**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, review of the Prehospital Care Report Summary, and review of the facility policy the facility failed to ensure Resident #7 was provided timely and appropriate care and services to properly evaluate and treat a fall, Resident #7 was not administered pain medication for complaints of severe pain after the fall and was not transported to the hospital timely after the fall. This affected one resident (#7) of six residents reviewed for accidents. The facility census was 102. Actual Harm occurred on 06/17/24 at 7:55 P.M. when Resident #7 experienced a fall, voiced severe pain after the fall, did not have pain medication ordered, and the physician was not contacted and notified Resident #7 had a fall and was experiencing severe pain until 06/18/24 at 6:36 A.M., ten hours after the fall. The physician issued an order to send Resident #7 to the hospital for right hip and leg pain post fall. Evaluation at the hospital revealed Resident #7 was non-ambulatory, reported significant tenderness with right leg weight bearing, and significant tenderness to palpation of the right femur and right hip, and was diagnosed with a closed displaced fracture of the right acetabulum the socket of the hip joint, where the head of the femur sits). Findings include: Review of Resident #7's medical record revealed an admission date of 02/09/21 with diagnoses including unspecified injury of the head, displaced associated transverse-posterior fracture of the right acetabulum, type two diabetes mellitus with hyperglycemia, major depressive disorder, and end stage renal dialysis. Review of Resident #7's care plan initiated 02/10/21 and revised on 06/28/24 revealed Resident #7 was at increased risk for falls related to generalized weakness and diabetes mellitus. Resident #7 had an actual fall at the facility and outside the facility. Resident #7 would be free of falls through the review date. Interventions included to anticipate and meet the resident's needs, be sure Resident #7's call light was within reach, and encourage Resident #7 to use it for assistance as needed, and Resident #7 needed prompt response to all requests for assistance. Review of Resident #7's Fall Risk Review dated 04/16/24 revealed Resident #7 was at moderate risk for falls. Review of Resident #7's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #7 was cognitively intact. Resident #7 required partial to moderate assistance for toileting, bathing, lower body dressing, sit to stand and chair, bed-to-chair transfer. Resident #7 was always continent of urine and bowel. Review of Resident #7's Incident Report dated 06/17/24 at 7:55 P.M. included Resident #7 had an unwitnessed fall, and his pain level was a ten out of ten on a scale of zero to ten, ten being the worst pain. There was no further documentation on 06/17/24. On 06/18/24, documentation included Resident #7 had an unwitnessed fall in his bedroom, Resident #7 stated he was transferring himself from the bed to the chair to go to the bathroom when he lost his balance and fell. Resident #7 denied hitting his head, vital signs were within normal limits (WNL), and he was able to move all extremities. Resident #7 was assisted into his wheelchair by Licensed Practical Nurse (LPN) #704 and State Tested Nursing Assistants (STNAs) #542 and #549. Resident #7 had complaints of right leg pain, his pain level was a ten out of ten, and Medical Doctor (MD) #705 was notified. Resident #7 was assessed by the day shift nurse after she received report. Resident #7 was still in bed complaining of right hip pain and stated, I can't get up for dialysis. MD #705 was notified, and a new order was given to send Resident #7 to the hospital emergency room (ER) via 911. The ambulance arrived on 06/18/24 at 6:45 A.M. for transfer. The nurse contacted the ER on [DATE] at 2:55 P.M. and was told Resident #7 was transferred to the main campus with a displaced right hip. MD #705 and Resident #7's son were notified of Resident #7's transfer to the main campus and admission to the hospital. Review of Resident #7's progress notes dated 06/17/24 at 7:55 P.M. through 06/18/24 at 4:24 A.M. did not reveal documented evidence that Resident #7 experienced a fall, had an evaluation for a fall including a pain evaluation, or evidence the physician was notified. Review of Resident #7's Medication Administration Record (MAR) dated 06/17/24 at 7:55 P.M. through 06/18/24 did not reveal documented evidence Resident #7 was administered pain medication, including Tylenol for complaints of right leg pain of ten out of ten on a scale of zero to ten, ten being the worst pain. Review of Resident #7's Neurological Review dated 06/18/24 at 4:24 A.M. and initiated on 06/17/24 at 7:55 P.M. included Resident #7's right lower extremity was weak, and he had pain. Review of Resident #7's Fall Packet dated 06/18/24 included a witness statement written by Licensed Practical Nurse (LPN) #704 revealed on 06/17/24 Resident #7 had an unwitnessed fall in his bedroom. Resident #7 stated he was transferring himself from the bed to a chair to go to the bathroom when he lost his balance and fell. Resident #7 denied hitting his head, vital signs were within normal limit (WNL), and he was able to move all extremities. Resident #7 complained of right leg pain and his pain was a ten out of ten on a scale of zero to ten, ten being the worst pain. The physician was notified. LPN #704 and two STNAs transferred Resident #7 to the wheelchair. STNA #549's witness statement included on 06/17/24 at 7:55 P.M. Resident #7's roommate came to the door of their room and yelled [Resident #7] fell on the floor. STNA #549 stated she told the nurse, and two STNAs and the nurse went into the room to assist Resident #7. The nurse took Resident #7's vital signs and asked him questions. The three of them lifted Resident #7 into his wheelchair. Review of Resident #7's progress notes dated 06/18/24 at 4:29 A.M. included Resident #7 had facial expressions, protective body movements, and vocal complaints of pain. Resident #7 rated his pain as a ten out of ten on a scale of zero to ten, ten being the worst. Resident #7 said he had intermittent, aching pain which was worse with movement in his right lower leg. Non-medication interventions did not provide relief. Resident #7 had no complaints of pain up until he fell. There was no evidence the physician was notified of Resident #7's fall or pain. Review of Resident #7's physician orders dated 06/18/24 at 5:49 A.M. revealed an order for an x-ray of the right lower extremity, one time only for fall purposes. Review of Resident #7's progress notes dated 06/18/24 at 5:55 A.M. revealed Resident #7's son was notified by phone and would like to be notified about the results of the x-ray. Review of Resident #7's physician orders dated 06/18/24 at 6:36 A.M. revealed send to ER for right hip and leg pain post fall. Review of Resident #7's Prehospital Care Report Summary dated 06/18/24 included a call was received from the facility at 6:32 A.M. and Emergency Medical Services (EMS) were on site at 6:39 A.M. The report stated Resident #7 fell on [DATE] at 8:00 P.M. Upon arrival, Resident #7 was lying supine in his bed, and staff said he fell yesterday and was able to transfer himself from the chair to his bed but now could not transfer from the bed to the chair. Resident #7 stated he was having pain since the fall. Resident #7 was taken by ambulance to the ER and had no new complaints during the transport. Review of Resident #7's Emergency Department (ED) Provider Notes dated 06/18/24 at 2:55 P.M. included Resident #7 had a fall at the facility last night when he was transitioning from his bed to the wheelchair, and he fell on his right hip. Resident #7 has been experiencing pain since his fall. Resident #7 was non-ambulatory and reported significant tenderness with weight bearing on the right leg, and significant tenderness to palpation on right femur and right hip. Resident #7 had a closed nondisplaced fracture of the right acetabulum. Review of Resident #7's progress notes dated 06/18/24 at 2:58 P.M. included after nurse to nurse (report) this A.M., Resident #7 was assessed post fall, and he was still in bed complaining of right hip pain and stating he could not go to hemodialysis. The unit manager (UM) and physician were notified, and orders were obtained to send Resident #7 to the local hospital ER to be evaluated. Resident #7 exited the facility at 6:54 A.M. via a stretcher. The ER was contacted, and Resident #7 was transported to the local hospital main campus with a displaced right hip. Observation on 09/10/24 at 3:09 P.M. of Resident #7 revealed he was sitting in a wheelchair in his room and his roommate (Resident #12) was sitting in a wheelchair next to him. When asked if he had any concerns, Resident #7 stated he broke his hip and had been paying for it ever since. Resident #7 stated his knees were no good and gave out, and no one was helping him the day he fell (06/17/24). Resident #7 indicated he stood up and was trying to transfer himself to his wheelchair that was by his bed, his knee gave out and he fell, landing directly on his knees. Resident #7 stated he did not have his call light on because he thought he could get up and walk by himself, he did not think he was wearing shoes or socks but could not remember for sure. Resident #7 stated he felt a lot of pain in his knees and right leg when he fell. Resident #7 stated it hurt so much because he fell on the hard floor. Resident #12 stated he yelled for help, and when the nurse and aides arrived, he told them Resident #7 needed an ambulance right away, but they would not call an ambulance, and did not call an ambulance until the next day. Resident #7 stated on 06/17/24 he fell around bedtime, which was about 7:00 P.M. or 8:00 P.M., and he was pissed off because he laid in bed all night, his leg hurt like hell, and the ambulance was not called until the next morning. Interview on 09/10/24 at 4:15 P.M. of the Director of Nursing (DON) revealed when a resident had a fall a nurse assessed the resident, and the resident was not to be moved or touched until the nurse arrived. Vital signs including neuro checks should be documented in the nurse's notes, but neuro checks were documented on paper and were not uploaded into the electronic record. The nurse should check for range of motion, internal or external rotation, length of leg, skin redness, discoloration, pain and this should also be documented in the nurse's notes or on the incident report. The DON stated if the resident had pain, it should be documented where the pain was and how bad it was. If a resident was having pain such as in the hip, neck, back staff should not move the resident and call 911. The DON confirmed 911 was not called when Resident #7 fell on [DATE] at 7:55 P.M. and Resident #7 reported pain at a ten out of a ten. Interview on 09/11/24 at 9:45 A.M. of LPN #704 revealed she was administering medications to the residents, and while she was doing the med pass STNA #549 told her Resident #7 fell and was on the floor. LPN #704 stated Resident #12 yelled out to tell them that Resident #7 fell, and when she found Resident #7 on the floor, she took his vital signs, he said his right leg was bothering him, and he was trying to go to the bathroom when he fell. LPN #704 stated two STNAs assisted her, and they helped the resident into his wheelchair, where he sat for at least two hours. LPN #704 stated Resident #7 did not have physician orders for pain medication, but she gave Tylenol to Resident #7 because the facility had standing orders to give Tylenol if needed for pain. The LPN stated she was busy that night and forgot to put the orders in his medical record. LPN #704 stated she documented she administered Tylenol and notified the physician, but the physician never responded, and on 06/18/24, in the morning, Resident #7 was still complaining of leg pain. LPN #704 indicated she called the on-call physician and received an order for an x-ray of Resident #7's right leg, but the day shift nurse arrived and said to just send the resident to the hospital via 911. LPN #704 stated Resident #7 said he had pain in his right leg, but it was not a ten anymore, and she checked him throughout the night but forgot to document she checked him and what his pain level was. In the morning, the STNA said Resident #7 did not want to get out of bed due to pain in his right leg. LPN #704 stated she wrote a note in the secure message system that Resident #7 had a fall, had bilateral bruising on his knees, and he complained of a pain level of ten out of ten on a zero to ten pain scale, ten being the worst, and he did not have pain medication ordered. LPN #704 stated she text the physician, but could not remember which physician, the physician never responded back, and she did not try again. Interview on 09/11/24 at 2:37 P.M. of the DON revealed she did not know all the details of Resident #7's fall, just what was written in the nurse's notes. The DON stated LPN #704 no longer worked at the facility. The DON stated she did not think MD #705 called back until 06/18/24 in the morning, did not know why MD #705 did not respond to the notification, and Resident #7 was sent to the ER. The DON confirmed LPN #704 did not place orders in Resident #7's medical record for Tylenol, and did not document she gave the Tylenol either. The DON confirmed Resident #7's pain was a rated a ten out of a ten which was pretty severe pain, and LPN #704 did not obtain orders for pain medication or administer pain medication. When Registered Nurse (RN) #627 arrived for work on 06/18/24 at 6:00 A.M. she contacted Medical Doctor (MD) #705 and received orders to send Resident #7 to the ER via 911. Interview on 09/12/24 at 8:01 A.M. of RN #627 revealed Resident #7 experienced a fall on 06/17/24 and when she arrived for work on 06/18/24 at 6:00 A.M. Resident #7 stated he was having hip pain, his pain was a ten out of ten and he could not go to dialysis because of the pain. RN #627 stated Resident #7's facial expressions looked like he was in pain. RN #627 indicated she notified MD #705, and he gave orders to send Resident #7 to the ER via 911.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility policy the facility failed to ensure individualized care planned interventions were developed and followed to prevent Resident #32 and Resident #1 from developing in-house pressure ulcers and failed to ensure the pressure ulcers were timely identified, properly treated, and interventions were initiated to promote healing. Additionally, the facility failed to ensure Resident's #24, #29 and #71 had pressure ulcer risk evaluations completed quarterly, failed to ensure Resident #81 had skin checks and treatments completed as ordered, and failed to ensure Resident #81's physician orders and care planned interventions were followed for heel protectors. This affected six residents (#32, #1, #24, #29, #71, and #81) of seven residents reviewed for pressure ulcers. The facility census was 102. Actual Harm occurred on 08/07/24 when Resident #32, who was at risk for developing pressure ulcers, and was dependent on staff for bed mobility and incontinence care was identified to have new areas of in-house acquired skin impairment with no additional assessment or new treatment at that time. On 08/07/24 the facility assessed Resident #32 to have one new, in-house acquired Stage III pressure ulcers (full-thickness loss of skin that extended to the subcutaneous tissue, but did not cross the fascia beneath it) on his sacral area and a right below the knee amputation (BKA) eschar covered surgical wound, without proper prevention, treatment and interventions implemented. Resident #32's family voiced concerns staff did not provide timely assistance with turning and repositioning and off-loading his right BKA. Resident #32's wounds deteriorated, and he was transported to the hospital on [DATE] for evaluation and treatment of osteomyelitis (inflammation of the bone caused by an infection). Findings include: 1. Review of Resident #32's medical record revealed an admission date of 12/04/19 and a reentry date of 02/20/24. Diagnoses included unspecified sequelae of cerebral infarction, dementia, type two diabetes mellitus with hyperglycemia, and acquired absence of right leg below the knee (10/28/19) and left leg below the knee (08/31/21). Review of Resident #32's physician orders dated 04/25/24 revealed to turn and reposition frequently with rounds and as needed every shift. Review of Resident #32's Braden Scale for Predicting Pressure Ulcer Risk dated 05/16/24 revealed Resident #32 was at high risk for pressure ulcer development. Review of Resident #32's medical record, including progress notes, medication administration record (MAR), treatment administration records (TAR), physician orders from 07/01/24 through 08/14/24 did not reveal evidence Resident #32's right BKA was off loaded, or he was encouraged to off load his right BKA. Review of Resident #32's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the Brief Interview for Mental Status (BIMS) was not completed due to the resident being rarely or never understood. Resident #32 was dependent (on staff) for toileting hygiene, personal hygiene, bathing, dressing, chair, bed-to-chair transfer and rolling left and right. Sit to lying, lying to sitting on side of bed, sit to stand, and toilet transfer were not attempted due to medical condition or safety concerns. Resident #32 was at risk of developing pressure ulcers, injuries and did not have one or more unhealed pressure ulcers, injuries. Resident #32 received 51 percent of his total calories through a tube feeding, percutaneous endoscopic gastrostomy (PEG) tube. Review of Resident #32's TAR dated 07/29/24 and 07/30/24 at 6:00 P.M., 08/04/24 at 6:00 P.M., 08/10/24 and 08/11/24 at 6:00 A.M., 08/15/24 at 6:00 A.M., 08/20/24 at 6:00 P.M., and 08/21/24 at 6:00 A.M. did not reveal documented evidence Resident #32 was turned and repositioned frequently with rounds and as needed as ordered. Review of Resident #32's medical record including progress notes did not reveal documentation indicating why this was not completed. Review of Resident #32's shower sheet dated 08/04/24 revealed Resident #32 had an area on his buttocks (sacrum) that was not intact. There was no description of the area on the shower sheet. Review of Resident #32's medical record including physician orders, progress notes and evaluations from 08/04/24 through 08/07/24 did not reveal evidence Resident #32's area to his buttocks (sacrum) was evaluated, the physician was notified and a treatment ordered. Review of Resident #32's progress notes dated 08/07/24 at 4:07 P.M. included an unidentified