**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that 1 of 89 residents received adequate supervision and assistance devices to prevent accidents. Specifically, a resident was transferred with the help of one staff member using a sit to stand device. This was determined to have occurred at a harm level. However, based on the facility's investigation and corresponding correction, this was cited at past non-compliance. Resident identifier: 217. Findings include: 1. Resident 217 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included cerebrovascular accident, right bundle branch block, heart failure, and major depressive disorder. Resident 217's medical record was reviewed from 7/8/24 through 7/16/24. On 9/27/23, the facility completed a Functional Performance Evaluation for resident 217. The evaluation indicated that the resident was unable to stand up from a seated position due to medical condition or safety concerns. The evaluation also indicated that the resident was dependent on staff to help him transfer to and from a bed to a chair. On 9/29/23, a Weekly Skin Evaluation was completed for resident 217. The resident's skin was observed to have no bruising or wounds, and was documented to be warm, dry and intact. On 9/30/23, a nurses note documented that at 6:10 PM, aide reported pt's (patient's) L (left) shoulder swollen and bruised. L shoulder very swollen, firm, looks like it/s (sic) further forward than R (right) Shoulder. Bruising on shoulder and down inner and outer upper arm. When I attempted to move arm, pt called out and flinched. An X ray was subsequently ordered. On 10/1/23, a nurses note documented that resident 217 returned from the emergency room with .findings of a fracture of the left humeral surgical neck, including displaced greater and lesser tuberosity . On 10/1/23, the facility submitted form 358 to the State Survey Agency. The form indicated that resident 217 was observed to have bruising on his left shoulder, and the resident had subsequently been sent to the local emergency room for evaluation. On 10/4/23, the facility submitted form 359 to the State Survey Agency. The form indicated that during the course of the investigation, it was determined that CNA 4 used a sit to stand machine to transfer the resident from a chair into bed. CNA 4 stated that while transferring the resident, the resident was unable to bear weight causing his arms to move upward, but was able to finish the transfer. The resident was not noted to be in any pain at that time. A unit manager indicated that on 9/30/23, she was made aware of bruising to resident 217's left shoulder. The resident had an X-ray completed which showed a fracture and was sent to the local emergency room for evaluation. In the emergency room, resident 217 had a confirmation X-ray completed that indicated a comminuted, impacted, and angulated fracture of the left humeral neck. secondary to CVA resident is non verbal and unable to voice how he is feeling. The resident was discharged back to the facility the same day due to poor prognosis secondary to CVA the hospital stated he is not a candidate for surgery at this time. Resident is to remain on hospice care with comfort measures. The facility determined that abuse/neglect was verified, as upon investigation it was determined that the fracture most likely occurred while [resident 217] was being transferred in the sit to stand and was unable to bear weight. The facility's investigation that accompanied form 359 was reviewed. The facility noted that on 9/28/23 CNA 4 worked with resident 217. Also on that day, CNA 3 reported bruising to SM 2. SM 2 reported that there were no complaints of pain from resident 217, and that he observed resident 217's bruising, but thought it was old. [Note: The weekly skin assessment inaccurately documented that there were no skin issues on 9/29/23 even though bruising had been observed the day prior.] The investigation also indicated that resident 217's bruising was not reported to management until 9/30/23, approximately 2 days after the bruising to resident 217's left shoulder was initially observed. The following investigation was provided by the facility: Investigation [resident 217]. admission Date: 10/2/2023, admission DX (diagnoses): CVA (cerebrovascular accident), Right bundle branch block, heart failure, MDD (major depressive disorder). REPORT: [Staff member (SM) 1] phoned to this DON (Director of Nursing) on 9/30/2023 1833 (6:33 PM) Left shoulder with bruising and swollen, change in ROM (Range of Motion). Provider and family made aware order in place for hospital transfer to verify the X ray result. He did come back on 10/1/2028 (sic) with written report of fracture to the left humeral surgical neck. He is not a surgical candidate at this time secondary to poor health condition. He will remain on hospice care PRN (as needed) pain medication and change of condition charting in place. INVESTIGATION: DON came to the building on Sunday 10/1/2023. Multiple staff members were interviewed that worked with resident. [Certified Nursing Assistant (CNA) 3) CNA reported that on Tuesday morning they went into [resident 217's] room where the sit to stand was noted to be in the room. Monday 9/25/2023 staff members were interviewed [CNA 4] stated that on 2-10 shift that did he did use a sit to stand lift to transfer resident. Resident is unable to bear weight his plan of care requires a hoyer transfer. [CNA 4] reported that he (resident 217) did not complain of pain or show any signs of pain at the time he was able to finish the transfer into his bed. He (CNA 4) did report that his (resident 217's) arms moved up while he was in the sit to stand lift. [CNA 4] did not report this to the nurse because he did not believe any injury had occurred. ((CNA 4) was suspended during this investigation). Residents were interviewed to see if they had any care concerns with [CNA 4] they had no concerns. The following residents were interviewed. [Name of 5 residents]. 