**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 4 of 6 residents (R6, R1, R10, and R22) reviewed for accidents. * On 2/13/2025, a Certified Nursing Assistant (CNA) transferred R6 not according to R6’s plan of care and bumped R6’s leg. R6 required surgical intervention to R6’s right leg as a result of the CNA not following R6’s plan of care for transferring. * R1 had a fall on 4/11/2025 and no documentation was located that the facility did a thorough investigation. * R22 had a fall out of bed when staff did not follow R22’s plan of care. R22 was receiving cares with assist of one when R22 rolled out of bed. R22’s plan of care was to have assist of 2. * R10’s Wanderguard was incorrectly placed on R10’s wheelchair according to the manufacturer guidelines. R10’s Wanderguard was placed directly on metal which would inhibit the Wanderguard from functioning properly. Findings include: The facility policy titled “Safe Resident Handling and Transfers” reviewed/revised 8/5/2022 documents: “Policy: It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure, and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. Policy Explanation: All residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them. … Compliance Guidelines: … 10. Two staff members must be utilized when transferring residents with mechanical lift. 11. Staff will be educated on the use of safe handling/transfer practices to include use of mechanical lift devices upon hire. …13. Staff members are expected to maintain compliance with safe handling/transfer practices. Failure to maintain compliance may lead to disciplinary action up to and including termination of employment.14. Resident lifting and transferring will be performed according to the resident’s individual plan of care. …” 1.) R6 was admitted to the facility on [DATE] with diagnoses that include peripheral vascular disease, weakness, morbid/severe obesity, osteoarthritis, major depressive disorder-recurrent, dementia with psychotic disturbance, right and left artificial knee joints, and nonrheumatic aortic valve disorder. R6’s quarterly Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 13, indicating that R6 had intact cognition. The MDS assessed R6 as needing extensive assist with staff member for upper and lower body dressing, repositioning, and personal hygiene and assist of 2 staff members for toileting hygiene. The MDS also documents that R6 required a Hoyer lift for transfers with 2 staff members. R6 has an activated power of attorney (POA). On 7/29/2025 at 9:58 AM, Surveyor observed R6 lying in bed with the right leg elevated on a pillow. Surveyor noted a kerlix wrap to R6’s right extremity and asked R6 what the wrap was for. R6 replied that a couple months ago R6’s leg got bumped during a Hoyer transfer and ended up needing a surgery to removed “blood build up” in the area. Surveyor asked how the area was healing. R6 stated slowly but is doing well. Surveyor asked R6 how R6’s leg got bumped during the transfer. R6 replied was not sure if R6’s leg hit the Hoyer lift or R6’s bed but stated R6’s leg swung hard into something. R6 stated the aide transferred R6 using the Hoyer lift alone. R6 could not remember who the aide was that did the transfer alone. On 7/29/2025, Surveyor reviewed R6’s medical record and noted the following in R6’s care plan and progress notes: R6’s activities of daily living (ADLs) deficit . care plan was initiated on 12/18/2023 with the following intervention:-Transfer: Hoyer lift with 2 assist, X-large sling. On 2/12/2025 at 23:52 (11:52 PM) in the progress notes nursing documented: (R6) asked for pain cream for R6’s right leg. (R6's) right leg was noted to be swollen, warm to touch, red color with a blister and some drainage present. (R6) stated that R6’s leg was bumped when transferred from R6’s chair to R6’s bed. … Order received to send out for further evaluation. On 2/13/2025 at 2:40 AM in the progress notes nursing documented: received phone call from emergency department and was informed (R6) will be admitted to the hospital for further evaluation and treatment due to a hematoma to the right leg with changes and R6 being on Eliquis (blood thinner). Surveyor reviewed R6’s hospital admission paperwork and noted that R6 underwent surgical excision of hematoma with Jackson Pratt (JP, surgical drain used to remove fluid from a surgical site) drain placement on 2/17/2025. On 2/24/2025 at 16:30 (4:30 PM) in the progress notes nursing documented: (R6) returned from the hospital following a surgical procedure for evacuation of a large hematoma (clot) to the right lower extremity. Assessment revealed a large ecchymotic (bruising) area to the extending right foot with pitting edema present. 13 centimeter incision, well approximated with 14 visible sutures, JP drain present. … On 7/29/2025 at 3:03 PM, Surveyor requested to view facility self-reports for R6 since January 2025. On 7/30/2025, Surveyor was provided a facility self-report that was initially submitted to the State Agency on 2/12/2025 at 11:52 PM. The final investigation was submitted to the State Agency on 2/18/2025 at 9:27 PM. Surveyor reviewed the facility self-report. Surveyor reviewed a written statement from CNA-O documenting CNA-O worked with (R6) on 2/12/2025. CNA-O put R6 into bed about 6:30 PM. CNA-O documented that R6 did hit R6’s leg on the side of the bed railing but R6 did not complain during the remainder of CNA-O’s shift. Surveyor reviewed the interview between Nursing Home Administrator (NHA)-A and CNA-O which documented that CNA-O did admit to transferring R6 with a Hoyer lift with only 1 assist and did not ask other staff for assistance to transfer R6. Surveyor noted that CNA-O is no longer employed with the facility and was not able to be reached for an interview. On 7/31/2025 at 10:14 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-Q who stated R6 requested some pain cream for R6’s leg. LPN-Q stated when went to get cream and looked at area on R6’s leg it was red and swollen. LPN-Q stated R6 told LPN-Q that R6's leg got bumped during a transfer. LPN-Q stated that the Director of Nursing (DON) and physician were contacted, and an order was received to send R6 out to get evaluated. LPN-Q stated that CNA-O did not ask LPN-Q for help and LPN-Q stated the other aides on duty were not asked to assist CNA-O for putting R6 to bed with the Hoyer lift. LPN-Q stated LPN-Q was not made aware that R6 bumped R6’s leg during a transfer. LPN-Q stated that facility policy is to have 2 staff assist with all mechanical lifts. On 7/31/2025 at 10:18 AM, Surveyor shared concerns with NHA-A and [NAME] President of Success (VPS)-D regarding R6 requiring surgical intervention after CNA-O transferred R6 using a Hoyer lift with one staff member instead of two staff members as indicated on R6’s plan of care. No additional information was provided. 2.) The facility's policy and procedure titled, NSG (nursing) Accidents and Supervision, last reviewed 7/14/22 documents in part: “Policy: The resident environment will remain as free of accidents hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s). 2. Evaluating and analyzing hazard(s) and risk(s)… 2. Evaluation and Analysis- the process of examining data to identify specific hazards and risks and to develop targeted interventions to reduce the potential for accidents. Interdisciplinary involvement is a critical component of this process. a. Analysis may include, for example, considering the severity of hazards, the immediacy of risk, and trends such as time of day, location, etc. b. Both the facility-centered and resident-directed approaches include evaluating hazard and accident risk data, which includes prior accidents/incidents, analyzing potential causes for each hazard and accident risk, and identifying or developing interventions based on the severity of the hazards and immediacy of risk. c. Evaluations also look at trends such as time of day, location, etc…” R1 was readmitted to the facility on [DATE] with pertinent diagnoses that include chronic obstructive pulmonary disease (lungs become inflamed, damaged and narrowed), lymphedema (a condition characterized by swelling that occurs when the lymphatic system fails to properly drain fluid from the tissues), restless legs syndrome (a condition that causes a very strong urge to move the legs. The urge to move usually is caused by an uncomfortable feeling in the legs. It typically happens in the evening or at night when sitting or lying down), and insomnia (common sleep disorder that can make it hard to fall asleep or stay asleep).R1's Quarterly Minimum Data Set (MDS) with an assessment reference date of 6/23/25, documents a Brief Interview for Mental Status (BIMS) score of 14, indicating that R1 is cognitively intact. The MDS documents R1 is understood and understands others. R1’s Patient Depression Questionnaire (PHQ-9) score was 00 indicating no depressive symptoms. R1 exhibited no behaviors during the look back period of the MDS assessment. R1 is documented to have had one fall since admission or prior assessment. R1’s care plan for “Resident is at risk for falls r/t (related to) Deconditioning/weakness , Disease process RESTLESS LEG SYNDROME, History of falls, Pain, use of psychotropic medications” revised on 5/14/25, has the following interventions: “4/11/25 IDT (interdisciplinary team) review fall- DOR (director of rehabilitation) provided R1 with reeducation regarding asking for assistance, remind resident to ask for assistance. Date Initiated: 4/11/2025 •Anticipate and meet the Resident's needs. Encourage the Resident to always call for assistance.Date Initiated: 9/26/2022 •Education the Resident on fall prevention measures. Assure Resident that calling for help is not a bother.Date Initiated:9/26/2022 •Ensure that the Resident is wearing appropriate footwear (specify)Date Initiated:9/26/2022 •Follow Therapy recommendations for transfers, mobility and ambulationDate Initiated:9/26/2022 •Place bed at lowest position.Date Initiated:9/26/2022 •Place call light or communication device within reach. Answer call light promptly - alwaysDate Initiated:9/26/2022 •PT (Physical Therapy) to eval (evaluate) and treat. Seat cushion to be assessed. Revision on: 5/14/2025 •Resident wheelchair needs to be halfway in the bathroom to transfer to the toilet from the wheelchair with the chair locked. Date Initiated: 10/6/2024 •Review information on past falls and attempt to determine cause of falls for prevention and to minimize injuries.”Date Initiated: 6/9/2024 R1’s care plan for “at risk for falls due to: arthritis, history of falls, impaired balance/poor coordination” revised on 9/30/2024, has the following interventions: “•Have commonly used articles within easy reach.Date Initiated: 9/30/2024 •Medication regimen review.Date Initiated: 9/30/2024 •Medications as ordered.Date Initiated: 9/30/2024 •Provide assist to transfer and ambulate as needed.Date Initiated: 9/30/2024 •Reinforce need to call for assistance.Date Initiated: 9/30/2024 •Reinforce w/c (wheelchair) safety as needed such as locking brakes.Date Initiated: 9/30/2024 •Reminders to resident to reposition while on the toilet to help prevent numbness in legs while on the toilet.Date Initiated: 12/23/2024 •Report development of pain, bruises, change in mental status, ADL (activities of daily living) function, appetite, or neurological status post fall.Date Initiated: 9/30/2024 •Therapy eval and treat as ordered.”Date Initiated: 9/30/2024 On 07/29/2025, at 8:58 AM, Surveyor interviewed R1 and was told that R1 had one fall, R1 stated they fell flat down. R1’s progress note dated 4/11/2025, written at 04:45 am, documents: “Resident was sitting on her butt with both legs stretched out in front and both hands by her side palms down on the ground. When asked what happened she stated that she was trying to go to the bathroom and her legs gave out. Resident was helped off the floor and back into her chair her ROM (range of motion) was WNL (within normal limits) VSS (vital signs stable), and neuro (neurological) checks have stared. All personnel have been notified per facility protocol No new orders at this time just continue wit POC (plan of care). Her immitted intervention was education her on planting her feet firmly on the ground and standing momentarily before she began to walk”. R1’s “Un-witnessed Fall” assessment dated [DATE] was reviewed. The assessment documents “no injuries at time of incident” and “no injuries observed post incident”. “Predisposing Environmental Factors” identified as “clutter”. “Predisposing Physiological Factors” identified as “sedated”. “Predisposing Situation Factors” identified as “ambulating with assist”. For “Statements” it is documented “no statements found”. On 07/30/2025, at 3:17 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B regarding additional documentation on witness statements and investigation post fall for R1. Surveyor was told they will look to see if there's more information related to the fall. On 07/31/2025, at 3:42 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-Q, who completed the “Un-witnessed Fall” assessment on 4/11/25, and asked what is done to investigate after a fall. LPN-Q stated the nurse should get statements from people working with resident. Surveyor asked do you document when resident was last seen or toileted. LPN-Q stated that is asked in one of the assessment questions in the computer. Surveyor asked why LPN-Q had checked clutter as a predisposing environmental factor and was told it was probably on accident to be honest. Surveyor asked why LPN-Q checked ambulating with assistance for predisposing situation factors and was told it means R1 was using their walker. LPN-Q explained that the “Un-witnessed Fall” assessment is what nurses fill out, it is on the computer. Surveyor asked if there is a fall packet with additional information to complete and LPN-Q stated they were pretty sure there is a fall packet but may have been noncompliant and not completed it. On 08/04/2025, at 9:47 AM, Surveyor interviewed LPN-E regarding what is documented or completed post fall and was told in the computer system is the risk management documentation. The post fall assessment is all done in the computer, there is no fall packet to complete. On 08/04/2025, at 9:50 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-X regarding post fall sharing of information that is observed. Per CNA-X there is a form to complete that asks when last seen, toileted, where was seen, if the fall was witnessed, etc. Gave Surveyor a copy of document titled “Witness Statement” that has the following questions: name of resident, name of witness, date of event, location of event, time resident last seen, time resident last toileted, was resident in w/c (wheelchair), recliner, bed or other, was resident using walker, was resident incontinent, what was resident’s footwear, is there a change of condition noted with resident, and general statement of knowledge of the event. Surveyor noted neither the “Witness Statement” document or the information it asks for was located for R1’s 4/11/25 fall. On 08/04/2025, at 10:00 AM, Surveyor interviewed LPN-K regarding what is documented or completed post fall and was told in the computer system you document the fall under risk management. There is a section for statements, when the fall is witnessed this is completed. There is no packet or place for putting statements about when last saw or toileted the resident in the computer. LPN-K is unaware of any witness paper form to complete. On 08/04/2025, at 10:45 AM, Surveyor interviewed DON-B regarding how to document post fall and was told that vitals and neuro checks are done in the computer, the computer generates what to complete. Staff do witness statements. The medical doctor and Power of Attorney are updated, the resident is put on the 24-hour board for monitoring. On 08/04/2025, at 11:44 AM, Surveyor relayed concern regarding lack of documentation of post fall assessment for R1’s 4/11/25 fall to NHA-A and 2 consultants. No additional information regarding R1’s post fall assessment was provided. 