**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, staff and resident interviews, review of video footage, review of facility investigation, and facility policy review, the facility failed to ensure residents were safely transferred using a Hoyer lift. Actual Harm occurred on 05/08/25 at approximately 2:15 P.M. when Hospice Nurse Aide (HNA) #869 completed a Hoyer lift (a type of mechanical lift used to safely transfer individuals with limited mobility from one surface to another) transfer of Resident #21 without the assistance of a second person, resulting in Resident #21's arm becoming fractured. Resident #21 required an x-ray examination which revealed a displaced (a bone fracture where the broken bone fragments are no longer in normal alignment), separated (the bone is broken in two or more places creating a separate segment of bone between breaks), overriding (the broken ends of a bone overlap causing shortening) oblique (a type of bone fracture where the break occurs at an angle to the bone's long axis) fracture of the midshaft of the right humerus. Resident #21 was sent to the emergency room for evaluation and treatment. Resident #21 required surgical intervention on 05/14/25 for the fracture to her right arm. Resident #21 had an open reduction and internal fixation (ORIF) (a surgical procedure to repair a fracture which includes realigning of bone fragments and stabilizing with plates, screws or wires) of the right humerus with insertion of an intramedullary implant (a medical device used to stabilize fractures). This affected one Resident (#21) of three residents reviewed for transfers with a Hoyer lift. The facility identified 20 residents (#2, #3, #4, #5, #10, #11, #12, #13, #17, #21, #24, #28, #31, #32, #40, #41, #42, #43, #44, and #45) who required a Hoyer lift for transfers. The facility census was 45. Findings include: Review of the medical record for Resident #21 revealed an admission date of 03/13/25 and diagnoses including multiple myeloma in relapse, generalized muscle weakness, paraplegia, spinal stenosis of cervical region, severe protein calorie malnutrition, and anxiety disorder. Review of Resident #21's physician's orders revealed an order dated 03/14/25 for a Hoyer lift for all transfers. The order further specified that two staff members were needed to assist with the Hoyer lift. Resident #21 additionally had an order dated 03/17/25 noting that the resident was receiving hospice services for a diagnosis of multiple myeloma (a cancer of the plasma cells). Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #21 had intact cognition. Resident #21 required total staff assistance for toileting hygiene, showering/bathing self, dressing, personal hygiene, bed mobility, and transfers. Review of the plan of care, revised 03/17/25, revealed Resident #21 required assistance with a majority of activities of daily living (ADLs) related to multiple myeloma. Interventions included using a Hoyer lift for all transfers with two staff member assistance, use one to two staff to assist with bed mobility and dressing, and bilateral upper grab bars to the bed to assist with bed mobility and repositioning. Review of the Hospice Nurse Aide (HNA) Plan of Care report dated 05/08/25 at 12:37 P.M. revealed Resident #21 was the client, and HNA #869 was the hospice staff assigned for care. The report indicated Resident #21 was paralyzed in her lower extremities from spinal cord compression and could be anxious at times. The report noted on 05/08/25, various personal care tasks were completed including a bath, oral hygiene, and transferring. The report included an entry by HNA #869 which noted she had to wait on staff to bring the Hoyer lift and shower chair, then a shower was given. The HNA indicated Resident #21 stated her right arm was broken. There was no additional information related to the incident or actions taken identified on HNA report. The bottom of the report in the section titled observations reported to the nurse listed there was nothing unusual to report. Review of a nursing progress note dated 05/08/25 at 2:29 P.M. revealed Resident #21 believed she broke her arm after a visit with the hospice aide during a Hoyer transfer into bed. The nurse was notified by the facility nurse aide. Resident #21 was assessed lying in bed with notable swelling and discoloration to her right arm. Resident #21 complained of pain and was unable to move her right arm. The nurse practitioner (NP) was notified and ordered a status immediate (STAT) x-ray. The nurse administered pain medication and immobilized Resident #21's right arm. Review of the physician's order dated 05/08/25 revealed an order for an x-ray of Resident #21's right humerus. Review of the Radiology Results Report dated 05/08/25 at 3:09 P.M. revealed Resident #21 had a displaced, separated, and overriding oblique fracture of the midshaft of her right humerus. Review of a nursing progress note dated 05/08/25 at 3:51 P.M. revealed the resident's x-ray resulted in the identification of a displaced, separated and overriding oblique fracture of the midshaft of the right humerus. The NP was notified of the results and gave an order to send Resident #21 to the emergency room for evaluation and treatment. Resident #21 was transported via non-emergent transport service. Review of the physician's order dated 05/08/25 revealed an order to send Resident #21 to the emergency room for treatment and evaluation of a right humerus fracture. Review of the hospital After Visit Summary dated 05/08/25 revealed Resident #21 was seen in a local emergency department for an arm injury and diagnosed with closed displaced oblique fracture of the shaft of the right humerus. A splint was applied, and pain medication was administered. Review of a nursing progress note dated 05/09/25 at 12:54 A.M. revealed Resident #21 returned to the facility. Review of the Physicians Medical Visit assessment dated [DATE] revealed Resident #21 was seen following an incident with a Hoyer lift and a hospice caregiver. Resident #21 insisted her arm was broken and an x-ray was completed revealing a right humerus fracture. Resident #21 was sent back from the emergency room with surgery scheduled for the following week. Review of an incident note dated 05/09/25 at 3:18 P.M. revealed Resident #21 was being transferred via Hoyer lift on 05/08/25 by a hospice aide and got scared during the transfer. Resident #21 stated she grabbed onto the grab bar on the bed during the transfer and felt like her arm was broken. Resident #21 stated she immediately notified the hospice aide and was told to stop being dramatic. The hospice aide did not request nor did she wait for a second person to assist during the Hoyer transfer. It was noted that Resident #21's daughter had a camera in the resident's room and was able to view video footage. Review of an order note dated 05/11/25 at 12:13 P.M. revealed the NP gave a new order to start 30 milligrams (mg) of Morphine Sulfate (an opioid analgesic used to treat moderate to severe pain) controlled-release every eight hours, 15 mg Oxycodone (an opioid used to treat moderate to severe pain) every three hours, and 650 mg Tylenol three times per day for severe pain. Review of the physician's order dated 05/12/25 revealed an order for Resident #21 to direct admit to the hospital for surgical intervention of a right upper extremity fracture. Review of the Transfer Form assessment dated [DATE] revealed Resident #21 had a planned transfer to the hospital for a scheduled surgical procedure. Review of a nursing progress note dated 05/12/25 at 11:10 A.M. revealed Resident #21 was transferred to the hospital. Resident #21 was given as needed (PRN) Oxycodone prior to the transfer. Review of an incident note dated 05/16/25 at 12:43 P.M. revealed the facility Administrator received camera footage from Resident #21's daughter related to Resident #21's right arm fracture. The Administrator initiated a self-reported incident (SRI) after reviewing the video footage. The Administrator met with Resident #21's daughter who confirmed Resident #21's surgery went well. Review of the SRI Form Initial Report dated 05/16/25 revealed the facility had reported allegations of physical abuse and neglect for Resident #21 to the State Agency. On 05/08/25, the facility was notified that Resident #21 complained of pain and the inability to move right arm. It was found that Resident #21 had a fracture of her right arm sustained during a Hoyer lift transfer by a hospice aide. On 05/14/25, Resident #21 had surgical repair of her right arm fracture. On 05/16/25, camera footage was received from