**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure fall interventions were in place per the care plan and each residents received adequate supervision to prevent accidents for 3 of 23 sampled Residents (R27, R59, & R82) reviewed for falls and supervision. R27 is being cited at scope/severity level 3 (isolated/actual harm). R27 was a fall risk and has had 23 falls since admission on [DATE]. R27's falls typically occurred in the dining room or resident room; there were similarities to the falls including location and time of day. The facility completed a root cause analysis (RCA) and collected data on the falls; however, there is no evidence the interdisciplinary team (IDT) comprehensively reviewed the data or considered increasing R27's supervision. R27 fell resulting in a head injury requiring sutures. R59 is at risk for falls and is care planned to walk with her walker and to have a sign in her room to remind her to walk with her walker. Surveyor observed two instances on different days of R59 walking without her walker. Surveyor was unable to locate a sign in R59's room reminding her to walk with her walker. R82 has long-standing behaviors that include wandering into other residents' rooms as well as acting out toward staff and other residents. The facility staff did not provide increased supervision to prevent R82 from wandering into other Residents' rooms, which puts R82 at risk for potential resident to resident altercations to occur. This is evidenced by: The facility's fall policy titled Fall Prevention Program, dated 2/28/25, states in part: Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Policy and Explanation and Compliance Guidelines: 1. The facility utilizes a standardized risk assessment for determining a resident's fall risk. a. The risk assessment categorizes residents according to low, moderate or high risk. b. For program identification purposes, the facility utilizes high risk and low/moderate risk, using the scoring method designated on the risk assessment. 2. Upon admission, the nurse will complete a fall risk assessment along with the admission assessment to determine the resident's level of fall risk. 3. The nurse will indicate on the (specify location) the residents' s fall risk and initiate interventions on the resident's baseline care plan, in accordance with the resident's level of risk. 4. The nurse will refer to the facility's High Risk or Low/Moderate Risk protocols when determining primary interventions. 5. Low/Moderate Risk Protocols: a. Implement universal environmental interventions that decrease the risk of resident falling including, but not limited to: a. A clear pathway to the bathroom and bedroom doors. ii. Bed is locked and lowered to a level that allows the resident's feet to be flat on the floor when the resident is sitting on the edge of the bed. iii. Call light and frequently used items are within reach. iv. Adequate lighting. V. Wheelchairs and assistive devices are in good repair. b. Implement routine rounding schedule. c. Monitor for changes in resident's condition, gait, ability to rise/sit, and balance. D. Encourage residents to wear shoes or slippers with non-slip soles when ambulating. e. Ensure eye glasses, if applicable, are clean and the resident wears them when ambulating. f. Monitor vital signs in accordance with facility policy. g. Complete a fall risk assessment every 90 days and as indicated when the resident's condition changes. 6. High Risk Protocols: a. The resident will be placed on the facility's Fall Prevention Program. i. Indicate fall risk on care plan. ii. Place Fall Prevention Indicator (such as star, color coded sticker) on the name plate to resident's room. iii. Place Fall Prevention Indicator on resident's wheelchair. B. Implement interventions from Low/Moderate Risk Protocols. c. Provide interventions that address unique risk factors measured by the risk assessment tool: medications psychological, cognitive status, or recent change in functional status. D. Provide additional interventions as directed by the resident's assessment including but not limited to i. Assistive devices ii. Increased frequency of rounds iii. Sitter, if indicated iv. Medication regime review v. Low bed vi. Alternate call system access vii. Schedule ambulation and toileting assistance viii. Family/caregiver or resident education ix. Therapy services. 7. When a resident who does not have a history of falling experiences a fall, the resident will be placed on the facility's Fall Prevention Program. 8. Each resident's risk factors, and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. a. Interventions will be monitored for effectiveness. b. The plan of care will be revised as needed. 9. When any resident experiences a fall, the facility will: a. Assess the resident b. Complete a post-fall assessment c. Complete an incident report d. Notify the physician and family e. Review the resident's care plan and update as indicated f. Document all assessments and actions g. Obtain witness statements in the case of injury. R27 was admitted to the facility on [DATE] with diagnoses that include dementia, seizure disorder, psychotic disturbance, mood disturbance and anxiety, altered mental status, and malaise (weakness). R27's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/20/25 indicates Brief Interview for Mental Status (BIMS) was unable to be performed. A staff assessment of R27's mental status indicates R27 has moderate cognitive impairment. Section C1310 of the assessment indicates R27 has periods of inattention and disorganized thinking. Section GG indicates R27 requires setup assistance with eating, supervision for oral hygiene and upper body dressing, partial to moderate assistance for toileting and personal hygiene, and substantial to maximum assistance for showers, lower body dressing, and footwear. R27's mobility indicates she requires partial to moderate assistance for rolling left to right, sitting to standing, lying to sitting, chair to bed transfer, toilet transfer and walking 50 feet. R27 utilizes a wheelchair and is dependent on locomotion of 150 feet while in the wheelchair. Section J1800 any falls prior assessment indicates yes. Section J1900 number of falls since admission or prior assessment indicates the following: No Injury two or more. B. Injury two or more. C. Major injury indicates one. R27's Activities of Daily Living (ADL) care plan initiated 9/4/24 revised on 11/25/24 states: Focus: At risk and/or potential for complications with deficits with ADLs r/t current medical/ physical status. Has meds/dx (medications/diagnosis) that can/may affect ADLs dated initiated 9/4/24 revised 9/7/24. Goal: Will be clean, dry, dressed appropriately and maintain ability to participate in ADLs through next review date 9/7/24 revised 11/25/24. Will be more independent with ADLs after set-up, cues and able to return to assisted living by discharge date . Interventions: Ambulation - may ambulate in room or hallway with w/c (wheelchair) trail 9/4/24 revised 2/28/25. Bed mobility: 1 assist 9/4/24 revised 2/28/25. Locomotion: 1 assist in Broda Chair 4/1/25. Transfers: 1 assist pivot with gait belt 9/4/24 revised 2/28/25. Prefers to get up around 7:00 AM and goes to bed around 8:00 PM 9/7/24. R27's Safety/Falls care plan date initiated 9/7/24 and revised on 12/16/24 states: Focus: At risk/and/or Potential for complications with or falls r/t (related to) current medical / physical and mental status. Has meds/dx (medication/diagnoses) that can/may affect fall risk. Goal: Reduce risk of fall related injuries date initiated 9/7/24. Revised on 12/18/24. Interventions/Tasks: Assist resident to sit up to table at mealtimes 9/14/24 revised on 2/28/25. Busy box on side of the bed 12/30/24 revised on 2/28/25. Do not recline resident back in wheelchair when resident is agitated 3/12/25 revised on 2/28/25. Due to increasing behaviors, support resident in her room with low lighting, low noise level, no visual stimulation 10/8/24 revised on 2/28/25. During the night when she is restless, frequent attempts to get out of bed offer shower and/or weighted blanket for comfort 1/9/25 revised on 2/28/25. Elevate HOB (head of bed) in seated position for comfort 12/30/24 revised on 2/28/25. Immediate intervention s/p (status post) fall - increased monitoring, given breakfast, NP (nurse practitioner) to see resident. Will re-educate the staff regarding current interventions 1/24/25 revised on 2/28/25. Immediate intervention s/p fall offered/received snack and placed into bed. Discussion with guardian for a perimeter mattress. Guardian in agreement. IDT (Interdisciplinary Team) to review recommendation. Add perimeter mattress to bed 1/3/25 revised on 2/28/25. Immediate intervention s/p (status post) fall send to ER (emergency room) for further evaluation 1/21/25 revised on 2/28/25. Immediate Intervention: Heated blanket placed on resident for comfort and 1:1 with staff. Suggest medication review. Medicated with Tylenol, pain gel and Melatonin 10/16/24 revised on 2/28/25. Move resident closer to the nurses station for increased supervision. Immediate intervention s/p fall 2/11/25 resident moved closer to the nurses station for increased monitoring 11/21/24 revised on 2/28/25. Nonskid socks when up in wheelchair 11/18/24 revised on 2/28/25. Offer a snack during the evening hours, around the time she is going to bed for the night and as requested 1/7/25 revised on 2/28/25. Offer assistance with ambulation in hallway if resident is restless or repeatedly attempting to stand 12/28/24 revised on 2/28/25. Offer hydration and/or snack at change of shift from PM to NOC shift if resident is awake. IDT: During routine rounding and as needed staff to ensure resident has fresh ice water or fluid of choice 12/15/24 revised on 2/28/25. Offer toileting IMMEDIATELY after meals 12/30/24 revised on 2/28/25. Perimeter mattress to better define edges of bed 1/6/25 revised on 2/28/25. Provide a quiet space to be able to rest and relax. Provide her soft lighting and white noise via the light and sound machine provided 12/27/24 revised on 2/28/25. Staff to offer assistance with walking to and from the dining room (per resident's choice) 4/1/25. Therapy to screen and treat for possible BRODA chair till current w/c (wheelchair) is fixed so resident's feet can touch the floor 4/28/25. Walk to the dining room every meal 2/14/25 revised on 2/28/25. When resident is restless, upset, crying, speaking of family offer warm heated blanket and/or busy box for comfort 10/17/24 revised on 2/28/25. Will have therapy eval for w/c positioning and safety 2/12/25 revised on 2/28/25. Call light positioned for easy access 9/7/24. Check for unmet needs: pain, toileting, hunger, thirst, temperature 9/7/24. Do not leave unattended in the Bathroom [ROOM NUMBER]/7/24. Encourage / Assist with non-skid shoes / socks 9/7/24. Ensure environment is free of clutter 9/7/24. Have commonly used articles within easy reach 9/7/24. Scoop mattress to bed 1/22/25 revised on 2/28/25. Other: (Specify) - Nonskid mat to wheelchair 11/18/24. R27's Care plan for Mood/Behavior dated 9/7/24 and revised on 12/17/24 states: Focus: Has a dx of MDD (mood disturbance disorder). She is at risk for changes in mood and cognition. She experiences episodes of tearfulness and heightened anxiety. Curses and makes derogatory statements to people who are not there likely r/t previous stay at ALF (assisted living facility) or past trauma. Also exhibits aggression toward staff as evidenced by grabbing, hitting, and spitting d/t cognitive impairment. Anxiety related to death of parents. She makes paranoid statements about staff at times. Goal: Mood / Behavior will not interfere with ADL status through next review 9/7/24 revised 11/25/24. Will have choices and able to make decisions through next review date 9/11/24 revised 11/25/24. Interventions/Tasks: Offer resident one of her robotic cats to assist with keeping resident calm 11/11/24 revised on 2/28/25. Offer weighted blanket 1/10/25 revised 2/28/25. Provide a quiet space for [Resident's name] to be able to rest and relax. Provide her soft lighting and white noise via the light and sound machine provided date initiated 12/27/24 revised 2/28/25. Provide a warm blanket when she is in bed and agitated 11/11/24 revised 2/28/25. Provide music therapy with resident's CDs (compact disc) 11/11/24 revised 2/28/25. Remove from noisy environment and take to a quiet area to decrease external stimuli 11/20/24 revised on 2/28/25. Resident to be on floor mate [sic] while in room [ROOM NUMBER]/17/25. Allow resident to wander within unit 9/7/24. BIMS / PHQ9 completed upon admission, quarterly, annually, and PRN (as needed) - Notify MD as needed with concerns 9/7/24 revised 2/28/25. Calm approach. Remove stressors i.e.: noisy/overstimulating area or other residents in personal space who are too close 9/7/24. Check for comfort levels - pain, thirst, hunger, temperature - offering comfort as able / accepted 9/7/24. Encourage / Assist to activities of choice 9/7/24. Encourage resident to be out of room [ROOM NUMBER]/7/24. Meds / Labs / Treatments as Ordered 9/7/24. Observe / Monitor / Document behaviors/mood and notify supervisor, SW (social worker), and / or MD as needed 9/7/24. Offer opportunities for resident to express feelings 9/7/24. PASARR Level II - Review & Follow Recommendations as able / accepted 9/7/24. Remind / Redirect and/or reassure as needed 9/7/24. Turn white noise machine on at bedtime. Progress notes dated 9/14/2024 at 12:04 PM state in part: Resident seated in w/c at dining room table. CNA (Certified Nursing Assistant) at nurse station when resident slid out of w/c (wheelchair) and onto to left LUE (left upper extremity) and LLE (left lower extremity) making contact with the carpeted area of floor. CNA alerted wtr (writer) and nurse assessment was completed. Resident was baseline A&O (alert and oriented) and able to state her name and DOB (date of birth ), denied injury, and reported she was trying to scootch closer to the table. No apparent injuries noted on assessment, resident denied pain, nonverbal indicators of pain not present AEB (as evidenced by) a score of 0 on PAINAD scale (scale used to measure pain levels). Dr.'s nurse on call notified. Charge