifications of physician and family. UM #422 verified she initially assessed Resident #79's wound on 05/30/24 and obtained a photo. UM #422 indicated the wound was open and draining blood-tinged exudates. The wound photo was provided to the Director of Nursing (DON) and measurements with descriptions were obtained using the photo. UM #422 further stated Resident #79 had been declining with nutritional intake and was unable to reposition herself. UM #422 verified prior to 05/30/24, Resident #79 was on a standard mattress and not an air mattress as listed in the plan of care. UM #422 confirmed no measurements or wound description was obtained until 05/30/24 and confirmed there was no documentation indicating Resident #79 was repositioned in accordance with a repositioning program every two hours. Interview on 07/31/24 at 8:31 A.M. with the DON verified there were no measurements or description of Resident #79's wound obtained until 05/30/24, no evidence of an air mattress was in place until 05/30/24, and there was no consistent documentation of turning and repositioning during the third shift between 12:00 A.M. and 6:00 A.M. in the months of May and June 2024. The DON verified there was no investigation completed including staff interviews into the origin of the wound before it was discovered open and draining blood-tinged exudates. The DON also confirmed the wound was not staged while the resident resided at the facility due to the amount of slough contained inside the wound. Additional interview on 08/01/24 at 9:42 AM with the DON stated UM #522 observed Resident #79's wound and obtained a photo. The DON stated she reviewed pictures of the wound and utilized the pictures to determine the wound description. The DON further confirmed she did not physically observe the wound to determine a description and measurements. The wound was unable to be staged due to the amount of slough tissue inside the wound.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review, staff interviews, review of hospital documentation, review of witness statements, review of a fall policy, and review of the facility's fall investigation, the facility failed to ensure care was provided per Resident #71's plan of care, failed to prevent an avoidable fall with injuries and failed to conduct a thorough post-fall investigation including a root cause analysis to identify potential hazards and resident-specific interventions to reduce and/or eliminate falls. This resulted in Actual Harm on 10/20/23 when State Tested Nursing Assistant (STNA) #180 provided care to Resident #71, who was cognitively impaired and dependent on two staff for bed mobility and toileting, without the assistance of two staff resulting in the resident rolling away from the STNA and falling onto the floor. Subsequently, Resident #71 was transported to the hospital where he was found to have lacerations to his head and mouth due to the fall which required sutures. This affected one (#71) of three residents reviewed for falls. The census was 64. Findings include: Review of the closed medical record for Resident #71 revealed the resident was admitted on [DATE] and discharged on 10/25/23. Resident #71 had diagnoses including chronic respiratory failure with ventilator (vent) dependent, tremor, constipation, cerebral vascular accident (stroke), muscle weakness, tracheostomy, encephalopathy, dysphagia, and pulmonary embolism. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #71 revealed the resident was cognitively impaired and required total dependence of two staff members for bed mobility, transfers, and toileting care. Review of the plan of care dated 08/21/23 for Resident #71, revealed the resident had an impaired musculoskeletal status, a self-care performance deficit and was at risk for falls and injuries related to respiratory failure, stroke, gunshot wound, multiple fractures, hepatic encephalopathy, history of physical injury and trauma, and muscle weakness and the resident was dependent on staff for all activities of daily living (ADLs). Interventions included for the resident to have assist bars for bed mobility and repositioning, bolsters to bed, Hoyer lift for transfers, and extensive assistance of two persons for bed mobility, and bathing. The care plan was revised on 10/20/23 to include fall mats to bilateral bedside. Review of the physician's orders dated 02/24/23 for Resident #71, revealed the resident was ordered to have a specialty air mattress with built in bolsters to establish safe parameters. The physician's orders dated 06/15/23, revealed the resident was ordered to be transferred via Hoyer lift with two staff members. The physician's orders dated 09/08/23, revealed the resident was ordered to have one quarter (1/4) side rails for bed mobility related to muscle weakness. The physician's orders dated 10/23/23, revealed the resident was ordered to be sent to the emergency room (ER) for an evaluation and for the resident to have floor mats placed to bilateral