9/26/2023 . [CNA 3] reported the sit to stand was in the room. No bruising no co (complaints of) pain. 9/28/2023 . [CNA 3] reported bruising to [SM 2]. [SM 2] reports no co pain, no change in ROM . He thought brusing (sic) was old. 9/30/2023 . [SM 3] reported to [SM 4 and SM 1]. Assessment complted (sic) X-ray ordered. Conclusion: Team believes that the fracture occurred when he was transferred with a sit to stand on Monday 9/25/2023 with [CNA 4]. Secondary to [resident 217's] current condition he is a hoyer lift for all transfers. He is not able to bear weight because of his CVA. [CNA 4] reported that he thought he had a change and was able to use the sit to stand. He did transfer him with a one person transfer. [CNA 4] has prior educated on this (sic). [Resident 217] has Q (every) shift monitoring in place with pain monitoring and management. His condition remains poor prior to the incident and stable after. Family and provider are aware of the updated POC (plan of care). 10/4/2023 [CNA 4) was terminated from St. [NAME] Villa secondary to using a sit to stand with a hoyer lift resident and performing the transfer with 1 person. [SM 2] was given 1:1 education regarding following up on change of condition and reports of the bruise. [SM 5] was given 1:1 education regarding skin check that was performed on 9/29. Performance Improvement plan: 1. Audit of all residents with current sit to stand transfers are being evaluated by therapy. This will ensure the current lift that is being used are (sic) appropriate for the resident status. 2. Re education is being performed 1:1 in huddles or over the phone regarding COC (change of condition), bruising ROM. Which lift is appropriate for resident current condition. 3. Audits are being completed with department heads on spot checking rooms to ensure staff members are using the appropriate lift with two-person transfer. 4. Unit managers were made aware of any changes with therapy evaluation with the lifts. Update 10/23/2023 Resident condition remains baseline at this time. Staff audits have been conducted along with re education. No further transfers with one person, staff audits have been completed they are using two person with transfers. Attached to the investigation was a document entitled St. Joes Education Sheet which stated, . If you're (sic) resident is not able to stand up and assist with the transfer, they are NOT able to use a sit to stand lift. The sit to stand lift is only for residents that can help stand. TWO people are required with the sit to stand lifts and hoyer lifts. If you use a lift with one person you will be terminated. If you have a resident with bruising, change in range of motion, complaining of pain you must notify your nurse immediately. Nurses it is your responsibility to do the assessment. You must notify the unit manager of the bruise to ensure that we know how it happened. Any unknown bruise must be reported to [Administrator] and [DON] immediately . On 7/15/24 at 11:25 AM, an interview was conducted with the DON. The DON stated that resident 217 could shake his head yes or no and answer yes and no questions. The DON also stated that resident 217 stated that resident 217 could indicate if he was in pain, but was unable to describe anything specific. The DON stated that resident 217 was supposed to be transferred using a hoyer lift with 2 people. The DON stated that each CNA receives a document that is informally referred to as a brain that they can reference for specific instructions on what assistance each resident requires. The DON stated that resident 217 was listed on the CNA brain as requiring a hoyer lift, and she was unsure why resident 217 was transferred by CNA 4 using a sit to stand instead. The DON stated that she had reviewed video footage, and confirmed that CNA 4 did enter resident 217's room with a sit to stand machine. The DON also confirmed that the Weekly Skin Assessment that was completed on 9/29/23 was inaccurate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined, for 1 of 42 sampled residents, that the facility did not ensure that a resident with pressure ulcers (PU) received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. Specifically, the resident developed multiple areas of new pressure ulcers after admission to the facility. The deficient practice identified was found to have occurred at a harm level. Resident identifier: 83. Findings included: Resident 83 was admitted to the facility on [DATE] with diagnoses which consisted of incomplete paraplegia, osteomyelitis, neurogenic bowel, type 2 diabetes mellitus, gastro-esophageal reflux, severe protein-calorie malnutrition, atrial fibrillation, hypertension, and major depressive disorder. On 8/29/22 at 1:59 PM, an interview was conducted with resident 83. Resident 83 stated he had a PU on the buttocks. Resident 83 stated he received dressing changes to the wounds every 3 to 4 days. Resident 83 stated that the wound on his buttocks was dry skin that would flake off and then would become raw. Resident 83 stated he was not sure if the wound was treated properly. Resident 83 stated he had been on air mattress since admission. On 9/1/22 resident 83's medical records were reviewed. Review of resident 83's physician orders revealed the following: a. WOUND CARE: LEFT PLANTAR FOOT: 1. Cleanse with Vashe or Dakins 0.25% and soak for 5 minutes 2. Apply skin prep to peri wound 3. Apply Iodosorb to wound bed 4. Cover with Aquacel and with padded dressing. Change Tuesday, Thursday and Sunday and as needed (PRN) if soiled or missing. The order was initiated on 9/1/22. b. WOUND CARE: RIGHT HEEL, RIGHT ANTERIOR LOWER EXTREMITY (LE): Apply Betadine to wound areas and cover right anterior LE with non bordered foam dressing and wrap with Kerlix rolled Gauze and Coban. Change every Tuesday, Thursday and Sunday and as needed if soiled or missing. The order was initiated on 9/1/22. c. WOUND CARE: MOISTURE ASSOCIATED SKIN DAMAGE (MASD) ISCHIUM, SACRUM, BUTTOCKS AND ALL REDNESS TO PERI AREA: Cleanse with Peri cleanser and wipes. Apply Venelex mixed