**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to prevent an avoidable fall related to fall safety for 1 of 3 sampled residents (#1) reviewed for accidents. Resident 1 fell out of bed and sustained a right shoulder fracture. Findings include: Resident 1 was admitted to the facility in 7/2024 with diagnoses including quadriplegia (paralysis that affects all a person's limbs and body from the neck down) and a Stage 4 (full thickness skin loss) pressure injury. The admission MDS dated [DATE], revealed Resident 1 was cognitively intact. A care plan dated 7/25/24, revealed Resident 1 was limited in performing ADLs and was encouraged to perform as much of her/his ADLs as their condition allowed. Staff were to follow the most recent instructions and posted wall signs for mobility, transfers, exercises, and restorative programs. A revision on 7/27/24, revealed Resident 1 had half siderails on both sides of her/his bed to assist with repositioning and bed mobility. Two undated bedside care plans revealed the resident required the assistance of one or two people to roll from side to side in bed and required the assistance of two-people for scooting and repositioning. The resident had a Foley catheter and was incontinent of bowel. A Fall Investigation dated 8/22/24 revealed the following: -Staff 6 (Agency CNA) had multiple interactions with Resident 1 throughout her shift on 8/17/24 and followed the care plan. However, when she recognized the resident's positioning was possibly unsafe, she did not request a second staff person to assist with repositioning the resident prior to providing incontinent care. This created additional risk, contributing to Resident 1's fall. Staff 6 acknowledged Resident 1's positioning in bed led to her/his fall. -Resident 1 stated Staff 6 was going to provide cares and she/he was supposed to roll to the left side. Resident 1 indicated she/he was close to the edge of the mattress and the CNA pushed me too far over. When Staff 6 realized she/he was too close to the edge of the mattress, Resident 1 fell off the bed. -Staff 2 (DNS) determined and indicated Staff 6 recognized the potential safety issue with Resident 1's positioning but did not seek peer assistance. While this was a safety risk that led to an injury, it was not a willful infliction of injury or failure to provide a necessary service. However, the fall was an avoidable situation. On 9/16/24 at 5:18 PM, Resident 1 stated on 8/17/24, Staff 6 was going to provide care and had her/him too close to the edge of the bed, causing her/him to fall out of the bed. Resident 1 stated her/his right arm caught in the bed railing, resulting in a fractured right shoulder. Resident 1 stated she/he was a quadriplegia and needed assistance with cares and most of the time two staff would assist her/him with repositioning and care. On 9/17/24 at 1:43 PM Staff 8 (Physical Therapist) stated Resident 1 was able to use her/his arms and required one staff person to assist with rolling in bed but required two staff to reposition her/him in bed. Staff 8 stated the resident had a care plan in her/his room and pictures on the wall to ensure staff assisted the resident appropriately. On 9/18/24 at 9:58 AM, Staff 6 stated she worked on 8/17/24 which was her first time working at the facility. Staff 6 stated she received a report from a male nurse who indicated Resident 1 required one-person assistance for all her/his ADL care needs. Staff 6 stated she did not review or have access to the care plan. Staff 6 stated she did not know where the bedside care plan was located for Resident 1. Staff 6 stated she interacted with Resident 1 throughout the shift because the resident used her/his call light often. Staff 6 stated the resident was close to the edge of the bed but indicated the resident refused to be repositioned prior to providing incontinence care. Staff 6 stated when she went to gather supplies in the room for incontinent care, Resident 1 slid out of bed but did not fall. Staff 6 stated Resident 1's right arm was stuck in the side rail. Staff 6 stated she called for assistance, and a nurse entered the room to assess and help get the resident back into bed. Staff 6 further stated the resident did not report any pain or discomfort in the right shoulder. On 9/18/24 at 2:14 PM, Staff 3 (Agency RN) stated on 8/17/24, Staff 6 alerted her that Resident 1 was too close to the edge of the bed and had slid out of bed, legs first. Staff 3 stated when she entered the room, the resident was holding onto the side rail with her/his right arm and said, get me up. Staff 3 stated she assessed the resident, who was able to move both her/his arms and denied any pain to her/his right arm or shoulder area. Staff 3 stated the resident was put back into bed. On 9/18/24 at 2:27 PM, Staff 4 (LPN) stated she was aware Resident 1 fell out of bed on 8/17/24, and her/his right arm was caught in the bed rail, but the resident did not complain of any pain to the right shoulder until 8/20/24, which an X-ray was ordered. However, the resident was out to an appointment when the technician arrived on 8/20/24. Staff 4 stated Resident 1 was sent out to the hospital on 8/21/24, due to a critical lab result, and an X-ray of the right shoulder was obtained and revealed a fractured right shoulder. On 9/19/24 at 10:40 AM Staff 2 stated she completed the investigation regarding Resident 1's fall out of bed on 8/17/24. Staff 2 confirmed Resident 1 was too close to the edge of the bed, causing the resident to fall and fracture her/his right shoulder. Staff 2 stated the fall was avoidable. Staff 2 stated during shift change, she expected CNAs to have a peer-to-peer report, review the care plan and communicate with the nurses regarding care needs for all residents.