nurse notified. POA (power of attorney) notified. Progress notes dated 9/14/2024 at 13:17 (1:17 PM) state in part: Resident transferred by staff into w/c (wheelchair) and engaged with other residents in activities at table nearest nurse station. Resident was monitored and observed by staff the remainder of the shift. Progress notes dated 9/14/2024 at 16:13 (4:13 PM) state in part: IDT (Intradisciplinary Team) met to review fall. Root cause determined to be resident failed attempt at scooting self closer to the table. Intervention added for staff to assist resident to sit up to table at mealtimes. Kardex up to date. Therapy notes dated 9/20/2024 at 08:04 AM state: patient discharging from physical, occupational, and speech therapy today, 9/20/24. Recommend continued 1 assist with transfers, ambulation, and ADLs. Diet consistency is accurate and appropriate. Patient will remain in this LTC (long-term care) facility which is most appropriate for patient. Patient scored 3.2 on the ACL ([NAME] Cognitive Level screen - a test to assess cognitive function) cognition assessment indicating patient is appropriate for 24-hour supervision. Progress note dated 9/26/2024 at 20:44 (8:44 PM) states: resident had an unwitnessed fall in evening after supper. The resident was lying on the floor on her left side and reports that she did not hit her head. Vitals within normal limits, pain minimal to the left elbow and butt cheek. Resident reports that she was trying to move her wheelchair herself when she slipped out onto the floor. Nurse sat with the resident for an hour to monitor vitals and neuro status. Resident was baseline. Guardian contacted, nurse manager contacted, NP (nurse practitioner) contacted. Will continue to monitor. Progress notes dated 9/27/2024 at 14:41 (2:41 PM): IDT met to review fall. Root cause of fall noted to be resident scooting to move wheelchair into place. Intervention related to root cause: non-skid pad placed in wheelchair. Therapy notes dated 10/2/2024 at 15:51 (3:51 PM) state: PT (physical therapy) evaluated w/c positioning on 10/1/24. Patient is very short making it difficult for her to keep herself properly positioned in the wheelchair and causes her to slide forward in the wheelchair. Therapist searched through all wheelchairs in the building and in extra rooms to see if there was an appropriate w/c for patient. Patient needs a super hemi-wheelchair which most supply companies cannot provide. PT completed work order for seat to be adjusted for drop seat/seat slope: 1.5 (higher front) to see if this helps with better w/c positioning. Progress notes dated 10/3/2024 at 13:20 (1:20 PM) state: IDT Risk. Risk Factors: Frequent Falls, Wheelchair Mobility, Height challenged, Dx Related to Risk: Unspecified Dementia, Failure to Thrive, Disc Disorder, Osteoarthritis, CKD 3 (chronic kidney disease), Unspecified Convulsions, Muscle Weakness. Nursing Issues: Pain control, Decreased mobility, Incontinence, Medications that can attribute to risk: Keppra and Sertraline. Behaviors that can attribute to risk: Noncompliance related to memory issues, Heightened startle reflex, Nutrition Risk Factors: Pureed Diet (no teeth). Weights are good - good intakes. Care Plan review and Risk intervention updates: Nonskid added to wheelchair. CP (care plan) updated. Wheelchair is being adjusted to drop the seat. Plan of care ongoing. Progress notes dated 10/3/2024 at 20:18 (8:18 PM): Patient attempted to stand up multiple times during the shift. States that she left let [sic] hurt. Behavior improved with supper and once she laid down for the evening. Did encourage to elevate leg in WC which the resident did accept and that did help some of the behavior. Progress notes dated 10/6/2024 at 06:00 AM: excerpt from fall report: resident was found lying in prone position on the bedside floormat in resident's bedroom. Resident was log rolled and transferred back to bed with 2 assists by mechanical lift after assessing for injury, no injury was noted, and resident did not verbalize pain. All extremities moved well per residents' baseline. Unit RN completed Neuro (neurological checks - check for potential head injury). Assessed and found to be without injury. Transferred off floor via Hoyer lift and 2 staff assist. Guardian updated. MD updated. DON updated. Care plan updated. Progress notes dated 10/7/2024 at 15:16 (3:16 PM) state: IDT met to review fall. Root cause analysis determined root cause of fall to be resident sitting up on side of bed without assistance (lacking trunk strength/coordination to successfully lay herself back down in bed). Immediate intervention related to root cause: Care plan and Kardex updated to reflect that resident should not be left alone while sitting on the edge of her bed. Progress notes dated 10/8/2024 at 18:21 (6:21 PM): patient was observed self-transferring writer ran to assist patient back to wheelchair patient became weak was lowered to floor, assessed patient from head to toe no injuries observed, performed rom (range of motion - check for injury to extremities) no complaints of pain, vitals measured started neuro checks, nurse on call notified order to call if any new abnormal symptoms occur, guardian notified, educated patient to ask for assistance when needed, distract patient with activities of choice offer snacks. Progress notes dated 10/9/2024 at 12:57 PM Late Entry: IDT met to review fall. Root cause analysis performed. Root cause determined to be resident restlessness and weakness upon standing. Assessment info relayed to NP - new orders received and noted for labs (TSH lab to check thyroid function), change of sertraline timing to HS (at bedtime), and seeing psych (physician for psychiatric/behavioral health) next week. Progress note dated 10/10/2024 at 12:43 PM: IDT clarification regarding root cause: Prior to falling, resident was sitting up at the side of her bed. CNA had offered to assist resident to lay down in bed, and resident refused. Progress note dated 10/17/2024 at 03:02 AM: resident noted sitting on floor mat; her back against the bed with feet extended outwards toward bathroom door. Bed noted in lowest position at this time. Resident stated, I got to go to my momma's house. Resident noted restless, crying and breathing rapidly. Resident denied hitting her head but stated, her legs hurt. Tylenol administered for pain and pain gel rubbed on bilateral legs. No injuries or bruises noted this shift. Neuros WNL (within normal limits). ROM WNL (Range of Motion within normal limits) for resident. PRN (As needed) Melatonin given for sleep. A heated blanket placed on resident for comfort and 1:1 with staff. Charge nurse, On-call physician, and emergency contact notified. Fall intervention suggestion: Medication review needed. All needs met at this time. Call light within reach. Will continue to monitor. Progress note dated 10/17/2024 at 09:28 AM Late Entry: IDT met to review fall. Root cause analysis (RCA) performed. Root cause identified as agitation related to bad dreams/delusions. Intervention related to root cause: Labs, Change of Zoloft to HS and Psych follow-up scheduled. It should be noted the IDT RCA review, dated 10/17/24, is 8 days after R27's fall on 10/9/25. Progress note dated 10/17/2024 at 15:31 (3:31 PM) Activity Progress Note: The writer is updating about a busy box that was created for the patient. Inside this busy box will be a number of things that the patient has seem to take interest in there is some jewelry in there for her to sort due to the fact she loves jewelry. Furthermore, there is a fake pet cat in there along with some puzzles and lastly coloring pages. This is to be located in the dining room of her unit and on her table of where she sits. This is to be used for when activity staff isn't present or to occupy her. Therapy notes dated 10/24/2024 at 13:27 (1:27 PM): Pt's (Patient's) guardian came to writer's office today asking about getting patient a different wheelchair. Guardian feels the wheelchair is not working for her. Discussed that patient has not had any falls from current wheelchair and pt (patient) had two falls from previous wheelchair. Guardian still adamant about therapy trialing different wheelchairs. Guardian requested that elevating wheelchair footrests be on patient's w/c, to have wheelchair footrests slightly elevated, and for footrest cushion to be on patient's wheelchair at all times. Guardian also requested we trial a recline back wheelchair. Writer educated guardian that we [sic] therapy can attempt to trial different chairs but will discuss with IDT before changing anything. Progress notes dated 10/25/2024 at 18:14 (6:14 PM): nurse was advised by CNA (Certified Nursing Assistant) that patient was on the floor in the dining room. Upon assessment, patient was observed laying on the floor in dining room, in front of wheelchair. Inquired about incident and patient stated, I was looking for the door to use the restroom. Nurse assessed for injuries. No apparent injuries noted. ROM (range of motion) applied and patient complained of lower right leg pain. Received routine acetaminophen 1000 mg. Assisted patient off the floor x 2 staff members using Hoyer lift. Patient toileted. Vitals obtained bp (blood pressure): 128/114 p (pulse): 96 r (respirations): 16 O2 (oxygen): 96% room air and t (temperature): 97.1. NP notified. Received orders for neuro checks. Call placed to (guardian name). Voicemail left to call facility back. Currently sitting in wheelchair in dining room coloring. Voiced no concerns at this time. It should be noted R27 has had several falls in the dining room however there is no evidence the IDT discussed not leaving R27 alone in the dining room or increasing supervision for R27 r/t (related to) falls in the dining room. Progress notes dated 11/1/2024 at 16:37 (4:37 PM) state IDT note: 10/25/24, unwitnessed fall without injury. Resident observed lying on the dining room floor. Resident relayed looking for the bathroom door. She most likely needed to use the bathroom. Her dx include Dementia, weakness, failure to thrive, malaise, osteoarthritis. She has poor safety awareness, severe cognitive impairment with a BIMS of 3. Neuro checks initiated. NP, Guardian, and Family Care RN notified. Care plan and CNA Kardex updated to include toilet before and after meals. Will monitor the effectiveness of the interventions and modify as necessary. Of note, toileting before and after meals should be a normal standard of practice for all residents. Toilet upon rising, before and after means at HS (bedtime) and as needed was a care planned intervention dated 9/7/24 on R27's bowel and bladder care plan. Progress notes dated 11/20/2024 at 23:17 (11:17 PM): CNA found the resident on the floor and notified nurse. Doctor was notified as well as POA (power of attorney) and director. There was no apparent injury. Resident was checked and put back in bed. Neuro checks within normal limits and low bed and mat continue to be in place. No new interventions at this time, staff is updated to round frequently throughout the night. NOC (night) charge updated. It should be noted there is no evidence the staff asked R27 what she may have been attempting to do or if R27 had an unmet need; the facility simply returned R27 to her bed. Progress notes dated 11/22/2024 at 08:09 AM state: IDT note unwitnessed fall 11/20/24 without injury. Resident observed on the floor beside her bed. Resident with severe cognitive impairment, BIMS (Brief Interview Mental Status) of 3, dx (diagnosis) of dementia and unable to relay how the incident occurred. She has poor safety awareness and attempted to get out of bed unassisted and slid out of bed onto the fall mat. Bed in lowest position and call light within reach at the time of the incident. No c/o (complaints of) pain. Resident was monitored frequently thru out the night and will be moved closer to the nurses station for increased monitoring. Dr. and guardian notified. Care plan and CNA Kardex updated. Will monitor the effectiveness of the interventions and modify as necessary. Progress notes dated 12/14/2024 at 23:00 (11:00 PM): CNA coming down the hall at 2220 (10:20 PM) and heard resident talking from her room. CNA went to res room and found resident laying on the floor mat with bed in low position. Due to cognitive impairment per res baseline, res unable to articulate what she was attempting to do. VSS (vital signs stable) with neuro checks WNL (within normal limits) to res baseline. No reports of physical pain or signs of injury. PERRLA (pupils equal, round, reactive to light and accommodation - normal eye exam - check for head injury). Res incontinent pad was dry. Res was rambling with rapid speech tearful and frustrated talking about going home to be with her mother. Speech is mostly word salad per res baseline. Res thirsty and asking for something to drink. Hydration provided. Resident's primary care provider notified as residents guardian and case manager. Administrator and DON for facility also updated of fall without injury. New intervention added to POC to offer hydration and/or snack at PM to NOC (night) shift change if res awake. 