**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, record review and interview the facility failed to ensure Resident #49 was transferred safely between the bed and the wheelchair. Actual harm occurred on 07/02/23 when Resident #49 began complaining of pain in her right leg after her leg got caught between her bed and wheelchair during a staff assisted transfer. X-ray results dated 07/04/23 indicated Resident #49 had a right tibia and fibula fracture. The facility investigation determined this injury was caused from the staff assisted transfer. This affected one resident (#49) of six residents reviewed for accident hazards. The total census was 143. Findings include: Record review for Resident #49 revealed the resident was admitted to the facility on [DATE] and had diagnoses including diabetes, spinal stenosis, and venous insufficiency. A plan of care, dated 11/04/22 revealed staff were to provide assistance with transfers as needed. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 05/04/23 revealed the resident was cognitively intact and required extensive two-person assistance for transfers. Review of a nurse's note dated 07/02/23 at 10:00 P.M. revealed the authoring nurse asked an STNA to assist Resident #49 to bed. The same STNA came to the nurse to tell her Resident #49 was complaining of arthritis pain and wanted some cream for it. The nurse completed a skin check and found no redness, bruising or edema in the right lower extremity. Between 11:00 P.M. to 11:30 P.M. the STNA told the nurse Resident #49 wanted to see her. Resident #49 told the nurse she had pain in her right leg, the nurse completed an assessment, offered Tylenol, and called the physician who ordered a STAT x-ray. The nurse completed another skin check and found no bruising, redness or swelling. Review of a nurse's note dated 07/03/23 at 12:30 A.M. revealed a late entry indicating Resident #49 had told the nurse during the transfer by the STNA she had hurt her leg. The resident declined to go out to the hospital for evaluation at that time but agreed to a STAT x-ray order. The resident was given Tylenol for pain and fell asleep. Further review of nurse's notes revealed the x-ray was documented as completed on 07/03/23 and reported 07/04/23, which identified an acute fracture to Resident #49's right tibia and fibula. She was sent to the emergency room on [DATE] and returned the same day with orders for follow-up orthopedic appointments. The resident's plan of care was updated on 07/05/23 to include having two staff assisting when providing transfers for Resident #49. Review of the facility investigation documentation into Resident #49's injury revealed an undated statement by STNA #938 stating she transferred Resident #49 to the wheelchair for a visit with family the morning of the event, and she had no complaints of pain. While trying to transfer her to the bed after the visit, the resident said ou so she stopped, sat the resident down in her chair, and retrieved another aide. The resident did not complain of pain until she was in the bed and staff notified the nurse. A documented interview with Resident #49 dated 07/03/23 revealed she stated her leg got caught between the wheelchair and the bed when the aide tried to transfer her and she said ouch. Later while lying down she began having pain again and informed the nurse. Undated documentation of a family interview revealed they denied any events occurred during the visit which could have resulted in injury. Review of physician's orders revealed an order dated 07/06/23 for the resident to be non-weight bearing on her right lower extremity and an order dated 07/11/23 for an immobilizer to her right lower extremity. Interview with Resident #49 on 07/31/23 at 10:06 A.M. revealed around the 4th of July, she suffered a broken leg when a single staff member tried to transfer her from the wheelchair, and her leg became caught between the wheelchair and the bed. She said the aide left after the transfer, and she called the nurse for pain medicine which was given. The next day the facility ordered x-rays and identified the leg had a fracture. Observation of Resident #49 at the time of the above interview revealed her right leg to be in a removable cast. Interview with the Director of Nursing (DON) on 08/02/23 at 8:05 A.M. revealed the facility had previously investigated Resident #49's alleged injury event. The nurse aide (STNA #938) who did the transfer no longer worked at the facility. The DON revealed during the investigation, STNA #938 said the resident complained of pain as soon as she tried to stand up during the transfer on 07/02/23. Resident #49 said her leg got caught between the bed and the wheelchair during the transfer, which STNA #938 denied. Interview with the Administrator on 08/02/23 at 5:11 P.M. confirmed the above findings. He said the facility did not determine the event to be an injury of unknown origin, as the facility concluded the injury occurred during the bedside transfer. Interview with STNA #871 on 08/03/23 at 3:58 P.M. revealed she was called into Resident #49's room on the evening of 07/02/23 to assist STNA #938 with providing positioning care. The STNA indicated Resident #49 did not complain of pain to her during the care. The deficiency was corrected on 07/06/23 when the facility implemented the following corrective actions: o On 07/03/23 an x-ray was completed and reported 07/04/23, which identified an acute fracture to Resident #49's right tibia and fibula. o On 07/04/23 Resident #49 was sent to the emergency room and returned the same day with orders for follow-up orthopedic appointments. o A fall investigation was completed including a statement by Resident #49. o On 07/05/23 Resident #49's plan of care was updated to include having two staff assisting when providing transfers. o On 07/06/23 and 07/11/23 Physician's orders were obtained related to Resident #49's injury. o On 07/06/23 a QAPI Plan was developed including the root cause was identified, education and audits were developed, and the Medical Director was notified. o On 07/06/23 an in-service was completed related to appropriate resident transfers by all State Tested Nurse Aides (STNAs) and Nurses. Education was provided by the Director of Nursing and Nursing Scheduler. o On 07/06/23 a house wide audits was completed for all residents' transfer status. o On 07/10/23 audits of transfers continued via observation of three residents three times a week for four weeks. The audits will be completed by the DON/designee. Audit findings will be presented to Quality Assurance and Performance Improvement (QAPI) committee for recommendations. Three weeks of audits (07/10/23, 07/19/23 and 07/26/23) were reviewed with no concerns noted. o On 07/31/23, during the interview with Resident #49, she voiced no current concerns related to inappropriate transfers. o During the course of the survey from 07/31/23 to 08/03/23 no current identified concerns related to inappropriate transfers were identified related to the regulation at F689.