3.) The facility policy titled “Resident Alarms”, with implementation date of 7/21/2022 and revision date of 9/9/2022 documents: “Policy: It is the policy of this facility to utilize resident alarms only in accordance with the resident’s needs, goals, and preferences, so the resident will be able to attain or maintain his or her highest practicable level of physical, mental, and psychosocial well-being. … Definition: An “alarm” is any physical or electronic device that monitors resident movement and alerts the staff, by either audible or inaudible means, when movement is detected. … … Types of alarms include: …e. wander/elopement alarms – includes devices such as bracelets, pins/buttons worn on the resident’s clothing, sensors in shoes, or building/unit exit sensors worn/attached to the resident that alert the staff when the resident nears or exists an area of the building. This includes devices that may be attached to the resident’s assistive device or other belongings. … The facility shall establish and utilize a systematic approach for the safe and appropriate use of resident alarms that includes risks vs benefits consideration… a. Interventions shall be communicated to all relevant staff, including frequency/time frames for alarm use b. When alarms are utilized, additional measures should be taken, including but not limited to: i. Verifying alarms are used in accordance with the resident’s care plan ii. Verifying alarms are working properly iii. Observing for adverse consequences associated with the use of the alarms, including psychosocial concerns. …” R10 was admitted to the facility on [DATE] with diagnoses that include Alzheimer's disease, dementia without behavioral disturbance, and other recurrent depressive disorders. R10’s significant change Minimum Data Set (MDS) completed 1/3/25 documents R10’s Brief Interview for Mental Status (BIMS) score as 10, indicating moderate cognitive impairment. R10’s MDS documents no mood or behavior symptoms, and a wander/elopement alarm is used daily. R10’s MDS documents R10 uses a wheelchair independently and does not ambulate, and R10 requires maximal assistance for dressing, bed mobility, and transfers. The facility documents the cognitive loss/dementia Care Area Assessment (CAA) was triggered for R10 due to … “BIMS score of 10 … contributing factors include … dementia, change in mental status, and short term/long term memory loss … cognitive loss already care planned…” R10’s most recent quarterly MDS completed 7/4/25 documents R10’s BIMS score as 7, indicating severe cognitive impairment. R10’s MDS documents no mood or behavior symptoms, and a wander/elopement alarm is used daily. R10’s MDS documents R10 uses a wheelchair independently and does not ambulate, R10 requires maximal assistance with lower body dressing, and R10 requires moderate assistance for upper body dressing, bed mobility, and transfers. The most recent wandering risk assessment for R10 completed on 6/30/25 documents a score of 19.0, indicating R10 has a high risk for wandering. R10’s care plan documents “… resident has potential for elopement due to … Alzheimer’s disease … dementia, and other recurrent depressive disorder” with the following interventions: … -wander guard placement had been moved to wheelchair due to [history] of swelling of ankles/wrists and rashes to skin. Resident does not ambulate without use of wheelchair…, initiated 4/7/25 and revised 4/9/25 … -at moderate risk for elopement, [history] of following family outside. Redirect and provide distraction … and remind family to notify staff when leaving, initiated 11/24/24 and revised 4/7/25 … -check placement of wander guard on wheelchair and functioning per manufacturer recommendations and MD orders, initiated 4/7/25 and revised 4/14/25 … R10 has the following orders in place: -check wander alert bracelet function and expiration date daily every shift for elopement risk, active 4/9/2025 -check wander alert bracelet placement to wheelchair every shift for elopement risk, active 8/21/24 -okay to place wander alert bracelet for safety/elopement risk to wheelchair…, active 8/21/24 Surveyor reviewed a progress note dated 4/27/25 that documented R10 became anxious … tried leaving the facility multiple times … resident was not easily redirected. Wander guard in place . On 7/29/25, at 8:48 am, Surveyor observed R10 sitting in R10’s wheelchair in the hallway, wander guard observed on a metal bar behind the wheelchair seat on the back of the wheelchair. On 7/30/25, at 7:46 am, Surveyor observed R10 sitting in R10’s wheelchair in the hallway, wander guard observed on a metal bar behind the wheelchair seat on the back of the wheelchair. On 7/30/25, at 12:20 pm, Surveyor reviewed “Code Alert” wander management user essentials manual from RF Technologies, Inc. dated 2014. On page 5 of the manual, a highlighted “note” documents: “to monitor a resident in a wheelchair, attach the transmitter to the seat or the back of the chair, as the metal on the chair can interfere with the transmitter’s signal”. On 7/30/25, at 1:11 pm, Surveyor interviewed Director of Nursing (DON)-B regarding the use of wander guards. DON-B stated a nurse would do an assessment to determine potential elopement and then place a wander guard on the resident’s ankle or wheelchair. DON-B stated nursing staff tests the wander guard alarm system with a machine weekly and takes any residents with wander guards near the alarm to make sure the alarm is working. DON-B stated DON-B was not aware the wander guard should not be placed on a metal bar of a wheelchair. On 7/31/25, at 9:45 am, Surveyor spoke with Tech Support Code Alert (TSCA)-Z regarding wander guard placement for a resident in a wheelchair. TSCA-Z stated the transmitter could be wrapped around the handle of the wheelchair if needed. When Surveyor asked if the transmitter could be placed on a metal bar on a wheelchair, TSCA-Z stated to follow the manual instructions. On 7/30/25, at 3:00 pm, Surveyor shared the above concern with Nursing Home Administrator (NHA)-A and DON-B due to risk that R10’s attempts at elopement may go undetected. NHA-A and DON-B understood the concern. No additional information was provided. 4.) R22's diagnoses includes hypertension (high blood pressure), aphasia (language disorder that affects a person's ability to communicate) following cerebral infarction (condition where blood flow to the brain is disrupted leading to the death of brain tissue, also known as ischemic stroke), morbid obesity, seizure, and unspecified psychosis (mental health condition characterized by a loss of contact with reality). R22's ADL (activities daily living) self-care deficit care plan initiated 10/12/24 & revised 6/10/25 includes an intervention of BED MOBILITY: Dependent extensive assist of 2, does not ambulate. Initiated 10/12/24 & revised 5/9/25. R22's at risk for falls care plan initiated 10/12/24 & revised 4/28/25 documents the following interventions: *Encourage to transfer and change positions slowly. Initiated 12/31/24. *Have commonly used articles within easy reach. Initiated 12/31/24. *Medications as ordered. Initiated 12/31/24. *Reenforce need to call for assistance. Initiated 12/31/24. *Reenforce w/c (wheelchair) safety as needed such as locking brakes. Initiated 12/31/24. *Report development of pain, bruises, change in mental status, ADL (activities daily living) function, appetite, or neurological status post fall. Initiated 12/31/24. Therapy eval (evaluation) and treat as ordered. Initiated 12/31/24. R22's significant change MDS (minimum data set) with an assessment reference date of 6/23/25 assess R22 as having short & long term memory problem and documents that R22 has severely impaired cognitive skills for daily decision making. R22 is assessed as being dependent for toileting hygiene & chair/bed to chair transfer and substantial/maximal assistance for roll left and right. R22 has an indwelling urinary catheter and is always incontinent of bowel. R22 is assessed as not having any falls since prior assessment. R22's nurses note dated 6/24/25 written by Licensed Practical Nurse (LPN)-K documents: At approx. (approximately) 1040 am this morning Writer had resident positioned on her side in bed performing wound care to coccyx/sacrum. Resident was on her side near the center of the bed. After writer completed washing buttocks/sacral area and dried, skin prepped. During opening of the dressing prepping dressing to place resident started reaching toward window calling out Hey rolled toward side of air mattress. As writer tried to grab at resident to prevent rolling. Resident continued to roll face down and started sliding off side of air mattress and onto the fall mat on the floorHospice RN (Registered Nurse) and this writer further resident while in bed with x2 (times two) abrasions noted. Abrasions with some redness noted to left scapula and mid left side of back. Offers no s/sx (signs/symptoms) of pain or discomfort. Sites cleansed and left open to air. VSS (vital signs stable) stable T. (temperature) 97.4- P (pulse). 93- Resp (Respirations). 18- B/P (blood pressure) 122/70- POX% (pulse oximeter percentage) on room air 95. Respirations are even and unlabored. POA (power of attorney) contact called with message left to call back for update. Sister Emergency contact 1 [Name] updated and aware. [Medical Group Name] called APNP (Advanced Practice Nurse Prescriber) not available at the time. on call service to send message for her to call facility for update. NNOR from RN hospice nurse r/t incident. Will visit again tomorrow. Instructed to call for any changes or concerns. R22's Incident report dated 6/24/25 under incident description for nursing description documents: Writer had resident positioned on her side in bed performing wound care to coccyx/sacrum. Resident was on her side near the center of the bed. After writer completed washing buttocks/sacral area and dried, skin prepped. During opening of the dressing prepping dressing to place resident started reaching toward window calling out Hey rolled toward side of air mattress. As writer tried to grab at resident to prevent rolling. Resident continued to roll face down and started sliding off side of air mattress and onto the fall mat on the floor. Under action taken for description documents writer immediately called for help to speech therapist out in hall to assist while writer unlocked the bed to pull away from resident. Checked injury, no visible injury noted noted with skin intact. Range of motion at baseline and WNL (within normal limits) to all extremities. Speech therapy assisted placement of sling to hoyer resident off floor to get into bed. [Name] RN with [Name] Hospice arrive during this time and assisted as well. Resident then hoyered off floor back to bed to further assess for any injury and take vitals. After R22's fall on 6/24/25, R22's ADL self care deficit care plan was revised with an intervention Resident cares/respositioning/wound care: Dependent extensive assist of 2 does not ambulate. Initiated 6/26/25. Surveyor noted R22's care plan prior to R22's fall on 6/24/25 already had an intervention for bed mobility of dependent extensive assist of 2. On 7/31/25, at 9:59 a.m., Surveyor interviewed LPN-K regarding R22's fall on 6/24/25. LPN-K explained it was R22's treatment day. She pulled R22 all the way over literally in the exact center of the bed, a little past center, and had the treatment supplies set up. LPN-K informed Surveyor she went to apply medi honey noticed it wasn't cut appropriately but had an extra one. LPN-K indicated she pulled R22 a little more, covered R22 with a sheet, opened the medi honey and when she was cutting the medi honey R22 yelled hey, reached forward and went flat on R22's chest. LPN-K explained R22 only had a gown on, she tried pulling on R22's gown and tried to grab R22's shoulder but R22 slid on floor mat. LPN-K informed Surveyor she yelled for the speech therapist who was out in the hall, checked for injuries, didn't see any injuries and reassessed R22 every half hour. Surveyor asked LPN-K prior when doing R22's wound treatments did you do the treatments by yourself. LPN-K replied I never had any problem. Surveyor informed LPN-K R22's ADL care plan has an intervention which documents two people for bed mobility and this intervention was implemented prior to R22's fall. On 7/31/25, at 10:50 a.m., Surveyor asked Interim Director of Nursing (DON)-B if staff should follow a resident's plan of care. Interim DON-B replied yes. Surveyor informed Interim DON-B R22's ADL self care deficit care plan had an intervention prior to R22 fall on 6/24/25 to use two for bed mobility. Surveyor informed Interim DON-B LPN-K did not follow R22's plan of care. No additional information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility did not ensure that residents with pressure injuries received the necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing for 2 of 2 residents (R5 and R7) reviewed. * R5, who was assessed to be at risk for pressure injuries, developed a stage 3 ischium pressure injury identified on 11/21/24. R5's care plan was not updated with new offloading interventions after the development of the ischium pressure injury. On 11/21/24, Wound Doctor (WD)-H recommended to upgrade offloading chair cushion. This was not completed by the facility. WD-H's treatment orders were not initiated until 11/26/24. During the survey process, Surveyor observed R5 to not be repositioned at least every 2 hours and R5 was not wearing heel boots at all times per R5's plan of care. * R7 was admitted with a Deep Tissue Injury to the left heel. Registered Nurse (RN)-D had inaccurate staging of the pressure injury staging it a Stage I. The treatment to the left heel was not initiated until 10/18/2024, two days after R7's admission. No assessments were documented in R7's medical record after 11/5/2024 showing the area had healed. Observation on 11/26/2024 showed R7 had a dark area to the left heel that was not documented. Findings include: The facility's policy Pressure Injuries implemented 8/2/21 and last revised on 7/20/22 documents: Policy: .This center will complete a comprehensive assessment to identify risk factors for the development of pressure injuries and put in place measure intended to achieve the goal of prevention of pressure injuries in our Residents. For those Residents admitted with, or who subsequently developed a pressure injury or impaired skin integrity, they will receive care, treatment, and services that seek to promote healing, prevent infection, and prevent further development of pressure injuries/impaired skin integrity. Examples of impaired skin integrity include, but not limited to, pressure injuries, venous (stasis) ulcers, arterial (ischemic) ulcers, diabetic (neuropathic) ulcers, surgical wounds, skin tears, and rashes. The staging of pressure injury is consistent with recommendation of National Pressure Injury Advisory Panel (NPIAP) and RAI Manual, Section M. Policy Explanation and Compliance Guideline: b. Assess current wounds at least every 7 days, or more frequently as needed. If a wound fails to show some evidence of progress towards healing within 2-4 weeks, the area and the Resident's overall clinical condition should be reassessed. Re-evaluation of the treatment plan includes determining whether to continue or modify the current interventions. Results may vary depending on the Resident's overall condition and interventions/treatments used. The complexity of the Resident's condition may limit responsiveness to treatment or tolerance for certain treatment modalities. The clinicians, if deciding to retain the current regimen, should document the rational for continuing the present treatment to explain why some, or all, of the plan's interventions remain relevant despite little or no apparent healing. Care Planning: A comprehensive skin integrity care plan is based on Resident history, review of skin assessment, braden scale scoring, nutritional assessment, Resident and family interviews, and staff observations. Consider the areas of risk, as well as overall risk assessment score braden scale. Communicate identified risk factors and interventions to direct care staff. 2. Develop interventions based on individual risk factors including, but not limited to, weight, presence of edema, overall health status/comorbidities, use of medical devices, presence of acute infection, end of life/hospice, Resident preferences/choices, or medications that may impact healing. a. In the context of the Resident's choices, clinical condition, and physician input, the Resident's care plan should establish relevant goals and approaches to stabilize or improve co-morbidities, such as attempts to minimize clinically significant blood sugar fluctuations, and other interventions aimed at limiting the effects of risk factors associated with pressure injuries. Alternatively, center staff and practitioners, should document clinically valid reasons why such interventions were not appropriate or feasible. For a Resident to exercise his/her right appropriately to make informed choices about care and treatment, to decline treatment, the center and the Resident (or if applicable, the Resident representative) must discuss the Resident's condition, treatment options, expected outcomes, and consequences of declining treatment or interventions. Centers should document this discussion in the Risk vs. Benefit UDA in the electronic medical record. The care plan should be updated to reflect the Resident's choice and what interventions will be in place to minimize risk to the Resident. 