1:1 provided to resident by staff with active listening and validation of resident sadness and frustration provided. Neuro checks initiated per facility policy. Will monitor. Progress notes dated 12/16/2024 at 21:00 (9:00 PM): resident was found sitting on the floor in front of her bed on the floor mat. The resident did not appear to be in any pain or discomfort, she does not report any injuries. The resident was able to move all extremities without issue. The resident was able to stand up with 2-assist and a gait belt and into the bed. A footrest pillow was placed under her feet to elevate her legs and keep her lower extremities in bed for increased comfort. The resident then became upset and agitated with staff and began yelling and asking not to be touched. The charge nurse was notified of no injuries with the incident. A phone call was placed to the GNP (geriatric nurse practitioner) to alert her of the incident. POA (power of attorney) notified of the incident. Will continue neuro checks and vitals assessments. Progress notes dated 12/17/2024 at 12:50 PM Addendum: IDT NOTE: unwitnessed fall 12/14/24 without injury. Resident observed on the floor parallel to bed. Resident with severe cognitive impairment, BIMS of 3, dx of dementia and unable to relay how the incident occurred. She has poor safety awareness and most likely attempted to get out of bed unassisted and slid out of bed onto the fall mat. Bed in lowest position, gripper socks, and brief clean and dry at the time of the incident. No c/o (complaints of) pain. Neuro checks initiated. Resident verbalized being thirsty and hydration provided. Will offer hydration and/or snack at pm night shift change. Staff will ensure during routine rounds and as needed she has fresh ice water or fluid or choice. Dr. and guardian notified. Care plan and CNA Kardex updated. Will monitor the effectiveness of the interventions and modify as necessary. Progress notes dated 12/18/2024 at 13:15: IDT note met to review resident's recent fall. Fall was in her room. Root cause analysis completed. Root cause identified as confusion and attempting to get out of bed. Resident has been experiencing recent behavioral episodes. Resident was yelling out at the time of assessment. Bed was in lowest position and fall mat was in place. She had been toileted and had been offered snacks. New interventions: positioning the bed at transfer height with fall mat in place and maintaining a low stim environment in resident's room. Progress notes dated 12/18/2024 at 13:41 (1:41 PM): IDT met to review resident's recent fall. Root cause analysis completed. Root cause identified as resident feeling thirsty. Immediate intervention was resident was assisted with a beverage. New interventions: ensure bedside pitcher will be filled with resident's drink of choice. Plan of care ongoing. Progress notes dated 12/19/2024 at 15:15 (3:15 PM): Resident was in the dining [sic] at about 3:15pm when writer heard resident fall in the dining area. When writer looked, resident was laying on her back on the floor, wheelchair by the feet, she had non-slip socks on, she was screaming and calling out, using profanities on staff. Meanwhile, all shift today, resident was up and down in her wheelchair, standing up and dragging her wheelchair while walking around. Staff tried each time to redirect but resident kept fighting and swatting at staff. Assessment completed, VSS wnl (Vital signs stable and within normal limits), resident had a bump on the back of her head from the fall but denies pain, no other injuries noted at the time of assessment. Patient was transported to the hospital via 911. It should be noted that resident was self-transferring in her w/c, standing up and dragging her w/c all day. Staff did attempt to redirect however this was not successful. However, this behavior should have put staff on notice of the high potential of a fall occurring. There is no evidence the facility increased supervision despite this known behavior throughout the day. Progress notes dated 12/19/2024 at 20:45 (9:45 PM): Resident returned from the ER at 8:45pm, no new orders, follow up with primary PCP for symptom management in one week. Resident is currently eating. Floor nurse to complete skin assessment after resident is done eating and in bed. Progress notes dated 12/20/2024 06:43 AM: Repeated fall review-Repeated falls occur due to behavioral outburst and unable to redirect of [sic] touch resident during violent outburst. Injury prevention, resident safety are intervention focus. MD team inform[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review the facility failed to ensure that the facility was free of accident hazards in 1 of 7 residents R9 reviewed for accident hazards of 14 sample residents. The facility failed to prevent a fall for R9 Findings include: Review of the facility's policy titled, Fall Prevention Program, dated 02/28/25, indicated Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Definitions: A fall is an event in which an individual unintentionally comes to rest on the ground, floor or other level, but not as result of an overwhelming external force .Policy Explanation and Compliance Guidelines: 1. The facility utilizes a standardized risk assessment for determining a resident's fall risk. A. The risk assessment categorizes resident according to low, moderate, or high risk .5. Low/Moderate Risk Protocols: a. Implement universal environmental interventions that decrease the risk of resident falling .b. Implement routine rounding schedule. C. Monitor for changes in resident's cognition, gait, ability to rise/sit and balance .g. Complete a fall risk assessment every 90 days and as indicated when resident's condition changes .8. Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care . Review of the facility's policy titled, Elopements and Wandering Residents, dated 02/28/25, indicated Policy: This facility ensures that residents who exhibit wandering behavior and/or risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Definitions .Elopement occurs when a resident leaves the premises or a safe area without authorization .and or any necessary supervision to do so. Policy Explanation and Compliance Guidelines: 1. The facility shall establish and utilize a systemic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risks, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. 2. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering. A Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team .Procedure Post-Elopement a. A nurse will perform a physical assessment, document and report findings to physician .d. The resident and family/authorized representative will be included in the plan of care. E. Staff may be educated on the reasons for elopement and possible strategies for avoiding such behavior .g. Documentation in the medical record: findings from nursing and social service assessments, physician/family notification, care plan discussion . Example 1 Review of R9's Face Sheet located under the Profile tab of the electronic medical record (EMR) revealed R9 was admitted to the facility on [DATE] with diagnoses of anemia, history of falling, age related osteoporosis, major depression disorder, and dementia. Review of R9's significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/24/25, located under the Resident Assessment Instrument (RAI) tab indicated R9 was substantial/ maximum assistance for eating; partial/ moderate assistance for oral hygiene; dependent on toileting hygiene, dressing, transfers, and personal hygiene; and substantial/ maximum assistance to dependent for bed mobility. The MDS revealed a Brief Interview for Mental Status (BIMS) of 13 out of 15 indicating R9 was cognitively intact. Review of R9's Progress Notes under the Progress Note tab of the EMR, dated 10/24/24 Note Text: CNA reported resident noted sliding out of recliner. Writer immediately assessed resident and noted resident sitting in recliner with legs sliding off recliner. No fall. Writer and 2 CNA's repositioned resident into recliner appropriately with BLE's elevated. Writer called Therapy department to request non slip gripper for recliner or recommendations to prevent a fall and therapy recommended green Posey non-slip matting available in med room to prevent fall. Writer updated ADON and states will update care plan. Resident in no apparent distress, in good spirits. Resident denies pain or discomfort. Will continue to monitor until end of shift. Review of R9's Progress Notes under the Progress Note tab of the EMR, dated 11/05/24, indicated Resident noted on the floor, on her back with feet towards the door and head towards recliner. Remote to recliner in resident's hand and recliner noted tilted in the highest position. Resident assessed at this time. She denies any pain or discomfort. Tylenol administered as scheduled. No new injuries or bruises noted at this time. Neuros WNL [within normal limits]. ROM [range of motion] WNL for resident. Resident stated, she does not know why she held button until falling out of it. VSS [vital signs stable]. -New intervention: Unplug recliner due to resident's lack of safety awareness. CP [care plan] and [NAME] updated. Charge nurse, nurse manager .NP [Nurse Practitioner], and POA [power of attorney] notified. R9's plan of care states in part; Complications with or falls related to current medical physical status. Goal: Reduced risk with falls with interventions through next review date. Interventions: Unplug recliner due to resident lack of safety awareness, initiated date: 11/5/24. Resolved date: 11/6/24. Reinforce nonskid strips in front of recliner intiated date: 11/6/24. It should be noted R9's lift chair was plugged back in allowing R9 to use the lift function, the facility did not have evidence of assessing R9's safety to utilize the lift chair safely prior to plugging the lift chair back in. It should be noted R9 had a fall out of the lift chair on 1/20/25 due to lifting the chair in upright position this resulted in a femur fracture, Review of R9's Progress Notes under the Progress Note tab of the EMR, dated 01/20/25, indicated writer found resident in her room on the floor around 8pm. Resident had used electric control for recliner and put the chair all the way up causing her to fall out on her left side. Fully clothed with shoes on, her head was toward the bed and feet next to the recliner and throw blanket was under her. All needed items were on table next to chair with call button on her neck. Stated she did not hit her head. Review of R9's Progress Notes under the Progress Note tab of the EMR, dated 01/21/25, indicated IDT [Interdisciplinary Team] NOTE . The recliner chair was observed all the way up at the time of occurrence. Most likely she used the electric control and put the recliner all the way up causing her to fall out onto her left side. Increased rounding after dinner provided. Upon return from hospital therapy to eval for recliner safety and therapy needs s/p [status post] left femur fracture with ORIF (open reduction internal fixation) .Will monitor the effectiveness of the interventions and modify as necessary. Review of R9's Progress Notes under the Progress Note tab of the EMR, dated 01/24/25, indicated SW [Social Worker] contact .Son to inform, recliner has been removed due to non-usage and inability to safely operate furniture . Review of R9's Fall Risk Screening Tool under the Assessments tab of the EMR indicated the following completed screenings: 09/28/24 no falls; 11/05/24 - three to no falls, resident was incontinent, had cognitive impairment, resident did not always use call light appropriately, problem with cognition, judgement, memory and safety awareness; unsteady with gait, patient alert to self; 01/04/25 quarterly no falls, was resident at risk for falls - no. During an interview on 03/28/25 at 3:24 PM, the Administrator stated we really do not have fall prevention education for staff that is specific at orientation but when CNAs go to floor fall prevention is covered when they review the [NAME]. Said no specific fall prevention training for staff in past 6 months. Explained that they have a charge nurse that is over building each shift and that nurse attends stand up and stand down meeting where falls and new interventions would be discussed and then brought to unit staff and [NAME] changed. Surveyor inquired about R9's falls from the lift chair. Administrator stated he could not locate a document or discussion between Therapy and Nursing regarding why R9's recliner control was plugged back in. The Administrator explained the therapy group is no longer employed by the facility and documentation for R9 is not been located. The Administrator stated Therapy/Nursing discussion about recliner and plugging back in was done between staff and will try to locate something about decision. Said have one PT that is still here that may have knowledge. No further information is provided. The facility failed to assess R9's ability to safely operate a lift chair. R9 was found sliding out of the lift chair on 10/24/24, had a fall out of the lift chair on 11/5/24 when R9 raised the chair in the upright position and slid out of the chair on to the floor. The facility is unable to produce evidence they assessed R9's ability to safely use the lift chair. R9 had a second fall out of the lift chair when R9 lifted the chair in the upright position R9 fell out of the lift chair and was found with a femur fracture. The facility completed a performance improvement plan related to the fall with fracture however there the facility was unable to provide evidence of staff education regarding the changes in recliner/lift chair process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (R5) reviewed for supervision and accidents. R5 was served coffee while in his bed and dropped the coffee cup in the bed on his right side which pooled up against him. R5 sustained superficial partial thickness burns to right flank and right buttocks, estimated approximately 7% Total Body Surface Area (TBSA). Facility had no process in place regarding safety to residents with hot liquid temping or any type of safety assessment. After the incident occurred, coffee brewers were temped at 185° Fahrenheit. Evidenced by: The facility policy titled Food Safety: Preventing Burns dated 2021, states, in part: Policy: Hot food and beverages will be served at a safe temperature that prevents burns. Procedure: 1. Staff will monitor hot food and beverage temperatures at the point of service . 