State Tested Nursing Assistant (STNA) notified Wound Nurse (WN) #629 that Resident #32 had a new area to the buttocks (sacrum). During the skin assessment WN #629 also noticed a new area to Resident #32's left (right) BKA surgical site. Both areas were noted to have drainage and Certified Wound Nurse Practitioner (CWNP) #700 was in the facility and evaluated the wounds. All responsible parties were notified. Review of Resident #32's Visit Report dated 08/07/24 and authored by CWNP #700 included this was an initial wound encounter, and Resident #32 had a sacral Stage III pressure injury, pressure ulcer. Measurements were length 2.97 centimeters (cm), width 1.89 cm and depth of 0.3 cm. Adipose (fat tissue) was exposed and there was a moderate amount of serosanguineous drainage with no odor. The wound margin was undefined, wound bed had 26 to 50 percent bright red, pink, firm, granulation, one to 25 percent slough, and one to 25 percent epithelialization. Treatment orders were to cleanse the wound with mild soap and water, apply MediHoney (antibacterial ointment that promotes a moist wound environment, reduces inflammation, reduces odor, and lifts dead tissue) to wound base, apply calcium alginate (highly absorbent wound dressing) and cover with foam dressing two times per day and as needed, and off-loading per the facility pressure injury prevention, relief protocol. Review of Resident #32's Visit Report dated 08/07/24 and written by CWNP #700 included this was an initial wound encounter and Resident #32 had a right BKA eschar (dry, black, hard, dead tissue) covered surgical wound. Measurements were length 1.7 cm, width 0.93 cm and had no measurable depth. There was a moderate amount of yellow drainage noted with no odor, and the wound bed was one to 25 percent pink, firm, granulation, 76 to 100 percent slough (dead tissue, usually cream or yellow in color). Treatment orders were cleanse wound with mild soap and water, protect peri wound with no sting Skin-Prep (forms a barrier between the skin and adhesives to help preserve skin integrity), apply MediHoney to the wound base, apply calcium alginate and foam dressing daily and as needed, and off-loading per the facility pressure injury prevention, relief protocol. Review of Resident #32's care plan revised on 08/09/24 (with an initiation date of 02/22/24) included Resident #32 was at risk for impairment to skin integrity related to impaired mobility, incontinence, history of pressure injury to left gluteal fold, and history of pressure injury to the coccyx. Resident #32 had an actual area of skin impairment to the sacrum and right BKA. Resident #32 would maintain or develop clean and intact skin by the review date. Interventions included to administer treatments per physician order; follow facility protocols for treatment of injury; low air loss (LAL) mattress to bed at all times(AAT); monitor, document location, size and treatment of skin injury and report abnormalities, failure to heal, signs and symptoms of infection, maceration, etcetera (etc.) to the medical doctor (MD); turn and reposition frequently with rounds and as needed (PRN). Resident #32 had an amputation of bilateral lower extremities (BLE). Resident #32 would have an acceptable level of comfort and have well-controlled phantom pain (painful perception that an individual experiences relating to a limb that is not physically there) through the review date. Interventions included to change position frequently, alternate periods of rest with activity out of bed to prevent complications including skin pressure areas. Further review of Resident #32's care plan revised on 08/09/24 (initiated 02/22/24) did not reveal interventions to off-load right BKA or to avoid direct pressure to wound sites as ordered. Review of Resident #32's TAR dated 08/04/24 at 6:00 P.M., 08/10/24 at 6: A.M., 08/11/24 and 08/15/24 at 6:00 A.M., 08/20/24 at 6:00 P.M. and 08/21/24 at 6:00 A.M. did not reveal evidence Resident #32 was turned and repositioned frequently with rounds and as needed was completed. Review of Resident #32's progress notes did not reveal documentation indicating why Resident #32 was not turned and repositioned as ordered. Review of Resident #32's TAR dated 08/10/24, 08/20/24 and 08/21/24 did not reveal documented evidence the treatment to cleanse right BKA with normal saline, apply MediHoney then calcium alginate, overlay bordered foam dressing daily and as needed was completed as ordered. Review of Resident #32's medical record including progress notes did not reveal documentation indicating why the treatment was not completed as ordered. Review of Resident #32's TAR dated 08/10/24 at 6:00 A.M., 08/20/24 and 08/21/24 at 6:00 A.M., and 08/20/24 at 6:00 P.M. did not reveal documented evidence the treatment to cleanse sacrum with normal saline, apply MediHoney, calcium alginate and overlay bordered foam dressing every shift and as needed was completed as ordered. Review of Resident #32's medical record, including progress notes, did not reveal documentation indicating why Resident #32's treatment was not completed as ordered. Review of Resident #32's TAR dated 08/10/24 at 6:00 A.M., 08/11/24 at 6:00 A.M., 08/20/24 and 08/21/24 at 6:00 A.M., 08/25/24 at 6:00 A.M., 08/10/24 at 6:00 P.M., 08/20/24 and 08/26/24 at 6:00 P.M. did not reveal documented evidence the daily wound evaluation for sacrum document abnormalities in the progress notes, document if there was drainage, if the dressing was dry and intact, signs and symptoms of infection, necrotic tissue present, odor, surrounding skin tissue, wound pain every shift for wound assessment was completed as ordered. Review of Resident #32's medical record, including progress notes, did not reveal documentation indicating why Resident #32's assessment was not completed as ordered. Review of Resident #32's TAR dated 08/10/24 and 08/11/24 at 6:00 A.M., 08/20/24 and 08/21/24 at 6:00 A.M., 08/25/24 at 6:00 A.M., 08/10/24, 08/20/24 and 08/26/24 at 6:00 P.M. did not reveal documented evidence the daily wound evaluation for Resident #32's right BKA, document abnormalities in the progress notes, record drainage, if dressing dry and intact, signs and symptoms of infection, if necrotic tissue present, odor, surrounding skin appearance, wound pain every shift for wound assessment. Review of Resident #32's medical record, including progress notes, did not reveal documentation indicating why Resident #32's assessment was not completed as ordered. Review of Resident #32's STNA documentation in the electronic record dated 08/13/24 through 08/28/24 revealed on 08/13/24, 08/14/24, 08/17/24, 08/19/24, 08/25/24, and 08/28/24 Resident #32 was turned and repositioned two times in 24 hours. On 08/15/24, 08/20/24, and 08/24/24 Resident #32 was turned and repositioned three times in 24 hours. On 08/16/24, 08/21/24, 08/23/24, 08/26/24, and 08/27/24 documentation revealed Resident #32 was turned and repositioned one time in 24 hours. On 08/18/24 and 08/22/24 there was no documented evidence that Resident #32 was turned and repositioned. Review of Resident #32's Skin Only Evaluation dated 08/14/24 and completed by WN #629 included Resident #32 had a right BKA surgical wound, the length was 2.6 cm, width was 2.2 cm, and the depth was not determined. The wound exudate was serosanguineous, the dressing had moderate (26 to 75 percent) saturation, and there was no wound odor. The wound was painful to touch. Further review revealed Resident #32 had a Stage III pressure ulcer, injury to the sacrum. The length was 2.97 cm, width 1.89 cm, and the depth 0.3 cm. The wound exudate was sanguineous (bloody drainage) and dressing saturation was minimal (less than 25 percent). There was no wound odor, and the tissue was painful to the touch. The wound to Resident #32's sacrum remained stable at this time. No change to the treatment was made. The non-healing surgical wound to Resident #32's right BKA noted to be deteriorating and increased in size. The treatment remained the same. Review of Resident #32's physician orders dated 08/14/24 revealed an order to off-load the right BKA AAT every shift. This order was discontinued on 08/20/24. Review of Resident #32's TAR dated 08/15/24 at 6:00 A.M. revealed no documented evidence the right BKA was off-loaded AAT every shift as ordered. Review of Resident #32's medical record, including progress notes, did not reveal documentation why this was not done as ordered. Review of Resident #32's physician orders dated 08/20/24 revealed an order to encourage the resident to off-load the right BKA every shift. Review of Resident #32's TAR dated 08/20/24 at 6:00 P.M., and 08/21/24 at 6:00 A.M. did not reveal evidence Resident #32 was encouraged to off-load the right BKA every shift. Review of Resident #32's medical record, including progress notes, did not reveal documentation why this was not completed as ordered. Review of Resident #32's Visit Report dated 08/21/24 and completed by CWNP #700 included Resident #32 had an unstageable pressure injury (full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed, obscured full-thickness skin and tissue loss) to the sacrum. Resident #32's pressure ulcer was acquired on 08/07/24. Measurements were length 5.06 cm, width 4.85 cm with no measurable depth. Adipose was exposed. There was a moderate amount of serosanguineous drainage with no odor. The wound bed had 51 to 75 percent bright red, pink, firm, granulation, 26 to 50 percent eschar, no slough and epithelialization present. Resident #32's wound was deteriorating. Treatment was cleanse with mild soap and water, apply MediHoney to the wound base and cover with calcium alginate, apply an abdominal (ABD) pad and secure with paper tape. Change the dressing two times a day and as needed. New orders to turn and reposition every two hours, avoid direct pressure to the wound site, and implement the facility pressure injury prevention, relief protocol. Review of Resident #32's Visit Report dated 08/21/24 and completed by CWNP #700 included Resident #32's right BKA was an eschar covered surgical wound acquired on 08/07/24. The wound length was 2.23 cm. width 2.17 cm with no measurable depth. There was no drainage noted. The wound bed had no granulation, 76 to 100 percent eschar, no slough and no epithelialization present. The wound was completely covered with eschar. Resident #32's wound was deteriorating. New orders included the treatment was cleanse wound with normal saline, apply MediHoney to the wound base, cover with calcium alginate apply an ABD pad, Kerlix gauze, and secure with paper tape. Use a small piece of tape to also secure the Kerlix gauze to the leg. Change the dressing daily and as needed. New orders to turn and reposition the resident every two hours, avoid direct pressure to the wound site, and implement the facility pressure injury prevention, relief protocol. An x-ray of Resident #32's right BKA was ordered to rule out osteomyelitis. Review of Resident #32's progress notes dated 08/21/24 at 3:35 P.M. revealed Resident #32 was seen by CWNP #700, and a new order for an x-ray of the right knee and femur was given. Review of Resident #32's physician orders did not reveal physician orders from 08/21/24 through 08/28/24 for turning and repositioning every two hours and avoiding direct pressure to the wound. Further review from 08/21/24 through 08/28/24 did not reveal orders for Resident #32's right BKA to cleanse wound with normal saline, apply MediHoney to the wound base, cover with calcium alginate apply an ABD pad, Kerlix gauze, and secure with paper tape. Use a small piece of tape to also secure the Kerlix gauze to the leg. Change the dressing daily and as needed. Review of Resident #32's medical record, including progress notes, MAR, TAR, and electronic STNA documentation from 08/21/24 through 08/28/24 revealed no documented evidence Resident #32 was turned and repositioned every two hours, or direct pressure was avoided to the wound sites. Review of Resident #32's TAR dated 08/25/24 revealed no documented evidence the order to cleanse the right BKA with normal saline, apply MediHoney then calcium alginate, cover with an ABD pad and paper tape every dayshift and as needed was completed as ordered. The TAR did not reflect new orders written on 08/21/24. Review of Resident #32's TAR dated 08/21/24 through 08/28/24 did not reveal evidence treatments were completed for new orders written on 08/21/24 for Resident #32's right BKA which was cleanse wound with normal saline, apply MediHoney to the wound base, cover with calcium alginate apply an ABD pad, Kerlix gauze, and secure with paper tape. Use a small piece of tape to also secure the Kerlix gauze to the leg. Change the dressing daily and as needed. Review of Resident #32's TAR dated 08/25/24 at 6:00 A.M. revealed no documented evidence the treatment to cleanse the sacrum with normal saline, apply MediHoney, calcium alginate, and cover with an ABD pad and paper tape every shift and as needed was completed. There was no documentation in the medical record, including progress notes, indicating why the treatment was not completed. Review of Resident #32's Visit Report dated 08/28/24 and completed by CWNP #700 included Resident #32's sacral unstageable pressure injury acquired on 08/07/24 measured length 4.55 cm, width 4.19 cm with no measurable depth. There was no change in the wound progression. Treatment orders were unchanged from 08/21/24. Turn and reposition Resident #32 every two hours, avoid direct pressure to the wound site, implement the facility pressure injury prevention, relief protocol. Review of Resident #32's Visit Report dated 08/28/24 and completed by CWNP #700 included Resident #32's right BKA was an eschar covered wound acquired on 08/07/24. Wound measurements were length 2.16, width 2.54 cm and depth 1.2 cm. Bone was exposed and undermining noted at 12:00 o'clock with a maximum distance of 2.2 cm. There was a small amount of purulent drainage noted with no odor. The wound was deteriorating. Treatment orders were unchanged from 08/21/24. Turn and reposition every two hours, avoid direct pressure to the wound site, and implement the facility pressure injury prevention, relief protocol. Review of Resident #32's progress notes dated 08/28/24 at 12:07 P.M. included CWNP #700 evaluated Resident #32 and recommended and emergency department (ED) visit for further treatment. A new order was received to send the resident to the ED for evaluation and treatment. Review of Resident #32's After Visit Summary and Provider Notes for his hospital stay from 08/28/24 through 09/10/24 included Resident #32 had chronic osteomyelitis of the femur. Resident #32 had a right BKA stump complication, an open wound and was sent to the ED for an infection at the surgical site. Resident #32 had an ulceration to the surgical site of the right stump. Resident #32 had right BKA stump wound with acute right tibial osteomyelitis and was status post right BKA stump debridement on 09/03/24. Resident #32 had a full thickness wound to the right BKA stump, and the wound base was fibrotic with eschar noted. The wound was granular with edema, minor drainage and bleeding. Resident #32 had a Wound Vac placement. Resident #32 had an area of necrotic tissue on his sacrum about the size of a quarter and had a debridement of the sacral decubitus. Measurements on 08/29/24 of Resident #32's right knee were length 3.0 cm, width 3.0 cm and the depth was not determined. The wound was dry, pink, red in color and had a small amount of thick drainage. Resident #32's sacral measurements on 08/29/24 were length 8.0 cm, width 8.0 cm, depth was not determined, and there was a moderate amount of pink, red thick drainage. Interview on 09/09/24 at 9:54 A.M. of Family Member (FM) #701 revealed Resident #32 was a double amputee, could not speak, was admitted to the facility and resided on the rehab nursing unit. Resident #32 developed a bed sore which cleared up, then was transferred to the long-term care nursing unit. While residing on the long-term care nursing unit, Resident #32 developed another bed sore on his bottom, a wound on his stump, and was admitted to the hospital. FM #701 stated Resident #32 had an infection that went to the bone, and he required a procedure on his stump and had a peripherally inserted central catheter (PICC) line. FM #701 stated the facility was like two separate nursing homes and one received good care, and one side (the long-term side) received poor care. FM #701 stated there was a huge difference between the nursing units. FM #701 indicated when the family visited, and Resident #32 resided on the long-term hall the call light would be activated because Resident #32 needed care, and the nurses and aides did not come. FM #701 stated Resident #32 was not turned and repositioned unless the family requested it, and his right leg was not propped up, so it wasn't resting on the mattress. FM #701 stated the right stump must have been rubbing against the sheet. FM #701 stated every time the family visited the facility, Resident #32's right stump was not propped up and they had to constantly tell the nurses and aides about it. FM #701 indicated he talked to Social Services Designee (SSD) #632 and Unit Manager (UM) #702 about Resident #32's care. FM #701 revealed on the long-term side the black props were not used and instead the staff used pillows or sheets, and often when he visited, he found Resident #32's right stump resting directly on the pillow or sheets causing pressure directly to the area where the wound developed. FM #701 stated he told SSD #632 and UM #702 the staff on the long-term side needed education on how to properly position Resident #32. Observation on 09/11/24 at 11:48 A.M. with CWNP #700 and WN #629 of Resident #32's dressing changes revealed his right leg amputation site dressing was intact with a moderate amount of pink and brown drainage. The wound size was approximately one inch in diameter, and the wound bed was a dark pink, red with a white center, fascia (a thin, flexible, connective tissue) per CWNP #700). CWNP #700 stated when she first saw the wound on 08/07/24 it was 100 percent covered in eschar and it progressed to have a hole in the center with purulent drainage, she ordered an x-ray to rule out osteomyelitis, but the x-ray was fine and did not show osteomyelitis. Further observation revealed Resident #32 had a bilateral sacral open area with pink, brown drainage, the wound base had a white center (fat tissue per CWNP #700) and muscle could be visualized. CWNP #700 stated an area of eschar was taken off at the hospital. The wound was cleansed with normal saline, and MediHoney, calcium alginate, and an ABD pad were applied. CWNP #700 stated it could be he was not turned and