1.) R5 was admitted to the facility on [DATE] and has diagnoses that include Dementia with Mood Disturbance, Adult Failure to Thrive, Atherosclerotic Heart Disease of Native Coronary Artery, Severe Protein-Calorie Malnutrition, Unspecified Psychosis, and Anxiety Disorder. R5 was admitted into Hospice on 5/5/2023 with a diagnosis of severe protein calorie malnutrition and was discharged from hospice on 6/17/24. R5's Quarterly Minimum Data Set (MDS) dated [DATE], documents that R5 has severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of 0. The MDS documents that the facility assessed R5 as needing total assistance with activities of daily living (ADLs) with one staff member. R5 has no impairment to her upper extremities and impairment to her bilateral lower extremities and uses a wheelchair. R5 is dependent for assistance with showers, upper and lower body dressing, and transfers. R5 requires substantial/maximum assistance for mobility. The Quarterly MDS also documents that R5 is always incontinent of urine and bowel and wears an adult brief. R5 needs assistance with meal set up and there are no concerns with loss of liquids, holding food, choking, or swallowing difficulties when eating. R5's MDS documents R5 is at risk for developing a pressure injury. At the time of assessment, R5 had 1 stage 1 pressure injury that was unhealed. R5's Pressure Ulcer Care Area Assessment (CAA) completed 7/8/24 documents R5 has an existing pressure ulcer/injury. Extrinsic risk factors include pressure requiring special mattress or seat cushion to reduce or relieve pressure, maceration due to moisture associated skin damage. Intrinsic risk factors include altered mental status, cognitive loss, incontinence, poor nutrition, antipsychotics and antidepressants, diagnoses of chronic or end-stage renal disease, malnutrition, other dementia, and depression. R5's CAA summary documents, R5 is at risk for developing pressure ulcer due to needing of extensive assistance with bed mobility and is frequent incontinent of bladder and bowel. Goal is to ensure R5 maintains current clean and intact skin free of pressure ulcer. Will proceed plan of care. On 8/13/24 and 11/21/24, R5's skin assessments document a score of 14.0, indicating R5 is at moderate risk for pressure injuries. R5's Bedside [NAME] Report as of 11/26/24, instructs staff to avoid positioning R5 on left side, monitoring/reminding/assistance to turn/reposition at least every 2 hours, more often as needed or requested, float heels when able, requires low air mattress on bed and cushion to chair and treatments as ordered. R5's open areas with start date: Stage 3 pressure wound on left ischium-11/21/24 1st right toe-arterial wound-11/14/24 2nd right toe-unstageable due to necrosis-11/14/24 Right inner ankle-6/11/24-healed Inner left thigh-10/3/24-healed Left outer ankle-11/5/24-healed Below left pinky toe-11/5/24-healed R5's comprehensive care plan documents: -Stage 3 pressure ulcer to left ischium-initiated on 11/25/24 Original focused problem was initiated on 10/30/24 for an actual open area to left inner peri area due to impaired mobility, incontinence, nutritional deficit Interventions initiated 10/30/24 with no revisions -Administer analgesia per MD (medical doctor) orders -Administer treatment per MD orders -Diet and supplements per MD orders -Encourage and assist as needed to turn and reposition; use assistive devices as needed -Report evidence of infection such as purulent drainage, swelling, localized heat, increased pain. Notify MD PRN (as needed). -Special mattress/cushion on bed/wheelchair -Toileting program as indicated -R5 has unstageable pressure ulcer to the right 2nd hammer toe-initiated 11/25/24 Interventions initiated: -Administer treatments as ordered and monitor for effectiveness -Avoid positioning R5 on left side-revised 11/25/24 -Follow facility policies/protocols for the prevention/treatment of skin breakdown. -If R5 refuses treatment, confer with R5, team and family to determine why and try alternative methods to gain compliance. Document alternative methods. -Monitor nutritional status. Serve diet as ordered, monitor intake and record. -Monitor/document/report PRN any changes in skin status: appearance, color, wound healing, signs/symptoms of infection, wound size (length x width x depth), stage. -R5 needs monitoring/reminding/assistance to turn/reposition at least every 2 hours, more often as needed or requested. -R5 requires low air loss mattress on bed and cushion to wheelchair. -Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue. Surveyor noted that the interventions for R5's open areas were initiated on the first day of the survey process on 11/25/24 and no new interventions have been implemented at the time the pressure injuries were discovered. The open areas on R5's 2nd toe were identified on 11/14/24, but a care plan was not initiated until 11/25/24. R5's stage 3 pressure wound on ischium was identified on 11/21/24, but a care plan was not initiated until 11/25/24. R5 was evaluated and treated by wound doctor (WD)-H on 11/21/24. WD-H documents: 2. Stage 3 pressure wound of the left ischium, 2 x 1.5 x 0.1. Moderate Sero-sanguinous, 70% devitalized necrotic tissue, 20% slough, 10% granulation. Leptospermum honey apply once daily with foam silicone border once daily. Recommendations: cleanse with wound cleanser at time of dressing change. Limit sitting to 60 minutes. Upgrade offloading chair cushion. Identified 11/21/24 3. Unstageable pressure (due to necrosis) of the right 2nd hammer toe. 1.0 x 0.8 x not measurable. Depth is unmeasurable due to presence of nonviable tissue and necrosis. 100% devitalized necrotic tissue. Betadine apply once daily. Recommendations: Pressure Off-loading Boot when in bed, recliner. Identified 11/14/24 R5's current physician orders for wound care were initiated on 11/25/24 with a start date of 11/26/24 and document: -Cleanse left ischium wound with wound cleanser, apply medi honey to the wound bed and cover with a border gauze daily every day shift for pressure wound. -Cleanse right 2nd toe, hammer toe with wound cleanser. Apply betadine to calloused area daily every day for pressure wound. Both physician orders were added to the Treatment Administration Record on 11/26/24 at 6:00 AM. Surveyor noted that WD-H initiated the physician orders on 11/21/24, however, the facility did not implement both wound treatment orders until 11/25/24. R5's physician orders also document that R5 should be wearing off-loading bilateral boots at all times every shift for pressure relief effective 11/1/24. On 11/25/24 at 10:15 AM, Surveyor observed R5 up in wheelchair with a cushion in the chair. Surveyor observed an air mattress on the bed. Surveyor observed 2 heel boots on top of the dresser. On 11/25/24 at 11:22 AM, Surveyor observed R5 in the same position in wheelchair and not wearing heel boots. On 11/25/24 at 12:55 PM, Surveyor observed R5 in wheelchair eating lunch and not wearing heel boots. On 11/25/24 at 2:39 PM, Surveyor observed R5 in bed on R5's left side, facing window. R5 has heel boots on. Surveyor noted that R5 had not been repositioned to relief pressure on R5's left ischium pressure injury as documented in R5's pressure injury plan of care. Surveyor noted that R5 did not have her heel boots on to relief pressure per R5's pressure injury plan of care. On 11/26/24 at 7:35 AM, Surveyor observed R5's treatments being completed by Director of Nursing (DON)-B. Surveyor observed medi-honey applied with border gauze placed on the stage 3 ischium pressure wound. DON-B applied skin prep to the 1st and 2nd right toes. Surveyor noted that DON-B completed the wrong treatment to the 2nd hammer toe. On 11/26/24 at 9:10 AM, Surveyor observed R5 in wheelchair, eating breakfast. R5 did not have heel boots on. On 11/26/24 at 10:28 AM, Surveyor observed R5 in wheelchair, no heel boots on, in common area in front of the television. On 11/26/24 at 11:15 AM, Surveyor observed R5 in wheelchair, no heel boots on, in common area in front of the television. On 11/26/24 at 12:10 PM, Surveyor observed R5 in wheelchair, no heel boots on, in common area in front of the television. On 11/26/24 at 12:56 PM, Surveyor observed R5 in wheelchair, no heel boots on, eating lunch in the dining room. Surveyor has not observed R5 to be repositioned at least every 2 hours during the survey process. On 11/26/24 at 9:30 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-F. CNA-F stated that R5 wears heel boots when in bed. CNA-F knows this because I usually take the heel boots off in the morning. On 11/26/24 at 10:20 AM, Surveyor interviewed WD-H. WD-H explained that the left inner thigh area that is healed started as a scratch. WD-H stated that the left ischium is a stage 3 pressure ulcer, and that bone can be felt. WD-H stated the left inner thigh and the left ischium are considered 2 different areas. WD-H explained that WD-H's company policy does not allow for staff to leave the facility until all documentation including orders are completed and communicated with the facility. WD-H usually rounds with DON-B but did not on 11/21/24. However, WD-H cannot remember who WD-H rounded with on that date. WD-H confirmed there is a problem in the treatment of a pressure injury when there is a delay of treatment. On 11/26/24 at 10:38 AM, DON-B informed Surveyor that Licensed Practical Nurse (LPN)-C was the LPN that rounded with WD-H. Surveyor interviewed LPN-C. LPN-C explained it was LPN-C's first time rounding with WD-H. LPN-C stated that WD-H enters the information into WD-H's computer. WD-H assesses the wound and completes the treatment. LPN-C stated that the particular bandage WD-H wanted for R5 was on order at this time. LPN-C stated LPN-C did not take any verbal orders from WD-H because it was LPN-C's first time rounding. On 11/26/24 at 11:37 AM, Surveyor interviewed DON-B regarding R5's current open wounds. Surveyor and DON-B reviewed R5's comprehensive care plan addressing R5's open areas. Surveyor shared the concern that R5's care plan was revised on 11/25/24 and has no new interventions with the development of the 3 open areas. DON-B agreed R5's care plan should have been updated with new person-centered interventions when first identified. Surveyor shared that a documented root cause analysis of the open areas is not in R5's EMR. DON-B stated she is not sure completely how R5 developed the open areas. DON-B stated that WD-H does not verbally give treatment orders. The facility gets a print out on the rounding. DON-B confirmed DON-B did not do the rounding with WD-H on 11/21/24. DON-B stated the floor nurse does not know how to put in the treatment orders and that DON-B is the only person who puts in new treatment orders. DON-B stated that is the disconnect. DON-B agreed that R5's treatment orders from 11/21/24 did not get processed by the facility and DON-B realized it when Surveyor brought it to the facility's attention. Surveyor discussed with DON-B that a surveyor from the team observed DON-B complete the wrong treatment on the second hammer toe in which DON-B applied skin prep instead of betadine. DON-B confirmed DON-B put the wrong treatment on R5's second hammer toe pressure injury and forgot the treatment order had been switched. DON-B informed Surveyor that DON-B believes that the left inner thigh wound identified on 10/30/24 started as a scratch and is now currently healed. DON-B believes the left inner thigh open area is the same area of the stage 3 left ischium pressure area. Surveyor informed DON-B that no new interventions have been put in place once the stage 3 pressure wound was identified on the left ischium. Surveyor informed DON-B that Surveyor has observed R5 to not have bilateral heel boots on at all times per R5's physician orders during the survey. DON-B stated that R5 sometimes doesn't keep the boots on, but agreed this is not addressed in R5's care plan and that R5's care plan did not include interventions on how staff can reapproach R5 with encouragement to wear the bilateral heel boots. Surveyor informed DON-B that Surveyor has had observations of R5 not being repositioned during the survey process. Surveyor shared with DON-B that WD-H requested an upgrade to R5's off loading chair cushion. DON-B informed Surveyor that R5 has not received a new off loading chair cushion and has not followed up with therapy regarding R5 getting a new chair cushion. DON-B stated it was discussed that R5 needed a spare chair cushion because R5 soils the chair cushion. DON-B was unaware that WD-H recommended a new upgrade off loading chair cushion. On 11/26/24 at 1:30 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A that R5 has had new open areas identified with no root cause analysis. Surveyor informed NHA-A that R5's person-centered care plan focus for the new areas on the toes and ischium was not initiated until 11/25/24 and contained no new interventions. Surveyor shared with NHA-A that R5 has not had R5's bilateral heel boots on at all times and has not been repositioned every 2 hours during the survey process per physician orders and R5's care plan. Surveyor shared that WD-H recommended a new off loading chair cushion appropriate for R5's stage 3 ischium which has not been implemented by the facility. NHA-A informed Surveyor that NHA-A understood the concerns and had no further information at this time. On 11/26/24 at 1:55 PM, Surveyor spoke with Rehabilitation Director (RD)-I regarding R5's chair cushion. RD-I stated that R5 is not on current caseload. RD-I was asked to get a new cushion because R5 had soiled R5's current chair cushion. RD-I informed Surveyor that R5 currently has a Stage 2 Comfort Support Pro 16x16 wheelchair cushion. RD-I confirmed RD-I did not receive a referral for an upgrade for an off loading cushion for R5 and was not aware that WD-H had recommended the upgrade. RD-I stated that R5's current cushion is not appropriate for a Stage 3 pressure wound on the ischium. No additional information was provided as to why the facility did not ensure that R5 received the necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing.2.) R7 was admitted to the facility on [DATE] with diagnoses of open wound to the left lower leg, morbid obesity, diabetes, lymphedema, unstageable pressure ulcer of the left heel, cellulitis of the left lower leg, and anxiety. R7's admission Minimum Data Set (MDS) assessment dated [DATE] documented R7 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 and impairment to the lower extremity. The assessment documented R7 had a Stage I pressure injury, one venous or arterial ulcer, and a surgical wound. The Pressure Ulcer/Injury Care Area Assessment (CAA) that is associated with this MDS assessment documented R7 had a potential for pressure ulcers. The CAA did not document where the current Stage I pressure injury was located or the individualized characteristics of R7 to help develop a Care Plan to address R7's needs. R7's discharge paperwork from the long-term acute care facility dated 10/16/2024 had orders to treat the left heel pressure injury with skin prep daily. Wound notes were included in the discharge paperwork. The wound note dated 9/23/2024 documented the left heel pressure injury developed on 8/26/2024 and was a Deep Tissue Injury (DTI) that measured 3.2 cm x 3.7 cm with no visible necrotic tissue and a distinct outline of the wound. The wound was being treated at that time with betadine and open to the air daily. On 10/16/2024 on the admission Evaluation form, nursing documented R7 had a pressure injury to the left heel that measured 6 cm x 3 cm. No staging or description of the pressure injury were documented on the form. On 10/16/2024 at 8:46 PM, in the progress notes, a Registered Nurse (RN) documented R7 had a DTI to the heel that was not open. R7's Skin Integrity Care Plan for the DTI to the left heel was initiated on 10/16/2024. On 10/18/2024, an order was initiated to treat the deep tissue injury to the left heel: wash area with soap and water, pat dry, apply skin prep to area daily and as needed. Surveyor noted the treatment order was not started until two days after R7 was admitted to the facility. On 10/22/2024 at 9:49 AM, in the progress notes, the Registered Dietician documented R7 had a DTI to the left heel and recommended protein liquid 30 ml twice daily for wound healing. Surveyor noted that the order was initiated. On 10/23/2024 on the Skin Review-Weekly form, nursing documented R7 had yeast under the abdominal fold with a current order for antifungal in place. R7's Pressure Injury Weekly Tracker dated 10/16/2024 signed by RN-D on 10/23/2024, RN-D documented the left heel