**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility did not ensure 1 (R1) of 3 resident reviewed for accidents had adequate supervision, and associative devices to prevent accidents. Certified Nursing Assistance (CNA)-W transferred R 1 with assist of 1 and a pivot transfer. R1's care plan documents R1 is assessed to require assist of 1 and an EZ stand for transfers. R1 complained of pain at a level of 10/10 with swelling and bruising noted following the transfer. R1 experienced a change of condition following the transfer and passed away four days after the transfer. An autopsy was conducted and it was determined R1 suffered a fracture of the left distal femur related to the transfer. The Medical Examiner determined the femur fracture was the cause of R1's death. Findings include: The Facility policy titled, Fall Management Program, dated 8/20, documents, .Policy: The facility is committed to minimizing resident falls and/or injury so as to maximize each resident's physical, mental and psychosocial wellbeing. While preventing all resident falls is not possible, it is the facility's policy to act in a proactive manner to identify and assess those residents at risk for falls, plan for preventive strategies and facilitate a safe environment. Procedure: . 4. Plan of care reviewed and updated at time of occurrence, quarterly and as needed in order to minimize risk for fall incidents. 5. Use standard fall/safety precautions for all residents: a. All staff will be trained on the Fall Management Program.d. The bed will be maintained in a position appropriate for resident transfers. e. The bed will be checked to assure they are in locked position at all times. The Facility policy titled, Management of Falls, dated 8/20, documents, .Policy: The facility will assess hazards and risks, develop a plan of care to address hazards and risks, implement appropriate resident interventions, and revise the resident's plan of care in order to minimize the risks for fall incidents and/or injuries to the resident. Procedure: Complete a Fall Risk Assessment upon admission, re-admission, with significant change, post-fall, quarterly, and annually. Orient resident to room, call light, unit and location of the nurse's station upon admission to the facility. Develop a plan of care to include goals and interventions which address resident's risk factors. Risk factors may include but are not limited to the following: Contributing diagnoses/disorders/disease processes/active infections/other comorbidities, history of fall incidents, Incontinence, Medications (Narcotics, Antihypertensives, etc.), assistance required with ADL's (Assistance with Daily Living), gait/transfers/balance issues, Behaviors, and/or cognitive status. Monitor for changes in medical condition and notify physician as necessary to manage changes in status of the resident. Conduct Care Plan Meetings with the Resident, Responsible Party, and Facility Interdisciplinary Team quarterly and as needed. Review and/or modify the resident's plan of care at least quarterly and as needed in order to minimize risk for fall incidents and/or injury. The Facility policy titled, Change in Condition (Resident), dated 9/20, documents, Purpose: To ensure that the resident's physician/physician on call/NP (Nurse Practitioner) and responsible party is kept informed regarding the residents change in condition. Policy: The attending physician/physician on call/NP and responsible party will be notified with changes in the resident's condition. Procedure: Attending physicians or physicians on call/NP and responsible party will be notified of all changes in condition. Follow framework for reporting changes in vital signs or laboratory values based on AMDA (American Medical Directors Association) Guidelines. Follow suggested guidelines for reporting clinical problems based on AMDA guidelines. Document time of call, physician or nurse practitioner or other person spoken to; reason for call and result or orders received. Place call to responsible party to notify them of the resident's change in condition. R1 was admitted to the facility on [DATE], with diagnoses that include, Parkinson's Disease (A disorder of the central nervous system that affects movement, often including tremors.), and Old Myocardial Infarction (heart attack). R1 was admitted to Hospice Care on 6/15/23 with a primary diagnosis of atherosclerotic heart disease and other co-morbidities. R1 has a Health Care Power of Attorney and it was not activated. R1's Minimum Data Set (MDS) quarterly assessment, dated 2/4/25, documents R1 has a Brief Interview of Mental Status (BIMS) score of 14, indicating intact cognition, a Patient Health Questionnaire (PHQ-9) score of 0, indicating no depressive symptoms, and no indicators of psychosis including no hallucinations or delusions. Sit to stand, chair/bed to chair transfer, sit to lying, lying to sitting and toilet transfer are with substantial/maximum assist. R1's MDS annual assessment, dated 5/9/24, R1 was assessed to require the same level of assistance as the 2/4/25 Quarterly MDS, substantial/maximum assistance sit to stand, chair/bed to chair transfer, sit to lying, lying to sitting and toilet transfer. R1's Care Area Assessment (CAA), dated 5/9/24, documents, triggered for self-care mobility, psychotropic drug use, urinary incontinence, falls, nutritional status, and pressure ulcer/injury. Resident is 1 assist with assistance with daily living (ADL's) and transfers with EZ stand. R1's Care Plan, dated 6/13/23, documents, Focus: R1 has an ADL Self Care Performance Deficit r/t (related to) Parkinson's, weakness and the need for staff to assist with ADL's. Is currently enrolled in [Name] Hospice for end-of-life comfort care related to ASHD (Atherosclerotic Heart Disease) Date initiated: 6/13/23. Interventions/Tasks: Allow enough time for completion of ADL tasks. Transfers: EZ stand, 1 assist, all with date initiated of 6/12/23. Focus: R1 is at risk for falls r/t (related to) Parkinson dx (diagnosis), weakness and limited mobility. Res (Resident) is dependent on staff for transfers and mobility needs. R1's Facility Incident Report dated 2/8/25, at 3:40 AM documents: Bruise: Resident: R1, Incident Location: Resident's room, Person Preparing Report: Registered Nurse (RN)-G. Incident Description: Nursing Description: Certified Nursing Assistant (CNA) called nurse into room d/t (due to) resident complaining of left knee pain. R1 was laying (sic) in bed with a pillow under her knees. Resident Description: Resident stated that the CNA on PMs (evening shift) did not use the EZ stand (sit to stand) to transfer her to bed and that her left knee is now hurting. When asked if she fell stated she had not and when asked if she had hit her knee on anything she again stated she had not. Was the incident witnessed: No. Immediate Action Taken: Description: Focused assessment findings: swelling to left knee and hematoma to lateral aspect of left knee. Localized pain of 10/10 reported and resident was given PRN (as needed) tramadol at 3:48 AM. After speaking with the on-call provider and ice pack was applied to her left knee for 20 minutes. Injuries Observed at Time of Incident: Injury Type: No Injuries observed at time of incident Injury location: No documentation Level of Pain: Level of Consciousness: No documentation Mobility: No documentation Mental Status: (Check Box) Oriented to Person: unchecked Oriented to Time: unchecked Oriented to Place: unchecked Injuries Report Post Incident: Injury Type: No injuries Observed Post Incident Injury Location: No documentation Level of Pain: No documentation R1's [Telehealth Health] Physical Exam dated 2/8/25, at 4:17 AM, Advanced Practice Nurse (APN)-H documents, (service start time 3:58 AM) Exam findings per nurse and video observation Physical Exam- Notes: GEN (General): alert, NAD (nothing abnormal detected), R1 is alert, flat affect, simple responses. Left knee effusion, no erythema or warmth. Left knee effusion, no erythema or warmth, left knee pain and effusion noted, swelling left (greater than) right, pain with flexion and mobility, left lateral knee with ecchymosis no noted fall, Tramadol available PRN, Morphine PRN available, Tylenol scheduled. Will add voltaren 1% topical gel TID (three times per day), ice TID, no imaging at this time as comfort focused measures. This is an acute new problem. Condition is stable. Orders: Voltaren 1% topical gel TID PRN, Ice to left knee TID 20 minutes x (for) 48 hours. Notify a clinician of any change in condition. Disposition: Stay at Facility. Technology used: Audio and video with patient and nurse present. R1's Facility Nurses Note dated 2/8/25, at 4:19 AM, Registered Nurse (RN)-G documents, TEH (Telehealth) consulted for evaluation of pain to left knee and swelling-new onset, pain rated 10/10. Patient is on Hospice, she is on tramadol 50 mg (milligrams) po (per oral) q (every) 6 hours PRN, she has tylenol scheduled. R1 uses easy stand, noted to be x 1 (assist 1) transfer last evening. No falls or injury known, but she does have left lateral knee ecchymosis blue-ish discoloration. R1 has restriction in her mobility and flexion in her left knee. R1 states pain started post transfer last night. Review of Systems: ROS (Review of Systems) as per HPI (History of Present Illness), all other systems reviewed and are negative PMH (Past Medical History) and SH (Social History). Reviewed PMH and SH and Medications Source. Vital Signs: T (Temperature): 98.4 F (degree Fahrenheit), HR (Heart Rate): 68 BP Sys (Blood Pressure Systolic): 167 mm/Hg (millimeters of mercury)/ bmp (beats per minute), / (over) D (Diastolic): 85 mm/Hg, RR (Rate Respirations): 20 rpm (rate per minute), O2 (Oxygen): 94%. R1's Facility Nurses Note dated 2/8/25, at 4:30 AM, RN-G documents, R1 is complaining of new onset of left knee pain 10/10, swelling and hematoma to lateral aspect of left knee. Contacted on call APN (APN-H), who saw R1 and gave new orders for ice pack to left knee 20 minutes TID for 2 days and voltaren gel TID PRN. Called Hospice and left a detailed message for her case manager. R1's Hospice Progress Note, dated 2/8/25 at 4:27 AM, documents, TC (Telephone Call) from facility staff, [RN-G] wanting to report an update on patient. Patient having more pain to left knee. [RN-G] got new orders from [APN-H] for Voltan (sic) TID and ice for 20 minutes BID (two times a day). [RN-G] reported that patient has dx (diagnosis) of arthritis and that when staff assisted her to bed they did a pivot transferred instead of a mechanical lift. R1's Hospice Progress Note, dated 2/8/25, at 2:04 PM, documents, Check in call to facility to assess patients knee pain after injury. Spoke with charge nurse [Hospice staff] patient was having pain and received Tramadol and staff is obtaining Volteren (sic) gel to apply as well. Surveyor notes, there are no nursing notes documentation on 2/9/25. R1's Facility Nurses Note, dated 2/10/25, at 8:16 AM, Licensed Practical Nurse (LPN)-F documents, R1 had swelling of the outer aspect of her left knee over weekend. Staff got order for Voteran (sic) Gel to knee prn and ice pack to knee every shift for 3 days. Knee remains swollen and warm to touch, R1 declined ice pack or pain medication at this time, R1 is also less cognitive today than last