**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined the facility failed to provide adequate supervision, follow care plans, complete thorough investigations and timely assess smoking for 4 of 4 sampled residents (#s 6,15, 23, and 134) reviewed for accidents. Resident 15 and Resident 134 experienced falls resulting in fractures. Findings include: 1. Resident 15 was admitted to the facility in 2022 with diagnoses including Alzheimer's disease and stroke. A 7/13/22 admission MDS and CAAs indicated Resident 15 was impaired on both sides, at risk for falls due to weakness, required increased ADL support and her/his care plan was to include interventions to reduce the risk of falls. a. A 3/10/23 revised care plan indicated Resident 15's bed would be in a low position for safety. A 3/20/23 Fall Investigation indicated Resident 15 fell out of her/his bed around 12:15 AM, her/his bed was not in the lowest position at the time of the fall. No staff interviews were completed as part of the investigation. At the time of the fall Resident 15 did not complaint of pain and alert monitoring began. A 3/22/23 Alert Note (monitoring after the 3/20/23 fall) indicated Resident 15's foot and ankle were observed swollen with bruising to her/his ankle by staff, the resident had uncontrolled pain even after pain medication was provided and Resident 15 was sent to the emergency room. A 3/22/23 hospital History and Physical indicated Resident 15's was diagnosed with an ankle fracture after x-rays were completed in the emergency room. Resident 15 remained in the hosptial for pain control. On 12/13/23 at 4:29 PM and 12/14/23 at 4:44 PM Staff 2 (DNS) acknowledged Resident 15's care plan at the time of the 3/20/23 fall was not followed, Resident 15's fall resulted in an ankle fracture and staff interviews were needed for a thorough investigation. b. A 10/29/23 Fall investigation revealed Resident 15 was found on the floor in the dining room at 8:57 AM (after the breakfast meal) near her/his wheelchair which was in the upright position. A new intervention for Resident 15's fall prevention was to ensure she/he did not remain alone in the dining room. No staff interviews were found. A 12/11/23 revised care plan did not include Resident 15 was to be supervised after meals. On 12/13/23 at 10:48 AM Staff 6 (LPN) confirmed she completed the 10/29/23 fall investigation and did not update Resident 15's care plan as needed. Staff 6 acknowledged, because of many new staff, care plan updates to prevents further falls for Resident 15 were important. On 12/13/23 at 3:23 PM Staff 24 (CNA) stated Resident 15's care plan was not updated to include active fall preventions which were necessary to know to prevent further falls. On 12/14/23 at 9:02 AM, 10:33 AM and 4:44 PM Staff 2 (DNS) acknowledged she needed to improve fall investigations to include staff interviews especially at the time of the fall and Resident 15's care plan was not updated as necessary after her/his 10/29/23 fall. 2. Resident 134 was admitted to the facility in 2023 with diagnoses including falls and back fracture. The Fall CAA dated 6/18/23 revealed Resident 21 was a fall risk due to the need for assistance with mobility, transfers and ADLs due to self-care deficit, recent hospitalization, weakness, balance problems and pain. The resident's 7/6/23 revised care plan indicated Resident 134 required the assistance of two staff members for toileting. A 9/18/23 Quarterly MDS indicated Resident 134 required one person to assist her/him to and from the toilet due to unsteadiness and only able to stabilize with staff assistance. A 9/20/23 FRI indicated on 9/19/23 Resident 134 was assisted to stand at the toilet by Staff 21 (Former CNA) before shift change at 10:00 PM. Staff 21 left the resident standing in front of the toilet in the bathroom to give report to the oncoming shift. The night shift staff found the resident on the floor 15 minutes later. Resident 134 complained of pain related to the fall, was sent to the hospital and found to have a pelvic fracture from the fall. On 12/14/23 at 10:11 AM Staff 2 (DNS) acknowledged the resident was a fall risk, the care plan was not revised and indicated Resident 134 was two person assistance to the toilet and Staff 21 did not follow the care plan. 3. Resident 6 was admitted to the facility in 2023 with diagnoses including diabetes and respiratory