with anti-fungal cream and zinc. Apply to all red areas every Shift and PRN with Brief changes. The order was initiated on 9/1/22. d. WOUND CARE: LEFT LATERAL FOOT, PLANTAR HEEL AND LATERAL MALLEOLUS: Apply Betadine and wrap with Kerlix rolled Gauze and lightly with Coban from toes to 2 finger breadths below knee. Change every Tuesday, Thursday and Sunday and as needed if soiled or missing. The order was initiated on 9/1/22. e. WOUND CARE ANTERIOR NECK: HOLD WOUND VAC UNTIL NEXT VISIT FROM WOUND CARE TEAM- NEW ORDERS WHILE VAC ON HOLD: Cleanse are with Vashe or Dakins solution and soak for 5 minutes. Apply 1/4 inch Iodosorb packing strip at 3 o'clock undermining lightly. Mupirocin topical ointment. Skin Prep peri wound and cover with bordered foam. Change every Tuesday, Thursday and Sunday and as needed if soiled or missing. The order was initiated on 8/31/22. f. Weekly skin checks to be done every day shift on Monday. The order was initiated on 8/22/22. g. Mupirocin Ointment 2 % , apply to anterior neck topically every day shift every Tuesday, Thursday, and Saturday. The order was initiated on 9/1/22. h. Refer to wound team for clavicular wound vac treatment. The order was initiated on 7/18/22. i. Reduced Concentrated Sugar (RCS) diet, regular texture, thin liquids consistency. The order was initiated on 7/18/22. j. Juven Packet, give one packet by mouth in the morning for supplement. The order was initiated on 8/2/22. k. Thiamine 100 mg by mouth in the morning for supplement. The order was initiated on 7/18/22. l. Folic Acid 1 mg by mouth in the morning for supplement. The order was initiated on 7/18/22. m. Cholecalciferol 3000 international units (IU) by mouth in the morning for supplement. The order was initiated on 7/18/22. On 7/25/22, resident 83's Minimum Data Set (MDS) admission assessment documented that the resident was an extensive 2 person assist for bed mobility, transfer, and toilet use. The assessment documented that resident 83 was an extensive 1 person assist for dressing and personal hygiene, and was total dependence with a 1 person physical assist for bathing. The assessment documented that resident 83 had an impairment on both sides to the lower extremities (hip, knee, ankle, foot) in Range of Motion (ROM). The assessment documented that resident 83's Brief Interview for Mental Status (BIMS) score was a 15 out of 15, which indicated cognitively intact. On 7/18/22 at 3:33 PM, resident 83's admission assessment documented the reason for admission was osteomyelitis Thoracic (T) 8 fracture with paraplegia. Supportive devices initiated on admit was an alternating air mattress. The assessment documented that resident 83 was alert and oriented to time, place, person and able to follow simple commands. The assessment documented that resident 83 had an indwelling urinary catheter in place for urinary incontinence. The assessment documented a right heel Stage II PU and a left heel Stage I PU, MASD on the sacrum, and anterior neck wound. The assessment documented, Resident admit with wound area to anterior neck as a result of osteomyelitis of the sternoclavicular joint, requiring wound vac therapy at this time. Stage 2 Pressure ulcer present to R [right] heel, stage 1 pressure ulcer also present to L [left] heel and arch, areas are intact with non blanchable redness present. Sacral area has masd present which is treated with zinc barrier cream. Sent referral for [name of company omitted] wound team to evaluate and treat. Review of resident 83's weekly skin evaluations revealed the following: a. On 7/22/22 at 3:36 PM, the evaluation documented, Patient has a wound vac to upper chest, excoriation to bottom, barrier cream applied as ordered, open area to left heel, dressing applied as ordered, patient has good skin turgor. b. On 7/28/22 at 2:42 PM, the evaluation documented a right heel pressure ulcer. Wound vac present and functioning to anterior neck. R [right] heel pressure ulcer dressing changed per orders. barrier cream applied to excoriation to buttocks area. c. On 8/3/22 at 3:21 PM, the evaluation documented a left heel PU with suspected deep tissue injury and measured 4 centimeters (cm) by (x) 1.5 cm. The evaluation documented a left plantar foot PU that was unstageable and measured 2.5 cm x 2.6 cm x 0.1 cm. Additional comments documented, Resident returned from observation at [name of hospital omitted] from being sent out from Medical Doctor (MD) appointment on 8/1/22 and returned back to facility today 8/3/22. New orders received to dc (discontinue) wound vac and start daily dressing changes to wound area anterior neck. Observed new open pressure area to L plantar foot as well as new DTIs (deep tissue injuries) present to L heel and L lateral foot. see above for measurements. d. On 8/5/22 at 6:21 PM, the evaluation documented, Patient has multiple dressing to heels and upper chest, dressing applied as ordered. e. On 8/11/22 at 5:50 PM the evaluation documented, Skin alteration to right ischium, chest, and bilateral feet. f. On 8/26/22 at 5:55 PM, the evaluation documented, Pt (patient) continues with wound to ischium, rash to chest, wound care as ordered. Review of the Nurse Practitioner (NP) notes revealed the following: a. On 7/19/22 at 10:15 AM, the NP note documented that resident 83's left foot Soft touch and Sharp/dull sensations were present and the right foot Soft touch and Sharp/dull sensation were diminished. The wound head-to-toe exam documented Wound 1 as the anterior neck wound and Wound 2 as the right lateral heel wound. Wound 1 was a full thickness wound with granular, slough and new epithelialization to the wound bed. Wound 1 measured 2.5 cm x 1.2 cm x 1.1 cm and had undermining of 2.5 cm at the 2 to 5 o'clock location. Wound 1 had moderate serosanguineous exudate documented. Wound 2 was a stage 2 PU with partial thickness skin loss. Wound 2 measured 5.5 cm x 4.6 cm x 0.1 cm and no undermining was noted. The surrounding skin of wound 2 was documented as white macerated, friable, with skin breakdown. Wound 