week. R1's Facility Nurses Note, dated 2/10/25, at 11:20 AM, LPN-F documents, R1 has been doing some pursed lip breathing, O2 (Oxygen) at 76%, R1 was started on Oxygen at 2L (Liters), recheck 1/2 hour later O2 at 91%. Hospice was notified of this change. R1's Hospice Progress Note, dated 2/10/25, at 12:00 PM, documents, Call received from [LPN-F] at [Facility] reporting, I found out this morning that over the weekend, staff attempted to transfer patient without a lift and dropped her on the floor. She has significant swelling to her L (left) outer knee and is complaining of pain. Looks like the nurse over the weekend got an order for voltaren gel, but nothing was mentioned regarding the fall. My management will investigate we are counting it as a fall. They also got an order for an ice pack to use every shift for the next 3 days. When I gave her scheduled Tylenol this morning, she did say her pain level was fine. I think someone should look at it as it is quite swollen, and I think it's more than arthritis. Call log reviewed and no mention of a fall but did report increase pain with new orders. MAR (Medication Administrative Record) reviewed, and no tramadol order is listed. We do have an active order on our end. [LPN-F] aware RN will make a visit today to complete fall assessment, and writer will update MAR with tramadol order. R1's Hospice Progress Note, dated 2/10/25, at 2:13 PM, [R1's] [Responsible Party] called with concern that [R1] needs a visit today. He reports staff dropped her on her head and didn't tell anyone until my son was here today and now she is unresponsive. Writer updated [Responsible Party] that facility did notify [Name of Hospice] hospice today that a nurse is scheduled to see her. The RN (registered nurse) will call him with an update if he is no longer present at the facility. He was very upset with her condition. Visit RN [Responsible Party] updated to call him during visit if he is not present. R1's Facility Nurses Note, dated 2/10/25, at 3:47 PM, late entry, Assistant Nursing Home Administrator (ANHA)-C, documents, [Responsible Party] stated that he is convinced that someone dropped R1. He stated that Responsible Party was in on Saturday morning, and all was normal with R1. The Responsible Party then again visited on Sunday morning and stated they noticed a change in condition from the previous day. He stated he thinks she was dropped on her knee and head and has facial swelling. At the time, I was only aware that her knee was swollen. I stated that we will be doing a thorough investigation as to what happened and that we are still unclear as to what had happened. I then had the nurse LPN-F go look at her face, and LPN-F stated that her eye did not seem swollen, just droopy. R1's Hospice Collaboration Note dated 2/11/25, at 11:05 AM, documents, Writer received a call from [DON- B] following writer's message to facility that she would like to update PCP (Primary Care Physician). [PCP-I] per [name of hospice] hospice protocol following fall visits. [DON-B] called and wished to clarify with writer that the incident was currently under investigation. Writer acknowledged that the form she is currently completing is an occurrence report, and that in the report it was uncertain what happened and that staff nurse [LPN-F] had informed writer that the incident was under investigation. [DON-B] was able to inform writer that [PCP-I] was off over the weekend when the incident occurred but that she had been informed as of Monday, yesterday. Writer thanked [DON-B] for letting her know that [PCP-I] was aware. R1's Hospice RN Comprehensive Assessment Visit Nursing dated 2/11/25, at 2:21 PM, documents, R1 is in bed with eye's slightly open and unresponsive. She does not respond to touch or sounds. [LPN-F] reports that Sat (Saturday) am (morning) around 2:30 CNA (Certified Nursing Assistant) from Facility was doing pivot transfers and dropped patient. [R1] is sit to stand for transfers. Large bruise to left side of knee and knee is swollen during assessment today. Unknown if patient hit her head. No bumps or bruising to head noted at visit today. Unknown if patient had medical episode at time of fall. Patient did not go to ER (Emergency Room) per [LPN-F]. She reports that HCPOA (Health Care Power of Attorney) had not been contacted by the night staff. An order was obtained to apply ice to left knee and voltaren cream to left knee. [LPN-F] reports that she found patient Monday morning and lips were blue and she was gasping for air. [LPN-F] placed R1 on oxygen at that time. Writer contacted [Responsible Party]. [Responsible Party] reports he was not contacted the morning of the fall. [Responsible Party] reports family member contacted him Sunday to come see R1, as she was minimally responsive at that time. RN had seen R1 on Monday for follow up visit d/t (due to) change in condition. [Responsible Party] was offered to have patient be seen in ER (Emergency Room) if he wishes. [Responsible Party] denied the need at this time for patient to go to the ER. Writer discussed holding her other medications and putting patient on comfort medications at this time. [Responsible Party] was in agreement and writer contacted NP to get order to DC (discontinue) all meds except comfort medications. Team updated on change in condition. R1's Facility Nurses Note dated 2/11/25, at 2:42 PM, LPN-F documents, Hospice aide here for cares, during cares, R1 passed. Hospice informed and on the way. PCP-I and management aware. R1's Facility Nurses Note dated 2/11/25, at 4:42 PM, Assistant Nursing Home Administrator (ANHA)-C documents, . [Responsible Party] stated he thinks it is clear, cut and dry that R1 was dropped on her head due to someone transferring her without the EZ stand and he was not contacted for two days and now she is dead. R1's Hospice Visit Information dated 2/11/25, documents, Reportable death due to patient fall with injury: Reported a fall on 2/8/25 and head strike may have occurred. Patient did have a change in condition following the fall including increased swelling to left knee, decreased verbal communication and inability to feed self. R1's Hospice Visit Information dated 2/11/25, documents, Death Visit Note Narrative: Triage received a phone call stating patient has passed away. No response to physical stimuli. Pupils fixed and dilated. No auscultated bilateral respirations or heart tones for a complete minute. Patient pronounced at 1655 (4:55 PM). Family coping: Family coping well considering frustration with rapid decline following fall. Left leg has bruising from thigh to knee. Right leg has bruising on shin to foot. Facility's investigation staff statements: RN-G's Staff Statement dated 2/11/25, documents I was called into R1's room on Saturday 2/8/25 around 3:40 AM d/t (due to) left knee pain. After a focused assessment I noted swelling and hematoma to the lateral aspect of her left knee, which was new. R1 was clearly communicating with me and speaking in full sentences at this time-she usually doesn't say much or will respond with single words. When I asked her if she knew what happened to her knee she said the CNA on PM shift did not use the EZ stand when transferring her to bed. I asked her if she hit it on something or fell and she said that neither of those things had happened. I administered PRN Tramadol at 3:48 AM and contacted the on-call physician Advanced Practice Nurse (APN)-H immediately. She saw resident through the iPad and gave me new orders for ice pack to left knee 20 minutes TID (three times a day) x (for) 2 days as well as voltaren gel TID PRN. I then called [name of hospice] Hospice and left a detailed message with the on call nurse who said she would update her case manager. I explained that the on call provider didn't order x-rays because she believed it was tissue related and that the resident was on hospice-the on call hospice nurse agreed and said that they wouldn't be ordering an x-ray either. New orders were followed and R1 was checked on frequently over the next two nights I was here. Saturday night 2/9/25 I administered PRN Tramadol at 1:21 AM and R1 was back to her baseline of not saying much or responding with more than one word at a time. Sunday night she was sleeping whenever I was in her room to check on her and she did not wake up when I put an ice pack on her knee. There were no signs over the weekend that she was declining or would pass away within the next couple of days. LPN-Z's Staff Statement dated 2/12/25, documents On Friday, 2/7/25. I worked the pm shift. At approximately 2130 (9:30 PM), I noted that resident in [room number] was still up. I requested the CNA to assist resident to bed. The CNA responded Ok. I was not aware of any incidents that occurred during the CNA/resident interaction. On Saturday 2/8/25, I worked the PM shift. I was told in report that R1 had a swollen knee and it was unsure how it happened. I went and observed resident first, I noted swelling to bruising to the L (Left) knee. I asked resident what happened, and resident reported, I hit my knee on the ground. I also asked if the EZ stand was used and resident responded, No. Resident received prn pain medication per her request. Resident remained in her bed throughout the shift. On Sunday, Resident continued to stay in bed throughout the shift. Resident continued to request prn medication which were administered. I applied iced and observed her knee. Resident continued to have bruising and swelling. LPN-F's Staff Statement dated 2/12/25, documents I, [LPN-F] got report Monday morning from [RN-G]. It was reported that she was called to R1's room early in the morning on Saturday morning because resident was complaining of knee pain. After assessment was completed she notified Telehealth and received orders for ice packs and voltaren gel for her left knee. It was discussed the CNA had pivot transferred her and not used the EZ stand. It was noted that the resident had left knee pain, swelling, hematoma was getting ice pack q (every) shift and the ordered (sic) ended 7:59 this morning. At approximately 7:30 am writer went to administer medications. Resident was not opening her mouth enough to administer medications she had pursed lip breathing and had blueish lips, O2 (Oxygen) was checked and at 76%, 2 L (Liters) of O2 was administered and rechecked in 30 mins (minutes) she was at 88%, rechecked 30 min later and she had dropped to 82%, O2 increased to 3L. Hospice notified spoke with triage nurse, [Name]. Writer reported O2 was not maintaining and bumped it up to 3L, discussed the knee pain, swelling, and warmth. Writer reported, I was unaware of how the injury happened but management was aware and investigating. Informed that on call nurse would call back and be out for visit. [Responsible Party] was notified during in person visit between 8:00 AM and 9:00 AM. Writer asked if [Responsible Party] was aware of bruising and swelling to left knee. [Responsible Party] stated he was unaware of any changes. Updated on complaint of knee pain over the weekend and change of condition. [Responsible Party] came approx. (approximately) 9:30 AM, I reported that I had spoke with hospice and updated on condition, he reported that she had swelling and bruising to her head. The [Responsible Party] and I went to room, writer