positioned, and that was how pressure ulcers work. CWNP #700 stated the black wedge positioning device should be under the sheet and under Resident #32, and it had to be positioned properly to work. Interview on 09/11/24 at 1:59 P.M. of FM #703 revealed Resident #32 did not have a problem with his stumps until he was moved to the long-term nursing care side of the facility. FM #703 stated when Resident #32 was moved to the long-term care unit, he was not always turned and repositioned, and his leg was not always elevated off the mattress. FM #703 stated the family often reminded staff to turn and reposition Resident #32 and to elevate his right BKA. Observation on 09/11/24 at 2:00 P.M. of Resident #32 revealed he was lying on his back in bed, and his right and left BKA's were lying directly on the mattress, not off-loaded. Interview on 09/11/24 at 2:21 P.M. of STNA #555 confirmed Resident #32's right and left BKA's were not off-loaded from the mattress. Interview on 09/11/24 at 3:28 P.M. of WN #629 revealed the first time she saw Resident #32's wounds on his right stump and buttock was on 08/07/24 when the aides informed her that Resident #32 had a wound on his butt. WN #629 stated, when Resident #32 was rolled onto his side to look at his sacral area, she also saw a wound on the right BKA. WN #629 indicated Resident #32 had a sacral pressure ulcer in the past, but it was cleared up in 05/2024, and Resident #32 did not have wounds to his right BKA and sacrum before 08/07/24. WN #629 confirmed Resident #32's treatments were not documented as completed in the TAR, and it was challenging to make sure treatments and skin checks were completed as ordered. WN #629 stated, sometimes the nurses charted they did the treatments, but she would find dressings with old dates that did not correspond to the date they were signed off they were completed on the TAR. Interview on 09/11/24 at 3:37 P.M. of STNA #529 revealed she worked on the rehab side of the facility and took care of Resident #32. STNA #529 stated Resident #32 did not have a sore on his right BKA or a sore on his butt (sacrum) when he was transferred to the long-term care side of the facility. Interview on 09/12/24 at 11:16 A.M. of STNA #546 revealed Resident #32's treatments were not getting done on either his right BKA and his butt wound (sacrum). STNA #546 stated it depended on the nurse to determine if his treatments were completed. Interview on 09/12/24 at 11:52 A.M. of STNA #544 revealed he was aware Resident #32 had a sacral wound, but he did not know about the right BKA wound because Resident #32's right leg rested on the mattress right where the sore was. Interview on 09/18/24 at 1:00 P.M. of the Director of Nursing (DON) confirmed Resident #32's shower sheet dated 08/04/24 had an area to his buttocks (sacrum) identified, and the area was not documented or evaluated until 08/07/24. The DON stated the nurse did not sign the sheet and turned it in without addressing the area to Resident #32's buttocks (sacrum). The DON confirmed she was aware random treatments were not being completed for Resident #32's sacral pressure ulcer and right BKA wound. Interview on 09/18/24 at 2:05 P.M. of UM #702 revealed Resident #32's son talked to her about his care, and he was concerned about Resident #32 not getting turned and repositioned and was also concerned about his wound care. Review of the facility policy titled Prevention of Pressure Injuries, revised 04/2020, included the purpose was to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Assess the resident on admission (within eight hours) for existing pressure injury risk factors and repeat the risk assessment weekly and upon any changes in condition. Inspect the skin daily when performing or assisting with personal care or activities of daily living (ADL). Identify any signs of developing pressure injuries, inspect pressure points, and reposition resident as indicated on the care plan. Choose a frequency for repositioning based on the resident's risk factors and current clinical practice guidelines. Evaluate, report and document potential changes in the skin. 2. Review of Resident #1's medical record revealed an admission date of 10/08/23 with diagnoses including displaced bicondylar fracture of left tibia, Alzheimer's disease, anxiety disorder, and legal blindness. Review of the Braden Scale for Predicting Pressure Ulcer Risk dated 12/03/23 revealed Resident #1 was high risk for pressure ulcer development. Further review of Resident #1's medical record did not reveal another Braden Scale for Predicting Pressure Ulcer Risk was completed until 07/18/24. On 07/18/24, Resident #1 was at high risk for developing a pressure ulcer. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #1 had moderate cognitive impairment. Resident #1 was dependent for toileting and personal hygiene, bathing, and upper and lower body dressing. Resident #1 required substantial to maximal assistance to roll left and right, and was dependent for sitting to lying, lying to sitting on side of bed, sit to stand and chair, bed-to-chair transfer. Resident #1 was always incontinent of urine and bowel. Resident #1 was at risk of developing pressure ulcers, injuries and did not have one or more unhealed pressure ulcers, injuries. Review of Resident #1's progress notes dated 07/18/24 at 3:56 P.M. included Registered Nurse (RN) #627 was called to Resident #1's room by an unidentified STNA who noted an area to Resident #1's sacrum. The area was assessed and cleansed with normal saline, it was not open but was dark purple in color and measured 1.0 cm by 1.0 cm and appeared to be a deep tissue injury (DTI), (A purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue due to pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue). A new order was obtained to change to a thicker cream (Triad cream) to peri area, sacrum, and buttocks. Wound care was to refollow, and the physician, unit manager, and Resident #1's daughter were notified. Review of Resident #1's physician orders dated 07/18/24 revealed apply Triad cream to buttocks (purple area to sacrum), peri area, every shift for wound care. Review of Resident #1's medical record including progress notes, physician orders, TAR, and evaluations dated 07/18/24 through 09/12/24 did not reveal documented evidence that Resident #1's dark purple area on the sacrum was evaluated or treated. Review of Resident #1's care plan initiated on 10/10/23 and revised 08/26/24 included Resident #1 had actual impairment to skin integrity related to a Stage III pressure ulcer to the right buttocks present on admission to the facility and was at increased risk for further impairment to skin integrity related to incontinence, impaired mobility, and history of Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough, may also present as an intact or open/ruptured serum filled blister) to the left medial buttock. Resident #1 had a history of dark area to the sacrum, unopened. The goal was for Resident #1's skin injury to be healed by the review date. Interventions included to administer treatment per physician order, monitor, document location, size and treatment of skin injury. Report abnormalities, failure to heal, maceration etc. Review of Resident #1's shower sheet dated 08/05/24 revealed Resident #1 had a red spot on the tail bone. The shower sheet was signed by Licensed Practical Nurse (LPN) #601. There was no further evidence in Resident #1's medical record from 08/05/24 through 09/12/24 that the red spot on Resident #1's tail bone was evaluated or treated. Interview on 09/09/24 at 1:15 P.M. of STNA #554 revealed Resident #1 usually agreed to have all care completed and did not resist turning and repositioning. Interview on 09/11/24 at 8:48 A.M. of WN #629 revealed she accompanied CWNP #700 on wound rounds every Wednesday, and if there were new wounds between wound rounds, the concerns were handled by UM's #643 and #702, and the UMs would notify her of the new wounds. WN #629 stated UM's #643 and #702 kept a wound grid and updated it every Wednesday. When there was a new pressure injury, the physician, the DON, the Administrator, and CWNP #700 were notified. WN #629 stated a picture of the wound was texted to CWNP #700 and she would order treatments until she visited the facility the next Wednesday. WN #629 stated that she [NAME][TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, Emergency Medical Services (EMS) documentation, hospital record review, facility policy review, and interview the facility failed to develop and implement an effective, comprehensive and individualized fall prevention program for Resident #197 to decrease the resident's risk of repeated falls. The facility failed to ensure Resident #197 was provided timely assistance with toileting and failed to ensure the resident was not left unattended in a chair in the activity room without proper footwear and clothing resulting in a fall on 08/26/24 with multiple fractures. The facility also failed to ensure accurate and complete fall risk assessments were completed for Resident #61. This affected two residents (#61 and #197) of six residents revealed for falls and/or accident hazards. The facility census was 102. Actual Harm occurred on 08/26/24 between approximately 1:30 A.M. to 1:40 A.M. when Resident #197, who was severely cognitively impaired, assessed to be at moderate to high risk for falls, dependent on staff for toileting and incontinent of both bowel and bladder sustained an unwitnessed fall resulting in a left femur fracture, a large left intramuscular hematoma, right tibia fracture, right fibula fracture, a non-displaced fracture of the right superior pubic ramus, an anterior acetabular column fracture, an inferior right pubic ramus fracture, and right sacrum fractures as a result of a fall. Prior to the fall, the resident had last been toileted on 08/25/24 at 9:21 P.M. (five hours earlier). The resident had been left unattended with bare feet and no pants, wearing only a brief, in a chair in the activity room at 1:00 A.M. by State Tested Nurse Aide (STNA) #518. Resident #2, who was alert and oriented, was in the activity room and watched Resident #197 stand up from a regular high back chair and remove her brief, which was saturated with urine, and throw it away in the trash can. Resident #197 then walked out activity room door and walked down the hallway and entered another resident's room where she fell. The resident was hospitalized from [DATE] to 09/08/24 as a result of the fall with injuries. Findings include: 1. Review of the medical record for Resident #197 revealed an initial admission date 05/05/24, Resident #197 was sent to the emergency room for increase in behaviors on 05/07/24 and returned to the facility on [DATE]. Resident #197 had diagnoses included chronic atrial fibrillation, muscle weakness, type two diabetes mellitus, unsteadiness on feet, osteoarthritis, hypertension, Alzheimer's disease, cognitive communication deficit, and dysphagia. Review of the plan of care for Resident #197, initiated on 05/06/24, revealed Resident #197 was at increased risk for falls related to Alzheimer's dementia. Resident #197 had an actual fall at the facility on 05/05/24. Goals included Resident #197 would be free from injury through the review date. Interventions included to anticipate and meet the resident needs, be sure the resident's call light was within reach, and encourage the resident to use it for assistance, educate the resident/family/care givers about safety reminders and what to do if a fall occurs, encourage the resident to participate in activities that promote exercise, physical activity, for strengthening and improved mobility. Additional interventions included staff to identify cause of falls, neurological checks for unwitnessed falls, occupational therapy (OT) and physical therapy (PT), to evaluate and treat as ordered. On 05/08/24 an intervention was added for staff to encourage resident to lay down on the couch when she falls asleep in chair. Further review of Resident #197's care plan for falls revealed the plan of care was not updated following falls sustained by the resident on 05/20/24, 06/17/24, 06/27/24, and 08/26/24. Review of the plan of care for Resident #197, initiated on 05/06/24, last revised on 07/31/24 revealed Resident #197 had frequent bladder incontinence related to Alzheimer's disease. Goals and interventions included Resident #197 would remain free form skin breakdown due to incontinence and brief use. Staff were to encourage and assist with toileting frequently with rounds and as needed, staff were to ensure the resident had an unobstructed path to the bathroom, establish voiding patterns check the resident frequently with rounds and as required for incontinence. Wash, rinse, and dry perineum, change clothing as needed after incontinence episodes. (There was no documented evidence in the medical record that the facility attempted to establish voiding patterns). Review of Resident #197's physician orders dated July 2024, August 2024, and September 2024 revealed staff were to encourage and assist with toileting frequently with rounds and as needed. Review of Resident #197's medical record revealed the resident had a witnessed fall in the facility on 05/05/24 at 8:10 P.M. The fall investigation revealed an STNA notified LPN #596 they observed Resident #197 was standing up beside her wheelchair and fell. Resident #197 was attempting to fold up her blanket. LPN #596 observed the resident sitting upright on her buttocks. She denied pain and was assessed with no apparent injuries, vital signs were noted to be within normal limits (WNL), range of motion (ROM) was WNL, and the resident was noted to be alert with confusion per her usual. LPN #596 noted in the report the resident did not speak to describe what happened, she just smiled at the nurse and denied pain when asked. Immediate action taken was the resident was placed under close supervision for the remainder of LPN #596's shift. Resident #197's family was not notified until 05/06/24 at 1:45 P.M., and the physician was notified on 05/06/24 at 3:32 A.M. Additionally, under the notes section, it stated the resident stumbled and fell before the STNA could reach the resident to assist. The resident was observed between her wheelchair and a couch (it was not specific where the fall happened in the facility). The resident was assisted back to her wheelchair by two staff members. PT and OT were to evaluate and treat the resident. (PT and OT were noted to be an original order from her admission on [DATE]). Review of Resident #197's Fall Risk Assessment completed on 05/06/24, revealed the resident was at a moderate risk for falls with a score of 11. A second witnessed fall happened on 05/20/24 at 3:30 P.M. in the lounge area. The incident description included the resident was in the lounge area sleeping in her chair, she awakened and attempted to transfer herself onto the couch, and she fell onto her buttocks. The fall was witnessed by an STNA. Resident #197 did not hit her head, ROM was WNL, and there was no discoloration noted with head-to-toe assessment. The physician and family were notified. Immediate action taken was when the staff notice that the resident is awake, they will assist in transferring the resident to the couch. The Fall Risk Assessment completed on 05/20/24 revealed the resident was at moderate risk for falls with a score of 14, with discrepancies in section four, staff did not mark the resident was on antihypertensives, section seven staff marked the resident was occasionally incontinent; however, all other documentation revealed the resident was totally incontinent of both bowel and bladder and dependent on staff for toileting hygiene, section eight, staff marked no behaviors noted, but nursing staff documented behaviors less than daily, and the vital signs used were from the day before on 05/19/24. A third unwitnessed fall occurred on 06/17/24 at 6:00 A.M. Resident #197 was found on the floor in the hallway sitting on her bottom. Resident #197 stated, going, going, fall. Nursing staff completed an assessment, vital signs were obtained, and the resident complained of pain to the right hip at a ten on a pain scale of zero to ten, ten being the worst. The physician, the on-call supervisor, and emergency medical services (EMS) were called, and the resident was taken to the hospital. Under the section titled Predisposing Environmental Factors it was marked inappropriate assistive device. The resident was admitted to the hospital from [DATE] to 06/20/24 for hyperkalemia (elevated potassium level). All scans and x-rays revealed no fractures. No new fall prevention interventions were implemented upon return from the hospital. The Fall Risk Assessment completed on 06/18/24 revealed the resident was a high risk for falls with a score of 16, with discrepancies noted in section seven, staff marked the resident was occasionally incontinent; however, all other documentation revealed the resident was totally incontinent of both bowel and bladder and dependent on staff for toileting hygiene. A witnessed fall occurred on 06/27/24 at 9:30 P.M. LPN #598 witnessed Resident #197 try to stand up, she asked the resident to sit back in the chair, the resident grabbed the table and was trying to sit down, there was no chair behind her, and LPN #598 guided her to the floor. LPN #598 and two STNAs assisted the resident up and back into the wheelchair, it was noted there was no intervention put in place, therapy was already working with the resident at this time. The Fall Risk Assessment completed on 06/27/24 was incomplete and no score was given but indicated the resident was a high risk; however, there were discrepancies noted in section four with no medications marked, the resident took antihypertensives and psychotropics, and in section seven staff marked the resident was occasionally incontinent; however, all other documentation revealed the resident was totally incontinent of both bowel and bladder and dependent on staff for toileting hygiene. The quarterly Fall Risk Assessment competed on 07/14/24 revealed the resident was at moderate risk for falls with a score of 13, with discrepancies noted in section four with no medications marked. The resident was on antihypertensives and psychotropics, in section eight no behaviors were marked; however, nursing documentation indicated the resident was exhibiting behaviors less than daily, and in section 11 the gait analysis was left blank. Review of Resident #197's progress note dated 08/25/24 at 8:13 P.M. revealed the resident was given Benadryl 25 milligrams (mg) as needed for itching. Review of STNA task documentation revealed the last time Resident #197 was provided incontinence