2 had moderate serosanguineous exudate documented. The note documented wound orders for the anterior neck, right lateral heel, and left heel. Wound care goals included offloading pressure. b. On 8/16/22 at 1:15 PM, the NP note documented Wound 1 (anterior neck) with a history of osteomyelitis of the sternum. Wound 1 measured 1.0 cm x 0.5 cm x 0.6 cm with undermining of 2.3 cm at the 3 o'clock location. The wound bed was documented as pink or red non-granular, unable to fully visualize the undermining, and slough. Wound 1 had a small amount of serous exudate documented. Wound 2 (right lateral heel) was a stage 3 PU with full thickness skin loss without visible muscle, tendon, or bone. Wound 2 measured 0.3 cm x 0.3 cm and no undermining was noted. The wound bed was documented as pink or red non-granular. The surrounding skin of wound 2 was documented as friable and callus with blanching erythema. Wound 2 had a small amount of serous exudate documented. Wound 4 (left plantar foot) was documented as a diabetic wound. Wound 4 measured 3.0 cm x 3.5 cm with no undermining noted. The wound bed was documented as granular, slough, pin or red non-granular, and dry eschar. The surrounding skin of wound 4 was documented as macerated and maroon/purple in color. Wound 4 had a scant amount of serous exudate documented. Wound 5 (left lateral metatarsal foot) was documented as a deep tissue pressure injury. Wound 5 measured 1.5 cm x 0.3 cm. The wound bed was documented as a deep tissue injury and no exudate was documented. Review of resident 83's progress notes revealed the following: a. On 7/19/22 at 7:35 PM, the skin/wound note documented, Resident was seen today by [name of wound care provider omitted] secondary to pressure sore noted to right heel noted upon admission. Resident with wound vac noted upon admission to wound noted to neck secondary to osteomyelitis of sternum. Dressings are in place for specific's see wound care notes. b. On 7/26/22 at 8:47 PM, the skin/wound note documented, Resident was seen today by [name of wound care provider omitted] secondary to pressure sore noted to right heel noted upon admission. Resident with wound vac noted upon admission to wound noted to neck secondary to osteomyelitis of sternum. Received new orders to cleanse R heel and apply Iodosorb mixed with collagen to wound bed and cover with padded dressing and change dressing every other day. L heel, apply skin prep and cover with bordered foam, change every other day. Wound area anterior neck measurements are smaller than the previous week. c. On 8/9/22 at 10:08 PM, the skin/wound note documented, [Name of wound care provider omitted] continues to address wound to anterior neck secondary to osteomyelitis of sternum. Recently returned from [name of hospital omitted] for observation from 8/1/22- 8/3/22 a few days with new orders to dc [discontinue] wound vac and start daily dressing changes. Wound area evaluated by wound team. Received new orders to obtain wound culture. Cleanse area with veshe and soak for 5 minutes. Reinstate previous wound vac orders and change wound vac every tues, thurs and Sun. New DTIs present to L foot received during observation stat at hospital as well as open dti to L plantar foot. Received new orders to apply betadine to closed DTI areas to L foot and heel and cover with padded dressing. Open area plantar foot, cleanse with wound cleanser and apply iodosorb mixed with collagen to wound bed and cover with padded dressing. Change dressing every other day. L heel, apply skin prep and cover with bordered foam, change every other day. d. On 8/12/22 at 4:50 AM, the NP note documented, .Diagnostic testing ordered with noted consistent with leukocytosis of 21.4, increased platelets level, neutrophil, C-reactive protein. Results consistent with sepsis versus metabolic encephalopathy. e. On 8/13/22 at 10:42 PM, the note documented, Resident taking Zosyn for Leukocytosis and osteomyelitis. Dressing and wound vac intact. Resting and watching tv. f. On 8/17/22 at 6:54 PM, the skin/wound note documented, [Name of wound care provider omitted] continues to address wound to anterior neck secondary to osteomyelitis of sternum. Resident started on zosyn last week via IV [intravenous] r/t [related to] wound culture growing MRSA [Methicillin-resistant Staphylococcus aureus]. Wound area evaluated by wound team. Wound to neck continues to improve slowly, wound vac functioning well. well as open dti to L plantar foot. Received new orders to apply betadine to closed DTI areas to L foot and heel and cover with padded dressing. Open area plantar foot, wound bed is stable, continuing with current treatment orders with frequency changed to tues, thurs and Sun. g. On 8/25/22 at 7:28 PM, the note documented, wound care for this resident was done late last night and did not need to be done today. h. On 8/31/22 at 2:39 PM, the skin/wound note documented, [Name of wound care provider omitted] continues to address wounds to anterior neck, L plantar foot, DTI's to lateral LE [lower extremity], Plantar heel and lateral malleolus as well as DTI's to R Foot and LE. Received new orders to apply betadine to closed DTI areas to L foot and heel and lateral LE, Open area plantar foot: Cleanse with vashe or dakins 0.25% and soak for 5 minutes, then apply iodsorb and aquacel and cover with padded dressing, wrap LLE [left lower extremity] with rolled gauze and coban, lightly change dressings every tues, thurs and Sun. New orders for RLE [right lower extremity], Apply betadine to DTI's Present to R LE as well as fluid filled blister anterior LE, If blister opens and drains apply betadine and if moist apply aquacel over area and cover with foam dressing, wrap with rolled kerlix gauze and then light with Coban. R ischium is no longer open, MASD still present buttocks, coccyx and Sacral area. New order to dc current order for ischium. Cleanse area with peri cleanser and apply mixture of venelex, antifungal cream and zinc to area every shift and brief change. Hold wound vac to anterior