**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 physician orders were followed, and care planned interventions for oral care were implemented for Resident #109, Resident #112, and Resident #126, and failed to ensure Resident #12, #29 and #94 were provided proper incontinence care timely Actual Harm occurred on 03/19/23 at 4:19 P.M. when Resident #126, who exhibited moderate cognitive impairment and required extensive staff assistance for personal care was assessed (by hospital staff upon transfer from the facility) to have poor oral/denture condition. The resident's upper dentures were stuck in place and coated in thick, white yellow mucous and coating. Resident #126 had dryness of the mouth, dry, cracked lips, teeth, and tongue. There were large amounts of white patches noted to Resident #126's dentures, tongue, and gums. Resident #126's gums were bright red, and her teeth were covered in spots of thick and fuzzy white patches and areas of light yellow. Resident #126's tongue was cracked, hairy, with white plaque. The facility failed to provide evidence of adequate oral/denture care being provided on an ongoing basis prior to the hospitalization to prevent this condition. This affected three residents (Resident's #12, #29 and #94) out of four residents reviewed for incontinence care and three residents (#109, #112 and #126) of four residents reviewed for oral care. The facility census was 122. Findings include: 1. Review of the closed medical record for Resident #126 revealed an admission date of 02/01/23. Resident #126's diagnoses included traumatic subdural hemorrhage with loss of consciousness of 30 minutes or less, chronic pain syndrome, dementia with agitation, and Alzheimer's Disease. Resident #126 was discharged from the facility on 03/19/23. Review of Resident #126's physician orders dated 02/01/23 revealed the resident's overall plan of care and services were approved. Review of Resident #126's progress note, dated 02/02/23 at 4:00 P.M. included Resident #126 was admitted from the local hospital, had Alzheimer's disease, a history of multiple falls and had a pacemaker. Resident #126 wore full dentures. Review of Resident #126's progress notes from 02/03/23 through 03/19/23 did not reveal documented evidence Resident #126 refused to have her dentures removed from her mouth for cleaning, or documentation Resident #126 was missing her lower dentures. There was no documentation the family and responsible party were informed Resident #126's dentures were missing. Review of Resident #126's State Tested Nursing Assistant documentation from 02/02/23 through 03/19/23 indicated the opportunity to document personal hygiene three times a day on each shift noted personal hygiene assistance was not completed three times a day, every day as planned. Review of Resident #126's care plan dated 02/04/23, included Resident #126 had an ADL (activity of daily living) self-care deficit related to disease process, dementia. Resident #126 would receive assistance necessary to meet ADL needs. Interventions included to assist with daily hygiene, grooming, dressing, oral care and eating as needed. The care plan noted Resident #126 was resistive, non-compliant with treatment, care, refusing meds, ADL's and showers related to cognitive impairment. Resident #126 would participate in developing a personal schedule of care. Interventions included to allow for flexibility in ADL routine to accommodate mood, preferences, and customary routine. If Resident #126 resisted care, leave (if safe to do so) and return later; provide non-care related conversation proactively before attempting ADL's. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 02/07/23 revealed Resident #126 had moderate cognitive impairment. The assessment revealed Resident #126 required extensive assistance of one staff for personal hygiene (included brushing teeth), bed mobility, transfers, and extensive assistance of two staff for toilet use. Resident #126 did not have broken or loosely fitting full or partial dentures, did not have an abnormal mouth issues such as ulcers, masses, oral lesions, and did not have inflamed or bleeding gums. Resident #126 did not have mouth or facial pain, discomfort or difficulty with chewing. Review of the facility Concern Log dated 03/03/23 and documented by Unit Manager #562 revealed Resident #126 was missing her lower dentures, and the concern type was loss, theft, damage. Review of Resident #126's Periodic Dental Examination and Charting dated 03/12/23, revealed bite registration, full upper and lower. Resident #126 was difficult, and an aide was present at 10:30 A.M., told nurse, kept in contact with Resident #126's spouse, and saw Resident #126 two times. Further review did not reveal documentation under areas of illnesses, medications, existing prostheses, oral hygiene, and ridges upper and lower. Review of Resident #126's progress note dated, 03/19/23 at 4:20 P.M. revealed Resident #126 was lethargic and slow to respond. Resident #126's husband was at bedside and wanted the resident to go to hospital to be evaluated. Resident #126's vital signs were a blood pressure of 109/51, pulse 81, respirations were 16, oxygen saturation was 88%, and her temperature was elevated at 101 degrees Fahrenheit. Resident #126's pupils were pin point and lung sounds were clear in all bases. The note documented mouth was dry, and tongue was dry with no coating noted. Certified Nurse Practitioner (CNP) #633 was notified and Resident #126 was transported via 911 to the local hospital Emergency Department. Review of Resident #126's hospital records revealed she arrived to the Emergency Department on 03/19/23 at 4:19 P.M. for altered mental status, fever, hypoxia and lethargy. Further review of the