Resident #21's daughter and was reviewed with suspicion of abuse and/or neglect. Review of the SRI Form Follow-up Investigation Report dated 05/22/25 revealed Resident #21 stated she was returned to her room after receiving a shower and the hospice aide was in the room stated she needed to leave. Resident #21 reported feeling rushed by the hospice aide. Resident #21 reported the hospice aide transferred her via Hoyer lift without getting assistance from another caregiver. Resident #21 stated she got scared during the transfer and put her arm out to hold onto the grab bar. Resident #21 stated she told the hospice aide she broke her arm, and the hospice aide told her to stop being dramatic. Resident #21 stated she felt pain and discomfort. It was confirmed the hospice aide did not request assistance for a Hoyer transfer and had been trained that the Hoyer lift required two people for use. The facility unsubstantiated physical abuse and neglect. It was noted that the hospice company also filed an SRI related to the situation. Review of the hospital Patient Discharge Instructions dated 05/23/25 revealed Resident #21 admitted to the hospital on [DATE]. Resident #21 had an open reduction and internal fixation (ORIF) of the right humerus with insertion of an intramedullary implant (a medical device used to stabilize fractures). Review of a nursing progress note dated 05/23/25 at 4:43 P.M. revealed Resident #21 returned from the hospital. Resident #21 had sutures present on her right shoulder and down her arm. Review of a physician's order dated 05/23/25 revealed an order to monitor the 34 staples on Resident #21's right arm for signs and symptoms of infection. An observation on 06/05/25 at 10:40 A.M. revealed Resident #21 was sitting up in bed with her right arm propped on a pillow. There was a healing surgical area to Resident #21's right arm. There were no bruising or visible signs of infection noted. An interview on 06/05/25 at 10:40 A.M. with Resident #21 confirmed there had been an incident with a Hoyer lift resulting in a broken arm. Resident #21 stated she had received a shower from a hospice aide and needed to be transferred back to bed. Resident #21 stated she was fearful of the Hoyer lift. Resident #21 stated she asked HNA #869 if two people were required for the Hoyer transfer and HNA #869 told her she did not have time to wait for another staff member. Resident #21 stated during the transfer she had grabbed onto the grab bar and when HNA #869 pushed her in the lift she heard a loud pow. Resident #21 stated her arm went completely limp and she knew it was broken. Resident #21 stated she informed HNA #869 her arm was broken and HNA #869 told her to stop being so dramatic. Resident #21 stated she continued to state her arm was broken, however HNA #869 did not report to anyone what had happened and made no attempts to comfort her. Resident #21 described the event as traumatic and depressing. Resident #21 stated she had to have surgery on her right arm. An interview on 06/05/25 at 11:28 A.M. with the daughter of Resident #21 revealed on 05/08/25 at 2:42 P.M. she had received a call from her mother. Resident #21's daughter reported her mother was hysterical and she could not understand her. She indicated at the same time, the facility called to report there had been an incident involving her mother, and they would be obtaining an x-ray for suspicion of a broken arm. The nurse reported there was an incident involving a Hoyer lift operated by a hospice staff member. Resident #21's daughter stated she had a camera in Resident #21's room and she had reviewed the footage. The daughter reported HNA #869 had completed a Hoyer lift transfer alone and HNA #869 did not attempt to obtain assistance or call for help. The daughter stated the video had audio and visual of when Resident #21's arm was broken mid-transfer. An interview on 06/05/25 at 1:08 P.M. with Hospice Director of Quality #868 and the Administrator confirmed HNA #869 had transferred Resident #21 using a Hoyer lift by herself rather than with two staff as required. Hospice Director of Quality #868 and the Administrator confirmed at no time did HNA #869 seek assistance from the facility for the Hoyer lift transfer of Resident #21 back into bed. Hospice Director of Quality #868 and the Administrator confirmed upon review of the camera footage there was a very obvious break with disfigurement at Resident #21's shoulder. An interview on 06/05/25 at 1:58 P.M. with Licensed Practical Nurse (LPN) #806 revealed she was the assigned nurse to Resident #21 on 05/08/25. LPN #806 stated Certified Nursing Assistant (CNA) #816 had alerted her that Resident #21 thought her arm was broken. LPN #806 stated during her assessment, Resident #21 was in pain and her arm was visibly swollen. Resident #21 reported the injury occurred during a Hoyer transfer into bed. LPN #806 confirmed she had not been notified by HNA #869 that there had been an injury to Resident #21's arm. LPN #806 indicated HNA #869 had not requested assistance for the Hoyer transfer back to bed nor had she utilized the call light to attempt to call for other staff to assist. LPN #806 stated she had gotten into contact via phone with HNA #869. LPN #806 indicated she was able to confirm with HNA #869 that she had operated the Hoyer alone. HNA #869 indicated she did not have time to wait around and HNA #869 stated I don't know how dramatic she (Resident #21) is. LPN #806 stated she was very upset that HNA #869 was calling Resident #21 dramatic for being in pain. LPN #806 stated there were plenty of staff available at the facility to assist hospice caregivers with Hoyer lift transfers or other care. An interview on 06/05/25 at 2:57 P.M. with CNA #816 revealed she was the assigned nurse aide for Resident #21 on 05/08/25. CNA #816 indicated she had assisted HNA #869 with Hoyer lift transfer into a shower chair. CNA #816 indicated she set up supplies for HNA #869 and changed the bed sheets for Resident #21. CNA #816 indicated she told HNA #869 to use the call light when she was ready to get Resident #21 back into bed. CNA #816 indicated another resident's call light was activated so she answered the light. CNA #816 indicated she saw the call light on for Resident #21 and figured they were done with the shower. CNA #816 indicated when she entered the room, she found Resident #21 back in bed and she was alone in the room. Resident #21 stated her arm was broken and she was in pain. CNA #816 indicated she reported it to the nurse immediately. CNA #816 confirmed HNA #869 did not request assistance after the shower to Hoyer transfer Resident #21 back to bed. CNA #816 confirmed Hoyer lift transfers required two staff assistance. An interview on 06/06/25 at 1:43 P.M. with HNA #869 confirmed she had been to the facility to care for Resident #21 on 05/08/25. HNA #869 confirmed the hospice policy was to transfer a patient via Hoyer lift with two people. HNA #869 indicated this was the first time she had cared for Resident #21. HNA #869 stated Resident #21 requested a shower, so she rang the call light for the facility nurse aide. HNA #869 stated several times she had to wait on facility staff. HNA #869 stated Resident #21 was able to assist with bathing her upper body and able to hold herself forward in the shower chair to wash her back. HNA #869 stated she brought Resident #21 back to her room after the shower. HNA #869 stated I cannot sit and wait more time for someone to come help her get Resident #21 back into bed. HNA #869 stated Resident #21 was small, and she felt she could certainly do it herself. HNA #869 stated during the Hoyer transfer Resident #21 had put her hand on the grab bar then stated her hand was broken. HNA #869 stated I didn't want her to get too excited or overly dramatize. HNA #869 stated Resident #21 was able to move her fingers, so she did not think anything was broken. HNA #869 stated she finished care on Resident #21 and left the facility. HNA #869 stated she normally worked as a home health aide and did not operate a Hoyer lift on a day-to-day basis. HNA #869 confirmed she did not call for assistance from another staff member for a Hoyer transfer. HNA #869 indicated she had already had to wait on the facility staff and indicated if they knew Resident #21 needed a Hoyer transfer then they should have just come back to the room. Review of the camera footage from the camera in Resident #21's room dated 05/08/25 (provided to the surveyor on 06/06/25) revealed: a. Review of the one minute and 30 second video dated 05/08/25 at 1:56 P.M. revealed CNA #816 and HNA #869 were in Resident #21's