neck. New orders to cleanse with vashe or dakins 0.25 % and soak for 5 minutes, lightly pack 3 o clock undermining with 1/4 iniodoform (sic) packing strip. Apply mupirocin ointment to redness, skin prep peri wound and cover with bordered foam change tues, thurs and Sat. Fluid filled blister to R thigh, apply skin prep to area and cover with padded dressing. Review of resident 83's care plan revealed a focus area that resident 82 had the potential for pressure ulcer development and other skin issues related to nontraumatic spinal cord injury, incomplete paraplegia, neurogenic bladder, diabetes mellitus, malnutrition and osteomyelitis to the left sternoclavicular. The care plan documented a pressure sore to the right heel upon admission. Interventions identified were to administer medications as ordered; assess/record/monitor wound healing; educate resident on causes of skin breakdown including transfer/position requirements; encourage fluid intake; monitor nutritional status and serve diet as ordered; notify nurse immediately of any new skin breakdown; out of bed unless contraindicated; resident to be followed by wound care specialist; and weekly head-to-toe skin assessment. The care plan was initiated on 7/20/22. On 9/1/22 at 9:50 AM, an observation was made of resident 83's wound care provided by Licensed Practical Nurse (LPN) 1 and Unit Manager (UM) 1. LPN 1 and UM 1 performed hand hygiene and gloves were donned. LPN 1 stated that the neck and planter foot had to soak for 5 minutes with the Vashe solution. UM 1 cleaned the bedside table with a Sani germicidal bleach wipe. The bedside table was allowed to air dry for 5 minutes prior to all wound supplies being placed on top. LPN 1 removed the dressing to neck wound and discarded in a garbage sack. LPN 1 doffed gloves, performed hand hygiene, and new gloves were donned. LPN 1 poured the Vashe solution inside a 4 x 4 gauze package, and the neck wound was wiped from the center outward two times with two different gauze pads. LPN 1 placed a third Vashe soaked gauze pad on the center of the wound. LPN 1 doffed gloves and washed their hands. UM 1 performed hand hygiene and donned new gloves. LPN 1 donned new gloves and removed the Prevalon boots on the bilateral lower extremities (BLE). LPN 1 removed the old rolled gauze and Coban dressings to the BLE. The left plantar was observed with a bordered adhesive dressing with a date of 8/30/22 written on it. A DTI was observed on the left heel, deep purple coloring. LPN 1 reviewed the wound order; 1/4 inch Iodosorb packing strip at 3 o'clock undermining injury, Mupirocin topical ointment, Skin prep to peri wound, and cover with bordered foam dressing. LPN 1 performed hand hygiene and new gloves were donned. Supplies were laid out on clean bedside table by UM 1. UM 1 performed hand hygiene and new gloves were donned. LPN 1 applied the 1/4 inch Iodosorb packing strip to the neck wound with a sterile cotton tipped applicator. LPN 1 doffed gloves, performed hand hygiene, and new gloves were donned. UM 1 cleaned the left plantar with a gauze soaked in Vashe solution. The gauze was left resting on the left plantar wound. UM 1 doffed gloves, performed hand hygiene and donned new gloves. LPN 1 applied Mupirocin ointment with a sterile cotton tipped applicator to the neck wound bed; cleaned the peri wound with skin prep; and the wound was covered with a Tegaderm foam adhesive dressing. LPN 1 signed and dated the dressing. UM 1 stated that all DTIs were to be cleaned with Betadine. The right heel was observed with 3 DTIs in close proximity and one healed/intact pink wound noted to the heel. LPN 1 doffed gloves, washed hands, and new gloves were applied. UM 1 opened a multipack of Betadine swabs and held the package open for LPN 1 to utilize. LPN 1 cleaned the right heel with Betadine swabs, using a new applicator for each wound. LPN 1 cleaned the right anterior LE wound with a Betadine soaked applicator. UM 1 stated that the right anterior LE wound was a blister that had now opened up. LPN 1 applied a non bordered foam dressing to right anterior LE wound, and the leg was wrapped with Kerlix rolled gauze bandage. UM 1 asked resident 83 if he was ok, and the resident replied with a nod of the head. UM 1 held the right LE while LPN 1 applied the gauze wrap. LPN 1 then applied a cohesive/Coban rolled dressing over the gauze wrap. LPN 1 signed and dated the right leg dressing. LPN 1 reviewed the left plantar wound orders; Vashe soak for 5 minutes; skin prep to periwound; Iodosorb to wound bed; cover with Aquacel and padded dressing. LPN 1 doffed old gloves, performed hand hygiene and new gloves were applied. UM 1 cleaned the left plantar wound with a 4 x 4 gauze soaked with Vashe solution. The left leg was observed with wounds on left lateral LE closed with slough, left lateral malleolus closed, left heel DTI, and left plantar open with granulation tissue noted. UM 1 applied skin prep to periwound of the left plantar wound, and Iodosorb to the wound bed with a sterile cotton tipped applicator. UM 1 doffed gloves, performed hand hygiene, and new gloves were donned. UM 1 cut the Aquacel dressing to the size of the plantar wound. LPN 1 performed hand hygiene and new gloves were applied. LPN 1 applied the Aquacel to the left plantar wound bed and covered with a bordered adhesive dressing. LPN 1 cleaned the left leg, ankle and heel with Betadine swabs. LPN 1 doffed gloves, washed hands and donned new gloves. UM 1 signed and dated the left plantar dressing. Resident 83 was asked if he had any pain, the resident denied pain with a shake of the head. UM 1 doffed gloves, washed hands, and new gloves were applied. LPN 1 held the left leg while UM 1 cleaned the heel, ankle and upper calf wounds with a Betadine swab, utilizing a new swab for each wound. LPN 1 confirmed the order was Betadine, wrap with Kerlix and Coban. UM 1 and LPN 1 doffed gloves, performed hand hygiene, and donned new gloves. UM 1 wrapped the left leg with a rolled Kerlix gauze bandage and then Coban was wrapped