care was on 08/25/24 at 9:21 P.M. Review of Resident #197's progress note dated 08/26/24 at 3:02 A.M. revealed Registered Nurse (RN) #621 documented she was flagged down by Resident #74 because Resident #197 had fallen. Resident #197 was observed lying on her left side in another resident's room crying out in pain. The resident was not wearing pants or a brief, and her left leg had a visible bone protrusion mid-thigh. The resident's left thigh was observed to be swollen about two time the size of her right thigh. RN #621 documented she observed the resident approximately five minutes prior to the incident sitting in the dining room, and at that time she was wearing her pants. Review of Resident #197's discharge Minimum Data Set (MDS) dated [DATE] revealed the resident was severely cognitively impaired. Resident #197 required set up or clean up assistance for eating, she was independent with bed mobility, she required supervision or touching assistance with walking, and was dependent on staff for oral hygiene, toileting hygiene, showering, dressing, and personal hygiene. Review of the ambulance run report from responding emergency medical service (EMS) revealed they received the call at 1:38 A.M., they were enroute at 1:40 A.M., on scene at 1:45 A.M., made patient contact at 1:47 A.M., and left the scene at 2:00 A.M. Review of the narrative text revealed they were dispatched for a fall. Upon arrival, they found the resident (Resident #197) lying supine on the floor. The resident was alert to self only, facility staff reported they were unsure how the resident got to the location, the resident was a fall risk, and they suspected the resident was attempting to use the restroom due to the absence of pants. At this time, the resident was noted to have remarkable deformity to the left femur. They log rolled the resident onto a sheet and lifted her onto the stretcher without incident. The resident was transported to the ambulance and secured for transport to the hospital. They applied a traction splint to the residents left leg. Review of Resident #197 discharge summary for hospital stay from 08/26/24 to 09/09/24 revealed the resident was treated for an acute, transverse, mildly displaced fractures of the proximal tibia and fibular shafts as seen on right knee x-rays, an acute fracture of the distal femoral diaphysis with posterior displacement and overlapping of the distal fracture fragment with anterior angulation, it also appeared laterally rotated, a large hematoma, as seen on computed tomography (CT) scan of the left femur with contrast, there were non-displaced fractures of the right superior pubic ramus and anterior acetabular column, the inferior right pubic ramus, and the right sacrum, as seen on a CT scan of the abdomen and pelvis with intravenous (IV) contrast. The resident required surgery on 08/27/24 to fix the left femur fracture and the right tibia and fibula fractures. Interview on 09/10/24 at 9:48 A.M. with STNA #511 (not present at the time of the fall) revealed Resident #197 walked prior to her fall on 08/26/24. She stated the resident does not know how to use her call light. Prior to her fall on 08/26/24, the resident was able to stand up on her own, she had a wheelchair to use but would often stand up from the wheelchair then walk everywhere. She stated the resident had a walker at one point, but someone took it from her. STNA #511 stated Resident #197 had been sleeping mostly since she returned from the hospital. STNA #511 stated the resident did not have any falls out of bed, all had been from her wheelchair or while she was standing. Interview on 09/10/24 at 10:15 A.M. with Resident #74 revealed he came out in the hallway on the night of 08/26/24 when he heard Resident #197 screaming for help. He stated he found the resident on the floor in another resident's room. He stated there was another female resident (Resident #2) in her wheelchair outside of the room where Resident #197 was. The other female resident was trying to calm Resident #197. Resident #74 stated he then went to go and find the STNA or nurse who were assigned to the 1400 hall that night but was not able to locate anyone. He stated he went back down to where Resident #197 was on the floor and told Resident's #197 and #2 that he was going to the 1300 unit to find a nurse to help. He went to the 1300 unit and found the nurse and told her a resident needed assistance, and the 1300-unit nurse ran over. When they were returning to the 1400 unit, the nurse assigned to the 1400 unit was returning and went to where Resident #197 was at on the floor. He stated Resident #197 did not have shoes, pants, or a brief on when he saw her. Interview on 09/10/24 at 4:24 P.M. with Resident #2 revealed she was awake in her room on 08/26/24 and had wheeled herself in her wheelchair to the activity room and upon entering the activity room, she smelled a very strong odor of urine and watched Resident #197 stand up from a regular high back chair and remove her brief which was saturated with urine and throw it away in the trash can. Resident #197 then walked out the one door and walked down the hallway a little way and went into another resident's room. Resident #2 stated she did not follow Resident #197 down the hall but heard the resident fall then scream out in pain. At this time Resident #2 went to find Resident #197 and found her on the floor in another resident's room crying in pain. This was when Resident #74 wheeled himself to them and stated he was going to go find the STNA or nurse for the unit. Resident #2 stated Resident #74 then returned after about five minutes and stated he could not find anyone and was going to go to the 1300 unit to get the aide or nurse from that unit. When asked if the resident had on pants or shoes when she first saw her in the activity room, she stated no, she did not have on pants or shoes. She stated she was in her bare feet. Interview on 09/11/24 at 1:00 P.M. with STNA #518 revealed she worked the night of 08/26/24 and last saw Resident #197 at approximately 1:00 A.M. when Resident #197 was attempting to walk and could not redirect the resident to sit down in her wheelchair, so she had her sit in the activity room on the 1400 hall. She stated the resident had on a brief and a shirt but no pants or shoes, she stated she then left the unit and went to the laundry room for approximately ten minutes and when she returned the resident had fallen and was injured. (The fall occurred between 1:30 A.M. and 1:40 A.M., but she stated she was only gone for 10 minutes). She did not state why she left the resident in the common area with no pants or shoes on. Interview on 09/12/24 at 10:46 A.M. with RN #621 revealed she was on duty and assigned to the 1400 hall the night of 08/26/24 when Resident #197 fell. She stated she does not recall where she was or where the aide was when the resident fell. She could not recall the name of the STNA working on the unit. She could not recall if the resident was in her wheelchair or in a regular chair or if the resident took her medications that night. She could not recall the time of the fall. She stated after she called 911, she sent the Director of Nursing (DON) a text message stating that the resident was sent to the hospital. She stated she notified the family but does not know who she spoke too. RN #621 was unable to state why she documented she saw resident #197 five minutes before the fall as noted in the nursing progress note associated with the incident. Interview on 09/12/24 at 10:59 A.M. with Licensed Practical Nurse (LPN) #593 revealed she was scheduled on the 1300 unit on 08/26/24 and was notified by Resident #74 there was a fall on the 1400 unit, and he could not find the nurse or aide, and Resident #197 needed assistance. She stated she was unsure of the time and printed the paperwork needed to send the resident to the hospital and showed the emergency medical technicians (EMTs) to Resident #197, and at this point, the EMTs took over care. Interview on 09/16/24 at 10:30 A.M. with the DON revealed she did receive a text message the night of 08/26/24 informing her Resident #197 was going to the hospital for injuries from a fall. She stated she did not know any other information until the next day. When asked what fall interventions were implemented after each of Resident #197's falls, she provided a list stating for the fall on 05/05/24 the intervention was for PT and OT to evaluate and treat as necessary; the fall on 05/20/24 staff were to encourage resident to lay down on couch or bed when falling asleep in chair; the fall on 06/17/24; the resident was sent to the hospital with no new fall prevention interventions implemented; fall on 06/27/24 referred to therapy for strengthening; and for the fall on 08/26/24 the resident was sent to the emergency room. She confirmed at this time the care plan was not updated after each fall, and proper fall prevention interventions were not in place. Investigations were completed with each fall; however, they did not conclude what the root cause of each fall, including the fall on 08/26/24. Interview on 09/16/24 at 1:41 P.M. with Resident #197's daughter revealed she had asked facility staff to put different fall interventions in place (specific interventions not provided); however, the daughter indicated none ever were. The resident's daughter revealed she was not notified of fall on 08/26/24 until the next morning. 2. Review of the medical record for Resident #61 revealed an admission date of 10/28/20. Diagnoses included hypothyroidism, essential primary hypertension, hyperlipidemia, major depressive disorder, adjustment disorder, and dementia Review of the quarterly MDS assessment dated [DATE] revealed Resident #61 was severely cognitively impaired. Resident #61 was independent with eating and personal hygiene, required supervision or touching assistance with oral hygiene, lower body dressing, and putting on and taking off footwear, required partial to moderate assistance with toileting and upper body dressing, and was dependent on for shower/bathing. Resident #61 was frequently incontinent of bowel and bladder. Review of the care plan dated 10/29/20 revealed Resident #61 was at increased risk for falls related to history of falling at home, decreased mobility and endurance, and Resident #61 had an actual fall at the facility. Review of the facility provided incident and accident log from 09/01/23 to 09/09/24 revealed Resident #61 fell on [DATE], 01/06/24, and 06/07/24 which resulted in a major injury. Review of assessments for Resident #61 revealed last Fall Risk Review was completed on 01/06/24 and was identified as a moderate risk for falling. Interview on 09/11/24 at 4:30 P.M. with the DON revealed fall assessments should be done quarterly and annually. The DON confirmed no fall risk assessments were completed since 01/06/24 for Resident #61. Review of the facility policy Fall Risk Assessment, dated 03/18, revealed the nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. Review of the facility policy titled Falls-Clinical Protocol, last revised March 2018, revealed with each fall the facility was to identify the cause of the fall, identify any injury, notify the physician, family and supervisor, implement appropriate fall interventions, monitor or continue with follow-up after each fall.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, local police department call detail report, self-reported incident (SRI) review, review of prehospital care report summary, emergency department (ED) provider note, and facility policy review the facility failed to develop and implement an effective and individualized pain management program for Resident #147 following a significant change in condition resulting in severe pain that was not treated timely. This affected one resident (#147) of three residents reviewed for pain. The facility census was 102. Actual Harm occurred on 09/04/24 at 3:42 P.M. when Resident #147 notified staff repeatedly that she was having severe pain in her right knee and staff failed to thoroughly assess the resident, failed to notify the physician, and failed to administer pain medication resulting in the resident calling the local police for help three times (at 5:50 P.M., 5:56 P.M., and 6:59 P.M.). Local police subsequently sent an ambulance to the facility. Resident #147 was transferred to the local hospital where x-ray results revealed she had an acute fracture of the distal right femur, the fracture was slightly angulated and comminuted (broken into many pieces), and she had right knee soft tissue swelling and joint effusion. Findings include: Review of Resident #147's medical record revealed an admission date of 08/17/12 and a reentry date of 07/09/24. Diagnoses included unspecified fracture of the right ilium, sequela, fracture of sacrum, osteonecrosis of the right femur (death of bone tissue due to lack of blood supply), dependence on renal dialysis, and type two diabetes mellitus. Review of Resident #147's care plan dated 07/10/24 and revised on 08/27/24 included Resident #147 had pain related to a sacral fracture and right femur osteonecrosis. Resident #147 would verbalize adequate relief of pain or the ability to cope with incompletely relieved pain though the review date. Interventions included to administer analgesics per orders and give a half hour before treatments or care; anticipate Resident #147's need for pain relief and respond immediately to any complaint of pain; monitor and document for probable cause of each pain episode; monitor, record pain characteristics for example sharp, burning, and the pain severity on a scale of zero to ten, anatomical location, duration, aggravating factors and relieving factors; monitor, record and report to nurse any signs and symptoms of non-verbal pain; monitor, record, report to the nurse resident complaints of pain or requests for pain treatment; notify the physician if interventions were unsuccessful or if current complaint is a significant change from residents past experience of pain. Review of an (admission) Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #147 was cognitively intact. The assessment revealed Resident #147 was dependent (on staff) for toileting hygiene, bathing and lower body dressing, and required partial to moderate assistance for chair, bed-to-chair transfer. Resident #147 was occasionally incontinent of urine and always continent of bowel. Resident #147 experienced pain frequently in the last five days, pain made it hard for her to sleep at night, and she frequently limited her participation in rehabilitation therapy sessions due to pain. Resident #147 described her worst pain over the last five days as moderate. Review of Resident #147's physician orders dated 09/03/24 revealed hemodialysis Monday through Friday, with Dialyze Direct (in-facility hemodialysis treatment center) via right chest tesio (a twin catheter system that can be inserted into the chest through the internal jugular vein). Review of Resident #147's hemodialysis treatment information dated 09/04/24 included at 3:42 P.M. Resident #147 complained of a pain level of seven out of ten, ten being the worst pain, in her right knee. Further review revealed on 09/04/24 at 5:10 P.M. Resident #147 complained of pain rated a ten out of ten, ten being the worst pain, in her right knee. There was no documented evidence that Resident #147 was assessed, the physician was notified and/or pain medication was administered. Review of Resident #147's progress notes, physician orders and Medication Administration Record (MAR) from 09/04/24 at 3:42 P.M. through 09/04/24 at 5:10 P.M. revealed no documented evidence Resident #147 was assessed for pain by the facility nurses while she was in the on-site facility hemodialysis. There was no evidence Resident #147's physician was notified she was having pain, no documented evidence her pain level was rated on a scale of zero to ten, ten being the worst pain, and no evidence she had pain medication ordered and administered. Review of Resident #147's progress note dated 09/04/24 at 5:12 P.M. written by Licensed Practical Nurse (LPN) #589 included Resident #147 was having increased behaviors towards the staff and called a State Tested Nursing Assistant (STNA) an inappropriate name. Resident #147 activated her call light multiple times and stated she transferred herself on and off the toilet by herself. Resident #147 sat in the common area, then was assisted back to her room and into her bed by the STNAs using a mechanical lift. Resident #147 had no concerns or complaints. The local police department called and told LPN #589 that Resident #147 called them and stated she fell and needed an ambulance because her knee hurt. LPN #589 explained to the police Resident #147 recently returned to the facility after a hospital stay for a toe amputation. The local police decided not to dispatch police to the facility. A registered nurse (RN) was notified and went with LPN #589 to assess Resident #147 and look at her knee. No areas of redness swelling were noted, and Resident #147 was resting in bed and her dinner tray was in the room. There was no documented evidence that Resident #147 was assessed for pain or was asked to rate her pain using a pain scale of zero to ten, ten being the worst pain. Review of Resident #147's progress note dated 09/04/24 at 5:26 P.M. written by RN #629 revealed Resident #147 stated we broke her and my knee is killing me. Resident #147's skin was intact and no noticeable bruising was noted during the assessment. There was no documented evidence Resident #147 was assessed for pain or asked what her pain level was using a scale of zero to ten, ten being the worst pain. Review of Resident #147's local police department call detail report dated 09/04/24 between 5:50 P.M. and 5:56 P.M. included Resident #147 stated two aides hurt her, and she needed help. At 5:56 P.M. the report stated this was the second call from Resident #147, the facility was contacted, the police were told an order for an x-ray was obtained (ordered on 09/04/24 at 7:24 P.M.), and Resident #147 did not have visible injuries. The facility stated they did not want anyone sent right now, and the police department representative told them they would call back if Resident #147 continued to call. Review of Resident #147's local police department call detail report dated 09/04/24 at 6:59 P.M. included Resident #147 was calling again and saying she needed help. The dispatcher called the facility again and spoke to LPN #596 and advised her she was sending a squad. The ambulance company was notified and was enroute. Review of Resident #147's physician orders dated 09/04/24 at 7:15 P.M. revealed a new order for Xanax (anti-anxiety) oral tablet 