failure. The 10/17/23 admission Profile indicated Resident 6 smoked. The 10/17/23 care plan indicated Resident 6 was an independent smoker and would remain compliant with facility smoking policy. Interventions included: instruct the resident about smoking times, locations and safety concerns; staff were to observe clothing for cigarette burns and smoking supplies would be stored at the nurses' station. There was no smoking assessment or Resident 6's acknowledgement of the smoking policy found in the resident's clinical record. On 12/13/23 at 8:13 AM Resident 6 stated she/he smoked since arrival to the facility on [DATE]. Resident 6 stated she/he did not sign any paperwork related to smoking in the facility. On 12/13/23 at 12:50 PM Resident 6 was observed smoking outside alone. On 12/15/23 at 8:29 AM Staff 9 (CNA) and Staff 18 (CNA) stated they worked with the resident since she/he admitted to the facility and observed Resident 6 getting her/his smoking materials and going outside to smoke. On 12/15/23 at 9:10 AM Staff 3 (Social Service Manager) acknowledged Resident 6 was not assessed for smoking and did not sign a smoking agreement upon admission. 4. Resident 23 was admitted to the facility in 2023 with diagnoses including dementia and end of life care. Records indicated Resident 23 had a history of falls and remained at risk for further falls. A review of three fall investigations dated 9/26/23, 11/5/23 and 11/26/23 revealed a lack of witness statements and/or an explanation of how the facility ruled out abuse and neglect related to Resident 23's falls. On 12/15/23 at 11:02 AM Fall investigations were reviewed with Staff 2 (DNS). Staff 2 stated she interviewed staff as part of her investigation of falls. Staff 2 added further education was needed related to the facility staff's responsibility to gather information, document and rule out abuse and neglect at the time of the fall.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to ensure a surgical wound was monitored and assessed for 1 of 1 sampled resident (#177) reviewed for non-pressure skin. This resulted in Resident 177's surgical wound becoming infected, and the resident being hospitalized . Findings include: The facility's 4/2018 Skin at Risk Program Overview indicated: 16. Skin conditions other than pressure ulcers, etc. will be documented on the resident's treatment record. Other skin conditions (rashes, skin tears, excoriations, abrasions, bruises or surgical wounds) would be addressed with appropriate treatment orders. 17. The Non-Ulcer Skin Condition Evaluation would be completed weekly for wounds likely to result in complications including delayed wound healing or infections (examples: poorly approximated surgical wound or large skin tear, etc.). Resident 177 admitted to the facility on [DATE] with diagnoses including a right below the knee amputation, diabetes, and a left fifth toe amputation performed on 5/10/21. Resident 177 discharged from the facility on 10/18/21. The initial 10/5/21 Non-Pressure Skin Condition Assessment indicated the resident had a left toe scab that measured 1.5 cm x 0.5 cm x 0 cm. The note indicated there was no exudate (drainage) or odor. The wound bed had black/brown eschar (dead tissue) and necrotic tissue with normal edges for skin type. The assessment was completed by Staff 10 (LPN). An 10/5/21 Physician Order indicated for the left lower extremity fifth toe amputation, staff were to keep the dressing clean and dry and a referral to the surgeon was in process. The 10/10/21 admission MDS indicated Resident 177 was cognitively intact and had surgical wound(s). During the look-back period the resident had frequent, severe pain that made it difficult for the resident to sleep and participate in ADLs. The 10/10/21 Pain CAA indicated the resident's pain was related to the left foot. Resident 177's Care Plan did not mention the left fifth toe amputation surgical wound or include interventions to monitor or prevent worsening. An 10/12/21 Physician Visit indicated the resident had left foot rest pain symptoms. The resident reported in the last month she/he had increasing rest pain symptoms in the left lower extremity. The exam was noted as deferred. There was no indication the surgeon examined Resident 177's left lower extremity. An 10/13/21 primary care physician (PCP) visit indicated the resident felt her/his pain was