Emergency Department progress notes assessment at 8:44 P.M. included dryness of mouth, dry, cracked lips, teeth and tongue. Resident #126's upper dentures were stuck in place, coated in thick, white, yellow mucous and coating. There were large amounts of white patches noted to dentures, tongue and gums. Resident #126's gums were bright red, her teeth were covered in spots of thick and fuzzy white patches and areas of light yellow. Resident #126's tongue was cracked, hairy, with white plaque. Resident #126's appearance was disheveled, she was groomed inappropriately, and malodorous. Resident #126 was passive, noncommunicative, and had decreased responsiveness. Interview on 04/26/23 at 2:01 P.M. with Licensed Practical Nurse (LPN) #559 revealed Resident #126 was confused, would become agitated, was a high fall risk and was resistive to care. LPN #559 stated she remembered Resident #126 had dentures and she remembered Resident #126 wore her dentures a couple times. Interview on 04/26/23 at 2:37 P.M. with Unit Manager #562 revealed Resident #126's husband reported the resident's lower dentures were missing. Unit Manager (UM) #562 stated she documented the concern and it was addressed in an interdisciplinary team (IDT) meeting. UM #562 indicated Dentist #632 came to the facility, took impressions and dentures were made. UM #562 stated she did not know if the new dentures were delivered to the facility before Resident #562 was transported to the local Emergency Department, and could not remember if Resident #126's teeth were in the belongings her husband picked up from the facility. UM #562 stated when residents were cognitively impaired their teeth were often thrown in the trash or placed on the meal tray. UM #562 indicated she searched everywhere for Resident #126's teeth and could not find them. UM #562 stated Dentist #632 was contacted to have Resident #126's teeth replaced. UM #562 stated Dentist #632 had a helper when he visited the facility, and UM #562 did not make rounds with him. UM #562 stated she looked in Resident #126's mouth, she was missing her lower dentures, and the upper dentures were in her mouth. Interview on 04/26/23 at 3:10 P.M. with Director of Nursing (DON) revealed resident denture care should be completed in the morning and the evening as needed. The DON stated denture care included taking the dentures out of residents' mouths if the residents would allow it, and brushing the teeth. The DON stated residents would not always allow staff to remove their dentures from their mouth, but staff should reapproach the resident later to give denture care after the resident was comfortable and settled in. Interview on 05/01/23 at 7:08 A.M. with State Tested Nursing Assistant (STNA) #549 revealed Resident #126 had no issues with her dentures and did not have sores in her mouth that she was aware of. STNA #549 stated Resident #126 did not like to wear her top dentures because they were too big. STNA #549 indicated Resident #126 would take her dentures out as soon as they were put in her mouth. Interview on 05/01/23 at 7:13 A.M. with STNA #571 revealed she worked day shift, and two to three days a week she worked second shift as well. STNA #571 stated she usually worked in the memory care unit. STNA #571 stated STNA's from a staffing agency often worked second shift in the memory care unit. STNA #571 indicated she often was assigned to care for Resident #126, and she needed someone constantly monitoring her because she was a high fall risk, was combative, restless, and required extensive assistance of one staff with her ADL's. STNA #571 stated if the STNA staff took their time to work with Resident #126, she would allow them to take care of her. STNA #571 stated she was not aware Resident #126 had dentures until one day a man (Dentist #632) allowed her to stay in Resident #126's room while he was fitting her for dentures. STNA #571 stated Resident #126 did not like to have her dentures removed, would resist but eventually would allow dentures to be removed. STNA #571 stated she cleaned Resident #126's dentures and place them in a denture cup when she worked second shift, but she was not always assigned to her. Interview on 05/01/23 at 8:04 A.M. with DON revealed she could not say how long it would take for thick white yellow mucous and fuzz to grow on dentures. The DON stated it would depend on what the resident was eating and drinking and if they ate something that day. The DON stated if a resident was found to have red and inflamed gums it would be addressed right away. The DON stated the resident would probably complain of pain when eating and also when not eating. Interview on 05/01/23 at 8:17 A.M. with Dentist #632 revealed he was commissioned to make a full set of dentures for Resident #126. Dentist #632 stated he took impressions but did not do an oral exam because the facility only wanted dentures made. Dentist #632 stated he did not look underneath Resident #126's tongue and did not look at ridges on the top and bottom of her mouth. Dentist #632 stated he did not remember details of his visit, but Resident #126 was not cooperative. Dentist #632 stated it took four visits to complete a set of dentures and he saw Resident #126 two times. Dentist #126 stated if he only needed to make bottom dentures he might leave top dentures in the mouth when making the impressions. Interview on 05/01/23 at 8:50 A.M. with Licensed Social Worker (LSW) #543 revealed she did not document the missing lower dentures in Resident #126's progress notes and the Concern Form was the only documentation regarding Resident #126's missing dentures. LSW #543 stated if the Concern Form stated Resident #126 was missing her lower dentures then that is what would be replaced. LSW #543 stated upper dentures would not need to be replaced. Interview on 05/01/23 at 8:51 A.M. with Certified Nurse Practitioner (CNP) #633 revealed she examined Resident #126 on 03/19/23 at 9:15 A.M. as a follow up for hypertension medications. CNP #633 stated she examined Resident #126 including PERRLA (pupils equal, round, reactive to light and accommodation), listened to her heart, lungs, abdomen, and checked for edema (swelling) to her lower extremities. CNP #633 stated she did not do an oral exam and would only do an oral exam if needed. CNP #633 stated if the nurses or STNA's brought concerns to her attention then she would complete an oral