Based on observation, interview, and record review it was determined the facility failed to protect the resident's right to be free from sexual abuse by another resident for 1 of 2 sampled residents (#1) reviewed for sexual abuse. This resulted in Resident 1 experiencing psychosocial harm and increased distress. Findings include: Resident 1 was admitted to the facility in 3/2024 with diagnoses including dementia, mood disturbance, anxiety and developmental disorder of speech and language. A 3/22/24 Cognitive Loss and Dementia CAA revealed Resident 1 required one-step cueing for tasks, time to process cues and communication, and 24-hour supervision for safety. Resident 1 required a floor alarm because the resident did not remember to use the call light. Staff were to provide simple direct communication and interpret Resident 1's tone of voice and facial expressions. Resident 2 was admitted to the facility in 3/2024 with diagnoses including stroke and encephalopathy (damage or disease that affects the brain). Resident 2's care plan, initiated on 3/26/24, revealed Resident 2 had a stroke with left-sided weakness, was Spanish speaking only, had impaired eyesight and impaired cognition. A revision on 3/27/24 revealed Resident 2 had inappropriate physical behaviors and spoke inappropriately towards female caregivers. The resident was to be continuously supervised when in a public space, was impulsive and left her/his room independently. The staff were to provide care in pairs and remind Resident 2 what appropriate behavior and language were. Staff were to draw appropriate verbal and physical boundaries. Progress Notes revealed the following: -3/27/24 at 3:39 PM Staff 10 (Pastoral Care) visited Resident 2 but was unable to complete the assessment due to a language barrier. Resident 2 attempted inappropriate touch, which Staff 10 deflected. -3/27/24 at 6:08 PM Three CNAs reported Resident 2 grabbed and touched them during their shift, and made inappropriate remarks towards staff. Resident 2 was placed at a table away from other female residents. Staff 3 (LPN-Agency) spoke with Resident 2, with assistance from a Spanish-speaking CNA, and informed Resident 2 she/he was not allowed to touch staff inappropriately. -3/30/24 at 2:49 AM Staff 4 (LPN) revealed Resident 2 exposed herself/himself earlier in the shift, while a resident was outside of Resident 2's room. It was unclear if the exposure was intentional or not as Resident 2 made prior gestures to use her/his urinal. -3/30/24 [recorded as Late Entry on 4/2/24 at 10:15 AM] Staff 2 (DNS) was notified Resident 1 was inappropriately touched by Resident 2. The touch was unsolicited and not consensual. Staff were instructed to monitor Resident 2 and keep Resident 2 distanced from other patients for safety. Resident 2 was sent to the hospital at approximately 4:55 PM for nonemergent care related to inappropriate sexual behaviors. Random observations from 4/2/24 through 4/3/24 revealed Resident 1 was either in her/his room in bed, or up in her/his wheelchair out in the hallway, and was able to self-propel up and down the halls. Resident 2 was no longer in the building. On 4/2/24 at 11:07 AM Witness 10 (Police Officer) was interviewed and stated the following: -Witness 10 received a call from Staff 2 to report Resident 2 touched Resident 1 in an inappropriate sexual manner during breakfast on 3/30/24. -Witness 10 arrived at the facility and interviewed all parties involved. -Witness 10 stated Staff 5 (CNA) witnessed Resident 2 and Resident 1 move around the breakfast table toward one another when Staff 5 noticed Resident 2 started rubbing Resident 1's thigh in a sexual manner. Staff 5 moved Resident 2 out to the hallway, left both residents for approximately 90 seconds and returned with Staff 3. Resident 2 approached Resident 1 again and rubbed Resident 1's private area. Staff 3 and Staff 5 stopped Resident 2 and took Resident 2 back to her/his room. -Staff 5 reported Resident 2 attempted to touch her inappropriately when she took her/his blood sugar measurement, but was able to move out of the way. - Staff 3 reported Resident 2 was zeroing in on Resident 1 but did not give specific details as to what zeroing in meant. -Witness 10 interviewed Resident 1 but the resident was unable to recall what occurred. Resident 1 was upset, and stated to be nice because Resident 2 was her/his friend. -Witness 10 interviewed Resident 2, who denied touching Resident 1 in an inappropriate sexual manner. Resident 2 was able to carry a full conversation in Spanish with Witness 10 and understood Staff 5 told Resident 2 to go back to her/his room. -Witness 10 asked Resident 2 about sexually inappropriate behavior towards staff, such as offering money to staff for sexual favors. Resident 2 stated she/he did not have any money and then indicated she/he offered the nurse some money for the shower she/he received. On 4/2/24 at 11:35 AM Resident 1 stated she/he did not know how long she/he was at the facility. When asked if she/he recalled being inappropriately touched by another resident, Resident 1 replied, I don't remember, and mentioned she/he had difficulty remembering things. Resident 1 stated she/he had a bit of a headache. On 4/2/24 at 11:52 AM Staff 3 (LPN-Agency) stated she was familiar with Resident 1 and Resident 2. Staff 3 stated Resident 2 was Spanish-speaking but was able to communicate her/his needs. Resident 2 was impulsive and was sexually inappropriate towards staff. Resident 1 was pleasantly confused, impulsive and easily redirected. Staff 3 stated on 3/30/24 Resident 1 and Resident 2 were in the North Hall dining room, both within eyesight of staff. Staff 3 stated Staff 5 approached Staff 3 and indicated she needed assistance because Resident 2 rubbed Resident 1's leg and knee, and Staff 5 wheeled Resident 2 to the nurses station. Staff 3 entered the dining area with Staff 5, where they observed Resident 2 back at the dining table with Resident 1. Resident 2's hand was between Resident 1's legs, and Resident 2 was rubbing Resident 1's private area over Resident 1's brief and pants. Staff 3 stated she immediately wheeled Resident 2 away from Resident 1, and firmly stated, No, you can't touch people like that. Resident 2 understood the word no and Staff 3 escorted Resident 2 to her/his room. Staff 3 stated Resident 1 was initially upset when Resident 2 was removed from the area. Staff 3 stated Resident 1 was unable to answer questions and did not recall the incident. Later, Resident 1 requested to lay down for the day, which was uncharacteristic behavior. Resident 1 also expressed concern, stating, Don't let anyone sneak into my room. Staff 3 stated she believed Resident 1 had some awareness of what happened but was unable to voice it due to her/his dementia. On 4/2/24 at 1:22 PM Staff 5 (CNA) stated she worked with Resident 2 prior to the incident on 3/30/24. Resident 2 exhibited sexual behavior towards staff but not toward residents. Resident 2's care plan required two staff members in the room when interacting with Resident 2. Staff 5 recalled she heard about one incident when Resident 2 attempted to entice Resident 1 out of her/his room by flashing money. Resident 1 did not witness the behavior. Staff 5 stated during breakfast on 3/30/24 at approximately 8:30 AM Resident 1 and Resident 2 were seated across from