5. Appropriate supervision to obtain hot beverages and/or reheat foods in a microwave will be provided to any individual demonstrating decreased safety awareness and/or anyone who is at risk for burns or scalds based on clinical assessments . The chart below shows the estimated time for persons to receive second and third degree burns at various temperatures. Water Temperature Time to Receive 2nd Degree Burn Time to Receive 3rd Degree Burn 120°F 8 minutes 10 minutes 124°F 2 minutes 4.2 minutes 131°F 17 seconds 30 seconds 140°F 3 seconds 5 seconds . R5 was admitted to the facility on [DATE], and has diagnoses that include traumatic shock, major depressive disorder, and metabolic encephalopathy (a brain dysfunction caused by a chemical imbalance in the blood that affects the brain). R5's Quarterly Minimum Data Set (MDS) Assessment, dated 8/9/24, shows that R5 has a Brief Interview of Mental Status (BIMS) score of 15, indicating R5 is cognitively intact. Section GG shows that R5 uses a wheelchair for mobility and R5 has no impairment to upper extremities with range of motion and has impairment with range of motion on both lower extremities. R5 requires substantial/maximal assistance with showering/bathing and upper body dressing. R5 is dependent on staff for toileting, transfers, and dressing lower body. R5's Care Plan, dated 11/2/23, states, in part: Focus: Nutrition/Hydration - At risk/and/or Potential for Complications with Nutrition/Hydration d/t (due to) ESRD (End Stage Renal Disease), Lymphedema, quadriplegia and obesity . Date Initiated: 11/2/23. Revision on: 8/1/24 . Interventions: Fluid- Thin/Regular Liquids . Set-up meal per resident request. Honor food requests as able. Date Initiated: 11/2/23. Revision on: 6/21/24 . Focus: Safety/Hot Liquids: Actual/Potential for injury related to spillage of hot liquids. Date Initiated: 10/15/24. Revision on: 10/17/24. Goal: Resolved: Resident will remain free of serious injury related to handling of hot liquids. Date Initiated: 10/15/24. Revision on: 10/17/24. Target Date: 11/1/24. Resolved Date: 10/17/24. Resident will remain free of serious injury related to handling of hot liquids. Date Initiated: 10/13/24. Revision on: 10/17/24. Target Date: 11/1/24. Interventions: - Resolved: Evaluate for the presence of risk factors for spills and potential of injury from hot liquids on admission/readmission/quarterly and/or significant change. Date Initiated: 10/15/24. Revision on: 10/17/24. Resolved Date: 10/17/24. - Evaluate for the presence of risk factors for spills and potential of injury from hot liquids on admission/readmission/quarterly and/or significant change. Date Initiated:10/17/24 . -Resolved: Staff to assist with pouring/serving hot liquids. Date Initiated: 10/15/24. Revision on: 10/17/24. Resolved Date: 10/17/24. -Need to utilize cup with Coban added for texture to assist with grip. Date Initiated: 10/17/24 . R5's Incident Report dated 10/13/24, at 7:00AM, states, in part: . Incident Location: Resident's Room . Incident Description: Nursing Description: I was walking out of the resident in (Resident Room Number) room when CNA (Certified Nursing Assistant) was walking out of the clean linen closet. She yelled for me to come to the resident in (R5's Room Number) room right away. When I entered the resident's room CNA had the resident out of his clothing and in a brief and was changing the bedding. I asked the resident what happened (see resident's description for response). I observed the resident's skin and saw a reddened area and blisters extending from the resident's right thigh to the right abdomen up to the ribcage. I took the resident's vitals and completed a pain assessment. Resident stated he was trying to change hands from the left hand to the right hand holding his coffee thermos when it spilled. Immediate Action Taken: All the bedding and clothing was removed from the resident and bed. After the resident was cared for the coffee pot was emptied and the appropriate people were notified including the on-call physician who gave the order to send the resident to the ER (Emergency Room) for evaluation . Injuries Observed at Time of Incident: Injury Type: Injury Location: Burn 19) Right iliac crest (front) Burn 21) Right iliac crest (rear) Burn 31) Right Buttock Burn 64) Other (Describe) Level of Pain: Numerical: 0 Level of Consciousness: Alert Mobility: Wheelchair bound. Mental Status: -Baseline for individual -Oriented to Place -Oriented to Time -Oriented to Person Predisposing Environmental Factors: -None Predisposing Physiological Factors: -None Predisposing Situation Factors: -None . Email to Medical Director from DON B (Director of Nursing), dated 10/13/24, at 3:54 PM, states, in part: . Updating you that early this morning R5 sustained a significant burn to parts on his torso and buttock after dropped his coffee while in bed. R5 was sent to the ER and has returned with new treatment orders and an order for oxy prn (Oxycodone as needed, A pain medication) . Per R5, he was attempting to transfer his coffee from his good hand (L) to his bad hand (R) when the mug fell. R5 states he will only use his left hand when handling hot beverages from here on out. We are also looking over our process around serving hot beverages/checking temps, and updating for safety . R5's Progress Note dated 10/13/24, at 8:12AM, states, in part: Note Text: At 7 AM writer called to resident's room by CNA. Resident stated he was switching hands he was holding his coffee thermos cup with and spilled. Assessed resident's skin to find reddened area with fluid filled blisters on resident's right upper thigh to right lower abdomen and on resident's back. Resident denied any pain. Vitals taken. Charge nurse notified and On-Call provider notified. Order to send resident to ER (Emergency Room) . R5's Progress Note dated 10/13/24, at 3:01 PM, states: Returned from hospital. New orders received: Oxycodone 5 mg (milligrams) take one tab every 6 hours as needed for pain. Wound Care: Wash wound daily with Dial soap and water. Use a washcloth to scrub the area, cover with bacitracin and place cuticerin on top, cover with dry gauze, wear compression t-shirt to hold dressing in place. Follow up in 1 week. R5's Progress Note dated 10/16/24, at 2:31PM, states, in part: . Late Entry: Note Text: Wound Observation Completed . Wound Location & Description: Type of Wound: Other superficial partial thickness burn (2nd degree) . Wound Base/Bed: Granulation Slough: % Granulation- 50% Slough: 50 Drainage Amount: Heavy Right side of back/buttock 24 x 30 x 0.1cm (centimeters) Right Breast 10 x 8 cm Burn surface is a mixture of yellowish white slough and pink tissue. Drainage Color: Serous Surrounding Tissue: Intact . Pain Associated with wound: Yes, Pain noted with treatment . Treatments: Current Treatment/Dressing: Yes Bacitracin, cuticerin, gauze . R5's Dietary Progress Note dated 10/17/24, at 2:14 PM, states, in part: . Notified by RN (Registered Nurse) that R5 is having fluid losses from his burns. The TBSA is 7%. Due to wounds, he receives Vitamin C 500 mg, ZnSo4 (zinc sulfate) 220 mg, Juven bid (twice a day) to support healing . Hospital Discharge, dated 10/13/24, states, in part: . Date of Service: 10/13/24 9:17AM . S: accidentally spilled coffee on self this morning; does not feel pain, history of cervical injury, also history of poor wound healing on legs requiring VAC and at a skilled nursing facility. O: see picture of approximately 7% TBSA superficial partial thickness to right flank/buttock A/P: 2nd degree thermal burn and patient was history of cervical injury and ongoing wound care concerns and transferred to burn center for debridement and follow-up wound care after discussion with them. Tetanus updated here. Chief Complaint: Burn (coming from (Skilled Nursing Facility Name). Alert and Oriented (A&O) x 4. Spilled coffee on his abdomen, to his back, right upper thigh. Reddened areas and fluid filled blisters . Physical Exam: . Skin: Warm and dry. Superficial partial thickness burn present to right flank and right buttocks approximately 7% TBSA. Neuro: Awake. A&O x 3. Quadriplegic . Medical Decision Making, ED (Emergency Department) Course & Medical Complexity: . Patient with associated superficial partial thickness burn to right flank, right buttocks estimated approximately 7% TBSA . Patient declining any pain, additionally non-sensate to region given chronic quadriplegia. Care discussed with burn consult doctor with recommendations for ED transfer for formal burn consult/local wound debridement. Given no local burn consult, care at (Skilled Nursing Facility Name) will require transfer for higher burn consult. Per burn team, likely need for local wound debridement and discharged home with continued care at patient's current care facility with further burn follow-up without likely need for admission or other complicated cares . Diagnosis: Superficial partial thickness burns of abdominal wall . Emergency Department Notes, dated, 10/13/24, state, in part: . ED: 10/13/24 . Date of Service: 10/13/24 Chief Complaint: Patient presents with Burn. History: Patient with a history of tetraplegia (medical condition that causes partial or total loss of function in the arms, hands, trunk, legs, and pelvic organs) of from previous spinal cord injury who presents to the Emergency Department via EMS (Emergency Medical Services) for evaluation of burn injury. Patient states that earlier this morning he accidentally spilled hot coffee on his right lower flank and lateral hip area. Initially seen at (Hospital Name) Emergency Department where his tetanus status was updated, and the burn surgery team was consulted who recommended transfer to . Emergency Department for further wound evaluation . Physical Exam: Skin: . Findings: Burn present. Superficial partial-thickness burn with blister formation noted over the right lower flank and lateral hip/buttock. No obvious involvement of the inguinal region or penis/scrotum. TBSA about 5% . Medical Decision Making: . On exam he has a superficial partial thickness burn with blister formation noted over the right lower flank and lateral hip/buttock without obvious involvement of the inguinal region or penis/scrotum. TBSA about 5% . Burn surgery resident was consulted and evaluated patient at bedside, wound care was performed while in the ED. The following wound care recommendations were provided: -Pain control with Tylenol and PRN (as needed) ibuprofen. -Premedicate with 5 mg (milligrams) oxycodone. -Wash wound with soap and water. -Wound cares with bacitracin and cuticerin. -Wear a compression t-shirt. Post-discharge wound care: -Wash wound daily with Dial soap and water. -Use a washcloth to scrub the area. -Cover with bacitracin and place cuticerin on top. -Cover with dry gauze. -Wear a compression t-shirt to hold dressings in place. -Follow-up in clinic in 1 week . Impression: -Superficial partial thickness burn of abdominal wall (primary encounter diagnosis) -Superficial partial thickness burn of buttock, initial encounter . R5's Hot Liquids Safety Assessment, dated 10/13/24, at 10:09AM, states, in part: . -R5 has no memory problems and/or mental function. -R5's mood does not vary over course of day/easily agitated. -R5 does not have frequent impulsive acts/short tempered. -R5 does not have tremors in upper extremities. -R5 does have contractures in fingers/hands/wrists/elbows/shoulders. -R5 does have weakness/paresis in upper extremities. -R5 does not have loss of mobility/reduced movement in upper extremities. Care Plan-Hot Liquid Risk: R5 is at risk for hot liquid injury . R5's Hot Liquids Safety Assessment, dated 10/15/24, at 1:26PM, states, in part: . -R5 has no memory problems and/or mental function. -R5's mood does not vary over course of day/easily agitated. -R5 does not have frequent impulsive acts/short tempered. -R5 does not have tremors in upper extremities. -R5 does have contractures in fingers/hands/wrists/elbows/shoulders. -R5 does have weakness/paresis in upper extremities. -R5 does have loss of mobility/reduced movement in upper extremities. Care Plan-Hot Liquid Risk: R5 is at risk for hot liquid injury . Kitchen cart log for hot liquids dated 10/17/24 shows: 10/17/24- breakfast coffee temp - 135* 10/17/24- lunch coffee temp - 132* On 10/17/24 at 10:10 , Surveyor interviewed PT E (Physical Therapist). PT E indicated R5 has quadriparesis (a condition that causes muscle weakness in all four limbs.) R5 can use both arms and legs to propel in wheelchair. R5's sensation is intact. R5 is currently working with OT (occupational therapy) on standing tolerance, sitting balance, shoulder strength, grip strength, shoulder range of motion, and wheelchair propulsion. R5 is currently working with PT (physical therapy) on transfers, ambulation, pain management, and bed mobility. PT E indicated R5 has chronic muscular pain in bilateral thighs. On 10/17/24 at 10:20 AM, Surveyor interviewed R5. R5 indicated every day he drinks coffee in bed with the head of the bed up. CNAs bring coffee in every morning in R5's thermos cup/insulated coffee cup. R5 uses left hand to hold coffee but on 10/13/24, R5 indicated he got cocky and switched coffee to right hand, which is his bad hand. R5 dropped the coffee on the right side of bed alongside of him and the coffee pooled there, and he received burns to right side, back, and his butt. R5 indicated the cup he uses is his personal cup. It is a thermos cup with no handle but has a lid. R5 indicated the lid stayed on when he dropped the cup and the coffee poured out of the drinking area. R5 indicated he yelled out AHHHH!!! and CNA D (Certified Nursing Assistant) entered his room immediately and turned R5 and cleaned him up. RN G (Registered Nurse) came in right away with a couple other nurses. They sent me to the hospital. R5 indicated the burn lady told him he has 2nd degree burns. Surveyor asked R5 approximately how long after he received the coffee did he drop the cup into his bed and R5 indicated maybe 10 minutes after receiving the coffee. On 10/17/24 at 10:35, Surveyor interviewed RN G. Surveyor asked RN G if she could tell Surveyor about the morning R5 spilled his coffee in bed. RN G indicated around 6:55 AM - 7:00 AM, CNA D called for RN G to come to R5's room. When RN G arrived R5 just had a brief on. CNA D removed R5's pants and t-shirt and removed brief and had put a new one on R5. CNA D was in process of changing R5's bedding. R5 indicated he switched from holding his thermos cup of coffee from left hand to his right hand. R5's right hand does not work as well as the left hand. R5 dropped his thermos cup onto the right side of the bed. RN G indicated the thermos cup had a lid on it and the coffee had come out of the drinking portion of the cup and spilled onto R5's right side. R5 was rolled and skin was reddened. The on-call physician was called and R5 was sent to the ER. Surveyor asked how R5 typically gets his coffee and RN G indicated the CNAs get the coffee every morning for R5 in his personal thermos cup. Surveyor asked if R5 was care planned to receive coffee in his room unsupervised and