room. Resident #21 was in bed with HNA #869 standing on the right side at the foot of the bed and CNA #816 was standing on the left side of bed. The nurse aides were talking with Resident #21 while getting her ready to get into shower chair. Resident #21 began assisting with the removal of her clothing for the shower. Resident #21 was noted to be able to remove her own shirt with the use of both hands and arms. Resident #21 was able to help turn onto her right side using both arms while removing her pants. Resident #21 was not complaining of any pain at this time. b. Review of the 18 second video dated 05/08/25 at 2:12 P.M. revealed HNA #869 wheeling the shower chair back into Resident #21's room backwards. HNA #869 could be heard saying You ain't fitting to sit here because I am about to put you in this bed baby. Resident #21 asked You can do this on your own? HNA #869 indicated I am going to have to because I don't have all day to sit here. At no time was the call light visibly activated. c. Review of the 16 second video dated 05/08/25 at 2:13 P.M. revealed HNA #869 could be seen in the corner of the video attaching the Hoyer straps to the Hoyer lift. Resident #21 was instructing HNA #869 on which straps to use for the Hoyer sling. d. Review of the 16 second video dated 05/08/25 at 2:14 P.M. revealed HNA #869 continuing to try to attach Resident #21's Hoyer sling straps to the Hoyer lift. e. Review of the one minute and 43 second video dated 05/08/25 at 2:15 P.M. revealed Resident #21 was no longer seen in the shower chair. From out of frame, the shower chair was pushed further into the room by the foot of Resident #21's bed then Resident #21 comes into frame suspended in the Hoyer lift. HNA #869 was the only caregiver present in Resident #21's room. HNA #869 was seen pushing Resident #21 towards the right side of the bed in the Hoyer lift. Resident #21 was seen swinging back and forth in the Hoyer sling uncontrolled. Resident #21 tells HNA #869 to watch out for the cords on the floor. HNA #869 indicated Oh they have got the bed down low, [expletive], and she walks to the left side of the bed after moving the shower chair out of the way. At this time, HNA #869 had no hands on the Hoyer lift or Resident #21. Resident #21 was still suspended in the air and seen swinging back and forth in the Hoyer lift. Resident #21 could be seen with both hands holding onto the Hoyer sling. HNA #869 began raising the bed height and came back around to push Resident #21 over the right side of the bed. HNA #869 pushed the Hoyer lift over a bump and Resident #21 stated You are running into a cord. HNA #869 positioned Resident #21 with her bottom over the bed and Resident #21's legs remained hanging over the side of the bed. HNA #869 walked back around to the left side of the bed. Resident #21 had her left hand holding the Hoyer sling and her right hand reached out and grabbed the grab bar attached to the bed. Resident #21 was facing the base of Hoyer lift and HNA #869 grabbed ahold of the sling to turn Resident #21 over the bed. Resident #21 had visible bolsters on each side of the bed and her legs remained hanging over the side of the bed. HNA #869 pulled on the Hoyer sling and tried to turn Resident #21 unsuccessfully, then used a hand to grab Resident #21's legs. HNA #869 pulled one leg at a time over the bed. When HNA #869 pulled Resident #21's right leg over the bed, a loud popping noise could be heard and Resident #21 called out. Resident #21's right arm immediately went limp, and Resident #21 loudly says Ow I just broke my arm, I just broke my arm. HNA #869 walked back around to the right side of the bed. Resident #21 could be heard making a grunting and moaning sound, and her face was seen with a painful grimace. HNA #869 did not respond to Resident #21 in any way at this time. HNA #869 began pushing the Hoyer lift further over the bed with Resident #21 swinging in the sling and her right arm limp at her side. HNA #869 said Oh, your dressing is coming off and Resident #21 said Get me in the bed. HNA #869 said You are on the bed, honey; Just relax while lowering Resident #21 to the bed. Resident #21 said I think it is broken, I don't know then stated, No, I didn't, I can move my hand, as she wiggled the fingers on her right hand. HNA #869 said Yeah, stop being so dramatic. It's alright. You are fine. Relax. Chill out. HNA #869 began to unhook the straps from the Hoyer lift at the end of the video. f. Review of the 46 second video dated 05/08/25 at 2:17 P.M. revealed Resident #21's right arm remained limp at her side and Resident #21 could be heard grunting and moaning. HNA #869 was still removing the Hoyer straps from the Hoyer lift then removed the Hoyer lift from over the bed. Resident #21 could be seen grimacing. g. Review of the 17 second video dated 05/08/25 at 2:18 P.M. revealed Resident #21 lying on her back with her right arm remaining limp at her side. Resident #21 was looking up at the ceiling and making grunting and moaning noises. HNA #869 approached the right side of the bed and grabbed Resident #21's right arm by the wrist and lifted her arm. Resident #21 said No, don't move it. HNA #869 said No, you got to move it to get it out of the way. You are going to have to roll over so we can get this wet pad from under you. h. Review of the 51 second video dated 05/08/25 at 2:18 P.M. revealed HNA #869 said Just try to relax, okay? Don't be so dramatic that makes it worse. HNA #869 uncovered Resident #21's lower half of her body. Resident #21 was wiggling and writhing in the bed and continued to grimace and make groaning and moaning noises. HNA #869 was standing on the right side of bed then said, Come this way and reaches over Resident #21 for her left leg and arm. HNA #869 said You think you broke your arm come this way then pulled Resident #21 towards her right side. Resident #21 was unable to provide much assistance in rolling. HNA #869 tucked the Hoyer pad under Resident #21 then said, Okay now we have to go the other way. Resident #21 attempted to help turn onto her left side and reached with her left hand towards the grab bar. Resident #21's right arm was completely limp hanging by her side. Visible to the camera there was obvious deformity to the arm under Resident #21's right shoulder. Resident #21 was grimacing and yelled out Ow, ow. Resident #21 can be seen trying to lift her right arm, but it slipped further down, and the deformity can be seen further. Resident #21 appeared to be crying. HNA #869 continued to try to get the Hoyer sling out from under Resident #21. HNA #869 walked away from Resident #21 who remained rolled onto her left side and said, Relax a minute let me get you a diaper. Resident #21 laid back down and was still grimacing, and as she rolled back unassisted it appeared her right arm was partially under her. i. Review of the 17 second video dated 05/08/25 at 2:19 P.M. revealed Resident #21 was seen lying on her back grimacing and moving her left arm around. HNA #869 exited the bathroom with a brief. j. Review of the 30 second video dated 05/08/25 at 2:19 P.M. revealed HNA #869 had returned to the right side of the bed with a brief. Resident #21 was lying on her back. HNA #869 said Okay go that way again, then HNA #869 pushed Resident #21 over onto her left side by her right hip and right shoulder. The deformity on Resident #21's right arm could be seen again from the camera angle. Resident #21 was grimacing. HNA #869 tucked the brief under Resident #21 then turned her onto her right side by grabbing her left knee and hip. k. Review of the 41 second video dated 05/08/25 at 2:19 P.M. revealed Resident #21 was seen on her back with the brief under her. Resident #21 appeared to be opening and closing her mouth without saying anything. HNA #869 attempted to secure the brief and realized it was backwards. HNA #869 said Oh [expletive], it is [expletive] backwards. No wonder. Alright, roll back over to me. HNA #869, again, rolled Resident #21 onto her right side and said That is ridiculous as she forcefully grabbed Resident #21 by the back of her left hip pulling her over onto her right side. Resident #21's buttock wound could be seen with HNA #869's gloved fingertips pressing onto it as she pulled the brief out. Resident #21 could be heard saying Ow. HNA #869 said Hold on. Hold on. Sorry, then rolled her back to the left side. Resident #21's right arm was completely hanging behind her and Resident #21 was grimacing and crying. HNA #869 then said Alright, move that arm up there and grabs her by the right hand. Resident #21's head drops back to the bed. l. Review of the 28 second