Stage I pressure injury measured 6 cm x 3 cm with 100% epithelial tissue. Surveyor noted the pressure injury was now classified as a Stage I pressure injury rather than following the previous documentation of a DTI. RN-D documented on the Pressure Injury Weekly Tracker form assessments on 10/22/204 signed 10/23/2024, 10/29/2024 signed 10/30/2024, and 11/5/2024 signed 11/6/2024. Each assessment documented the Stage I pressure injury to the left heel was improving with the measurements on 10/29/2024 and 11/5/2024 having the same measurements of 3.3 cm x 2.7 cm closed with 100% skin. No other documentation was found of the pressure injury after 11/5/2024. On 11/26/2024, Surveyor requested from Director of Nursing (DON)-B all of R7's wound documentation for review. DON-B provided the Pressure Injury Weekly Tracker assessments dated 10/16/2024, 10/22/2024, 10/29/2024, 11/5/2024, and 11/14/2024. Surveyor noted the 11/14/2024 assessment had not previously been in R7's medical record. The 11/14/2024 Pressure Injury Weekly Tracker form was completed by DON-B and signed on 11/26/2024 documenting R7's Stage I pressure injury had healed. On 11/20/2024 on the Skin Review-Weekly form, Licensed Practical Nurse (LPN)-C documented R7 had a pressure injury. Surveyor noted DON-B had documented R7's pressure injury had healed on 11/14/2024. On 11/26/2024 at 10:36 AM, Surveyor observed R7 eating breakfast in bed. R7 had an air mattress in place and the left leg/foot was elevated on pillows. R7 stated the dressing to the left lower leg and left heel were done every day. R7 said the left lower leg wound had previously had a wound vacuum in place but R7 was sensitive to the adhesive and so the wound vac was discontinued, and a daily dressing is done. Surveyor asked R7 if R7 would agree to have Surveyor observe the dressing change to the left lower leg and left heel. R7 agreed. In an interview on 11/26/2024 at 11:30 AM, Surveyor asked RN-D why the pressure injury to R7's left heel had changed from a DTI to a Stage I pressure injury. RN-D stated RN-D did not do the initial assessment of R7's left heel so did not know why it was changed to a Stage I. RN-D had completed the Pressure Injury Weekly Tracker forms and Surveyor noted RN-D documented on the 10/16/2024 initial assessment form the left heel pressure injury to be a Stage I. RN-D stated RN-D did the weekly wound rounds but left the facility two weeks prior to work at a different facility so did not know anything currently about R7's heel wound. On 11/26/2024 at 2:01 PM, Surveyor observed R7's left heel with LPN-C. R7's left leg and heel were elevated on pillows. The left leg had a stretchy gauze wrap around the leg holding the dressing in place. No dressing was on the left heel. The left heel had a small black/purple area that measured approximately 0.75 cm x 0.75 cm to the lateral aspect of the heel that was not open and flush with the surrounding skin. LPN-C agreed there was discoloration to the area. LPN-C stated the heel had originally been completely open with red tissue that needed to be measured with a cotton-tipped swab, so the dark area looked much better than what had been there. LPN-C stated the treatment to the left heel had recently been discontinued. On 11/26/2024 at 2:24 PM, Surveyor shared with DON-B the concerns observed during R7's treatment to the left leg. Surveyor shared a dark area was observed on R7's left lateral heel and LPN-C had stated R7's left heel had been open and deep that they had to use a cotton-tipped swab to measure the wound. DON-B stated the wound had never been open. Surveyor shared the conflicting documentation of the pressure injury to be a DTI prior to and at admission and the staging got changed to a Stage I. Surveyor shared with DON-B that RN-D had changed the staging and then stated the wound had always been a DTI when that was not what RN-D had documented. Surveyor shared with DON-B the treatment to R7's left heel did not start until two days after admission and no assessment was documented after 11/5/2024 until Surveyor asked for the wound documentation. DON-B stated DON-B saw R7's left heel on 11/14/2024 and it was healed at that time; DON-B had not documented it until today, 11/26/2024 after realizing the assessment was not in R7's medical record. No additional information was provided at that time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the comprehensive assessment of a resident, the facility did not ensure that residents receive care, consistent with professional standards of practice, to prevent pressure injuries and to ensure residents do not develop pressure injuries unless the individual's clinical condition demonstrates they were unavoidable; and residents with pressure injuries receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 (R5 and R26) of 2 residents reviewed for pressure injuries. R5 developed a facility acquired, stage 3, pressure injury. R26 developed a facility acquired stage 3 pressure injury on the coccyx on 4/4/24. This pressure injury was assessed on 4/5/24 as a Stage 2 pressure injury. A comprehensive assessment was not completed as there was no documentation of the percentage of the wound bed. The pressure injury was incorrectly staged as a Stage 2 as the coccyx pressure injury had granulation tissue. A stage 2 pressure injury does not have granulation tissue and should have been staged as a Stage 3. R26's care plan was not revised until three days later and the treatment was not started until the next day, 4/5/24. During wound rounds on 4/30/24 R26's pressure injury was not cleansed prior to the clean dressing being applied. CNA's informed Surveyor R26 developed this pressure injury due to not being changed properly and not being repositioned. Findings include: The facility policy titled Pressure Injuries and Non pressure Injuries revised 7/20/22 documents (in part) . .This center will complete a comprehensive assessment to identify risk factors for the development of pressure injuries and put in place measures intended to achieve the goal of prevention of pressure injuries in our residents. For those residents admitted with, or who subsequently developed a pressure injury or impaired skin integrity, they will receive care, treatment and services that seek to promote healing, prevent infection, and prevent further development of pressure injuries/impaired skin integrity. 1. Upon admission: a. A head to toe body evaluation will be completed on every resident upon admission/readmission and will be documented on the Admission/readmission Evaluation. b. Complete the Braden Scale to assess risk of developing a PI (pressure injury). It consists of six categories: Sensory perception, moisture, activity, mobility, nutrition and friction/shear. c. Initiate the baseline plan of care related to current skin status and skin risk level. When determining skin risk status and appropriate interventions, consider the following: Braden scale score, Co-morbid conditions, such as end stage renal disease, thyroid disease or diabetes mellitus, drugs such as steroids that may affect healing, impaired diffuse or localized blood flow, for example, generalized atherosclerosis or lower extremity arterial insufficiency, resident declination of some aspects of care and treatment, cognitive impairment, the need or request to elevate the head of bed, exposure of skin to urinary and fecal incontinence, under nutrition, malnutrition and hydration deficits. 2. Weekly: a. Complete a head to toe skin check and document findings on the Skin Review - Weekly. b. Assess current wounds are least every 7 days, or more frequently as needed (e.g. decline in wound, presence of infection, wound healed). If a wound fails to show some evidence of progress toward healing within 2-4 weeks, the area and the resident's overall clinical condition should be reassessed. Care Planning: A comprehensive Skin Integrity Care Plan is based on resident history, review of Skin Assessment, Braden Scale scoring, Nutritional Assessments, resident and family interviews, and staff observations. Consider the areas of risk as well as overall risk assessment score of the Braden Scale. 1. Develop interventions based on subsets of Braden Scale that may include: Sensory Perception: Carefully assess ability to move in bed and supplement any deficit. Protect bony prominence's that are affected by sensory deficits. Moisture: Use moisture barrier. Use absorbent pads or incontinent products that wick and hold moisture. Address cause of moisture, if possible. Activity: If resident is chair bound or bed bound, provide good positioning, good support surface and scheduled repositioning in the plan (consider use of micro shifts to supplement routine repositioning for chair bound individuals). Mobility: As mobility scores decrease, concern about the adequacy of the support surface should increase - evaluate need for specialty wheelchair cushion and specialty mattress. Develop turning/repositioning schedule based on resident needs and risk factors. Nutrition: Refer each resident with nutritional risk and pressure injury risk to Dietician and other health care professionals as appropriate. Friction and Shear: Head of bed elevated no more than 30 degrees unless medically necessary, protect elbows and heels as appropriate, keep skin moisturized. 1.) R5 admitted to the facility on [DATE]. Diagnoses include: Type 2 Diabetes Mellitus with chronic Diabetic Neuropathy, Diabetic Retinopathy, Chronic Kidney Disease, Restless Leg Syndrome, Rheumatoid Arthritis, Spinal Stenosis lumbar region, Anemia, Atherosclerotic Heart Disease, Major Depressive Disorder and Hydronephrosis with renal and ureteral calculous obstruction and Clostridium Difficile (C-diff). R5's admission Minimum Data Set (MDS) with an Annual Reference Date of 2/5/24 documents: Section GG0170 Mobility. Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the bed: Partial/moderate assist. Bed mobility: partial/moderate assist. Section H0200 Urinary Toileting Program. Has a trial of a toileting program (scheduled toileting, prompted voiding, or bladder training) been attempted on admission/entry or reentry or since urinary incontinence was noted in this facility? No. Urinary continence - Select the one category that best describes the resident: Always incontinent. Bowel continence. Select the one category that best describes the resident: Always incontinent. Is a toileting program currently being used to manage the resident's bowel continence? No. Section GG0130 Self-Care. Toileting hygiene - The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement: Dependent. R5's Braden dated 2/13/24 documented a score of 16 (At risk). R5's Braden dated 2/20/24 documented a score of 12 (High Risk). R5's admission assessment dated [DATE] documents: Is Resident Continent of Bladder? No. How long has the resident been incontinent? Longer than 1 year. How often is the resident wet? Once or more per shift. Resident is wet during: Day and night time. Amount of urine: Large (puddles/soaks, clothes, bed, floor). Continent of Stool? No. Subsequent bladder/incontinence evaluations: 2/11/24: Incontinent of bladder. Clothes or incontinence pad wet. Impaired mobility/ambulation. Dependent transfer (2 persons). Leakage with cough, sneeze, physical activity. Incontinence without sensation of urine loss. Prolonged voiding. Nocturia greater than 2 times. Mixed incontinence (symptoms of both stress and urge). Not appropriate for toileting or retraining program. 4/1/24: Incontinent of bladder. Impaired mobility/ambulation. Dependent transfer (2 persons). Decreased manual dexterity. Urinary tract infection within 30 days. Mixed incontinence (symptoms of both stress and urge). Alzheimer's Disease/Dementia, Diabetes. R5's admission skin assessment dated [DATE] documents: Right heel 3 x 3 x 0.1 cm press (pressure) vs Diabetic. Surveyor noted there was not a comprehensive assessment or staging of the wound. Treatment was ordered and implemented: Apply skin prep to right heel daily every evening shift for skin protection. Surveyor noted no further documentation, assessments or measurements of R5's right heel pressure injury. Surveyor asked the facility to print R5's care plan with revisions. The copy provided did not include revisions and was not the care plan viewed in Point Click Care (PCC). Director of Nursing (DON)-B reported she printed the wrong one and re-printed the care plan. The 2nd care plan provided to Surveyor did not match information viewed on R5's care plan in PCC, such as information about the pressure injury. The facility was advised and printed another copy for Surveyor. The 3rd copy still did not match all information on R5's care plan in PCC. Surveyor was advised the facility is having problems printing and the Care Plan provided is R5's current care plan. R5's care plan documented: At risk for alteration in skin integrity related to: (blank) - initiated 1/29/24. Interventions: Barrier cream to peri area/buttocks as needed. Encourage to reposition as needed; use assistive devices as needed. Use pillows/positioning devices as needed. Surveyor noted although R5 required assistance for bed mobility, the care plan was not personalized to include how often R5 should be repositioned. Actual unstageable pressure wound to the right heel related to diabetes, impaired mobility, incontinence - initiated 2/5/24, resolved 2/20/24. Interventions: Administer treatment per MD (Medical Doctor) orders, diet and supplements per MD orders, encourage and assist as needed to turn and reposition, use assistive devices as needed, float heels as able, Specialty mattress/cushion on bed/wheelchair, heel protectors while in bed. Surveyor noted although R5 required assistance for bed mobility, the care plan was not personalized to include how often R5 should be repositioned. At risk for nutritional status change related to obesity due to excess PO (by mouth) intake, sedentary lifestyle AEB (as evidenced by) BMI (body mass index) greater than 30. Potential for inadequate PO intake r/t (related to) recent C-diff, Covid+, increased nutrient needs, resident reporting she is a fussy eater AEB variable meal intake at times, altered skin integrity - initiated 1/29/24. Surveyor identified concern R5 sustained severe weight loss since admission to the facility (cross reference F692), this was not identified by the facility as a potential concern in pressure injury development and care planned accordingly. ADL (Activity of Daily Living) self-care deficit as evidenced by impaired mobility, C-diff, RLS (Restless Leg Syndrome), rheumatoid arthritis, spinal stenosis, cervical spondylosis - revised 2/5/24. Interventions: Gel cushion in wheelchair - implemented 3/8/24. Bed mobility/Positioning: Extensive assist of 1. Bilateral LE (lower extremity) elevation while in bed - implemented 2/2/24. Toileting: Extensive assist of 1, check and change PRN (as needed) implemented 2/2/24. Bowel Incontinence r/t impaired mobility - initiated 1/29/24. Goal: Will have no skin breakdown. Interventions: Record BM (bowel movement) and report any abnormalities. Report changes in bowel movement frequency, consistency, control, etc. (etcetera). Surveyor noted the care plan was not personalized to include R5 had C-diff with frequent/multiple loose stools per day. R5's care plan indicated check and change PRN. R5 is not aware of incontinence and dependent on staff for incontinence care. The care plan did not specify how often R5 should be checked and changed. Actual stage 3 pressure wound to sacrum posteriorly r/t impaired mobility, incontinence, nutritional deficit - initiated 2/20/24. Interventions: Encourage and assist as needed to turn and reposition, use assistive devices as needed, float heels as able, specialty mattress/cushion on bed/wheelchair. Surveyor noted R5's care plan was not revised after the stage 3 pressure injury was identified. The interventions (including specialty mattress/cushion on bed/wheelchair) were not new and had been implemented on 2/5/24. Review of R5's medical record revealed a Physician's order dated 4/11/24 - Air Mattress: Check function and settings every shift. Every shift for Pressure Reduction. On 4/28/24 at 9:30 AM Surveyor observed R5 lying in bed on her back. Surveyor noted R5 has an alternating pressure air mattress. Surveyor noted the call light pinned to her sheet and asked if she uses it. R5 stated: Yes, but they don't answer it, then I scream for help. R5 reported she very rarely gets out of bed, They don't let me get up in my wheelchair. I screamed enough because I had a burning butt and they finally looked at it. I told them it was their fault, they were letting me sit in feces because they don't answer my light. R5 reported she is able to turn herself herself in bed and demonstrated by grabbing