exam. CNP #633 stated Resident #126 was sitting quietly in a padded wheelchair in the common area, and she did not find anything that concerned her during Resident #126's exam. CNP #633 stated later in the day Resident #126 developed a fever, the family was in the facility and requested Resident #126 to be transported to the local Emergency Department. Interview on 05/01/23 at 8:58 A.M. with Husband #634 revealed he thought Resident #126's care at the facility was terrible, and that was why he did not send her back after she was admitted to the hospital. Husband #634 stated he found Resident #126 drenched in urine, she did not have the correct size incontinence briefs on her even though he bought the correct size and brought them to the facility. Husband #634 stated he found Resident #126 wearing two incontinence briefs at the same time which were the wrong size. Husband #634 stated he would come to the facility at all hours because Resident #126 was unruly and he would help calm her down. Husband #634 stated Resident #126 was transported to the Emergency Department because she had a fever. Husband #634 stated Resident #126's lower dentures were lost and arrangements were made to replace them. Husband #634 stated he never saw any of the staff give Resident #126 mouth care, never saw staff clean her dentures, and never saw her dentures in the cup for cleaning. Husband #634 stated he brought Resident #126's denture cup from home and the staff did not use it, and he did not think it was ever used while Resident #126 was in the facility. Husband #634 stated he never saw Resident #126 take the dentures out of her mouth because she did not like the way they fit. Husband #634 stated Resident #126 only had top dentures because the bottom ones were lost. Husband #634 stated he asked an unidentified nurse about Resident #126's missing lower dentures and the nurse stated she was only in the facility temporarily, was passing medications and did not help him locate her teeth or even act like she cared. Interview on 05/01/23 at 2:23 P.M. with DON regarding Resident #126's denture and oral condition upon arrival to the hospital on [DATE] revealed Resident #126 was very combative and might not have allowed staff to remove dentures to clean them. The DON stated Resident #126 was combative when the dentist made impressions for dentures and would probably bite the aide if they tried to take her dentures out for cleaning. Review of the facility policy titled Personal Care and Activities of Daily Living dated, 06/2021, included personal care services included assistance with personal hygiene for example, hair, nails, skin, oral, shaving, eye care, make-up and jewelry, assistance with nighttime care and bathing. 2. Review of Resident #109's medical record revealed an admission date of 11/11/22 and diagnoses included other toxic encephalopathy, weakness, and dementia. Review of Resident #109's care plan dated 11/21/22 included Resident #109 had an ADL (activity of daily living) self-care deficit as evidenced by the need for assistance related to weakness, debility. Resident #109 would receive assistance necessary to meet ADL needs. Interventions included assist with daily hygiene, grooming, dressing, oral care and eating as needed. Review of Resident #109's quarterly MDS 3.0 assessment, dated 02/15/23 revealed Resident #109 had severe cognitive impairment. Resident #109 required extensive assistance of one staff member for bed mobility and personal hygiene (included brushing teeth) and required extensive assistance of two staff members for transfers. Review of Resident #109's physician orders dated 02/28/23 revealed overall plan of care and services approved. Review of Resident #109's State Tested Nursing Assistance documentation from 04/13/23 through 05/01/23 revealed Resident #109 required assistance of one staff member for personal hygiene including brushing teeth. Observation on 04/26/23 at 10:10 A.M. of State Tested Nursing Assistant's (STNA)'s #508 and #549 revealed they were providing incontinence care and morning care for Resident #109. STNA #508 filled a basin with warm water and had Resident #109 wash her face with a cloth. After Resident #109 washed her face STNA's #508 and #549 did not offer to brush her teeth and give oral care or ask Resident #109 if she would like to brush her teeth. STNA's #508 and #549 proceeded to give her a bed bath and provided incontinence care using appropriate standards of care. When STNA's #508 and #549 were finished with Resident #109's morning and incontinence care they assisted her into a wheelchair, and STNA #549 brushed Resident #109's hair. STNA's #508 and #549 did not offer to brush Resident #109's teeth or assist with brushing her teeth before finishing her morning care and leaving the room. Interview on 04/26/23 at 1:24 P.M. of STNA #549 confirmed Resident #109 did not have mouth care or her teeth brushed during her morning care. STNA #549 stated Resident #109 should have had oral care and her teeth brushed but she forgot to do it. 3. Review of Resident #112's medical record revealed an admission date of 12/03/21 and diagnoses included dementia, major depressive disorder, and hypertension. Review of Resident #112's care plan dated 06/03/22 included Resident #112 had an ADL self-care deficit related to physical limitations, dementia. Resident #112 would be clean, dressed and well groomed daily to promote dignity and psychosocial well-being. Resident #112 would receive assistance as necessary to meet ADL needs. Interventions included Resident #112 required extensive assistance with daily hygiene, grooming, dressing, supervision set-up oral care and eating as needed. Review of Resident #112's quarterly MDS 3.0 assessment dated [DATE] revealed Resident #112 had severe cognitive impairment. Resident #112 required extensive assistance of two staff members for bed mobility and personal hygiene (included brushing teeth) and had total dependence of two staff members for transfers. Interview on 04/26/23 at 11:16 A.M. with STNA #635 revealed he provided morning care for Resident #112 including washing her face and giving her a bed bath without initiating or completing oral care. When asked if he provided any other care during her morning care STNA #635 stated no. 4. Review of Resident #94's medical record revealed an admission date of 12/29/22 and diagnoses included other symptoms and signs