each other in the dining room area. A nurse was at the nurses station and the residents were visible from the nurses station. Staff 5 stated she avoided an attempt by Resident 2 to inappropriately touch her when she checked Resident 2's blood sugar. Resident 1 and Resident 2 received their breakfast trays and as Staff 5 emerged from a room around the corner she observed Resident 1 and Resident 2 scooted closer to one another. Resident 2 was rubbing Resident 1's leg and knee back and forth. In response to the situation, Staff 5 promptly wheeled Resident 2 to the nurses station and sought assistance from Staff 3, urgently stating, I need you right now. Staff 5 and Staff 3 rushed to the dining area. Resident 2, who was able to self-propel, approached Resident 1 and grabbed Resident 1's private area over Resident 1's brief and pants. Resident 2 glanced around to ensure no one was watching. Staff 3 firmly told Resident 2, No, no, and Resident 2 raised her/his hands in response. Staff 3 wheeled Resident 2 back to her/his room. Staff 5 stated Resident 1 initially indicated Resident 2 did not harm her/him and Resident 2 was a friend. Resident 1 later became upset and reacted negatively. Approximately an hour afterward, Resident 1 expressed fatigue and a desire to rest her/his legs. Resident 1 stated, Hopefully I could get some sleep and no one will sneak in my room. Staff 5 stated she noticed Resident 1 seemed unusually agitated during the day shift, as her/his typical baseline behavior was pleasantly confused. When Staff 5 checked on Resident 1, she/he firmly stated, Don't touch me, and I don't want anything from you. On 4/2/24 at 1:59 PM and 4/3/24 at 12:14 PM Staff 4 (LPN) stated she worked with Resident 2, who was Spanish speaking. Staff 4 stated in the early AM hours prior to 8:30 AM on 3/30/24 Resident 2 was in bed with her/his genitalia exposed. Staff 4 believed the exposure was directed at Resident 1, although Resident 1 did not observe it. Staff 4 stated she was uncertain whether Resident 2 intentionally exposed herself/himself or needed to use the urinal. Staff 4 stated Resident 1 was confused at baseline and on 3/31/24 expressed concern and asked if, that man was still there. Staff 4 reassured Resident 1 no one was in her/his room. On 4/2/24 at 3:27 PM Witness 11 (Family Member) stated she received a call on 3/30/24 regarding Resident 1. Witness 11 stated another resident maneuvered to the opposite side of the table while Resident 1 was having breakfast and the resident engaged in inappropriate sexual behavior, touching Resident 1's private area. Witness 11 stated a staff member witnessed the incident, intervened, and separated the residents. Witness 11 stated staff retrieved assistance and when the staff returned the resident made her/his way back to Resident 1 and was rubbing Resident 1's private area, necessitating a second separation. Witness 11 stated she was upset about the incident and Resident 1, who lacked awareness of the situation, couldn't recall her/his own name, or effectively communicate. Witness 11 was uncertain whether the touching occurred over or under Resident 1's clothing, but regardless, such behavior should not have occurred. On 4/3/24 at 8:52 AM Staff 8 (CNA) stated she was not present on 3/30/24, when Resident 2 inappropriately touched Resident 1. Staff 8 stated Resident 2 was Spanish-speaking only, and she assisted with Resident 2's admission due to the language barrier. Resident 2 reported a sexually inappropriate act to her, when Resident 2 became aroused by a staff member at the hospital. Staff 8 stated she reported the conversation to Staff 9 (RN) who was in the room. Staff 9 indicated Resident 2 made inappropriate sexual comments at the hospital. Staff 8 stated she worked with Resident 1 on multiple occasions and the resident was pleasantly confused. Staff 8 stated she worked with Resident 1 on 3/31/24, the day after the incident with Resident 2. During charting, Resident 1 was in her/his wheelchair, lifted her/his shirt, exposing her/his breast. Staff 8 addressed the unusual behavior and was concerned. Staff 8 stated later in the evening, during her shift, Staff 8 assisted Resident 1 to bed. Resident 1 immediately called and asked if someone was in her/his room and Resident 1 asked, is that guy still there? Staff 8 assured Resident 1 there was no one in her/his room. Approximately five minutes later, around 9:30 PM Staff 8 returned to Resident 1's room, and Resident 1 again asked if that man was still out there. Staff 8 reassured Resident 1 once more. Staff 8 stated she reported her concern to Staff 4 (LPN) and she charted the incident. Staff 8 further stated she was fairly certain she knew Resident 1 was referring to Resident 2. On 4/3/24 at 1:29 PM Staff 9 (RN) stated she assessed Resident 2 upon admission to the facility. Staff 9 stated Resident 2, who spoke only Spanish, received assistance from Staff 8, who was also fluent in Spanish, for communication. Staff 9 stated Resident 2 had confusion, and Staff 8 relayed Resident 2 stated he experienced a sexual incident at the hospital and became aroused. Staff 9 stated she stepped out of the room with Staff 8 and shared hospital records indicated Resident 2 made inappropriate sexual comments to staff during her/his hospitalization. Staff 9 stated on one occasion Resident 2 offered staff money for sexual favors, but staff members firmly declined. Staff 9 stated Resident 2 put the money away, and Staff 9 believed this was an isolated occurrence. Staff 9 stated the money incident occurred prior to the 3/30/24 incident, during which Staff 9 was not present. Staff 9 stated upon returning to work, Resident 2 was no longer in the building. The 4/3/24 Investigation Summary Abuse Allegation revealed Resident 2 exhibited inappropriate behaviors while at the hospital, but no known knowledge of sexual assault. After admission to the facility, Resident 2 demonstrated growing behavioral concerns, prompting appropriate response from staff. Resident 2's care plan was updated to include increased behavior monitoring, two-person cares, redirection and setting appropriate boundaries. On 3/30/24 Staff 5 was assigned to Resident 2 and brought Resident 2 to the common area for breakfast, placing Resident 2 across the table from Resident 1. A nurse was at the nurses station and the residents were visible from the nurses station. At approximately 8:30 AM, Staff 5 delivered a meal tray down the hall. Upon returning, Resident 2 and Resident 1 both came around the table and met. Resident 2 was looking