0.5 milligrams (mg), one tablet by mouth every eight hours as needed for anxiety and record unsuccessful medication in the progress notes. Review of Resident #147's progress note dated 09/04/24 at 7:20 P.M. revealed the police contacted the facility and stated Resident #147 called again and an ambulance would be sent due to multiple calls being made (from the resident). Resident #147 was alert and oriented, vital signs were within normal limits, range of motion was within normal limits. Emergency medical technicians (EMTs) arrived at this time. Review of Resident #147's physician orders dated 09/04/24 at 7:24 P.M. revealed an order for an x-ray to the right knee due to pain. Review of Resident #147's progress note and MAR dated 09/04/24 from 5:10 P.M. through 7:32 P.M. when she was transported via ambulance to the local ED revealed no documented evidence Resident #147 was administered pain medication, or her pain was comprehensively assessed. Review of Resident #147's pre-hospital care report summary dated 09/04/24 included a call was received at 7:02 P.M. and they were on scene at 7:19 P.M. Resident #147's nurse stated she did not know anything about what happened with Resident #147 because it happened on day shift, and when she arrived for work, she was told Resident #147 called the police three times because she said the staff at the facility bumped her right knee and bent it the wrong way, on the mechanical lift during a transfer, causing severe pain. Resident #147 also reported she fell out of bed onto the floor, when she was trying to walk to the bathroom. The staff reported Resident #147 was unable to walk and if she had fallen, she would not be able to get herself off the floor. The facility staff stated none of this happened, and the physician was contacted for a portable x-ray and to restart Resident #147's Xanax (anti-anxiety) medication. The nurse thought all this was related to behavior problems Resident #147 had in the past. Resident #147 refused the portable x-ray because the images would be crappy and not show anything and insisted on being transported to the hospital for x-rays and treatment. Resident #147's right knee, where she reported having most of her pain was examined and found to be very swollen and painful. Resident #147 also complained of pain in her foot and ankle. EMS administered Fentanyl (narcotic pain reliever) to Resident #147 with no improvement in her pain and she was crying and sobbing, and she was transported to the local hospital and her care was transferred to the charge nurse at the hospital. Review of Resident #147's Emergency Department (ED) provider notes dated 09/04/24 through 09/05/24 included on 09/04/24 at 9:25 P.M. Resident #147's x-ray results revealed she had an acute fracture of the distal right femur, fracture was slightly angulated and comminuted, and she had right knee soft tissue swelling and joint effusion. Resident #147 presented to the ED for knee pain. Upon arrival to the ED, Resident #147 was hypertensive with otherwise stable vital signs. On exam Resident #147 had obvious swelling noted to the right knee with severe pain to palpation. Due to Resident #147's severe pain she was administered intravenous Morphine (narcotic pain reliever) and Zofran (antiemetic) for nausea. Review of Resident #147's after visit summary for the hospital stay, 09/05/24 through 09/06/24, included Resident #147 had a closed fracture of the right femur, unspecified fracture morphology (number of fragments and fracture lines), unspecified portion of the femur. Review of facility self-reported incident (SRI) tracking number 251548 dated 09/05/24 at 11:48 A.M. revealed the facility reported an allegation of staff-to-resident physical abuse involving Resident #147. The staff, including the Administrator and Director of Nursing (DON), became aware of the incident on 09/05/24 at approximately 9:00 A.M. (the nurses were aware on 09/04/24). The SRI included Resident #147 did not provide meaningful information when she was interviewed, and was care planned for making false allegations (not included in the care plan until 09/04/24), behaviors, refusing care, and dialysis. Resident #147 was cognitively intact with confusion. Resident #147 frequently yelled out, moaned, and was verbally aggressive with staff. On the evening of 09/03/24 Resident #147 returned from the hospital at approximately 6:00 P.M. Upon entering the room to answer her call light, an unidentified STNA found Resident #147 had transferred herself into her wheelchair and then onto the toilet by herself. The STNAs assisted Resident #147 to her wheelchair and then she was transferred to her bed. On 09/04/24, Resident #147 had onsite dialysis at the facility and had no issues in dialysis (Resident #147 complained of pain at a seven out of ten pain while in dialysis). After dialysis, Resident #147 was in the common area and at 5:00 P.M. per her request she was transferred into her bed and voiced no concerns (she told staff she had pain). Later that evening the facility received a call from the police stating Resident #147 called and stated she was in pain. An unidentified nurse went into Resident #147's room, and Resident #147 complained of right leg pain. The nurse noted no swelling or discoloration (the ambulance personnel found her right knee swollen and painful). Resident #147 did not have orders for pain medication, the on-call nurse, and physician were notified, and new orders for pain medication (no pain medication was ordered; Xanax was ordered on 09/04/24 after the resident was transferred to the ED), and an x-ray was to be completed. An unidentified aide entered Resident #147's room to collect her tray and check on Resident #147, found her crying, she stated she was in pain and called 911. The police contacted the facility stating Resident #147 called them three times, and they were sending an ambulance to the facility. Resident #147 was yelling and told the nurse she needed to go to the hospital because her leg was broken. Resident #147 was told the facility had an order for an x-ray, and Resident #147 was insistent and screamed she wanted to go to the hospital. On 09/05/24, the facility was made aware via the hospital that Resident #147 had a fractured femur and reported she was dropped or fell from the mechanical lift. An SRI was initiated, and an investigation began. Resident #147 was not witnessed to have a fall, and not witnessed to have a fall from the mechanical lift. Resident #147 told the social worker she fell while transferring herself in the bathroom. Resident #147 had a complex medical history, idiopathic aseptic necrosis, an unhealing fractured pelvis, Resident #147's bones were fragile, and the bones could fracture with the slightest movement. The fracture could have happened anytime Resident #147 moved her leg, Resident #147 transferred herself, or possibly from the movement that occurred naturally during mechanical lifts. Resident #147 called 911 herself to be sent out to the hospital, and an investigation was immediately started (the investigation was not initiated until 09/05/24 at 11:48 A.M). The allegation was unsubstantiated. Review of a witness statement dated 09/04/24 and written by STNA #524 stated, on 09/04/24 she entered Resident #147's room to collect her dinner tray, and Resident #147 was crying. Resident #147 stated she was crying and saying she could not eat because she was in pain, someone pushed her too hard, and she called 911. Review of a witness statement dated 09/05/24 and written by LPN #596 stated, on 09/04/24 the police called and told her Resident #147 called 911, this was the third call today, and the police were sending an ambulance. LPN #596 found Resident #147 crying when she entered her room, and said she wanted to leave and go to the hospital. LPN #596 asked Resident #147 why, and she said, my leg is broke, they were rough with me, I want to go, I want to go. The ambulance arrived shortly after and the DON and LPN #596's supervisor were notified. LPN #596 stated, Resident #147 did not have a prescription for pain medication because her pain medication was discontinued at the hospital prior to her discharge. LPN #596's unidentified supervisor told her Resident #147 had an order for Xanax and an order for an x-ray. Resident #147 refused the x-ray ordered to be done at the facility and left the facility via the ambulance on 09/04/24 at approximately 7:32 P.M. Review of Resident #147's progress note dated 09/07/24 at 2:11 P.M. and written by Medical Director #640 included Resident #147 had concerns including leg pain (was transferred from the local ED for a femur fracture) and had a knee immobilizer to her right leg. Resident #147 was at the acute care facility and had excruciating pain in the right leg and was recognized to have a right distal femur fracture. Resident #147 was offered pain control, nonoperative management, and a brace. Resident #147 had been in and out of acute care facilities multiple times. Interview on 09/16/24 at 4:48 P.M. of LPN #589 revealed on 09/04/24 she spoke to the police one time about Resident #147, and Resident #147 told the police she was hurt by the Hoyer (mechanical lift) when they got her up in the morning. LPN #589 stated the police told her Resident #147 needed to go to the hospital and called two more times on the next shift regarding Resident #147. LPN #589 stated she went with RN #629 to evaluate Resident #147 for cuts, bumps, bruises, swelling, redness because she was complaining of knee pain. LPN #589 stated she did not remember if Resident #147 was asked how bad her pain was, it was towards the end of the shift, and the physician was not notified Resident #147 was having right knee pain. Resident #147 was lying in bed, they moved her arms and legs and checked for redness inside her legs. LPN #589 stated Resident #147 stated she needed to go to the hospital because her knee hurt and said it was bumped when they were getting her up in the morning, but she did not identify any staff. LPN #589 indicated Resident #147 told them that was why she called the police. LPN #589 stated STNA #555 took care of Resident #147 on 09/04/24 and said Resident #147 did not get hurt while they were using the mechanical lift to transfer her. Resident #147's narcotic was discontinued at the hospital, and she did not have anything ordered for pain when she said her knee hurt. LPN #589 stated she did not call the physician, and she was not sure if anyone else did. LPN #589 stated her shift was over, and she left the facility shortly after Resident #147 was evaluated. Interview on 09/17/24 at 9:33 A.M. of STNA #529 revealed on 09/04/24 she helped STNA #555 transfer Resident #147 from the wheelchair to her bed, using the mechanical lift, and Resident #147 did not fall or slip and hit her knee, nor did her knee get caught on the bar. Interview on 09/17/24 at 10:42 A.M. of Resident #147 revealed I broke my femur at the facility when two aides were transferring her. Resident #147 stated the mechanical lift kind of collapsed and I slipped down and hit my femur but she could not remember which aides were transferring her. Resident #147 stated she told a nurse it happened but could not remember which nurse because she stated she was in so much pain. Interview on 09/17/24 at 10:57 A.M. of STNA #540 revealed Resident #147 had already hit her knee and stated her knee hurt when she assisted STNA #555 with Resident #147's transfer on 09/04/24. STNA #540 stated she told a nurse Resident #147 was complaining her knee hurt, but the nurses already knew because Resident #147 was complaining loudly about it in the common areas when she was being transported, and everyone could hear her say it. Interview on 09/17/24 at 12:02 P.M. of RN #629 revealed (on 09/04/24) she answered Resident #147's call light and Resident #147 stated she was in pain. RN #629 stated LPN #589 was Resident #147's nurse and the two of them checked Resident #147 for bruising, redness, cuts, but nothing was identified. RN #629 stated Resident #147 could not give them a straight answer about what happened and said she was dropped from the mechanical lift, and she also stated she fell in the bathroom. RN #629 stated Resident #147 called the police. RN #629 stated Resident #147 was in a lot of pain, was crying, and she did not remember if Resident #147 was asked to rate her pain on a scale of zero to ten. RN #629 stated she did not give Resident #147 pain medication or call the physician for an order for pain medication because she was not the resident's assigned nurse. RN #629 stated the physician was notified, an x-ray was ordered, and her shift was over, the resident left the facility and she did not know what happened after that. Interview on 09/17/24 at 3:30 P.M. of STNA #555 revealed she provided care for Resident #147 on 09/04/24 and Resident #147 did not tell her she had pain in her right knee, and there was no fall from the mechanical lift. Resident #147's leg never hit the mechanical lift (unable to give times). STNA #555 stated later in the day, Resident #147 put her call light on and said her knee hurt, and she called the police a few times and was transported to the hospital. STNA #555 stated Resident #147 did not tell her how bad the pain was, and she had behaviors. STNA #555 stated Resident #147 was not bumped or dropped during her transfers using the mechanical lift. Interview on 09/18/24 at 7:56 A.M. of Dialysis Nurse #644 revealed on 09/04/24 Resident #147 was upset and said her right leg was bumped when the girls were moving her. Dialysis Nurse #644 confirmed Resident #147 had pain rated a seven out of ten on a pain scale of zero to ten, ten being the worst pain, during dialysis and had complaints of pain at a ten out of ten when dialysis was finished on 09/04/24. Dialysis Nurse #644 stated the dialysis nurses did not give pain medication, but stated she told the facility nurses about Resident #147's complaints of severe pain. Dialysis Nurse #644 stated she did not document that she told the nurses about the pain, and stated she could not remember who she told. Review of the facility policy titled Administering Pain Medications, revised 03/2020, included the purpose of the procedure was to provide guidelines for assessing the resident's level of pain prior to administering analgesic pain medication. Pain management was a multidisciplinary care process that included the following: assessing the potential for pain, recognizing the presence of pain, identifying the characteristics of pain, addressing the underlying causes of the pain, developing and implementing approaches to pain management, monitoring the effectiveness of interventions and modifying approaches as necessary. Comprehensive pain assessments were conducted upon admission to the facility, at the quarterly review, whenever there was a significant change in condition, and when there was onset of new pain or worsening of existing pain. Acute pain (or significant worsening of chronic pain) should be assessed every 30 to 60 minutes after the onset and reassessed as indicated until relief was obtained. Document the following in the resident's medical record: results of the pain assessment, medication, dose, route of administration, results of the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #10's medical record revealed an admission date of 10/18/18 with diagnoses including hyperlipidemia, type two diabetes mellitus without complications and moderate protein-calorie malnutrition. Review of Resident #10's physician orders dated, 11/30/21, revealed orders to encourage and assist to turn and reposition frequently with rounds and as needed. Review of Resident #10's Braden Scale assessment dated , 12/22/21, revealed Resident #10 was at moderate risk for developing pressure ulcers and injuries. There were no further Braden Scale assessments documented from 12/22/21 through 05/25/22. Review of Resident #10's medical record did not reveal documentation weekly skin checks were completed from 03/15/22 through 05/25/22. Review of Resident #10's Braden Scale assessment dated , 05/25/22, revealed Resident #10 was at high risk for developing pressure ulcers and injuries. Review of Resident #10's progress notes dated, 05/25/22, included while State Tested Nursing Assistant (STNA) was completing a two-hour check and change for Resident #10 an open area was noted to the right buttock. The STNA reported the open area to the nurse and measurements were 3.0 centimeter (cm) by 0.5 cm of the pressure area on mid right buttock. The area had uneven edges, no edema or redness noted. Area cleansed with normal saline solution, collagen with border foam for protection. Resident #10 would be placed on the list to be evaluated per the wound physician. All entities notified. Review of Resident #10's Wound Assessment and Plan dated, 05/26/22, completed by Wound Physician (WP) #802 revealed this was the initial evaluation and Resident #10 had a right central left buttock Stage III pressure ulcer. The measurements were length 6.3 centimeters (cm), width of 7.1 cm, and depth was 0.3 cm. The wound bed composition was 90 percent epthelial and 10 percent granulation. Treatment orders were to cleanse wound with normal saline or sterile water, apply collagen, and cover with bordered foam dressing daily and as needed. Preventative wound recommendations were to use a low air loss mattress (LAL) and a Roho (decrease amount of pressure on sitting area) cushion to chair (related to stage three pressure injury). The assessment further indicated to unload area and side to side turning per facility protocol. Review of Resident #10's physician orders dated, 05/26/22, revealed an order to cleanse pressure area on right buttock with normal saline solution, apply collagen, cover with bordered foam daily and as needed. There were no orders documented for a LAL mattress or Roho cushion to chair. Further review of Resident #10's physician orders from 05/26/22 through 11/30/22 revealed a LAL mattress was not ordered until 10/13/22, and there were no orders documented for a Roho cushion. Review of Resident #10's progress notes from 05/26/22 through 10/13/22 did not reveal documentation of a LAL mattress. Review of Resident #10's dietary progress notes and nutrition assessments from 05/25/22 through 07/21/22 revealed there were no dietary notes or nutritional assessments. Further review of Resident #10's dietary progress notes and nutritional assessments revealed there were no recommendations related to Resident #10's pressure ulcer from 05/25/22 through 07/21/22. Review of Resident #10's Wound Assessment and Plan dated, 07/21/22, revealed Resident #10 had a right central left buttock Stage III pressure injury. The length was 3.6 cm, width of 4.0 