bedside to minimize risk of injury. Review of the Nurse Practitioner (NP) progress note dated 10/18/23 for Resident #71, revealed the resident was awake, not alert, and could not follow any commands. Review of the nurse's progress note dated 10/20/23 at 1:00 P.M. for Resident #71, revealed during ADL care, the resident fell out of the bed, landed face down and received a laceration to his head, above his eyebrow, his head, and lip. The staff applied pressure to his head, 911 was called and the resident was transported to the hospital. The NP, who was in the building was notified. Review of the hospital notes dated 10/20/23 at 2:02 P.M for Resident #71, revealed the resident arrived in the ER with a chief complaint of a fall with lacerations to left forehead and lower left lip. The hospital notes indicated while the facility staff was performing morning bathing care, the resident rolled and fell on to floor, sustaining a left frontal scalp hematoma, lacerations to left forehead and left lower lip. The resident was diagnosed with a status post fall with lacerations, required sutures and was admitted to the intensive care unit (ICU) for lower left pneumonia. The hospital notes indicated a computerized tomography (CT) scan showed new areas of hypodensity in the brain which radiology reported as being subacute and a neurology consulted was ordered due to the abnormal CT scan and an magnetic resonance imagine (MRI) was ordered for further testing. Review of the initial fall report dated 10/20/23 at 2:16 P.M. for Resident #71, revealed the resident was getting a bed bath when he fell. The resident was bleeding from his head above his nose and his eyebrow. New interventions included floor mats on both sides of the resident's bed. Review of the nurse's progress notes dated 10/20/23 at 2:31 P.M. and recorded as a late entry for Resident #71, revealed per the hospital report, there were no serious injuries, and the resident had a laceration above his eyebrow and lip. The resident was being admitted for pneumonia. Review of the Situation Background Assessment Request (SBAR) communication form and progress note dated 10/20/23 at 2:24 P.M. for Resident #71, revealed the resident had a fall with an injury to his face. The resident was getting ADL's done by staff, when the resident turned, and he fell out of the bed. The resident landed face down next to the bed and had lacerations above his nose, left eyebrow, was bleeding from his mouth and his front tooth was loose. The NP was in the facility and ordered for the resident to be sent to the hospital. Review of a witness statement by State Tested Nursing Assistant (STNA) #180 dated 10/20/23 and recorded by Registered Nurse (RN) #150, revealed the STNA was doing the resident's ADLs and when she turned Resident #71 on his right side, his left leg went over the bolster and the resident kept going and she could not stop him. Review of the fall assessment dated [DATE] at 2:15 P.M., revealed Resident #71 had a fall on 10/20/23 where he rolled out of the bed during care. The report revealed the bed bolsters were in place and the cause of the fall was the resident's poor trunk control and poor safety awareness. The resident had lacerations on his eyebrow and lip and was transferred to the hospital. The assessment noted the resident had no serious injuries and was admitted for pneumonia. The Care plan modifications included placing floor mats on both sides of bed to minimize the risk of injury. Review of the facility's investigation and Quality Assurance Performance Improvement (QAPI) plan completed on 10/27/23, revealed STNA #180 was completing incontinence care for Resident #71 on 10/20/23 when the STNA rolled the resident on to his right side. The resident was noted with poor trunk control and began to roll and rolled over the bed bolster and on to the floor. The resident sustained lacerations above his eyebrow and lip and a bruise to his forehead. The resident was immediately sent to the ER for further evaluation and the hospital determined there were no other injuries. The resident was admitted for pneumonia. The resident was care planned for two staff members during bed mobility and this was also noted on the STNA's [NAME] (document for a resident's care needs) as well. The QAPI plan revealed the facility only provided education to the STNAs ensuring that residents were receiving the appropriate assistance based on their needs. The education/training did not include additional staff that may be called on to assist, including the nursing staff. The QAPI plan also did not include a root cause analysis on why the staff used only one-person to provide assistance to Resident #71 when they were aware the resident required a two-person assistance. The QAPI plan also failed to document what interventions the facility would put in place to prevent further avoidable falls with injuries. Interview with STNA #160 on 11/08/23 at 10:16 A.M., revealed Resident #71 required total assistance from staff