around while also reaching to rub Resident 1's thigh. Staff 5 intervened and expressed Resident 2's behavior was not appropriate. Staff 5 indicated despite the language barrier, Resident 2 indicated understanding and played it off with hand signals, suggesting Resident 2 was not doing anything wrong. Resident 1 expressed confusion and reported Resident 2 was my friend. Staff 5 moved Resident 2 into a separate hall and then sought help. Staff 5 returned in less than a minute with Staff 3. Resident 2 returned to the table and was witnessed rubbing between Resident 1's thighs and on her/his groin area. Staff 5 and Staff 3 separated Resident 1 and Resident 2, emphasizing Resident 2's behavior was not acceptable. Staff 5 indicated Resident 1 expressed frustration regarding their separation and Resident 2 was being nice. Staff 5 educated Resident 1 regarding the inappropriate touch. Resident 1 was agitated and in a poor mood for the remainder of the shift and requested to lie down because she/he was tired. After laying Resident 1 down, Resident 1 told Staff 5, Don't let anyone sneak into my room. Reassurance was offered. Although Resident 1 remained agitated into the evening, Resident 1 returned to her/his baseline according to Staff 5. The encounter between Resident 2 and Resident 1 on 3/30/24 was documented as unavoidable. Staff monitored Resident 2 and kept Resident 2 separated from other residents to the best of their ability. Resident 2 was sent to the hospital at approximately 4:55 PM for further evaluation due to her/his behavioral concerns. Resident 1 experienced a temporary change in her/his mood but returned to her/his baseline; no long-term harm occurred. Resident to resident sexual abuse was substantiated. On 4/3/24 at 2:18 PM Staff 2 (DNS) stated she initiated an investigation and concluded Resident 1 was sexually abused by Resident 2 based on her interviews and record review. The incident on 3/30/24 was witnessed by staff, and Resident 2 engaged in inappropriate sexual touch which was not consensual with Resident 1, as Resident 1 was unable to consent due to her/his cognition.

2. Resident 3 admitted to the facility in 2016 with diagnoses including right leg fracture, stroke and diabetes. A Pressure Ulcer Injury CAA dated 2/12/22 revealed Resident 3 was at risk for skin breakdown, especially related to pressure. Resident 3 had minimal position changes in a day, poor perfusion due to multiple comorbidities, and had generalized weakness. Resident 3 had a right leg fracture and had a brace on the right leg. A physician order dated 2/15/22 instructed staff to discontinue Resident 3's knee brace and was to continue non weight bearing activity. A 2/16/22 Occupational and Physical Therapy Note revealed Resident 3 was working with Staff 6 (Occupational Therapy) and Staff 7 (Physical Therapy) in therapy. Resident 3's brace was discontinued per physician order on 2/15/22, but just removed the brace during the session. In an attempt to don socks Resident 3 reported pain to the right ankle and Staff 6 noticed a wound near the right lower extremity on the ankle which was approximately 4 cm's in size. Staff 6 reported the finding to nursing staff. A 2/16/22 Progress note revealed therapy was working with Resident 3 and noted an open area to her/his right lateral malleolus (ankle). Resident 3 had been wearing a knee brace (immobilizer) until 2/16/22. Resident 3's right ankle bent in a way that her/his right foot faced inward at baseline. The open area was located at the area where the metal portion of the immobilizer was resting. The wound was a Stage 2 (partial thickness skin loss, a shallow open ulcer with a red, pink wound bed) pressure injury with a red wound bed. There was also one small area that was yellow/brown. A review of Resident 3's clinical record revealed on 2/16/22 treatment was initiated to address the new Stage 2 pressure ulcer. No documentation was found in the clinical record regarding an order for Resident 3's right leg immobilizer and no indication of how often to check for skin integrity under the right leg immobilizer. A Observation Detail List Report dated 2/16/22 revealed Resident 3 had a Stage 2 pressure ulcer. The wound to the right lateral ankle was red in color with one small area containing yellow and brown. The wound measured 4.6 cm x 3.0 cm and 0.1 cm, drainage was serosanguineous (watery fluid that is red to pink in color), no odor and the condition around the wound bed was pink with skin intact and was newly noted. No information regarding if Resident 3 had pain or discomfort to the area. A Observation Detail List Report dated 3/3/22 (15 days later) revealed Resident 3 had a Stage 2 pressure ulcer. The wound to the right lateral ankle measured 5.0 cm x 0.8 cm the wound color was black/brown eschar (dead tissue) and no drainage. The wound was scabbed with a completely healed area in the 5 cm length. No drainage or tenderness. No information regarding if Resident 3 had pain or discomfort to the area. A Observation Detail List Report dated 3/9/22 (six days later) revealed Resident 3 had a Stage 2 pressure ulcer. The wound to the right lateral ankle measured 3.0 cm x 0.8 cm the wound color was black/brown eschar and no drainage, odor or open skin, healing in progress. No information regarding if Resident 3 had pain or discomfort to the area. A Wound Management Detail Report dated 3/23/22 (20 days later) revealed the wound measured 1.5 cm x 1 cm, no drainage and the tissue type was closed/resurfaced. The wound had well defined wound edges and the skin surrounding the wound was pink/normal and was improving. No information regarding if Resident 3 had pain or discomfort to the area. A Wound Management Detail Report dated 3/30/22 (seven days later) revealed the wound measured 1.3 cm x 1.3 cm with light serosanguineous exudate, well defined wound edges and the skin surrounding the wound was pink/normal and was noted as declining. No information regarding if Resident 3 had pain or discomfort to the area. A Wound Management Detail Report dated 4/20/22 (31 days later) revealed the wound measured 4.5 cm x 1.0 cm was a Stage 2 pressure ulcer and the tissue type was closed/resurfaced with well-defined wound edges and the skin surrounding the wound was pink/normal and was noted as improving. No information regarding if Resident 3 had pain or discomfort to the area. A Wound Management Detail Report dated 5/27/22 (37 days later) revealed the wound measured 4.5 cm x 1.0 cm was a Stage 2 pressure ulcer and the tissue type was closed/resurfaced with