cm, and the depth was 0.2 cm. The wound bed was 95 percent epthelial tissue and five percent granulation tissue. Review of Resident #10's dietary progress notes dated, 07/21/22, revealed Resident #10's skin was intact and there was no documentation related to Resident #10's right central left buttock Stage III pressure ulcer. There were no further dietary progress notes or nutritional assessments from 07/21/22 through 10/03/22. Preventative wound recommendations documented included to use a LAL mattress and a Roho cushion. Review of Resident #10's care plan dated, 08/07/22 revealed Resident #10 was at increased risk for further impairment to skin integrity related to incontinence, impaired mobility, diabetes mellitus, lymphedema, history of pressure area to left buttock and sacrum. Resident #10 had a left buttock wound that healed on 01/20/22, a sacrum wound that healed 03/10/22 and on 05/25/22 a right central left buttock pressure ulcer was identified. The care plan revealed Resident #10 would be free of complications related to skin integrity through the review date. Interventions included to administer treatments per physician orders; encourage and assist to turn and reposition with rounds and as needed; encourage good nutrition and hydration in order to promote healthier skin; monitor, document location, size, and treatment of skin injury, report abnormalities, failure to heal, signs and symptoms of infection, maceration etcetera to physician; pressure redistribution cushion to chair and pressure redistribution mattress to bed. Review of Resident #10's Wound Assessment and Plan dated, 09/29/22, revealed Resident #10 had a right central left buttock Stage III pressure injury (onset date 05/25/22). The measurements were a length of 6.7 cm, width of 6.7 cm, and the depth was 0.2 cm. The wound bed was 97 percent epithelial tissue and three percent granulation. Review of Resident #10's Annual Nutritional assessment dated , 10/03/22, revealed no documentation related to Resident #10's right central left buttock stage three pressure ulcer. The assessment stated Resident #10 had no skin issues and no skin breakdown, therefore nutritional interventions were not reviewed for wound healing. Review of Resident #10's Annual Minimum Data Set (MDS) 3.0 assessment dated , 10/07/22, included Resident #10 was cognitively intact. Review of Resident 10's Quarterly MDS assessment dated [DATE] revealed resident required extensive assistance of one staff member for bed mobility and toilet use, had total dependence on two staff members for transfers, was always incontinent of urine and bowel, and had a stage three pressure ulcer. Review of Resident #10's physician orders dated, 10/13/22, revealed LAL mattress with perimeter overlay to bed at all times, check for placement, function, and comfort every shift. Review of Resident #10's Wound Assessment and Plan dated, 11/17/22, revealed Resident #10's right central left buttock pressure ulcer was healed. The assessment further stated Resident #10's pressure ulcer was at risk for reopening due to limited mobility, moisture, urine, stool. Observation on 11/29/22 at 1:59 P.M. of Resident #10 revealed she was lying in bed on her back with the head of the bed elevated about 45 degrees. Interview on 11/30/22 at 12:36 P.M. with Licensed Practical Nurse/Unit Manager/Wound Nurse (LPN/UM/WN) #801 confirmed Resident #10's pressure ulcer to her right central left buttock was found on 05/25/22. LPN/UM/WN #801 stated a treatment was initiated on 05/25/22 until Wound Physician (WP) #802 was able to evaluate the wound. Interview on 11/30/22 at 2:48 P.M. with the Director of Nursing (DON) revealed skin checks were to completed weekly, and documented in the residents medical record by the nurses. DON confirmed they were not completed as required for Resident #10. Observation on 12/01/22 at 10:20 A.M. with WP #802 and LPN/UM/WN #801 revealed Resident #10's sacral area and buttock were reddened and no open areas were noted. WP #802 stated the wound was healed to the right central left buttock. Interview on 12/01/22 at 3:00 P.M. with LPN/UM/WN #801 revealed she did not remember if Resident #10 had a Low Air Loss (LAL) mattress before 10/13/22 when the order was placed. LPN/UM/WN #801 stated WP #802 made the decision if a resident needed a LAL mattress. Interview on 12/01/22 at 3:10 P.M. with WP #802 indicated he usually ordered a LAL mattress for a resident with a stage three or four pressure ulcer. WP #802 stated if a resident's pressure ulcer was progressing before it reached a stage three or four then he would go to the next level and order a LAL mattress and roho cushion. Observation on 12/01/22 at 4:46 P. M and on 12/05/22 at 8:52 A.M., 10:05 A.M., and 11:57 A.M. revealed Resident #10 lying in bed and was positioned on her back. There was no observation of staff members repositioning or encouraging her to reposition. Interview on 12/05/22 at 11:55 A.M. with State Tested Nursing Assistant (STNA) #970 revealed today was a very busy day, and the staff was working hard to take care of residents. STNA #970 stated she knew Resident #10 was lying in her bed all morning in the same position, and did not get repositioned every two hours as she should on this day. STNA #970 stated what can I say, we are doing our best. Review of Resident #10's electronic record dated, 12/05/22, revealed there was no documentation by STNA staff Resident #10 was turned and repositioned. Interview on 12/05/22 at 2:49 P.M. with Registered Dietician (RD) #954 revealed he was contracted by the facility and briefly helped out in 06/2022 and again in 11/2022. RD #954 stated he would not necessarily put a note in the residents records regarding pressure ulcers because he was doing as needed work, and was not in facility reviewing weekly wound reports. RD #954 stated he worked remotely and had not been in the facility at all. RD #954 stated he worked approximately six to eight hours a week in June and his main task was completing assessments and care planning. RD #954 stated he would look to see if a resident had a pressure ulcer and make recommendations if he felt it was appropriate. RD #954 did not remember if Resident #10 had a pressure ulcer and he did not have his computer to check. Interview on 12/05/22 at 3:23 P.M. with the Administrator revealed RD #958 no longer worked for the facility and was not available to interview. Interview on 12/07/22 at 3:42 P.M. with RD #956 revealed she was hired by the facility approximately a week ago. RD #956 stated if a resident developed a new pressure ulcer or injury a nutritional assessment should be completed and there should be an assessment in the resident's medical record once a month regarding the pressure ulcer. Review of the facility policy titled Pressure Ulcer Risk Assessment, revised 09/2013, included pressure ulcers were a serious skin condition for the resident. Routinely assess and document the condition of the resident's skin per facility wound and skin care program for any signs and symptoms of irritation or breakdown. Immediately report any signs of a developing pressure ulcer to the supervisor. A pressure ulcer risk assessment would be completed upon admission, and then weekly times three weeks, with each additional assessment, quarterly, annually and with significant changes. Skin would be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated. Nurses would conduct skin assessments at least weekly to identify changes. Because a resident at risk can develop a pressure ulcer within two to six hours of the onset of pressure, the at-risk resident needed to be identified and have interventions implemented promptly to attempt to prevent pressure ulcers. 3. Review of Resident #9's medical record revealed an admission date of 02/26/22 and diagnoses included osteitis deformans (superficial inflammation of the cortex of the bone) of other bones, severe protein-calorie malnutrition, and obstructive and reflux uropathy. Review of Resident #9's Quarterly Minimum Data Set (MDS) 3.0 assessment dated , 11/25/22, revealed Resident #9 had moderate cognitive impairment. Resident #9 required extensive assistance of two staff members for bed mobility, transfers, and required extensive assistance of one staff member for toilet use. Resident #9 was always incontinent of urine and bowel. Resident #9 did not have a pressure ulcer or injury. Review of Resident #9's care plan 09/19/22 included Resident #9 had the potential for impairment to skin integrity related to impaired mobility, incontinence. Resident #9 had a stage one pressure area to left central right buttock and sacrum. Resident #9 would be free from complications related to skin integrity through the review date. Interventions included to encourage and assist to turn and reposition frequently with rounds and as needed; monitor and document location, size and treatment of skin injury, report abnormalities, failure to heal, maceration etcetera to the physician. Review of Resident #9's medical record from 10/15/22 through 11/17/22 did not reveal weekly skin assessments were completed. Review of Resident #9's Braden Scale For Predicting Pressure Sore Risk dated, 11/09/22, revealed Resident #9 was at moderate risk for developing pressure ulcer, injuries. Review of Resident #9's Wound Assessment and Plan dated, 11/17/22, included Resident #9's left central right sacrum butt wound was healed. The assessment revealed the wound was at risk for reopening due to limited mobility. The assessment further revealed to cleanse the area with saline, use skin prep and overlay a bordered foam dressing on Tuesday, Thursday, Saturday and as needed for one more week. The assessment stated to protect and unload the area. Observation on 11/29/22 at 9:09 A.M. of State Tested Nursing Assistant (STNA) #803 providing incontinence care for Resident #9 revealed there was no dressing on her sacrum. STNA #803 confirmed there was no dressing over Resident #9's sacral area and stated the nurses did not always replace dressings if they fell off during the night shift. Resident #9 had a large soft brown bowel movement and observation of her sacrum revealed the area was reddened, and an open area was noted. After surveyor intervention Registered Nurse (RN) #800 entered Resident #9's room, and confirmed there was a small open area with no dressing on Resident #9's sacral area. RN #800 cleansed the area with normal saline, applied collagen and a gauze border dressing. Interview on 11/30/22 at 2:48 P.M. with the Director of Nursing revealed skin checks were to completed weekly, and documented in the residents medical record by the nurses. DON confirmed they were not completed as required for Resident #9. Interview on 12/01/22 at 8:10 A.M. with LPN/UM/WN #801 revealed Resident #9's pressure ulcer was healed on 11/17/22 and WP #802 recommended the dressings continue for seven days after the wound was healed for preventative care. LPN/UM/WN #801 stated the dressing change orders were not discontinued after seven days and she would make sure she made the change in Resident #9's medical record to discontinue the dressing change. After surveyor intervention LPN/UM/WN #801 stated she would place Resident #9 on WP #802's schedule today. Observation on 12/01/22 at 9:47 A.M. of Resident #9 with WP #802 and LPN/UM/WN #801 revealed Resident #9 was lying on her back in bed. LPN/UM/WN #801 positioned Resident #9 on her side and removed her incontinence brief revealing it was wet with urine and a small bowel movement. Observation of Resident #9's sacral area revealed it was reddened and she had multiple open areas. The wound bed was pink, and in addition to the open areas Resident #9 had another small circular open area on the sacrum. LPN/UM/WN #801 applied skin prep and border foam to Resident #9's sacrum. LPN/UM/WN #801 stated she would have an STNA change Resident #9's incontinence brief and provide incontinence care for the bowel movement and urine. Review of Resident #9's Wound Assessment and Plan dated, 12/01/22, revealed the wound visit was an initial visit, the wound onset date was 12/01/22 and Resident #9 had a stage two pressure injury to the sacrum, buttock. The wound measurement was length 2.9 cm, width 0.4 cm width, and 0.1 cm depth. The periwound was within normal limits with minimal exudate (a mass of cells and fluid that has seeped out of blood vessels, or an organ, especially in inflammation) and erythema (superficial reddening of the skin) was noted. Treatment orders included to protect area and unload area. Review of Resident #9's physician orders dated, 12/01/22, revealed cleanse sacrum buttock with normal saline, apply skin prep to area, and overlay bordered foam dressing every day shift and as needed. Observation on 12/01/22 at 2:49 P.M., 4:46 P.M., and on 12/05/22 at 8:51 A.M., 10:04 A.M., and 11:54 A.M. revealed Resident #9 was lying on her back. There were no staff present repositioning Resident #9 or encouraging her to change position. Interview on 12/05/22 at 11:55 A.M. with State Tested Nursing Assistant (STNA) #970 revealed today was a very busy day, and the staff was working hard to take care of residents. STNA #970 stated she knew Resident #9 was lying in her bed all morning in the same position, and did not get repositioned every two hours as she should. STNA #970 stated what can I say, we are doing our best. 4. Review of Resident #81's medical record revealed an admission date of 08/25/22 and diagnoses included asthma, muscle weakness, and non-Hodgkin lymphoma. Resident #81 was discharged to another facility on 12/02/22. Review of Resident #81's physician orders dated, 08/25/22, revealed to complete a Braden Assessment every week for four weeks, every night shift, every Sunday for 21 days. Review of Resident #81's admission Minimum Data Set (MDS) 3.0 assessment dated , 09/01/22 revealed Resident #81 was cognitively intact and required extensive assistance of two staff for bed mobility and toilet use, and total dependence of two staff for transfers. Resident #81 had a stage two pressure ulcer. Review of Resident #81's Wound Assessment and Plan dated, 09/01/22, included Resident #81 had a stage two pressure ulcer on his coccyx which had a wound onset date of 08/25/22. The wound measurements were a length of 4.3 cm, width of 2.4 cm and a depth of 0.1 cm. Treatment orders included to protect and unload the area. Review of Resident #81's Wound Assessment and plan dated, 09/15/22, included Resident #81's stage two pressure ulcer to his coccyx was healed, but was at risk for reopening due to limited mobility. Treatment orders were to use a bordered foam dressing every Tuesday, Thursday, Saturday and as needed for one week. Treatment orders included to protect and unload area. Review of Resident #81's Braden Scale for Predicting Pressure Sore Risk dated, 09/01/22, and 09/08/22, revealed Resident #81 was at low risk for developing a pressure ulcer. There were no further Braden Scale assessments documented from 09/08/22 through 12/02/22. Review of Resident #81's care plan dated, 09/14/22, included Resident #81 had a stage two pressure ulcer to the coccyx and was at further risk for breakdown due to decreased mobility and incontinence. Resident #81's area to his coccyx would respond to treatment and heal without complication through the review date. The remainder os skin integrity would be maintained through the next review. Interventions included to encourage and assist to turn and reposition during rounds and as needed; observe and document location, size and treatment of skin injury, report abnormalities to the physician. Review of Resident #81's physician orders dated, 09/15/22, revealed to cleanse coccyx with normal saline, apply skin prep, area overlay bordered foam dressing daily and as needed, every day shift every Tuesday, Thursday, and Saturday, and as needed for one week. Review of Resident #81's medical record from 09/22/22 through 11/16/22 did not reveal weekly skin checks were completed. Review of Resident #81's physician orders dated, 11/16/22, revealed weekly skin checks by licensed nurse Thursday night shift, every night shift, every Thursday for skin checks. Interview on 11/30/22 at 2:48 P.M. with the Director of Nursing revealed skin checks were to completed weekly, and documented in the residents medical record by the nurses. DON confirmed they were not completed as required for Resident #81. Interview on 12/01/22 at 8:10 A.M. with LPN/UM/WN/IP #801 revealed Resident #81's pressure ulcer was healed on 09/15/22 and WP #802 recommended the dressings continue for seven days after the wound was healed for preventative care. LPN/UM/WN #801 stated the dressing change orders were not discontinued after seven days and she would make sure she made the change in Resident #81's medical record to discontinue the dressing change. Observation on 12/01/22 at 10:06 A.M. of Resident #81 revealed he was lying in bed on his back. WP #802 and LPN/UM/WN/IP #801 removed a dressing dated 11/29/22. Observation of Resident #81's coccyx revealed a two inch by approximately one quarter inch dark reddish-purple area which did not blanche, and WP #802 stated pressure caused it. LPN/UM/WN/IP #801 used skin prep and placed a border dressing. After finishing with Resident #81's dressing LPN/UM/WN/IP #801 positioned him on his back. Review of Resident #81's Wound Assessment and Plan dated, 12/01/22, included this was an initial assessment and the wound onset date was 12/01/22. Resident #81 had a stage one pressure injury (intact skin reddened with no blanche) to his coccyx. The wound measurements were a length of 2.8 cm, width of 0.4 cm, and depth was not applicable. Treatment orders included to protect and unload the area. Observation on 12/01/22 at 12:10 P.M., 2:46 P.M. and 4:47 P.M. revealed Resident #81 was lying on back in bed. Interview on 12/01/22 at 3:11 P.M. with WP #802 indicated if Resident #81 was lying longer than two hours in the same position without offloading it could lead to a pressure injury or ulcer. WP #802 stated he usually ordered a LAL mattress when a pressure ulcer was a stage 3 or 4, or if he saw a progression of the pressure ulcer then he would order a LAL mattress. Review of the facility policy titled Pressure Ulcer Risk Assessment, revised 09/2013, included pressure ulcers were a serious skin condition for the resident. Routinely assess and document the condition of the resident's skin per facility wound and skin care program for any signs and symptoms of irritation or breakdown. Immediately report any signs of a developing pressure ulcer to the supervisor. A pressure ulcer risk assessment would be completed upon admission, and then weekly times three weeks, with each additional assessment, quarterly, annually and with