video dated 05/08/25 at 2:20 P.M. revealed HNA #869 again rolled Resident #21 back onto her right side. Resident #21 continued to grimace and make grunting and moaning noises. m. Review of the one minute and 40 second video dated 05/08/25 at 2:21 P.M. revealed HNA #869 removed the wound dressing from under Resident #21's bottom. Resident #21 continued to grimace and was observed to rub her left hand over her face in clear distress. Resident #21's right arm remained limp by her side. HNA #869 said they do this twice a week for you? I can't believe it. That's too much for you. It's too much. Once a week. The way you are carrying on. No way you should be doing this twice a week. It's too much. Hmm, it's too much. HNA #869 got the brief secured and re-attached Resident #21's catheter bag to the bed, then grabbed a gown. HNA #869 sprayed Resident #21 with an unidentified spray from bedside table then applied lotion to her legs. HNA #869 began to rub lotion on Resident #21's limp right arm and Resident #21 gasped out as the HNA reached her upper arm. HNA #869 stopped momentarily and appeared to be looking at Resident #21's right arm then said, Does it hurt that bad? Resident #21 said Yeah. HNA #869 then picked up Resident #21's right arm by the elbow. Resident #21 reached down and touched her right arm saying, It is broken right here. As HNA #869 lifted Resident #21's right arm, the arm appeared unstable in the mid to upper arm region. n. Review of the 27 second video dated 05/08/25 at 2:22 P.M. revealed Resident #21 was heard saying I am already sensitive because of my multiple myeloma. HNA #869 said Yeah well you are supposed to keep your hands inside [the Hoyer lift]. Resident #21 said I know, I know. HNA #869 said and you just did the opposite then starts putting a gown on Resident #21. Resident #21 was still grunting and moaning. HNA #869 lifted Resident #21's right arm by the wrist saying, I am going to raise it up a little bit and Resident #21 gasps in a painful manner. o. Review of the 26 second video dated 05/08/25 at 2:23 P.M. revealed Resident #21 grunting and moaning and she had a pained facial expression. HNA #869 covered Resident #21 with a gown. p. Review of the 14 second video dated 05/08/25 at 2:23 P.M. revealed Resident #21 continued grunting and moaning and had a pained facial expression. HNA #869 was placing a catheter leg strap on her right leg. q. Review of the 22 second video dated 05/08/25 at 2:23 P.M. revealed HNA #869 placed a pillow behind Resident #21's head. r. Review of the 25 second video dated 05/08/25 at 2:24 P.M. revealed HNA #869 said Okay when I came in here your pillow was on this side indicating to her left side. I am going to put it on that side while indicating to her right side. HNA #869 grabbed a body pillow and while standing on Resident #21's left side, HNA #869 grabbed the bed pad and pulled Resident #21 over from the right to the left. HNA #869 said You just relax, honey. Resident #21 could be heard yelling loudly Ow. HNA #869 said Just relax and tucked the body pillow under Resident #21 who could be heard crying. HNA #869 said Hold on. Hold on. s. Review of the 51 second video dated 05/08/25 at 2:24 P.M. revealed Resident #21 could be heard crying and HNA #869 said You got to try to relax and know we know what we are doing. You know what I mean? I mean some of us know what we are doing, I don't know if everybody knows, but I know I know what I am doing, and I wouldn't do it if I didn't know. You know? HNA #869 tucked a pillow under Resident #21's feet and Resident #21 continued to grimace. HNA #869 asked You okay? and Resident #21 asked for another pillow under her head. HNA #869 tucked another pillow under her head. t. Review of the one minute and 40 second video dated 05/08/25 at 2:26 P.M. revealed HNA #869 raised the head of the bed. Resident #21's right arm remained limp and was laying on her right hip area. HNA #869 adjusted the tray table and covered Resident #21 with a blanket. Resident #21 reached out with her left hand to grab her folded glasses and was only able to open them with one hand. HNA #869 lowered the bed. u. Review of the 28 second video dated 05/08/25 at 2:27 P.M. revealed HNA #869 walked out of the video frame. v. Review of the 18 second video dated 05/08/25 at 2:29 P.M. revealed Resident #21 asked for her call light and pointed at it with her left hand. Resident #21's right arm was covered by the blanket. HNA #869 put the call light in Resident #21's left hand. It was observed to be a pad style call light. Resident #21 said I need pain pills. HNA #869 said Yeah, I'm sure you do at this point. Alright. Resident #21 immediately turned the call light on, and a small red light could be seen on the wall by call light cord. HNA #869 turned to leave and walked out of frame. Resident #21 reached for her cell phone. At no time during the video review was it evident that HNA #869 requested additional assistance with getting Resident #21 back into bed via the Hoyer lift. There was no activation of the call light until Resident #21 activated the call light at 2:29 P.M. There was no evidence HNA #869 addressed Resident #21's clear signs of pain or that she addressed the residents' concerns that her arm was broken. Review of the facility policy titled, Lifting Machine, Using a Portable, dated December 2013, revealed two nursing assistants were required to perform this procedure. Any problems or complaints made by the resident related to the procedure should be docume[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interview, review of the fall investigations, and policy review the facility failed to ensure fall prevention interventions were in place to prevent falls for Residents #5, #38, and #50. This resulted in Actual Harm on 04/07/23 when Resident #38 had a fall which resulted in her being sent to the hospital for a laceration to the posterior scalp requiring three staples. In addition, Actual Harm occurred 04/25/23 when Resident #50 had a fall which resulted in a nondisplaced, fractured hip. This affected three residents (#5, #38, and #50) of five residents reviewed for falls. The facility census was 49. Findings include: 1. Review of the medical record for Resident #38 revealed an admission date of 08/29/18 with diagnoses including muscle weakness, epilepsy, osteoarthritis, and dementia. Review of the fall risk assessment dated [DATE] revealed Resident #38 was at high risk for falls. Review of the fall risk plan of care dated 11/07/22 revealed Resident #38 had interventions for a low bed, cue to assist and toilet before meals (AC), after meals (PC), at bedtime (HS) and early morning (AM), toilet at 7:00 A.M. every morning, bed in low position, call in reach, monitor for pattern of risk or tendency to fall. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 had severe cognitive impairment and required supervision with one staff assist for bed mobility, supervision with two staff assist for transfers, supervision for walking, and was occasionally incontinent of bowel and bladder. Review of the nursing progress note dated 03/11/23 at 12:30 P.M. revealed Resident #38 was found on the floor in her bathroom lying on her right side by the housekeeping staff. She was assessed by nursing staff for injury and assisted back to her wheelchair by two staff members. She had a green and purple area on the left side of her forehead. Neurological checks were negative, pupils equal and reactive to light, and hand grasps equal and strong. She complained of left sided rib pain while being assisted to the wheelchair after the assessment. Certified Nurse Practitioner (CNP) #203 was notified and gave orders to continue neurological checks and get a chest x-ray. The residents Power of Attorney (POA) was notified. Review of the fall investigation dated 03/11/23 did not indicate if the call light was within reach and/or if the call light was activated and did not indicate when Resident #38 was last toileted as she was to be toileted AC, PC, HS and early AM, toilet at 7:00 A.M. every morning per the fall risk plan of care. A new intervention was initiated to place a sign on the resident's bathroom door to ask for assistance. Interview on 06/12/23 at 1:19 P.M. with the Director of Nursing (DON) verified the fall investigation was not thorough and did not include if care planned interventions were in place at the time of the fall on 03/11/23. Review of the nurses note dated 03/16/23 at 11:10 A.M. stated Resident #38 was found by housekeeping staff on the floor on her left side in front of the heating unit. A purple bruise was noted above her left eye. The