the right grab bar to turn herself halfway onto her right side. R5 reported she would very much prefer to sit up in the chair, but they rarely get me up anymore. This is me, lying in bed all the time. On 4/29/24 at 10:10 AM Surveyor observed R5 lying in bed on her back wearing a gown and pink robe. R5 did not remember Surveyor from previous day. Surveyor asked R5 if she was getting out of bed today. R5 laughed, stating: They never get me out of this bed. Surveyor noted R5 did not get out of bed prior to Surveyor leaving the building at 4:00 PM. On 4/29/24 at 11:53 AM Surveyor spoke with Certified Nursing Assistant (CNA)-K. CNA-K reported she usually works the other side, but does work with R5. Surveyor asked if R5 gets out of bed. CNA-K stated: Yes, it depends on her cognition, if she's really confused we worry she might be flailing or try to get out of her wheelchair, so we might wait awhile, but therapy gave orders that she is supposed to be up for 2 hours each shift. On 4/30/24 at 9:36 AM Surveyor spoke with Therapy Director-L who reported R5 does get out of bed, But it's on her terms, we can't force her but we strongly encourage. On 4/30/24 at 11:29 AM Surveyor spoke with CNA-M and CNA-N. Surveyor asked how they thought R5's pressure injury developed. CNA-M stated: When she (R5) first came she was more alert. She admitted with C-diff and that never stopped. At first she would use the call light to let us know she needed to be changed, but now we just check and change her. Her stool is always loose, watery and mucous - it has been since she came here, so we're supposed to check her every 2 hours, but we check her more often because literally, every time you change her she is incontinent of that watery stool and her butt has always been really red. CNA-M added: Sometimes if she starts yelling out and praying, you know she might be incontinent and uncomfortable, so we go check on her. CNA-N agreed, If she starts yelling, it's usually because she's incontinent, and her stool has always been loose/watery and her butt was red and raw. Surveyor asked if R5 gets out of bed. CNA-M stated: Yeah sometimes, night shift usually gets her up in the chair because she can be behavioral on nights. I know she gets up for therapy. Surveyor asked both CNA's if they have reported R5's loose, watery mucous stools to anyone. CNA-N reported R5's stools have always been that way since she got here, and the nurses know. CNA-M agreed. Surveyor noted the facility identified R5 to be incontinent of bowel and bladder with large amount of urine during day and night time and is dependent on staff for incontinence care. In addition, R5 had a diagnosis of C-diff with frequent loose, watery stools reported by staff. R5's care plan indicates R5 is to be checked and changed as needed. The facility did not complete a comprehensive bowel and bladder assessment to determine a pattern or if R5 needed to be changed more frequently to prevent skin breakdown and pressure injury. R5's Skin Review Weekly dated 2/14/24 documents: Select all impairments that are present: None. Are any new skin impairments present? No. R5's Daily Skilled Observation dated 2/20/24 at 4:14 AM documents: Skin conditions (Check all that apply). Surveyor noted a check mark next to bruises. Any skin treatment/dressing? No. Skin Integrity/Positioning Devices: Heel Relief/Protector/Lift, Chair/Seat Cushion, Alternating Pressure Mattress in bed, Other - please describe. Surveyor noted a check mark next to None of the above. Review of R5's medical record revealed a stage 3 pressure injury was identified on 2/20/24. Surveyor was advised the pressure injury was identified during the Physician and nurse weekly wound rounds. Director of Nursing (DON)-B advised Surveyor she goes around with the physician every week for wound rounds and measure wounds together, so the Physician and facility measurements should be the same. The (name of wound clinic) wound physician notes document: 2/20/24 Stage 3 pressure wound Sacrum full thickness. 1.8 x 5.2 x 0.1 cm (centimeters). Cluster wound open ulceration area of 5.63 cm. 10% slough, 50% granulation, 40% skin. Light serosanguineous exudate. Appropriate treatment was implemented. 2/27/24 visit rescheduled. The facility documentation of wound: Sacrum stage 3. 1.6 x 5.2 x 0.1. 45% granulation, 15% slough, 40% skin. 3/5/24 Stage 3 pressure wound Sacrum full thickness. 1.6 x 5.2 x 0.1 cm. Cluster wound open ulceration area of 4.99 cm. 15% slough, 45% granulation, 40% skin. Moderate serosanguineous exudate. Improved evidenced by decreased surface area. 3/12/24 Stage 3 pressure wound Sacrum full thickness. 1.6 x 3.8 x. 0.1 cm. 40% slough, 60% granulation. Moderate serosanguineous exudate. Improved evidenced by decreased surface area. Stage 3 pressure wound of the left buttock full thickness. 1 x 1 x 0.1 cm. 100% granulation tissue. Moderate serosanguineous drainage. Clustered wound from other listed pressure injury - now being tracked as separate wound instead of clustered. 3/19/24 Patient not seen due to a non-wound related hospitalization. 3/26/24 Stage 3 pressure wound Sacrum full thickness. 1 x 2 x 0.1 cm. 100% granulation. Moderate serosanguineous exudate. Improved evidenced by decreased surface area. Stage 3 pressure wound of the left buttock - Resolved. Surveyor noted the sacrum pressure injury continued to be followed weekly by the wound physician. Surveyor identified no concerns with treatment and the wound continued to improve. On 4/23/24 the measurements documented: 0.4 x 0.8 x 0.1 cm. 20% slough, 80% granulation tissue. Moderate serosanguineous exudate. Improved evidenced by decreased surface area. On 4/30/24 at 2:28 PM Surveyor attended wound rounds for R5 with Wound Physician-O and a facility nurse. Upon entering R5's room Surveyor noted R5 was sitting up in her wheelchair, dressed. This was the first time Surveyor observed R5 out of bed on survey. On 4/30/24 at 3:00 PM Surveyor, Wound Physician-O and facility nurse returned to R5's room where she was lying in bed. R5 was rolled onto her left side. Surveyor observed a heart shaped Mepilix dressing covering her coccyx/buttock area dated 4/29/24. Wound Physician-O removed the old dressing revealing intact pink skin. Wound Physician-O stated It's healed and advised the resident. Wound Physician-O showed Surveyor where the previous Stage 3 pressure injury was located by pointing to the area. No open skin was observed. Wound Physician-O recommended keeping a Meplix dressing on for protection for at least another week, and the nurse applied a new dressing. Surveyor asked to view R5's heels. Surveyor observed no open areas or signs of skin breakdown. On 4/30/24 at 12:49 PM Surveyor spoke with Director of Nursing (DON)-B about R5's facility acquired Stage 3 pressure injury. DON-B reported the wound was identified during wound rounds for her heel which was healed the same day. Surveyor advised there is no evidence of comprehensive assessments and measurements of R5's right heel wound in the medical record. DON-B reported she will look for the information. No evidence was provided. Surveyor advised DON-B of concern the facility identified a stage 3 pressure injury to R5's coccyx and the care plan was not revised. DON-B reported R5 was given an air mattress that day (2/20/24). Surveyor asked DON-B if she had a work order or delivery slip to confirm when the mattress was placed. DON-B reported she will provide evidence (No evidence was provided). Surveyor advised R5's care plan indicated Specialty mattress/cushion on bed/wheelchair which was implemented on 2/5/24. The care plan does not document an APM air mattress was implemented. In addition, Physician's orders documented an order for air mattress, check function and settings every shift for pressure reduction on 4/11/24. DON-B maintains the air mattress was put on R5's bed on 2/20/24. Surveyor advised DON-B of concern R5 admitted to the facility with C-diff, is incontinent of bowel and bladder and dependent on staff for incontinence care. R5's care plan indicates check and change as needed only. There is no evidence the facility recognized the increased risk for skin breakdown r/t urine and stool incontinence and did not complete a comprehensive bowel and bladder assessment to determine if there was a need for increased turning, checking and changing. In addition, staff report R5 has had loose, watery stools since admission, and currently with every check and change. DON-B reported she was not aware R5 was still having loose stools and staff is not documenting loose stools in Point of Care (POC). Surveyor asked if R5 was having multiple loose stools per day related to C-diff, did the facility do further assessment to determine if there was a need for increased check and change versus just as needed. DON-B stated: Not that I can see. Surveyor asked DON-B if she thought incontinence was a factor in R5's stage 3 pressure injury development. DON-B stated: Probably. I understand what your saying. The care plan should have been updated to check and change her more frequently because of her incontinence. No additional information was provided. On 5/1/24 at 12:04 PM Surveyor asked VP Clinical Services if the facility has evidence of a comprehensive bowel assessment for R5. VP Clinical Services stated: If it's not under assessments, then we don't have. We haven't been able to find any. No additional information was provided. 2.) R26's diagnoses includes chronic kidney disease stage 5, diabetes mellitus, lymphedema, and epilepsy. The actual skin impairment care plan initiated 11/3/22 & revised 4/22/24 documents interventions of * Barrier cream to peri area. Initiated 11/3/22 & revised 4/22/24. * Encourage to reposition as needed with staff assistance. Initiated 11/3/22 & revised 4/22/24. * Float heels as able. Initiated 11/3/22. * Observe skin condition with ADL (activities daily living) care daily; report abnormalities. Initiated 11/3/22. * Pressure redistributing device on chair. Initiated 11/3/23 & revised 1/23/23. * Therapy eval (evaluate) and treat as ordered. Initiated 11/3/22. * Diabetic nail care weekly by licensed nurse. Initiated 1/16/24. * Licensed nurse to complete diabetic foot checks nightly. Initiated 1/16/24. * Podiatric care as needed. Initiated 1/16/24. * Weekly skin assessment done by licensed nurse. Initiated 1/16/24. * Pressure redistributing mattress. Initiated & revised 4/7/24. * Remind resident to turn and reposition frequently. Educate on the importance of skin health. Initiated 4/28/24. The CNA (Certified Nursing Assistant) kardex as of 4/29/24 under skin section documents * diabetic nail care weekly by licensed nurse. * Float heels as able. * Inspect feet daily for open areas, sores, pressure areas, blisters, edema or redness. * Licensed nurse to complete diabetic foot checks nightly. * Pressure redistributing mattress * Remind resident to turn and reposition frequently. Educate on the importance of skin health. * Weekly skin assessment done by licensed nurse. APNP (Advanced Practice Nurse Prescriber)-CC note dated 3/28/24 under chief complaint documents CKD-5 (chronic kidney disease-Stage 5) and goals of care. Under subjective documents Nursing reports that patient has been more lethargic at times and refusing pain medications and not eating as well lately. Overall, patient has had a functional decline in health. Last creatinine with CKD 4 was 4.09 on 3/21/2024. Increase in BLE (bilateral lower extremity) edema despite BLE compression wraps and diuretics. Patient reports increase in bilateral lower extremity pain as well and limited relief with acetaminophen. She is seen sitting in her wheelchair and reports that her bilateral feet pain makes her cry especially at night, 5/10, throbbing, chronic and disruptive to her sleep. Labs ordered for follow up. Goals of care discussion done- please see below. Has a follow-up with nephrology next week Tuesday. No fever, chills, cough, sob (shortness of breath), cp (chest pain) or bowel/bladder concerns. Under Goals documents Recommendation given for hospice, end-stage renal disease,and overall function decline. Patient wants to remain a DNR (do not resuscitate). Wishes to be started on low dose oxycodone for comfort despite potential side effects with renal failure. Wishes for no more hospitalizations. Agreeable to hospice consult- would like to wait til next week to discuss matter over with her grand-daughter and family with a care conference. I also updated the grand-daughter, [name] via phone per patients wishes about conversation. DON (Director of Nursing) updated. The order administration note dated 4/2/24 at 13:36 (1:36 p.m.) documents Weekly skin review every day shift every Tue (Tuesday). If new skin area is identified follow protocol for SBAR (situation, background, assessment, and recommendation), MD (medical doctor) update and risk management. Only able to assess BLE's (bilateral lower extremities) and BUE's (bilateral upper extremities). Resident out for appointment most of the day. This note was written by RN (Registered Nurse)-H. The nurses note dated 4/4/24 at 23:04 (11:04 p.m.) documents F/U (follow up) pressure injury to the buttock, new dressing applied. This nurses note was written by RN-BB. The physician order with a start date of 4/5/24 documents Wound care to coccyx: remove old dressing and discard. Using clean technique, cleanse wound with normal saline or wound cleanser. Pat dry. Apply skin prep to peri wound skin. Apply thin layer of medihoney to wound. Cover area with bordered foam dressing. Change dressing daily and PRN ( as needed) if soiled or dislodged. every evening shift for wound care. This order was discontinued on 4/23/24. The physician order dated 4/5/24 documents Consult [Name] Wound Care for pressure injury to coccyx. The pressure injury weekly tracker dated 4/5/24 documents for date acquired 4/4/24. The site documents coccyx and type is pressure. The length is documented as 4 cm (centimeters), width 1 cm, and depth 0.1. The Stage is documented as II (2). The tissue type documents granulation tissue. The percentage of the wound bed was not completed. The drainage is serosanguineous. This assessment was completed by RN-H. Surveyor noted this is not a comprehensive assessment as the percentage of wound bed was not completed and the pressure injury was incorrectly staged as a Stage 2 pressure injury does not have granulation tissue. The pressure injury should have been staged as a Stage 3. There were no revisions in R26's care plan until 4/7/24 three days later. The pressure injury weekly tracker dated 4/9/24 documents for date acquired 4/4/24. The site documents coccyx and type is pressure. The length is documented as 5 cm, width 2 cm, and depth 0.1. The Stage is documented as III (3). The tissue type documents granulation tissue. The percentage of the wound bed is 100% granulation. The drainage is serosanguineous, moderate drainage. This assessment was completed by DON-B. R26 started receiving hospice services on 4/9/24. The nurses note dated 4/10/24 at 11:14 (11:14 a.m.) documents F/U O/A (open area) at the buttock, new dressing applied, encourage to change position and staff will continue to monitor. This nurses note was written by RN-BB. The nurses note dated 4/11/24 at 23:16 (11:16 p.m.) documents F/U O/A to the coccyx, dressing intact, repositioned and staff will continue to monitor. This nurses note was written by RN-BB. The significant change MDS (minimum data set) with an assessment reference date of 4/15/24 has a BIMS score of 5 which indicates severe cognitive impairment. R26 is assessed as requiring partial/moderate assistance for toileting hygiene, supervision or touching assistance for chair/bed to chair transfer & toilet transfer and independent with rolling left and right. R26 is assessed as being frequently incontinent of urine and always incontinent of bowel. R26 is assessed as being at risk for pressure injury development and is assessed as not having a pressure injury. Surveyor noted the assessment of rolling left and right is inaccurate as during the month of April for bed mobility the CNAs did not check independent. Bed mobility is checked as being extensive assistance - Resident involved inactivity, staff provide weight-bearing support or total dependence - Full staff performance. The pressure injury section is also inaccurate as R26 developed a Stage 3 pressure injury on the coccyx on 4/4/24. The pressure injury CAA (care area assessment) dated 4/24/24 under analysis of findings for nature of problem/condition documents CAA triggered r/t (related to) increased risk for skin impairment related to increased need for help with ADL such as bed mobility which can decrease blood flow and increase pressure leading to wounds. Under care plan considerations documents Pressure Ulcers