significant changes. Skin would be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated. Nurses would conduct skin assessments at least weekly to identify changes. Because a resident at risk can develop a pressure ulcer within two to six hours of the onset of pressure, the at-risk resident needed to be identified and have interventions implemented promptly to attempt to prevent pressure ulcers. Based on observation, record review, review of facility policy and interview, the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention and treatment program to ensure interventions were initiated timely to prevent the development of pressure ulcers and/or to ensure adequate treatments were in place to promote healing. This affected four residents (Resident #9, #10, #20, and #81) of five residents reviewed for pressure ulcers. The facility census was 83. Actual Harm occurred on 12/01/22 when Resident #20, who was severely cognitively impaired, totally dependent on staff for activity of daily living care, was noted to have contractures and had a history of pressure ulcers to the coccyx was assessed to have a Stage III (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present) pressure ulcer to the coccyx without adequate evidence of interventions being in place to prevent the development of or identify the ulcer prior to being found as a Stage III. Actual Harm occurred on 05/25/22 when Resident #10 was assessed to have a Stage III pressure ulcer to the right central left buttock. The facility failed to identify the pressure ulcer prior to it being identified as a Stage III. Findings include: 1. Resident #20 was admitted to the facility on [DATE] with diagnoses including dysphasia following stroke, hemiplegia affecting left, non-dominant side, traumatic brain hemorrhage, malnutrition, kidney transplant status, and type II diabetes. Review of the annual Minimum Data Set (MDS) 3.0 assessment of 09/06/22 revealed the resident was severely cognitively impaired, had continuous inattention, was totally dependent on two staff for activities of daily living, was always incontinent of bowel and bladder, and had an in-house developed Stage III and Stage IV (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) pressure ulcer. Review of the care plan of 9/15/22 revealed a care area for actual impairment to skin integrity related to pressure area to sacrum and right lateral ankle. The care plan also noted the resident was at increased risk for further impairment to skin integrity related to impaired cognition, diabetes incontinence, impaired mobility, generalized weakness, hemiparesis from a stroke and a history of skin tears and pressure ulcers. Interventions included wound care to evaluate and treat as needed, assessing, recording and monitoring wound healing, Prevalon boots (boots to offload heels), turning, monitoring diet as ordered and intake, and repositioning frequently with rounds and as needed. Review of Resident #20's progress notes for wound care from 03/03/22 to 12/03/22 revealed a wound to the sacrum was discovered on 02/27/22 and healed on 09/08/22, reopened on 09/15/22 and healed on 10/13/22. Review of Resident #20's most recent nutritional assessment, dated 06/13/22 included the need for supplements and monitoring to promote wound healing. There was no further nutritional assessment from a dietician since the reopening of the pressure ulcer on 09/15/22. Observations on 11/28/22 at 10:54 A.M., 1:15 P.M. and 3:54 P.M. revealed Resident #20 laying on his right side with his had tightly clenched around the transfer bar. Interview on 11/28/22 at 2:36 P.M. with the Director of nursing (DON), verified Resident #20's wounds on 02/27/22 and 09/15/22 were facility acquired. Interview on 11/28/22 at 3:02 P.M. with Resident #20's wife revealed she always sees the resident laying in the same position, on his right side. She reported the staff did not reposition the resident often enough. Observation on 12/01/22 at 9:23 A.M. of Resident #20's left sacral area (left sacrum right central buttock) revealed a new open wound approximately two inches by one inch. The wound bed had yellowish colored tissue in the center and was red around the edges. There was a moderate amount of yellowish-green drainage on the dressing. Wound Physician (WP) #802 stated Resident #20 was at high risk for developing pressure ulcers due to his contractures. WP #802 cleansed the wound with 0.125 percent Dakins solution and Licensed Practical Nurse/Unit Manager/Wound Nurse/Infection Preventionist (LPN/UM/WN/IP) #801 applied skin prep, silver alginate and a border dressing to the wound. Review of the wound nurse's note of 12/03/22 revealed wound doctor visit on 12/01/22 discovered a new Stage III pressure ulcer to Resident #20's left central right sacrum measuring 3.0 cm by 2.1 by 0.4. There was no evidence the facility identified the pressure ulcer prior to 12/01/22. Interview on 12/05/22 at 2:49 P.M. with Registered Dietician (RD) #954 revealed he was contracted by the facility and briefly helped in June 2022 and again in November 2022. RD #954 stated he would not necessarily put a note in the resident's records regarding pressure ulcers because he was doing as needed work and was not in facility reviewing weekly wound reports. RD #954 stated he worked remotely and had not been in the facility at all. RD #954 stated he worked approximately six to eight hours a week in June and his main task was completing assessments and care planning. RD #954 stated he would look to see if a resident had a pressure ulcer and make recommendations if he felt it was appropriate. Interview on 12/06/22 at 10:21 A.M. with LPN/UM/WN/IP #801 verified the wound on Resident #20's left sacral area was healed on 09/08/22, was found to re-open as a Stage III on 09/15/22 which had healed. The resident was assessed to have a new Stage III pressure ulcer on 12/01/22. Review of the March 2014 Pressure Ulcer Risk Assessment policy, revealed pressure ulcers usually occur when a resident remained in the same position for increased periods of time causing increased pressure or decreased blood flow. Staff were to perform skin inspections with routine daily care and notify nurses of any changes. Nurses were to conduct weekly skin assessments.

**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 #72's catheter was inserted timely. This affected one resident (Resident #72) out of three residents reviewed for catheter care. Actual Harm occurred on 11/15/22 at 5:37 P.M. when Resident #72 pulled his indwelling catheter out causing redness, irritation and bleeding, and the catheter was not reinserted until Resident #72 experienced abdominal pain and tenderness, was transported to the local Emergency Department on 11/16/22 at 1:57 P.M, a catheter was inserted in the Emergency Department and approximately a liter of urine was returned. Findings include: Review of Resident #72's medical record revealed an admission date of 11/03/22 and diagnoses included obstructive and reflux uropathy, benign prostatic hyperplasia without lower urinary tract symptoms, and mood disorder due to known physiological condition with depressive features. Resident #72 was discharged to the hospital on [DATE]. Review of Resident #72's care plan dated,11/04/22, revealed Resident #72 had an indwelling catheter related to obstructive uropathy. The care plan indicated Resident #72 would show no signs and symptoms of urinary infection through the review date. Resident #72 would remain free from catheter-related trauma through review date. Interventions included to monitor and document intake and output per facility policy; observe for signs and symptoms of discomfort on urination and frequency; observe, document for pain and discomfort due to catheter; observe, record, report to physician for signs and symptoms of urinary tract infection, including pain, burning, blood-tinged urine, no output; Resident #72 had an indwelling 16 French catheter with a 10 milliliter (ml) balloon. Review of Resident #72's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #72 had severe cognitive impairment. Resident #72 required extensive assistance of two staff members for bed mobility, extensive assistance of one staff member for transfers, and had total dependence on one staff member for toilet use. Resident #72 had an indwelling catheter. Review of Resident #72's progress notes dated, 11/15/22 at 8:12 A.M., written by Medical Director #940 included Resident #72 had issues with his indwelling catheter and pulling it out. Resident #72's indwelling catheter was intact and draining upon examination. Review of Resident #72's nursing progress note, dated 11/15/22 at 5:37 P.M. revealed an unidentified State Tested Nursing Assistant (STNA) notified Licensed Practical Nurse (LPN) #971 that Resident #72 pulled out his indwelling catheter. when LPN #971 assessed the situation she noted stool and blood trailing from Resident #72's bed to the bathroom. Resident #72 was confused. LPN #971 called Medical Director (MD) #940 and was given verbal orders to reinsert Resident #72's catheter. LPN #971 attempted to reinsert Resident #72's catheter, and Resident #72 yelled out in pain. LPN #971 administered Tylenol (acetaminophen) and would pass on in report to try again. Review of Resident #72's nursing progress note written on 11/16/22 at 5:42 A.M. revealed Resident #72's catheter was out. Review of Resident #72's progress notes from 11/15/22 at 5:37 P.M. through 11/16/22 at 12:39 P.M. did not reveal documentation Resident #72's physician was notified the nurses were unable to insert an indwelling catheter. Review of Resident #72's nursing progress note dated, 11/16/2022 at 12:39 P.M revealed Resident #72's abdomen was distended and he was complaining of pain and discomfort. Resident #72 pulled foley catheter out and the nurse was unable to replace due to significant trauma to urethra. Bloody drainage noted. Resident #72 was transported to the local hospital by an Emergency Response ambulance company. Review of Resident #72's Prehospital Care Report Summary dated, 11/16/22, included a call was received from the facility at 12:34 P.M., the ambulance was dispatched at 1:32 P.M. and arrived at the facility at 1:36 P.M. The ambulance arrived with Resident #72 at the local hospital Emergency Department at 1:55 P.M. The Report revealed the dispatch reason was a sick person with a urination problem. The report further revealed Resident #72 had a foley catheter (indwelling catheter), Resident #72 pulled it out and the nurses were unable to reinsert a catheter. Resident #72 had pain on palpation to the abdomen and did not have a catheter in place. The facility wanted Resident #72 sent out to the Emergency Department to see the urology service and have a new catheter inserted. Emergency Medical Services (EMS) arrived at the Emergency Department, Resident #72 was registered and given a bed after about an hour of waiting in line. Review of Resident #72's Emergency Department Encounter dated, 11/16/22 at 1:57 P.M. included Resident #72 presented to the Emergency Department for urinary retention which started 11/15/22. Complaint was constant, moderate severity, nothing made it better or worse. Resident #72 had a chronic indwelling catheter secondary to neurogenic bladder, and pulled it out multiple times and again on 11/15/22. The facility was unable to reinsert an indwelling catheter and reported hematuria when the catheter was pulled out. Resident #72 pointed and localized the pain to his lower abdomen. Resident #72 was unable to provide further history due to his baseline mental status. Resident #72 had an indwelling catheter (coude catheter, designed to maneuver around obstructions or blockages in the urethra) placed in the Emergency Department and approximately one liter of urine was returned. Resident #72's labs show evidence of a urinary tract infection. Resident #72 was hypotensive to 77/47 and urinalysis was consistent with urinary tract infection, demonstrating packed [NAME] Blood Cells (WBC) with many bacteria, large LE (leukocyte esterase, used to determine urinary tract infection) with hematuria. Resident #72 was started on levaquin and doxycycline. Further review of Resident #72's Emergency Department report included a clinical impression of sepsis, due to unspecified organism and urinary tract infection associated with catheterization of urinary tract. Resident #72 was admitted to the intensive care unit and his condition was critical. Review of Resident #72's progress notes dated,11/17/2022 at 9:09 A.M., revealed Resident #72 was admitted to the local hospital with a diagnosis of catheter associated urinary tract infection. Interview on 11/30/22 at 2:51 P.M. with Registered Nurse (RN) #804 revealed on 11/16/22 she arrived for work and the midnight nurse told her Resident #72 pulled his catheter out on 11/15/22. RN #804 stated the midnight nurse did not try to replace it because Resident #72 had significant trauma to the urethra and she wanted to give him a break. RN #804 indicated the night nurse did not say if she attempted to contact Resident #72's physician to notify her the catheter was unable to be inserted. RN #804 stated she did not call the physician when she first assessed Resident #72 around 7:30 A.M. or 8:00 A.M. RN #804 stated Resident #72's urethra was red and inflamed and there was some urine and blood leakage noted. RN #804 stated she did not try to insert a catheter and thought Resident #72 was okay. RN #804 stated she proceeded to administer medications to the residents she was assigned to, and when she finished the med pass the aides told her Resident #72 was complaining of pain and discomfort in the bladder area. RN #804 stated she could not remember for sure but thought it was around 11:30 A.M. when this occurred. RN #804 stated she did not attempt to insert a catheter and called Resident #72's physician immediately. RN #804 stated she received orders from the physician to send Resident #72 to the Emergency Department. RN #804 revealed Resident #72 pulled out at least four indwelling catheters out since he admitted to the facility. RN #804 stated LPN #971 was working on 11/16/22 and told her Resident #72 pulled his indwelling catheter out on 11/15/22 and she passed the information to the night nurse. Interview on 12/01/22 at 4:37 P.M. with LPN #971 revealed she worked on 11/15/22, and around 5:00 P.M. an unidentified STNA told her Resident #72 pulled his catheter out. LPN #971 stated she entered Resident #72's room to evaluate him and saw blood and stool everywhere, noted trauma to Resident #72's urethra and also blood coming out of Resident #72's urethra. LPN #971 stated she called Medical Director (MD) #940, told her Resident #72 pulled his catheter out and there was trauma to his urethra and blood draining from his urethra. LPN #971 stated she received orders from MD #940 to reinsert Resident #72's catheter. LPN #971 verified Resident #72 yelled out in pain and she was unable to insert the catheter, but did not call MD #940 to notify her she could not reinsert Resident #72's catheter. LPN #971 stated she administered Tylenol (acetaminophen) to Resident #72 and told the next shift nurse Resident #72's catheter was out and needed reinserted. LPN #971 stated 11/15/22 was a very busy and hectic day and she felt overwhelmed with her assignment. LPN #971 stated when she called MD #940 she was told Nurse Practitioner (NP) #972 was on call because MD #940 was going out of town. LPN #971 indicated there were no memos stating Nurse Practitioner #972 was on call for MD #940. LPN #971 stated she did not call NP #972 to notify her Resident #72's catheter was unable to be inserted. LPN #971 stated she worked the next day and the nurse taking care of Resident #72 knew about the situation with his catheter, and knew he was on a blood thinner. LPN #971 stated she had another assignment on 11/16/22 and went on about her business. Interview on 12/07/22 at 9:03 A.M. with the Director of Nursing (DON) revealed she did not know anything about Resident #72 pulling his catheter out, or it was unable to be reinserted until he was sent to the Emergency Department on 11/16/22. The DON stated none of the day shift or night shift nurses contacted her. The DON stated NP #972 told her no nurses notified her Resident #72's catheter was pulled out or they were unable to reinsert it. Interview on 11/30/22 at 6:20 P.M. with MD #940 revealed she was unable to look at her messages from 11/15/22 and 11/16/22 because Resident #72 was discharged from the facility. MD #940 stated she remembered she was called about Resident #72 pulling his catheter out but could not verify the time. MD #940 stated she did not remember any nurse calling her to tell her Resident #72's catheter was unable to be reinserted after she gave the order to insert a catheter. Review of the facility policy titled Change in Resident's Condition or Status, revised 06/2013, included the facility should promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical, mental condition and or status. The Nurse/Dietitian/Respiratory Therapist would notify the resident's Attending Physician or On-Call Physician when there had been a significant change in the resident's physical/emotional/mental condition. A significant change of condition was a decline or improvement in the resident's status that would not normally resolve itself without intervention by staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review and facility policy review, the facility failed to timely implement nutritional interventions for residents who experienced weight loss or were at risk of compromised nutrition. This affected four residents (Residents #38, #44, #66, and #80) out of five residents reviewed for nutrition. The facility census was 83. Actual harm occurred on 11/30/22 when Resident #44 was assessed to have a significant weight loss of 40 pounds (22.5 percent) from Resident #44's previous weight on 10/14/22 of 177 pounds and the facility failed to ensure nutritional interventions were implemented to prevent and address the weight loss. Findings include: 1. Medical Record review revealed Resident #44 had an admission date of 09/13/22 and diagnoses included unspecified cerebral infarction (stroke), traumatic hemorrhage of cerebrum (acute loss of blood in the brain), altered mental status, gastro-esophageal reflux disease (GERD) with esophagitis, depression, type two diabetes, and dysphagia following cerebral infarction. Review of Resident #44's admission nutrition assessment dated [DATE], revealed the resident needed assistance with meals. The resident was confused and had no skin issues or known significant weight changes. Resident #44 was consuming 75 percent of meals. Review of Resident #44's nutritional care plan dated 09/14/22 revealed the resident had a nutritional problem or potential nutritional program due to COVID 19, asthma, diabetes mellitus, cerebrovascular accident, GERD, and hypothyroidism. Interventions included intakes of greater than 50 percent (%) for three months, maintain current body weight for three months, monitor weights, intakes, provide adequate nutrition/hydration, and monitor resident and make adjustments to the plan of care as needed. Review of Physician #940's progress note dated 09/27/22 revealed a suspicion that Resident #44 was not consuming much during mealtimes, since his albumin level was low, and the staff were to encourage him during mealtimes. Review of Physician #940's progress note dated 10/03/22 revealed the need to monitor his nutritional intake due to uncontrolled blood sugars. Review of Resident #44's 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was severely impaired and required extensive one person assistance with eating. Review of facility weights revealed Resident #44's weight was stable between 176.2 pounds and 180.8 pounds between 09/14/22 and 10/14/22. Review of medical record revealed Resident #44 was hospitalized from [DATE] to 11/25/22 for a urinary tract infection. Review of hospital records revealed the nutrition assessment completed on 11/23/22 for Resident #44 indicated Resident #44 had an average meal intake of 25 to 50 %, was at nutritional risk due to noted poor appetite for one to two weeks prior to admission, had a stated weight of 160 pounds, was started on an oral nutritional supplement while in the hospital, and would continue to be monitored. Review of hospital discharge paperwork printed 11/25/22 at 11:14 A.M. revealed Resident 44's latest vitals showed a weight of 152 pounds and 6.4 ounces. Review of admission/readmission evaluation dated 11/25/22 for Resident #44 revealed the most recent weight was 177.0 pounds on 10/14/22. Review of physician orders for Resident #44 indicated an order for a mechanically altered chopped texture, thin texture dated 11/25/22. Review of November 2022 meal intakes for Resident #44 revealed 52 meals with no data recorded; however, of the meals recorded, Resident #44 consumed 0% to 75% of his meals prior to hospital stay and after being readmitted on [DATE], all recorded meals were refused. Resident #44's medical record, including progress notes, showed no evidence of nutritional intervention on the days meals were refused or not recorded. Review of the weight obtained on 11/30/22 for Resident #44 (after surveyor requested it) revealed a weight of 135.8 pounds, and a reweight of 137.0 pounds was obtained on the same day, reflecting a significant weight loss of 40 pounds (22.5 %) from Resident #44's previous weight on 10/14/22 of 177 pounds. Assistant DON #837 verified the weight at the time of observation. Review of nutrition assessment started on 11/30/22 but signed on 12/04/22 revealed meal intakes were poor with refusal to 25% of meals being consumed, was on mirtazapine (Remeron) which might affect appetite stimulation, daily needs were 1550-1860 calories, 62-68 grams of protein, and fluid needs were 1860 milliliters, and ensure three times a day would be recommended secondary to significant weight loss and poor meal intakes. Review of Resident #44's breakfast, lunch, and dinner diet tray cards dated 11/30/22 revealed there was nothing listed in the dislike/do not serve or the special instructions sections. Review of Resident #44's physician orders revealed a nutritional supplement was not added until 12/04/22 to include Ensure three times a day. Interview on 12/01/22 at 4:25 P.M. with family of Resident #44 revealed she was not aware of the weight loss. She confirmed the resident had not been eating, and he needed assistance with eating due to his impaired vision. She stated Resident #44 would refuse meals at times, and she felt the weight loss was from a combination of not receiving the assistance with meals that he needed and from the meal refusals. She voiced his current weight was low for him. Interview on 12/01/22 at 4:38 P.M. with Physician #940 revealed she was unaware of Resident #44's weight loss. Interview on 12/01/22 at 5:58 P.M. with Dietitian #954 revealed Resident #44's weight was all over the place and he had requested an additional weight to ensure the present weight was accurate. He stated Resident #44's meal intakes were all over the board, and he was already on Remeron which could help increase his appetite. Dietitian #954 felt if the weight was still down after the requested reweight was obtained, Resident #44 would need some sort of intervention. He then stated he would no longer be covering the home since a new contracting company was starting. Interview on 12/05/22 at 11:35 A.M. with Director of Nursing (DON) revealed the unit manager was the one who would check the admissions to ensure nothing was missed. The nurse who completed the admission/readmission evaluation dated 11/25/22, came from another facility where the weights for readmits and admits were entered differently. The DON confirmed the unit manager missed that a new weight was not obtained for Resident #44, and there was not a new weight attained upon readmission for Resident #44. Interview on 12/05/22 at 12:52 P.M. with State Tested Nursing Assistant (STNA) #904 revealed she was the one who communicated with Resident #44 since they both spoke Spanish. STNA confirmed he had lost weight since she could see it on his body. She stated she told him he was wasting away. She fed him every meal when she worked, and he could hold a drink container or some finger foods if you put them in his hand. She voiced he ate better when he was first admitted , and he has told her he was not hungry. She would often offer him something else if he refused items, but he refused those items. When he was done eating, he would say in Spanish That's it. He has told her he did not like the food. She has told the kitchen his preferences and nothing has been done. He has continued to receive items on his tray, like apple juice, that he did not like. She has let the nurses know that he has not been eating and has been losing weight multiple times. The family did bring in supplements and snacks over the weekend. Someone would need to offer him the snacks since Resident #44 would not ask for the snacks. Interview on 12/05/22 at 10:52 A.M. with Licensed Practical Nurse (LPN) #962 revealed on certain days Resident #44 had a great appetite. If he was in pain, he would not eat. If Resident #44 was comfortable with the aide, he would eat better. LPN #940 completed his admission note in the progress notes. She stated until a new weight was put in the admission screener, the most recent weight was pulled forward in her note. She stated the person who completed the admission screener was responsible for obtaining a readmission weight. Observation on 12/06/22 at 1:35 P.M. revealed Resident #44's tray was observed sitting on the over bed table with the meal of two chicken tenders, one roll, one scoop mashed potatoes, and jello all untouched. The 8-ounce milk carton and the container of ensure plus were both unopened. Interview on 12/06/22 at 1:36 with STNA #980 revealed she did not know why his meal was not touched since she was not his aide that day. At the time of observation and questioning, the unit nurse went into his room and opened the Ensure plus, put a straw in it and held it to his mouth. Resident #44 then took some sips of the supplement but did not want his meal. Interview on 12/06/22 at 1:45 P.M. with STNA #803 revealed she passed out all of the meal trays and STNA #980 was supposed to feed Resident #44. Interview on 12/07/22 at 1:08 P.M. with LPN #960 revealed if a resident refused a meal, the facility should provide something else to eat. Interview on 12/07/22 at 1:20 with LPN #961 revealed if a resident was not eating well she should tell a supervisor. Review of facility policy titled Resident Nutrition Services, revised November 2009, revealed nursing would evaluate food and fluid intake in residents with, or at risk for significant nutritional problems. Nursing staff would assess and document the amounts eaten as indicated for individuals with, or at risk for, impaired nutrition. Significant variations from usual eating or intake patterns would be recorded in the resident's medical record. The nurse supervisor and/or unit manager would evaluate the significance of such information and report it. Review of facility policy titled Weight Assessment and Intervention, revised 2008, revealed residents would be weighed on admission, the next day and weekly for two weeks thereafter. If no weight concerns are noted, weights would be measured monthly thereafter. The multidisciplinary team would strive to prevent, monitor, and intervene undesirable weight loss. 2. Review of medical record for Resident #80 revealed an admission date of 07/25/22 and diagnoses included end stage renal (kidney) disease, essential (primary) hypertension (high blood pressure), acute on chronic diastolic (congestive) heart failure, and type 2 diabetes with hyperglycemia (excessive amount of glucose circulating in the blood) Review of care plan dated 07/26/22 revealed Resident #80 had a nutritional problem, or the potential of a nutrition problem, related to hyperkalemia, nausea and vomiting prior to admission, Acute Kidney Injury on chronic kidney disease, oral nutritional supplement, and therapeutic diet with goals of providing adequate nutrition hydration, maintain weights, and intakes greater than 50 %. Interventions included provide diet/supplements per orders and honor food preferences and monitor weights. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #80 was cognitively intact, was independent with set up only eating, had no significant weight loss, was on a therapeutic diet, and was on dialysis. Review of physician orders for Resident #80 indicated an order for hemodialysis every Tuesday, Thursday, and Saturday dated 08/16/22, an order for a renal/controlled carbohydrate diet, regular texture, thin Liquids consistency dated 08/15/22 with a 100 gram protein added on 11/17/22 and an order for ensure with meals dated 12/04/22. Review of meal intakes for Resident #80 revealed for October 2022 six meal intakes were recorded with consumption varied from 0% to 75%. For November 2022, 27 meals were recorded with consumption between 0-25%. Review of facility weights revealed Resident #80 weighed 207 pounds on 7/25/22, 177.4 pounds on 08/08/22, 162.4 pounds on 08/25/22, 162.2 pounds on 09/01/22, and 163.0 on 10/18/22 which reflected a significant weight loss of 44.6 pounds (21.5 percent) from 7/25/22 to 8/25/22. Review of dietary progress notes for Resident #80 revealed ensure plus daily and ensure clear daily was recommended related to poor appetite on 08/19/22 and there were no other nutritional notes until 10/25/22 when the 44 pound weight loss within three months was noted to be anticipated due to fluid shifts and variable intakes from stomach discomfort. Resident #80 was to continue with current interventions. Interview on 12/01/22 with Dietitian #954 on 12/01/22 at 5:58 P.M. confirmed Resident #80 had lost a significant weight loss. He felt some of the weight loss could have been anticipated related to fluid shifts however this weight loss was so severe not all of it was anticipated. He confirmed Resident #80 was not assessed in a timely manner for the weight loss. He revealed if the weight loss was anticipated it would be care planned, and he confirmed there was no planned weight loss as a goal in the care plan. Interview on 12/01/22 at 9:40 A.M. with Renal Dietitian #964 confirmed Resident #80 had lost weight. On 7/30/22 Resident #80 left the dialysis center weighing 85.4 kilograms(kg) (187.9 pounds). He missed three treatments on 08/06/22, 08/09/22, and 08/11/22. On 08/13/22, he left the facility weighing 76.9 kg (169.2 pounds). On 08/30/22 he left the facility weighing 71.9 kg (158.2 pounds). His weight had remained stable since 08/30/22. Resident #80's albumin levels have decreased from 3.9 gram (g) per deciliter (dl) on 09/06/22 to 3.8 g/dl on 10/4/22 to 3.5 g/dl on 11/05/22. Renal Dietitian #964 has tried to reach out by email and has called several times with no return response from the facility. The renal doctor was concerned about the decreased albumin levels and ordered Resident #80 to be on a 100 g protein diet. Interview on 12/07/22 at 1:28 PM with Resident #80 confirmed he had lost weight, which he thought was from a combination of improved edema status and from poor meal intakes. He had never been asked his preferences. He was unaware there were alternatives for meals. He stated he either ate the meal or did not. Staff had never offered anything else if he did not eat. He stated he often used his supplements as meal replacements. Interview on 12/07/22 at 2:20 P.M. with LPN #902 confirmed his weight loss back in July and August of this year was a combination of resolved edema and poor meal intakes. Review of facility policy titled Resident Nutrition Services, revised November 2009, revealed nursing would evaluate food and fluid intake in residents with, or at risk for significant nutritional problems. Nursing staff would assess and document the amounts eaten as indicated for individuals with, or at risk for, impaired nutrition. Significant variations from usual eating or intake patterns would be recorded in the resident's medical record. The nurse supervisor and/or unit manager would evaluate the significance of such information and report it. 3. Review of medical record for Resident #38 revealed an admission date of 07/05/22 and diagnoses included acquired absence of left leg above knee (12/05/22), cerebral infarction (stroke), end stage renal disease, and type two diabetes with diabetic neuropathy. Review of care plan dated 07/06/22 revealed Resident #38 was had a nutritional or potential nutritional problem related to diabetes, end stage renal disease, therapeutic diet, and oral nutritional supplement with interventions which included provide diet/supplements per orders and honor food preferences as able, monitor weights, and adjust the plan of care as needed. Review of five day Modified Data Set (MDS) assessment dated [DATE] revealed Resident #38 was cognitively intact, was independent with no set up required for eating, was on a therapeutic diet, and had no significant weight changes. Review of progress note dated 11/17/22 revealed Resident #38 had been admitted to the hospital on with diagnoses of osteomyelitis of the left foot. Review of admission/readmission evaluation dated 11/26/22 for Resident #38 revealed he had returned from the hospital and had new left above knee amputation. Review of facility weights revealed Resident#38 weighed 200.8 pounds on 11/15/22, 187.0 pounds on 11/28/22, 182.1 pounds on 11/29/22, and 181.7 pounds on 12/01/22 which resulted in a significant weight loss of 6.8 percent (%) from 11/15/22 to 11/28/22. Review of Dietitian #956 weight change note for Resident #38 dated 12/04/22 revealed resident had experienced a significant weight loss and the weight fluctuation was in relation to dialysis. Interview on 12/07/22 at 3:35 P.M. with Dietitian #956 confirmed Resident #38 had a significant weight loss. She felt the weight loss was related to the weight fluctuation since he was on dialysis. She confirmed she did not read the hospital records was unaware Resident #38 had an amputation while in the hospital, which would result in a weight loss. Dietitian #956 stated she would have recalculated his needs and his BMI if she had known he had an amputation. Review of facility policy titled Nutrition (Impaired)/Unplanned Weight Loss-Clinical Protocol revealed the nursing staff will monitor and document the weight and dietary intake of residents in a format that permits readily available comparisons over time. The physician and/or dietitian will review possible causes of anorexia or weight loss. The staff and physician will identify pertinent interventions based on identified causes. 4. Resident #66 was admitted on [DATE] with diagnoses including history of stroke, Monoclonal gammopathies (conditions in which abnormal proteins are found in the blood), diabetes type II, acute respiratory failure with hypoxia, hyperlipidemia, hypomagnesemia, Vitamin D deficiency, congestive heart failure, edema, hypokalemia, acidosis, chronic kidney disease stage IV and cyst of kidney. Review of Resident #66's physician orders revealed orders for a renal /controlled carbohydrate diet, regular texture with thin liquids. Review of the Medicare 5-day MDS 3.0 assessment revealed the resident was cognitively intact, required extensive assist of two for ADLs, received oxygen therapy and dialysis. A nutritional assessment was completed on 09/29/22 by the former facility dietician revealed the resident was at risk of malnutrition related to his increased needs with hemodialysis. There was no further communication from a dietician at the facility Review of care plan of 10/23/22 for Resident #66 revealed a care area for nutrition related to edema, congestive heart failure and diabetes with interventions including providing diet and supplements per orders and honoring food preferences. Interview with Resident #66 on 11/28/22 at 3:56 P.M. revealed he does not receive the right diet. He normally eats one starch a day, as a diabetic. The facility was giving him two starches at each meal. They gave him a donut with icing for breakfast. He would like to have more protein, instead on the one old egg he sometime got. He would like fish, chicken. Sometimes the facility did not give him any meat for three days. Resident #66 revealed dietician at dialysis agreed with him that he was not eating right. Resident #55 revealed nobody at the facility asked him his preferences but the dietician at dialysis did. Observation and interview with Resident #66 on 11/30/22 at 8:35 A.M. revealed he received a pancake with syrup, coffee and diet lemonade for breakfast. Interview on 11/30/22 09:31 A.M. with Registered Nurse (RN) #804 revealed they made sure Resident #66 received his breakfast, medication and a blood sugar right away because his sugar tended to run low in the morning. She verified all residents usually received a donut or danish for breakfast. Interview on 12/01/22 at 9:20 A.M. Renal Dietitian (RD) #963 revealed she has been unable to reach a dietician or someone in dietary at the facility about Resident #66's diet preferences. The resident voiced to her that he was always hungry and was not getting enough to eat. She had a whole list of his preferences. She reported he has had a 6.9% weight loss from 10/02/22 to 12/01/22.