resident was assessed by nursing staff, and no injuries were noted. Neurological checks were initiated and within normal limits, pupils were equal and reactive, hand grasps were equal and strong, push pulls with feet were also equal and strong. The resident was assisted to the wheelchair by two staff. The resident stated she was trying to go around the side of the bed and lost her balance and fell. CNP #203 was notified with no new orders, and the residents POA was notified. The resident was taken to the nurse's station for observation and would be served lunch in the dining room today. Review of the fall investigation dated 03/16/23 did not indicate if the call light was within reach and/or if the call light was activated and did not indicate when Resident #38 was last toileted as she was to be toileted AC, PC, HS and early AM, toilet at 7:00 A.M. every morning per the fall risk plan of care. A new intervention was a referral to physical therapy (PT) and speech therapy (ST). Interview on 06/12/23 at 1:19 P.M. with the DON verified the fall investigation was not thorough and did not include if care planned interventions were in place at the time of the fall on 03/16/23. Review of the nurse's note dated 03/20/23 at 10:35 A.M. revealed Resident #38 was evaluated and picked up by PT for strengthening related to the fall on 03/16/23. Resident #38 also continued to work with ST for cognitive decline. Review of the nurse's note dated 03/22/23 at 3:17 P.M. revealed Resident #38 complained of left lower back and left upper hip pain. CNP #203 was notified and ordered an x-ray of lumbosacral (LS) spine, left hip, and left pelvis- two views. The resident's POA was present during the assessment and notified of the orders for the x-rays. Review of the nurse's note dated 03/25/23 at 11:10 A.M. (three days after the x-ray was ordered) revealed the x-ray results revealed an acute nondisplaced fracture of the inferior sacrum is not excluded. CNP #203 was notified and stated to continue to monitor for pain levels with no new orders. Resident #38's POA was notified and requested a consult for hospice. Review of the nurse's note dated 03/30/23 at 1:10 P.M. revealed Resident #38 was admitted to hospice today. Review of the significant change in status MDS assessment dated [DATE] revealed Resident #38 had severe cognitive impairment and now required minimal assistance of one staff for bed mobility and walking and limited two staff assistance for transfers. She was now frequently incontinent of bowel and bladder. Review of Resident #38's fall risk care plan dated 04/03/23 stated the resident had a potential risk for falls related to decreased mobility, weakness, impaired safety awareness. Resident #38 was educated regarding wearing proper footwear during transfers/ambulation and utilize call light for assistance but was still impulsive despite one on one (1:1) education, Dycem (non-slip material) to the seat of the wheelchair, cue to assist and toilet AC, PC, HS and early AM, toileting every two hours, low bed, call light in reach, monitor for pattern of risk or tendency to fall. A fall assessment for significant change was completed on 04/04/23, and the resident was high risk. Review of the nurse's note dated 04/07/23 at 4:47 P.M. the laundry aide came to this nurse and stated, The aide is back there with resident on the floor, he is asking for a nurse. Upon entering, Resident #38 was lying on the floor, head lying beside armoire, under the window with feet pointed toward the floor. Resident #38 stated I was trying to come around here (the bed) and fell. The resident had a diagnosis of dementia and was alert and oriented times two. Pressure was enforced to the head wound, 911 was called, vital signs were obtained, and the resident was sent to the local emergency room. The resident's POA, the physician, and hospice were notified. Review of the nurse's note dated 04/07/23 at 9:45 P.M. revealed Resident #38 returned from the local emergency room with stitches (staples) in the back of her head. Review of the fall investigation dated 04/07/23 stated Resident #38 was incontinent at the time of the fall but did not indicate if the call light was within reach and/or if the call light was activated and did not indicate when the resident was last toileted as she was to be toileted AC, PC, HS and early AM, toilet at 7:00 A.M., every morning per the fall risk plan of care. The investigation also did not indicate what footwear the resident was wearing at the time of the fall or if Dycem was on the wheelchair. Interview on 06/12/23 at 1:19 P.M. with the DON verified the fall investigation was not thorough and did not include if care planned interventions were in place at the time of the fall on 04/07/23. Review of the medical record revealed Resident #38's bed was moved against the wall on 04/08/23 at 9:10 A.M. Review of the nurse's notes dated 04/09/23 revealed the nurse heard Resident #38 yelling from inside her room. Upon entering the room, Resident #38 was found sitting on the floor on her bottom in front of her dresser. Her wheelchair was to the left side with the extra seat cushion on the floor next to the chair. Resident #38 was assessed for injury and vitals were obtained; no injuries were noted. Resident #38 was moved to the 300-hall dining room. Review of the fall investigation dated 04/09/23 stated Resident #38 was heard yelling from room, sitting on bottom on the floor on front of dresser, wheelchair at her side. The extra cushion for the wheelchair seat was beside her on the floor. The resident stated she was trying to get out of the wheelchair. Dycem was added as on immediate intervention. (Dycem was to be on the wheelchair before the fall per the 04/03/23 care plan). The resident was not incontinent. The fall investigation did not indicate if the call light was within reach and/or if the call light was activated and did not indicate when the resident was last toileted as she was to be toileted AC, PC, HS and early AM, toilet at 7:00 A.M. every morning and every two hours per the fall risk plan of care. The investigation also did not indicate what footwear the resident was wearing at the time of the fall. Interview on 06/12/23 at 1:19 P.M. with the DON verified the fall investigation was not thorough and did not include if care planned interventions were in place at the time of the fall on 04/09/23. Review of the nurse's note dated 04/14/23 at 6:51 P.M. stated the nurse and caregiver heard Resident #38 yelling out for help. Upon entering the room, the nurse observed the resident lying on her back on the floor in front of the bathroom door. Vital signs were obtained, and skin assessment performed with no injuries were noted. The resident complaint of back pain, and the as needed Tylenol (analgesic) was administered. CNP #204 was notified and advised to monitor. Hospice and the resident's POA were notified. The note included the resident was to be up in the 300-hall dining room for all meals. Review of the fall investigation dated 04/14/23 stated the nurse and aide heard Resident #38 yelling out for help. Upon entering Resident #38's room, she was observed by the nurse lying on her back on the floor in front of the bathroom door. Vital signs were obtained, and she was assessed for injuries; none were found. An immediate intervention of to be up in the 300-hall dining room for all meals was implemented. The resident was not incontinent. The fall investigation did not indicate if the call light was within reach and/or if the call light was activated and did not indicate when the resident was last toileted as she was to be toileted AC, PC, HS and early AM, toilet at 7:00 A.M. every morning and every two hours per the fall risk plan of care. The investigation also did not indicate what footwear the resident was wearing at the time of the fall. Interview on 06/12/23 at 1:19 P.M. with the DON verified the fall investigation was not thorough and did not include if care planned interventions were in place at the time of the fall on 04/14/23. 2. Review of the medical record for the Resident #50 revealed an admission date of 04/21/23 and a discharge date of 05/07/23. Diagnoses included kidney disease, osteoarthritis, dementia, and right femur fracture. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #50 had impaired cognition and required limited assistance of one staff for bed mobility, transfers, and ambulation. Review of the fall risk assessment dated [DATE] revealed Resident #50 was at moderate risk for falls. Review of the plan of care dated 04/21/23 revealed Resident #50 was at risk for falls due to deconditioning. Interventions included bed in lowest position, use and accessibility of call light, non-skid socks at all times when not wearing shoes, assisting and toileting each morning, afternoon, evening and as needed (prn), and ensure frequently used items within reach at all times. Review of physician orders for June 2023 identified orders for a low bed at all times unless providing personal care and assisting and toileting each morning, afternoon, evening prn. Review of the nurse's note dated 04/25/23 at 9:59 A.M. revealed Resident #50 was found on the floor on her right side. The nurse completed an assessment and reported Resident #50 had pain to the right buttock, hip, and leg. Review of the fall investigation dated 04/25/23 revealed Resident #50 was to be checked for incontinence at 11:00 P.M., 1:00 A.M., 3:00 A.M., 5:00 A.M. and 7:00 A.M. She was last incontinent and changed at 2:55 A.M. At 4:29 A.M., Resident #50 was witnessed on the floor by the STNA who notified the nurse immediately. The nurse observed Resident #50 lying on her bedroom floor on her right side. Resident #50 reported pain in her buttock, hip, and right leg. An assessment was completed, and the physician was notified. An order for an x-ray of the right hip and leg was obtained. Resident #50 was noted to be clean and dry. The bed was placed against the wall with a fall mat to the exit side of the bed. The x-ray results reported at 1:58 P.M. revealed no fracture. During an assist in transferring Resident #50 at 2:00 P.M., the resident complained of pain and was not able to bear weight on her right leg. The physician ordered another x-ray which was reported at 7:00 P.M. to show a nondisplaced right hip fracture. The fall investigation revealed no documented evidence the bed was in the lowest position or Resident #50 was wearing non-skid socks at the time of the fall. Interview on 06/12/23 at 1:19 P.M. with the DON verified the fall investigation was not thorough and did not include if care planned interventions were in place at the time of the fall on 04/25/23. 3. Review of the medical record for Resident #5 revealed an admission date of 04/27/21 with diagnoses including bilateral above the knee amputation ([NAME]), cardiac pacemaker, atrial fibrillation, and heart failure. Review of the quarterly MDS assessment dated [DATE] revealed Resident #5 had moderate cognitive impairment, required extensive assistance of one staff for bed mobility, was dependent on two staff for transfers, was non-ambulatory, and always incontinent of bowel and bladder. Review of the fall risk assessment date 01/12/23 revealed Resident #5 was at high risk for falls. Review of the fall risk care plan for Resident #5 revealed interventions including bed to be in the lowest position at all times except during personal care (04/27/21), Dycem to the bottom of the cushion in the chair when out of bed (11/25/21), Dycem to the top of the cushion in the chair when out of bed (04/02/22), Broda (tilt-in-space positioning wheelchair) chair when out of bed (04/04/22), bed against the wall with fall mat to the exit side of the bed (04/12/23). Review of the nurse's note dated 03/07/23 at 5:15 A.M. revealed Resident #5 was found undressed on the floor mat lying next to the bed. No injuries were noted, and the resident denied any pain. The resident was on Warfarin (blood thinning medication). The physician and emergency contact were notified, and the physician ordered the resident be sent to the local emergency room for evaluation. The resident was sent out the hospital, and the bed was placed against the wall with a mattress to the open side of the floor to maintain safety. Review of the fall investigation dated 03/07/23 stated Resident #5 was observed lying on her back on the floor mat next to her bed by the State Tested Nurse Aide (STNA) answering the call light. The fall investigation did not indicate how long the call light had been on or if the bed was in the lowest position at the time of the fall. Interview on 06/12/23 at 1:19 P.M. with the DON verified the investigation was not thorough and did not include if all fall prevention interventions were in place at the time of the fall on 03/07/23. Review of the nurse's note dated 05/19/23 at 4:30 P.M. stated the nurse was called to the room by the STNA. Resident #5 was observed lying on her back on the floor next to her Broda chair. The call bell was within reach but not utilized. The resident denied pain and denied bumping her head. No injuries were noted. She was transferred back to bed with two staff assist. The bed was placed in the lowest position with the mat to the right of the bed and call bell within reach and the physician and the resident's son were notified. The resident stated, I did not fall, I slid out of the chair because I had something to do. Therapy to evaluate the resident. There was no documented evidence Dycem was in place per the plan of care at the time the resident slid out of the Broda chair. Review of the fall investigation dated 05/19/23 stated Resident #5 was observed lying on her back on the floor next to her Broda chair. The call light was in reach and not utilized. The fall investigation did not indicate how long the call light had been on or if the bed was in the lowest position at the time of the fall. There was no documented evidence Dycem was in place per the plan of care at the time the resident slid out of the Broda chair. Interview on 06/12/23 at 1:19 P.M. with the DON verified fall interventions were not in place at the time of Resident #5's fall on 05/19/23 and verified there was no documented evidence the Dycem was in place to the Broda chair at the time of the fall on 05/19/23. Review of the incident note dated 05/30/23 at 5:33 P.M. stated Resident #5 was observed lying on floor next to the bed. Resident #5 stated she got herself on the floor because she needed to be changed. No injuries were noted. Fall mat was not in place at the time of the fall. The STNA was disciplined for not maintaining fall interventions. Interview on 06/08/23 at 1:17 P.M. with Resident #5's POA/ friend revealed Resident #5 had fallen multiple times in a one-week period. Interview on 06/12/23 at 1:19 P.M. with the DON verified fall interventions were not in place at the time of Resident #5's fall on 05/30/23. Review of the facility policy titled Fall Prevention and Protocol Policy, dated 12/10/22, revealed fall interventions would be initiated as appropriate. This deficiency represents non-compliance investigated under Complaint Number OH00143246.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility policy the facility failed to ensure Resident #36 did not develop avoidable pressure injuries of the knees. Actual harm occurred when Resident #36 developed a right knee deep tissue injury (Persistent non-blanchable deep red, maroon or purple discoloration intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue.) and a left knee Stage 3 pressure ulcer (Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and rolled wound edges are often present. Slough and/or eschar may be visible but do not obscure the depth of tissue loss.). This affected one resident (Resident #36) of three residents reviewed for pressure injuries. The census was 49. Findings include: Review of Resident #36's medical record revealed an admission date of 07/30/21 and diagnoses including senile degeneration of the brain, multiple fracture of ribs on the left side, acute respiratory failure with hypoxia, dementia, and generalized muscle weakness. Review of Resident #36's physician orders dated 07/30/21 revealed turn and reposition every two hours right, back, left every shift. Review of Resident #36's Braden Scale For Predicting Pressure Sore Risk dated 02/14/22 revealed Resident #36 was at risk for developing a pressure ulcer, injury. Review of Resident #36's progress notes dated 05/07/22 at 2:55 P.M. revealed Resident #36 was sitting in her Broda chair, tipped it over head first and fell on the floor. The fall was witnessed by Registered Nurse (RN) #376, but she could not reach Resident #36 quickly enough to stop the chair from tipping over. No injuries were noted, neuro checks were initiated, and the responsible party and physician were notified. Review of Resident #36's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was not completed due to resident was rarely or never understood. Resident #36 required extensive assistance of one staff member for bed mobility and toilet use, was always incontinent of urine and bowel, and was totally dependent on two staff members for transfers. Resident #36 did not have a pressure ulcer