well-defined wound edges and the skin surrounding the wound was pink/normal and was noted as improving. No information regarding if Resident 3 had pain or discomfort to the area. A Wound Management Detail Report dated 6/3/22 revealed the Stage 2 pressure ulcer was healed but with a slight red scar to the area. On 7/28/22 at 7:32 AM Staff 3 (LPN) and Staff 5 (RN) both stated Resident 3 acquired a pressure injury to her/his right ankle because of how her/his ankles rolled outward at rest but could not recall the leg brace. On 8/1/22 at 11:36 AM Staff 6 stated she worked with Resident 3 on 2/16/22 and removed the brace from her/his right leg and was donning a sock to the right foot and Resident 3 stated ouch that is really painful. Staff 6 stated she could see a wound to the area which was roughly 4 cm's around and appeared it was caused by the brace rubbing on the right ankle. Staff 6 stated she alerted nursing staff to assess the wound. On 8/1/22 at 1:57 PM Staff 7 indicated she worked with Resident 3 after she/he had fractured her/his right leg and returned from the hospital in 2/2022. Staff 7 stated on 2/16/22 it was ok to remove the right leg immobilizer and attempted to place a sock on her/his right foot when Resident 3 said ouch when lifting up her/his foot. Staff 7 stated she could see a wound to the right ankle from the immobilizer. Staff 7 stated therapy was stopped and a nurse was notified. On 8/1/22 at 11:18 AM and 7/29/22 at 12:00 PM Staff 2 (DNS) stated Resident 3 returned from the hospital on 2/3/22 with a right leg immobilizer, however there was not an order for the immobilizer and facility staff should have followed up on the order. Staff 2 stated the investigation into the Stage 2 pressure ulcer to the right ankle was documented in the 2/16/22 progress note. Staff 2 stated she did not find documentation from 2/3/22 through 2/16/22 of a staff assessment of Resident 3's skin integrity to the right lower leg to ensure there were no wounds under the right leg immobilizer. Staff 2 stated staff initiated weekly observational forms to monitor the Stage 2 pressure ulcer and additionally utilized the wound management detail report. Staff 2 further stated weekly assessments should be completed by staff. Based on observation, interview and record review it was determined the facility failed to ensure pressure injury wounds were appropriately assessed, monitored and treated for 2 of 3 sampled residents (#s 3 and 18) reviewed for pressure injuries. This placed residents at risk for inaccurate wound assessments and worsening wounds. Resident 18 had a coccyx wound that worsened from Stage 2 to Stage 4. Findings include: 1. Resident 18 was admitted to the facility in 2/2022 with diagnoses including infection of the tailbone and sacrum/coccyx (portion of spine between lower back and tailbone), a Stage 2 pressure injury (a partial thickness loss of skin with exposed dermis) to the sacrum/coccyx and quadriplegia. The 2/25/22 initial assessment of Resident 18's Stage 2 sacral pressure injury indicated the wound was 1.2 cm in length and 0.6 cm in width, with epithelial tissue (thin protective layer), well-defined edges, no drainage, no odor and the skin surrounding the wound was dark purple or rusty discoloration. The assessment identified the wound as stable and present on admit with the surrounding skin blanchable (becomes lighter when pressed). The family indicated the wound was much more open and has been healing. The wound was covered with Allevyn (foam) dressing for protection. A photo provided by the facility of the area, from 2/25/22, showed an area of deep red to purple with a defined darker area in the center over the resident's coccyx. The wound appeared to have a shallow open area in the center, although there was also a deep purple area within the border. The facility classified the wound as a Stage 2 pressure ulcer. However, the appearance of the wound, including the area surrounding the center in the photo was consistent with a description of Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration over intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. The wound may evolve rapidly to reveal the actual extent of the pressure injury. The resident's 2/25/22 Care Plan revealed the following information regarding her/his pressure ulcer: The resident had impaired skin integrity related to Stage 2 pressure injuries (on heels) and unstageable-S4 on her/his coccyx/sacrum; care approaches include: wound care to coccyx per current orders, ensure her/his special mattress was operational, regular diet per SLP services, general mulitivitamin with minerals and vitamin C for healing, supplements including Boost mixed with ice cream to help with providing extra protein for healing, minimize layers between her/his skin/wounds and mattress, assist her/him to reposition frequently and float heels while in bed. Will need to help reposition the bed or devices as well so she/h can see her/his tablet/TV and reach her/his call light straw with her/his lips and alert the nurse of any skin changes. The following wound care orders for Resident 18's sacral/coccyx wound were located in her/his medical record: -2/25/22 discharge orders from the physician at the hospital: Use liquid/spray skin protectant, cover with foam dressing, adhesive, change every two days or PRN if soiled. -2/25/22, Staff 38 (Medical Director): Change Allevyn dressing to coccyx two times per week and PRN. There was no documentation in the medical record to indicate the wound care orders were reviewed to determine which one was appropriate. Resident 18's MARs revealed wound care was provided to her/his coccyx two times a week from 2/27/22 through 3/15/22. On 3/18/22 Staff 38 discontinued the Allevyn dressing and provided new orders to apply moisture barrier cream to the coccyx every shift and ensure the resident was turned and off-loaded from her/his coccyx. A 3/18/22 Wound Management Detail Report indicated the wound measured 1.2 cm in length and 0.7 cm in width, had light exudate (drainage) and granulation tissue (healing) and was noted to be improving. On 3/27/22 the wound status was documented as 2.8 cm in length and 0.3 cm in width, declining, larger in size and open more than before. On 4/7/22 the hospital physician provided new wound orders for the resident's sacrum: Use liquid/spray skin protectant and cover with foam dressing, adhesive and change every two days. Special instructions included to wake the resident to do the dressing. There was no documented evidence the 4/7/22 orders were implemented