RN G indicated previously no and RN G did not know if R5 was now care planned since incident. Surveyor asked if residents are assessed for safety regarding hot liquids and RN G indicated just meal tickets, but no indication for hot liquid safety for residents. Surveyor asked how would staff know if it is safe for residents to receive hot coffee unsupervised and RN G indicated the staff knows what residents need assistance with meals and if a resident drinks from a sippy cup, we would not give hot liquids unsupervised. Surveyor asked what the process is for serving hot liquids to residents and RN G indicated if residents are independent with meals staff will just give coffee or hot fluids with no assessments. On 10/17/24 at 10:55 AM, Surveyor interviewed LPN C (Licensed Practical Nurse) and asked what the process is for serving residents hot liquids unsupervised. LPN C indicated by the MDS section GG, looking at residents' movements and whether they can move their upper body. Surveyor asked if there were assessments completed for residents to determine safety with hot liquids and LPN C indicated this week we started completing them for all residents. Surveyor asked LPN C how staff know if it is safe to give residents hot fluids in their rooms and LPN C indicated the CNA [NAME] lists the diet orders, but she is not sure. On 10/17/24 at 11:06 AM, Surveyor interviewed CNA H and asked how staff know if a resident is safe to be served hot liquids in their room unsupervised and CNA H indicated if a resident drinks out of a normal cup, we just give it to them. Surveyor asked what the process was prior to incident on 10/13/24 to administer hot liquids/coffee to residents. CNA H indicated prior to 10/13/24 staff would make coffee in the kitchenettes and just pour the coffee in a cup and take it to residents. CNA H indicated now staff must get the coffee from the main kitchen and the kitchen temps the coffee prior to getting it to staff on the floor. CNA H indicated coffee cannot be over 130 degrees Fahrenheit. CNA H indicated some residents want their coffee warmed in microwave and staff can use the microwave, but staff must temp the coffee to be sure it does not exceed 130 degrees. On 10/17/24 at 11:20 AM, Surveyor interviewed VPC F (Vice President of Culinary). Surveyor asked to see the coffee temp log that was on the cart about to leave kitchen going to unit. VPC F had a dietary aide temp it and Surveyor observed temp at 138.7 degrees F. Surveyor asked when temping hot liquids started and VPC F indicated right after the incident with R5 spilling coffee. VPC F indicated prior to the incident the brewers on the units were not being temped. VPC F indicated right after the incident the brewers on the floor were temped and all were at 185 degrees Fahrenheit. VPC F indicated the facility brought in a technician for the brewers to see if they could bring the temperatures down on the brewers. The technician indicated the temps could not be brought down below 185 degrees due to a sanitation issue. VPC F indicated the facility cools the coffee down to 140 degrees or under by adding ice. The brewers upstairs on the units are not being used anymore and the facility is working on getting new brewers. Surveyor asked if residents could get coffee when the kitchen is not open and VPC F indicated the facility does not offer coffee during the night, only when the kitchen is open now. VPC F indicated prior to incident we were not temping the brewers/coffee but now the facility is which started 10/13/24 the day of the incident. On 10/17/24 at 1:00 PM, Surveyor interviewed CNA D and asked CNA D to tell Surveyor about the morning R5 spilled his coffee in bed. CNA D indicated she had taken R5 his coffee in his personal cup with a screw-on lid at 6:50 AM. CNA D indicated she placed the coffee cup in R5's left hand and left room. CNA D got to another room and heard R5 moaning and went back into R5's room. R5 indicated to CNA D that he had spilled his coffee. CNA D indicated telling RN G that R5 spilled coffee and then removed R5's clothes immediately and changed the bedding. CNA D indicated the whole right side of R5 was red and started blistering. R5 indicated to CNA D that he went to put coffee cup into his right hand and spilled the coffee in bed. CNA D indicated R5 is left hand dominant and does better with left hand. CNA D indicated it is normal for R5 to have coffee in his personal cup in his bed in the mornings. Surveyor asked what the process is for staff to serve coffee to residents. CNA D indicated staff gets the coffee from the coffee pot in the kitchenette. CNA or staff on the floor makes the coffee. CNA D indicated staff has never had to temp coffee, it was never a thing. When staff take R5 his coffee we put it in his left hand. Surveyor asked how staff know if a resident is deemed safe for hot liquids and CNA D indicated she assumed the facility coffee pots are safe to give to residents temp wise. Surveyor asked CNA D if care plans indicate safe for hot liquids in rooms unsupervised and CNA D indicated no. CNA D indicated any resident that can have thin liquids she would just give it to them. CNA D indicated the process has changed since the incident. The temps on the coffee pots in the kitchenettes were checked immediately after the incident of R5 spilling his coffee and found to be hotter than they were supposed to be and are now marked out of order. If a resident requests coffee now the kitchen temps it and brings it up for staff on the floor to administer the coffee. CNA D indicated the kitchen now sends pots of coffee up with the meals or if a resident requests a cup and temps it. On 10/17/24 at 1:41 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B about the incident on 10/13/24. DON B indicated R5 is a partial quadriplegic. When DON B met with R5, R5 indicated to DON B that he tried to hold his personal coffee cup in his right hand, which is his weaker hand. R5 indicated to DON B that he got cocky and tried to switch hands from left hand to right hand and dropped the coffee cup into his bed on his right side where the fluid pooled alongside him. DON B indicated it was R5's personal insulated coffee cup with no handle, but had a lid. Surveyor asked DON B what the process is for staff to serve coffee to residents in their rooms and DON B indicated with general services if a resident with no precautions such as, no supervision with meals or swallowing difficulties they could have hot fluids in rooms. The facility had nothing in place regarding safety with hot liquids. Unless a resident had something stating they could not have coffee or hot liquids unsupervised they could. Surveyor asked if this were something you would care plan and DON B indicated we have never had hot liquid assessments before but since incident we should have. DON B indicated hot liquids and coffee should be temped for safety. DON B indicated since incident with R5 the facility immediately halted service of hot liquids/soups that day. When hot liquids/soups resumed they were to be in temperature parameters of 140 degrees or below. Thermometers are on the units now. 1:1 on liquid temperatures with nursing staff and dietary and a reminder was put on dashboard in PCC (Point Click Care; the electronic health record). Dietary staff are now responsible to temp hot liquids and bring hot liquids/coffee up from the kitchen to the floor. The brewers upstairs are not in use. DON B indicated after the incident, therapy assessed R5 and ordered a U-drink adaptable holder that goes around cup and hand straps in so if resident lets go of cup it won't slip out of hand. DON B indicated if residents request coffee during times the kitchen is not open, we tell them we are working on it. They are not able to get coffee outside of kitchen hours currently. Surveyor asked DON B about the education and DON B indicated she would get back to Surveyor. On 10/17/24 at 2:30 PM, Surveyor interviewed NHA A (Nursing Home Administrator). Surveyor asked NHA A what facility has done to ensure what happened with R5 does not happen to another resident. NHA A indicated that the brewers on the units are marked Not in Service, and the facility has spoken with the manufacturer of the brewers to find the brewers can't be turned down in temperature because they would be susceptible to bacteria growth. The facility diverted coffee service to the kitchen and the kitchen will be temping coffee temperatures. The kitchen is using the same coffee dispensers but now add ice to the coffee to bring the temperatures down. Dietary staff is now responsible for temping the coffee/hot water or hot chocolate. Surveyor asked if residents request coffee like on night shift or at a time the kitchen is not open could they get coffee. NHA A indicated there has been no formal request for coffee on the night shift, but the assumption would be for nursing to go to the kitchen and make coffee or the staff could get coffee in the break room and whoever brings the coffee to the resident would be responsible to temp the coffee. NHA A indicated education has been started and was focused on identifying residents for hot liquid risk. NHA A indicated residents have had a hot liquid assessment. Surveyor asked if all residents have had the assessment completed and NHA A indicated (the corporate group) is working on them he would get back to Surveyor. OT (Occupational Therapy) evals on any residents deemed at risk for hot liquids completed. Clothing protectors have been ordered. The facility is not sure how to implement those yet. The facility is ordering special coffee lids for facility coffee cups. Surveyor asked NHA A if he would have expected hot liquids to have been temped prior to incident and NHA A indicated yes, he believed they were. The facility failed to ensure they were monitoring temperatures of hot liquids including coffee. R5 was served hot coffee and received secondary burns requiring emergency treatment at the burn unit. As a result of the incident with R5 the facility began education with staff, implemented a new procedure for dietary staff to bring coffee to the units and to temp the coffee/hot liquids. Additionally, the facility completed hot liquid assessments on all residents. At the time of survey not all staff received education and were educated on 10/18/24 after survey had begun.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The following example is cited at a isolated/potential for harm. Example 2 R7 indicated on 1/5/24 R7 had her call light on for over an hour before receiving assistance off commode. R7 was admitted to the facility on [DATE] with a diagnoses including: diabetes, congestive heart failure, muscle weakness, kidney failure, and other reduced mobility. R7's most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 10/13/23, indicates R7 has a Brief Interview for Mental Status (BIMS) score of 15 indicating R7 is cognitively intact. R7 is own person. R7's Certified Nursing Assistant (CNA) Care Card states, in part; ADL .TRANSFERS: 2 assist bariatric mechanical stand. On 1/8/24, R7 indicated that R7 sat on commode for two hours. R7 indicated that R7's call light was not on the entire time. R7 indicated call light was on for over an hour and then R7 began yelling for assistance. R7 voiced concerns with the assistance R7 received with transfer, CNA's overall attitude, and the long call light wait time. R7 indicated R7 has voiced concerns with long call light wait times in the past. R7 indicated that R7 utilizes an EZ stand and that R7 requires 2 staff assistance for transfer. R7 indicated filing a grievance regarding the concerns with the transfer. Surveyor reviewed call light wait times for R7 on 1/5/24. Call light wait times, states, in part; .event time 10:43 .Clear time .11:52 .Response time .1:09:15 On 1/8/24 at 5:00 PM, RNC C (Regional Nurse Consultant) indicated the goal is for call lights to be answered within 20 minutes. RNC C indicated over an hour is too long of a wait time. NHA A (Nursing Home Administrator) indicated NHA A has concerns with this call light wait time as well. RNC C indicated a person left on a commode for this amount of time would be at greater risk for falls. NHA A and RNC C indicated the facility is now running call light audits daily and reviewing documentation. UNCORRECTED AT VERIFICATION VISIT. See SOD for Event ID OC8I11. Based on observation, interview, and record review, the facility did not ensure adequate supervision or fall interventions were in place for residents who required increased supervision to prevent accidents/hazards from occurring for 2 of 5 sampled Residents (R5 and R7). R5 did not have fall interventions in place. R5's care plan documents: Do not leave unattended in the Bathroom. R5 ambulated independently to the bathroom and her alarm was sounding. CNA N (Certified Nursing Assistant) heard the alarm sounding and identified that R5 ambulated independently to the toilet. CNA N turned the alarm off, exited the room, and shut the door leaving R5 unattended in the bathroom. CNA N did not assist R5 or alert other staff that she had self-transferred on the toilet. CNA N is aware that R5 is not to be left alone in the bathroom and does not use her call light for assistance. Ten (10) minutes later R5 ambulated independently from the bathroom and fell sustaining multiple right pelvic fractures. The facility did not speak with CNA N or identify that CNA N turned off R5's alarm and did not assist her. Surveyor observed staff leave R5 unattended in the bathroom. The facility has no policy for alarms and no process to monitor alarm implementation dates, expiration dates, and function to ensure safety. This is evidenced by: The facility policy, Accidents/Falls, revised October 2022, documents, in part: The facility strives to promote safety, dignity, and overall quality of life for its residents by providing an environment that is free from any hazards for which the facility has control and by providing appropriate supervision and interventions to prevent avoidable accidents. All fall is defined as an occurrence characterized by the failure to maintain an appropriate lying, sitting, or standing position resulting in an individual's abrupt, undesired relocation to the ground. The