involving the musculoskeletal system, dementia, and weakness. Review of Resident #94's care plan dated 12/30/22, included Resident #94 was at risk for alteration in skin integrity related to impaired mobility. Resident #94 would have decreased, minimized skin breakdown risks. Interventions included to provide preventive skin care routinely and as needed. Review of Resident #94's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #94 had moderate cognitive impairment. Resident #94 required extensive assistance of one staff member for bed mobility and toilet use. Resident #94 required extensive assistance of two staff members for transfers, and was frequently incontinent of urine and bowel. Observation on 04/12/23 at 7:50 A.M. of State Tested Nursing Assistant (STNA) #579 providing incontinence care for Resident #94 revealed Resident #94's incontinence brief, gown, draw sheet and bed sheet were soaked with urine. Resident #94 stated her incontinence brief did not get changed last night. Observation revealed redness and skin irritation between Resident #94's legs and on her bottom and barrier cream was applied by STNA #579. STNA #579 stated third shift was a problem and often when she came in at 7:00 A.M. the residents were not changed timely, were very wet and needed complete bed changes. STNA #579 stated this happened depending on which staff worked third shift. STNA #579 stated Resident #94 was not a heavy wetter and it looked like it had been a while since Resident #94 had her incontinence brief changed. STNA #579 stated residents told her when she was not working they did not have their incontinence briefs changed timely. 5. Review of Resident #29's medical record revealed an admission date of 03/23/22 and diagnoses included dementia, schizoaffective disorder, and overactive bladder. Review of Resident #29's care plan dated, 03/24/22 included Resident #29 had an ADL (activity of daily living) self-care deficit related to physical limitations and weakness. Resident #29 would be clean, dressed and well groomed daily to promote dignity and psychosocial well being. Interventions included Resident #29 required supervision to limited assistance with daily hygiene, grooming and dressing. Review of Resident #29's Annual MDS 3.0 assessment dated , 02/22/23 revealed Resident #29 had moderate cognitive impairment. Resident #29 required supervision and assistance of one staff member for toilet use. Resident #29 was occasionally incontinent of urine. Observation on 04/12/23 at 8:25 A.M. of STNA #584 providing incontinence care for Resident #29 revealed Resident #29's incontinence brief, draw sheet and sheet were soaked with urine. STNA #584 stated Resident #29 was not a heavy wetter. STNA #584 stated depending on which staff worked third shift determined if residents were changed timely, and as you can see Resident #29 was not changed timely. STNA #584 stated Resident #29 had recently become incontinent of urine more often, and if a staff member was not familiar with Resident #29 report should be given by the outgoing STNA to the new STNA arriving for work. Resident #29 stated the last time she was changed was after dinner sometime. 6. Review of Resident #12's medical record revealed an admission date of 07/19/19 and diagnoses included protein-calorie malnutrition, heart failure and hemiplegia (paralysis) and hemiparesis (weakness) following nontraumatic intracerebral hemorrhage affecting the left non-dominant side. Review of Resident #12's Quarterly MDS 3.0 assessment dated , 03/07/23 revealed Resident #12 had moderate cognitive impairment. Resident #12 required extensive assistance of two staff members for bed mobility and toilet use and had total dependence of two staff members for transfers. Resident #12 was always incontinent of urine and bowel. Observation on 04/12/23 at 8:46 A.M. of STNA #584 providing incontinence care for Resident #12 revealed Resident #12's incontinence brief was soaked with urine. Further observation revealed Resident #12 was wearing two incontinent briefs. STNA #584 stated Resident #12 should not have two incontinence briefs on and the previous STNA probably put two incontinence briefs on Resident #12 on because he was a heavy wetter. Review of the facility policy titled Personal Care and Activities of Daily Living dated, 06/2021 included the community goal was to maintain the resident's routine with personal care and activities of daily living, as specified in the Service Plan. It the resident's routine or changes in the routine present a health or hygiene concern, approaches were developed to address specific concerns. Resident Services staff promoted resident independence and self-care in these areas as practicable. Family involvement was encouraged. Personal care services included assisting with bathing and assisting with toileting, bladder and bowel management. This deficiency represents non-compliance investigated under Master Complaint Number OH00141926 and Complaint Number OH00141329.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy and procedure review, and interview, the facility failed to ensure interventions were implemented to prevent and timely identify the development of Resident #125's pressure ulcer and/or to ensure adequate treatments for Resident #47 were in place to promote healing. Actual Harm occurred on 02/21/23 when Resident #125, who required extensive assistance from two staff for bed mobility, developed a new, in-house acquired deep tissue injury (purple or maroon localized area of discolored, intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) to the sacrum without evidence of adequate preventive interventions including turning and repositioning. The facility failed to identify the pressure ulcer prior to it being identified as a deep tissue injury. This affected two residents (#47 and #125) of three residents reviewed for pressure ulcers. The facility census was 122. Findings include: 1. Review of Resident #125's medical record revealed an admission date of 02/14/23 and diagnoses included two part displaced fracture of surgical neck of right humerus, type two diabetes mellitus, and vascular dementia, mild, without behavioral disturbances, psychotic disturbance, mood disturbance and anxiety. Review of Resident #125's hospital discharge instructions dated 02/14/23, included Resident #125 was discharged to the facility, level of care was