CAA triggered secondary to potential for pressure ulcers. Contributing factors include ADL (activity daily living)/functional/mobility impairment and incontinence. Risk factors include pain, development of PU (pressure ulcer)/skin condition, and fluid deficit risk. Nurse assesses skin each week and provides interventions to prevent skin breakdown. Skin is also assessed by caregivers with each bathing and dressing. The physician is to be notified of any abnormal findings and treatment orders are obtained. The dietitian is monitoring intake, and implementing dietary interventions Caregivers assist with repositioning frequently and as needed for comfort. Care plan will be initiated or reviewed to improve or maintain current ADL status and functional ability, maintain continence status, prevent pain, and decrease pressure ulcer/fluid deficit risk. Location of documentation: see NN (nurses notes)/Braden/TAR (treatment administration record) for the look back period. The pressure injury weekly tracker dated 4/17/24 documents for date acquired 4/4/24. The site documents coccyx and type is pressure. The length is documented as 3.3 cm, width 1 cm, and depth 0.1. The Stage is documented as III (3). The tissue type documents granulation tissue. The percentage of the wound bed is 80% granulation and 20% slough. The drainage is serosanguineous, moderate drainage. This assessment was completed by DON-B. The pressure injury weekly tracker dated 4/23/24 documents for date acquired 4/4/24. The site documents coccyx and type is pressure. The length is documented as 2.5 cm, width 1 cm, and depth 0.1. The Stage is documented as III (3). The tissue type documents granulation tissue. The percentage of the wound bed is 100% granulation. The drainage is serosanguineous, moderate drainage. This assessment was completed by RN-H. The physician order dated 4/23/24 documents Wound care to [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) The facility policy entitled Smoking Policy revised 7/14/2022 states: To identify factors that may put residents at risk for smoking or nicotine use independently and to provide appropriate supervision/approaches for safety. This center shall establish and maintain a safe resident environment, while maintain resident rights, smoking or nicotine use will be limited to designated areas, supervision, and safety plans. Those residents who wish to engage in these practices will be educated, assessed, and provided with appropriate supervision to safely do so. Policy Explanation and Compliance Guidelines . 2. Risk factors identified through the assessment process shall be used in the development of the plan of care. 5. If a resident is deemed to be unsafe, they will be required to use a smoking apron, extender, or gloves and they may be required to smoke with supervision only. 9. Residents who are assessed to require supervised smoking will have nicotine materials secured in a container that is maintained by the licensed nurse. R19 was admitted to the facility on [DATE] and has diagnoses that include rheumatoid arthritis, schizophrenia, major depressive disorder, lymphedema, and restless leg syndrome. R19's quarterly minimum data set (MDS) dated [DATE] indicated R19 had intact cognition with a brief interview for mental status (BIMS) score of 15 and the facility assessed R19 having no impairments to R19's upper extremities, having impairments to lower extremities and modified independent with transfers and repositioning with assistive devices. R19's at risk for smoking related injury due r/t (related to) poor decision making, memory loss care plan initiated 1/30/2023 has the following interventions: - Assure smoking material is extinguished prior to resident leaving smoking area. - Complete nicotine assessment per facility policy. - Observe resident for unsafe smoking behaviors or attempts to obtain smoking material from outside sources. Immediately inform facility management of concerns. - Resident not to have cigarettes or smoking material on person. (Initiated 2/27/2024) R19's care Kardex has the following interventions for safety as of 4/29/2024: -Resident not to have cigarettes or smoking material on person. On 4/28/2024 at 1:42 PM Surveyor spoke with R19 who stated R19 smoked cigarettes outside. Surveyor asked if R19 held onto R19's smoking materials. R19 stated R19 had own smoking materials in R19's bedroom and sometimes has to get from nursing. Surveyor asked R19 if R19 can smoke outside alone or if R19 needed to have someone when R19 smoked. R19 stated R19 goes outside and smokes alone. Surveyor reviewed R19's last Nicotine assessment that was completed on 2/27/2024, based on the assessment staff determined that R19 was AT RISK: requires staff, family, or friend for physical support or supervision with tobacco/nicotine products. Smoking materials will be kept under control of center staff. On 4/30/2024 at 2:04 PM Surveyor interviewed registered nurse (RN)-H who stated R19 was supposed to give staff back R19's smoking supplies when R19 was done with them. Surveyor asked if R19 required supervision when smoking. RN-H stated R19 can go outside alone to smoke and does not require supervision. Surveyor asked RN-H how often R19 goes outside to smoke. RN-H stated that some days R29 never goes out and other days R19 goes out several times, but nothing consistent. On 4/30/2024 at 2:04 PM Surveyor interviewed director of nursing (DON)-B. Surveyor asked DON-B what expectations are of staff when a resident is a supervised smoker. DON-B stated that staff will go out with a resident if a supervised smoker and make sure the resident is safe while smoking. Surveyor asked DON-B if there are designated times a staff member goes out with residents to supervise smoking. DON-B stated whatever staff is available when a resident that requires supervision wants to go smoke will go out with the residents, but there was not an arranged time or staff member. Surveyor asked DON-B about R19 being supervised while smoking. DON-B stated DON-B assessed R19 requiring supervision because R19 usually smokes at night and has a tendency to fall asleep easily when sitting in R19's wheelchair so made R19 supervision so staff could light R19's cigarette and monitor R19 so R19 did not fall asleep with the cigarette lit. On 5/1/2024 at 8:41 AM Surveyor interviewed certified nursing assistance (CNA)-N who stated R19 is able to hold onto R19's cigarettes, but staff have to get the lighter from nursing. Surveyor asked if staff had to supervise R19 while smoking. CNA-H stated that staff light the cigarette for R19 but does not need to be supervised and can smoke alone. On 5/1/2024 at 11:41 AM Surveyor shared concerns with DON-B regarding staff not knowing R19 had to be supervised while smoking and that R19 may sometimes have R19's smoking materials. Surveyor also shared that R19 smoking care plan and care Kardex does not indicate that R19 is to be a supervised smoker. No further information provided at this time. Based on interview and record review the Facility did not ensure each Resident received adequate supervision and assistance devices to prevent accidents for 2 (R21 & R19) of 4 Residents. R21 is being cited as actual harm/isolated. * R21's falls on 10/1/23 & 10/23/23 were not thoroughly investigated & root cause not determined to help prevent future falls. On 10/28/23 the Certified Nursing Assistant (CNA) did not use a gait belt & R21 fell in the bathroom. On 11/14/23 R21 sustained another fall. This fall was not thoroughly investigated, root cause not determined and there were no revisions in the care plan or indications the interventions remain appropriate. On 11/19/23 R21 was left alone in the bathroom fell and sustained a hip fracture. On 1/7/24 R21 fell. The facility did not conduct a thorough investigation, determine a root cause to help prevent future falls and did nor revise the care plan or indicate the interventions are appropriate. On 1/18/24 R21 fell. The facility did not conduct a thorough investigation and did not revise the care plan to include the intervention to call for assistance to adjust the bedding. R21 was observed in bed without the bed being at the lowest level and was not wearing gripper socks in bed according to R21's plan of care. * R19 was not supervised while smoking according to R19's plan of care. Findings include: The Fall Prevention and Management Guidelines policy last reviewed/revised 11/8/22 under Policy Explanation and Compliance Guidelines includes documentation of: 8. Review each fall/fall investigation during the next morning meeting/clinical meeting with the interdisciplinary team (IDT). Actions of the IDT may include: a. Review of investigation and determination of potential root cause of fall. b. Review of fall risk care plan and any updates to plan of care completed post fall. c. Additional revisions to the plan of care including any physical adaptation to room, furniture, wheelchair, and/or assistive devices. d. Education of staff as to any care plan revisions. e. Scheduling resident/family conferences. f. Verification of timely notification of physician and responsibly part of the fall. Note: If after IDT review, it is determined that existing interventions in the care plan are most appropriate, document rationale and describe any additional actions taken. 1.) R21's diagnoses includes diabetes mellitus, congestive heart failure, atrial fibrillation, anxiety disorder, and depressive disorder. The at risk for falls care plan initiated 1/31/22 & revised 12/28/23 documents the following interventions: * Bed in low position. Initiated 1/31/22. * Encourage to transfer and change position slowly. Initiated 1/31/22. * Fall Risk (FYI) (for your information). Initiated 1/31/22. * Have commonly used articles within easy reach. Initiated 1/31/22. * Medication as ordered 1/31/22. * Provide assist to transfer and ambulate as needed. Initiated 1/31/22. * Reinforce need to call for assistance. Initiated 1/31/22. * Reinforce w/c safety as needed such as locking brakes. Initiated 1/31/22 * Report development of pain, bruises, change in mental status, ADL (activities daily living) function, appetite, or neurological status post fall. Initiated 1/31/22. * Therapy eval (evaluate) and treat as ordered. Initiated 1/31/22. * Increase rounding at night and offer toileting while awake. Initiated 6/29/22 & revised 7/7/22. * Encourage resident to wear non skid footwear at all times even while in bed. Initiated & revised 3/13/23. * Sign was placed in resident's room to remind her to use the call light for assistance. Initiated 3/16/23. * Frequent reminders to use call light prior to unassisted ambulation/transfers as needed. Initiated 3/13/23. * Anti-tippers to w/c (wheelchair). Initiated 4/24/23. * Offer/toilet every hour between the hours of 12 am - 5 am as needed. Initiated 5/12/23. * Resident has anti-roll back brakes. Initiated 10/24/23 & revised 11/9/23. * Anti-rollbacks to wheelchair. Initiated 12/1/23. * Scoop mattress. Initiated 12/1/23. * Fall mat beside bed. Initiated 12/1/23. The CNA (Certified Nursing Assistant) kardex as of 5/1/24 under the safety section documents * Anti-tippers to w/c (wheelchair). * Anti-rollbacks to wheelchair. * At moderate risk for elopement. * Bed in low position. * Educate resident on need to lock brakes on wc when it is not in motion and to call for assistance for safety. * Encourage resident to wear non skid footwear at all times even while in bed. * Fall mat bedside bed. * Fall Risk (FYI) (for your information). * Frequent reminders to use call light prior to unassisted ambulation/transfers as needed. * Increase rounding at night and offer toileting while awake. * Resident has anti-roll back brakes. * Scoop mattress. The nurses note dated 10/2/23 at 03:02 (3:02 a.m.) documents Resident was calling writers name and writer heard her as writer was walking out of resident room on (name of unit). Writer followed her voice to find her by the front entrance on the floor sitting on her butt. Resident had on a long winter goldish-green coat that went down to her ankles and was way to big on her. Resident stated she was looking for her mother and father and thought they were calling to her from up there. Resident then stated she slid out of her wheelchair onto the floor because of the coat. VSS (vital signs stable), ROM WNL (range of motion within normal limits), Neuro (neurological) checks negative. Assessment was positive for bruising in L (left) Thigh, otherwise negative for any other noted injuries. Resident stated she did not hit her head. Writer and Med Tech [initials] assisted resident off floor and back into chair c sic (with) mechanical lift. [medical group] On Call MD (medical doctor) updated. Nephew [name] updated as well. DON (Director of Nursing) updated. This nurses note was written by RN (Registered Nurse)-R. The incident report dated 10/1/23 under incident description for nursing description documents Resident was calling writers name and writer heard her as writer was walking out of resident room on (name of unit). Writer followed her voice to find her by the front entrance on the floor sitting on her butt. Resident had on a long winter goldish-green coat that went down to her ankles and was way to big on her. Resident stated she was looking for her mother and father and thought they were calling to her from up there. Resident then stated she slid out of her wheelchair onto the floor because of the coat. VSS, ROM WNL, Neuro checks negative. Assessment was positive for bruising in L Thigh, otherwise negative for any other noted injuries. Resident stated she did not hit her head. Writer and Med Tech [initials] assisted resident off floor and back into chair c sic (with) mech lift. [medical group] On Call MD updated. Nephew [name] updated as well. DON updated. Under resident description documents Resident had on a long winter goldish-green coat that went down to her ankles and was way to big on her. Resident stated she was looking for her mother and father and thought they were calling to her from up there. Resident then stated she slid out of wheelchair onto the floor because of the coat. Under notes dated 10/4/23 documents On 10/01 resident was observed on floor near business office door, Pt was observed wearing oversized jacket that was too long for her. Pt stated she was looking for her parents. Resident stated she slipped out of her chair due to oversized jackets. Resident called out to Nurse for help. Nurse and MT (med tech) used mechanical lift to place back in chair. Resident appeared more confused than usual but no other changes noted. Resident currently has a wander guard but it was placed on her w/c due to the resident not wanting it on her person per the staff. Intervention Resident reports will wear wander guard if it can be bedazzled (Activities Director will handle) Educate staff and let them know all wander guard bracelets are to be placed on resident; not on their assistive device. Surveyor noted the Facility did not conduct a thorough investigation as there are no staff interviews as to who last saw R21, what was R21 doing, etc. The Facility did not determine a root cause and did not revise R21's care plan to include bedazzling R21's wanderguard, although this would not prevent R21 from falling in the future. The fall assessment dated [DATE] has a score of 5 which indicates low risk. The nurses note dated 10/24/23 at 00:00 (12:00 a.m.) documents Writer and Med Tech/CNA-[initials] charting at nurses station and heard a crash. [Initials] went down the hallway to check on residents and found resident in front of her closet with back towards closet and resident on floor in sitting position in front of closet. Resident stated she was trying to get briefs from closet and lost her balance. Resident stated she did hit her head, but on the closet as she slid down. Writer was called down by [initials] and upon performing physical assessment, writer noted a large 9 x 2 x 0.2 abrasion/scrape-mid back-just barely off to the right of the spine. Resident states that the abrasion is painful. The rest of physical assessment is negative and resident was assisted off the floor via lift and 2 staff. Resident was brought to the nurses station. Acetaminophen administered for pain. Neuro checks negative, VSS, ROM WNL. Area on back cleansed c sic (with) NS (normal saline), TAO applied and covered c sic (with) border gauze. MD Updated. [name] called and updated. This nurses note was written by RN-R. Incident report dated 10/23/23 under incident description for nursing description documents Writer and Med Tech/CNA-[initials] charting at nurses station and heard a crash. [initials] went down the hallway to check on residents and found resident in front of her closet with back towards closet and resident on floor in sitting