definition of a fall extends to include the following factors: .When a resident is found on the floor, a fall is considered to have occurred Resident care plans should be evaluated and updated with each fall with a new and applicable intervention based on root cause. The focus is to be on prevention and maintaining a safe environment. Each incident/accident or fall must be investigated and/or assessed to determine the root cause of the episode to prevent any further injury. Witness statements should be obtained as applicable. The administrator and Director of Nursing/Wellness should have knowledge of all reports. The interdisciplinary team will review all incidents/accidents. The resident's individualized care plan is to be updated with any changes or new interventions post fall/incident/accident, communicated to appropriate staff, and implemented. R5 was admitted to the facility 12/7/22 with diagnoses including, but not limited to: Alzheimer's disease, history of falls, displaced trimalleolar fracture of left lower leg open fracture with routine healing, Methicilin-resistant Staphylococcus aureaus (MRSA; a type of bacteria that can cause serious infections) removal of internal fixation device chronic multifocal osteomyelitis left ankle and foot, spinal stenosis, muscle weakness, and reduced mobility. R5's most recent Minimum Data Set (MDS) dated [DATE] documents the following: R5 is severely cognitively impaired. R5 has had 1 fall since admission and no falls with major injury. R5's Visual/Bedside [NAME] Report, dated 1/3/24, indicates, in part, the following interventions: ADL (Activities of Daily Living): Ambulation: Therapy only at this time; Bathing: 1 assist; Bed Mobility: 1 assist; Daily Routine: Assist resident to activities, enjoys crossword puzzles, word games and trivia, loves to talk, seat with other residents that will engage; Resident has a neck pendant call light (note, she does not use her neck pendant). Dressing: 1 assist; Eating: Set up; Hygiene: 1 assist; Locomotion: Wheelchair self-propel; Toilet use: 1 assist; Transfers: 1 assist ex stand may be used for increased weakness or fatigue. Bladder/Bowel: Toilet upon rising, between meals, at HS (bedtime) and as needed. Cognition Break tasks into subtasks, providing simple one-step instructions. Remind/redirect and/or reassure as needed. Resident has a call pendant but is not using it. Anticipate needs. Round throughout shift. Safety-Fall Interventions: 12/8/23 Fall intervention: Staff will ask resident is she is tired after she returns from activity and offer her to rest in recliner chair after toileting resident. Bed/Chair sensor at all times. Check for unmet needs: pain, toileting, hunger, thirst. Do not leave unattended in the Bathroom. If resident refuses cares, re-attempt in 30 minutes. Keep bathroom door shut at all times. Low bed. Floor mat. R5's comprehensive Care Plan indicates the following: Safety/Falls Focus: Actual potential for complications with OR fall R/T (related to) current medical/physical status. 5/14/23 12/8/23 unwitnessed fall in room; Goal: Will be free of falls, but if does, will be free from serious injuries r/t (related to) falls through next review date. Interventions: 12/8/23 Fall intervention: Staff will ask resident is she is tired after she return from activity and offer her to rest is recliner chair after toileting resident. 5/22/23 Complete rounds per standards of care to ensure needs are met, before leaving the room ask if there is anything else needed or would like assistance with. 5/22/23 If resident refuses cares, re-attempt in 30 minutes. 4/16/23 low bed 4/16/23 floor mat 3/7/23 Bed/Chair sensor at all times 2/27/23 Call light positioned for easy access. 2/27/23 Check for unmet needs: pain, toileting, hunger, thirst, temperature *3/7/23 Do not leave unattended in the Bathroom. R5's Fall risk assessments indicate she is at risk for falls. R5 fell on [DATE] at 4:11 PM. R5's fall report documents the following: Incident Description: Nursing Description: Pharm Tech J (Pharmacy Technician) heard somebody knocking on the door entered the resident room and found the resident sitting on the floor in the doorway. Writer found the resident sitting on the floor with her leg extended out, her back resting on the wall. Resident reported pain in her right ankle and knee. Resident alert oriented x1 has a short memory problem dementia and she stated that she was trying to perform self-transfer but tripped on her feet and fell, but she couldn't give more detail. Resident Description: Resident reported pain in her right ankle and knee. Resident alert oriented x1 has a short memory problem dementia and she stated that she was trying to perform self-transfer but tripped her feet and fell, but she couldn't give more details. Description of action taken: NP (Nurse Practitioner) notified, POA (Power of Attorney) contacted, care plan was updated. RN Charge Nurse M (Registered Nurse/Charge Nurse) documented the following Progress Note: Fall - Unwitnessed Incident Description: Pharm Tech J (Pharmacy Technician) heard somebody knocking on the door entered the resident room and found the resident siting on the floor in the doorway. Writer found the resident sitting on the floor with her leg extended out, her back resting on the wall. Resident reported pain in her right ankle and knee. Resident alert oriented x1 has a short memory problem dementia and she stated that she was trying to perform self-transfer but tripped on her feet and fell, but she couldn't give details. During the assessment writer found no changes in resident condition compared to her baseline. No changes in skin color or swelling. No lumps or skin discoloration on the scalp/head were noted during assessment. Vital signs BP (blood pressure) 110/67, P (pulse) 65, )2 sat (oxygen saturation) 93% RA (room air), temp (temperature) 97.1. After the resident was assessed and no sign of injury was found she was transferred back to the bed with mechanical lift with no sign of pain during transfer. In 10 minutes, writer reassessed the patient in the bed in the lying position and noted that resident reported pain in right inner thigh. According [SIC] staff resident was watching TV concert in the west atrium with activity department till 3:30 PM. Resident Description: Resident reported pain her right ankle and knee. Resident Alert x1 has a short memory problem dementia and she stated that she was trying to perform self-transfer but tripped her feet and fell, but she couldn't give more details. Immediate Action Taken: Notified provider extender, POA (Power of Attorney) contacted. Care plan was updated. Injury Observed at Time of Incident: Fracture - right trochanter (hip) Mental Status: Oriented to Situation Injuries Reported Post Incident: Bruise right shoulder (rear) Predisposing Psychological Factors: Impaired memory Predisposing Situation Factors: Other (see description - self transfer) R5's Interdisciplinary Team (IDT) documents the following Post Fall Review, in part: Date and time fall occurred: 12/8/23 4:11 PM Location: resident's (R5's) room What was the resident doing prior to the fall, if known: sitting WC (wheelchair) watching TV. Did the resident sustain an injury? If yes, describe yes, mons pubis fracture. Fall History: 1-3 falls in 3 months. Underlying Disease or Conditions: Cardiac diagnosis or pacemaker, Orthopedic/joint/arthritis, Medications: Psychotropics, Antihypertensives Sensory, Cognitive, Psychological Status: Does the resident have problems with cognition, judgement, memory, and safety awareness? (Indicates yes). Is the resident able to communicate their needs? (Indicates yes), Does the resident express pain, have signs of any pain, or take pain medications? (Indicates yes). Environmental Status/Equipment Factors: Are there any environmental factors that may have contributed to the fall? Yes Review of Post Fall Findings: Summarize the post-fall findings: IDT review of root cause analysis determined resident is impulsive and noncompliant with using call light and waiting for assistance to toilet. Describe new fall prevention interventions to be implemented as a result of the assessment: Resident to be toileted after activity then provided the option to rest in her recliner. List suggestions of referrals to be made as a result of the fall: Therapy. R5 was sent to the emergency department. The hospital report documents, in part, as follows: Chief Complaint: Pain Hip and Fall (Patient fell when transferring back to her bed. Pt report her right leg gave out, now having severe right hip pain. No deformity noted. Denies hitting head. Not anticoagulated. Chest x-ray is personally interpreted with right-sided pubic rami fractures noted without further acute fracture or other acute abnormality such as pneumothorax. Discharge Diagnosis: Fall, initial encounter. Closed fracture of multiple pubic rami, right, initial encounter. R1 was discharged and returned to the facility that evening. Pharm Tech J's (Pharmacy Technician) statement documents the following: This is a written statement of my finding on Friday 12/8/23. I, Pharm Tech J, was delivering medications to Wingra, the 200 unit, somewhere between 4:15 PM and 4:20 PM. I placed the medications in the nurses medication cart and was walking back to the pharmacy when I heard a loud bang (knock) on R5's room. I stopped and knocked on her door which was closed, and I opened it saying R5's name as I opened the door, she was lying against the wall with feet out straight with her back propped up against the wall. I found her about 2 or 3 feet from her door. I immediately popped my head out of her door and hollered down to the nurses station where I saw RN K and CNA L sitting and said, We have a resident who fell and is on the floor. I then talked to R5 to reassure her that help was on the way. She told me that she fell out of her chair. I also did not hear any alarms going off as I entered the room. Once medical staff came, R5 said I am glad you heard me knocking on the door. CNA N's statement documents the following: *1. What did you last note the resident doing prior to fall? on the toilet. *2. What time was cares last given or resident visualized? she isn't my resident today, so I don't know. 3. Was resident continent or incontinent when located on the floor? Continent *4. Last time toileted? 10 mins (minutes) prior to fall *5. What care plan or safety measure were in place? I'm not sure. 6. How do you think the fall could have been prevented? I'm not sure. 7. What was determined the immediate intervention by nurse/CNA? Tell patient to call for help. Document staff education given if needed and by which nurse: RN Charge Nurse M CNA L's statement documents the following: R5 as in room after the musical busy time preparing dinner. Nurse asked was R5 out in kitchen. I told her no she comes down, but I have to go get her to remind her after 4:15 PM. I usually get her she doesn't like to come down to [SIC] early. Sometimes she is playing cards in kitchen. Resident transfers herself constantly. Turns off call light. Sometimes she calls or comes out the room when she needs to toilet. Today she did neither and self-transfer and Pharm Tech J said she was down on floor as she walked by. RN K's statement 1. What did you last note the resident doing prior to fall? I did not see resident prior to the fall. 2. What time was cares last given or resident visualized? No idea 3. Was resident continent or incontinent when located on the floor? RN Charge Nurse M did assessment, No idea 4. Last time toileted? No idea, assessment done by RN Charge Nurse M 5. What care plan or safety measure were in place? N/A (not applicable) 6. How do you think the fall could have been prevented? N/A 7. What was determined the immediate intervention by nurse/CNA? N/A sent to ER (emergency room) Document staff education given if needed and by which nurse: N/A On 1/4/24 at 8:39 AM, Surveyor observed R5's empty wheelchair in her room and the bathroom door closed. Surveyor observed CNA O walk from the end of the hallway to R5's room. Surveyor entered R5's room and R5 agreed to Surveyor observing cares. Surveyor observed R5 in the bathroom sitting on the toilet while connected to the stand lift. CNA O left R5 in the bathroom unattended. Surveyor observed R5's [NAME] posted on the cabinet in the bathroom which indicates Do not leave unattended in the Bathroom. CNA provided cares to R5, and Surveyor spoke with R5 prior to CNA O transporting her to breakfast. On 1/4/24 at 8:51 AM, CNA O left R5's room and Surveyor spoke with R5. Surveyor spoke with R5. Surveyor asked R5 if the staff take good care of her. R5 stated, Always. Surveyor asked R5 if she gets help when she needs it. R5 stated, I don't need much help, I do pretty well by myself. Surveyor asked R5 if she could show me her call light/pendant. R5 pointed to the call pendant around her neck. (Care Plan indicates she does not utilize this.) Surveyor asked R5, have you had any falls recently. R5 stated, No. Surveyor asked R5 have you broken any bones recently. R5 stated, Not since I was young. Surveyor asked R5, do you feel safe here. R5 stated, Perfectly safe. Surveyor asked R5 if she currently has any pain. R5 stated, No. On 1/4/24 at 8:53 AM, CNA O returned to R5's room. Surveyor asked CNA O, should staff stay with R5 while she is in the bathroom. CNA O stated, sometimes R5 transfers herself and forgets she needs assistance to the toilet. CNA O stated, R5 tries to transfer frequently and doesn't think she needs help. Surveyor asked CNA O to read R5's [NAME] and pointed out the intervention: Do not leave unattended in the Bathroom. Surveyor asked CNA O, should you have stayed with R5 while she was in the bathroom on the toilet. CNA O stated, Yes, I should have. On 1/4/24 at 9:54 AM, Surveyor spoke with Pharm Tech J (Pharmacy Technician). Surveyor asked Pharm Tech J to describe what she witnessed on 12/8/23 when she discovered R5 on the floor. Pharm Tech J stated around 4:15 - 4:20 PM she was delivering medications to the 200 unit. Pharm Tech J stated, when she is walking down the hall, she heard a knock. Pharm Tech J stated she knocked on R5's door before entering and saw R5 on the floor. Pharm Tech J stated she was leaning against