skilled, and placement was for rehabilitation for 10 to 30 days. Further review revealed Resident #125 was at risk for developing a pressure ulcer, injury. Resident #125's skin was intact and there were no pressure ulcers, injuries. Review of Resident #125's Braden Scale For Predicting Pressure Sore Risk dated 02/14/23, revealed Resident #125 was at risk for developing a pressure ulcer, injury. Review of Resident #125's admission Evaluation dated 02/14/23, included Resident #125 was admitted from an acute care hospital. The evaluation revealed Resident #125 had a right great toe diabetic ulcer and measurements were length 0.9 centimeters (cm), width 0.9 cm and depth was unable to be determined. Resident #125 had a callous on the right foot and bruises and scabs to his upper extremities. Further review of the evaluation revealed Resident #125 was not independent with bed mobility, not independent moving supine to sitting, not able to sit on edge of bed with little or no support, not able to independently transfer from sit to stand, and not able to perform a stand pivot transfer with contact guard assist or less. Review of Resident #125's care plan dated 02/15/23 included Resident #125 had an activity of daily living (ADL) self-care deficit as evidenced by right proximal humerus fracture related to physical limitations. Resident #125 would receive assistance necessary to meet ADL needs. Interventions included bed mobility and transfers with extensive assistance of two staff and encourage and, or assist to reposition frequently. Review of Resident #125's physician orders dated 02/14/23 through 02/24/23 did not reveal orders for Resident #125 to be turned and repositioned. Review of Resident #125's Medication Administration Record (MAR) and Treatment Administration Record (TAR) from 02/14/23 through 02/24/23 did not reveal documentation Resident #125 was turned and repositioned. Review of Resident #125's progress notes from 02/14/23 through 02/24/23 did not reveal documentation Resident #125 was turned and repositioned or Resident #125 refused to be turned and repositioned. Review of Resident #125's progress notes dated 02/15/23, included follow up skin assessment following admission to the facility revealed Resident #125 had a fungal rash to the groin, nystatin powder was ordered, healing bruises to bilateral upper extremities from blood draws were scabbed over. Resident #125 had a healed diabetic ulcer to the right great toe. Review of Resident #125's progress notes dated 02/16/23, included Resident #125 had a body audit and no new areas were found. Review of Resident #125's shower sheets dated 02/17/23 did not reveal a new skin area of concern was documented. Review of Resident #125's admission Minimum Data Set (MDS) 3.0 assessment dated , 02/21/23 revealed Resident #125 was cognitively intact. Resident #125 required extensive assistance of two staff members for bed mobility and toilet use. Resident #125 required extensive assistance of one staff member for transfers, and was frequently incontinent of urine and always incontinent of bowel. Resident #125 was at risk for developing a pressure ulcer, injury and was not on a turning and repositioning program. Review of Resident #125's physician orders dated 02/21/23, revealed treatment to sacrum, cleanse with normal saline solution, pat dry, apply calcium alginate, cover with dry, clean, dressing, and change every day and as needed for wound care. Review of Resident #125's Braden Scale For Predicting Pressure Sore Risk dated 02/21/23 revealed Resident #125 was at moderate risk for developing a pressure ulcer, injury. Review of Resident #125's shower sheet dated 02/22/23, and documented by STNA #502 revealed a new area of concern was reported to the nurse and Resident #125's sacral area was circled on the shower sheet. Review of Resident #125's progress notes dated 02/22/23, included Resident #125 had decreased mobility leaving him at risk for skin alterations. A new area was noted to Resident #125's sacrum. Resident #125 had an unstageable deep tissue injury to the sacrum which measured length 9.0 centimeters (cm), width 7 cm, and depth was 0 cm. The sacrum was deep purple, red. Review of Resident #125's Treatment Administration Record (TAR) dated 02/23/23, revealed there was no documentation Resident #125's treatment to the sacrum was completed. Review of Resident #125's progress notes dated, 02/24/23 at 6:00 P.M. included Resident #125 was lethargic, Resident #125's blood sugar was 439, Resident #125 having large amounts of loose stool. Resident #125 was pallor in color, extremities cool and vital signs were blood pressure 99/58, heart rate 108, respirations 24, temperature 97.9 Fahrenheit and oxygen saturation 96 percent. Physician order to sent Resident #125 to the local hospital Emergency Department. Resident was transported via 911 to the local hospital Emergency Department. Resident #125 was sent to rule out sepsis. Review of Resident #125's Prehospital Care Report Summary dated, 02/24/23, included Emergency Medical Services (EMS) received a call on 02/24/23 at 6:13 P.M. from the facility for a sick person. EMS arrived at the facility at 6:19 P.M. and Resident #125's vital signs were blood pressure 112/62, pulse 110 per minute, respirations 16 per minute, and oxygen saturation was 99 percent. EMS started an intravenous to administer fluids. Staff informed EMS that Resident #125 experienced blood sugars of over 500, had a fracture of the right humeral head, and was likely septic due to a bedsore. Resident #125's blood sugar was 496 and Resident #125 was transported to the local hospital Emergency Department. Interview on 04/10/23 at 9:51 A.M. of Family Member (FM) #500 revealed Resident #125 was discharged from the facility after he was transported to the Emergency Department and admitted to the local hospital, and now resided at a different facility. FM #500 stated on 02/02/23, Resident #125 had a fall at home, sustained a fracture to his humerus and was transported via 911 to the local hospital. FM #500 stated Resident #125 was a patient in the hospital until 02/14/23. FM #500 stated Resident #125 needed skilled care until his arm healed and that was why he was admitted to the facility. FM #500 indicated discharge instructions from the local hospital were to make sure Resident #125 was turned and repositioned every two hours, and Resident #125 could not