position in front of closet. Resident stated she was trying to get briefs from closet and lost her balance. Resident stated she did hit her head, but on the closet as she slid down. Writer was called down by [initials] and upon performing physical assessment, writer noted a large 9 x 2 x 0.2 abrasion/scrape-mid back-just barely off to the right of the spine. Resident states that the abrasion is painful. The rest of physical assessment is negative and resident was assisted off the floor via lift and 2 staff. Resident was brought to the nurses station. Acetaminophen administered for pain. Neuro checks negative, VSS, ROM WNL. Area on back cleansed c NS, TAO (topical antibiotic ointment) applied and covered c (with) border gauze. MD Updated. [name] called and updated. Resident description documents Resident stated she was trying to get briefs from closet and lost her balance. Resident stated she did hit her head and her back but on the closet as she slid down. Under notes dated 11/9/23 On 10/23 approx 2345 (11:45 p.m.) resident had a fall in room during a self-attempt to stand from w/c d/t (due to) trying to retrieve a brief from closet. Resident is a repeat faller (sic) and has poor safety awareness. Resident acquired a skin tear to mid spine. Neuro check initiated. MD and POA (power of attorney) notified. Intervention: Treatment to back in place; wound consult ordered. On 10/24 anti-rollback brakes were placed on the residents w/c. Care plan updated. Surveyor noted the Facility did not conduct a thorough investigation as there are no staff interviews as to who last saw R21, when was R21 last toileted. The Facility did not determine a root cause. The order note dated 10/28/23 at 20:31 (8:31 p.m.) documents Writer was in room [number] giving meds to resident when CNA [initials] came in thru the [NAME] n [NAME] bathroom and informed writer that resident fell during the transfer to toilet to wheelchair. Writer went into bathroom with CNA [initials] to see the resident laying on the floor, face up, depends at knees, shoes on. Writer did not see a gait belt. CNA stated resident was standing up at the bar, holding onto the bar. CNA [initials] stated she was standing behind the resident and attempted to catch resident as she fell to the left. Writer performed a physical assessment on resident. Resident stated she did not hit her head, she stated her hip and butt hurt. Writer noted some scratches and bruising on left and right hips and left upper thigh, left leg. Neuro check was negative, ROM was WNL, VSS. [Name]-Nephew and On call [medical group] update c sic (with) NOR (new order received). This order note was written by RN-R. The incident report dated 10/28/23 under incident description for nursing description documents Writer was in room [number] giving meds to resident when CNA [initials] came in thru the [NAME] n [NAME] bathroom and informed writer that resident fell during the transfer to toilet to wheelchair. Writer went into bathroom with CNA [initials] to see the resident laying on the floor, face up, depends at knees, shoes on. Writer did not see a gait belt. CNA stated resident was standing up at the bar, holding onto the bar. CNA [initials] stated she was standing behind the resident and attempted to catch resident as she fell to the left. Writer performed a physical assessment on resident. Resident stated she did not hit her head, she stated her hip and butt hurt. Writer noted some scratches and bruising on left and right hips and left upper thigh, left leg. Neuro check was negative, ROM was WNL, VSS. [Name]-Nephew and On call [medical group] update c sic (with) NOR. Resident description documents Resident stated she lost her balance. Under notes dated 11/2/23 documents Resident had a witnessed fall while in the bathroom with the CNA. Resident was not wearing a gait belt and fell during transfer from toilet to w/c. CNA was not positioned correctly during transfer. CNA was attempting to assist with transfer from behind the w/c during transfer. Upon resident standing, the CNA was unable to catch the resident and the resident fell. No injuries noted but resident reported pain. Pain meds given. MD notified and POA made aware. Intervention CNA transfer education provided PT OT to screen eval and treat as indicated. Surveyor noted the Facility's investigation revealed the CNA was did not use a gait belt as required. The fall assessment dated [DATE] has a score of 7 which indicates low risk. The quarterly MDS (minimum data set) with an assessment reference date of 10/31/23 has a BIMS (brief interview mental status) score of 10 which indicates moderate cognitive impairment. R21 is assessed as requiring partial/moderate assistance for toileting hygiene, chair/bed to chair transfer and toilet transfer and is independent with wheeling the wheelchair. R21 has fallen since the prior assessment with one fall no injury and 1 fall with injury except major. The nurses note dated 11/14/23 at 18:30 (6:30 p.m.) documents Writer was called to residents room due to resident being found sitting on floor. Upon entering the residents room, writer found resident sitting on her buttocks with her back against her nightstand, her bed on her left, wheelchair on her right, and tray table in front of her. Resident was holding onto her bed and chair. When writer asked resident what she was doing prior to falling. Resident stated she was trying to get into her wheelchair from her bed. Resident bed was down too low for resident to be able to transfer, resident call light was within reach. wheelchair wheels were locked, resident was barefoot. Writer performed physical assessment with negative results. Resident states she did not hit her head, and does not hurt anywhere not, but will feel it tomorrow. Writer expects some bruising on resident buttocks. Writer and Executive Director [initials] assisted resident off the floor with Hoyer. Resident assisted back into wheelchair. Writer updated nephew [name], on call [medical group] [name], and DON [initials]. This nurses note was written by RN-R. Surveyor was not provided with an investigation regarding R21's fall on 11/14/23 and no revisions were made to R21's fall care plan or have evidence the care plan was reviewed and all interventions remain appropriate. The fall assessment dated [DATE] has score of 11 which indicates moderate risk. The nurses note dated 11/19/23 at 21:45 (9:25 p.m.) documents Resident is being transferred to the hospital by Menomonee Falls 911 EMT's (emergency medical technicians). This nurses note was written by LPN (Licensed Practical Nurse)-U. The nurses note dated 11/19/23 at 22:06 (10:06 p.m.) documents Called to resident room and observed resident on the floor in the bathroom. Resident was lying on her back with her head by the opposite door and her feet by the toilet. This nurses note was written by LPN (Licensed Practical Nurse)-U. The incident report dated 11/19/23 Under incident description for nursing description documents At 2055 (8:55 p.m.) I was called to resident room while in the hallway and observed resident on the floor in the bathroom. Toilet (sic) resident was lying on her back with her head by the opposite door and her feet by the toilet. Urine and bowel movement noted in toilet resident dry and shoes on feet. While doing neuro check resident complaint of pain to left and unable to have range of motion to leg. Resident description: I had to get up. My back and legs were starting to hurt. Under immediate action taken documents Assessment and vitals done. Placed a call to the MD orders obtained and 911 called to transfer resident to the hospital. Under notes dated 11/26/23 documents On 11/19 approx 2055 resident was noted to have a fall due to self attempt to transfer from toilet to w/c. Resident was assisted to toilet by med tech. Med tech checked on resident times 2 while on toilet and handed resident call light in in bathroom stating to put on call light when ready. Within approx 5 min med tech heard resident yelling and found resident on the floor laying on back side in bathroom. Med tech asked resident why did she not use her call light and resident was noted saying My back and legs were starting to hurt. I had to get up During neuro checks resident complaint of pain to left leg without ROM (range of motion). Resident last fall was on 11/14 due to self transfer. MD and RP made aware. Intervention Resident sent out to eval and treatment. Resident to not be left alone while being toileted. R21's previous fall was 5 days prior when according to this incident fall R21 had self transferred. There was no revision in R21's care plan for the previous fall nor was the care plan revised to include not being left alone on the toilet following this fall. R21's care plan was not revised until 12/1/23 R21 sustained a left femur fracture and was hospitalized until 11/29/23 when R21 returned to the Facility. The fall assessment dated [DATE] has a score of 8 which indicates low risk. The significant change MDS with an assessment reference date of 12/6/23 has a BIMS score of 3 which indicates severe cognitive impairment. R21 is assessed as substantial/maximal assistance for toileting hygiene, chair/bed to chair transfer and toilet transfer. R21 is assessed as partial/moderate assistance to wheel the wheelchair 50 feet and substantial/maximal assistance to wheel the wheelchair 150 feet. R21 is assessed as not having any falls since prior assessment period. The fall assessment dated [DATE] has a score of 11 which indicates moderate risk. The nurses note dated 1/7/24 at 22:13 (10:13 p.m.) documents Writer was at nurses station speaking with CNA [initials] when [initials] noted that resident was on floor in front of her doorway. Writer and other staff went down to assess resident and to assist off the floor. Resident stated she was looking for her yellow stick but could not find it. So she was coming back to talk to writer at the nurses station. Resident stated she slid out of her chair onto her butt and hit her head. Resident states she has a headache. Report given to [name] RN at [hospital initials] ER (emergency room). [Name of ambulance] called for Transport. Resident is on eliquis. Writer examined resident and assessment was negative. No red marks, bruises, or lumps on head or thru out body that could be attributed to fall. ROM WNL, Neuro checks negative. BP (blood pressure) high- On call NP (Nurse Practitioner) [Name] informed and gave new orders to send out due to resident being on blood thinner. Writer called and informed POA Nephew [Name]. Writer updated resident as well to let her know what was going on. Report given to [Name] RN at [hospital initials] ER. (name of ambulance) called for Transport. This nurses note was written by RN-R. The incident report dated 1/7/24 for Incident description under nursing description documents Writer was at nurses station speaking with CNA [initials] when [initials] noted that resident was on floor in front of her doorway. Writer and other staff went down to assess resident and to assist off the floor. Resident stated she was looking for her yellow stick but could not find it. So she was coming back to talk to writer at the nurses station. Resident stated she slid out of her chair onto her butt and hit her head. Resident states she has a headache. Report given to [Name] RN at [hospital initials] ER. [Ambulance name] called for Transport. Resident is on eliquis. Writer examined resident and assessment was negative. No red marks, bruises, or lumps on head or thru out body that could be attributed to fall. ROM WNL, Neuro checks negative. BP high- On call NP [Name] informed and gave new orders to send out due to resident being on blood thinner. Writer called and informed POA Nephew [Name]. Writer updated resident as well to let her know what was going on. Report given to [Name] RN at [Hospital initials] ER. [Ambulance name] called for Transport. Under Resident description documents Resident stated she was looking for her yellow stick but could not find it. So she was coming back to talk to writer at the nurses station. Resident stated she slid out of her chair onto her butt and hit her head. Resident states she has a headache. The nurses note dated 1/8/24 at 01:00 (1:00 a.m.) documents returned from hospital with NNOR (no new orders received). Negative CT and negative hip Xray. Resident at baseline, awake alert and cooperative upon arrival via [ambulance name]. This nurses note was written by RN-R. Surveyor noted the Facility did not conduct a thorough investigation as there are no staff interviews as to who last saw R21, when was R21 last toileted, what was R21 doing. The Facility did not determine a root cause and did not revise the care plan or have evidence the care plan was reviewed and all interventions remain appropriate. The nurses note dated 1/18/24 at 06:37 (6:37 a.m.) documents Resident found on the floor in front of wheelchair at bedside. Resident stated I was fixing my bed so that I could get in it and fell out on wheelchair. Resident vitals taken and given PRN (as needed) Tylenol for comfort. Resident Neuro check negative. This nurses note was written by LPN-U. The incident report dated 1/18/24 under incident description for Nursing description documents Resident found on the floor in front of wheelchair at bedside. Resident description documents I was fixing my bed sheets and fell out of the chair. Under notes dated 1/18/24 Root cause: Resident was fixing sheets on her bed and leaned to far forward sliding out of the chair. Intervention Reminders to call for assistance from staff to adjust her bedding. Surveyor noted the Facility did not conduct a thorough investigation as there are no staff interviews as to who last saw R21, when was R21 transferred out of bed and how was R21's bed when R21 was transferred out. R21's care plan was not revised to include the intervention to call for assistance to adjust the bedding. The fall assessment dated [DATE] has a score of 7 which indicates low risk. The nurses note dated 1/19/23 at 10:59 (10:59 a.m.) documents Resident is on follow up for: On 1/18/24 resident was found on the floor in front of wheelchair at bedside. Resident stated I was fixing my bed so that I could get in it and fell out on wheelchair. The current status is Resident is alert. No s/s (signs/symptoms) of pain noted. No changes in ROM noted. Skin remains free from any injuries This nurses note was written by RN-H. On 4/29/24 at 7:05 a.m. Surveyor observed R21 in bed on the right side. R21's bed is in the low position, there is a mat on the floor on the right side of R21's bed and there are two transfer bars up. There is a glass of water on the over bed table not within R21's reach. On 4/29/24 at 7:34 a.m. Surveyor observed CNA (Certified Nursing Assistant)-M in R21's room. CNA-M washed her hands, placed gloves on, removed clothing from the closet and removed the gait belt from the back of R21's room door. CNA-M raised the height of the bed and removed the bedding off R21. Surveyor observed R21 has bare feet and is not wearing gripper socks according to the plan of care. CNA-M placed gripper socks on R21, swung R21's legs so R21 was sitting on the edge of the bed and placed the gait belt around R21. R21 placed shoes on R21, told R21 she was going to go to the rest room and assisted R21 with standing up and transferring into the wheelchair. CNA-M wheeled R21 into the bathroom, assisted R21 with standing up and then step backwards to the toilet having R21 sit on the toilet. At 7:47 a.m. CNA-M removed her gloves, washed her hands, removed the wheelchair from the bathroom and placed gloves on telling R21 she was going to wash her face & get her dressed. CNA-M washed R21's face & upper body and placed a dress & sweater on R21. CNA-M placed a brief on R21 and the gait belt around R21. At 7:54 a.m. CNA-M asked R21 if she was ready and stood R21 up. R21 stated she can't and R21 was sat back on the toilet. CNA-M removed her gloves, stated sometimes she does that and exited the bathroom and closed the bathroom door. Surveyor noted R21 was left alone in the bathroom. At 7:56 a.m. CNA-M left R21's room and returned back at 7:59 a.m. While CNA-M was washing her hands, CNA-K entered R21's room, washed her hands and staff placed gloves on. At 8:01 a.m. CNA-K stood R21 up and CNA-M washed R21's frontal perineal area and buttocks. CNA-K & CNA-M pulled up and refastened the incontinence product and transferred R21 into the wheelchair. On 4/30/24 at 7:18 a.m. Surveyor observed R21 in bed on the left side. R21's call light is within reach & there is a mat on the floor on the right side. Surveyor observed R21's bed is not in a low position. On 4/30/24 at 8:21 a.m. Surveyor asked CNA-N if she could show Surveyor R21's feet. R21 was observed in bed on her back, head of the