the wall with the nightlight (Surveyor observed this to be the wall next to the door and just around the corner from R5's bathroom). Pharm Tech J stated, R5 said, Help me up. Pharm Tech J told R5 she needed to get help and opened the door and asked for help and saw the CNA L and RN K sitting at the desk. Pharm Tech J stated CNA L and a tall male CNA (identified as CNA N) asked if R5 was ok and if she was hurt. Pharm Tech J stated, R5 said her ankle hurt. Pharm Tech J stated RN-Charge Nurse M came in to assess R5. Pharm Tech J stated, No alarms sounded. Pharm Tech J stated, R5 stated she fell out of her chair and added she was unsure if it was her wheelchair or stationary chair. Pharm Tech J stated, CNA N told R5, you need to call and not get up. On 1/4/24 at 10:05 AM, Surveyor spoke with RN K. Surveyor asked RN K to describe what he witnessed on 12/8/23 when R5 fell. RN K stated, she thinks she was passing medications when Pharm Tech J brought her medications and then yelled to me that a resident is on the floor with her legs stretched out. RN K stated, she went to R5's room and saw RN Charge Nurse M. RN K stated, she had medications in her hand and RN Charge Nurse M took over. Surveyor asked RN K, was R5's alarm sounding. RN K stated, I don't think so. On 1/4/24 at 10:46 AM, Surveyor spoke with CNA N. Surveyor asked CNA N to describe what he witnessed on 12/8/23 when R5 fell. CNA N stated, I heard an alarm going off, she (R5) was already on the toilet. CNA N stated, R5 transferred independently onto the toilet and no lift was in use. CNA N stated, he turned off the alarm, exited the room, closed the door, and did not assist R5 as she was not his resident. Surveyor asked CNA N, did you return to R5's room to assist her. CNA N stated, No. Surveyor asked CNA N, did you tell anybody R5 was on the toilet and transferred independently. CNA N stated, No, I didn't let anybody know. Surveyor asked CNA N, are your familiar with R5's care plan. CNA N stated, Yes. Surveyor asked CNA N, does R5 self-transfer often. CNA N stated, Yes, every day. Surveyor asked CNA N, if you see a resident self-transfer what do you do. CNA N stated, If she was my patient, I would help her. Surveyor asked CNA N, if a resident that is not on your assigned wing that needs assistance would you help them. CNA N stated, I would if I had time, I saw she was safe and left the room. (Note, her wheelchair was not within reach and Care Plan indicates Do not leave unattended in the Bathroom.) Surveyor asked CNA N, is it okay to leave R5 unattended in the bathroom. CNA N stated, No. Surveyor asked CNA N, if this same situation presented itself again what would you do differently. CNA N stated, I would stay with her, assist her back to her chair and turn her alarm on. Surveyor asked CNA N, did anybody provide education to you following this fall. CNA N stated, RN Charge Nurse M and the previous DON (Director of Nursing) provided education to him. Surveyor requested documentation of education to CNA N. Regional Nurse Consultant C stated there is no documented education to CNA N regarding this incident. On 1/4/24 at 11:41 AM, RN Charge Nurse M was out of the country on vacation and unavailable for interview. On 1/4/24 at 11:45 AM, RN P toileted R5. When R5 was in the bathroom Surveyor observed her chair and bed alarms. Surveyor observed R5's chair alarm, Posey TLC Posey Total Location Coverage. First Use Date and Expiration Date were both blank. The alarm documents: Warranty: This product is warrantied for thirty (30) days from date of first use. CAUTION: Sensor pad beyond expiration date is out of warranty and may not function properly causing false alarm or no alarm. Surveyor observed R5's bed alarm, Posey Single Patient Use Bed Sensor Pad (30-day). Warranty: This product is warranted for thirty (30) days from date of first use. It is important to note the facility has no policy or process for alarms and labeling First Use Date and Expiration Date. The facility also has no system nor documentation in place to monitor the function of the alarms. Surveyor asked RN P, how long an alarm is good for upon being implemented. RN P stated, I have absolutely no idea, it has always been on there (R5's chair and bed). Surveyor asked RN P, does the facility document the function of the alarms. RN P stated, I don't believe so. RN P stated, it would be the right thing to check it, but I don't know if we document it. Surveyor asked RN P, should R5's alarms be dated with the First Use Date and Expiration Date. RN P stated, If that's what the manufacturer instruction indicate then yes. On 1/4/24 at 12:49 PM, Surveyor spoke with RN Q. Surveyor asked RN Q, does the facility document, and check the function of resident alarms. RN Q stated, no, there is no schedule nor documentation to check the function of alarms. RN Q stated the extra alarms are in the Medication Rooms and there is no process when implementing or replacing an alarm. On 1/4/24 at 1:09 PM, Surveyor spoke with CS R (Central Supply). Surveyor asked CS R, is there a process for resident alarms. CS R stated, there is a supply in her office and in the medication rooms. CS R stated, there is no sign out sheet for alarms or tracking. On 1/4/24 at 4:08 PM, Surveyor spoke with NHA A (Nursing Home Administrator). Surveyor asked NHA A to tell me regarding R5's fall on 12/8/23. NHA A stated R5 resides on MCU (Memory Care Unit), she is very impulsive, transfers by herself and didn't use the call light. NHA A stated, I think she transferred to the bathroom independently. NHA stated, Pharmacy Tech J found her on the floor and got nursing to assist her. NHA A stated, at first, they were going to get a mobile X-ray; however, a few minutes after the fall she was complaining of further pain, and we sent her to the ER (emergency room). NHA A stated, CNA N was not assigned to R5. NHA A added, I know he saw her on the floor. Surveyor asked NHA A, are you aware that CNA N turned off R5's alarm after he observed her on the toilet and was aware that she transferred independently and then exited R5 without assisting her or notifying other staff. NHA A stated, CNA N turned off R5's alarm? NHA A added, That's news to me. NHA A stated, she is of the mindset of not having alarms and is working to reduce the usage of alarms in the facility. NHA A stated, staff have told her that R1 will turn off her alarm. NHA A stated, it's not effective if the resident can turn the alarm off. NHA A stated, R5's alarm is in place because family want her to have it. Surveyor asked NHA A, are you aware that CNA N saw that R5 self-transferred herself onto the toilet. NHA A stated, No. NHA A stated, she did not realize the transfer was not complete. Surveyor asked NHA A, what would you expect CNA N to have done in this situation. NHA A stated, either stay with her or call for additional help since she was not his assigned resident. NHA A stated, we've been doing a lot of education since another resident fell and passed away because of injuries. Surveyor asked NHA A, would you expect staff to stay with R5 and follow her care plan. NHA A stated, Yes. Surveyor shared observation (above) of CNA O leaving R5 unattended on the toilet in the bathroom this morning while hooked up to the sit to stand lift. Surveyor asked NHA A, would you expect staff to not leave R5 unattended in the bathroom per her care plan. NHA A stated, Yes. Surveyor asked NHA A, would you expect CNA O to be aware of R5's care plan interventions. NHA A stated, Yes. Surveyor asked NHA A, Surveyor shared with NHA A, that the facility has no process to check resident alarms for function. Surveyor asked NHA A, should the facility be checking alarms for function. NHA A stated, Yes. Surveyor asked NHA A, were you aware there's not facility policy/procedure regarding checking alarms for function. NHA A stated, Not that I know of. Surveyor asked NHA A, are you aware that pad alarms expire. NHA A stated, she was not aware.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not implement professional standards of practice to prevent pressure injuries (PI) from worsening for 1 of 5 residents reviewed for PIs, out of a sample of 34 residents (R104). The facility did not ensure weekly measurements/assessments and treatments were being completed to R104's sacral PI. MD (Medical Doctor) notifications were not done when changes were noted to the wound. R104 was admitted to the facility with a stage 2 PI which progressed into a stage 4 PI causing R104's PI to become infected and R104 was placed on antibiotics. This is evidenced by: The facility's policy, entitled Pressure Injuries (Management/Treatment,) with a revision date of 12/22, states, in part: The purpose of the policy is to help assure residents with pressure injuries prompt assessment, treatment, and services by the Interdisciplinary Team (IDT) to promote healing, prevent infections and prevent new injuries from developing while maintaining optimal quality of life and functional ability .Definitions: *Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities, and condition of the soft tissue . *Stage 2 Pressure Injury: Partial- thickness skin loss with exposed dermis . *Stage 4 Pressure Injury: Full-thickness skin and tissue loss. Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer . *Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar . PROCESS: I. Pressure injuries will be reported to the MD/Provider as indicated, and orders will be obtained for treatment as indicated . The course of treatment will be documented until the pressure injury is resolved . II. Wound assessment and measurements will be completed for pressure injuries at least weekly . A. Pressure Injury Assessment: .2. Assess and measure wounds weekly: (Measure the injury length (head to toe), width (side to side), and depth . Indicate condition of peri-wound; tissue surrounding the wound or macerated/denuded skin. Note condition of wound edges. Document percentage of tissue type such as slough (yellow/white fibrous tissue) or granulation (red, healthy tissue). If tunneling is present, document location (using face of clock) and depth. Document undermining (edge of wound opening underneath parameter) if present. Note scar tissue. Note any warmth or induration, (hard, thickened tissue). i. Measure wound size, (in centimeters (cm)) length, width and depth, location ii. Tunneling or undermining iii. Drainage: type, amount iv. Infection-color, odor, heat, inflammation v. Wound bed: color, presence of granulation, slough, or necrotic tissue vi. Wound edges: color and condition vii. Peri-wound: maceration, induration, edema, excoriation, erythema viii. Wound Progress: improvement, deterioration, healed ix. Presence or absence of pain 3. With each dressing change observe for developments that indicate a need for change in treatment (e.g., deterioration, sign of infection or complications). If change in treatment is warranted update MD/Provider, plan of care and treatment plan. VII. Methods for monitoring healing: . B. Licensed nurse will re-evaluate the pressure injury, the plan of care and the resident's status if the pressure injury does not show progress of healing. C. Report signs of deterioration in pressure injury to MD/Provider. D. Assessment and Treatment of Infections: 1. Assess for the following which may indicate the presence of infection: i. Presence of erythema ii. Edema iii. Induration iv. Heat/fever v. Foul odor (after cleansing) purulent drainage vi. Streaking vii. Increased pain in the wound viii. Increasing wound size x. Crepitus . XII. Healed Pressure Injuries: . B. Continue to provide daily skin observations and weekly skin assessments . The facility policy, entitled Skin/Hydration Assessment, with a revision date of 12/22, states, in part: Skin and Hydration assessments will be completed and documented on all residents on admission, weekly, and as needed. Weekly skin/hydration assessments will take place on residents' individual shower/bath day . PROCESS - SKIN ASSESSMENT: . V. Once a pressure injury has been identified, it will be: . B. Assessed, measured, and documented on by the Wound Nurse, or Nurse Manager in his/her absence, weekly. This includes: 1. Stage 1-4 Pressure Injuries 2. Unstageable Pressure Injuries . D. MD/GNP (Adult Gerontology Nurse Practitioner) will be notified if: 1. Pressure injury worsens or enlarges. 2. It shows signs of infection. 3. No improvement is noted in 2 weeks. 