over the top. LPN 1 held the leg while UM 1 applied the bandages. LPN 1 dated and signed the left leg dressing. UM 1 applied the bilateral Prevalon boots. LPN 1 doffed gloves, washed hands, and applied new gloves. Resident 83 was able to assist with rolling to the left lateral side by holding onto the left side rail and pulling. UM 1 assisted with positioning resident 83 on his left lateral side by rolling the BLE. UM 1 stated that resident 83 had MASD to buttocks and it was treated with Venelex cream mixed with antifungal cream and zinc. LPN 1 verified the orders for the MASD to ischium, sacrum, buttocks and all redness to peri areas; cleanse with peri cleanser and wipes, apply Venelex mixed with antifungal cream and zinc. UM 1 stated that resident 83 had a fluid filled blister on the upper right thigh that was cleaned with Betadine and covered with a bordered foam dressing. UM 1 stated that the thigh blister was noted on Tuesday with the wound care team and the orders were not in the computer yet. UM 1 stated that the wound team identified that the Foley catheter had caused the thigh pressure wound. UM 1 stated that the resident was probably going to have a suprapubic placed. UM 1 removed the old dressing from the upper right thigh. UM 1 doffed gloves, performed hand hygiene, and donned new gloves. The right thigh blister was cleaned with a Betadine swab and the peri wound was cleaned with skin prep. UM 1 placed a new bordered foam dressing on the right thigh wound. UM 1 signed and dated the right thigh dressing. UM 1 moved the Foley catheter and positioned it over the left leg. UM 1 secured the catheter with a Tegaderm dressing over a Duoderm dressing. LPN 1 doffed gloves, performed hand hygiene, and new gloves were applied. LPN 1 cleansed the buttock, coccyx, and perineum with cleansing wipes and foam wound cleanser. LPN 1 identified a new open area on the coccyx. UM 1 called the provider and notified of the new coccyx wound. LPN 1 doffed gloves, performed hand hygiene and donned gloves. UM 1 informed the provider that the new coccyx wound had granulation tissue with blood, no slough, and measured 1 cm x 0.5 cm. UM 1 stated that the provider's new verbal order for the coccyx wound was apply skin prep to surrounding wound, Medihoney mixed with collagen to wound bed, and cover with a bordered foam dressing, change daily. UM 1 stated that the provider was the NP from the wound care team. UM 1 doffed gloves, gathered supplies coccyx wound supplies, washed hands, and donned new gloves. LPN 1 doffed gloves, performed hand hygiene, and donned new gloves. UM 1 stated that the order was to cleanse with Vashe or wound cleanser first. UM 1 was observed to cleanse the wound with a 4 x 4 gauze soaked with Vashe solution, skin prep was applied to the periwound, a sterile cotton tipped applicator was used to apply the Medihoney with collagen to the wound bed, and the wound was covered with a bordered foam dressing. UM 1 doffed gloves, performed hand hygiene, and donned new gloves. UM 1 applied the Venelex cream mixed with antifungal cream and zinc to the MASD with a cotton tipped applicator. LPN 1 was observed to wipe the cream over the MASD areas with a gloved hand. LPN 1 doffed gloves and washed her hands. UM 1 gathered the remaining supplies and sanitized the side table with another Sani germicidal bleach wipe. An immediate interview was conducted with UM 1. UM 1 stated that resident 83 was admitted with osteomyelitis and he was a known IV drug user. UM 1 stated that resident 83 admitted with a wound vac to the sternum and had some DTIs. UM 1 stated that resident 83 had new pressure wounds on the right anterior LE and the left lateral/posterior LE that was caused when the facility staff had left resident 83's LE crossed. UM 1 stated that the right upper thigh fluid filled blister was caused by the Foley catheter stat lock stabilization device, and they had switched the dressing to Duoderm with an Adaptic overlay. UM 1 stated that the new wounds were identified on Tuesday with the wound care team. UM 1 stated that the NP with the wound care team did not have her visit note in the medical records yet. UM 1 stated that she was going to provide the staff with education on resident 83's care and positioning needs. UM 1 stated that resident 83 had asked today for increased protein with meals. UM 1 stated that resident 83 did not like Medpass and would prefer to have protein needs met with food. UM 1 stated that resident 83 had declined the Prostat supplement for wound healing. UM 1 stated that resident 83 was admitted with orders for an air mattress, and Prevalon boots. UM 1 stated that resident 83 had arrived from the hospital with foam egg crate foot cushions, and they ordered Prevalon boots to prevent any further breakdown. Um 1 stated that resident 83 was compliant with care. UM 1 stated that the cream mixture was applied every shift to the MASD or with every brief change. UM 1 stated the cream was applied every shift or with every brief change. UM 1 stated that the facility acquired pressure wounds were the right LE open blister, left lateral/posterior LE DTI, right thigh fluid filled blister, and the coccyx wound. On 9/1/22 at 12:00 PM, an interview was conducted with the Director of Nursing. The DON stated that resident 83 was only able to use his bilateral upper extremities, and was not familiar with resident 83's lower extremity mobility capabilities and needs. The DON stated that nutritional supplements for wound healing and fortified diets depended on the resident's needs and preferences and that it was not automatically implemented as a standard of practice with wound care. On 9/1/22 at 1:13 PM, an interview was conducted with Certified Nurse Assistant (CNA) 1 and 2. CNA 2 stated that she had worked with resident 83 two times and had provided incontinence care with the use of the hoyer lift. CNA 2 stated that she was still in the orientation process. CNA 1 stated that resident 83 was totally dependent on staff for mobility and could not