assessed and did not note any swelling, bumps or abrasions to head I asked resident, when the incident happened over the weekend, did you hit your head at all. She responded, no, I was dropped. CNA-P's Staff Statement, not dated, documents, I, [CNA-P] Sat (Saturday) morning noticed R1 [room number] was restless in her bed, when normally she sleeps most all nights. I went to her and asked if she was all right, I said your (sic) not sleeping yet is everything okay, this was around 1:00 AM. She told me her knee was hurting her. I looked at it n (sic) it was all swollen. I ask R1 what happened, R1 said she dropped me, I asked R1 now, did she use the easy stand, R1 said No! She picked me up! I asked her if she needs an ice pack, and then she said n (sic) a pain pill. She is very soft spoken and she clearly asked for a pain pill, she never asks for a pain pill. I called the nurse and told her R1 said she dropped me and would like a pain pill. [RN-G] came and assed (assessed) her knee and called another nurse and gave her pain pill and ice pack. Sunday morning R1 said she didn't want to get up n (sic) in to her chair. Same on Monday morning when I would change her. She would just say ouch softly. I reported to both am nurses and that R1 is in pain n (sic) doesn't want to get up today. On 3/31/25, at 11:01 AM, Surveyor interviewed [Responsible Party] who states, he could not visit R1 on 2/8/25 due to a snowstorm and this is the only day either himself or someone from his family has not been to the Facility to see R1 in 1 year and 7 months. On 2/9/25, when one of his family members visited R1, she could not even tell family what was wrong. Family had to try to feed her, and she could barely talk. Family member went to ask nurse what was wrong, and she just replied with, she is having a bad day. On 2/10/25, Responsible Party went to see R1 early morning. R1 could not eat, could barely talk and just making noises. He went up to a nurse and asked her what was wrong with R1 and she said she has been this way since night staff dropped her. Responsible Party spoke with Nursing Home Administrator (NHA)-A and expressed his concerns by telling her R1 was dropped, and no one has done anything about it for days and now she is comatose. NHA-A states, she did not know of any incident and would investigate it and get to him. Responsible Party states NHA-A never called him back. Responsible Party states R1's legs were all bruised and he took pictures. On 3/31/25, at 1:00 PM, Surveyor interviewed Medical Examiner (ME)-U, who states, she typically does not order autopsy's except if abuse, neglect or injury is suspected. She ordered an autopsy for R1. ME-U states she had a phone conversation with NHA-A and DON-B on 2/12/25 which revealed the following: NHA-A states R1 was transferred from chair to bed via pivoting and not EZ stand. ME-U asked NHA-A for a fall report and NHA-A states, they did not have one as CNA-W states she did not drop her, nor did R1 fall and did not have complaint of pain during transfer. ME-U asked if anyone was called and NHA-A states, Hospice was called. NHA-A states, Family was not called because R1 was her own decision maker. NHA-A states, there was a telehealth visit made around 4:00 AM in the morning on 2/8/25 because of R1's knee. Voltaren gel and ice packs was ordered. NHA-A states, R1 had a soft tissue injury and not a bone injury and no x-rays were ordered at this time. R1 was bed bound the remainder of the weekend. NHA-A states, R1 was minimally responsive on 2/10/25 and needed Oxygen. DON-B, states, she specifically looked at R1's knee and noticed bruising with nothing else noted. Prior to knee injury, R1 was baseline. R1 did not need Morphine and used Tramadol as needed. ME-U states the preliminary results of the autopsy on 2/14/25, reveal the primary reason for R1's death is fracture of the distal left femur, and the secondary reason is natural occurring diseases. ME-U asked the physician who completed the autopsy, Medical Doctor (MD)-X, if the injury was from a pivot transfer or a blunt fall injury and MD-X states, this would be consistent with a fall/drop and much less consistent with her hitting the side of the bed or something like that with transfers. On 4/1/25 at 8:39 am, Surveyor was provided a timeline of events dated 2/10/25, no author, documents, in part, .Writer contacted CNA-W regarding statement. CNA-W reported she does not work that unit often and could not remember resident. Writer attempted to explain the resident and CNA-W continued to state she could not remember. Writer asked CNA-if she knew how residents transfer. CNA-W reported that it was listed in the book and she would take report from the previous shift. CNA-W also stated that if she was un-sure she would ask the nurse. CNA-W reported she would not deviate from what was care-planned for resident. Tuesday, February 11, 2025, Writer spoke with CNA-W, . asked if she could recall any additional information. CNA-W then reported that she asked the nurse how the resident transferred and she stated 1 assist, so she transferred R1 as a 1 assist. CNA-W denied R1 falling or any known incidents during transfer. Writer requested to have aide come give demonstration of how R1 was transferred and to obtain a written statement. Writer contacted [Name] Hospice RN (Registered Nurse) [Name], Writer reported to Hospice RN [name] that facility was investigating reports of a fall and at this time facility has ruled out a fall based off statements obtained from staff. Writer reported that resident was transferred incorrectly. Writer assessed resident on 2/11/25 approximately 1 PM. Resident was unresponsive in her room, appeared comfortable, no swelling, lumps or bruising noted to her head or face. Writer assessed Left knee to have increased swelling and bruising to the lateral side of the knee. Resident did not have any indicators of pain at this time. On 4/1/25, at 9:57 AM, Surveyor interviewed Hospice RN-HH, who states, she knew R1 was transferred via a pivot transfer when she should have been a sit to stand transfer. The Facility did not tell Hospice R1 fell. If Facility would have told Hospice R1 fell, Hospice would have gone out right away for a follow up visit. Hospice RN-HH stated hospice would have approved an x-ray only if family requested and then decide if they wanted something done about the results. On 4/1/25, at 9:00 AM, Surveyor interviewed CNA-D who states, she knows how to care for the residents by reviewing their care cards located in a binder that tells them everything about the residents. CNA-D stated they would never use a different transfer method other than what is stated on the care plan or per therapy direction. On 4/1/25, at 12:08 PM, Surveyor interviewed telehealth APN-H who states, she remembers R1 to have side of the knee bruising. She was told R1 uses an EZ stand and a pivot transfer as completed. APN-H did not order an x-ray because she is just addressing the urgent needs which was pain and swelling. APN-H stated after that the primary team can change the Plan of Care or diagnose. APN-H was not aware if family was updated or what family wishes were as it was not discussed during the visit. APN-H states she is called during off hours when the primary team is unavailable. She is not there to diagnose, just to address the acute need until the primary team is back to address issues. On 4/1/25, at 1:58 PM, Surveyor interviewed, Medical Examiner (ME)-U who states, during the autopsy, Medical Doctor (MD)-X, indicates R1 did have severe cardiac disease and remote infarct (prior stroke) but no signs of an acute (new) cardiac event or stroke. On 4/1/25, at 3:37 PM, Surveyor interviews LPN-F who states, she did not work the weekend on 2/8/25 or 2/9/25 and when she came in on Monday, 2/10/25, the night shift RN provided very little information to her regarding R1's condition. She did administer medication for R1's pain due to bruising but did not know how she was bruised. A family member approached LPN-F with concerns regarding R1's condition and LPN-F informed family member it may be because of her pain from bruising. LPN-F states family member did not know she was bruised. LPN-F and family member went into R1's room and LPN-F asked R1 how she got her bruises and R1 states, she was dropped. LPN-F reported this information during morning stand up meeting to NHA-A and DON-B. LPN-F reports R1's knee was bruised, red, swollen from mid-thigh all the way down to calf. On 4/2/25 at 3:05 PM, the Survey Team, notified NHA-A, DON-B, ANHA-C, ANHA-T,Corporate Consultant (CC)-S, and Regional Director (RD)-V of the concerns R1 was transferred with assist of 1 and pivot and not with an EZ stand and assist of 1 as documented on R1's care plan. R1 complained of left knee pain at 10/10, bruising and swelling following the transfer. R1 told staff she was dropped, her knee hit the ground, and she was transferred without the EZ stand. R1 continued to physically and cognitively decline following the incorrect transfer and passed away on 4/11/25. An autopsy was performed and the preliminary cause of death was identified as a left distal femur fracture.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) R2 was admitted to the facility on [DATE] with primary diagnoses of cerebral infarction due to embolism of left middle cerebral artery (stroke), aphasia, abdominal aortic aneurysm, moderate protein-calorie malnutrition, encounter for attention to gastrostomy, unsteadiness on feet, muscle weakness and age-related physical debility. R2's admission MDS (Minimum Data Set) assessment dated [DATE], documented R2 is severely cognitively impaired with a BIMS (Brief Interview for Mental Status) score of 0 with both short- and long-term memory problems. MDS section GG, documents R2 is dependent with oral hygiene, toileting, shower/bathing, upper/lower body dressing and putting on footwear. R2 needs substantial to maximum assistance with eating and personal hygiene. MDS section H, documents R2 is frequently incontinent of both urine and bowel. MDS, section K, documents R2 has a feeding tube and is on a mechanically soft diet requiring change in texture of food or liquids. Record review of R2's Falls Risk assessment dated [DATE] documents a score of an 8, indicating R2 is at risk for falls. The assessment documents for mobility R2 has an unsteady gait and/or use of ambulatory device. Predisposing conditions documented, include CVA, (cerebral vascular accident) and visual deficit. R2's assessed mentation documents, R2 has impaired memory. R2 has had no falls in the past 3 months. Record review of R2 care plan dated 10/19/24 documents resident is at risk for elopement related to cognitive impairment and will attempt to walk and wander on her own. A Wanderguard was implemented for safety. Interventions include determine preferred setting, consider potential variables such as boredom, thirst, hunger, need for toileting, pain, exercise, companionship, exhaustion and over stimulation. Staff is directed to redirect, calmly and positively guide back to her room, provide 1:1 interaction with encouraging, uplifting comments and attempt to address any agitation. Additionally, staff is to initiate frequent checks and supervision. Record review documents R2's falls occurred on 10/21/2024, 