on the 4/2022 MAR. The previous orders from Staff 38 on 3/18/22 were continued through 4/15/22 when Resident 18 was admitted to the hospital. Resident 18 was discharged from the hospital on 4/18/22 with wound care information and orders completed by the wound/ostomy RN: -Wound Assessment: Sacrum: 4 cm by 3 cm by 1 cm, Stage 3 (Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by location; Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage or bone is not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.) pressure injury; community acquired. Surrounding skin indicates the wound started as a deep tissue injury and has now demarcated (formed defined edges) to reveal pink, moist tissue with slough or fibrin in the base. The resident has had a pressure injury in the same spot and is now at higher risk for continued breakdown. The wound/ostomy RN's 4/18/22 recommendations for wound care: Wound gel to the wound bed, followed by silicone foam dressing; change every two days. The resident will need aggressive turning and repositioning continuously to help heal the wound and prevent further breakdown. The plan for the wound at discharge was a referral for outside wound care support. There was no documentation the resident's care plan was updated to reflect aggressive turning and repositioning to help heal the wound. Resident 18's 4/18/22 hospital discharge orders also included a second set of coccyx wound orders: Stage 2 pressure injury at coccyx: clean with normal saline and place protective dressing PRN. The medical record revealed on 4/18/22 Staff 42 (RN) initiated the resident's pre-hospitalization coccyx wound orders for use of moisture barrier cream and ensure the resident was floated, turned and off-loaded from her/his coccyx. The treatment was documented from 4/18/22 through 4/30/22. In addition, on 4/19/22, Staff 38 ordered a sacral wound treatment to cleanse the wound, apply Iodoflex or Iodosorb (iodine-based) ointment to wound bed, cover with Allevyn dressing and change three times per week. There was no documentation in the resident's medical record to demonstrate the multiple wound orders on 4/18/22 and 4/19/22 were reviewed to determine which were appropriate for the resident's wound care. The hospital wound care orders were not added to the 4/2022 MAR. A Wound Management Detail Report on 5/6/22 revealed the resident's sacral wound was 7 cm in length and 5 cm in width with a moderate amount of seropurulent (watery, pus-like) drainage. The skin surrounding the wound was dark purple or rusty discoloration; blanchable. It was noted the wound looked much worse than the previous week. The 5/2022 MAR revealed the treatment with Iodoflex or Iodosorb ointment to wound bed, cover with Allevyn dressing and change three times per week was provided to the sacral wound from 5/1/22 through 5/18/22. On 5/19/22 a new treatment was implemented with the use of iodine on a yeast rash on the buttocks and in the gluteal cleft, use of Santyl (removes dead tissue from wounds) in coccyx wound if open and draining, cover with Allevyn dressing and change every other day. On 5/26/22 packing the wound with gauze was added to the wound care treatment and the wound care was changed to daily. A 5/26/22 Wound Management Detail Report revealed the resident's coccyx wound was 5 cm in length, 6 cm in width, with a depth of 2 cm. The wound was noted to now be a Stage 4 (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the wound bed, it is an unstageable PU/PI.), with mild odor, necrotic tissue and declining in healing status. The wound was described to have multiple areas of undermining and tunneling, with the surrounding skin dark red/purple around wound, warm to touch and blanching. There was no documentation in the medical record of a thorough assessment to describe how the coccyx wound progressed from a Stage 2 to Stage 4 wound, including what factors caused it to worsen or what new interventions were implemented. On 6/7/22 wound care orders were implemented to include the use of cacium alginate dressing with silver (absorbs wound fluids) and cover the wound with ABD dressing (highly absorbent). 6/13/22 Progress Notes indicated the resident's family notified facility staff one of the wound consultant physicians wanted Resident 18 to be seen at the ED (Emergency Department) for bacteria in her/his wound, surgical debridement of the wound and imaging. The resident was transported to the ED via EMS (emergency medical services). According to hospital medical records from 6/13/22 through 6/22/22 the resident required IV (intravenous) antibiotics for treatment of wound infection. The IV antibiotic treatment would continue after discharge for a total of six weeks. The 6/22/22 Hospital Discharge Summary indicated Resident 18 was diagnosed with a worsening Stage 4 pressure wound with multiple contibutors including: quadriplegia, nutrition, hard wheelchair/cushions, local wound care, potentially under-treated muscle spasticity. Plastic surgery would not recommend a flap until these factors were remediated. The Discharge Summary included further recommendations: Every two hour turns: turn side to side, NO TIME on back; needs a specialized wheelchair cushion, baclofen 10 mg BID to treat spasticity and plastic surgery follow-up in three months. The 6/22/22 Discharge Summary included new coccyx wound treatment orders: Cleanse and irrigate wound with normal saline, paint peri-wound skin with Cavilon skin prep (ultra-thin skin barrier) moisten kerlix gauze with Dakin's solution (wound cleanser), loosely fill wound with Dakin's moistened gauze - ensure all undermined areas of wound are loosely filled; cover with ABD pad and secure with mesh underwear or minimal tape, twice daily. On 7/25/22 at 2:20 PM this surveyor observed Resident 18 and Witness 5 (Family), in the resident's room. The resident was alert, oriented and talked freely about her/his medical needs and care at the facility. Witness 5 stated there was almost always a family member here with the resident for support and to ensure care was given correctly. Witness 5 indicated the resident had an open area on her/his coccyx that was infected. The resident was observed on a specialized fluid immersion simulation bed and Witness 5 stated it was their own bed and they brought it into the facility for the resident to use. On 7/26/22 at 11:36 AM Witness 4 (Family) was visiting Resident 18 and Witness 4 voiced concern because staff told them pressure sores were not preventable. Both the resident and Witness 4 told this surveyor the