bed elevated and R21's bed is not in a low position. CNA-N removed the bedding off R21's feet. Surveyor observed R21 is not wearing gripper socks according to her plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility did not ensure residents at risk for pressure injuries, and with pressure injuries, were comprehensively assessed with an individualized plan of care. This was observed with 2 (R1, R2) of 3 residents reviewed with pressure injuries, and at risk for pressure injury. *R1 was assessed at high risk for pressure injuries. The facility did not initiate a turning or repositioning schedule for R1. On 10/10/23, R1 was noted with an unstageable necrotic pressure injury to their sacrum. The facility did not individualize R1's care plan related to their pressure injury or discuss risks versus benefits related to repositioning with R1 or R1's representative. *R2 was assessed at risk for pressure injuries. The facility did not ensure R2's pressure relieving interventions were in place in accordance with R2's comprehensive care plan. Findings include: 1. R1 was admitted to the facility on [DATE] with diagnoses of hemiplegia, vascular dementia, and malnutrition. R1's admission assessment dated [DATE] documented R1 had a Braden score of 12, indicating R1 was at high risk for pressure injuries. R1's admission MDS (Minimum Data Set) assessment dated [DATE] indicates a BIMS (Brief Interview for Mental Status) score of 02, indicating R1 was noted with severe cognitive impairment related to daily decision making. R1's MDS indicated that R1 was dependent upon staff for bed mobility and the ability to reposition. R1's MDS indicated the facility did not initiate a repositioning or turning schedule upon R1's admission to the facility. R1's admission MDS assessment did not indicate R1 had pressure injuries upon admission to the facility on 9/26/23 or refusal or inconsistency with repositioning or off-loading. R1 was discharged from the facility on 11/22/23 for debridement of their pressure injury. Surveyor reviewed R1's closed medical record including physician orders, progress notes, and care plans. Surveyor noted skin integrity care plan with initiation date of 9/26/23 reading, At risk for alteration in skin integrity related to: impaired mobility, incontinence. Care plan interventions included: Barrier cream to peri area/buttocks as needed, encourage to reposition as needed, use assistive devices as needed, float heels or use heel protector boots as resident allows. On 10/10/23, R1 was noted with an unstageable necrotic pressure injury (referencing the sacrum area) measuring 2.5 x 1.7 x 0.1 cm with 70% granulation tissue and 30% thick adherent devitalized necrotic tissue. On 12/13/23, Surveyor reviewed a facility document titled Incident description dated 11/29/23. Surveyor noted the documentation included the following: .It is reasonable to conclude that the area developed was unavoidable and as a result of the resident's co-morbidities, inconsistency with allowing repositioning and off-loading . Surveyor noted that R1's care plan interventions for encourage to reposition as needed, barrier cream to peri area/buttock, use assistive devices as needed, float heels or use heel protector boots as resident allows were not updated to reflect the need for the facility to establish an increased need for a routine repositioning program upon discovery of R1's sacral pressure injury on 10/10/23. Surveyor noted that there was no indication in R1's care plan that R1's mattress was appropriate for an unstageable pressure injury. R1's care plan was not updated when the facility documented an Incident description on 11/29/23 which determined R1's pressure injury was unavoidable as a result of co-morbidities and inconsistencies or resistance with allowing repositioning and off-loading. On 12/14/23 at 11:18 AM, Surveyor conducted a telephone interview with Certified Nursing Assistant (CNA)-E. Surveyor asked CNA-E if they had ever had concerns with R1 being resistive with cares or positioning. CNA-E responded that they never had any issues with R1 being resistive or uncooperative with repositioning. CNA-E added that R1 needed a lot of help because of the inability to reposition independently. Surveyor asked CNA-E if a resident or their representative are resistive to cares including repositioning or refusing treatment, should that be reflected in a resident's care plan. CNA-E responded that they would assume that any refusals of care would be reflected in a resident's care plan. On 12/14/23 at 10:44 AM, Surveyor conducted a telephone interview with Wound MD-F. Wound MD-F is no longer conducting wound rounds at the facility. Surveyor asked Wound MD-F if they had ever had concerns with R1 being resistive with cares or positioning. Wound MD-F recalled that R1's daughter had once refused debriding of R1's unstageable pressure injury but later agreed to have debriding performed by Wound MD-F at the facility. Surveyor asked Wound MD-F if a resident or their representative are resistive to cares including repositioning or refusing treatment should that be reflected in a resident's care plan. Wound MD-F responded that they would think that any refusals of care should be reflected in a resident's comprehensive care plan. Surveyor asked Wound MD-F if residents with unstageable pressure injuries should be on a turning and repositioning schedule. Wound MD-F responded, Yes. On 12/14/23 at 10:44 AM, Surveyor conducted telephone interview with Wound MD-G. Wound MD-G is the facility's current wound physician and conducts weekly rounds at the facility. Surveyor asked Wound MD-G if they had ever had concerns with R1 being resistive with cares or positioning. Wound MD-G told Surveyor that they had only seen R1 a few times before they were discharged from the facility and they didn't remember R1 that well. Surveyor asked Wound MD-G if they recalled R1 ever being resistive to care including repositioning. Wound MD-G responded that they did not recall R1 being resistive to cares or repositioning while they conducted weekly wound rounds. Surveyor asked Wound MD-G if a resident or their representative are resistive to cares including repositioning or refusing treatment, should that be reflected in a resident's care plan. Wound MD-G responded that they would expect that any refusals of care should be reflected in a resident's comprehensive care plan. Surveyor asked Wound MD-G if residents with unstageable pressure injuries should be on a turning and repositioning schedule. Wound MD-G responded that they would have the expectation for any resident either at risk for pressure injuries or with any current pressure injury should be on a repositioning schedule. On 12/14/23 at 2:10 PM, Surveyor conducted interview with DON-B (Director of Nursing.) DON-B told Surveyor that R1's representative was very challenging throughout R1's stay at the facility. Surveyor asked DON-B to elaborate. DON-B told Surveyor that R1's representative had often refused or changed her mind frequently throughout R1's overall treatment including being resistive or refusing immunizations, medications ordered by physicians, and pressure injury treatments including offloading, repositioning, and debridement of R1's sacral pressure injury. Surveyor asked DON-B if a resident or their representative is resistive to care or recommendations made by a physician, should that be reflected in the resident's comprehensive care plan. DON-B nodded their head yes at this time. Surveyor asked DON-B if there had ever been discussion with R1's representative regarding risk versus benefits of not repositioning R1 on a scheduled basis. DON-B told Surveyor that they would check with Social Services Director-H for more information. On 12/18/23 at 10:30 AM, Surveyor reviewed Social Services documentation including care conference documentation. Surveyor could not identify any documentation related to discussion with R1's representative related to risk versus benefit of not repositioning R1 on a scheduled basis due to their unstageable pressure injury. Surveyor conducted interview with Social Services Director-H. Social Services Director-H did not recall ever discussing any risk versus benefit related to R1's unstageable pressure injury because that would be a more clinical thing that would involve nursing rather than social services. Surveyor asked Social Services Director-H if a resident or their representative is resistive to care or recommendations, should that be reflected on a resident's care plan. Social Services Director-H responded that they would think that any refusals by residents or their representative should be documented and reflected on the resident's care plan. On 12/18/23 at 11:10 AM, Surveyor shared concerns with NHA (Nursing Home Administrator)-A, DON-B, VP (Vice President) of Operations-C and Interim DON-D related to R1's development of a facility acquired unstageable pressure injury, lack of repositioning schedule, lack of care plan update and lack of documentation related to alleged refusals of repositioning and treatment from R1's representative. The facility submitted additional information after the facility exit which was written by MD-F documenting the following: MD-F saw R1 for the first time on 10/10/23 as a new patient with a pressure wound to her sacrum. During the course of treatment, the patient used to resist reposition during my wound rounds. The healing process was slow because of non-repositioning as the DON-B used to tell me, the patient also has low albumin level which is indicator for protein level. The patient's daughter (POA) refused the debridement in the beginning which also delay wound healing and increase risk of infection. Even after healing, the area will be weaker than normal skin and reopening is easier through the new scar, which means if the patient after wound healing is not off loading the area, the wound will happen again. With all these factors and the patient is not following the wound care prevention recommendations the wound will take longer time of healing or non-healing and reopening is expected. Surveyor reviewed the above information however, the facility did not update R1's care plan when R1 was observed to have an unstagable pressure injury on 10/10/23, did not update the care plan after the 11/29/23 Incident description which indicated R1's inconsistencies or resistance with allowing repositioning and off-loading, R1's care plan did not reflect R1's refusals for repositioning and off-loading, and there was no evidence that the risks and benefit's of not repositioning was discussed with R1 and their POA. 2. R2 was originally admitted to the facility on [DATE]. R2 has diagnosis that includes; Charcot's joint left foot and ankle (syndrome in patients who have peripheral neuropathy or loss of sensation in the foot and ankle) Type 2 Diabetes Mellitus with Diabetic Neuropathy, Chronic kidney disease, major depressive disorder, hemiplegia and hemiparesis following cerebral infarction affecting non-dominant side. R2 has a history of a sacral pressure ulcer and cellulitis to the right lower limb. The most recent quarterly MDS (Minimum Data Set), dated 9/22/23 indicates that R2 has a BIMS (brief interview for mental status) score of 15 - cognitively intact. R2 is said to be at risk for pressure injuries and at the time of the assessment has an unstageable deep tissue injury. Interventions included pressure relief for the bed and chair. Physical Therapy treatment encounter note, dated 9/18/23, states; during session, noticed left lower leg has small red mark, is slightly swollen. RN made aware and RN looking at R2's left lower extremity during physical therapy session. Also, during session, socks taken off and a large amount of dry/dead skin in socks and falling off feet. Much old dry skin sticking to feet. Left heel dark in color. Director of Nursing (DON) made aware. Repositioned lower extremity on the bed with left foot boot on for heel protection. Surveyor conducted further medical record review for R2, and it was noted that the skin review- weekly note, dated 9/18/23 states that R2 has a pressure injury to the left heel, suspected deep tissue injury measuring 2 centimeters by 1.7 centimeters and no depth. R2 was assessed by the Wound Physician on 9/19/23. Chief complaint- R2 had a wound on her left heel. Unstageable deep tissue injury within and around wound. Measures 1.9 centimeters by 0.9 centimeters by 0.1 centimeters. Surface area is 1.71 centimeters, 100% granulation tissue. Duration: less than 1 day. Treatment: Leptospermum honey apply three times per week for 30 days; Xeroform gauze apply once daily for 30 days. Recommendations: off- load wound; float heels in bed. A review of the plan of care for R2 indicated that R2 is at risk for skin integrity condition, or pressure sores due to impaired mobility and preferring to sleep in wheelchair, incontinence. This plan of care was initiated on 10/4/21 and last revised on 1/25/23. Interventions included apply pressure reduction chair cushion on wheelchair and pressure reduction mattress on the bed. Ensure cushion is properly placed, clean and dry. A revision was made on 11/10/21 for R2 to be encouraged to wear left heel lift boots at all times to offload pressure. Prevalon boots while in bed. Appropriate to remove for cares. Further review of the plan of care did not show that R2 was resistive to wearing the Prevalon boots in bed. On 12/12/23, Surveyor conducted a review of the most current wound assessment for R2 that was conducted on 12/5/23. R2 remains with the pressure injury to left heel, Stage 3. Measures 0.8 centimeters by 0.8 centimeters by 0.1 centimeters. Wound progress- not at goal, objective healing/ maintain healing. Duration R2 has had the area is 76 days. On 12/12/23 at 12:10 p.m., Surveyor made observations of Licensed Practical Nurse (LPN)- I conducting the treatment on R2's left heel. The Wound Physician was also present for an assessment of the wound. MD states that the area is making progress and will be changing the treatment to everyday. LPN- I then applied latex gloves, cleansed the area to the left heel and applied the treatment. R2 is laying in bed during the treatment with a pillow under her knees lifting up her leg. Surveyor asked R2 about the area to her left heel. R2 stated that she had a sore to her heel over a year ago and it re-opened. R2 stated that she got new diabetic shoes and wore them for just 1 day as she sat in her chair. R2 stated that the left shoe was much too tight and said this caused the sore to her left heel. Surveyor asked R2 if staff check her feet daily and R2 responded no they do not. LPN- I continued to apply the treatment and applied the foam dressing. LPN- I did not provide any additional of R2's left review toes or the right foot. On 12/14/22 at 8:52 a.m., Surveyor interviewed DON- B regarding R2's left heel pressure injury. DON- B stated that she had conducted an assessment, on 9/18/23, on R2's lower extremity because her leg and foot were warm to touch. As she was assessing her leg, she noted that the left heel had a deep tissue injury. DON- B stated that she believed the area developed because R2 was wearing her diabetic shoes even when she was in bed. Surveyor confirmed with DON- B that R2 is unable to ambulate and is either in her bed or up in a Broda chair. DON- B stated yes, but R2 wanted to wear the new shoes as she had worn diabetic shoes in the past. Surveyor asked DON- B why R2 would be wearing the diabetic shoe in bed and not the Prevalon Boots as per the plan of care. DON- B stated she was not aware she was wearing the shoe while in bed, but she was aware she would wear it while up in the chair. Surveyor shared that during the interview with R2 that R2 said she wore the shoe once and it was not fitting correctly. Surveyor asked DON- B if anyone had explained the risks of R2 continuing to wear the diabetic shoe instead of the pressure relief boots while in the chair or bed. DON- B stated she could not recall. DON- B was asked if the diabetic shoe was part of R2's plan of care. DON- B verified that it was not an intervention. DON- B was able to confirm that R2 had received the diabetic shoes on 8/31/23. On 12/18/23 the facility submitted additional information to indicate the area on R2's heel was unavoidable as a result of wearing diabetic shoes. Surveyor noted the diabetic shoes were not noted to be part of R2's plan of care to specify when to wear and to monitor for fit. Additionally, the plan of care continued to indicate R2 was at risk for pressure injuries and continued to have a plan of care to off load the foot/heels. R2 developed an unstageable/deep tissue injury as a result of not having a clear plan of care to address R2's risk factors for developing pressure injuries.