including two staff for his care. STNA #160 revealed she heard of Resident #71's fall on 10/20/23 and noted STNA #180 was newer and provided care by herself as she rolled the resident off the bed and onto the floor. STNA #160 revealed at times the facility does not have enough staffing and the high acuity residents and the resident's care would often be provided with one staff. STNA #160 indicated Resident #71 was in a hall where almost all of the residents required two-person assistance, but only one STNA was scheduled for hall. Interview with STNA #170 on 11/08/23 at 10:21 A.M., revealed the staff were able to check the assistance needs of each resident by checking the [NAME]. STNA #170 was asked about a resident she provided care for, and the STNA referenced Resident #57, indicating this resident was independent with their ADLs. As STNA #170 was demonstrating how the staff could look up information on the [NAME], specifically for Resident #57, the STNA noted the [NAME] information for Resident #57 differed from what she was informed. STNA #170 noted Resident #57's [NAME] indicated the resident required assistance of one person assist. Interview with STNA #180 on 11/08/23 at 10:47 A.M., revealed she had worked at the facility for a few months and revealed she was caring for Resident #71 when he fell on [DATE]. STNA #180 revealed she was aware of Resident #71 needed two staff members for his care, but looked around and did not see any available staff so she decided to provide care by herself as she did not want resident sitting in a dirty brief. STNA #180 verified she did not ask anyone to assist her in the resident's care. STNA #180 revealed she first rolled the resident on his left side, which was closest to her and towards the resident's window. STNA #180 then rolled the resident towards the door and away from her. STNA #180 indicated the resident's leg must have gone over the bolster pad and once he started to roll off the bed, she could not stop or catch him. Interview with DON on 11/08/23 at 11:15 A.M., revealed the facility investigation found that STNA #180 was providing care to Resident #71, who was a dependent resident, unassisted, and the resident should have been cared for using two staff members. The DON stated after the fall, the facility put new interventions in place for fall mats to both sides of the resident's bed. The DON confirmed the fall interventions put in place for Resident #71 should have been related to the cause of the fall and to prevent a future fall and not necessarily an intervention for fall mats. The DON revealed the STNAs were educated related to using the [NAME] to ensure proper number of staff were present and available for assistance with the resident's care. The DON indicated Resident #71 had poor trunk control, poor core strength and lack of safety awareness, but verified the fall was caused by staff not following the care plan and procedures for providing care to a dependent resident. The DON stated her expectations would be if a resident was assessed and required the need for two staff members, then the staff should be following the care plans. Interview with RN #150 on 11/08/23 at 11:55 A.M., revealed she was working on 10/20/23 around shift change when STNA #180 yelled for help from Resident#71's room. RN #150 noted the resident was found on the floor and was assessed to have lacerations to his head and mouth and 911 was called. RN #150 stated STNA #180 did not ask for assistance prior to the fall, and she was unaware STNA #180 was in the room when the fall occurred. RN #150 revealed the residents at the facility required more assistance than most nursing facilities since they have a vent population and many of their residents required two-person assistance. Interview with Resident #71's family member on 11/08/23 at 12:20 P.M., revealed the resident fell out of bed, went to the hospital, and had to get sutures. Resident #71's family noted the resident's sister took care of his medical needs and she would have the sister call the Surveyor with additional details. At the time of exiting the facility on 11/11/23, no return call from Resident #71's sister had been received. Interview with Administrator on 11/08/23 at 1:29 P.M., revealed the facility did not have a policy related to providing ADL care for dependent residents. Review of 11/02/23 facility policy titled Falls-Clinical Protocol, revealed as part of an ongoing resident assessment, staff shall help identify falls risk factors and include information in the care plan including necessary and appropriate interventions taking into account a resident's abilities and deficits, balance, adaptive equipment needs and proper use of mechanical lifts and transfer devices, shower beds, shower chairs and bathroom safety. Interventions should also be placed on the care card for the aides as well as the [NAME] in the electronic health record. This deficiency represents non-compliance investigated under Complaint Number OH00148140.