not well controlled and may need something for nerve pain. The exam of the left lower extremity noted no tenderness to palpitation, no edema, or ecchymosis (discoloration/bruising of skin) and no pain during ROM. The assessment noted Continue Wound care to foot per the surgeon's orders. The resident's narcotic pain medication was increased. A verbal order was received on 10/14/22 to monitor the left foot, fifth toe amputation site for breakdown every shift for fragile skin. An 10/15/21 at 11:28 AM Nursing Note indicated Resident 177 had a new skin issue, a 0.5 cm x 0.5 cm blood blister on top of the left great toe. The amputation site of fifth toe was noted as covered with a dry crusty scab and no drainage or open area noted. The amputation site was left open to air. Weekly Skin Sheets indicated the following: *10/7/21: No new skin issues noted at this time. There were no measurements or description of the fifth toe amputation wound or worsening/healing noted. The note was completed by Staff 14 (LPN). *10/14/21: Open area on L foot at 5th toe amputation site. Order entered. There were no measurements or description of the fifth toe amputation wound. The note was completed by Staff 13 (LPN). *10/18/21: Left foot big toe noted red with a big toe scab and oozing clear fluids. Treatment order in place at this time. Patient to see MD today for follow up appointment. There were no measurements or description of the fifth toe amputation wound or worsening/healing noted. The note was completed by Staff 14 (LPN). The 10/2021 TAR indicated Resident 177 had the following orders: *Order implemented 10/11/21: Check skin and indicate + if a new skin condition is present and - if no new skin condition is present. Initiate skin documentation form every day shift on Monday. The TAR was marked as negative on 10/11/21 and 10/18/21. *Order implemented 10/15/21 Order: Monitor left foot, 5th toe amputation site for breakdown every day shift for fragile skin. The TAR was checked off as completed on 10/15/21 through 10/18/21. Nursing Progress Notes and Skilled Service Notes indicated the following: *10/14/21: The resident was assessed for pain. Resident had left foot pain. Intensity and frequency varied. Sometimes she/he waited too long to ask for pain medication and cried. The resident had Norco (narcotic pain medication) at 12:30 PM and was comfortable at 4:00 PM. The resident wanted to wait until later for another pill. The resident was crying at 7:00 PM and had another Norco and was feeling better at 9:00 PM. *10/15/21: The resident did not need any narcotics this shift and stated her/his left foot was feeling better today. *10/16/21: The resident had a narcotic pain medication two times that evening. The first time was before dinner, when staff saw her/him wincing when moving and then again after getting on and off the commode. The resident was crying after getting back in bed from the commode. *10/17/21: The resident was assessed for pain and reported left foot pain and back pain. The intensity and frequency varied. Pain medication provided per physician order. *10/18/21 at 11:08 AM: spoke with resident's son regarding the resident's pain. The resident stated the pain medication was not really helping but the doctor stated the resident was already on too much medication and did not want to add anything else. *10/18/21 at 2:34 PM: Received a call from the resident's PCP clinic and they sent the resident to the ER via ambulance for intractable left foot pain. *10/18/21 at 5:52 PM: Resident went out to a doctor appointment and was sent and admitted to the hospital for possible gangrene. An 10/18/21 PCP appointment note indicated the resident's family had asked for wound care by the facility and it was not provided. The resident saw the surgeon the week prior, and the PCP feared the resident was not getting better at the facility and was getting weaker. The resident's left foot was noted to have purulent (puss) drainage, was severely tender, and was not even dressed. The exam indicated the resident had severe tenderness to palpitation present to the dorsum of foot, the left fifth toe amputation site had a thick ulcer draining purulent material, and the wound was red and inflamed. The resident was unwilling to walk and was not able to stand and pivot any longer on the left lower extremity ulcer. Cultures were obtained and the resident was