11/05/2024 and 11/24/2024. Review of R2's progress notes dated 10/21/2024 at 11:18 am, documents a post occurrence with a complete body check completed with no injuries. Description of occurrence was [R2] was noted on her knees in from of her closet. [R2] unable to give reason. On 10/21/2024 a Falls Investigation Report was completed which documented, under incident description, CNA (Certified Nursing Assistant) called nurse to resident's room to note resident on her knees in front of her closet. Resident unable to give description. Immediate action taken documented, resident assessed for injuries and pain, neuros completed and assisted off the floor. Resident taken to the dining room for supervision. NP (Nurse Practitioner) guardian, DON, Administrator notified. No injuries observed at time of incident and no hospitalization. Pain is documented at a score of 0. Level of consciousness documented as alert. The following was not documented, mental status, predisposing environmental factors, predisposing physiological factors, and predisposing situation factors to include no known time last seen or last time toileted. There were no staff statements documented nor was a root cause analysis completed. The Falls Risk assessment dated [DATE] following R2's first fall, documents a score of 11, indicating R2 is at risk for falls. R2's mobility includes unsteady gait and/or use of ambulatory device and decreased mobility. Predisposing conditions documented for R2 include, CVA and no visual deficit. R2's mentation assessment is documented as confused. R2 has a history of 1-2 falls in the past 3 months. Documented under medications assessed as risk factors is drugs that have a diuretic effect or increased GI (gastrointestinal) motility. Drugs that affect the thought process. Drugs that create a hypotensive effect. R2's care plan fall interventions documented the following additions post first fall on 10/21/2024: Offer resident to be in common areas while awake. Date initiated, 10/22/2024. Monitor for changes in ability to navigate the environment. Date initiated, 10/23/2024. Keep frequently used items within reach in room. Date initiated, 10/23/2024. Ensure adequate lighting for tasks. Date initiated, 10/23/2024. Encourage resident to report falls. Date initiated, 10/23/2024. Encourage resident to keep room free from obstacles. Date initiated, 10/23/2024. Encourage resident to call, don't fall. Date initiated, 10/23/2024. Encourage participation in activities to keep resident focused and on task. Date initiated, 10/23/2024. Review of R2's progress notes dated 11/05/2024 at 12:06 pm document a post occurrence with a complete body check completed with no injuries. No description of occurrence. On 11/05/2024 a Falls Investigation Report was completed which documented under incident description, Summoned to resident room to observe resident sitting by her doorway by the white trash can. Resident was fully clothed with shoes and socks on Resident unable to give description. Immediate action taken documented, neuros taken No injuries observed at time of incident and no hospitalization. Pain is documented at a score of 0. Mental status documented as orientated to person. Level of consciousness documented as lethargic (drowsy). Predisposing environmental factors documented, wheelchair. Predisposing physiological factors documented incontinent, confused, weakness, gait imbalance, impaired memory, and poor safety awareness. Predisposing situation factors documented, resident last toileted is checked but does not specify a time and resident last observed indicated, staff reports just checking on her prior to event and she was in recliner. There were no staff statements documented nor was a root cause analysis completed. Revised care plan fall interventions for R2 documented the following additions post second fall on 11/05/2024: Medication adjustment and reviews. Resident also likes to crawl/place self in doorway and repeat hi at staff. Date initiated: 11/06/2024. Aromatherapy to promote calmness and relaxation. Date initiated: 11/06/2024. On 11/05/2024 a Falls Investigation Report was completed which documented under incident description, Summoned to resident room to observe resident sitting by her doorway by the white trash can. Resident was fully clothed with shoes and socks on Resident unable to give description. Immediate action taken documented, neuros taken No injuries observed at time of incident and no hospitalization. Pain is documented at a score of 0. Mental status documented as orientated to person. Level of consciousness documented as lethargic (drowsy). Predisposing environmental factors documented, wheelchair. Predisposing physiological factors documented incontinent, confused, weakness, gait imbalance, impaired memory, and poor safety awareness. Predisposing situation factors documented, resident last toileted in a check box but does not specify a time and resident last observed indicated, staff reports just checking on her prior to event and she was in recliner. There were no staff statements documented nor was a root cause analysis completed. Surveyor noted following the 10/21/24 fall R2's care plan indicates to offer to R2 to be in a common area. There is no documentation to indicate if this was offered to R2 and R2 refused or if the care plan had not been implemented to prevent this fall. Record review of R2's Falls Risk Assessment documented on 11/5/24, following second fall, assessed R2 to have a of 10, indicating R2 is at risk for falls. Mobility documented includes unsteady gait and/or use of ambulatory device. Predisposing conditions documented, CVA with no visual deficit. R2's mentation is documented as confused. History of falls documents R2 has had 1-2 falls in the past 3 months. Medications documented includes drugs that have a diuretic effect or increased GI motility. Drugs that affect the thought process. Drugs that create a hypotensive effect. Care plan fall interventions documented the following additions post second fall on 11/05/2024: Medication adjustment and reviews. Resident also (patterns herself) likes to crawl/place self in doorway and repeat hi at staff. Date initiated: 11/06/2024. Aromatherapy to promote calmness and relaxation. Date initiated: 11/06/2024. Surveyor noted the fall risk assessment dated [DATE] references medication effects that could increase R2's risk for falls. However, it is not documented or individually assessed what specific medications R2 takes in the risk categories and how they may impact R2's falls. On 11/24/2024 at 8:43 pm, progress notes document a post occurrence with a complete body check completed with injury, bruising and hematoma over right eye. Description of occurrence was [R2] was noted on her knees in front of her closet. [R2] unable to give reason. Note text documented, CNA notified writer that resident was noted to be sitting on the floor, near the door of her room. Writer notified RN to come assess, as well as notify the charge RN. When asked what happened resident repeated, no Hello. Hello! I don't know. I don't know. Resident noted to be alert and oriented only to self. It is noted that this is her mental base line for orientation. Upon assessment it was noted that an approximately 5 x 4 cm (centimeter) hematoma was over her R (right) eye, on her forehead. No deformities noted upon head-to-toe assessment. ROM (range of motion) in BUE (bilateral upper extremities) and BLE (bilateral lower extremities) to baseline, able to bear weight. Non-slip socks noted on her feet. Neuro checks immediately initiated and noted to be baseline. Resident is PERLLA, (pupils are equal, round and reactive to light and accommodation). Resident refused to have her blood pressure taken repeatedly. Gathered vitals noted to baseline. Resident not showing any signs of SOB, (shortness of breath). Resident noted to be restless and very challenging to redirect. Writer educated resident to please remain still and remain in the same place until further assessment could be completed, however she continued to move around and even scooted across the floor and placed herself onto the edge of the bed. Staff continued to attempt to attempt to redirect without success. (Name of) , (Medical Doctor), (name of tele-medical group) contacted and provided order to send this resident to the ER (Emergency Room). Writer reached out to residents Son/POA, (Power of Attorney) (name of) , conveying the situation to him and the Doctor's orders to send her to the ER, which he agreed with and stated he would meet her at the ER. EMS (Emergency Medical Service) activated and transported resident to the ER. Management updated by charge RN. Writer called (name of hospital) ER and provided a verbal report of resident. EMS was handed transfer papers for continuity of care. Care plan updated with a new intervention for fall prevention. Discuss with family or visitors if needed to notify staff when they leave. On 11/24/2024 a Falls Investigation Report was completed which documented under incident description an exact copy of the progress note dated on 11/24/2024 at 8:43 pm. Resident unable to give description. Immediate action taken documented, RN assessed, vitals taken as able, neuros initiated, MD notified, POA/family notified, EMS activated, report given to ER. Resident taken to hospital with a hematoma top of scalp. Pain is documented at a score of 0. Mental status documented as orientated to person. Level of consciousness documented as alert and ambulatory with assistance. Predisposing environmental factors documented, other. Predisposing physiological factors documented, confused, gait imbalance and impaired memory, weakness and poor safety awareness. Predisposing situation factors documented, resident last toileted is checked but does not specify a date/time and resident last observed is checked but does not specify a date/time. There were no staff statements documented nor was a root cause analysis completed. Record review of R2's Falls Risk assessment dated [DATE] documented following R2's third fall, on 11/24/2024 a risk score of 15, indicating R2 is at high risk for falls. Mobility is documented as, unsteady gait and/or use of ambulatory device, decreased mobility and decreased muscular coordination. Predisposing conditions are documented as, CVA and visual deficit. Mentation is documented to be, confused. History of falls documents R2 has had 3 or more falls in the past 3 months. Medications contributing to risk are documented to include drugs that have a diuretic effect or increased GI motility. Drugs that affect the thought process. Drugs that create a hypotensive effect. Surveyor noted despite care plan intervention to review R2's medications, the specific medications R2 receives are not assessed to show how they may impact R2's fall risk. The care plan fall interventions for R2 post the third fall documented the following additions: Discuss with family or visitors if needed to notify staff when they leave. Date initiated, 11/24/2024. Sound machine placed in resident room for comfort and inhibit agitated behaviors at HS (hours of sleep) and during the night. Date initiated, 11/25/2024. Surveyor noted this is the third fall R2 has had where R2 is found on their knees with this being the second by the doorway. The