independently move his legs. CNA 2 stated that resident 83 required extensive assistance for bed mobility and was a total assist for transfers. CNA 1 stated that resident 83 asked for a great deal of pain medication, and the majority of the resident's call lights were for requesting pain medication. CNA 1 stated that he noticed that resident 83 would grimace and say owe when being repositioned and with any movement of the lower extremities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined, for 1 of 42 sampled residents, that the facility did not provide adequate supervision and assistance devices to prevent accidents. Specifically, a dependent resident sustained a fall from a Hoyer lift after a one person physical assist which resulted in a head lacertion and a tibial fracture. Resident identifier: 44. Findings include: Resident 44 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included displaced bicondylar fracture of left tibia, subsequent encounter for closed fracture with routine healing, spastic quadriplegic cerebral palsy, severe protein-calorie malnutrition, profound intellectual disabilities, blindness, osteoarthritis and limited range of motion. Resident 44's medical record was reviewed on 9/1/22. A Minimum Data Set, dated [DATE] revealed that resident 44 had limited range of motion to both upper extremities and one side of the lower extremities. Resident 44 required extensive two plus physical assistance with transfers. A care plan initiated on 5/27/22 and updated on 7/27/22 revealed resident 44 .had an actual fall on 5/27/22. Was sent to ED (emergency department) and returned with a dx (diagnosis) of laceration to head. Per hospital documentation page 1 MD (medical doctor) reports no overt signs of trauma no extremity fractures of deformities noted. Patient has otherwise been in his regular state of health. The goal developed was Will resume usual activities without further incident through review date. The intervention developed on 5/27/22 was . resident was sent to the ER (emergency room) secondary to head laceration. Additional interventions developed on 7/27/22 were pillow for proper positioning, brace to remain in place; staff educated, wheelchair removed from room; check range of motion; frequent monitoring of pain.; frequent repositioning. An Activities of Daily Living (ADL) care plan dated 6/10/22 revealed that resident had self care performance deficits related to tibia fracture, Cerebral Palsy, Quadriplegic, seizures, fall. One of the goals developed was [Resident 44] will safely perform (bed mobility, transfers, eating, dressing, grooming, toilet use, and personal hygiene) with (staff assistance) through the review date. One of the interventions dated 6/10/22 was Transfer: Requires (Hoyer) with transferring. Nursing progress notes revealed the following entries: a. On 5/27/22 at 4:02 PM, Registered Nurse (RN) 3 documented, At about 06:30 am CNA came to nurse and asked if this nurse can assist her in this Resident's room. Nurse went quickly in this resident's room and found resident on the floor lying on his back. Nurse assessed for an apparent injuries. Noted laceration of skin on back of Head of about 3.5cm (centimeters) long. Bleeding r/t (related to) this laceration was stopped by applying pressure on the lacerated area. Cleansed lacerated area with wound cleanser. Provider on call was notified. Unit manager notified. This Resident POA [relationship omitted] notified. Provider order to send him to ER (emergency room) at [local hospital] as per [POA's] request. Neurological assessment initiated. He was treated at ER of [local hospital name] with 8 staples on the lacerated skin on the back of his head. Came back at about 11:20 am. Neurological assessment continues he appear on his baseline neurologically at this time. Will continue to monitor for any changes r/t to this fall incident for the next 72 hours. b. On 5/29/22 at 8:03 AM, .staples to the back of the head.Patient is a 2 person transfer with nurse supervision. c. On 6/2/22 at 1:17 PM, Upon assessment, resident left knee is swollen and hot to the touch. Mild grimacing with ROM (range of motion). d. On 6/2/22 at 2:02 PM, New order for STAT x-ray of left knee.swelling of left knee that is hot to touch. e. On 6/2/22 at 6:15 PM, x-ray results revealed a finding of inconclusive. The Director of Nursing (DON) phoned resident 44's POA and reported the x-ray results, and the decision was made to send resident 44 to the local hospital. f. On 6/8/22 at 5:55 PM, [Resident 44] was picked up at 1:45 and taken back to his old room of 1202. He is returning to us on his Medicare Benefit, used 29 days prior to hoyer incident. He was seen at the hospital for Sepsis, left tibial plateau fracture, sacral pressure ulcers with seizures and quadriplegia history. He is non weight bearing with a brace on left leg that should be in locked position at all times. We have agreed with [POA] and facility that he will be fed in his room [ROOM NUMBER]:1. The incident report revealed the same note from RN 3 in the progress notes on 5/27/22. The incident report further revealed Per CNA who assisted this resident to transfer from bed to his w/c this resident slipped of (sic) the sling on the Hoyer lift and fell on the floor. The DON documented she spoke with the aide on 6/3/22 and the CNA was using the tan sling and not the blue sling. The DON documented the CNA reports that bed was above knee level, he slid out of the sling made contact with the floor on his buttocks then made contact with his head. The DON documented the employee was educated in regards to appropriate sling and 2 person transfer with resident. On 8/31/22 at 12:31 PM, an interview was conducted with RN 3. RN 3 stated there was a new CNA and RN 3 told the CNA to ask for help with using the lift. RN 3 stated the CNA asked him to help her and he saw resident 44 was on the floor and found a laceration on the back of his head. RN 3 stated that the CNA stated she was transferring resident 44 from the bed to the wheel