resident was not always turned every two hours as required. During the interview at 12:00 PM two CNAs entered the resident's room to reposition her/him. After the CNAs left the room Witness 4 stated she had been there all morning and the last time the resident was turned or repositioned was at 9:00 AM. On 7/27/22 at 5:39 PM Witness 3 (complainant) stated he observed Resident 18's sacral wound during her/his hospitalization in 6/2022 when he took care of the resident's medical needs. Witness 3 stated the Stage 4 pressure injury was quite deep and due to the resident's inability to care for herself/himself, staff were responsible for most of her/his needs and ensuring pressure relief was provided appropriately. Witness 3 indicated the resulting wound was likely the result of neglect due to lack of enough position changes. Witness 3 stated he discussed his concerns regarding the sacral wound with the resident's family. On 8/1/22 at 10:26 AM Staff 32 (RN) stated she was part of the staff who participated in Resident 18's initial admission and her/his wound was pretty minor at that time. Staff 32 stated the wound was a Stage 2 on admit. Staff 32 revealed the resident was turned every two hours and required two staff to do so. Staff 32 indicated the completion of the resident's turning schedule was documented on the TAR and by the CNAs, plus they give shift-to-shift report when the last time the resident was repositioned. Staff 32 stated the resident's wound had worsened around the end of May of this year when there was a staffing decrease. Staff 32 indicated after the wound worsened it required surgical debridement in the hospital. On 8/1/22 at 1:22 PM Staff 42 (CNA) stated the resident's transfers or position changes were always two-person and they used a transfer blanket for him/her which was very helpful. Staff 42 stated they tried to do at least every two hour position changes and the resident was very alert and patient during her/his care. On 8/1/22 at 1:22 PM Staff 33 (CNA) stated they used a draw-sheet type blanket to move the resident to assist with changing her/his position. Staff 33 stated the resident got out of bed sometimes and she/he liked to get a shower at least once a week. In an interview on 8/1/22 at 4:17 PM Staff 34 (RN/Infection Preventionist) stated she had previously seen the resident's wound and written some wound care orders in her capacity as a wound care nurse. Staff 34 stated the wound was a Stage 2 when the resident was admitted , then it became unstageable and was now a Stage 4 wound. During interviews on 8/2/22 at 9:28 AM and 11:11 AM Staff 2 (DNS) and this surveyor reviewed Resident 18's coccyx wound care information. Staff 2 stated the resident's wound care orders came from multiple sources including: Staff 34, Staff 38, doctors at the wound clinic and hospital orders. Staff 2 indicated she did not know specifically how the wound progressed from Stage 2 to a Stage 4, but stated the facility provided multiple things including changing treatments, outside consults, dietary consults. Staff 2 stated she did not feel they caused the resident's coccyx wound to worsen because they were changing orders all the time and trying to find something that worked. Staff 2 indicated she did not see the 4/18/22 referral from the hospital wound nurse regarding wound care. On 8/4/22 at 8:40 AM, Staff 38 (Medical Director) acknowledged he treated Resident 18's sacral wound and stated there were multiple reasons why wounds worsen. Staff 38 indicated pressure injury wounds were difficult to care for and there were many challenges involved, including staffing at the time. Staff 38 indicated many were involved with the care of the resident's wound including outside wound care. Staff 38 stated he was not sure how worsening of the wound could have been avoided. Staff 38 indicated pressure ulcers still happen even when people are getting good care it was difficult to prevent them.

Based on interview and record review it was determined the facility failed to re-evaluate a resident injury after the resident reported additional symptoms for 1 of 4 sampled residents (#3) reviewed for accidents. Resident 3 experienced pain from an undiagnosed leg fracture. Findings include: Resident 3 admitted to the facility in 2016 with diagnoses including right leg fracture, stroke and diabetes. A 1/13/22 Progress Note revealed Resident 3 was found on the floor by staff in the early morning. Resident 3 used the commode without calling for assistance and when attempting to get back in her/his recliner slipped down to the floor and landed on her/his buttocks. An assessment was completed with ROM which was within normal limits and at the time of the fall the resident had no complaints of pain however later during the shift Resident 3 complained of right calf pain and discomfort. A Late Progress Note entry on 1/14/22 (for 1/13/22) revealed a request was made on 1/13/22 for an X-ray of Resident 3's right foot and ankle but a technician was unable to get to the facility due to staff shortages and the X-ray would not be completed until 1/14/22. Resident 3 complained of foot and ankle pain and Staff 3 (LPN) noticed dark purple bruising around her/his right ankle and Resident 3 stated the pain was 10 out of 10. Results of the right ankle/foot X-ray was negative for a fracture. Progress Notes from 1/15/22 through 1/18/22 revealed Resident 3's right ankle was swollen; bruising had lessened and Resident 3 complained of pain off and on. Resident 3 did report her/his ankle was painful with touch. Pain medications were given and at times were effective. Resident 3 was being assisted with use of mechanical lift for toileting because she/he could not bear weight to her/his right lower ankle. A Physical Therapy Note dated 1/18/22 revealed Resident 3 was agreeable to physical therapy but reported she/he was unable to move her/his RLE since her/his fall and was not open to Staff 7 (Physical Therapist) touching her/his leg due to fear of pain. Resident 3 was unwilling to allow Staff 7 to move her/his RLE with her hands or use a sheet (due to hypersensitivity of skin per Resident 3's report). Resident 3 responded It will move when it moves. I'm not going to let people force it. Resident 3 declined transfer reporting that she/he was voiding in her/his brief to avoid transfers and was only agreeable to move her/his leg, once she/he felt it was ready and did not want to be pushed with activity. Prior to her/his fall she/he was able to use a front wheeled walker and transfer with assistance to a bed