or injury. Review of Resident #36's Braden Scale For Predicting Pressure Sore Risk dated 05/10/22 revealed Resident #36 was at risk for developing a pressure ulcer, injury. Review of Resident #36's Physical Therapy Plan of Treatment dated 05/10/22 revealed diagnoses of senile degeneration of the brain, abnormal posture, and unsteadiness on feet. The plan stated clinical impressions were Resident #36 was a high fall risk due to impulsive behaviors in Broda chair and getting a new chair with increased depth and seat belt would help mitigate the fall risk. The plan also included level of skilled services were not applicable at this time and this was an evaluation only for chair assessment. Review of Resident #36's physician orders dated 05/10/22 revealed Resident #36 would benefit from an improved Broda chair with increased seat depth and arm rest height as well as self-releasing seat belt to help reduce fall risk and improve safety in the facility. Review of Resident #36's progress notes dated 05/10/22 revealed the Director of Nursing (DON) contacted Hospice Representative (HR) #382 regarding recommendations for seating to see if hospice was able to accommodate the recommendations. The DON would follow up with the Director of Rehab (DOR) after speaking with hospice for confirmation. Review of Resident #36's progress notes dated 05/11/22 revealed therapy evaluated Resident #36 and made recommendation for a Broda chair with a seat depth of 20 inches and adjustable arm rests. The noted indicated currently awaiting a return call from hospice to confirm. Review of Resident #36's care plan dated 05/23/22 revealed Resident #36 had a potential for alteration in skin integrity related to decreased physical mobility, and bowel and bladder incontinence. Resident #36's skin was fragile and bruised and tore easily. The goal indicated Resident #36 would have decreased risk of alteration in skin integrity through next review date. Interventions included to monitor for new bruising when present every shift and report changes promptly to nurse in charge; turn and reposition per schedule; monitor for changes in skin and notify physician as needed; skin care protocol per state tested nursing assistants (STNA). Review of Resident #36's progress notes dated 05/26/22 at 12:32 P.M. revealed the DON spoke with HR #383 regarding a new chair for Resident #36. HR #383 stated chair would not be provided through hospice due to resident being discharged from hospice in two weeks. Review of hospice notes from 05/10/22 through 06/10/22 did not reveal a reason Resident #36 was discharged from hospice services. The notes did not reveal documentation hospice evaluated Resident #36's position in the rental Broda chair with tray. Review of Resident #36's progress notes dated 05/27/22 at 8:25 A.M. revealed the DON and DOR spoke to determine new seating for resident. A new Broda chair was ordered for Resident #36 with a 20 inch seat depth and a tray table to facilitate easy access to her snacks and personal items due to inability to place Resident #36 at table related to injuries from Resident #36 kicking tables. While awaiting new Broda chair a Broda chair with an 18 inch seat and tray table were being rented from the facility supply company. Review of Resident #36's progress notes from 05/27/22 through 06/16/22 did not reveal documentation Resident #36 had redness or sores on her right or left knee. Review of a delivery order revealed an 18 inch Broda Midline Chair and an 18 inch Broda Tray were delivered to the facility on [DATE] for Resident #36. Review of Resident #36's progress notes dated 06/17/22 at 12:58 P.M. written by Registered Nurse (RN)/Wound Nurse (WN) #365 revealed an unidentified State Tested Nursing Assistant (STNA) reported Resident #36 had new areas of skin impairment to her knees. Observation revealed Resident #36 had a new deep tissue injury (DTI) to right knee, and a new Stage 3 pressure ulcer to the left knee. The areas were caused by Resident #36's tray table being too low and causing continuous pressure to areas. Application of skin prep and foam dressing to right knee. Cleansed area to the left knee with normal saline solution, applied calcium alginate, and covered with foam dressing. Therapy was consulted to evaluate chair to see if tray table could be raised or seat could be lowered to relieve pressure from knees. The physician and power of attorney (POA) were notified. Review of Resident #36's Skin and Wound Evaluation dated 06/17/22 at 12:17 P.M. revealed Resident #36 had a right knee DTI and the injury was a medical device related pressure injury. The DTI was new, in-house acquired and measured a length of 1.7 centimeters (cm), width of 1.5 cm, and depth was unable to be determined. The edges were attached, the skin was intact with unbroken skin, and no swelling noted. Resident #36 experienced pain when the area was touched and pulled her knees up to her chest. The Evaluation further indicated Resident #36 had a new DTI due to pressure from tray on the chair. Skin prep was applied and the area was covered with a foam dressing. Therapy to evaluate chair to see if tray can be raised or seat lowered to relieve pressure from the area. Review of Resident #36's Skin and Wound Evaluation dated 06/17/22 at 12:18 P.M. revealed Resident #36 had a Stage 3 medical device related pressure injury to the left knee. The left knee Stage 3 pressure injury was new, in-house acquired and measured a length of 2.0 cm, width of 1.9 cm and depth was unable to be determined. The wound bed was 70 percent epithelial tissue, 30 percent granulation tissue, was red in color, and had a light amount of serosanguinous (pink colored) drainage. The surrounding tissue had redness of the skin. Resident #36 experienced pain when the area was touched or cleansed and pulled knees up to her chest. The Evaluation indicated Resident #36's new Stage 3 pressure ulcer to the left knee was due to pressure from the tray on the chair. The wound was cleansed with normal saline solution, calcium alginate applied, and covered with a foam dressing. Therapy to evaluate the chair to see if tray can be raised or seat lowered to relieve pressure from the area. Observation on 06/22/22 at 12:00 P.M. revealed Resident #36 was sitting in a Broda chair in her room and there was no tray attached to the chair. RN/WN #365 and RN/Infection Control Prevention Officer (ICPO) #390 were preparing to change Resident #36's dressings. During observation of the dressing change on 06/22/22 at 12:00 P.M., RN/WN #365 stated Resident #36's Broda chair tray was too tight on her knees and caused the wounds. RN/WN #365 stated the dressings were changed daily by the nurses assigned to take care of Resident #36, and RN/WN #365 changed them once a week when she made rounds with the wound physician. RN/WN #365 stated the left knee pressure ulcer wound bed had 80 percent eschar (dead) tissue, and 20 percent epithelial tissue with redness around edges, and the peri-wound had reddened, dry flaky skin. RN/WN #365 stated the measurements were length 3.0 cm, width 1.6 cm, and depth was unable to be determined. RN/WN #365 cleaned the wound with normal saline soaked gauze, applied calcium alginate and a border dressing. RN/WN #365 stated Resident #36's right knee pressure ulcer wound bed had 80 percent very dark colored eschar, redness around the edges with dry flaky skin, 10 percent granulation tissue and 10 percent slough (dead tissue). The measurements were length 1.4 cm, width 1.5 cm, and depth unable to be determined. RN/WN #365 cleaned the right knee pressure ulcer with normal saline, applied skin prep and a border dressing. RN/WN #365 revealed Resident #36 was not evaluated by the wound physician today because RN/WN #365 did not get approval from Resident #36's POA. RN/WN #365 did not request the approval because she wanted to wait a week after finding the pressure ulcers to see if the wounds improved. RN/WN #365 stated Resident #36's knee pressure ulcers had not improved and she would get approval from the POA to have the wounds evaluated by the wound physician. Review of Resident #36's Skin and Wound Evaluation dated 06/22/22 revealed Resident #36's left knee Stage 3 pressure ulcer acquired in-house on 06/17/22 measured a length of 1.9 cm, width of 1.9 cm and depth unable to be determined. The wound bed was 20 percent epithelial tissue, 80 percent slough with light amount serosanguinous drainage. The wound was red around the edges and had dry flaky skin. The Evaluation stated the wound had little to no improvement from the previous week. The wound physician was to be consulted, and