move his arm due to the fracture. FM #500 stated Resident #125 needed an incontinence brief and when she visited she would check to see if Resident #125's incontinence brief was changed timely. FM #500 revealed she checked Resident #125's incontinence brief and observed dried feces on his legs near his butt and thought to herself what was going on. FM #500 stated she activated the call light, but it took and hour and ten minutes for someone to answer the call light. FM #500 stated an unidentified nurse finally came in the room and assured FM #500 that Resident #125's incontinence brief would be checked every two hours and he would be repositioned every two hours, and an aide changed the incontinence brief and cleaned the feces off Resident #125's legs. A few days after this happened FM #500 saw Licensed Practical Nurse (LPN) #501 in the hall, called her into Resident #125's room, and asked her to examine him because she was his admitting nurse when he arrived at the facility. FM #500 stated LPN #501 did not find any pressure ulcer when Resident #125 was admitted to the facility. FM #500 stated she told LPN #501 she was furious with Resident #125's care and the facility had not been changing his incontinence brief timely, he had dried poop on his thighs, and his lower back hurt him. FM #500 indicated LPN #501 rolled Resident #125 onto his side, and exclaimed oh my god because she noticed a bedsore. FM #500 stated LPN #501 asked her if she had her permission to send Resident #125 to the hospital because the wound needed taken care of. FM #500 stated the wound was approximately three inches by two inches and was flaming red. FM #500 revealed Resident #125 was sent to the hospital via 911, the hospital staff told her he had a severe wound on his lower back and he needed to stay in the hospital. FM #500 stated Resident #125 was seen by a surgeon who told her Resident #125 was a very sick man and needed a wound vac to pull out the bacteria from the wound. FM #500 stated in addition to the wound vac Resident #125 had a PEG (percutaneous endoscopic gastrostomy) tube placed because he needed a lot of protein. FM #500 stated Resident #125 had a swollen right leg, had a blood clot in the leg and was placed on an anticoagulant. FM #500 stated Resident #125 was receiving therapy to help strengthen him while residing at the new facility, but the wound on his bottom was so painful it is getting in the way of the therapy because Resident #125 was unable to sit up. FM #500 indicated Resident #125 resided on the second floor skilled nursing unit when he was at the facility, he was neglected, she trusted the facility to take care of him and they did not take care of him. FM #500 stated Resident #125 was her whole world. Interview on 04/10/23 at 4:27 P.M. with Licensed Practical Nurse (LPN) #501 revealed Resident #125 was admitted to the facility on [DATE], and she completed his admission assessment. LPN #501 stated Resident #125 did not have a wound on his sacrum or buttocks when he was admitted , and developed a wound on his sacrum while residing in the facility. LPN #501 indicated the wound did not look good to her. LPN #501 stated the first day she saw Resident #125's sacral wound was the day he was transported to the hospital Emergency Department. LPN #501 revealed the sacral wound was butterfly shaped, had yellow slough, was purple and had black areas. LPN #501 stated she remembered thinking Resident #125 was not well, stat labwork was not quick in nursing home facilities, and she called Resident #125's physician to have Resident #125 sent to the local hospital. LPN #501 stated Resident #125 was in her assignment routinely when she worked at the facility and no State Tested Nursing Assistants (STNA)'s told her his bottom was red. LPN #501 stated Resident #125's wife told her Resident #125 did not activate his call light for help and he was not continent of urine and bowel. Interview on 04/11/23 at 12:00 P.M. with STNA's #502 and #503 revealed they could not remember all the details of Resident #125's wound on his bottom and his care because it was a couple months ago. STNA #503 stated the area on Resident #125's butt was about the size of a quarter, it was black and looked like the skin was ready to fall off. STNA #503 stated she reported the wound to Unit Manager/Registered Nurse (UM/RN) #504 when it was found. STNA #502 and #503 stated they worked together when Resident #125 was provided incontinence care. STNA #503 stated the area on his bottom did get bigger before Resident #125 was transferred to the hospital. Interview on 04/11/23 at 1:56 P.M. with UM/RN #504 revealed all residents should be turned and repositioned if they were not able to do it for themselves. UM/RN #504 stated if a resident required extensive assistance for care and the aides knew the resident needed assistance turning and repositioning then it was automatically initiated. UM/RN #504 stated the facility did not have physician orders for turning and repositioning, and she was not really sure how she could check if residents who need turned and repositioned were getting turned and repositioned because there was no documentation in the resident records regarding turning and repositioning. UM/RN #504 stated she learned of Resident #125's pressure injury on 02/21/23 and charted it on 02/22/23. UM/RN #504 stated Resident #125's deep tissue injury developed quickly. Interview on 04/11/23 at 2:23 P.M. with STNA's #502 and #503 revealed there was nowhere in residents records for the aides to chart turning and repositioning, and the aides knew to do it if a resident was bed bound or had trouble moving about the bed. STNA #502 stated Resident #125 was not always in bed and would sometimes get out of bed with assistance. STNA's #502 and #503 stated Resident #125 was not turned and repositioned before the wound on his sacrum was found, and it was after the wound was found that the aides initiated turning and repositioning. STNA #503 stated Resident #125 was not turned and repositioned before the aides found the wound on his sacrum. Interview on 04/11/23 at 3:21 P.M. with the Administrator revealed turning and repositioning was a standard of care and that was why there were no physician orders or documentation for turning and repositioning in the residents medical records. Interview on 04/12/23 at 10:59 A.M. with Unit Manager/Registered Nurse (UM/RN) #504 confirmed on 02/23/23, Resident #125's treatment to the sacrum was not documented it was completed. UM/RN #504 stated she did not know if the nurse completed the treatment and forgot to document she completed it, or she did not do the dressing change. Review of the facility policy titled Skin Management Guidelines dated, 03/2022 included the purpose was to describe the process steps required for identification of patient's at risk for the development of skin alterations, identify prevention techniques and interventions to assist with the management of pressure injuries and skin alterations. Care plan interventions to consider based upon the Braden risk categories included repositioning, off-loading, heel protection; manage moisture, pressure reduction support surface. If at moderate risk for developing a pressure ulcer, injury add position, maintain 30 degree lateral lying position. 