facility noted in the plan of care R2 likes to be by the door and say hi but did not create an intervention to assist R2 to do this and keep R2 safe from falls. On 11/25/2024 at 2:58 am, progress note documented, Resident medically cleared to return from ER. On 12/03/2024 at 9:24 am, surveyor interviewed R2's family member-V who stated, she was told by Director of Nursing (DON)-B that R2 is known to be a crawler. DON-B says R2 gets out of their wheelchair and crawls on the floor. Family member-V feels like R2 is falling more frequently and the facility is telling her R2 is found on floor due to crawling and not actually falling. Family member-V stated she is concerned about the interventions put in place to mitigate falls. Family member-V stated, my [R2] had a fall with a major bruise on her head and was told the intervention was a sound machine was placed in room. Family member-V does not feel this is an adequate intervention. On 12/3/24, at 3:33 p.m. NHA (Nursing Home Administrator)-A, DON-B, Regional Nurse Consultant-C and Assistant Administrator-D were informed of the above. Surveyor asked if there is any additional information regarding all areas investigated. As of 12/05/24, at 1:15 pm, Surveyor did not receive any additional information. Based on interview and record review, the facility did not ensure 2 (R3 & R2) of 2 residents received adequate supervision and assistance devices to prevent accidents. * On 5/25/24 while the night Certified Nursing Assistant (CNA) was providing incontinent cares to R3, R3 indicated she couldn't hold onto the transfer device and rolled out of bed sustaining a laceration to the forehead and a right femur fracture. According to CNA-Q's statement she guided R3 out of bed however, when Surveyor spoke to R3, R3 informed Surveyor the CNA watched her roll out of bed. The facility did not conduct a thorough investigation, as there isn't a statement from the nurse who assessed R3 or a statement from R3, there are no details as to what the position of the bed was in relation to where R3 fell, and whether care plan interventions were in place at the time of the fall. R3's care plan does not address the air mattress on the bed. * R2 sustained multiple falls with one fall resulting in injury. A thorough investigation after every fall was not completed to determine root cause analysis. Some Interventions established were not specific to prevent further falls. Findings include: The facility's policy titled, Management of Falls and dated 8/2020 under Policy documents The facility will assess hazards and risk, develop a plan of care to address hazards and risks, implement appropriate resident interventions, and revise the resident's plan of care in order to minimize the risks for fall incidents and/or injuries to the resident. Under Procedure documents .3. Develop a plan of care to include goals and interventions which address resident's risk factors. Risk factors may include but are not limited to the following: Contributing diagnoses/disorders/disease processes/active infections/other comorbidities, history of fall incidents, Incontinence, Medications (Narcotics, Antihypertensives, etc.), assistance required with ADL's (activities daily living), gait/transfer/balance issues, Behaviors, and/or cognitive status. 1.) R3 was originally admitted to the facility on [DATE]. R3's diagnoses includes multiple sclerosis, chronic inflammatory demyelinating polyneuritis (disorder that involves nerve swelling & irritation that leads to a loss of strength or sensation), contracture of muscle of right & left hand, hypertension, paraplegia, diabetes mellitus, depressive disorder, and anxiety disorder. R3 was admitted with a Stage 3 right gluteal pressure injury. Review of R3's care plans document: The [R3's first name] has an ADL (activities daily living) functional performance deficit r/t (related to) paraplegia, MS (multiple sclerosis), atrophy, contractures, impaired AROM (active range of motion) and DM2 (diabetes mellitus). Has need to assist with mobility and repositioning with use of bilateral quarter assist rails to bed initially initiated 4/18/24 & last initiated date of 10/4/24 documents the following interventions: * Enhanced Barrier Precautions will be implemented during high contact resident care activities. Initiated 4/18/24. * Assist with ADL tasks as needed. Initiated 4/18/24. * Allow enough time for completion of ADL tasks. Do not rush the resident. Initiated 4/29/24. * Ask resident if room temperature is okay. If not contact Maintenance. Initiated 4/29/24. * Assist resident with oral care daily as needed. Initiated 4/29/24. * Assist resident with set up for supplies of bathing as needed. Initiated 4/29/24. * Assist with locomotion as needed. Initiated 4/29/24. * Assist with personal hygiene as needed. Initiated 4/29/24. * Assist with toileting needs as necessary. Initiated 4/29/24. * Assist with transfers as needed. Initiated 4/29/24. * Barrier cream with incontinence care. Initiated 4/29/24. * Check skin for changes during bathing. Initiated 4/29/24. * Encourage to eat slowly. Initiated 4/29/24. * Encourage use of call light for assistance when needed. Initiated 4/29/24. * Encourage use of positioning device for bed mobility as needed. Initiated 4/29/24. * Prompt and use hand over hand assist as needed to enable increased independence with bed mobility and repositioning with aide of bilateral assist rails to bed. Use of bed ladder was not effective. Initiated 4/30/24. * Provide needed level of assistance and support to complete Activities of Daily Living. Document in POC (plan of care). Initiated 11/12/24. * Transfers: Hoyer. Initiated 4/29/24. The at risk for falls care plan initiated 4/18/24 and last revised 10/4/24 documents the following interventions: * Encourage appropriate use of wheelchair. Initiated 4/18/24. * Promote placement of call light with in reach. Initiated 4/18/24. * Encourage resident to keep room free of obstacles. Initiated 4/29/24. * Ensure adequate lighting for tasks. Initiated 4/29/24. * Fall risk assessment quarterly and as needed. Initiated 4/29/24. * Keep frequently used items within reach in room. Initiated 4/29/24. * Monitor resident for tolerance and endurance. Schedule tasks accordingly. Initiated 4/29/24. * Notify family and MD (medical doctor) of any new fall. Initiated 4/29/24. * Provide an environment clear of clutter. Initiated 4/29/24. * Apply pillow/pillows to side when doing cares to prevent rolling out of bed. Initiated 5/28/24. R3's fall risk assessment dated [DATE] has a score of 4 which indicates at risk for falls. The admission MDS (minimum data set) with an assessment reference date of 4/26/24 has a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. R3 is assessed as not having any behavior. R3 is assessed as being dependent for chair/bed to chair transfer & toileting hygiene and substantial/maximal assistance for roll left and right. R3 is assessed as being frequently incontinent of urine and bowel. R3 is assessed as not having any falls prior to admission or since admission. R3 is 5 feet 10 inches in height & 179 pounds. The falls CAA (care area assessment) dated 5/1/24 under analysis of findings for nature of problem/condition documents Resident came to [NAME] long term transfer from nursing home in NC (North Carolina). Resident has MS, G-tube that receives fluids and meds (medication) through. Also treatment in place for PU (pressure ulcer) Stage 3 to gluteal fold right. Res (Resident) pain assessment completed. Res is noted to have c/o pain at times occasionally and is noted to be utilizing both PRN (as needed) and scheduled pain medications via G tube. Res is alert and is able to make her needs known and can alert staff about her discomfort. Res does not utilize glasses for vision and is able to see without them. Res is noted to have upper dentures. Res receives a mechanical altered diet and also tube feeding according to the amount that is eaten. Resident is incontinent of bowel and bladder. Resident requires assistance from staff for ADLs/IADLS. Under care plan considerations documents Staff will ensure room is well lit and free from clutter. Staff will follow policies and procedures for bed mobility and transferring a dependent patient utilizing equipment appropriately. The occupational therapy note for date of service of 4/29/24 and written by OTR (Occupational Therapist Registered)/DOR (Director of Rehabilitation)-O documents Physician's order received, chart reviewed, hx (history) noted, evaluation completed and POT (program of treatment) developed on this date. Due to mm (muscle) atrophy, contractures and impaired AROM (active range of motion) throughout B UE's (bilateral upper extremities), all joints, ulnar nerve symptoms B L including (bilateral left including) hyperextension of MCPs (metacarpophalangeal joint) (knuckle joint of the finger) and flexion of PIPIs (proximal interphalangeal joint) (middle joint of finger), throughout B (bilateral) hands, pt (patient) is unable to roll or reposition herself in bed when needed/desired. She is able to make weak fists B L in order to pull herself over onto her sides. Due to OA (open area) buttock pt is only up for 4 hours in her wc (wheelchair) and spends the rest of her day in bed, and must be repositioned side to side each time by staff. With assist rails pt is able to participate in mobility and reposition in bed to reach items as she chooses, which may not be anticipated prior. Diagnoses which make I (independent) use of body difficult included: paraplegia, chronic inflammatory demyelinating polyneuritis, unspecified pain and MS. Recommend B (bilateral) assist rails. Pt trialed use of wc (wheelchair) next to bed to pull over using arm rests on w/c which was difficult and additionally required mod (moderate) A (assist) to roll R (right) when supine. However wc will be plugged in at night to charge in another room. She attempted reaching to L by grabbing window sill, which was ineffective, and pulling self over with bed ladder however it didn't position high enough to reach and pull. The CNA (Certified Nursing Assistant) Kardex dated 5/25/24 under the category for bed mobility documents Bilateral assist rails to bed to enable participation in bed mobility and repositioning. Prompt and use hand over hand assist as needed to enable increased independence with bed mobility and repositioning with aide of bilateral assist rails to bed. Use of bed ladder was not effective. Under the category for safety documents Elevate the head of the bed while napping or sleeping to avoid shortness of breath while lying flat. Encourage appropriate use of wheelchair. Monitor and report signs/symptoms of abuse. The nurses note dated 5/25/24, at 0735 (7:35 a.m.), by Nursing-P includes documentation of Patient had a fall this AM (morning) witness out of bed, she had a laceration above her left eye pain rated 10/10 to her right leg. Per RN (Registered Nurse) her right knee had a deformity sent out prior to page d/t (due to) urgency. The incident report dated 5/25/24 under incident description for nursing description documents Paged on the radio for help in resident room, on arrival found resident on the floor. Under resident description documents I couldn't hold the rail anymore, I let go. Under the section immediate