an attempt to contact the POA was made with no answer. Review of Resident #36's Skin and Wound Evaluation dated 06/22/22 revealed Resident #36's right knee deep tissue pressure injury acquired in-house on 06/17/22 measured a length of 1.1 cm, width of 1.2 cm and depth was unable to be determined. The wound bed had 10 percent granulation tissue, 10 percent slough, and 80 percent eschar. The wound had light serous drainage, and the edges were red with dry flaky skin. The Evaluation indicated the wound had little to no improvement from the previous week and the wound physician was to be consulted. An attempt to contact the POA was made with no answer. A message was sent to Resident #36's physician to change the treatment to cleanse with normal saline solution, apply calcium alginate and cover with foam dressing. Interview on 06/22/22 at 4:30 P.M. with DOR #391 revealed she was not allowed to work with Resident #36 while she was receiving hospice services, and these were hospice rules. Resident #36 came off hospice on 06/10/22 but DOR #391 was not notified until 06/17/22. DOR #391 had no input fitting Resident #36 in her rented Broda chair; hospice fitted Resident #36 to the Broda chair. DOR #391 indicated the DON told her Resident #36 was off hospice and she evaluated Resident #36 around 06/21/22. The DON told DOR #391 there were problems feeding Resident #36 because her legs bent so much and the tray was causing pressure. DOR #391 stated Resident #36 was not positioned great in the Broda chair, and she observed bruises the tray table made. The therapy department tried to make recommendations for a deeper Broda to help elongate Resident #36 but that did not happen. The therapy department wanted a deeper Broda chair. DOR #391 did not know why hospice did not follow the recommendations. The Broda chair was lowered to give Resident #36's legs more length and flexion. DOR #391 stated a different chair specific to the resident needed ordered, and the chair she had was a standard Broda chair and not fit to Resident #36. Interview on 06/23/22 at 2:46 P.M. with STNA #325 revealed he found the Broda chair tray on Resident #36's knees. STNA #325 had not worked for a few days and noticed the tray attached to Resident #36's Broda chair. STNA #325 stated Resident #36 looked like she was uncomfortable with the tray on the chair and the tray should not have been on the chair. STNA #325 immediately repositioned Resident #36 in her chair. STNA #325 indicated Resident #36 was wearing capri pants (longer than shorts but not as long as trousers), and when he readjusted the pants he noticed spots on her knees, reddened circular areas with skin breakdown which looked like rug burn. STNA #325 stated he had not taken care of Resident #36 for awhile and she probably slid in her chair and her knees pressed up against the tray. STNA #325 stated he made the observation around the time of the lunch meal and he told RN/WN #365 right away; RN/WN #365 was walking past and he called her over to look at the wounds. STNA #325 stated the tray was removed from the chair and had not been on it since. STNA #325 stated Resident #36's legs were contracted and he asked the nurse why Resident #36 had a tray table on her chair but could not remember which nurse he talked to or what she said. Interview on 06/23/22 at 3:59 P.M. with the DON and RN/ICPO #390 revealed Resident #36 was using a standard Broda chair ordered on 08/03/21, and had numerous falls. The DON and RN/ICPO #390 felt the standard chair did not fit Resident #36 appropriately and they wanted to find a way to keep her from getting severely injured from falling and requested recommendations from the therapy department. The DON stated therapy gave recommendations on 05/10/22 for Resident #36 to have a custom Broda chair with a lower seat and a seat belt. The DON indicated Resident #36 received hospice services and she reached out to hospice to facilitate obtaining the custom Broda chair recommended by therapy. The hospice representative told her hospice was planning to have an interdisciplinary team meeting and would get back to her regarding the Broda chair. The hospice representative did not call back, and the DON followed up with hospice on 05/26/22. The hospice representative told the DON they were not going to buy the Broda chair and Resident #36 was going to be dropped from hospice services in two weeks. The DON stated after she found out Resident #36 was going to be dropped from hospice she placed an order on 05/27/22 for a custom Broda chair from the facility supply company. After the DON ordered the custom Broda chair she contacted the supply company to order a rental chair with a tray that was similar to the Broda chair ordered to use until the custom Broda chair arrived. The DON stated the supply company did not have a rental chair similar to the chair ordered but sent a rental chair with a tray around 06/16/22. The DON stated she wanted therapy to re-evaluate Resident #36 but therapy stated they could not be involved because Resident #36 was on hospice. The DON indicated the rental Broda chair with the tray arrived around 06/16/22 and the Broda chair should have stayed in the front of the facility until therapy could fit Resident #36 in the chair. The DON stated if the Broda chair was used before therapy fit Resident #36 to the chair the tray should not have been used until they had physician orders to use the tray. The DON and RN/ICPO #390 stated they did not know which staff member took the chair and tray from the front of the facility and placed Resident #36 in the chair for the first time. The DON was not aware the rental Broda chair and tray were being used until RN/WN #365 was called to check Resident #36's knees and the tray was taken off the chair immediately. The DON stated STNA #363 who worked night shift, told RN/WN #365 on 06/17/22 Resident #36's knees were red and sores were noted. The DON stated RN/WN #365 did not evaluate Resident #36's knees immediately because she was busy doing something else. The DON and RN/ICPO #390 indicated they wanted to have a tray on the Broda chair to keep Resident #36 away from the tables in the common area because she kicked at the tables when she got close to them. Interview on 06/23/22 at 4:15 P.M. with RN/WN #365 confirmed STNA #363 told her Resident #36 had sores on her knees in the morning and she did not evaluate the sores until later in the day because she was taking care of issues for other residents. Interview on 06/24/22 at 5:56 P.M. with STNA #363 revealed she worked night shift, took care of Resident #36 on 06/17/22 and noticed she had nickel size sores on both knees. The sores had scabs on them and did not have drainage. STNA #363 had taken care of Resident #36 before 06/17/22 and Resident #36 did not have sores on her knees. STNA #363 indicated Resident #36 was lying in bed when she noticed the sores on her knees, and immediately told RN/WN #365 about the sores. STNA #363 stated she assisted Resident #36 from her bed into the Broda chair which had the tray attached. STNA #363 stated she was not in the facility when the Broda chair with the tray arrived and did not put Resident #36 in it for the first time. STNA #363 stated Resident #36 was using the Broda chair with the tray at least a couple weeks and maybe longer. STNA #363 thought the Broda chair with the tray caused the sores on Resident #36's knees because Resident #36's legs were contracted and her knees pushed and bumped against the tray table. Interview on 06/27/22 at 8:50 A.M. with RN/WN #365 confirmed the measurements on the Skin and Wound Evaluations dated 06/22/22 were different from the measurements taken manually during the dressing changes on 06/22/22. RN/WN #365 stated the facility used an electronic wound application and the wound application did not measure the same as the manual measurements. RN/WN #365 stated the wound nurse practitioner called the company recently about the wound application inaccuracy. RN/WN #365 stated the wound physician and nurse practitioner wanted manual measurements, but she was instructed by the facility to use the electronic wound application for the Skin and Wound Evaluations. Review of the facility policy titled Wound Care Management Protocol dated, 04/14/16 included it was the facility policy to screen, assess, and monitor the residents for pressure ulcers as follows. The wound care nurse designee was to be notified as soon as possible. The wound care nurse designee would obtain a consult for the wound nurse practitioner as soon as possible for all in-house pressure areas and other wounds deemed appropriate.