2. Review of Resident #47's medical record revealed an admission date of 02/10/23 and diagnoses included an unstageable right hip pressure ulcer, bipolar disorder, schizophrenia, and multiple sclerosis. Review of Resident #47's care plan dated, 02/10/23 included Resident #47 was at risk for alteration in skin integrity related to impaired mobility, MS (Multiple Sclerosis), and CVA (cerebrovascular accident). Decrease, minimized Resident #47's breakdown risks. Interventions included to encourage to reposition and use assistive devices as needed. Review of Resident #47's admission MDS 3.0 assessment dated [DATE], revealed Resident #47 had severe cognitive impairment. Resident #47 required extensive assistance of two staff members for bed mobility, transfers, and toilet use. Resident #47 had an indwelling catheter and was frequently incontinent of bowel. Review of Resident #47's Braden Scale For Predicting Pressure Sore Risk dated, 04/01/23 revealed Resident #47 was at moderate risk for developing a pressure ulcer, injury. Review of Resident #47's Mobile Wound Care Provider Program Follow-Up progress notes dated 04/11/23, included Resident #47 had multiple wounds at multiple sites. Wounds were pressure injuries of sacrococcygeal region, unspecified stage, (measurements were length 2.2 centimeters (cm), width 2.8 cm and depth 1 cm), right hip, lateral buttock, Stage 3 (measurements were length of 3.5 cm, width 5 cm, and depth 1.5 cm), left perineal ischial region, Stage 2 (measurements were length 1.5 cm, width 2.5 cm, and depth 0.1 cm). Further review of the progress notes included Resident #47 was previously on a pressure relieving mattress but not at the time of the visit. Staff would obtain another air mattress for Resident #47. The notes stated diligent offloading and repositioning, turning at least every hour. Observation on 04/11/23 at 10:15 A.M. of Resident #47's wound care with Staff Development Coordinator/ Registered Nurse (SDC/RN) #517 and Wound Certified Nurse Practitioner (WNP) #630 revealed Resident #47 had a right hip wound approximately three inches in diameter, a sacral wound about three inches in diameter, and a left ischial wound approximately a half inch by an inch. WNP #630 measured the wounds and a treatment was ordered and completed. Observation revealed Resident #47 was not on a low air loss mattress and this observation was confirmed by WNP #630 and SDC/RN #517. WNP #630 stated Resident #47 was previously in a different room, was transferred to the room she currently resided in temporarily, and was on a low air loss mattress in the original room. WNP #630 stated the low air loss mattress was not transferred to the bed Resident #47 currently was lying in and WNP #630 asked SDC/RN #517 to make sure the low air loss mattress was put on Resident #47's bed. SDC/RN #517 stated Resident #47 went to an appointment recently, and when she returned she was moved to the room she was currently in due to the floor was being waxed. SDC/N #517 stated the bed Resident #47 was lying in did not have a low air loss mattress but this was a temporary bed and Resident #47 would soon be moved back to her original room. WNP #630 stated residents were placed on an air mattress when their pressure wounds were stage three and stage four. Observation on 04/12/23 at 7:45 A.M., 10:38 A.M., and 12:18 P.M. of Resident #47 revealed she was lying in bed, on her back, and the head of the bed was elevated approximately thirty degrees. There was no observation of a low air loss mattress on the bed. There was no observation of staff turning and repositioning Resident #47 or encouraging her to turn and reposition. Interview on 04/12/23 at 12:23 P.M. of State Tested Nursing Assistant (STNA) #503 confirmed Resident #47 was lying in bed on her back with the head of the bed elevated, and had been in bed all morning. STNA #503 stated she turned and repositioned Resident #47 while she was in bed with the assistance of STNA #502. Interview on 04/12/23 at 12:21 P.M. with Licensed Practical Nurse (LPN) #501 revealed Resident #47 had an appointment on 04/03/23, she had a procedure where a PEG (percutaneous endoscopic gastrostomy) tube was placed and when she returned on 04/03/23 she was moved to a temporary room due to the floor in her original room was being waxed. LPN #501 was not sure why Resident #47 was not moved back to her original room. LPN #501 confirmed Resident #47 did not have a low air loss mattress on her bed and the air mattress should have been moved to the temporary room. Observation on 04/12/23 at 3:53 P.M. and 4:30 P.M. lying on her back in bed and the head of the bed was elevated about 30 degrees. There was no observation of staff turning and repositioning Resident #47 or encouraging her to turn and reposition. Review of the facility policy titled Skin Management Guidelines dated 03/2022, included the purpose was to describe the process steps required for identification of patient's at risk for the development of skin alterations, identify prevention techniques and interventions to assist with the management of pressure injuries and skin alterations. Care plan interventions to consider based upon the Braden risk categories included repositioning, off-loading, heel protection; manage moisture, pressure reduction support surface. If at moderate risk for developing a pressure ulcer, injury add position, maintain 30 degree lateral lying position. This deficiency represents non-compliance investigated under Complaint Number OH00141200.