action taken for description documents Assessed v/s (vital signs) and skin for abrasions and lacerations. Applied pressure to laceration to the forehead. called 911. Under other info (information) documents CNA providing incontinent cares in bed. [R3's first name] was unable to continue holding onto rail and began to slide out of bed to floor. Under statements CNA-Q's statement documents @ (at) 5:00 I entered [R3's first name] room [number] to do her cares. I got all of her essentials needed to perform them as I did proceed to talk with her to let her know that I was going to start cares on her. [R3's first name] replied Ok [NAME]! I asked [R3's first name] to turn as I helped her into the position she was propped up on her left side as I cleaned her bottom, and when doing so she said was slipping out of bed, I tried to ease ger (sic) to the floor as safe as possible without her harming herself. I then proceeded to call for help. Surveyor noted CNA-Q is not listed as a current employee on the staff list provided by the facility. Under the note section dated 5/28/24 by Assistant Administrator (AA)-E documents IDC (interdisciplinary care) Team reviewed fall on 5/25/24. The goal of the facility is resident safety. The root cause was resident was holding onto side rail during cares, let go and fell. Resident was sent to hospital post fall. The interventions will be a larger bed for positioning during cares and pillow placement if necessary for positioning during cares. Staff member was also educated by DON (Director of Nursing) [Regional Nurse Consultant-C's first name]. [R3's first name] notified and in agreement. Under the note section dated 5/31/24 by RNC (Regional Nurse Consultant)-C documents [R3's name] is a 73 y/o (year old) that admitted on [DATE] for LTC (long term care) from out of state SNF (skilled nursing facility). She has the following medical conditions: chronic inflammatory demyelinating polyneuritis, paraplegia, type 2 diabetes mellitus, with polyneuropathy, multiple sclerosis, major depression, copd (chronic obstructive pulmonary disease), pressure injury stage 3, chronic pain, hypertension, anxiety disorder and achalasia. [R3's first name] is alert and oriented to person, place, time and situation and has a BIMS score of 15. She is able to assist with turning side to side with use of the bilateral transfer bed rails and 1 assist. She is non-ambulatory, and a total lift is required for transfers. On 5/25 @ approx (approximately) 0500 (5:00 a.m.) [R3's first name] was on her left side for peri-care following incontinence, was unable to hold onto transfer rail and slipped off her bed. Due to c/o (complaint of) right leg discomfort and laceration to head she was transferred to the hospital and admitted with right femur fracture. The hospital Discharge summary dated [DATE] under chief complaint documents Fall out of bed while doing bed change at [NAME] this morning. Head injury, no LOC (loss of consciousness). Under admission information documents Patient is a [AGE] year-old female nursing home resident who is wheelchair-bound from numerous medical issues and who was being helped in bed and ruled (sic) out and fell on the floor. Patient sustained significant pain and deformity of the right leg and was brought in for evaluation. In the ER (emergency room) patient is found to have a right hip fracture causing 8/10 pain and worse with movement. Under physical exam for Musculoskeletal documents Right leg in cast from upper thigh to toe, does not have sensation in feet at baseline, but is able to wiggle toes, and feet are equal warmth. On 12/2/24, at 9:35 a.m., Surveyor observed R3 using the electric wheelchair in the hallway. R3 asked Surveyor who Surveyor was. After Surveyor identified self, R3 informed Surveyor she would like to speak with Surveyor. During this conversation, Surveyor asked R3 if she has had any falls at the facility. R3 replied oh sure she rolled me out of bed and I broke my femur. R3 explained she told them she needed a wider bed, they did put rails on and she rolled over the rail. R3 informed Surveyor she was in a cast for 8 weeks. Surveyor asked if she had any falls after this fall. R3 replied no. R3 informed Surveyor she had to wait until her insurance to kick in to get a wider bed which was June 1st. R3 informed Surveyor she is now on hospice and has a hospice bed. R3 informed Surveyor she transfers with a hoyer lift and has never fallen out of the hoyer lift. On 12/2/24, at 11:08 a.m., Surveyor observed R3 in her electric wheelchair going down the hallway from the front entrance. On 12/2/24, at 12:09 p.m., Surveyor observed R3 sitting in her wheelchair with an over bed table across and her lunch on the over bed table. On 12/2/2, at 1:59 p.m., Surveyor observed R3 sitting in her wheelchair in her room with visitors. On 12/3/24, at 7:17 a.m., Surveyor observed R3 on her back with the head of the bed elevated sleeping in bed. There are two quarter side rails up and there is an air mattress on the bed. On 12/3/24, at 11:03 a.m., Surveyor asked DON (Director of Nursing)-B who Surveyor should speak with regarding R3's fall on 5/25/24. DON-B informed Surveyor she thinks RNC (Regional Nurse Consultant)-C was the acting DON at that time. On 12/3/24, at 11:35 a.m., Surveyor observed R3 reclined slightly back in her wheelchair in the room. Surveyor asked R3 if Surveyor could talk to her again about her fall in May when she fractured her femur. Surveyor asked R3 if she could tell Surveyor what happened again. R3 replied she rolled me off the bed. She purposely turned me. I told her I wouldn't be able to hold on. Surveyor asked if there was one or two staff in the room. R3 replied one. Surveyor asked R3 if the CNA rolled her away from her (the CNA). R3 replied yes. R3 informed Surveyor at the time of the fall she had smaller bars on her bed than she has now. R3 stated I just rolled, she didn't put the bed against the wall as I asked her. I rolled right out. Surveyor asked R3 before rolling out of the bed was she holding onto the bar. R3 replied yes. Surveyor asked R3 what did the CNA do when she started to roll off the bed. R3 replied watched me go to the floor. Surveyor asked R3 if anyone spoke to her about the fall. R3 replied there was a lot of people. Surveyor asked if she remember who spoke with her. R3 replied no was after I came back, probably not even here. On 12/3/24, at 12:14 p.m., Surveyor met with RNC-C to discuss R3's fall on 5/25/24. RNC-C informed Surveyor she thought R3's fall was on the day shift but when she spoke with the day shift CNA, the night CNA was already gone. RNC-C explained CNA-Q from nights was changing R3 & cleaning her up as R3 was incontinent and when R3 has a BM (bowel movement) it is usually large. R3 was holding on the transfer rail, just said she can't hold on and slide down. RNC-C indicated CNA-Q tried to guide her with the sheet and went to the floor. The nurse came in and assessed her. Surveyor inquired who was the nurse. RNC-C informed Surveyor it was a [name of agency] nurse. Surveyor asked RNC-C if she spoke with R3. RNC-C replied afterward, after she came back from the hospital. Surveyor asked

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure they provided the necessary care, consistent with professional standards of practice, to prevent the development of pressure ulcers for 1 out of 5 residents (R38) reviewed who were at high risk. R38 returned to the facility following surgical repair to the left knee. R38 was to wear an immobilizer to the left lower extremity for 6 weeks after the surgery. The facility did not provide monitoring of R38's skin under the immobilizer and R38 developed a stage 4 pressure ulcer to the back of her left lower leg. This is evidenced by: R38 was readmitted to the facility on [DATE] following an acute left distal femoral fracture with surgical repair. Hospital discharge instructions included, wound/skin care: may reinforce left knee dressing; otherwise leave in place until ortho follow-up. Stage #3 coccyx pressure injury - silicone boarded foam change 3 times a week, offload from pressure. Surveyor conducted a review of the physician orders for November 2023. R38 had an order that stated, may reinforce left knee dressing; otherwise leave in place until ortho follow-up. As needed for wound healing. Start date 11/10/23. (d/c date 12/27/23). A review of the plan of care for R38 indicates: R38 Requires an immobilize to LLE (Left Lower extremity) secondary to Limitation in ROM (Range of Motion) from recent surgery. Date Initiated: 11/17/2023. Interventions include: o Will tolerate splint use through next review. Date Initiated: 11/17/2023 o Apply splint/brace per MD (Medical Doctor) order to affected area. Date Initiated: 11/17/2023 o Monitor splint for cleanliness, need for refitting, repair, or fit as needed. Date Initiated: 11/17/2023 o Report any changes in ability to use the affected area. Date Initiated: 11/17/2023 R38 has alteration in skin integrity r/t (related to) non-removable medical device stg (stage) 4 to LLE, Left thigh/knee wound near surgical incision, decreased mobility, need for staff assistance for ADLs (Activities of Daily Living) and transfers, diagnosis of lymphedema, hemiplegia and hemiparesis, epilepsy, anemia, hx of falls, poly osteoarthritis. Recurrent shingles/zoster, rashes, dx (diagnosis) atopic neurodermatitis. Non-compliance with repositioning/chair time. Date Initiated: 09/05/2023 Interventions include: o Skin will show s/s (signs/symptoms) of healing thru next review Date Initiated: 09/05/2023 o Absorbent to wick up moisture. Date Initiated: 06/25/2023 o Barrier cream to areas exposed to moisture/incontinence. Date Initiated: 09/26/2021 o Bathe with mild soap. Date Initiated: 09/18/2021 o Inspect skin daily with care Date Initiated: 09/05/2023 o LAL (Low Air Loss) mattress to bed. Date Initiated: 11/10/2023 o Moisturize dry skin Date Initiated: 09/26/2021 o Monitor nutritional status Date Initiated: 09/26/2021 o Monitor wound related pain and administer pain medications as appropriate. Date Initiated: 06/25/2023 o Position body with pillows/support devices Date Initiated: 09/26/2021 o Pressure reduction support on wheelchair with LLE calf support in W/C (wheelchair) Date Initiated: 09/26/2023 o Remind of importance of frequent position changes. Explain risks of prolonged sitting in her w/c. Date Initiated: 11/27/2023 o Treatment as ordered Date Initiated: 09/18/2021 R38 had a follow up Orthopedic consult on 11/22/23. The progress note indicates there is a slow stable fracture alignment. Staples removed today. May allow running water over incision. No soaking under water. Steri strips may be removed after 1 week. Continue non-weight bearing on left lower extremity. No rx (prescription) changes. The facility conducted a comprehensive assessment on 12/19/23 for R38's development of a pressure ulcer to the left lower leg (rear). Pressure Ulcer is unstageable. 5.0 centimeters in length by 2.0 centimeters in width and depth is less than 0.1 centimeters. Area described as superficial. 