4. Improved and/or alternative treatment options are available . Example 1 R104 was admitted to the facility on [DATE] and has diagnoses that include Pressure Ulcer of Sacral Region, Non-Pressure chronic ulcer of unspecified part of right lower leg and left lower leg, and Morbid Obesity due to excess calories. R104's MDS (Minimum Data Set) admission Assessment, dated 9/7/22, indicated that R104 has a BIMS (Brief Interview of Mental Status) score of 9 indicating moderate cognitive impairment. Section G indicates R104 is totally dependent with two assists for bed mobility, transferring, and toilet use. R104 requires total dependence of one staff for locomotion on and off unit. R104's Care Plan, dated 9/1/22, states, in part: Problem: Impaired Skin Integrity .Manifested by: Stage 1 Pressure Ulcer to coccyx, Surgical wounds Goal: No sign or symptom of infection Goal Time: 12/1/22 Nurse Aide: Skin Care: Apply barrier cream as delegated by nurse. Keep skin clean and dry. Assist with hygiene and general skin care. Report worsening skin condition to nurse immediately. Nurse Aide: Positioning Device: Use draw sheet when repositioning to prevent shearing. Nurse Aide: Bed Positioning: Turn and reposition every two hours to prevent skin breakdown .Nurse Aide: MATTRESS: PressureGuard Custom Care Convertible with Pump .Nurses: Develop and monitor turning schedule . Nurses: Weekly skin assessment. Nurses: Implement and initiate weekly wound assessment and documentation per facility protocol . R104's Braden Scale, dated 9/1/22, shows a score of 14 indicating R104 is at moderate risk for skin breakdown. R104's Braden Scale, dated 9/8/22, shows a score of 16 indicating R104 is at mild risk for skin breakdown. R104's Braden Scale, dated 9/15/22, shows a score of 16 indicating R104 is at mild risk for skin breakdown. R104's Braden Scale, dated 9/22/22, shows a score of 18 indicating R104 is at mild risk for skin breakdown. R104's Mini Nutritional Assessment, dated 10/27/22, shows a score of 7 indicating R104 is malnourished. R104's skin assessments show the following: 9/2/22: Type of Wound: Pressure Ulcer Origination: Upon Admission Stage Of Pressure Injury: Stage 2 Location: Sacrum Peri-wound Description: Red, blanching Edges: Red Length (Head to toe): 7cm (centimeters) Width (left to right): 10 cm Wound Bed: Non Blanchable redness with subtle blistering noted to areas of wound bed Odor Present: No Drainage: None Progress: Initial Assessment Pain related to treatment: No Recommendations: Apply sacral mepilex after cleansing skin, change weekly on shower day and prn (as needed) if soiled. RN J (Registered Nurse) R104's Physician's Orders for sacral PI are as follows: 9/2/22 - Treatment to Sacral Stage 2: 1 time per week Tuesday 1x/Day EVES 1. Cleanse skin and dry 2. Apply sacral Mepilex Dressing Discontinued 11/15/22 9/10/22: Type of Wound: Pressure Ulcer Origination: Upon Admission Stage Of Pressure Injury: Stage 2 Location: Sacrum Peri-wound Description: Healthy Edges: Pink Length (Head to toe): 7.5 cm Width (left to right): 12 cm Depth: 0.1 cm Wound Bed: 2 distinct open areas within measurements with pink wound beds, the rest of the skin involved is red and non-blanching Odor Present: No Drainage: Type: Serosanguinous Amount: Small Progress: Affected areas has opened as anticipated. No s/sx of infection noted. Pain Related to Treatment: Yes, Explain: Tender to touch Recommendations: Continue treatment as ordered. RN J 9/16/22: Type of Wound: Pressure Ulcer Origination: Upon Admission Stage of Pressure Injury: Stage 2 Location: Sacrum Peri-Wound Description: Healthy Edges: Pink Length (Head to toe): 5 cm Width (left to right): 9 cm Depth: 0.1 cm Wound Bed: Pink Odor Present: No Drainage: Type: Serosanguinous Amount: Small Progress: Improved: measuring smaller Recommendations: Continue treatment as ordered Assessed by: RN J 9/25/22: Type of Wound: Pressure Late Entry for 9/24/22 Ulcer Origination: Upon Admission Stage of Pressure Injury: Stage 2 Location: Sacrum Peri-Wound Description: Healthy Edges: Pink Length (Head to toe): 0.5 cm Width (left to right): 0.5 cm Depth: 0.1cm Wound Bed: Pink Granulation: 100% Odor Present: No Drainage: Type: Serosanguinous Amount: Scant Progress: Improved: Only a small open area remains, the rest of the wound has healed and epithelialized and presents as pink scar tissue Pain Related to Treatment: No Recommendations: Continue treatment as ordered Assessed by: RN J 9/30/22: Type of Wound: Pressure Ulcer Origination: Upon Admission Stage of Pressure Injury: Stage 2 Location: Sacrum Peri-Wound Description: Healthy Edges: Pink Length (Head to toe): 0.5 cm Width (left to right): 0.5 cm Depth: 0.1 cm Wound Bed: Bleeding Odor Present: No Drainage: Type: Sanguineous Amount: Small Progress: No significant changes. A small open area remains present. Pain related to treatment: No Recommendations: Continue treatment as ordered Assessed by: RN J R104's eTAR (Electronic Treatment Administration Record) for September shows: Entry Date: 9/7/22 - Turn and reposition every 2 hours. Repositioning Schedule: 12am-2am (Left side), 2am-4am (right side), 4am-6am (left side), 6am-8am (right side), 8am-10am (left side), 10am-12pm (right side), 12pm-2pm (left side), 2pm-4pm (right side), 4pm-6pm (left side), 6pm-8pm (right side), 8pm-10pm (left side), 10pm-12am (right side) (sacral pressure injury): The following times were left blank on eTAR for September: 9/10/22- 4am, 9/20/22- 8am,10am, noon, 2pm, 9/28/22- 12am 9/29/22- 12am, 8am, 4pm, 6pm, 8pm, 10pm. (Please note there is no documentation of the PI after 9/30/22 until 10/25/22. Additionally, the PI was not measured from 9/30/22 - 11/17/22.) R104's eTAR (Electronic Treatment Administration Record) for October 2022 shows: Entry Date: 9/2/22 Treatment to Sacral Stage 2: 1 time per week Tuesday 1x/Day EVES 1. Cleanse skin and dry. 2. Apply sacral mepilex Dressing The following dates were left blank on eTAR for October: 10/18/22 The following entries show changes: 10/25/22- Type of Wound: Pressure Stage of Pressure Injury: Stage 2 Location: Sacrum Odor Present: No Drainage: None Procedure Done: open area noted. Wound bed yellow with dark spots, no signs of infection (Note: change noted to R104's wound bed including yellow wound bed with dark spots and no MD notification) R104's eTAR (Electronic Treatment Administration Record) for October 2022 shows: Entry Date: 9/7/22 - Turn and reposition every 2 hours. Repositioning Schedule: 12am-2am (Left side), 2am-4am (right side), 4am-6am (left side), 6am-8am (right side), 8am-10am (left side), 10am-12pm (right side), 12pm-2pm (left side), 2pm-4pm (right side), 4pm-6pm (left side), 6pm-8pm (right side), 8pm-10pm (left side), 10pm-12am (right side) (sacral pressure injury): The following times were left blank on eTAR for October: 10/1/22- 10pm 10/2/22- 4am, 6pm, 8pm, 10pm 10/3/22- 4pm, 6pm, 8pm, 10pm 10/5/22- 6pm, 8pm, 10pm 10/6/22- 4pm, 6pm, 8pm, 10pm 10/9/22- 10am, noon, 2pm, 4pm, 6pm, 8pm, 10pm 10/16/22- 8am, 10am, noon 10/17/22- 4pm, 6pm, 8pm, 10pm 10/18/22- 4pm, 6pm, 8pm, 10pm 10/19/22- 10pm 10/26/22- 4pm, 6pm, 8pm, 10pm 11/1/22 - Type of Wound: Pressure Stage of Pressure Injury: Stage 2 Location: Sacrum Odor Present: No Drainage: None Procedure Done: open area noted. Wound bed yellow with dark spots, no signs of infection. (Note: 2nd week with changes noted to R104's wound bed, no measurements, and no MD notification indicated) 11/5/22 - Type of Wound: Pressure Stage of Pressure Injury: Stage 2 Location: Sacrum Odor Present: no odor from pressure area but foul odor from dressing, could be due to soiling Drainage: no active drainage noted from pressure area, but noted moderate darkish discoloration on old dressing 11/9/22 - Type of Wound: Pressure Late Entry for 11/8/22 Stage of Pressure Injury: Stage 2 Location: Sacrum Odor Present: yes Drainage: dressing wet, wound bed soft yellow tissue treated as ordered and notified Hospice of odor and increased drainage noted with dressing change 11/11/22 - Stage 2 noted upon admission was essentially healed with a 0.5 x 0.5 cm open area remaining, wound subsequently deteriorated and is currently presenting as an unstageable slough covered wound. Location: Sacrum Peri-wound Description: Erythema (redness) Edges: Bright Red Length (Head to toe): 4 cm Width (left to right): 3 cm Wound Bed: Slough (dead skin tissue) Slough: 100% Slough Color: Yellow- green Slough Characteristic: Adherent Odor Present: Yes- Strong pungent smell Drainage: Type: Purulent Amount: Large Progress: Deteriorated: As noted above, presentation today concerning for infectious process at site Pain related to treatment: Yes, Explain: tender to touch Recommendations: MD/GNP notified. Suggest oral antibiotic course and treatment change as follows: Irrigate wound thoroughly with normal saline, dry. Apply Santyl. Cover with foam border type dressing supplied by Hospice daily until healed. R104's progress note, dated 11/11/22, at 11:58am, states: Conversation with: NP (Nurse Practitioner) Regarding: Presentation of sacral wound Result: New orders received and noted: (Specify briefly) Wound culture and sensitivity. RN J Physician Orders dated 11/11/22 - Wound culture and sensitivity. Physician Orders dated 11/11/22 - Clindamycin 300mg (milligrams) by mouth every 8 hours 3x/Day 3pm 11pm 7am x 7 days (wound infection) Discontinued on 11/16/22 11/15/22 - Type of Wound: Pressure Stage of Pressure Injury: Stage 2 Location: Sacrum Odor Present: Yes Drainage: None Procedure Done: Dressing in place, Hospice nurse in today, also GNP (Geriatric Nurse Practitioner)/wound nurse new orders tx (treatment) written for wound, continues with oral abx (antibiotic) for infection, (Please note this wound should be indicated as an unstageable and not a stage 2.) Physician orders dated 11/15/22 - Treatment to Sacral Wound: 1x/Day until healed 1. Irrigate thoroughly with Normal Saline and dry 2. Apply Medihoney to wound bed 3. Cover with foam border dressing **Supplies to be supplied by Hospice** Discontinued 12/2/22 Physician orders dated 11/16/22 Cefprozil 500 mg by mouth 2x/day Breakfast: HS (hour of sleep) x 14 days (sacral wound infection) Discontinued 11/30/22. 11/17/22 - Late entry for 11/16/22 Type of Wound: Pressure Ulcer Origination: Upon Admission Stage of Pressure Injury: Initially a stage 2 now presenting as unstageable Location: Sacrum Peri-Wound Description: Reddened 2 cm circumference to peri-wound Edges: Pink Length (Head to toe): 4.5 cm Width (left to right): 4.5 cm Depth: 1.5 cm Wound Bed: Slough Slough Color: Yellow Slough Characteristic: Adherent Odor Present: Yes Drainage: Purulent Amount: Large Progress: Remains on oral antibiotics for wound infection. Presentation today consistent with ongoing infectious process at site. Pain related treatment: Yes Explain: Tender to touch Recommendations: Continue tx as ordered Assessed by: RN J R104's eTAR for November 2022 shows: Entry Date: 11/15/22 Treatment to Sacral Wound: 1x/Day until healed 1. Irrigate thoroughly with Normal Saline and dry 2. Apply Medihoney to wound bed 3. Cover with foam border dressing **Supplies to be supplied by Hospice** The following times were left blank on eTAR for November 2022: 11/19/22 & 11/23/22 11/30/22 - Late Entry for 11/23/22 Type of Wound: Pressure Ulcer Origination: Upon Admission Stage of Pressure Injury: Initially a stage 2 now presenting as unstageable Location: Sacrum Peri-Wound Description: Reddened 2 cm circumference to peri-wound Edges: Pink Length (Head to toe): 4.5 cm Width (left to right): 4.5 cm Depth: 1.5 cm Wound Bed: Slough Slough Color: Yellow Slough Characteristic: Adherent Odor Present: Yes Drainage: Purulent Amount: Moderate Progress: Remains on oral antibiotics for wound infection. Less drainage noted today, less odorous as well. Pain related to treatment: Yes Explain: Tender to touch Recommendations: Continue treatment as ordered Assessed: RN J R104's eTAR (Electronic Treatment Administration Record) for November 2022 shows: Entry Date: 9/7/22 - Turn and reposition every 2 hours. Repositioning Schedule: 12am-2am (Left side), 2am-4am (right side), 4am-6am (left side), 6am-8am (right side), 8am-10am (left side), 10am-12pm (right side), 12pm-2pm (left side), 2pm-4pm (right side), 4pm-6pm (left side), 6pm-8pm (right side), 8pm-10pm (left side), 10pm-12am (right side) (sacral pressure injury): The following times were left blank on eTAR for November: 11/1/22- 10am, noon 11/3/22- 4am 11/5/22- 8am, 10am, noon, 2pm 11/6/22- 8am, 10am, noon, 2pm 11/8/22- 4pm, 6pm, 8pm, 10pm 11/11/22- 4pm, 6pm, 8pm, 10pm 11/12/22- 6pm, 8pm, 10pm 11/13/22- 10pm 11/15/22- 2am, 4am 11/17/22- 8pm, 10pm 11/19/22- 4pm 11/27/22- 10pm 11/29/22- 4pm, 10pm Physician Orders dated 12/2/22 - Treatment to Sacral Wound (per Hospice recommendations) 1x/Day until healed 1. Cleanse with normal saline or wound cleanser and pat dry. 2. Apply AG Rope (supplied by Hospice) to wound bed. 3. Apply skin prep to peri-wound. 4. Dress with mepilex border. Discontinued 12/9/22. 12/9/22 - Type of Wound: Pressure Ulcer Origination: Upon admission Stage 2 at admission, now stage 4 Location: Sacrum Peri-Wound Description: Denuded (loss of the epidermal skin layer) Edges: Pink Length (Head to toe): 4.5 cm Width (left to right): 4.5 cm Depth: 2 cm Wound Bed: 25% slough from 10 - 1 o'clock, 75% exposed muscle fascia Slough: 25% Slough Color: Yellow green Slough Characteristic: Tacky Odor Present: Yes Drainage: Type: Purulent Amount: Moderate Progress: 14-day antibiotic course of cefprozil and flagyl completed on 11/30/22. Since last week's assessment the peri-wound has deteriorated with areas of denuded skin and what appears to be areas of further deep tissue injury around the 10 o'clock and 6 o'clock peri wound regions. The drainage has returned to being purulent and malodorous and has increased as well. Medihoney continues to debride slough well but overall, the wound and peri-wound are concerning for unresolved/returning infectious process at site. Pain related to treatment: Yes, Explain: Tender to touch Recommendations: Changes recommended: Restart oral antibiotics, may need maintenance antibiotics for duration of wound. Also concern for c-diff infection post antibiotic course, resident had loose mucousy stool present during dressing change today. Topical treatment remains appropriate. MD/GNP notified. Assessed by: RN J R104's eTAR for December 2022 shows: Entry Date: 12/2/22 - Treatment to Sacral Wound (per Hospice recommendations) 1x/Day until healed 1. Cleanse with normal saline or wound cleanser and pat dry. 2. Apply AG Rope (supplied by Hospice) to wound bed. 3. Apply skin prep to peri-wound. 4. Dress with mepilex border. The following date was left blank on eTAR for December 2022: 12/4/22 Physician orders dated 12/9/22 - Treatment to Sacral Wound: (per Hospice recommendations) 1x/Day until healed 1. Cleanse with normal saline or wound cleanser and pat dry. 2. Apply non-sting barrier spray to peri-wound 3. Apply medihoney to slough. 4. Gently pack AG Rope (supplied by Hospice) to wound bed. 5. Cover with sacral mepilex border or Hospice supplied foam dressing that is large enough to cover wound and peri wound. 12/14/22 - Type of Wound: Pressure Ulcer Origination: Upon Admission Stage of Pressure Injury: Initially a stage 2 upon admission, now presenting as stage 4 Location: Sacrum Peri- wound Description: Denuded Edges: Pink Length (Head to toe): 4.5 cm Width (left to right): 4.5 cm Depth: 2 cm Undermining: 2 cm from 9 o'clock to 3 o'clock Wound Bed: 90% exposed muscle fascia, 10% slough from 10 o'clock to 12 o'clock, with slough noted to be superficially attached to wound and not extending the depth of the wound Slough Color: Yellow- green Slough Characteristic: Tacky Odor Present: No Drainage: Type: Yellowish, greenish, reddish Amount: Moderate Progress: No odor noted today. Less slough noted. No s/sx (signs/symptoms) of infection noted. Pain related to treatment: Yes Explain: Tender to touch, tolerable per resident report, subsides immediately after touch as complete Recommendations: Continue treatment as ordered