chair using a hoyer lift. RN 3 stated that he and the other CNA working had told her she needed to use 2 staff when transferring with a Hoyer lift. RN 3 stated the CNA had reported that resident 44 slid out of the sling onto the floor. RN 3 stated that the CNA reported that the back of resident 44's head hit the grown but nothing else hit the ground. RN 3 stated he completed a full body assessment. RN 3 stated that he looked all over and saw that resident 44's head was bleeding so he treated the head wound. RN 3 stated resident 44 did not have any facial grimacing when he performed ROM to all extremities. RN 3 stated resident 44 was sent to the emergency room right away after calling the physician. RN 3 stated resident 44 received stitches to the back of his head and he returned to the facility. RN 3 stated he completed an incident report. RN 3 stated that the policy of the facility was to always use 2 staff when transferring residents using a Hoyer lift. RN 3 stated if there was only 1 staff member it was hard to get the resident turned while using the lift controls. RN 3 stated resident 44 was unable to reposition or transfer himself. RN 3 stated resident 44 was able to rock his upper body and move his arms but was not aware of his movements. RN 3 stated after the fall resident 44 had increased pain, was groaning and restless. RN 3 stated staff asked the POA if resident 44 could have more pain medication than Tylenol. RN 3 stated the POA did not like him to have pain medication that was stronger than Tylenol. RN 3 stated that a week or so later staff found out resident 44's knee was swollen and an X-ray showed he had a fracture. RN 3 stated resident 44 was sent him back to hospital and he had a brace placed on his left knee. On 8/31/22 at 1:09 PM, an interview was conducted with Physical Therapy Assistant (PTA) 1. PTA 1 stated she was assisting resident 44 with transferred using the Hoyer lift. PTA 1 stated since November 2021, when she started, all transfers with Hoyer lifts were to be done with 2 staff members. PTA 1 stated she did not know about resident 44's fall, but after the fall the facility did a wonderful job. PTA 1 stated the facility management asked PTA 1 to give transfer lift instructions to the CNAs. PTA 1 stated there should always be 2 staff during a transfer with any mechanical lift. PTA 1 stated resident 44 was unable to move all on his own. On 8/31/22 at 1:17 PM, resident 44 was observed to have 2 staff members use a Hoyer lift to transfer him into bed from his wheelchair. On 8/31/22 at 4:04 PM, an interview was conducted with the DON. The DON stated that she went to resident 44's room to talk to the CNA on the date of the incident. The DON stated that all staff were educated on utilizing 2 staff members for all mechanical lift transfers. The DON provided a message dated 5/27/22 at 1:03 PM through a secured application regarding the need for 2 staff members to assist with all lifts. The DON stated the therapy staff also provided education with the Administrator placed in the lift. The DON stated there were slings that were 2 pieces so resident 44's bottom slid through the sling. The DON stated facility staff completed a sweep of the facility to remove all 2 piece slings from use. The DON stated if a staff found one they received a candy bar. The DON stated that resident 44 had a fracture after the fall but it was not discovered for about a week. The DON stated resident 44 was sent to the ER for a laceration to his head and x-rays were obtained at the ER the day of the fall. The DON stated that resident 44's knee was swollen and an x-ray was obtained and resident 44's POA agreed to send him to the hospital. On 9/1/22 at 10:20 AM, DON stated she did not have a policy and procedure for the mechanical lifts. The facility provided a copy of the training information provided to the staff on 5/31/22. The topic was to use 2 people every time a hoyer lift transfer was performed. The education further revealed that Transferring with only one employee puts the resident and you at risk. If another aide if (sic) not available to come and help you. Please ask your nurse, unit manager, or any therapy personnel. If you have any questions or concerns in regards to this please ask thank you. Staff signed their name. Another education was provided on 7/19/22 regarding 2 staff when transferring a resident with a lift. On 8/15/22 another in-service was completed regarding Always use 2 people to transfer with hoyer. On 8/29/22 a fall prevention in-service was completed. The facility provided a Quality Assurance and Performance Improvement plan dated 6/10/22 and ongoing related to fall with fracture. The problem was Resident sustained a fall on 5/27/2022. (Resident was being transfer with the tan sling with one person assist) Per assessment resident had a laceration noted to his head he was immediately sent out to the ER. Resident returned with order for laceration care. On 6/2/2022 during rounds team noticed redness and swelling noted to left leg. Team anticipated this was cellulitis, provider was notified X ray was ordered. X ray results showing fracture to left leg. Resident was sent out to ER for treatment. One of the interventions developed was Resident had post fall monitoring in place Q (every) shift, no concerns were noted with ROM (Range of Motion). DON spoke with aide that was transferring resident that morning 5/27/2022 in regards to the appropriate sling and 2 people transfer with hoyer lift. General education was provided with staff in regards to not using tan slings and 2 people assist with transfers. The follow up was Continue with education in regards to not using the tan slings. Searched the building to discard all tan slings. Continuous education in regards to not transferring with 2 people. All incident reports to be reviewed in IDT (interdisciplinary team) meeting for post assessment documentation and ROM. DON will report to QA (Quality Assurance) monthly in regards to any falls with fracture and concerns noted with falls.