25% granulation, 75% slough, and 0 eschar. Margins are irregular, peri-wound is intact. Comments: Unstageable pressure ulcer noted to left lower extremity. New orders received. Low air loss mattress in place. Education on importance of repositioning with R38, who verbalized understanding. On 12/18/2023 at 6:01p.m., Physician progress note: DATE OF SERVICE: 12/19/2023 CHIEF COMPLAINT: Mobility and ADL dysfunction secondary to h/o (history of) of CVA (Cerebral Vascular Accident) with left ORIF (Open Reduction and Internal Fixation) distal femur with removal of hardware. REASON FOR RE EVALUATION: R38 was discharged on 11/07 and was re admitted in the facility due patient undergone left ORIF distal femur with removal of hardware. HOSPITAL COURSE: R38 is a [age and sex of R38] who is a LTC (Long Term Care) resident with h/o of CVA with left ORIF distal femur with removal of hardware in the presence of multiple medical comorbidities leading to a functional decline. Patient admitted to the SNF (Skilled Nursing Facility) on 09/16/2021 for skilled nursing and rehab. Patient asked to be seen by primary team to optimize therapy, pain control and discharge planning. Patient's plan and progress was discussed with nursing staff and therapy. HPI (History of Present Illness): R38 seen and examined. R38 is going out for an appointment today. Unfortunately, R38 has a pressure injury from rubbing from knee immobilize brace which she has had at all times located on that left LE (left extremity). She does not feel a lot of pain there which she states she has not report it to nursing. She does have PRN (as needed) pain medication available. Spoke with nursing and will follow-up with her team today. Hopefully will get the immobilizer switch (sic) out to something that will allow for relief. Pain is a 0/10 today at rest. Pain is well controlled on pain medications. No reported side effects. On 12/19/2023, the facility conducted an Unavoidable Pressure Injury or Condition Review of clinical Manifestations. The progress note states R38 has a non-removable brace to LLE. Does not like to reposition. Chooses not to drink nutritional supplement to aide in healing. Nursing note dated 12/19/2023 at 4:36 p.m.: R38 returned from ortho appointment with orders for NWB (Non Weight Bearing) x (for) 6 more weeks to dc (discontinue) immobilizer, follow up in 6 weeks, to also consult with [name of doctor] for the wound on her left calf and heel noted and carried out. On 12/26/23, the facility conducted a weekly comprehensive assessment of R38's pressure ulcer to the left lower extremity (rear). Stage is assessed to be a stage 4 measuring 5.5 cm in length by 2.5 cm in width by 0.1 cm in depth. 25% epithelization, 25% granulation, and 50% slough. Margins are irregular. Moderate exedute. This area is offloaded with pillow. R38 complains of pain with washing, subsides when completed. Wound is healing. NP (Nurse Practitioner) updated and continue treatment. On 1/2/24, the facility's weekly skin assessment indicates R38 has a stage 4 pressure ulcer to the left lower extremity-rear measuring 5.6 cm by 2.3 cm by 0.1 cm. This area is offloaded with pillow. Wound bed is 25% epithelization, 50% granulation and 25% slough. No eschar present. Continue treatment. On 1/9/24, the facility's weekly skin assessment indicated R38 had a stage 4 pressure ulcer to the left lower extremity-rear measuring 4.5 cm by 2.0 cm and depth is unable to measure. 10% slough and 90% eschar. Continue treatment. On 1/16/24, the facility's weekly skin assessment indicates R38 has a stage 4 pressure ulcer to the left lower extremity-rear measuring 3.4 cm by 1.0 cm by 0.4 cm. Description - cavity or crater. On 1/23/24, the facility's weekly assessment indicates that R38 has a stage 4 pressure ulcer to the left lower extremity measures 3.5 cm by 1.1 cm by 0.5 cm depth. 100% granulation. This area is offloaded with pillow. NP updated. Continue treatment, improved. Continued weekly assessments were completed by the facility. The pressure ulcer continued to improve towards healing which was indicated by decrease in size of the area. On 3/5/24, the weekly skin assessment indicated that the pressure ulcer to R38's left lower extremity is noted to be healed. On 03/13/24 at 1:31p.m., Surveyor interviewed Director of Nursing (DON) - B regarding R38's acquired pressure ulcer to her left lower extremity-rear. Surveyor asked DON-B if the staff should have been monitoring R38's skin underneath the leg immobilizer. DON-B stated Nursing should have been looking at the skin and typically this would have been conducted each shift. DON-B stated she would need to investigate this further and get back to Surveyor to confirm skin assessments. Surveyor asked DON-B how the pressure ulcer was discovered. DON-B stated that I went to conduct a skin check, I was just doing random skin checks and I found the area. DON-B confirmed that no other staff had reported discovering the pressure ulcer prior to her finding it. DON B stated staff reported looking at the skin under the immobilizer and that CNAs would wash the left lower leg and put lotion on it. Surveyor reviewed with DON-B the facility's assessment that the pressure ulcer development was unavoidable because the brace R38 was wearing was non-removable and how did the facility staff wash and apply lotion if the immobilizer was not to be removed. DON-B was unable to provide additional information at this time and stated she would follow-up. On 03/13/24 at 03:11 p.m., Surveyor shared concerns about the development of the stage 4 pressure ulcer that developed under R38's immobilizer on her left lower extremity-rear. Surveyor shared concerns the facility staff were not checking R38's left lower extremity daily knowing that R38 was at high risk for developing a pressure ulcer. The facility did provide evidence R38's skin was checked weekly, every day shift on Mondays with her shower however, the information did not document if the staff removed the immobilizer during the skin checks. In addition, the facility provided discharge documentation from 11/7/23 stating R38 is non-weightbearing to her left lower extremity for at least the next 6 weeks. Knee immobilizer to remain in place. Surveyor noted the order did not indicate if the skin under the immobilizer should or should not be checked and there is no documentation this was clarified with R38's physician. No additional information has been provided as of the time of exit from the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility did not ensure residents received care consistent with professional standards of practice in the development and healing of pressure injuries for 1 (R72) of 3 residents reviewed for pressure injuries. R72 developed deep tissue injuries (DTI) to the left heel and the left outer ankle on 7/28/2022, the right heel on 9/27/2022, and the right and left buttocks on 11/22/2022. The left heel DTI healed on 9/20/2022. The left outer ankle DTI was recategorized as a diabetic ulcer and then reclassified as a DTI with eschar. The definition of a DTI by the National Pressure Injury Advisory Panel (NPIAP) is a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. A DTI is not open, covered by eschar, or have any other type of tissue present. The right heel DTI developed eschar and the staging of the pressure injury did not reflect the new tissue type. R72 was readmitted to the facility on [DATE] with an Unstageable pressure injury to the left lateral heel. Findings include: R72 was admitted to the facility on [DATE] after hospitalization for right shoulder surgery with diagnoses of hemiplegia and hemiparesis following cerebral infarction, seizures, diabetes, heart failure, chronic kidney disease, depression, anxiety, anemia, and history of myocardial infarction. On 7/7/2022 on the Initial Nursing Assessment form, nursing charted in the skin section of the form R72 had a healing incision to the right shoulder and a small abrasion from glasses to the right side of the nose. Nursing charted in the additional notes section R72 did not have any open areas to the skin. On 7/7/2022, R72's Braden scale was 17 indicating mild risk for skin breakdown. R72's Skin Integrity Care Plan was initiated on 7/8/2022 with the following interventions: -Absorbent to wick up moisture. -Bathe with mild soap. -Encourage mobility and/or ambulation. -Inspect skin daily with care. -Monitor for signs/symptoms of infection. -Monitor nutritional status. -Monitor wound related pain and administer pain mediation as appropriate. -Pericare after incontinent episodes. -Pressure reduction support on wheelchair. -Treatment as ordered. Surveyor noted there are no interventions for heel/foot protection or offloading. There also are no individualized interventions for repositioning despite R72 having hemiplegia and and hemiparesis. R72's admission Minimum Data Set (MDS) dated [DATE] indicates R72 is cognitively intact with a Brief Interview of Mental Status (BIM) score of 14. R72 is identified as needing extensive assistance of two plus staff for bed mobility. R72 was identified as being at risk for pressure injuries and did not have any pressure injuries. The MDS also indicated R72 did not demonstrate any behaviors including refusal of cares. On 7/14/2022, R72's Braden score was 14 indicating moderate risk for skin breakdown. On 7/21/2022, R72's Braden score was 15 indicating mild risk for skin breakdown. On 7/28/2022, R72 developed a DTI to the left outer ankle. The facility uses a form entitled WASA to document wounds. On the WASA form, nursing charted the left outer ankle DTI measured 1.5 cm (centimeters) x 1.4 cm x 0 cm that was maroon/purple and not open or draining. In the additional comments section of the form, nursing charted R72 had two new areas to the left foot both maroon/purple non-blanching: one area to the outer ankle bone and one area to the outer heel. Nursing charted R72 stated they sleep mostly on the left side and spends most time in bed. Surveyor noted the left heel did not have any measurements documented. Surveyor noted there were no changes to R72's care plan. On 8/4/2022, on the WASA form, nursing charted the left outer ankle DTI measured 1.2 cm x 1 cm that was purple in color. In the additional comments section nursing charted R72 wears heel boots to prevent further or new skin conditions. On 8/4/2022 on the WASA form, nursing charted the left heel DTI measured 1 cm x 0.6 cm that was purple in color. In the additional comments section nursing charted R72 wears heel boots to prevent further or new skin conditions. Surveyor noted this was the first comprehensive assessment of the left heel DTI. R72's left outer ankle DTI and left heel DTI were comprehensively assessed weekly from 8/4/2022 through 9/7/2022. On 9/7/2022 on the WASA form, nursing charted R72's left outer ankle DTI measured 1.4 cm x 1.5 cm x unknown depth with 100% eschar. Surveyor noted a DTI does not have eschar and the pressure injury was now Unstageable. In the additional comments section, nursing charted R72 had a low air mattress in place. On 9/7/2022 on the WASA form, nursing charted R72's left heel DTI measured 1 cm x 0.5 cm and was dry and intact. On 9/13/2022 on the WASA form, nursing charted R72's left outer ankle wound was a diabetic ulcer that measured 2 cm x 2 cm x unknown depth with 100% eschar. Surveyor noted no explanation was documented as to the change from a pressure injury to a diabetic ulcer. On 9/13/2022 on the WASA form, nursing charted R72's left heel DTI measured 0.8 