sent to the ED. The 10/18/21 Hospital Records indicated the resident was admitted for wound care and the left lateral foot wound status post pinky toe amputation was Odorous and weeping; unstageable. Labs indicated the resident had local osteomyelitis (infection of the bone) with diagnoses of gangrene. The records further indicated hospital staff spoke with Staff 10 (LPN Resident Care Manager) at the facility and Staff 10 stated the resident was admitted for therapy unrelated to wound care and Staff 10 completed the initial wound assessment on 10/5/21. At that time the resident's toe amputation site was a small scab. Staff 10 stated the resident refused all showers and physical therapy since arrival due to pain level. The note indicated Staff 10 further stated the resident refused to be touched by staff except to be put on a bed pan and screamed in pain when touched. Staff 10 stated facility staff were unaware of wound progression on foot. An 10/20/21 Hospital Record indicated the wound was not healing and the surgeon stated he would advise an above knee amputation or hospice care for Resident 177 but would stabilize the resident for now. On 9/12/22 at 12:39 PM Witness 3 (Family Member) stated the resident had so much foot pain she/he would not lift the bedding covers at the facility so the resident was sent to the doctor. Witness 3 stated at the clinic on 10/18/21 they had to put a pad on the floor to collect the brown drainage from Resident 177's left foot. Witness 3 stated facility staff told Resident 177's family that if they moved the covers the resident would become upset, so staff were not looking at the wound. Witness 3 stated the resident had a lot of pain due to her/his left foot and stated to the family, I hurt and they are not helping. Witness 3 stated the doctor was not notified of refusals or wound concerns. Witness 3 stated Resident 177 ended up losing her/his left leg due to the infection. Interviews were conducted on 9/13/22 and 9/14/22 with Staff 13 (LPN) and Staff 14 (LPN) who were unable to recall the resident or if the resident had skin issues related to her/his fifth toe amputation site. Both Staff 13 and Staff 14 stated resident care managers (RCMs) were responsible for assessing new/worsening wounds once identified by nursing staff. On 9/13/22 at 12:01 PM and 9/14/22 at 1:04 PM Staff 10 (LPN Resident Care Manager) stated for surgical site wounds, if a wound worsened the floor nurses did the initial assessment and treatments and then RCMs measured the wounds once a week and notified the provider if worsening. Staff 10 stated she completed the initial skin assessment for Resident 177 on 10/5/21 and did not observe the left fifth toe amputation after the initial assessment. Staff 10 confirmed there was no description on 10/18/21 of the left fifth toe amputation site and stated this was due to the resident having an appointment with her/his PCP that same day. Staff 10 stated the resident experienced a lot of pain but did not want to see the facility's medical provider and there was difficulty contacting the resident's PCP for orders and appointments. Staff 10 stated the resident had relentless pain and was never not in pain. Staff 10 stated the facility did not send the resident to the ER as they were under the impression the resident wanted to be seen in-house but the resident changed her/his mind and wanted to be seen by her/his outside PCP and the on-call provider would not prescribe narcotics. Staff 10 stated she was not made aware of any changes to Resident 177's left fifth toe amputation site. On 9/15/22 at 2:09 PM and 2:31 PM Staff 2 (DNS) stated for any change from baseline to a wound, the expectation was for staff to assess, measure, and monitor until healed. Staff 2 stated staff absolutely should have measured and described the wound and how it changed. Staff 2 stated it would be hard to go from nothing on the early morning of 10/18/21 to then fully infected later that day. Staff 2 further stated for pain management, if the doctor was not available and the on-call provider was not willing to prescribe pain medications, the expectation was to send the resident to the hospital if the resident was crying out in pain or not participating in therapy due to pain. Staff 2 acknowledged Resident 177's wound worsened from baseline and became infected, resulting in hospitalization on 10/18/21.