side commode. A Occupational Therapy Note dated 1/19/22 revealed Resident 3 was seen by Staff 6 (Occupational Therapist) and she/he complained of 10/10 foot pain. Resident 3 declined standing or attempts to transfer out of her/his recliner. Resident 3 declined occupational therapy treatment due to fear of standing and did not want to use her/his power scooter. A 1/19/22 Progress Note revealed Resident 3 was painful, fearful of more pain with touch, moving or weight bearing and declined to stand or attempt to transfer out of her/his recliner in her/his room. A Physical Therapy Note dated 1/20/22 revealed Resident 3 declined treatment due to pain in RLE. There was no documented evidence the physician was notified of Resident 3's inability to participate in therapy due to increased pain. A 1/25/22 Progress Note revealed Resident 3 complained of severe pain during care. Nursing staff assessed Resident 3 and she/he stated the pain was from her/his right knee to her/his right hip while laying on her/his right side. There was no redness, swelling or bruising noted to the right hip or knee area but the extremity was slightly warm. The physician was notified would assess the resident on 1/26/22. A Physical Therapy Note dated 1/26/22 revealed Resident 3 reported to nursing staff significant pain in RLE from hip to foot with rolling and a hip X-ray was requested. CNA staff were assisting Resident 3 with ADL care in bed and Staff 7 provided breathing techniques to help decrease complaints of pain because she/he was yelling in pain with attempts to roll her/him to the left side. Resident 3 required two or three staff to roll partially to the left with Resident 3 complaining of significant right hip pain. Resident 3 continued to experience and report high levels of RLE pain. A Progress note dated 1/27/22 revealed an X-ray of the right hip and knee was completed. 18 days after the fall on 1/13/22. A Progress note dated 1/28/22 revealed the X-ray results verified Resident 3 had a distal right femur fracture with significant displacement. Witness 1 (Family Member) and physician were notified and Resident 3 was sent to the hospital. On 7/28/22 at 11:46 AM Staff 5 (RN) stated she was not present for the fall but on 1/14/22 she assessed Resident 3 and she/he had faint bruising on the right knee and she/he complained of ankle pain but could move her toes and lift her/his right leg a little bit. Staff 5 stated by evening shift Resident 3 had bruising and swelling around the ankle and was complaining of more pain to the ankle. An X-ray was completed and indicated she/he did not fracture her/his ankle or foot. Staff 5 stated as time went by Resident 3 refused to stand or transfer due to her/his pain and discomfort and was provided ADL care with use of a mechanical lift to get her/him on the bedside commode because she/he refused to use a bed pan due to pain and discomfort. Staff 5 stated roughly a few days prior to the resident being sent out to the hospital she/he started screaming and had increased pain when ADL care was provided. An stat X-ray was ordered and confirmed Resident 3 fractured her/his right leg and she/he was sent out to the hospital. On 7/28/22 at 1:07 PM Staff 9 (CNA) stated Resident 3 had on-going pain after the 1/13/22 fall and was painful with repositioning or during ADL care. Staff 9 stated Resident 3 would grimace and moan with any sort of touch to her/his RLE not just her/his ankle. On 7/28/22 at 1:29 PM Staff 6 (Occupational Therapist) and Staff 7 (Physical Therapist) were present for an interview. Staff 6 stated she completed an evaluation on 1/19/22 (six days after the fall) but Resident 3 was very painful to her/his RLE and declined standing, transfers and did not want to use her/his power chair. Staff 7 stated she completed an evaluation on 1/18/22 (five days after the fall) and stated Resident 3 did not appear in pain at rest but would not bear weight to her/his right leg, would not allow her/his leg to be touched. On 7/28/22 at 7:32 PM and 3:03 PM Staff 3 (LPN) stated she worked evening shift on 1/13/22 and after the fall noticed some bruising and swelling to the right ankle and Resident 3 was complaining of pain. Resident 3 was able to move her/his toes, ankle and lift her leg slightly. Resident 3 complained of severe pain when CNAs provided incontinence care in bed. Staff 3 stated the resident was screaming and when she assessed her/him there was no bruising or swelling in her/his right leg but Resident 3 refused care and did not want to move the right leg. Staff 3 confirmed an X-ray of Resident 3's ankle was obtained. On 7/29/22 at 10: 11 AM Staff 37 (LPN) stated she was not present for the 1/13/22 fall but two days after the fall Resident 3 was in a lot of pain to her/his entire right leg and any type of movement caused her/him severe pain. Prior to the fall she/he was a one-person assist with a front wheeled walker from her/his recliner to the bedside commode. Staff 37 stated she had been concerned with Resident 3's continued severe pain and was not sure how helpful her/his pain medications were. The physician was not notified of Resident 3's increased pain and decrease in her/his ADL status. On 7/29/22 at 2:37 PM Staff 38 (Medical Director) stated regarding the right femur fracture he covered for Staff 39 (Physician) and determined the right leg fracture was not identified timely. Staff 38 stated he did not believe Resident 3 complained of pain but was not sure. On 7/29/22 at 10:39 AM Resident 3 stated she had a fall earlier in the year and had ongoing pain to her/his RLE which hurt with movement. Resident 3 stated she/he was frustrated because staff did not listen to me! On 8/1/22 at 12:48 Staff 2 (DNS) stated Resident 3 self-transferred on 1/13/22 which resulted in her/his fall but Resident 3 only complained of right foot and ankle pain. Staff 2 indicated the facility obtained an X-ray to the area which was negative. Staff 2 stated Resident 3 had increased pain a few days prior to being sent out to the hospital on 1/28/22. Staff 2 stated if Resident 3 had increased pain and was not participating in therapies it would be expected for staff to notify the physician. Staff 2 stated Staff 39 ordered an X-ray of the entire right leg and she was shocked that she/he had a fractured right leg because Resident 3 had no swelling or bruising other than the ankle area. There was no documented evidence the physician was notified until 1/25/22 (12 days after Resident 3's fall) regarding Resident 3's increased pain and her/his inability to participate in ADL's.