cm x 0.4 cm with 100% eschar. Surveyor noted a DTI does not have eschar and the pressure injury was now Unstageable. In the additional comments section, nursing charted the DTI was intact with treatment in place. On 9/20/2022 on the WASA form, nursing charted R72's left outer ankle diabetic ulcer measured 1.8 cm x 1.8 cm with 100% eschar. On 9/20/2022 on the WASA form, nursing charted R72's left heel DTI had healed. On 9/27/2022 on the WASA form, nursing charted R72's left outer ankle wound was a DTI that measured 2.0 cm x 2.8 cm x 0 cm with 100% granulation and the wound was no longer covered with eschar. Surveyor noted a DTI does not have granulation tissue and the wound should have been staged if it was a pressure injury. On 9/27/2022 a new pressure area was discovered on R72's right heel. On the WASA form, nursing charted the right heel DTI measured 2.5 cm x 4.0 cm x 0 cm. On 10/4/2022 on the WASA form, nursing charted the left outer ankle DTI measured 1.8 cm x 2.8 cm x 0 cm with 100% granulation. Surveyor noted a DTI does not have granulation tissue and the wound should have been staged. On 10/4/2022 on the WASA form, nursing charted the right heel DTI measured 2.5 cm x 3.8 cm x 0 cm. On 10/9/2022 on the WASA form, nursing charted the left outer ankle DTI measured 1.6 cm x 2.6 cm x 0.1 cm with 100% eschar. In the additional comments section, nursing charted the wound bed was a mix of white and black soft tissue with no slough identified and R72 had an appointment scheduled at the wound clinic on 10/10/2022 for evaluation and treatment. Nursing charted R72 was immobile and required turning every 1-2 hours, R72 gets up to chair after breakfast, and heels floated with pillows due to refusal of the Prevalon boots. Surveyor noted a DTI does not have eschar and should have been documented as Unstageable. On 10/9/2022 on the WASA form, nursing charted the right heel DTI measured 2 cm x 3.6 cm x 0 cm with 100% eschar. In the additional comments section, nursing charted the wound bed was black, dry, and intact with margins peeling up from the peri wound. Nursing charted the total dry area measured 4.6 cm x 4 cm x 0 cm with the eschar being in the center measuring 2 cm x 3.6 cm x 0 cm. Nursing charted R72 was immobile and required turning every 1-2 hours, R72 gets up to chair after breakfast, and heels floated with pillows due to refusal of the Prevalon boots. Surveyor noted a DTI does not have eschar and should have been documented as Unstageable. R72's Skin Integrity Care Plan was revised on 10/10/2022 with the following intervention: float heels as tolerated and to comfort. Surveyor noted the interventions documented in R72's nurses notes are not included in the care planned interventions to ensure implementation. R72's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R72 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 and coded R72 as needing extensive assistance with all activities of daily living including bed mobility and was always incontinent of bowel and bladder. The MDS indicates R72 has two unstageable-deep tissue injuries and is at risk for pressure injuries. Review of the behavior section indicated R72 did not demonstrate any behaviors including refusal of cares. R72's left outer ankle wound and right heel wound were measured weekly from 10/14/2022 through 11/7/2022. The wounds were charted as being DTIs with 100% eschar. Surveyor noted a DTI does not have eschar and the wounds should have been documented as Unstageable. R72 was in the hospital from [DATE] through 11/14/2022. On 11/15/2022 on the WASA form, nursing charted the left outer ankle DTI measured 2.5 cm x 1.9 cm x 0.1 cm with 50% granulation, 25% slough, and 25% clean non-granulation tissue. Surveyor noted a DTI does not have granulation, slough, or any other type of tissue in the wound bed and the wound should have been staged. On 11/15/2022 on the WASA form, nursing charted the right heel DTI measured 3.2 cm x 3.3 cm x 0 cm with 100% eschar. In the additional comments section, nursing charted R72 continued to refuse heel boots and would kick pillows away; R72 was re-educated on the risks of continued pressure to areas such as wound deterioration, infection, pain, loss of feet and to potential death. R72 verbalized understanding. R72 was to have a follow up appointment at the wound clinic. Surveyor noted a DTI does not have eschar and the wounds should have been documented as Unstageable. On 11/15/2022 on the WASA form, nursing charted the left lateral heel Unstageable pressure injury measured 5.0 cm x 2.0 cm x 0 cm with 100% eschar. In the additional comments section, nursing charted R72 returned from the hospital with this wound. On 11/22/2022 on the WASA form, nursing charted the left outer ankle DTI measured 2.5 cm x 1.1 cm x 0.2 cm with 50% granulation and 50% slough. In the additional comments section, nursing charted R72 was noncompliant with heel lift boots and risks of not following recommendations were discussed. Nursing charted the wound edges had epiboly. Surveyor noted a DTI does not have granulation, slough, or any other type of tissue in the wound bed and the wound should have been staged. On 11/22/2022 on the WASA form, nursing charted the right heel DTI measured 3.0 cm x 3.4 cm x 0 cm with 100% eschar. Surveyor noted a DTI does not have eschar and the wounds should have been documented as Unstageable. On 11/22/2022 on the WASA form, nursing charted the left lateral heel Unstageable pressure injury measured 5.0 cm x 3.5 cm x 0 cm with 100% eschar. On 11/22/2022, R72 developed a DTI to the right buttock and the left buttock. On 11/22/2022 on the WASA form, nursing charted the right buttock DTI measured 3.5 cm x 0.5 cm x 0 cm with red/purple non-blancheable area that was not open. On 11/22/2022 on the WASA form, nursing charted the left buttock DTI measured 1.0 x 1.8 cm x 0 cm with red/purple non-blancheable area that was not open. In the additional comments section, nursing charted education was provided to R72 on the importance of allowing staff to reposition side to side while in bed; R72 verbalized understanding and agreed on allowing staff to reposition. Nursing charted R72 had a low air loss mattress in place. On 11/28/2022, an Unavoidable Pressure Injury or Condition form was completed indicating comorbidities and risk factors. The physician and wound nurse Registered Nurse (RN)-I completed the form and determined the pressure injuries were unavoidable and all preventative measures had been in place. R72's Skin Integrity Care Plan was revised on 11/28/2022 with the following interventions: -Pressure reduction foam mattress or pressure redistribution support (low air or alternation air) in bed. (Surveyor noted this intervention had been in place prior to putting it in the Care Plan.) -Turn and reposition every two hours and as needed. On 11/29/2022 on the WASA form, nursing charted the left outer ankle DTI measured 2.5 cm x 1.2 cm x 0.1 cm with 50% granulation and 50% slough. Surveyor noted a DTI does not have granulation, slough, or any other type of tissue in the wound bed and the wound should have been staged. On 11/29/2022 on the WASA form, nursing charted the right heel DTI measured 3.2 cm x 3.4 cm x 0 cm with 100% eschar. Surveyor noted a DTI does not have eschar and the wounds should have been documented as Unstageable. On 11/29/2022 on the WASA form, nursing charted the left lateral heel Unstageable pressure injury measured 5.2 cm x 3.5 cm x 0 cm with 100% eschar. On 11/29/2022 on the WASA form, nursing charted the right buttock DTI measured 3.3 cm x 0.5 cm x 0 cm that was purple/red in color. On 11/29/2022 on the WASA form, nursing charted the left buttock DTI measured 2.0 cm x 1.6 cm x 0 cm that was purple/red in color. On 11/29/2022, R72 developed a pressure injury to the back of the left ankle. On the WASA form, nursing charted the Unstageable pressure injury measured 3.0 cm x 1.0 cm x 0 cm with 100% eschar. Surveyor reviewed R72's medical record and multiple refusals of pressure reducing devices and non-compliance were noted. On 11/29/2022 at 9:31 AM in the progress notes, nursing charted a return call was received from the wound clinic and the etiology of wounds were discussed; the wound physician stated the wound to bilateral lower extremities were pressure ulcers however they are worsened by ischemia as evidenced by the ankle-brachial index on the right and left that indicated severe resting ischemia. R72 failed a stent and has a return appointment to the vascular clinic on 12/2/2022. The wound clinic was updated by the facility that R72's family was considering hospice services. On 11/29/2022 at 2:32 PM, Surveyor observed R72 sleeping in bed on an air mattress with feet elevated off the mattress. On 11/30/2022 at 3:26 PM, Surveyor observed R72's wound treatments by RN-I and assisted by Certified Nursing Assistant (CNA)-H. R72 had heel boots on both feet that were removed by CNA-H. Both feet were wrapped in Kerlex. Surveyor observed the following wounds: the left outer ankle wound measured approximately 3 cm x 3 cm with slough in the center and eschar on the outer edge of wound, the right heel had an eschar cap that measured approximately 4 cm x 4 cm, the left lateral foot by the base of the fifth toe measured approximately 2 cm x 1 cm with eschar, the left posterior heel by the Achilles tendon had 2 areas each measuring approximately 1 cm x 1 cm with eschar, the left buttock had an open area measuring approximately 1 cm x 1 cm with light pink tissue, and the right buttock had no pressure areas. RN-I stated the right buttock had healed and the left buttock had opened since last observation. Treatments were completed to all areas and heel boots were put back on R72 before leaving the room. Surveyor noted the locations of wounds observed did not correlate with the locations of wounds that had been documented on. The facility documented on the left lateral heel and the back of the left ankle. Surveyor noted wounds to the left lateral foot and two wounds to the back of the left heel at the Achilles tendon. In an interview on 12/5/2022 at 9:38 AM, Surveyor asked RN-I why wounds were charted as DTI with eschar present. RN-I stated RN-I did not have an answer; the nurses that charted those assessments were no longer employed at the facility. Surveyor showed RN-I the charting completed by RN-I on 11/15/2022 where DTI was listed as the status of the pressure injury even when eschar or other tissue types were observed. RN-I stated the wounds should have been charted as Unstageable with eschar present and with other tissue types, they should have been staged a Stage 3. RN-I stated RN-I had just started working at the facility and did not know what previous nurses had been instructed to chart when it came to wounds. In an interview on 12/5/2022 at 10:20 AM, RN-I stated RN-I talked to Nurse Consultant-D and was told not knowing the depth, even if it has eschar, they do not change the staging from a DTI. RN-I stated the wound with eschar wound be an Unstageable pressure injury and not a DTI at that point. RN-I stated wound education needs to be done so that will be RN-I's focus. RN-I stated some education had been done regarding wounds, but the nurses may not be retaining it. No further information was provided at that time.